824 - A potential novel strategy for patients to ease discomfort of lead placement of spinal cord stimulation trial in the thoracic region

Case Diagnosis: A potential novel strategy for patients to ease discomfort of lead placement of spinal cord stimulation trial in the thoracic region

Case Description: A 65-year-old male with a history of CRPS due to left foot trauma and concomitant pain contributors (i.e. leg length discrepancy, scoliosis, and parental neglect) presented with chronic back pain radiating to both legs. Despite numerous treatments, his pain persisted. A spinal cord stimulation trial was proposed. Issues were encountered advancing leads in the epidural space, and adjusting the patient's position didn't help. However, having him take a deep breath facilitated the lead placement. After successful thoracic lead placement, the patient experienced significant pain relief and considered permanent SCS placement.

Discussions: Spinal cord stimulation devices emit electrical pulses to the spinal cord, interfering with pain pathways and inducing an overlapping sensation that can alleviate pain perceptions. There are adult patients with challenges like scoliosis that can contribute to limited thoracic epidural space. Two theories potentially explain this phenomenon.



The osteopathic theory of respiratory mechanism suggests the brain and spinal cord’s inherent motility and connection creates a wavelike motion. During inhalation, the spinal cord shrinks and thickens; during exhalation it lengthens and thins. Because the spinal cord flattens (lengthening effect) during inhalation, it increases the epidural space in the spinal canal which eases lead placement.



Biomechanically, deep inhalation expands the rib cage, reducing thoracic spine kyphosis for better lung air intake. Straightening the spine allows a straighter route for the leads to migrate during lead placement leading to less resistance in the epidural space and less lead manipulation/migration.

Conclusions: In patients with chronic back pain and spinal complications, deep inhalation during SCS lead insertion can facilitate SCS lead placement in the thoracic region, reduce procedural pain, and expedite the procedure.