V2-10: IDENTIFICATION OF THE S3 FORAMEN DURING TRANSFORAMINAL SACRAL NEUROMODULATION LEAD PLACEMENT – A NOVEL “ROLLING PEN” TECHNIQUE

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Introductions and Objectives
Sacral neuromodulation (SNM) is FDA approved for urinary urgency, urinary frequency, urgency urinary incontinence, non-obstructive urinary retention and fecal incontinence. SNM modulates electrical input to the bladder preventing and decreasing over stimulation, thus improving symptoms. The S3 foramen must be localized for lead implantation and the efficacy of implantation depends on the ability to localize S3 reliably and correctly. Localization is accomplished using various strategies, most commonly using a combination of palpation of bony landmarks and fluoroscopy. This paper will serve to introduce a novel “rolling pen” technique that eliminates the use of fluoroscopy for S3 identification. This technique is currently used in clinical practice by the two highest volume implanters in Louisiana.

Methods
The patients were positioned prone and prepped in the usual manner. Instead of using fluoroscopy or palpation to identify bony landmarks to localize the S3 foramen, we balanced a marking pen longitudinally in the midline of the sacrum. The pen was allowed to roll until horizontal equilibrium was established. The fulcrum of the balanced “rolling pen” identified the level of S3. A mark 2 cm proximal and 2 cm lateral to this landmark was made for entry of the finder needle at the level of the skin. We then proceeded with our implantation in the usual manner. The rolling pen technique was used for all patients as our initial strategy to identify the S3 foramen.

Results
228 implantations were performed between 7/2012 and 10/2014 at our 2 tertiary centers. All cases used the rolling pen technique as our initial S3 foramen identification strategy. Adhering to the ALARA principle, fluoroscopy was limited to confirming and adjusting needle and lead placement in the operating room. All office procedures were performed without fluoroscopy.

Conclusions
We conclude that the novel rolling pen technique can be used as yet another method for S3 localization during transforaminal lead placement during SNM implantation. This decreases radiation exposure and likely cost.

Funding: None