Procedure
description
A spinal
cord stimulator may be placed to help with lower extremity,
upper extremity, and low back pain. This pain may be
the result of nerve root scarring, reflex sympathetic dystrophy,
or other causes. Often patients may have had one or
more surgeries on the spine. A paddle of electrodes
is placed on the back surface of the spinal cord, outside
of the dura mater (the tough covering of the cord).
The electrodes are connected to an electrical signal generator,
and electrical impulses are used to stimulate the back of
the cord, in an attempt to mask the pain the patient is experiencing.
A small laminectomy (removal of bone covering the spinal cord)
is performed to allow the surgeon access to the back of the
spinal cord. The procedure to place the trial electrode
paddles may be done with the patient awake or asleep.
If done awake, the surgeon may manipulate the paddles to the
appropriate position in order to cover the region of pain.
There is the possibility of interaction with the patient and
feedback during the procedure (the patient can tell the surgeon
when the paddles are properly positioned so the the patient
"feels good" and gets pain relief). The patient
may go home with th trial electrode in place, and if he/she
finds, over the next several days, that the pain is
improved, then a permanent battery/electrical pulse generator
may be implanted.
During the operation, the patient may be awake or asleep.
If awake, the patient is sedated, and a local anesthetic is
used. The patient is then gently turned to the
prone (face and abdomen down) position, using cushions and
gel rolls to protect and cushion the body. The lower
back or neck (depending on the region of surgery) is cleaned
in a sterile manner, and the surgeon then makes a vertical
(up and down) incision. The surgeon will dissect down
to the spinous processes (bones protruding back from the spine)
and then push the muscle away from the lamina ( the roof of
the spinal canal). Often, an x ray or C arm (fluoroscopy
unit which allows the surgeon real time x-ray monitoring)
will be taken at this point to confirm that the appropriate
level is being operated upon. Next, the surgeon will
remove the lamina in order to allow access to the spinal
canal and cord. This may be done under magnification,
usually using the microscope. The surgeon will
then place the paddle of electrodes. If the patient
is awake, a variety of patterns of stimulation (varying by
paddle distance, location, amplitude and frequency) will be
attempted, until the patient feels the area of pain is being
covered. Patients will often describe this as a good
feeling. Next, the electrode wires will be brought out
through a separate incision. The retractors in the wound
are removed, and the muscle falls back into place. The deep
fascia (firm fibrous tissue of the low back) is sewn closed,
as is the subcutaneous tissue (tissue deep beneath the skin)
and skin. The wound is dressed with a sterile dressing,
and the patient is returned to the recovery room.
If, after several days of the trial stimulator in place, the
patient feels the procedure has been successful at improving
pain, he/she may return for permanent implantation of a battery/electrical
pulse generator. The patient is now taken to the operating
room, put to sleep, and a wire is tunneled from the electrodes,
under the skin, to a location, usually in the lower abdomen
or just below the collar bone in the chest, where a permanent
battery is implanted. This procedure is done under general
anesthesia.
Procedure
Risks
Spinal
cord stimulator placement does have some risk. Even
though the risks of complications are relatively low, there
are risks. These can be broken down into two categories,
1) those related to the operative site, and 2) those related
to the risks of anesthesia.
Risks
related to the operative site:
Surgical
Exposure: The patient is placed in a prone position
(on their abdomen). In this position,
there can be pressure sores, pressure injuries to nerves,
and injury to the eyes as a result of pressure to them.
During surgical dissection, injury to muscle surrounding
the spine can occur.
Spinal
Cord/Nerve Root injuries: If there is any injury to
the spinal cord or nerve roots, the consequences may
involve loss of sensation, increased burning sensation,
paralysis, weakness, loss of bowel, bladder, sexual function.
There may be a spinal fluid leak, which could occur after
a tear of the covering of the spinal cord or nerve roots. If
this did occur, it may be necessary to have the patient
flat in bed for several days after the surgery. Even
if everything goes as well as hoped, there is a risk of
instability of the spine and disc herniation in the future,
requiring additional surgery on the spine.
General
Risks: These include such general difficulties as bleeding,
infection, stroke, paralysis, coma and death. Incisions
in the low back and abdomen generally heal well, but they
could be tender, or may heal in an unpleasant
manner. There is also the possibility that the surgery
may not relieve the symptoms for which the procedure was
performed. The paddle of electrodes, or the conducting
wires and battery, may become infected, requiring
removal of the entire system. If the paddle is scarred
to the dura mater (covering of the cord), surgical removal
may not be possible. The problem for which the surgery was
performed may recur, requiring additional surgery in the
future. When the battery loses its charge, replacement
will be necessary. In addition, although every attempt
is made to protect all areas of the body from pressure on
nerves, skin and bones, injuries to these areas can occur,
particularly with prolonged cases.
Risks
of Anesthesia:
Blood clots in the legs, heart attacks, reaction to the
anesthetic, reaction to blood transfusion, if given.
Bone can bleed quite a bit, and if sufficient amounts of
blood are lost during the surgery, a transfusion may be
performed (chances of this are very low).
Post-operative
care:
There
shall be no bending, twisting, or heavy lifting for several
weeks after surgery. Your doctor will gradually ease
your work restrictions, depending on your progress.
Remember
to keep the wound dry and clean. Notify your surgeon
of any drainage or temperatures greater than 101 Fahrenheit.
We
expect you to do normal activities better because of the
surgery. Some continuuing back pain is not unusual
during the first few days and weeks following surgery.
Hurt does not necessarily mean harm. The following
is a list of suggestions that should help speed your recovery
and give you every possible chance for the best results
from your surgery.
- Immediately
upon discharge, contact our office and set up an appointment
for staple removal if one has not already been made.
- Take
it easy until seen by the physician. This does not
mean bed rest, but athletic activities during this period
are definitely not recommended. Please give your
incision a chance to heal. Avoid bending.
- Lift
nothing heavier than a half gallon of milk until seen
by your doctor.
- Avoid
sitting for periods of time longer than 45 minutes.
It is OK to sit in a lounge chair which is laid back,
for as long as you wish.
- No
jogging or running.
- After
you get home, you may begin walking up to one mile per
day.
- You
may walk up or down steps as often as you like.
Please take them smoothly and slowly.
- No
driving until OK with your physician. Do not ride
further than 50 miles at a time. This applies
during the first month after surgery.
- You
may shower after you go home unless otherwise instructed.
Cover the incision with plastic wrap before the shower
and remove it afterward. Change dressing immediately.
Tub baths are not advisable. You may shower without
covering the incision one week after the staples are out.
Follow instructions concerning care of tape strips, stitches
or staples. Your surgeon or nurse clinician
will explain the techniques used in the closure of your
incision.
- Sexual
activities are permitted.
- If
you notice swelling, redness or opening of the incision,
or if there is any clear fluid draining from it, please
contact your surgeon immediately! If you develop
a fever, stiff neck or chills, contact the office immediately.
Take your temperature at 4:00 PM daily until the clips
are removed. Call in greater than 101 degrees Fahrenheit.
- If
you have any questions, call our office, and for after
hours emergencies, call the medical society.
- Take
your medications prescribed on discharge, as directed.
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