Multicenter Retrospective Analysis of Dorsal Root Ganglion Stimulator Placement Using Intraoperative Neuromonitoring in Asleep Patients During Early Periods of Adoption

Falowski, Steven; Deer, Timothy R; Tubic, Goran; Mehta, Pankaj

doi:10.1111/ner.13286

Cited by 8 publications

(4 citation statements)

References 25 publications

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“…Muscle weakness in combination with other symptoms, radiological findings, and possibly electrodiagnostic findings are used in the diagnosis of lumbar radiculopathy, 10 and EMG is used during surgeries ranging from spinal fusion 11 to dorsal root ganglion stimulation. 12 Maps that accurately depict the variability and breadth of myotomes can prevent misinterpretation of electrophysiological monitoring during surgery and misdiagnosis of patients in the clinic.…”

Section: Discussionmentioning

confidence: 99%

A broad and variable lumbosacral myotome map uncovered by foraminal nerve root stimulation

London

Birkenfeld

Thomas

et al. 2022

Journal of Neurosurgery: Spine

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OBJECTIVE The human myotome is fundamental to the diagnosis and treatment of neurological disorders. However, this map was largely constructed decades ago, and its breadth, variability, and reliability remain poorly described, limiting its practical use. METHODS The authors used a novel method to reconstruct the myotome map in patients (n = 42) undergoing placement of dorsal root ganglion electrodes for the treatment of chronic pain. They electrically stimulated nerve roots (n = 79) in the intervertebral foramina at T12–S1 and measured triggered electromyography responses. RESULTS L4 and L5 stimulation resulted in quadriceps muscle (62% and 33% of stimulations, respectively) and tibialis anterior (TA) muscle (25% and 67%, respectively) activation, while S1 stimulation resulted in gastrocnemius muscle activation (46%). However, L5 and S1 both resulted in abductor hallucis (AH) muscle activation (17% and 31%), L5 stimulation resulted in gastrocnemius muscle stimulation (42%), and S1 stimulation in TA muscle activation (38%). The authors also mapped the breadth of the myotome in individual patients, finding coactivation of adductor and quadriceps, quadriceps and TA, and TA and gastrocnemius muscles under L3, L4, and both L5 and S1 stimulation, respectively. While the AH muscle was commonly activated by S1 stimulation, this rarely occurred together with TA or gastrocnemius muscle activation. Other less common coactivations were also observed throughout T12–S1 stimulation. CONCLUSIONS The muscular innervation of the lumbosacral nerve roots varies significantly from the classic myotome map and between patients. Furthermore, in individual patients, each nerve root may innervate a broader range of muscles than is commonly assumed. This finding is important to prevent misdiagnosis of radicular pathologies.

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Section: Discussionmentioning

confidence: 99%

A broad and variable lumbosacral myotome map uncovered by foraminal nerve root stimulation

London

Birkenfeld

Thomas

et al. 2022

Journal of Neurosurgery: Spine

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“…The goal of either anesthetic technique is to minimize potential patient harm, and optimize patient experience while placing DRG-S leads. 160,161 Preoperative evaluation of relevant patient factors and foreseeable procedural challenges influence the specific sedation and anesthesia plan for individuals undergoing DRG-S placement. Choice of anesthetic and monitoring should be discussed prior to the day of the procedure, and implanter and patient preferences should be aligned.…”

Section: Best Practices and Pearls Of Expert Opinion Safety Preoperat...mentioning

confidence: 99%

“…In two retrospective studies utilizing IONM with DRG-S, a total of 182 DRG-S cases elicited 16 IONM alerts, with three patients experiencing a transient paresthesia in the post-operative period and no serious neurologic complications. 160,161 Anesthetics and other factors can impact the reliability of IONM, [169][170][171] see Table 4. Importantly, both SSEP and spontaneous EMG allow the physician to detect abnormalities early, determine the cause, and avoid or prevent further neurological insult.…”

Section: Intraoperative Neuromonitoringmentioning

confidence: 99%

Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience

Chapman¹,

Sayed²,

Lamer³

et al. 2023

JPR

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With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion stimulation (DRG-S) has significantly improved the treatment of complex regional pain syndrome (CRPS), and it has broad applicability across a wide range of other conditions. Through funding and organizational leadership by the American Society for Pain and Neuroscience (ASPN), this best practices consensus document has been developed for the selection, implantation, and use of DRG stimulation for the treatment of chronic pain syndromes. This document is composed of a comprehensive narrative literature review that has been performed regarding the role of the DRG in chronic pain and the clinical evidence for DRG-S as a treatment for multiple pain etiologies. Best practice recommendations encompass safety management, implantation techniques, and mitigation of the potential complications reported in the literature. Looking to the future of neuromodulation, DRG-S holds promise as a robust intervention for otherwise intractable pain.

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“…Performing lead placement in an awake, responsive patient or in an asleep patient utilizing intra-operative neuromonitoring may help identify and prevent injury, and should be implemented in all cases. 19,22…”

Section: Thoracic Leadsmentioning

confidence: 99%

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

et al. 2021

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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.

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Multicenter Retrospective Analysis of Dorsal Root Ganglion Stimulator Placement Using Intraoperative Neuromonitoring in Asleep Patients During Early Periods of Adoption

Cited by 8 publications

References 25 publications

A broad and variable lumbosacral myotome map uncovered by foraminal nerve root stimulation

A broad and variable lumbosacral myotome map uncovered by foraminal nerve root stimulation

Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience

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

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