The Retrograde Approach of Surgical Paddle-Lead Placement for Spinal Cord Stimulation

IntroductionStandard anterograde placement of a surgical paddle lead (SPL) for spinal cord stimulation (SCS) can be challenging in patients with scarring from prior spine surgery, instrumentation obstructing the targeted level, or severe stenosis below the targeted level. One potential alternative is retrograde (caudal) insertion by performing laminotomies cephalad to the targeted levels. The literature is limited to only a small number of individual cases describing this technique. In this report, the authors present their experience over the last ten years of the retrograde insertion of SPLs for SCS.Materials and MethodsThis is a retrospective study of 298 consecutive surgical paddle implants performed by a single neurosurgeon from 2013 to 2023 in an academic medical center.ResultsA total of 26 patients underwent retrograde insertion of SPLs. The average patient age was 61 years, with women comprising 58% of cases. Three different manufacturers were used. The retrograde approach was planned before surgery in 96% of cases. The indications for the retrograde approach were 1) scarring from current or prior SCS leads placed from below in the standard anterograde fashion (46%); 2) scarring from prior extensive spine surgery and/or instrumentation (42%); 3) anatomical considerations of scoliosis and stenosis below the targeted levels or the requirement of high cervical stimulation (8%); or 4) intraoperative decision due to extensive scarring during planned anterograde placement (4%). The targeted spinal regions were thoracic (88%) or cervical (12%). There was one case of lead migration that required revision surgery. There were no paddle-lead fractures or deep surgical site infections.ConclusionsThe retrograde insertion of SPLs is a low-risk and feasible procedure that can be performed with minimal risk of lead migration, fracture, or deep surgical site infection. The retrograde strategy can be used in SPL trials or permanent placements.