Awake vs. Asleep Placement of Spinal Cord Stimulators: A Cohort Analysis of Complications Associated With Placement

Abstract

Abstract:Introduction: Patients will typically undergo awake surgery for permanent implantation of SCS in an attempt to optimize electrode placement using patient feedback about the distribution of stimulation-induced paresthesia. The present study compared efficacy of first-time electrode placement under awake conditions with that of neurophysiologicallyguided placement under general anesthesia. Methods: A retrospective review was performed of 387 SCS surgeries among 259 patients which included 167 new stimulator implantation to determine whether first time awake surgery for placement of spinal cord stimulators is preferable to non-awake placement.

Multimodal, Intraoperative Monitoring during Paddle Lead Placement for Cervicothoracic Spinal Cord Stimulation

“…However, as we observed in our cases of cervical and cervicomedullary SCS that showed a reduction in the amplitude of muscle MEP, we think that inserting an additional volume, i.e. a paddle lead, in the cervicothoracic epidural space has an inherent risk of neurologic injury, and the significance of anatomical consideration and preoperative evaluation of possible cervical stenosis has been emphasized by experienced authors of SCS [16,21,23,26]. …”

“…Monitoring of CMAP generated by the paddle lead for SCS was reported by Aló [18], Whitworth and Feler [29], Falowski et al [23], and Shils and Arle [21]. The latter authors systematically demonstrated that cervicothoracic SCS electrodes could be placed safely and accurately in 155 patients under general anesthesia using their proposed EMG recording technique, and the electrodes were repositioned intraoperatively in 15.9% of the patients.…”

“…Extensive work has been carried out previously for describing the mapping of the spinal structure and the relationship between the spinal level of stimulation and the somatotopy of paresthesia [22]. It is commonly believed that intraoperative testing in awake patients is likely to optimize the placement of the electrode, although this method has not been formally compared with other methods of guided placement [23]. Although local anesthesia with conscious sedation and spinal anesthesia are the preferred methods to confirm that painful regions are covered by stimulation-induced paresthesia [13,14], these techniques may be unreliable or misleading with respect to less reliable or nonideal effects of anesthetics, pain distribution, patient response and positional changes due to cord movement [21,24,25].…”

“…To eliminate the risks associated with the awake technique (the possibility of oversedation and loss of airway control) and to make the patients and surgical teams more comfortable during the procedure, along with placing the paddle lead safely and accurately, several groups have started to use neurophysiologic methods for paddle lead placement in SCS surgery under general anesthesia [20,21,23]. Falowski et al [23] conducted a retrospective analysis of awake versus asleep placement of spinal cord stimulators in 387 SCS surgeries among 259 patients which included 167 new stimulator implantations to determine whether first-time awake surgery is preferable to nonawake placement.…”

“…Falowski et al [23] conducted a retrospective analysis of awake versus asleep placement of spinal cord stimulators in 387 SCS surgeries among 259 patients which included 167 new stimulator implantations to determine whether first-time awake surgery is preferable to nonawake placement. The incidence of device failure for patients implanted using neurophysiologically guided placement under general anesthesia was half that for patients implanted awake (14.94 vs. 29.7%), and the authors claimed that paddle lead placement under general anesthesia is a viable alternative if neurophysiological guidance is combined [23]. …”