Sacral neuromodulation: sacral anatomy and optimal lead placement
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IUJ VIDEO
Sacral neuromodulation: sacral anatomy and optimal lead placement Whitney K. Hendrickson 1
&
Cindy L. Amundsen 1
Received: 10 August 2020 / Accepted: 11 November 2020 # The International Urogynecological Association 2020
Abstract Introduction and hyposthesis To develop an instructional video that correlates cadaveric anatomy with fluoroscopic images to assist in conceptualization of optimal placement of the foramen needle and lead to complete an efficient and successful sacral neuromodulation (SNM) procedure. Methods A SNM procedure was performed and recorded on a fresh female cadaver. Fluoroscopic images were obtained during the procedure to highlight the bony relationships to the S3 foramen and nerve. Dissection of the anterior and posterior sacrum was completed to highlight the tract of the S3 nerve. Techniques to increase the likelihood of optimal foramen needle and thus lead placement were highlighted. Conclusions This video demonstrates how achieving optimal foramen needle placement within the S3 foramen is key to optimal lead placement. Understanding the relationship of the bony landmarks on fluoroscopy to the S3 nerve and foramen, seen in the cadaveric dissections, are important in understanding how to achieve optimal lead placement. This optimization should lead to decreased operating room time, maximization of programming options, and decreased amplitude requirements. Keywords Sacral neuromodulation . Sacral neurostimulation . Optimal lead placement . Overactive bladder . Urgency incontinence . Fecal incontinence . Urinary retention
Aim of the video/introduction Pelvic floor disorders including overactive bladder (OAB), urgency incontinence (UUI), fecal incontinence (FI) and non-obstructive urinary retention (NOR) are debilitating and costly conditions [1]. Sacral neuromodulation (SNM) is approved by the FDA and is commonly used as a third-line agent for the treatment of each of these disorders [1]. Short- and long-term success rates are impressive. Approximately 50– 80% have a sustained > 50% reduction in UUI or FI episodes at 1–2 years [2, 3]. On average, 70% of those with NOR have a > 50% reduction in catheterized volume, and 69% are able to stop catheterizing after 6 months [1]. The International Continence Society (ICS) best practice statement on sacral neuromodulation recommends achieving intraoperative optimal lead placement, defined as an
* Whitney K. Hendrickson [email protected] 1
Division of Urogynecology, Department of Obstetrics and Gynecology, Duke University Medical Center, 5324 McFarland Drive, Unit 310, Durham, NC 27707, USA
appropriate motor and/or sensory response(s) at a stimulus amplitude of < 2 V at all four electrodes [1]. This is because optimal lead placement increases success rates and decreases costs and adverse events [1, 4, 5]. To achieve optimal lead placement, understanding how to elicit an appropriate motor and/or sensory response with the foramen needle is crucial. To do this, the needle and thus lead must be located in the correct foramen and closely
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