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Approaches to Common Peripheral Nerves Bioness StimRouter™ PNS COMMON BEST PRACTICES Stay north – electrodes implanted at target site cephalad/upstream of pain or injury 1st Incision – minimum 5cm from target • 2nd Incision – exit for tunneling = patch placement, 1-2cm more than residual lead Patch placement – visualize and test patch placement before implant • • • • Will patient need/have assistance for patch placement? Will patch placement create friction or be uncomfortable with patient movement? Will patient have to trim hair constantly in area of patch placement? Donning site should be in same dermatome as targeted nerve if possible 02525_Bioness ©2017 COMMON BEST PRACTICES Consider the “triangle”: completing circuit with user patch ‘Tighter’ Circuits = Higher Efficiency CATHODE 1st INCISION CATHODE Good Better Note: triangle not applicable to all nerves. Better Best 02525_Bioness ©2017 Best PERIPHERAL NERVES ARM TRUNK LEG AXILLARY ILIONGUINAL SAPHENOUS SUPRASCAPULAR INTERCOSTAL TIBIAL ULNAR GENITOFEMORAL PERONEAL MEDIAN PUDENDAL LATERAL FEMORAL CUTANEOUS RADIAL ILIOHYPOGASTRIC SURAL CLUNEAL 02525_Bioness ©2017 AXILLARY NERVE Humerus 2nd Incision Target 1st Incision Quadrangular Space Teres Major Teres Minor Triceps 02525_Bioness ©2017 AXILLARY NERVE Pathology Post Stroke Shoulder Pain (PSSP) Relevant Anatomy Quadrangular space (Humerus, Teres Major muscle, Teres Minor muscle, Long head of triceps muscle) Posterior Circumflex artery. Positioning/App roach Patient prone with effected UE slightly abducted. 1st Incision over Posterior Deltoid, superiomedial insertion of lead towards quadrangular space. Lead is “L shaped”, with remainder of lead tunneled across middle of Deltoid muscle. Patch Placement Cathode over receiving electrodes, Anode facing quadrangular space. Patch sits over Posterior Deltoid Muscle. Confirmation of Target Motor response of glenohumeral approximation, slight external rotation from Teres muscle group, and possible mild shoulder retraction. Paresthesia in region of pain. Notes Subluxation will be highly prevalent in these patients. The Post C-flex artery is easily identified lateral to QS when viewing via US. Be sure to follow artery into QS to locate root of Axillary nerve before it bifurcates 02525_Bioness ©2017 SUPRASCAPULAR NERVE Target Supraspinatus 2nd Incision Suprascapular 1st Incision Notch Scapular Spine Infraspinatus 02525_Bioness ©2017 SSN ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 SUPRASCAPULAR NERVE Pathology Adhesive Capsulitis, Hemiplegic shoulder pain. Relevant Anatomy Spine of the Scapula, Infraspinatus fossa, Suprascapular notch. Supraspinatus muscle, Suprascapular artery. Upper Trapezius muscle. Positioning/Appr oach Patient prone. 1st incision near medial border of Scapula, superior to spine of Scapula. Insert lead anteriolaterally towards lateral third of “boat”. Tunnel remainder of the lead towards upper medial shoulder/trapezius. Patch Placement Cathode over receiving electrodes, Anode facing “bow of boat”. Patch should not elicit motor in Upper Trapezius muscle and should not be placed over spine of Scapula. Confirmation of Target Paresthesia in painful region, per patient. Notes Suprascapular vs Axillary. Loop/Angle to ensure appropriate lengths. Consider that the lead spans the scapulothoracic joint. 02525_Bioness ©2017 ULNAR NERVE Target 2nd Incision Ulnar Groove 1st Incision Olecranon Medial Epicondyle 02525_Bioness ©2017 ULNAR NERVE ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 ULNAR NERVE Pathology Trauma and/or Entrapment to nerve with Pain within Ulnar distribution Relevant Anatomy Ulnar Groove/Cubital Tunnel, Olecrenon of Ulna, Medical Epicondyle of Humerus. Positioning/Appr oach Patient can be sidelying, effected limb on top, for a posterior approach. 1st Incision proximal to Ulnar groove, proximodistal insertion of lead towards Ulnar groove. Lead is turned, with remainder of lead tunneled posterior, across the triceps/back of arm. Patch Placement Cathode over receiving electrodes, Anode facing Ulnar groove. Patch sits over back of the arm/triceps. Confirmation of Target Paresthesia to ulnar distribution, medial/ulnar side of forearm, and 5th digit and medial half of 4th digit. Notes Many patients will have undergone nerve transpositions, taking the ulnar nerve out of the ulnar groove, and placing it on the other side of the medical epicondyle. Patients can become uncomfortable in these positions for long periods of time. 02525_Bioness ©2017 SAPHENOUS NERVE Adductor Canal/ Femoral Vessels 2nd Incision Semimebranous Sartorius 1st Incision Target Adductor Longus Vastus Medialis 02525_Bioness ©2017 SAPHENOUS NERVE Pathology Post-surgical trauma, Compression, and /or Viral infections Relevant Anatomy Vastus Medialis muscle, Sartorious muscle, Semimembranosis muscle, Adductor Canal, Adductor Longus muscle, Femoral vessels. Positioning/App roach Patient can be supine with LE externally rotated, exposing medial thigh. Incision is made proximal to target in Adductor canal. Insert lead inferiorly towards target. Remainder of lead is tunneled anteriolaterally towards front of thigh. Patch Placement Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Confirmation of Target Paresthesia to painful distribution, per patient. Notes Ensure patch placement is anterior enough to remain out of friction between legs during ambulation. 02525_Bioness ©2017 ILIONGUINAL NERVE External Obliques Transverse 2nd Incision Abdominis Inguinal Ligament 1st Incision Pubic Bone Primary Target Secondary Target ASIS 02525_Bioness ©2017 ILIONGUINAL NERVE Pathology Trauma and/or Entrapment to nerve post child birth, hernias and hysterectomies. Relevant Anatomy ASIS, Pubic bone, Inguinal Ligament and Canal, External Obliques muscle, Transverse Abdominus muscle. Positioning/Appr oach Primary: Patient supine. 1st incision 1-2cm inferiomedial to ASIS. Lead inserted inferiomedially towards lateral aspect of inguinal canal/ring. Remainder of lead tunneled superior or medial depending on patch placement planning. Alternative: Patient supine. 1st incision over inguinal canal/ring. Lead inserted superiolaterally towards target near ASIS. Remainder of lead tunneled superiorly. Patch Placement Cathode over receiving electrodes, Anode faces inguinal stimulating electrodes. Patch sits on lateral lower abdomen. Cathode over receiving electrodes, Anode faces inguinal stimulating electrodes. Patch sits on lateral lower abdomen. Confirmation of Target Paresthesia in pelvic/genital distribution. Paresthesia in pelvic/genital distribution. Notes Pre-op patch placement will be necessary to ensure comfort and to address any pubic hair, garment issues, or extra adipose or hernias in area. Pre-op stimulation to determine tolerance is recommended in this sensitive region. 02525_Bioness ©2017 TIBIAL NERVE Tibialis Posterior 2nd Incision Flexor Digitorum Longus Flexor Hallucis Longus 1st Incision Target Medial Malleous 02525_Bioness ©2017 TIBIAL NERVE Pathology Tarsal Tunnel Syndrome, crush injuries, trauma. Relevant Anatomy Tibialis posterior muscle, Flexor Digitorum muscle, Tibial Artery, Tibial Nerve, Flexor Hallucis Longus muscle(TDANH), Medial Malleous Target: 3-5 cm superior of medial malleous, 2cm posterior to tibia Positioning/App roach Patient in a supine position and leg externally rotated for access to the medial ankle area or lying on their side. 1st incision will be superior of the target keeping lead in the medial compartment of the leg. Tunneling done in line with medial compartment keeping patch placement in mind. Patch Placement Medial to the lower leg, next to the calf. Ensure patch placement is not stimulating the gastrocnemius or Achilles tendon Confirmation of Target Paresthesia in the toes/painful region. Notes Mixed nerve. May need to loop or shelf lead layout to fit the 15cm lead distal to calf. Use spinal needle (EPIMED) to go thru crural fascia that is in lower leg. 02525_Bioness ©2017 PERONEAL (COMMON FIBULAR) NERVE Popliteal Fossa Fibular Neck 1st Incision Target Evertors 2nd Incision Tibialis Anterior 02525_Bioness ©2017 PERONEAL NERVE US IMAGE (SHORT AND LONG AXIS) 02525_Bioness ©2017 PERONEAL (COMMON FIBULAR) NERVE Pathology Trauma, Compression, Surgical Insult, and Athletic injuries. Relevant Anatomy Fibular neck, Anterior Tibialis muscle, Evertor muscle group, Popliteal fossa. Positioning/App roach Patient can be sidelying/hooklying, effected limb on top. Incision distal to target posterior to fibular neck. Insert lead superiorly towards target. Tunnel the remainder of the lead to a location where patch placement will be comfortable and not elicit motor activation. Patch Placement Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Confirmation of Target Paresthesia to painful distribution, per patient. Notes Possible compression sleeve wear, due to impact and velocity of lower leg swing during gait. Clear presence of fixation hardware. 02525_Bioness ©2017 INTERCOSTAL NERVES 2nd Incision Sternum Spine Ribs Artery Target Intercostal Muscle 1st Incision 02525_Bioness ©2017 ICN ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 INTERCOSTAL NERVES Pathology Post-surgical trauma, Compression, and /or Viral infections Relevant Anatomy Ribs, Intercostal veins and arteries, Sternum and Spinal Column, Intercostal muscles Positioning/Appr oach Patient can be sidelying or prone. Incision is made anteriolateral to target. Insert lead lateral to medial towards spine and towards target. Remainder of lead is tunneled between ribs or to make patch placement convenient. Patch Placement Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Confirmation of Target Paresthesia to painful distribution, per patient. Notes Patch placement planning is critical to prevent location on lateral trunk, which can make the patch prone to being removed with armswing, etc. Remember to stay spinal/central to region of pain. 02525_Bioness ©2017 MEDIAN NERVE Radius 2nd Incision Flexor Pollicis Longus 1st Incision Flexor Digitorum Profundus Target Ulna 02525_Bioness ©2017 MEDIAN NERVE US IMAGE (SHORT AND LONG AXIS) 02525_Bioness ©2017 MEDIAN NERVE Pathology Trauma, and Entrapment within the carpal tunnel (Carpal Tunnel Syndrome). Relevant Anatomy Distal Ulna and Radius. Forearm flexor muscle group and their tendons. Ulnar Artery and Radial Artery. Positioning/App roach Patient supine with UE extended and forearm supinated. 1st incision is proximal to carpal tunnel/target. Insert lead distally towards target. Tunnel remainder of lead proximally up forearm in same line as implanted lead. Patch Placement Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Distal placement preference to minimize motor response in flexor group muscles. Confirmation of Target Paresthesia to painful region, in the median nerve distribution (the palmar surface of 1st, 2nd and 3rd digits, and lateral half of 4th digit). Notes Loop or shelf of lead may be needed to fit the 15cm lead distal to elbow. 02525_Bioness ©2017 LATERAL FEMORAL CUTANEOUS NERVE Asis Inguinal Ligament Target 1st Incision Sartorius 2nd Incision Quads 02525_Bioness ©2017 LFC ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 LATERAL FEMORAL CUTANEOUS NERVE Pathology Meralgia paresthetica (Tight Jean Syndrome), trauma, compression. Relevant Anatomy Inguinal ligament, ASIS, Sartorius muscle, Quadriceps muscle group. Positioning/App roach Patient supine. Target will be directly inferior of the ASIS/inguinal ligament junction, 1st incision should be below target. Tunnel remainder of the lead lateral to the 1st incision towards final patch placement. Patch Placement Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Keep patch anterior lateral. Keep anterior to the IT band. Confirmation of Target Paresthesia to superior, lateral compartment of the thigh (gun holsters) Notes Make sure patch placement is not too lateralized that patient is knocking it when sitting. 02525_Bioness ©2017 PUDENDAL NERVE 2nd Incision Sacrospinous Sciatic 1st Incision Piriformis Target Sacrotuberous 02525_Bioness ©2017 PUDENDAL NERVE Pathology Pudendal neuralgia, entrapment or compression Relevant Anatomy Sciatic nerve, sacrum, piriformis mm, gluteus maximus mm, sacrospinous and sacrotuberous ligaments Positioning/App roach Patient in sidelying position with hips flexed, operative side up. 1st incision superior and medial of sciatic nerve. Lead inserted in an inferiolateral direction towards the target, lateral of the sacrospinous and sacrotuberous crossing, medial to the sciatic nerve and inferior of the piriformis. Patch Placement Lead is tunneled for receiver electrode termination on superior medial aspect of the buttocks Confirmation of Target Paresthesia in the buttocks, external genitals, perineum and/or anus Notes Difficult procedure but successful in the past when done with proper planning 02525_Bioness ©2017 RADIAL NERVE Musculospiral Groove 1st Incision Target Biceps Triceps Lateral Epicondyle 2nd Incision 02525_Bioness ©2017 RADIAL NERVE ULTRASOUND IMAGE (SHORT AXIS) 02525_Bioness ©2017 RADIAL NERVE Pathology Radial Tunnel Syndrome, Injury or fractures of the arm, compression, ischemia Relevant Anatomy Musculo Spiral Groove, Biceps Brachii (Long), Triceps Brachii (Lateral and Medial), Lateral Epicondyle, Olecranon Positioning/App roach Sidelying with effected limb on top, posterior approach. Target is lateral to biceps and proximal to elbow. 1st incision proximal to the elbow, and approximately 7cm inferior of the target. Probe inserted inferior to superior, toward target between the long heads of the triceps and biceps. Patch Placement 2nd incision will be on the back of the arm to keep the receiver in the radial nerve dermatome distribution (C6-C8), and to ensure arm clearance during swing. Cathode proximal to elbow over receiver, anode superior toward target. Confirmation of Target Paresthesia in the radial distribution of the hand (back of the hand) Notes Lead mapping is encouraged pre-op to eliminate the possibility of the lead crossing the elbow joint and for comfort/ease during donning/doffing 02525_Bioness ©2017 GENITOFEMORAL NERVE External Obliques 2nd Incision Transverse Abdominis Inguinal Ligament Pubic Bone Target 1st Incision ASIS 02525_Bioness ©2017 GENITOFEMORAL NERVE Pathology Entrapment, Iatrogenic injury, Chronic Postherniorrhapy Inguinal Pain (CPIP), physcial injury/trauma to the lower abdominal area Relevant Anatomy ASIS, Pubic bone, Inguinal Ligament and Canal, External Obliques muscle, Transverse Abdominus muscle Positioning/App roach Patient supine. 1st incision inferiomedial to ASIS, approximately 7-10cm from the genitals. Lead inserted inferiomedially towards the genitals. Remainder of lead tunneled superiolateral, depending on patch placement planning. Patch Placement Cathode over receiving electrodes, Anode faces genital stimulating electrodes. Patch sits on lateral lower abdomen, out of the beltline. Confirmation of Target Paresthesia to genital distribution Notes Pre-op patch placement will be necessary to ensure comfort and to address any pubic hair, garment issues, or extra adipose tissue or hernias in area. Pre-op stimulation to determine tolerance is recommended in this sensitive region. 02525_Bioness ©2017 ILIOHYPOGASTRIC NERVE External Obliques 2nd Incision Transverse Abdominis Inguinal Ligament 1st Incision Pubic Bone Target ASIS 02525_Bioness ©2017 ILIOHYPOGASTRIC NERVE Pathology Entrapment, Iatrogenic injury, Chronic Postherniorrhapy Inguinal Pain (CPIP), physcial injury/trauma to the lower abdominal area Relevant Anatomy ASIS, Pubic bone, Inguinal Ligament and Canal, External Obliques muscle, Transverse Abdominus muscle Positioning/App roach Patient supine. 1st incision inferiomedial to ASIS, approximately 7-10cm from the target. Lead inserted inferiomedially towards the genitals. Remainder of lead tunneled superiolateral, depending on patch placement planning. Patch Placement In proximity of 2nd incision, Cathode over receiving electrodes, Anode toward genital stimulating electrodes. Patch sits on lateral lower abdomen, out of the beltline Confirmation of Target Paresthesia to Iliohypogastric distribution (lower abdominal area) Notes Being one of a group of nerves in the peripheral lumbar plexus, it is important to confirm with the patient that the paresthesia is distributed in the proper area 02525_Bioness ©2017 SUPERIOR CLUNEAL NERVE Multifidus Lattisimus Dorsi 1st Incision Longissimus Thoracis/Iliocostalis Ilium 2nd Incision Target L3 02525_Bioness ©2017 CLUNEAL NERVE Pathology Chronic lower lumbar back pain; spinal stenosis, osteoarthritis, bulging discs, herniated discs, entrapment, or injury Relevant Anatomy Lumbar Vertebrae (L3), Ilium, Multifidus, Longissimus Thoracis, Iliocostalis, Lattisimus Dorsi Positioning/App roach Patient in a prone position. 1st incision is made 7-10cm superior to target at L3. Insert lead superior to inferior caudad. Remainder of lead is tunneled laterally to make patch placement convenient. Patch Placement In proximity of 2nd incision, Cathode over receiving electrodes, Anode toward spine and stimulating electrodes. Patch sits on lateral lower back, out of the beltline. Confirmation of Target Paresthesia in the Cluneal Nerve distribution (upper buttocks/hip) Notes Lead mapping pre-op is highly recommended in order to arrive at a donning/doffing site that the patient can reach 02525_Bioness ©2017 SURAL NERVE Fibula 2nd Incision Achilles Tendon Soleus Evertors/Perone bros 1st Incision Target Lateral Malleous 02525_Bioness ©2017 SURAL NERVE ULTRASOUND IMAGE 02525_Bioness ©2017 SURAL NERVE Pathology Foot and ankle injuries common in athletes; Jones Fractures. Iatrogenic injury, traction and entrapments Relevant Anatomy Lateral Malleoulus, Fibula, the Peroneus bros; Fibularis Brevis and Fibularis Longus muscles, Achilles tendon and Soleus muscles Positioning/App roach Patient in prone position. 1st incision 7-10cm proximal to target. Lead inserted caudad; superior to inferior, toward target. Remainder of lead is tunneled on lateral lower leg, away from calf/achilles. Patch Placement 2nd incision on lateral aspect to keep user patch in the S1 dermatome. Cathode over receiver, anode directed toward ankle/target. Confirmation of Target Paresthesia in sural distribution of the foot (heel and side) Notes Plan the lead pathway with the intention of keeping the user patch off of the achilles/gastrocnemius to avoid discomfort during stim on. 02525_Bioness ©2017 REFERENCES McRoberts et al, Stimulation of the Peripheral Nervous System for the Painful Extremity, 02525_Bioness ©2017 REFERENCES http://www.ikonet.com/en/health/virtual-humanbody/virtualhumanbody.php WAPMU Lectures 2,3 and 4 Essential Anatomy 02525_Bioness ©2017