Surgical Technique: Placement of Thoracic Spinal Cord Stimulator Paddle Leads

Introduction Spinal cord stimulation (SCS) is a well‐established treatment for chronic pain. Thoracic laminotomy is highly effective for placing thoracic epidural leads; however, safely placing paddle leads midline at the correct target level can be challenging because of anatomic constraints and the inherent difficulty in counting vertebral body levels in the thoracic spine. Objective The authors outline three basic surgical techniques, focusing on identifying the correct level for placement and creating adequate decompression for safe midline placement. Methods We analyzed 289 patients who underwent SCS placement to characterize our surgical technique. We evaluated the operative setup, preoperative planning, and three basic surgical approaches: a “below‐level” laminotomy, “same‐level” laminotomy, and “second” or two‐level laminotomies at and below the lead's placement level. Results A total of 289 patients (mean age of 64.5 years) underwent thoracic SCS placement. Surgical techniques included below‐level laminotomy (55%), same‐level laminotomy (21%), and second laminotomy (24%). The majority of SCS paddle leads were placed at T8/9 (65%). The operative time from skin incision to closure for below‐level, same‐level, and second laminotomy techniques was 66, 74, and 87 min, respectively. Most patients (86%) were discharged on the same day. Conclusion This study highlights the surgical options for accurate midline placement of thoracic SCS paddle leads: below‐level laminotomy for most cases, same‐level laminotomy for patients with thoracic stenosis, and two‐level laminotomy for challenging placements. We advocate for preoperative imaging and individualized surgical methods based on preoperative canal diameter measurements and intraoperative findings to ensure safe placement.