The placement of a paddle electrode requires additional surgical skills as compared with the percutaneous placement of stimulation leads performed preferably by a functional neurosurgeon. Anesthetic choices are general anesthesia with or without neuromonitoring or awake placement with local anesthesia supported with iv medication or spinal anesthesia, which still allow appropriate paresthesia mapping.
The surgical paddle lead is implanted preferably through unilateral approach and interlaminotomy with preservation of the supraspinous ligament. Via undercutting technique under microscopic magnification, the epidural space can be widened by removing a small rim of the lamina and eventually present epidural scar tissue. In some patients the epidural canal is small due to bony spurs and hypertrophy of the ligamentum flavum and an extended approach is necessary like removing the interspinous ligament and carrying out a bilateral interlaminotomy. In severe cases even it may be necessary to extend the approach to the level above, especially in patients with extensive scar tissue in the epidural space that may develop when previously the patient did already underwent spinal cord stimulation. A full laminectomy is almost never necessary.
In general patients are mobilized the day after surgery. A thorac spine X-ray is performed to assure the correct position of the lead postoperatively.
intraoperative X rays of some surgical paddle leads