SCS Flashcards
5 factors of credibility
- Competence
- Caracter
- Compusure
- Likability
- High energy
Anatomie
- lamina (reference point)
- L1-2 (reference to insert needle)
- distinguish between foramen en intevertebral oramen (important for leadplacemment)
- ligamentum flavum
True AP view
Proc. spinosi in middle
pedicules on 1 line (2 eyes and a nose)
Posteroanterior (PA) view:
- Spinous processes should be identified and aligned precisely at vertebral midline.
- Vertebral end plates should be aligned to crisp, linear horizontal position.
- The pedicles at the epidural entry level and 2 levels below should be identified.
Why lateral view with fluroscopy?
To see if lead is away from vertebral body (avoid ventral stimulation)
optimal distance between leads.
- lenght of contact (3 mm)
- not toughing (weird impedances)
- to far lateral: ventral stimulation
Lead placement
- offset (too much lateral)
- to much ventral: real smal steps with stimulation (ribstim. uncomf for the patient)
IPG during implant?
- facing upwards (BSC logo inthe middle)
myeline schede
- conducting (faster)
- alfa/beta fibers (target SCS)
- depolarisatie, springt naar vogende knoop van ranvier
Target SCS
- Alfa en Beta vezels (snelle) (not delta en C vezels)
- dorsral colom (not root)
Dorsal colum vs dorsal roots
3 layers of meninges
- Dura mater
- arachoid mater
- pia mater
What’s in the box
- IPG
- charging kit
- Novi
- lead
- IPG
- IPG
- hex wrench
- tunneling tool assembly
- pocket template
- 4 port plugs
- charging kit
- charging base
- aCDC power supply
- charger 2.0
- charger belt Medium
- Novi
- perc lead
- perc. lead (50/70cm)with preloaded curved stylet
- stylet ring with curved and straight stylet
- 4 suture sleeves 2x1cm, 1x1cm, 1x4cm
- 4instraight insertion needle
- lead blank
- steering cap
- Surgical lead
- Lead
- 6 suture sleeves (2x1cm, 2x2m), 2x4cm)
IPG, leads & sizes
percutaneus
- linear ST (30-50-60)
- spacing 1mm
- span:
- Linear 3-4
- 52cm
- Linear 3-6
- 66mm
- Infinion 16
- 67 cm (1mm spacing)
surgical
- artisan (16)
- 45x8x2
- coverEdge (32) 50+70cm SEAMLESS COVERAGE
- 50x9x2
- CoverEdge 32X (unmatched vertebral coverage (but difficult, you might miss one)
- 67x10x2
Materials
- paddles
- leads
- IPG
- plugs
paddles
- silicone
leads
- platinum/irradium
- polyurythane
IPG
- Titanium (coil9
- epoxy (top)
plugs
- polyuryten
size
- hex wrench
- tunneling tool
hex wrench: 4,3 + 7,2
tunneling tool: 28/35
M8
- medtronic lead 0-7
- skrew directly on last contact
multi lumen technology
- 8 isolated lumen,
- 19 filamenten.
- prevent leadbreakage
Charging
- 3 charging cycles to charge IPG
- charging cycle: 2 hours
- dubble beep!
compatiblity remote
SPECTRA NOVI MONTAGE
ohms law
depolarisatie-
restingpotential-
sensory treshold
- -70
- +30
*
MICC
ex: water plants
key messages
coverage
fleexibility
advanved programming
MICC
- precise targetting
Illumina 3d
- model based algorytm (Holsheimer)
- CSF thicknes
- cerebro caudaal position
- mediolateral position
techno
- waveform
- CC
- MICC
- 3D targeting
- fieldshaping
Lead Location and Paresthesia Coverage
- High cervical regions such as C2 can cover regions of the posterior occiput and occasionally the lower jaw.
- C2-C4: neck, shoulder, and upper extremities and the lower face as a result of involvement of the descending nucleus of the trigeminal nerve.
- C5-C6:entire upper extremity including the hand.
- C7-T1 : arms, anterior chest wall, or the axilla.
- Occasionally, placement between C4 and T1 may result in coverage of upper and lower extremities, particularly when using current fractionation.
- Lateral placement at T11-T12 covers the anterior thigh.
- T11-L1 posterior thigh and the foot.
- T8-T10 midline placement of the electrodes in general seems to provide the best coverage for lower extremity pain.
- Low back pain may be difficult to cover because mid-thoracic stimulation can also affect the chest and abdominal wall and stimulation at lower levels preferentially recruits lower extremity fibers; T7-T8 levels are usual targets.
What is SCS
minimal invasive threatment for people suffering from chronic pain
How does SCS work
- the IPG produces electrical signals that via the kathodes are delivered to specifiek areas in the spinal cord. these are blocking the pain by blocking the nerves that deliver the painmessage to the brain.
fundamentels of
- our stimulator
- MDT & Abbot’s stimulator
- cochlear implant technology: vb altijd is kortjakje ziek
- pacemaker technologie.
- cochlear implant, how does it work
Indications
- FBSS
- CRPS
- peripheral neuropathy
Who is involved in pain management
- pain management specialist/paincenters
- anesthiologists
- psychiatrists
- neurologists
- neurosurggions
- ortopedic surgeons
- psychiatrist/psychologists
painladder
- NSAIDS etc
- FT/TENS
- Med, behavioral programs
- corrective surgery
- oral opiods
- neurostimulation/intracecal therapy
- neuroablation
- conservative therapies:
- tens/FT etc
- additional therapies
- prescr/painblock
- advanced
- neyroablation
- pump
- SCS
Spine ligaments
- ligamentum (flavum) holds lamina toether, limits flectie
- ligamentum intraspinalis
- ligamentum supraspinalis
- verschil a alpha/beta en a-delta C vezels
- myelinated, thicker, faster
Indication for use
management of chron. intractable pain of trunck/and or limbs
History of neuromodulation
- 2004-2005 micc multi indipendant current control
- precicion +
- 2013-2015 illumina 3D
- SPECTRA
- NOVI
- 2016: Multiwave
- 2016: full bodywave MRI
- Montage
hardware reset remote
P-botton en centernav for 6sec
MRI system heatcanceling technology
Montage
Avista MRI perc lead
ClickX MRI anchor
Footrint
- NOVI
- SPECTRA
- MONTAGE
- 33cc/11mm
*
- Fit patients need
Right neural target+right waveform= succesfol outcome
illumina 3D trial
- multiwave options
- prism#D
- Burst3D
- Whisper (HR)3D
MECHANISM OF ACTION
- “gate theory” by Melzack and Wall, whereby electrical stimulation of large myelinated Aβ (A beta) fibers in dorsal columns would result in closing the “gate” and obliterating onward central pain signal transmission from peripheral nociceptors (C fibers)
- still not sure
epidural space
The epidural space is circumferential wrapping around the dura. It is bound by:
- The ligamentum flavum posteriorly
- The posterior longitudinal ligament and vertebral bodies anteriorly
- The vertebral pedicles and intervertebral foramina with their penetrating nerve roots form the lateral borders
Lead placement
In the epidural space.
The posterior epidural space, dorsal to the dura, is the target of lead placement for spinal cord stimulation.
Dorsal column
Dorsal columns are the target of electrical stimulation.
They are formed by large-diameter, heavily myelinated, high conductance sensory fibers (Aβ)
The dorsal column’s fibers are somatotopically organized: from medial to lateral: sacral, lumbar, thoracic, and cervical.
Anatomy spinal canal
The epidural space is circumferential wrapping around the dura and is bound by the ligamentum flavum posteriorly, the posterior longitudinal ligament and vertebral bodies anteriorly. Vertebral pedicles and intervertebral foramina with their penetrating nerve roots form the lateral borders.
Current spread
Dorsal CSF (dCSF) fluid thickness along the spinal canal is the most important determinant of current spread.
dCSF thickness is largest at T4-T8.
perception threshold (PT).
the minimum current at which patients perceive paresthesia
As current continues to be increased, patients may experience discomfort at higher amplitudes. The minimum current at which patients perceive discomfort is defined as the discomfort threshold (DT). Typical stimulation is carried out between PT and DT.
Paresthesia coverage and parameters
- depends on the shape of the electrical field and
- recruitment of the nerve fibers.
Fine tuning of the paresthesia field is achieved by modifying the parameters:
- frequency,
- amplitude,
- pulse width.
- Amplitude (A, in mA or milliamperes). Affects the intensity and extent of paresthesiae. Increasing the amplitude expands the area of coverage but could result in uncomfortable stimulation. Typical range: 1.0 to 5 mA.
- Pulse width (PW, in μs or microseconds). PW is the duration of single delivered square stimulation pulse. Higher pulse width may help in recruiting smaller nerve fibers in the dorsal column. Pulse width range 20 to 1000 μs. ????
- Frequency (F in Hz or hertz). Frequency is the number of pulses per second. Frequency affects the quality of paresthesia and may be perceived by patients as “smooth” sensation or more of a “thump” sensation.
The use of higher amplitudes, higher pulse widths, and higher frequencies would obviously increase the energy consumption and tax recharging frequency.
Competitors: name of competitors products
- PC
- RC
- Perc lead
- Surg lead
MDT
- prime advanced
- restore ultra, restore sensor, restore intellis 13cc
- vectris
- specify 5-6-5
ABBOT
- Proclaim™ Elite Recharge-free SCS System
- protege
- DRG Axium
- penta
NEVRO
- Senza 35 cc
STIMWAVE
- freedom
NUVECTRA
- algovita
- Nevro Corporation. (2012). Nevro Physician Implant Manual 10186-Eng Rev. F. Menlo Park, CA.
- Nuvectra. (2014). Algovita™‡ Spinal Cord Stimulation Patient System Manual. Plano, TX.
- De Ridder, D., Vanneste, S., Plazier, M., & Vancamp, T. (2015). Mimicking the brain: Evaluation of St. Jude Medical’s Prodigy Chronic Pain System with Burst Technology. Expert Review of Medical Devices, 12(2), 143–150. http://dx.doi.org/10.1586/17434440.2015.985652
High Impedance
- Wipe dry
- Wipe wet
- Move
- Change OR cable
- Remove lead
Meassure impedance
- Take sure IPG is in the pocket (else it show high impedances-not grounded)
- Connect lead directly to OR cable and measure lead impedance
- attach extension and meassure again
When in Valencia they will try to distract yo by having someone coming in and ask something. While this happens they will do something like taking the IPG out of the pocket or disconnect the lead.
OR testing
- impedance test (150-800 Ohms)
- find CPS
You want to be FAST! finetuning is done afterwards
- Navigator joystick can be used to move quickly
- etroll = 10% steps
- Navigator = 3% steps
- Manual = 1% step
Ask if you can talk with the patient before surgery: explain what you are going to ask.
- Set up CPS (central point of stimulation)
- PW=350 us. F= 60
- increase current to about 4mA to create parasthesia. If you need higher than 8mA to get parasthesia, there is something wrong in the lead system. Ask: What do you feel, Where do you feel it. Increase PW: wider = ? Freq 60-80-100
- scroll fast with the joistick by holding the button down., to get an impression of the span of the leadplacement
- After testing switch stimulation OFF (in case lead is moved) Communicate with phycisian: I found the area, do you want to leave the stimulation on?
Settings:
PW:
- you found pain area but to high amplitude
- found area, but also ventral root stimulation
resolution
- fine, medium, coarse
Focus:
- good coverage, but ventral stimulation or dorsal root stim: first PW, than focus
Lead placement OR procedure
- needle entrance level L2 45 degrees
- proceed to you feel lamina
- lower to 30 degrees to enter epidural space
- LOR
- take out stylet
- enter lead check AP view: check placement lateral view
- impedance check + CPR
- take needle out
- put on click anchor
- remove stylet
- suture to facia
- click the anchor
- tunnel
Percutaneas leads
Linear ST (8) 30-50-70 cm
- span: 31 cm
- spacing: 1 mm (smallest on market)
- perc lead
- 2 curves stylets (one prealoaded)
- straight stylet
- 4 suture sleeves
- insertian needle with trocar stylet
- lead blank
- 2 lead positioning labels
- stearing cap
linear 3-4
- span 52
- spacing 4mm
Linear 3-6
- span 66 cm
- spacing 6mm
Avista MRI (8) 56 -74 cm
- span
- spacing
- perc lead
- 2 curves stylets (one prealoaded)
- stylet ring with curved and straight stylet
- 2 suture sleeves
- 4inn insertian needle
- stearing cap
Infinion CX (16)
Extensions (Kit & lenghts)
KIT
- lead extension
- hex wrench
- tunneling tool
25 cm, 35 cm, 55 cm
Spares:
- Click anchor
- tunneling tool
- Hex wrench
- insertian needle
- port plugs
Click anchor
- 4 cm click anchor
- 4 cm click MRI (avista lead)
Tunneling tool
- 28 + 35
Hex wrench
- 4,3 cm, 7,6 cm
Insertian needle
- 4,5,6 inch
Surgcal leads
Artisan (16) 50 + 70 cm
- 45x8x2 mm
CoverEdge (32) 50 + 70
- 50x9x2 mm
CoverEdgeX
- 67x10x2 mm
What stylet is preloaded
Curved enhanced stylet
What are the contacts made off
Platinum Irradium
MICC 1+2=3
get - overcome - maintain
first ligament to enter
lig supraspinalis
Preciscion plus
*
PROCO
THOMSON
Randomized controlled doubleblindcrossover study
- Optimal sweet spot vary from bottom T8 to top of t 11
- all frequencies alike.
- 1khz used 1/3 energy
Objection: Senza 50% painreleif
- different patient yield, different results
- 24mnths not reported
- single point VAS collection against realtime e-diary *3x a day, 3 pain areas)
objection 20pt
- because studydesign equivalent to more than 100 pt in paralel design study
- 3600 datapoints
objection: boston sponsored.
* 1 person in boston new. He wasn’t involved , just adjusting
objection wash out
- 80% baseline. 2days-2 weeks
Medtronic is also using it (high density) they say as long as the density is equivalent to 10K it doesnæ’t matter. But they don’t have the energysaving advantage
Illumina3D
Algoritm based on a 3D anatomic model of the spinal cord, designed to enable more quick and precise targeting
Illumina 3D portfolio is designed to customize therapy by delivering multiple waveforms to a precise neural Target
70% sustained painreleiv (lumina study)
Lumina study
Multicenter obeservational study of 213 spectra patients on 13 sites. highly signivicant painreleif was maintained in 24 months.
3D technology has proven to provide 70% better low back painreleiv than our previuous generation system
Tagline
- prec spectra
- montage
- novi
- more coverage and flexibility
- more than just MRI
- smallest high capacity cell
Spectra programming finetuning
- how to spread the field
- parasthesia is jumping from left to right
- Focus + Pulswidth
- change course to fine
