Dural Puncture During Spinal Cord Stimulator Lead Insertion: Analysis of Practice Patterns

Abstract

Background: Spinal cord stimulation (SCS) is an important modality for intractable pain not amenable to less conservative measures. During percutaneous SCS lead insertion, a critical step is safe access to the epidural space, which can be complicated by a dural puncture. Objectives: In this review, we present and analyze the practices patterns in the event of a dural puncture during a SCS trial or implantation. Methods: We conducted a survey of the practice patterns regarding spinal cord stimulation therapy. The survey was administered to members of the Spine Intervention Society and American Society of Regional Anesthesia specifically inquiring decision making in case of inadvertent dural puncture during spinal cord stimulator lead insertion. Results: A maximum of 193 responded to a question regarding dural punctures while performing a SCS trial and 180 responded to a question regarding dural punctures while performing a SCS implantation. If performing a SCS trial and a dural puncture occurs, a majority of physicians chose to continue the procedure at a different level (56.99%), followed by abandoning the procedure (27.98%), continuing at the same level (10.36%), or choosing another option (4.66%). Similarly, if performing a permanent implantation and a dural puncture occurs, most physicians chose to continue the procedure at a different level (61.67%), followed by abandoning the procedure (21.67%), continuing at the same level (10.56%), or choosing another option (6.11%). Conclusions: Whereas the goals of the procedure would support abandoning the trial but continuing with the permanent in case of inadvertent dural puncture, we found that decision choices were minimally influenced by whether the dural puncture occurred during the trial or the permanent implant. The majority chose to continue with the procedure at a different level while close to a quarter chose to abandon the procedure. This article sets a time stamp in practice patterns from March 20, 2020 to June 26, 2020. These results are based on contemporary SCS practices as demonstrated by this cohort, rendering the options of abandoning or continuing after dural puncture as reasonable methods. Though more data is needed to provide a consensus, providers can now see how others manage dural punctures during SCS procedures.

Post-dural Puncture Headache After Removal of Trail Spinal Cord Stimulator Leads: A Case Report

“…The Neurostimulation Appropriateness Consensus Committee guidelines rate intraoperative blood patch as evidence level III and recommendation C [ 8 ]. One survey study discovered that when dural compromise was seen during the placement of trail and permanent SCS, about 57% and 62%, respectively, of physicians would continue with placement but on a different level [ 9 ]. The study infers that when the procedure was not aborted by the interventionalist, an EBP was performed intraoperatively to facilitate closure of the known dural defect.…”

The contralateral oblique fluoroscopic view is associated with a lower incidence of postdural puncture headache in patients undergoing percutaneous spinal cord stimulation

“…24 Furthermore, a survey analysis of practice parameters among practicing interventional pain physicians on dural puncture during SCS procedures identified that up to 28% abandon trials and 22% abandon permanent implants if the dura is accidentally breached. 25 While the majority of physicians in the presence of known accidental dural puncture would elect to proceed with either the trial or the permanent SCS, there is enough practice variation that demonstrates that the management of this complication is not so straightforward and would be better off avoided. Accidental dural puncture is a precursor to spinal cord injury by needle contusion and as the two are mechanistically connected; a reduction in the former complication may potentially decrease the latter.…”