Why is the T12-L1 interlaminar space standard for SCS lead entry?

[cameroncarter]

Wouldn’t the L2-3 space provide added safety benefit of being located below the cord?

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[lobelsteve]

Shape of the canal. Look at cross sections from L4-T10. Easier to stay posterior.
Less distance from target placement means less movement-both in the canal and of the patient's spine to wiggle things loose.

 

[painfree23]

Won’t bump into conus either hopefully

 

[SommeRiver]

I find less migration with T11-12 entry, and I prefer to implant there but trial at T12-L1. Distance from electrode 1 to anchor is huge for migration risk in my few yrs of experience.

Entering at L2-3 and you'll find yourself anterior more often.

 

[painfree23]

Shape of the canal. Look at cross sections from L4-T10. Easier to stay posterior.
Less distance from target placement means less movement-both in the canal and of the patient's spine to wiggle things loose.

What do u mean specifically by looking at the cross sections?

 

[bedrock]

I enter at L2-L3 every time unless anatomy/hardware forces me higher. Never an issue going anterior, just need to place the needles midline.

 

[lobelsteve]

What do u mean specifically by looking at the cross sections?

Axial cuts on MRI. Look across the posterior epidural space at T12-L1 vs L2-3. A different shape.

 

[SommeRiver]

I enter at L2-L3 every time unless anatomy/hardware forces me higher. Never an issue going anterior, just need to place the needles midline.

That's a long lead man.

 

[nvrsumr]

I had an attendingg in fellowship who always accessed the epidural space at L2-3 for cervical placement....

 

[bedrock]

That's a long lead man.

takes 10 seconds to advance lead from L2 to T12. Very doable, If anything I'm quicker going through the LF, if I know there is nothing to worry about ventrally other than a wet tap. I'm faster doing it this way than at T12-L1

 

[SommeRiver]

takes 10 seconds to advance lead from L2 to T12. Very doable, If anything I'm quicker going through the LF, if I know there is nothing to worry about ventrally other than a wet tap. I'm faster doing it this way than at T12-L1

I'm saying that more for slack in the line and buckling/migrating.

 

[Orin]

That's a long lead man.

Reminded me of long long man

I’ve been ruined by Long Long Man, the greatest love story ever told by Japanese gum commercials

Looooong, loooooooong maaaaaaaaaaaaan!

www.theverge.com

 

[SommeRiver]

Reminded me of long long man

I’ve been ruined by Long Long Man, the greatest love story ever told by Japanese gum commercials

Looooong, loooooooong maaaaaaaaaaaaan!

www.theverge.com

"Gum infidelity." OMG.

 

[Ferrismonk]

I had an attendingg in fellowship who always accessed the epidural space at L2-3 for cervical placement....

I was taught to thread leads up to cervical from the lumbar area as well, although we usually did T12/L1.

 

[SommeRiver]

That works for what...8 hrs or until the pt looks left twice?

 

[painfree23]

That works for what...8 hrs or until the pt looks left twice?

Where do you enter?

 

[callmeanesthesia]

I was taught to thread leads up to cervical from the lumbar area as well, although we usually did T12/L1.

Did this for a recent implant (upper extremity CRPS). Went in upper thoracic for the trial and it was awful. Very skinny woman, small openings. Even with a coude needle and a couple pillows under her, it took over an hour for the trial. For the implant, I started at T12-L1 and threaded up. Went like a breeze. In her case I started with the needle before making incision since I wasn’t sure how it was going to thread - normally make incision then place the needle. It went so smoothly it took me less than an hour for the implant. She did get tripped by her dog about 2 weeks after implant. The leads only pulled down by about a level and she’s still getting relief. I put her in a soft c-collar for 6 weeks postop. It’s working so well for her though that if it does end up migrating badly I’ll recommend she goes to a surgeon for a paddle.

 

[nvrsumr]

I was taught to thread leads up to cervical from the lumbar area as well, although we usually did T12/L1.

im sure this was mainly for training purposes from my attendings perspective. Get a lot of hands on time manipulating lead starting that low and accessing at L2-3 is a lot safer for everyone when a new fellow is involved.

 

[soxman]

Also added benefit of some limitation of extension between the spinous processes at T12-L1 and above so theoretically can reduce possibility of leads being damaged

 

[ErrantWhatever]

I have a patient with a posterior fusion from L3-S1 followed more recently by T11-L2 lamies. The original op report said T12-L2 so I thought I likely could sneak in for a trial at 10-11. Anyone done a successful trial as high as 9-10? Trying to brainstorm options here.

 

[drmamba]

I have a patient with a posterior fusion from L3-S1 followed more recently by T11-L2 lamies. The original op report said T12-L2 so I thought I likely could sneak in for a trial at 10-11. Anyone done a successful trial as high as 9-10? Trying to brainstorm options here.

I'd consider retrograde at C7-T1/T1-2. T9-10 is possible but may be a narrower and more angulated space.

 

[Centurion38]

I have a patient with a posterior fusion from L3-S1 followed more recently by T11-L2 lamies. The original op report said T12-L2 so I thought I likely could sneak in for a trial at 10-11. Anyone done a successful trial as high as 9-10? Trying to brainstorm options here.

Yes, and I've done T8/9 as well.

Easier to put lead up at T6 and use bottom contacts then go retrograde and use "top" contacts.

Implant lowest I'd probably enter would be T9/10 due to risk for migration

 

[ErrantWhatever]

Appreciate the help! Got them in at 9/10 without much extra hassle.