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Spinal cord stimulator placement

Procedure description

A spinal cord stimulator may be placed to help with lower extremity, upper extremity, and low back pain.  This pain may be the result of nerve root scarring, reflex sympathetic dystrophy, or other causes.  Often patients may have had one or more surgeries on the spine.  A paddle of electrodes is placed on the back surface of the spinal cord, outside of the dura mater (the tough covering of the cord).  The electrodes are connected to an electrical signal generator, and electrical impulses are used to stimulate the back of the cord, in an attempt to mask the pain the patient is experiencing.  A small laminectomy (removal of bone covering the spinal cord) is performed to allow the surgeon access to the back of the spinal cord.  The procedure to place the trial electrode paddles may be done with the patient awake or asleep.  If done awake, the surgeon may manipulate the paddles to the appropriate position in order to cover the region of pain.  There is the possibility of interaction with the patient and feedback during the procedure (the patient can tell the surgeon when the paddles are properly positioned so the the patient "feels good" and gets pain relief).  The patient may go home with th trial electrode in place, and if he/she finds,  over the next several days, that the pain is improved, then a permanent battery/electrical pulse generator may be implanted.
 
 During the operation, the patient may be awake or asleep.  If awake, the patient is sedated, and a local anesthetic is used.  The patient is  then gently turned to the prone (face and abdomen down) position, using cushions and gel rolls to protect and cushion the body.  The lower back or neck (depending on the region of surgery) is cleaned in a sterile manner, and the surgeon then makes a vertical (up and down) incision.  The surgeon will dissect down to the spinous processes (bones protruding back from the spine) and then push the muscle away from the lamina ( the roof of the spinal  canal).  Often, an x ray or C arm (fluoroscopy unit which allows the surgeon real time x-ray monitoring) will be taken at this point to confirm that the appropriate level is being operated upon.  Next, the surgeon will remove  the lamina in order to allow access to the spinal canal and cord.  This may be done under magnification, usually using the microscope.    The surgeon will then place the paddle of electrodes.  If the patient is awake, a variety of patterns of stimulation (varying by paddle distance, location, amplitude and frequency) will be attempted, until the patient feels the area of pain is being covered.  Patients will often describe this as a good feeling.  Next, the electrode wires will be brought out through a separate incision.  The retractors in the wound are removed, and the muscle falls back into place. The deep fascia (firm fibrous tissue of the low back) is sewn closed, as is the subcutaneous tissue (tissue deep beneath the skin) and skin.  The wound is dressed with a sterile dressing, and the patient is returned to the recovery room.
If, after several days of the trial stimulator in place, the patient feels the procedure has been successful at improving pain, he/she may return for permanent implantation of a battery/electrical pulse generator.  The patient is now taken to the operating room, put to sleep, and a wire is tunneled from the electrodes, under the skin, to a location, usually in the lower abdomen or just below the collar bone in the chest, where a permanent battery is implanted.  This procedure is done under general anesthesia.

 

Procedure Risks

Spinal cord stimulator placement does have some risk.  Even though the risks of complications are relatively low, there are risks.  These can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

Risks related to the operative site: 

Surgical Exposure: The patient is placed in a prone position (on their abdomen).      In this position, there can be pressure sores, pressure injuries to nerves, and injury to the eyes as a result of pressure to them. During surgical dissection, injury to muscle surrounding the spine can occur.

Spinal Cord/Nerve Root injuries: If there is any injury to the spinal cord  or nerve roots, the consequences may involve loss of sensation, increased burning sensation, paralysis, weakness, loss of bowel, bladder, sexual function. There may be a spinal fluid leak, which could occur after a tear of the covering of the spinal cord or nerve roots.  If this did occur, it may be necessary to have the patient flat in bed for several days after the surgery.  Even if everything goes as well as hoped, there is a risk of instability of the spine and disc herniation in the future,  requiring additional surgery on the  spine. 

General Risks: These include such general difficulties as bleeding, infection, stroke, paralysis, coma and death. Incisions in the low back and abdomen generally heal well, but they could   be tender, or may heal in an unpleasant manner.  There is also the possibility that the surgery may not relieve the symptoms for which the procedure was performed. The paddle of electrodes, or the conducting wires and battery,  may become infected, requiring removal of the entire system.  If the paddle is scarred to the dura mater (covering of the cord), surgical removal may not be possible. The problem for which the surgery was performed may recur, requiring additional surgery in the future.  When the battery loses its charge, replacement will be necessary.  In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia:
Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if  given.  Bone can bleed quite a bit, and if sufficient amounts of blood are lost during the surgery, a transfusion may be performed (chances of this are very low).

 

Post-operative care:

There shall be no bending, twisting, or heavy lifting for several weeks after surgery.  Your doctor will gradually ease your work restrictions, depending on your progress. 

Remember to keep the wound dry and clean.  Notify your surgeon of any drainage or temperatures greater than 101 Fahrenheit.

 We expect you to do normal activities better because of the surgery.  Some continuuing back  pain is not unusual during the first few days and weeks following surgery.  Hurt does not necessarily mean harm.    The following is a list of suggestions that should help speed your recovery and give you every possible chance for the best results from your surgery.

  1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been made.
  2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incision a chance to heal.  Avoid bending.
  3. Lift nothing heavier than a half gallon of milk until seen by your doctor.
  4. Avoid sitting for periods of time longer than 45 minutes.  It is OK to sit in a lounge chair which is laid back, for as long as you wish.
  5. No jogging or running.
  6. After you get home, you may begin walking up to one mile per day.
  7. You may walk up or down steps as often as you like.  Please take them smoothly and slowly.
  8. No driving until OK with your physician.  Do not ride further than  50 miles at a time.  This applies during the first month after surgery.
  9. You may shower after you go home unless otherwise instructed.  Cover the incision with plastic wrap before the shower and remove it afterward.  Change dressing immediately.  Tub baths are not advisable.  You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tape strips, stitches or staples.  Your surgeon or  nurse clinician will explain the techniques used in the closure of your incision.
  10. Sexual activities are permitted.
  11. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call in greater than 101 degrees Fahrenheit.
  12. If you have any questions, call our office, and for after hours emergencies, call the medical society.
  13. Take your medications prescribed on discharge, as directed.

 

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