A paramedian approach for dorsal root ganglion stimulation placement developed to limit lead migration and fracture

Abstract

Introduction: Dorsal root ganglion stimulation (DRG-S), has demonstrated superiority in the treatment of complex regional pain syndrome and causalgia. Lead migration and fracture impact DRG-S therapeutic stability. Lead anchoring reduces DRG-S lead migration without increasing lead fracture. Lead fracture may be related to lead entrapment in the superficial fascial plane. A novel medialized approach for lead placement and anchoring is presented to address these issues. Methods:We suggest an alternative technique for implanting percutaneous DRG-S leads at the T10-L5 levels.Results: A novel medialized ipsilateral technique for lead placement and anchoring for single, bilateral, and adjacent segment placement is presented. The Tuohy needle puncture site is medial to the pedicle and adjacent to the spinous process, two vertebral levels caudad to the target foramen. Trajectory is maintained in the sagittal plane, to access the caudad interlaminar space near the midline. This technique allows for ipsilateral or contralateral lead placement. After epidural access, the introducer sheath is rotated toward the targeted foramen and advanced. The guidewire followed by the lead is passed, and once lead position is confirmed, tension "S" loops are created, followed by anchoring to the deep fascia. Conclusion:We describe a new paramedian technique for DRG-S lead placement.We propose it will decrease DRG-S complication rates through anchoring to reduce migration and by avoiding the fascial planes thought to be responsible for fracture. Long-term outcomes applying our proposed techniques are required for determining the true impact, however, early anecdotal results suggest that these new techniques are favorable.

Advances in Pain Medicine: a Review of New Technologies

“…Initially, anchoring was not recommended due to the risk of fracture, but a recent update in the literature now supports the use of anchoring in addition to an S-shape loop in the epidural space for strain relief. [55] Success rate is high in majority of studies with one notable exception [56]. Patients demonstrated improved QOL and a decrease in consumption of analgesics including opioids [51].…”

An Anatomy-Informed, Novel Technique for S1 Dorsal Root Ganglion Stimulation Lead Placement

“…Anchoring the 1-mm DRG-S lead has proven to be an integral step in decreasing lead migration and potentially lead fracture [ 2 ]. Additionally, an ipsilateral, paramedian approach for thoracolumbar DRG-S lead placement was described to decrease lead fracture and enable an alternative technique to the wider-angled contralateral approach [ 3 ].…”

“…Anesthesia for placement of a trial or permanent DRG device has evolved since the early cases were performed. Recognition of the sensitivity of the DRG to mechanical stimuli during placement has led to raised awareness of anesthetic management and the procedural approach [ 3 , 11–13 ]. Insult to neural structures can cause a neuritis, paresthesia, or weakness, and although commonly self-limiting, longer-term injuries during lead placement in asleep, unmonitored patients have been reported [ 14 , 15 ].…”

Determinants of Complex Regional Pain Syndrome Type I among Radial Head Fracture Patients with Unilateral Arthroplasty

“…9 Many studies reported that fracture was the most common trigger of CRPS I. [10][11][12] Jellad et al 13 reported that CRPS I occurred in 32.2% of distal radius fracture patients. The injury mechanism of distal radius fractures was similar to radial head fractures.…”

“…Many studies reported that fracture was the most common trigger of CRPS I. 10 , 11 , 12 Jellad et al . 13 reported that CRPS I occurred in 32.2% of distal radius fracture patients.…”