Monitoring

SSEPs, checking for "blocking." Check signals before starting the case. 

Imaging

Take a preop AP plain film to record the location of the trial. 

Positioning

Regular OR table with jelly rolls oriented up and down. 

Prone in pins. Wrap the arms. Moossy likes the single pin to be just above the right pinna. Double pins go in the axial plane, at the superior temporal line. 

Contrary to classic posterior cervical positioning, the patient's back is left bare of the sheet to accommodate the battery pocket. Tape goes low. 

Tape the shoulders back as depicted. 

Prep

1. Take down the bandage. Use adhesive remover to remove all residual adhesive.

2. Cut all securing sutures on the releasing loop of the stimulator trial before prep. Tape the stimulator trial to the patient's shoulder, in a position where it can be easily pulled by anesthesia at the right time. 
3. Classic Moossy prep with betadine, Chloraprep, betadine.
4. Before the final Chloraprep, cut the vertical mattress interrupted sutures on the prior posterior cervical incision.
5. Do the final Chloraprep. 

Draping

Standard draping with blue towels and Ioban. Do not include the trial catheter and exit site in the draped field. 

Steps

1. Make the battery pocket
2. Reopen the cervical incision by spreading with a pair of large scissors.
3. There should be a single Maxon suture holding the fascia closed. Cut this. 
4. Cut the silk sutures securing the leads to the fascia.
5. Cut the leads themselves from within the cervical incision. Do not remove the trial stimulator from the epidural space yet. 
6. Ask anesthesia to pull the cut leads and trial from under the drape. 
7. Tunnel from the flank incision to the cervical incision.
8. Pass the new stimulator leads from the cervical incision to the flank incision and remove the tunneling sheath. 
9. Connect the generator to the leads and place in the pocket. 
10. Remove the stimulator trial paddle and immediately replace it with the permanent stimulator paddle. 
11. Take an AP shot with the c arm to verify that the position of the permanent paddle matches the position of the trial. 
12. Have neurophys run their signals again to make sure the lead is functioning correctly. 
13. Secure each lead separately to the fascia with 2-0 silk suture. Secure both leads together to the fascia. Allow more most of the excess catheter to remain in the cervical incision to act as a releasing loop. 
14. Irrigate and close in standard Moossy fashion. ​