InterStim

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PROCEDURE PERFORMED:
1) Complete InterStim system removal of subcutaneous implanted right sacral nerve stimulator and removal of right implanted tined quadripolar lead.

2) Complete InterStim system implantation of tined quadripolar lead electrodes into Left Foramen S3 and placement of new IPG (Implantable pulse generator).

3) Fluoroscopic guidance for needle placement.

4) Subcutaneous implantation of sacral nerve neurostimulator and electronic analysis and complex programming.

DESCRIPTION OF THE PROCEDURE:

The patient was taken to the main operating theater and placed in supine position. Sequential compression devices applied to both lower extremities. Pt underwent general anesthesia.
The patient received intravenous IV Clindamycin prior to the surgical procedure.
An operative time-out was performed identifying the patient, the procedure to be performed and the surgeon.
Pt was placed in prone position, carefully padding all pressure points.
Surgical site was sterilely prepped and draped in a standard manner.

We interrogated the IPG first and had a detailed evaluation by Medtronic rep and a discussion with tech support specialist.

An incision was made on the previous IPG site about 4 cm long, the pocket was entered using blunt dissection and the neurostimulator was exposed. We disconnected the lead from the IPG and reconnected it.
We again ran the Interstim interrogation and found the lead to have same impedance on all electrodes.
After discussing with the Medtronic rep and a discussion with tech support specialist, a decision was made to change the entire Interstim system.

The neurostimulator was removed from the patient by cutting the electrode. Then the electrode is removed by using gentle traction pulling midline to lateral on the lead. Another 2 cm long incision was made over the sacral area where the wire was entering the sacral foramen. Once the electrode was removed, verification that the lead was intact was made. The wounds were irrigated with antibiotic irrigation.

We performed fluoroscopy to mark anatomical landmarks including the midline, ischial spine and S3 foramen. We then used a spinal needle to intubate the foramen on the right and left sides. We were able to successfully intubate both the S3 foramen, and this was tested to verify the exact location of S3 foramen. On lead testing, we got an excellent motor response on right at 5-6 volts and and left at 2 volts. There was a better response on the L side compared to the R side at lower voltage.
At this point, a decision was made to proceed with lead placement on the L side.

We used a bidirectional needle through the spinal needle under fluoroscopy control.
Following this, we used the lead introducer sheath over the bidirectional needle.
Then we placed tined leads under fluoroscopy control using the curved styllet, making sure that lead #3 is just at the level of anterior plate on lateral film. We tested all 4 electrodes and we got excellent motor response on all the 4 electrodes. The leads were deployed by releasing the lead itroducer sheath.
We elected to create a new pocket for the IPG on the left side. An incision was made about 4 cm long on left buttock area. Deep dissection was performed up to the gluteus muscle. With the help of a tunneling device, we tunnelled the wire in to the pocket. At this point, connections were made with tined lead wire and the IPG. Hemostasis was achieved at the generator site and the wound was closed with 3-0 polysorb and 4-0 Biosyn for the skin.
The skin puncture marks were closed with the help of 4-0 Biosyn. Steri-Strips and sterile dressings were applied.
The programming head was placed over the implanted neurostimulator. The impedance was verified to insure adequate lead placement. After implantation of the neurostimulator was completed, then complex programming of the neurostimulator was performed based on impedance values. Final electrode selections were set.


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