FormalPara Key Summary Points
Background
  The origins of spinal cord neuromodulation for pain were centered around paddle lead placement requiring extensive surgery and, more often than not, permanent lead placement even after treatment sensitization. Recently, percutaneous cylindrical lead placement has fallen in favor because of the less invasive implantation, flexibility of lead placement, and improved innovative technology
Aims
  The aim of this case is to demonstrate the technique used to remove a previous paddle lead implant and replace it with percutaneous cylindrical leads under direct visualization
Key Findings
  A technical example of successful long-term paddle lead removal with replacement by percutaneous cylindrical leads resulting in improved pain control and decreased opioid use

Case

Traditionally, spinal cord neuromodulation included paddle lead placement; however, recent technological innovations have led to less invasive techniques [1, 2]. There is debate on how to proceed with treatment in patients with previous paddle lead spinal cord stimulation (SCS) who are no longer reporting adequate pain relief, thought to be due to extensive scar tissue that can form over the paddle [3, 4]. Typically, if a paddle lead is no longer effective, a revision surgery is performed to place a new paddle, which may increase the risks of abandonment technology and perioperative complications, increased treatment costs, and potential worsening of the patient’s overall pain level [4,5,6]. This case describes a 58-year-old woman with a history multiple lower back surgeries who was originally implanted with an 8-electrode (4 × 2) paddle lead via a T11 laminectomy spanning the T10–T11 vertebrae. Years later, the patient presented with worsened pain and loss of therapy, with subsequent decision to remove the original paddle lead and place cylindrical leads compatible with her current generator system.

Fluoroscopy was utilized to identify the paddle lead, which was removed intact without complication with careful posterior surgical dissection. Two separate 8-contact cylindrical leads were then placed under direct visualization without needle guidance via the T10–T11 incision site into the epidural space. The original incision was extended cephalad along with further dissection, hemilaminotomies were performed to the right of the T9 and T10 vertebrae, and extensive epidural scar tissue was resected; two leads were then driven to the middle and top of the T8 and T9 vertebrae with double coverage of the T9–T10 disk space for targeted therapy. The leads were then anchored to the T12 spinous process and tunneled to the implantable pulse generator (IPG) site (Figs. 1, 2, 3, 4, 5, 6, 7). The IPG was replaced with the latest technology and implanted into the original pocket. Six weeks later, the patient reported excellent relief of her back pain and had successfully weaned off all opioid therapy.

Fig. 1
figure 1

Successful removal of paddle lead with insertion of first cylindrical lead

Fig. 2
figure 2

Two cylindrical leads inserted through surgical site

Fig. 3
figure 3

Notable bowing of second cylindrical lead secondary to extensive epidural scar tissue

Fig. 4
figure 4

Final lead position with lead anchors in place

Fig. 5
figure 5

Final posterior placement of cylindrical leads

Fig. 6
figure 6

Removal of paddle lead with placement of cylindrical leads under direct visualization into the epidural space

Fig. 7
figure 7

Magnified image of leads passing through epidural space after hemilaminotomy was performed under direct visualization