Fig. 21.1
Bilateral pelvic stimulation (left) with 3.8-mm quadripolar, selective, cephalocaudal paddles (S1 laminotomy). Distal contacts are anodes at each S2 foramen, and the proximal three contacts are each cathodes. Lateral radiograph (right). Penfield 3 elevating tool assisting with placement of 3.8-mm paddles toward the S2 foramen
For pelvic pain, the electrode is typically rotated off the midline toward the S2 foramen. For coccygodynia it generally remains midline, but stops at the S3 level (more caudal placements frequently produce painful stimulation). Other disorders may require other targeting. When the electrodes appear appropriately positioned on anteroposterior and lateral fluoroscopy, attention is turned to the physiological assessment of electrode position. When the nerve roots are stimulated, SSEP or motor unit action potentials (MUAPs) via EMG serve as the main monitoring tool used to verify accurate position of the electrodes over the roots of interest. The dermatomal distribution of postoperative paresthesia can be predicted from the pattern of intraoperative stimulation activation and is clearly associated with the specific pattern of responses coming from the muscles of the lower extremities. For example, the placement of an S2–3 paddle may result in EMG activation in adductor hallucis muscle (Fig. 21.2), which will correlate with an S2–3 paresthesia. The typical correlation pattern between muscles in the lower extremity and induced postoperative paresthesia is represented in Table 21.1.
Fig. 21.2
Permanent retrograde implantation of sacral root paddle leads. Stimulation is left sided, with the cathode at the second position and the anode at the third (left). In this older tracing (right), the stimulation in the second left contact produces primarily adductor hallucis activation, solely on the left side (a). This correlated with the postoperative paresthesia felt in the S3 perineal region (b)
Table 21.1
Correlation between EMG activation of specific muscles with postoperative-induced paresthesia-sacral paddle(s) S2–3 (laminectomy S1)
EMG Activation, Muscle Group | Induced paresthesia |
---|---|
Gastrocnemius | S1 (undesired) |
Adductor hallucis | S2–3 |
Perianal | S4 |
21.3 Conclusions
With the accumulation of knowledge and experience on intraoperative neuromonitoring with SSEP and EMG techniques, new applications such as intraoperative verification of neuromodulatory electrode placement under general anesthesia have emerged. In this chapter, we have reviewed the use of such techniques to determine effective stimulation of individual sacral roots when placing electrodes in the intraspinal, epidural space from a retrograde or open approach. As an objective method SSEP/EMG monitoring is an attractive alternative to awake methods in open cases owing to the significant muscle mass at the lumbosacral junction, which makes such awake cases quite uncomfortable and relatively impractical. With the increasing prominence of sacral root neuromodulation as an important treatment modality across a number of prevalent conditions, we expect that these techniques will become more widespread over coming years.
References
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