Salim Hayek, MD, PhD Division of Pain Medicine Department of Anesthesiology Case Western Reserve...
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Transcript of Salim Hayek, MD, PhD Division of Pain Medicine Department of Anesthesiology Case Western Reserve...
Salim Hayek, MD, PhDDivision of Pain Medicine
Department of AnesthesiologyCase Western Reserve
University
SCS Complications
Learning Objectives
Be aware of common SCS Complications
Understand the reasons for complications
Strategies to minimize complications
Turner JA et al., Pain. 2004 Mar;108(1-2):137-47
Complications AN UNAVOIDABLE PROBLEM
34% of patients who received a stimulator had an adverse occurrence
PROPORTIONATE TO NUMBERS MUST BE ADDRESSED EARLY AN IMPLANT COORDINATOR IS
ESSENTIAL CAN BE REDUCED
Minimizing Complications
Preoperative Patient selection
Intraoperative Technique
Postoperative VigilancePain relief
3 tracks “NANS, as a specialty society, neither accredits
training programs nor certifies individuals to perform SCS”
Understanding and being able to manage complications: Crucial
Complications of SCS
Technical Biologic Other
Kumar K etal., J Neurosurg Spine 5:191–203, 2006
Total = 31.9%; in 42/160 patients
162 paddle leads; 28 percutaneous leads
Kumar K. et al., Pain 132 (2007) 179–188
PROCESS Study
Kumar K etal., J Neurosurg Spine 5:191–203, 2006
Lead Migration 18 cases
13 in axial plane5 in transverse plane
Cervical leads2x > thoracolumbar
Multipolar/multichannel leads
Gluteal placement Flexion-Extension: Up
to 9 cm displacement
Henderson JM et al., Neuromodulation, Volume 9, Number 3, 2006 183–191
Kumar K etal., J Neurosurg Spine 5:191–203, 2006
IPG in Anterior Abdominal Wall
Minimal excursionWalking: 0.2cmTwisting: 1.7 cm
Scoliosis: lateral displacementPaddle leads
Rosenow J et al., J Neurosurg Spine 5:183–190, 2006
Kumar K etal., J Neurosurg Spine 5:191–203, 2006
Percutaneous Lead Breakage
just cephalad to anchoring point
risk when >1cm between anchor tip and lead entry point into fascia
Kumar K etal., J Neurosurg Spine 5:191–203, 2006
2.1 cm displacement between epidural space and the TL fasciaStrain relief
loop
Paddle Lead Breakage
Henderson JM et al., Neuromodulation, Volume 9, Number 3, 2006 183–191
Strain: Fascia--Epidural
Rosenow J et al., J Neurosurg Spine 5:183–190, 2006
Twist-Lock Anchor
Pressure Forces of flexion-
extension
Henderson JM et al., Neuromodulation, Volume 9, Number 3, 2006 183–191
Simulated/sheep model
Use of a soft silastic anchor pushed through the fascia to provide a larger bend radius for the lead was associated with a time to failure 65 times longer than an anchored but unsupported lead
Failures of surgical paddle leads occurred when used with an anchor, whereas without an anchor, no failures occurred to 1 million cycles
Henderson JM et al., Neuromodulation, Volume 9, Number 3, 2006 183–191
The panel recommendeda paramedian approachKeeping the lead midline—prevent
lateral maximizing bend radius by pushing the
anchor through the fasciaanchoring of the extension connector
near the lead anchorStrain relief loop
Henderson JM et al., Neuromodulation, Volume 9, Number 3, 2006 183–191
Generator Placement
The anchor should be placed as near as possible to the spinous process to avoid lead movement generated by muscle contractions
Placement of the IPG in the buttock region may produce up to a fivefold increase in tensile loading compared with placement in the abdomen or midaxillary line. The panel therefore recommended that buttock IPG placement be reserved for special clinical situations and should not be routinely performed
Kumar K et al., Neuromodulation 10 (1):24–33, 2007
0 black braided nylon
Strain relief loopStrain relief loop
Avoid Anchoring Paddle Lead
Alo KM et al., Neuromodulation 1:30–45, 1998
The Good News
Improved education/techniques Newer extensionless systems have
resulted in a marked decrease in revision rates (e.g. 3.8%)
Advancements in anchoring technology
Anchor Options
Enhanced Silicon suture sleeves
Mechanical Anchors
Silicone suture sleeves
Types of Mechanical Anchors
Swift-LockTM ClikTM TwistLockTM
Audible and tactile “Clik” confirms lock using hex wrenchRadio-opaqueBi-directional
Anchor Design
Infections
Cameron T. Safety and Efficacy of Spinal Cord Stimulation for the Treatment of Chronic Pain: a 20-year Review. J Neurosurg 2004; 100: 254-267.
Infections
12%
Gaynes RP et al., Clin Infect Dis 2001;33(S2):S69-77 Haridas M, Malangoni MA. Surgery 2008;144:496-503
Surgical Site Infection--SSI
Increased risk of SSIASA classificationprolonged operative time – defined as 75th
% hypoalbuminemia ( 3.4 mg/dL)anemia (Hgb 10 g/dL)excessive alcohol use (not defined)history of COPDhistory of CHFinfection at remote sitecurrent operation through a previous
incisionperioperative hyperglycemia
Nery PB et al., J Cardiovasc Electrophysiol 2010 Jan 22 Cesar de Oliveira J et al., Circ Arrhythmia Electrophysiol 2009;2:29-34
Lessons from the Heart
Historic infection rates for implanted cardiac devices (ICDs - pacemakers and defibrillators) 0.5-6%
More recently as low as 1% A PRDBPCT evaluated infection risk:
prophylactic cefazolin vs. placeboTrial was interrupted early by the safety
committee because of the dramatically higher rate of infection in those that did not receive antibiotics vs. those that did (3.28% vs. 0.63%)
Infection Prevention: Antibiotic Prophylaxis
RECOMMENDATIONCategory IA
cefazolin 1-2 g iv 30 minutes prior to incision
clindamycin 600 mg iv 30 minutes prior to incision [ß-lactam allergy]
vancomycin 1 g iv over 60 minutes prior to incision
[MRSA carriers]
Gyssens. Drugs 57:175-85; 1999
SCS Infection Prevention
Chlorhexidine more effective than Povidone Iodine skin prep
Minimize OR traffic Preoperative antibiotics Meticulous hemostasis Gentle tissue handling
Maki DG et al.,: Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 338:339-343, 1991
Kinirons B et al: Chlorhexidine versus povidone iodine in preventing colonization of continuous epidural catheters in children: a randomized, controlled trial. Anesthesiology 94:239-244, 2001
Infection Recommendations?
How to manage an Infected SCS?
The gold standard in treating deep SCS infections is a 2-stage procedure: the initial stage involves removal of
implanted material, wound debridement, and antibiotic treatment ID consult
After wound healing has occurred and no infection imminent, re-implantation can be performed
Can an Infected SCS be Salvaged?
SCS Leads epidural space IPG is by far the most expensive SCS
component No case reports of keeping generator in an
open incision after I&D Distinguish superficial vs. deep SSI Attempts at salvaging SCS in the setting of
SSI should be made only in the setting of:Complete patient understanding of potential risksClose follow up by implanter and ID specialist Careful serial monitoring of patient
Clinically Laboratory values such as CRP
Rare Surgical Complications CSF fluid leak/headache Post-op bleeding/hematoma Pocket Seroma Wound dehiscence Epidural abscess/meningitis Headache CSF Leak Pain in the incision site Allergic response to the system Programmer or telemetry problems Residual pain phenomenon Postural Changes
Technical Complications
Too deep an insertion Too superficial an insertion IPG flip Rib/iliac crest friction Anchor/lead erosion Anchor protrusion Uncomfortable position
sittingStanding: protrusionlaying down
CONCLUSION Overall SCS represents a low risk
effective therapy to control chronic pain
Complications do occur and range in severity from minor to fatal
Recognizing a complication early and understanding how to intervene appropriately is your responsibility
Surgical backup and extreme vigilance are highly desirable
Thank You!!
Do It Yourself
The EGL Scan(Electronically Generated Lead
scan)