Percutaneous cephalocaudal implantation of epidural stimulation electrodes over sacral nerve roots - A technical note on the importance of the lateral approach

Objective: Idiopathic overactive bladder, urgency-frequency syndromes, interstitial cystitis, pudendal neuralgia, vulvodynia, prostadynia, and coccygodynia have been effectively treated with sacral nerve root modulation. This is most commonly performed with placement of electrodes via a transforaminal approach, predominately to the S3 foramen. This approach is limited by a high lead migration rate and the limitations of stimulating a single nerve root. Beginning in the 1990s, some centers began pursuing retrograde percutaneous placement from the lumbar spine, but adoption of this technique was limited by the technical difficulty of the approach. Methods and Materials: We developed a lateral approach to the epidural space for these procedures, which has improved the learning curve and facilitated the application of the retrograde technique. In this technical note, we describe the "laterograde" approach. Results: A focused description of the technique is presented in this technical report. The epidural space is accessed from lateral to medial with the bevel facing up to keep the approach to the "shingled" lumbar laminae shallow. Conclusion: The "laterograde" modification of cephalocaudal approach appears to be technically less difficult method for accomplishing sacral nerve root stimulator electrode placement over multiple roots.