Download Approaches to Common Peripheral Nerves

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
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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
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Best
PERIPHERAL NERVES
ARM
TRUNK
LEG
AXILLARY
ILIONGUINAL
SAPHENOUS
SUPRASCAPULAR
INTERCOSTAL
TIBIAL
ULNAR
GENITOFEMORAL
PERONEAL
MEDIAN
PUDENDAL
LATERAL FEMORAL
CUTANEOUS
RADIAL
ILIOHYPOGASTRIC
SURAL
CLUNEAL
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AXILLARY NERVE
Humerus
2nd Incision
Target
1st Incision
Quadrangular
Space
Teres Major Teres Minor
Triceps
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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
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SUPRASCAPULAR NERVE
Target
Supraspinatus
2nd Incision
Suprascapular
1st Incision
Notch
Scapular
Spine
Infraspinatus
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SSN ULTRASOUND IMAGE (SHORT AXIS)
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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.
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ULNAR NERVE
Target
2nd Incision
Ulnar Groove
1st Incision
Olecranon
Medial Epicondyle
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ULNAR NERVE ULTRASOUND IMAGE (SHORT AXIS)
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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.
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SAPHENOUS NERVE
Adductor Canal/
Femoral Vessels
2nd Incision
Semimebranous
Sartorius
1st Incision
Target
Adductor Longus
Vastus Medialis
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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.
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ILIONGUINAL NERVE
External Obliques
Transverse
2nd Incision
Abdominis
Inguinal Ligament
1st Incision
Pubic Bone
Primary Target
Secondary Target
ASIS
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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.
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TIBIAL NERVE
Tibialis Posterior
2nd Incision
Flexor Digitorum Longus
Flexor Hallucis Longus
1st Incision
Target
Medial
Malleous
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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.
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PERONEAL (COMMON FIBULAR) NERVE
Popliteal
Fossa
Fibular
Neck
1st Incision
Target
Evertors
2nd Incision
Tibialis
Anterior
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PERONEAL NERVE US IMAGE (SHORT AND LONG AXIS)
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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.
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INTERCOSTAL NERVES
2nd Incision
Sternum
Spine
Ribs
Artery
Target
Intercostal
Muscle
1st Incision
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ICN ULTRASOUND IMAGE (SHORT AXIS)
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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.
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MEDIAN NERVE
Radius
2nd Incision
Flexor Pollicis Longus
1st Incision
Flexor Digitorum Profundus
Target
Ulna
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MEDIAN NERVE US IMAGE (SHORT AND LONG AXIS)
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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.
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LATERAL FEMORAL CUTANEOUS NERVE
Asis
Inguinal Ligament
Target
1st Incision
Sartorius
2nd Incision
Quads
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LFC ULTRASOUND IMAGE (SHORT AXIS)
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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.
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PUDENDAL NERVE
2nd Incision
Sacrospinous
Sciatic
1st Incision
Piriformis
Target
Sacrotuberous
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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
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RADIAL NERVE
Musculospiral Groove
1st Incision
Target
Biceps
Triceps
Lateral Epicondyle
2nd Incision
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RADIAL NERVE ULTRASOUND IMAGE (SHORT AXIS)
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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
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GENITOFEMORAL NERVE
External Obliques
2nd Incision
Transverse
Abdominis
Inguinal Ligament
Pubic Bone
Target
1st Incision
ASIS
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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.
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ILIOHYPOGASTRIC NERVE
External Obliques
2nd Incision
Transverse
Abdominis
Inguinal Ligament
1st Incision
Pubic Bone
Target
ASIS
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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
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SUPERIOR CLUNEAL NERVE
Multifidus
Lattisimus Dorsi
1st Incision
Longissimus
Thoracis/Iliocostalis
Ilium
2nd Incision
Target
L3
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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
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SURAL NERVE
Fibula
2nd Incision
Achilles Tendon
Soleus
Evertors/Perone bros
1st Incision
Target
Lateral Malleous
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SURAL NERVE ULTRASOUND IMAGE
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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.
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REFERENCES
McRoberts et al, Stimulation of the Peripheral Nervous System for
the Painful Extremity,
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REFERENCES
http://www.ikonet.com/en/health/virtual-humanbody/virtualhumanbody.php
WAPMU Lectures 2,3 and 4
Essential Anatomy
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