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Surgical Techniques For Peripheral Nerve Stimulation
Preoperative Considerations
Preoperative work-up for peripheral nerve stimulation (PNS) is similar to that for other advanced implantable procedures such as spinal cord stimulation (SCS). This includes an informed consent discussion with the patient about the different treatment options (including device selection), as well as the long-term consequences of the device itself (i.e., need to charge, use skin electrodes, can/cannot have magnetic resonance imaging [MRI], etc.). From a medical standpoint, a preoperative imaging review, appropriate labs, nasal swab for methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA/MSSA), and management of antiplatelet and/or anticoagulant medications are needed. For PNS, there needs to be consideration of the specific anatomic target, including planning for placement of the system for patient use. This includes ensuring that this patient is psychologically sound, appropriately informed, and functionally capable of using the system or has a support network in place to manage the system on their behalf (see Chapter 7 ).
Prevention of Infectious Complications
Infectious complications are better prevented than managed, and there should be adherence to recommended best practices from the 2017 Neuromodulation Appropriateness Consensus Committee (NACC) Recommendations ( Table 6.1 ). The serious neuromodulator must read and internalize this document and its best practices in conjunction with their local antibiogram and infectious disease best practices. The consequences of an infection to any implanted system are likely to result in loss of therapy and removal of the device, but the anatomic consequences of an infected PNS device will depend on the surrounding structures. Fortunately, the risk of epidural abscess or intraspinal infection is de minimis with most PNS approaches and, in general, infectious risk is low with PNS. Ilfeld et al. performed a retrospective review of 43 PNS studies using open coiled ( n = 21), noncoiled cylindrical ( n = 25), or both ( n = 3) lead types. The primary endpoint was the number of infections per 1,000 indwelling patient days, which was 25 times greater with noncoiled cylindrical leads (1 infection per 30,000 indwelling days) compared with open coiled leads (1 infection per 1200 indwelling days). Coiled leads are theorized to reduce the risk of infection by mitigating the piston effect of a transcutaneous stimulator that would essentially facilitate bacterial ingrowth along the piston track. As such, routine antibiotics are not recommended during trials of neurostimulation, but preoperative weight-based antibiotics and best practices for infection reduction do apply.
Table 6.1
The Neuromodulation Appropriateness Consensus Committee–Recommended Infection Management Practices With Defined Origin of Practice
From Deer TR, Provenzano DA, Hanes M, et al. The Neurostimulation Appropriateness Consensus Committee (NACC) recommendations for infection prevention and management. Neuromodulation . 2017;20(1):31–50.
| Statements | Origin of recommended practice a | Evidence levels | Recommendation strength | Consensus strength |
|---|---|---|---|---|
| Preoperative practices | ||||
| Identify and treat all remote infections for neuromodulation trials and implants | CDC IA | II-2 | B | Strong |
| Optimize glucose control for neuromodulation implants | CDC IB | II-2 | B | Strong |
| Discontinue tobacco use for neuromodulation implants B Strong | CDC IB | II-2 | B | Strong |
| Decolonize MSSA and MSRA carriers through the application of mupirocin nasal ointment and chlorohexidine baths | I | A | Strong | |
| Utilize preoperative antibiotics for neuromodulation trials and implants | CDC IA and NICE | I | A | Strong |
| Utilize preoperative weight-based antibiotic dosing for neuromodulation trials and implants | CDC IA and NICE | I | A | Strong |
| Use appropriate preoperative timing (within 1 hour prior to surgical incision excluding vancomycin) of prophylactic antimicrobial administration for neuromodulation trials and implants | CDC IA, NICE, SCIP | I | A | Strong |
| Remove hair (when required) with electric clippers immediately before the surgical procedure | CDC IA and NICE | I | A | Strong |
| Perform preoperative surgical scrub for a minimum of 2–5 min with an appropriate antiseptic prior to neuromodulation trials and implants | CDC IB and NICE | II-2 | B | Strong |
| Keep nails short and do not wear artificial nails for neuromodulation trials and implants | CDC IB and NICE | II-3 | B | Strong |
| Do not wear hand or arm jewelry for neuromodulation trials or implants | CDC IB and NICE | III | B | Strong |
| Intraoperative practices | ||||
| Wear a surgical mask for neuromodulation trials and implants | CDC IB | II-3 | B | Strong |
| Wear a cap or hood to fully cover hair for neuromodulation trials and implants | CDC IB | II-3 | B | Strong |
| Use sterile gown and gloves for neuromodulation trials and implants | CDC IB | II-3 | B | Strong |
| Double glove | CDC II and NICE | II-1 | B | Strong |
| Utilize chlorhexidine gluconate for preoperative skin antiseptic agent | CDC IB and NICE | I | A | Strong |
| If an incise drape is used, then iodophor-impregnated drape for neuromodulation implants are recommended | NICE | I | A | Strong |
| Use laminar flow and HEPA filters in OR for neuromodulation implants | CDC IB | I | A | Strong |
| Limit procedure room traffic for neuromodulation trials and implants | CDC II and NICE | I | A | Strong |
| Keep procedure room doors closed during neuromodulation trials and implants | CDC IB | II-3 | B | Strong |
| Limit tissue trauma, maintain hemostasis, eradicate dead space, and avoid electrocautery at tissue surface | CDC IB and NICE | III | B | Strong |
| Irrigate with saline through a bulb syringe prior to closure of surgical wound | I | B | Strong | |
| Employ implant strategies to limit operative time | II-2 | B | Strong | |
| Postoperative practices | ||||
| Apply an occlusive dressing following neuromodulation trials and implants for 24–48 hours | CDC IB and NICE | II-2 | B | Strong |
| Do not routinely use topical antimicrobial agents for surgical wounds that are healing by primary intention | NICE | I | B | Strong |
| Understand maximum time criterion for defining a deep surgical site infection of an implantable device (1 year postimplant) | CDC | III | B | Strong |
| Do not continue antibiotics into the postoperative period for neuromodulation trials and implants beyond 24 hours | SCIP | I | A | Strong |
| Educate patient and family on proper incision care, symptoms of SSI, and importance of reporting symptoms | CDC II and NICE | III | B | Strong |
| Wash hands before and after dressing changes | CDC IB | III | B | Strong |
| Use sterile technique for dressing changes | CDC II and NICE | III | B | Moderate |
| When SSI is suspected, prescribe an antibiotic that covers the likely causative organisms. Consider local resistance patterns and culture results in choosing an antibiotic | NICE | III | B | Strong |
CDC, Centers for Disease Control and Prevention; MRSA, methicillin-resistant S. aureus ; MSSA, methicillin-sensitive S. aureus ; NICE, National Institute for Health and Care Excellence; SCS, spinal cord stimulation; SCIP, surgical care improvement project; SSI, surgical site infection.
a The origin of recommended practice defines the supporting surgical guideline.
Anticoagulant and Antiplatelet Agent Management
Management of antiplatelet and anticoagulant medications surrounding PNS episodes of care may be guided by the same principles as that of other regional anesthesia practices. For specific guidelines, PNS trial and implant are considered “intermediate-risk” procedures by the 2018 multisociety guidelines on antiplatelet and anticoagulant medications for interventional pain and spine procedures. These guidelines are a critical reference for the interventional pain physician and should be referenced along with any updates. The principle of shared decision-making between the interventionalist, the patient, and the physician prescribing the blood-thinning agent, applies as does standard of care. In the authors’ practice, it is rare to discontinue antiplatelet or anticoagulant agents for ultrasound- or fluoroscopy-guided PNS trials.
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