Spinal Cord Stimulator Implantation Surgery: Step by Step

Surgical implantation of a spinal cord stimulator is considered if the trial is deemed successful. The procedure is minimally invasive and involves placing the stimulator device under the patient’s skin. If the leads (wires) used in the trial period need to be replaced, additional steps are performed during the surgery to remove the old leads and insert new ones. 

Preparing for a permanent implant procedure involves the same general guidelines followed during the trial procedure.

The implantation surgery takes about 1-2 hours to complete. It is performed as an outpatient procedure in a doctor’s office or outpatient surgical center, and patients return home the same day. 

Patients do not experience pain during the procedure due to the administration of local anesthesia and sedation. However, discomfort at the treatment site is common after surgery, and it is managed with medications.

The steps involved in a permanent implant procedure are outlined below.

Step 1: Removal of the Trial Leads

In a spinal cord stimulation trial, doctors usually use thin, slender leads, which are easy to insert into the spine through a small hollow needle. These are called percutaneous leads and have a cylindrical shape. 

During the permanent implant surgery, the percutaneous trial leads are sometimes replaced with a new set of sterile leads. This step is not always performed and depends on the discretion of the treating physician.

Removing the trial leads involves the following steps:

• Local anesthesia is administered to the target area in the lower back or neck, and sedating medication is given via an intravenous line.
• A 3-inch-long vertical incision is made along the midline of the spine, and guided by fluoroscopy (a type of x-ray), the physician locates the trial leads.
• The leads are carefully extracted through the epidural space.

If the physician chooses to keep the trial leads, an incision is not needed. 

Step 2: Insertion of New Leads and Laminectomy

Some physicians use broader and flatter leads – called paddle leads – for permanent implantation. Paddle leads cover the painful areas more effectively and carry a lower risk of lead migration (accidental displacement of the lead)¹Jeon YH. Spinal cord stimulation in pain management: a review. Korean J Pain. 2012 Jul;25(3):143-50. doi: 10.3344/kjp.2012.25.3.143^,2Kinfe TM, Schu S, Quack FJ, Wille C, Vesper J. Percutaneous implanted paddle lead for spinal cord stimulation: technical considerations and long-term follow-up. Neuromodulation. 2012;15(4):402-407. doi:10.1111/j.1525-1403.2012.00473.x

Paddle leads cannot be inserted through a needle. They require some amount of bone to be cut in order to facilitate proper insertion into the epidural space. If paddle leads are used for permanent implantation, these steps are followed after the trial leads are removed:

• All or a part of the lamina, a small bone covering the back of the spinal cord, is removed near the incision site to create space for the passage of the leads. This procedure is called lumbar laminectomy when performed in the lower back and cervical laminectomy when performed in the neck.

• The paddle leads are guided through this space into the same position as the trial leads.
• Anchoring sutures are placed to secure the leads and prevent displacement.

If the trial leads are replaced with percutaneous leads, the laminectomy procedure is not needed, and the percutaneous leads are inserted into the epidural space using a hollow needle (similar to the trial procedure).

Step 3: Implantation of the Stimulator Device

The stimulator is implanted near the chest for neck pain and in the lower abdomen or above the buttock for lower back pain. 

• To place the stimulator, the skin over the target area is numbed by injecting an anesthetic. 
• A 3-inch-long incision is made, and the device is placed under the skin.  

Patients are asked in advance about the preferred side for implantation of the stimulator. A person who usually sleeps on their right side, for instance, may prefer to have the stimulator on the left side. 

Step 4: Connecting the Leads to the Stimulator and Closing Up

After the stimulator is placed under the skin, the end(s) of the lead(s) that were inserted into the epidural space are connected to the stimulator. These wires are connected beneath the skin and no wires are visible outside the body.

Both incisions from steps 1 and 3 are closed and sutured. A bandage is placed over the sutured incisions. 

Step 5: Post-Surgical Monitoring and Discharge

The sedation is stopped and the patient is moved to an observation room where his or her vital signs are monitored for 30 minutes to an hour. 

When the patient is fully conscious, the handheld controller’s functions are explained by the doctor or nurse, and the patient is discharged to go home.

Using the Stimulator Controller After a Permanent Implant

It is usually advisable wait until the surgery-related swelling decreases, about 2 to 4 hours, before turning on the stimulator. 

Individuals are required to always carry their controller with them. As a precaution, it is helpful to teach a family member or close friend how to operate the controller in case the person is not able to reach it for any reason. Some doctors recommend switching off the stimulator while driving to avoid distractions caused by the stimulation.

Recovery after a Permanent Stimulator Implant

As with any surgery—even a minimally invasive one—the initial recovery following spinal cord stimulator implantation includes a number of restrictions and recommendations. Light activities may be resumed after 2 to 3 weeks, and complete recovery usually takes about 6 weeks. To avoid displacement of the leads, certain types of physical activities, such as twisting, turning, or bending, are limited for the first three months after the surgery. 

Any concerning symptoms must be reported to the treating physician.