C1-C2 sublaminar insertion of paddle leads for the management of chronic painful conditions of the upper extremity

While spinal cord stimulation has commonly been carried out using percutaneous leads, these devices have limitations in cervical implants due to problems with positional stimulation and lead migration. Paddle leads, by virtue of their design, are more stable in their apposition to the neural elements; however, mid and lower cervical insertions have been associated with both acute and subacute spinal cord injuries. These complications are likely related to limitations in canal diameter, as paddle leads occupy a greater volume than percutaneous leads. At C1-C2, the space around the spinal cord is more generous, and thus allows greater room for insertion of leads. We report a series of patients treated with a technique for the implantation of a C1-C2 paddle electrode that capitalizes on this anatomy while still meeting the need for paresthetic overlap in patients with upper extremity pain syndromes. While the technique is not novel, it has not yet been popularized (1). This paper is presented to increase implanters' awareness of the method, its safety and utility. Twenty consecutive patients with neuropathic pain syndromes of the upper extremity were implanted using this technique. Surgical implantation of leads was done under a general anesthetic. An upper cervical incision was used, and after performing minimal laminotomies at C1 and C2, the lead was passed rostro-caudally under direct visualization beneath the lamina. Paresthetic overlap of pain segments was achieved in all but one patient, Pre and postoperative VAS scores were compared to evaluate effectiveness of treatment. Eighteen of 20 patients reported a significant benefit from stimulation, with an average of 63 percent reduction in pain scores. The only complication was a malpositioned lead that required reoperation to adjust placement. No patient suffered neurologic sequelae as a result of this procedure. We have found C1-C2 sublaminar insertions of paddle leads to be a safe and effective way of treating neuropathic pain phenomenon involving the upper extremity. To further assess the relative benefit over percutaneous leads, a prospective trial would be required.