PREOPERATIVE DIAGNOSIS: Chronic pain syndrome.
PROCEDURES PERFORMED:
1. T11 laminotomy and revision/repositioning of spinal cord stimulator electrode.
2. Direct coupling of spinal cord stimulator electrode to subcutaneous rechargeable pulse generator.
SURGEON: John Doe, MD
ANESTHESIA: MAC with local.
ESTIMATED BLOOD LOSS: 25 mL.
FLUID IN: 1200 mL.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman with chronic pain syndrome who underwent a period of temporary external dorsal column stimulation through a paddle electrode placed 3 days prior. She had good relief of her chronic pain syndrome; although, the coverage was not completely corresponding to the area of her pain. For that reason, she was offered and we have elected to proceed with repositioning electrode and then direct coupling to an implanted subcutaneous pulse generator.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. After administration of MAC with local, the patient was positioned on the operating table in the prone position on chest bolsters. Pressure points were appropriately padded. The thoracolumbar spine was prepped and draped in the normal sterile fashion. Previous nylon sutures were cut and removed. The subcuticular stitches were also cut and discarded. The Vicryl sutures closing the fascia were cut and discarded as well.
The retractor was positioned in the wound exposing the laminotomy defect that had been previously placed. The dorsal column stimulator paddle electrode was then removed from the epidural space. It had been placed under the lamina of T10 and passed superiorly.
At this point, a Leksell rongeur was used to remove some of cephalad-most portion of the spinous process and lamina of T11, and the remainder of a small laminotomy at the superior aspect of T11 was made with Kerrison rongeurs. At this point, the dorsal column stimulator electrodes could then be inserted in the epidural space and passed inferiorly. They were passed just slightly off to the left of midline, and a fluoroscopic shot confirmed that this was the case.
Intraoperative stimulation was then performed, and we confirmed that the patient did have adequate stimulation over the areas of her pain from the lateral aspect of the foot and lateral toes all the way up to the hip and buttock. This was the case. This wound was then irrigated with copious amounts of antibiotic irrigation. We were done with temporary external stimulation, and the connection sites between the external wires and the distal end of the electrode array were disconnected.
Outside the drapes, the external wires were cut flush with the skin surface in a sterile manner and discarded. The remaining portion of the external wires were removed from field and then discarded as well. A pocket was made in the subcutaneous tissue off to the left-hand side of the incision. The fascia was then closed with 0 Vicryl sutures. The wound was irrigated a final time with antibiotic irrigation. The distal end of the wires from the electrode array were then placed in the pocket outside the fascia on the left side, and the incision itself was closed with several 0 Vicryl and staples. A sterile dressing was applied to the wound, and drapes were removed.
The patient was then transferred over to a stretcher and back onto the operating table in a supine position. She was then intubated and placed under general anesthesia. She was then repositioned on the operating table in the right lateral decubitus position on an axillary roll. The patient’s previous incision over the left lower quadrant of the abdomen from a cancer surgery was identified and marked. It was under the belt line and away from the hip bone.
This entire area on the left side of the flank, left side of the abdomen, and thoracolumbar area of the spine were then prepped and draped in normal sterile fashion. This abdominal incision was then opened with a scalpel. Monopolar electrocautery was used for hemostasis of the skin edges, and blunt dissection was used to dissect down to the external fascia and muscle of the abdominal wall. Tunneling of the posterior incision was then opened by removing the staples and the subcutaneous stitches. A tunneling device was passed into the pocket outside the fascia on the left side of the incision and used to tunnel around to the left lower quadrant of the abdomen. It was then used to pull back the implanted extension wires. These were then connected to the distal end of the electrode array wires and covered with a plastic boot. Some of the redundant wire was then pulled through to the abdominal incision with several loops of redundant wire left in the posterior incision.
The posterior incision was then irrigated with copious amounts of antibiotic irrigation. The subcuticular layer was closed with 2-0 Vicryl sutures, and the skin was closed using staples. On the abdominal incision, the distal end of the extension wire was connected to the pulse generator and a plug was placed in the other connection sites. Sutures of 2-0 Ethibond sutures were then used to secure the pulse generator in the abdominal pocket, and the redundant wire was loosely looped underneath the pulse generator.
This wound was irrigated with copious amounts of antibiotic irrigation. The subcuticular layer was closed with 2-0 Vicryl sutures, and the skin was closed using staples. Sterile dressings were applied to both wounds. Drapes were removed. The patient was then returned back to the supine position on the hospital gurney, awakened from general anesthesia, and taken to the recovery room in good condition. Needle and sponge counts were correct.
