Approaches to Common Peripheral Nerves

Bioness StimRouter™ PNS

Stay north – electrodes implanted at target site cephalad/upstream of

pain or injury

1st Incision – minimum 5cm from target

• 2nd Incision – exit for tunneling = patch placement, 1-2cm more than residual lead

Patch placement – visualize and test patch placement before implant

• Will patient need/have assistance for patch placement?

• Will patch placement create friction or be uncomfortable with patient movement?

• Will patient have to trim hair constantly in area of patch placement?

• Donning site should be in same dermatome as targeted nerve if possible

COMMON BEST PRACTICES

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Consider the “triangle”: completing circuit with user patch

COMMON BEST PRACTICES

02525_Bioness ©2017Note: triangle not applicable to all nerves.

CATHODE

1st

INCISION

Good Better Best

‘Tighter’ Circuits = Higher Efficiency

Better Best

CATHODE

PERIPHERAL NERVES

ARM TRUNK LEG

AXILLARY ILIONGUINAL SAPHENOUS

SUPRASCAPULAR INTERCOSTAL TIBIAL

ULNAR GENITOFEMORAL PERONEAL

MEDIAN PUDENDAL LATERAL FEMORAL

CUTANEOUS

RADIAL ILIOHYPOGASTRIC SURAL

CLUNEAL

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AXILLARY NERVE

Humerus

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Target

Quadrangular

SpaceTeres Major Teres Minor Triceps

2nd Incision

1st Incision

Pathology Post Stroke Shoulder Pain (PSSP)

Relevant

Anatomy

Quadrangular space (Humerus, Teres Major muscle, Teres Minor muscle, Long head of

triceps muscle) Posterior Circumflex artery.

Positioning/App

roach

Patient prone with effected UE slightly abducted. 1st Incision over Posterior Deltoid,

superiomedial insertion of lead towards quadrangular space. Lead is “L shaped”, with

remainder of lead tunneled across middle of Deltoid muscle.

Patch

Placement

Cathode over receiving electrodes, Anode facing quadrangular space. Patch sits over

Posterior Deltoid Muscle.

Confirmation of

Target

Motor response of glenohumeral approximation, slight external rotation from Teres muscle

group, and possible mild shoulder retraction. Paresthesia in region of pain.

Notes Subluxation will be highly prevalent in these patients. The Post C-flex artery is easily

identified lateral to QS when viewing via US. Be sure to follow artery into QS to locate root

of Axillary nerve before it bifurcates

AXILLARY NERVE

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SUPRASCAPULAR NERVE

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Target

Suprascapular

Notch

Scapular

Spine

Supraspinatus

Infraspinatus

2nd Incision

1st Incision

SSN ULTRASOUND IMAGE (SHORT AXIS)

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SUPRASCAPULAR NERVE

Pathology Adhesive Capsulitis, Hemiplegic shoulder pain.

Relevant

Anatomy

Spine of the Scapula, Infraspinatus fossa, Suprascapular notch. Supraspinatus muscle,

Suprascapular artery. Upper Trapezius muscle.

Positioning/Appr

oach

Patient prone. 1st incision near medial border of Scapula, superior to spine of Scapula. Insert

lead anteriolaterally towards lateral third of “boat”. Tunnel remainder of the lead towards upper

medial shoulder/trapezius.

Patch Placement Cathode over receiving electrodes, Anode facing “bow of boat”. Patch should not elicit motor in

Upper Trapezius muscle and should not be placed over spine of Scapula.

Confirmation of

Target

Paresthesia in painful region, per patient.

Notes Suprascapular vs Axillary. Loop/Angle to ensure appropriate lengths. Consider that the lead

spans the scapulothoracic joint.

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ULNAR NERVE

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Target

Medial Epicondyle

Ulnar Groove

Olecranon

2nd Incision

1st Incision

ULNAR NERVE ULTRASOUND IMAGE (SHORT AXIS)

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ULNAR NERVE

Pathology Trauma and/or Entrapment to nerve with Pain within Ulnar distribution

Relevant

Anatomy

Ulnar Groove/Cubital Tunnel, Olecrenon of Ulna, Medical Epicondyle of Humerus.

Positioning/Appr

oach

Patient can be sidelying, effected limb on top, for a posterior approach. 1st Incision proximal to

Ulnar groove, proximodistal insertion of lead towards Ulnar groove. Lead is turned, with

remainder of lead tunneled posterior, across the triceps/back of arm.

Patch

Placement

Cathode over receiving electrodes, Anode facing Ulnar groove. Patch sits over back of the

arm/triceps.

Confirmation of

Target

Paresthesia to ulnar distribution, medial/ulnar side of forearm, and 5th digit and medial half of

4th digit.

Notes Many patients will have undergone nerve transpositions, taking the ulnar nerve out of the ulnar

groove, and placing it on the other side of the medical epicondyle. Patients can become

uncomfortable in these positions for long periods of time.

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SAPHENOUS NERVE

Vastus Medialis

Adductor Canal/

Femoral Vessels

Semimebranous

Sartorius

Adductor Longus

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Target

2nd Incision

1st Incision

SAPHENOUS NERVE

Pathology Post-surgical trauma, Compression, and /or Viral infections

Relevant

Anatomy

Vastus Medialis muscle, Sartorious muscle, Semimembranosis muscle, Adductor Canal,

Adductor Longus muscle, Femoral vessels.

Positioning/App

roach

Patient can be supine with LE externally rotated, exposing medial thigh. Incision is made

proximal to target in Adductor canal. Insert lead inferiorly towards target. Remainder of

lead is tunneled anteriolaterally towards front of thigh.

Patch

Placement

Cathode over receiving electrodes, Anode facing towards stimulation electrodes.

Confirmation of

Target

Paresthesia to painful distribution, per patient.

Notes Ensure patch placement is anterior enough to remain out of friction between legs during

ambulation.

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Primary Target

Secondary Target

ILIONGUINAL NERVE

ASIS

Inguinal Ligament

Pubic Bone

Transverse

Abdominis

External Obliques

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1st Incision

2nd Incision

ILIONGUINAL NERVE

Pathology Trauma and/or Entrapment to nerve post child birth, hernias and hysterectomies.

Relevant

Anatomy

ASIS, Pubic bone, Inguinal Ligament and Canal, External Obliques muscle, Transverse

Abdominus muscle.

Positioning/Appr

oach

Primary: Patient supine. 1st incision 1-2cm

inferiomedial to ASIS. Lead inserted

inferiomedially towards lateral aspect of

inguinal canal/ring. Remainder of lead

tunneled superior or medial depending on

patch placement planning.

Alternative: Patient supine. 1st incision over

inguinal canal/ring. Lead inserted superiolaterally

towards target near ASIS. Remainder of lead

tunneled superiorly.

Patch

Placement

Cathode over receiving electrodes, Anode

faces inguinal stimulating electrodes.

Patch sits on lateral lower abdomen.

Cathode over receiving electrodes, Anode faces

inguinal stimulating electrodes. Patch sits on

lateral lower abdomen.

Confirmation of

Target

Paresthesia in pelvic/genital distribution. Paresthesia in pelvic/genital distribution.

Notes Pre-op patch placement will be necessary to ensure comfort and to address any pubic hair,

garment issues, or extra adipose or hernias in area. Pre-op stimulation to determine tolerance is

recommended in this sensitive region.

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TIBIAL NERVE

Medial

Malleous

Flexor Hallucis Longus

Flexor Digitorum Longus

Tibialis Posterior

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Target

2nd Incision

1st Incision

TIBIAL NERVE

Pathology Tarsal Tunnel Syndrome, crush injuries, trauma.

Relevant

Anatomy

Tibialis posterior muscle, Flexor Digitorum muscle, Tibial Artery, Tibial Nerve, Flexor

Hallucis Longus muscle(TDANH), Medial Malleous

Target: 3-5 cm superior of medial malleous, 2cm posterior to tibia

Positioning/App

roach

Patient in a supine position and leg externally rotated for access to the medial ankle area or

lying on their side. 1st incision will be superior of the target keeping lead in the medial

compartment of the leg. Tunneling done in line with medial compartment keeping patch

placement in mind.

Patch

Placement

Medial to the lower leg, next to the calf. Ensure patch placement is not stimulating the

gastrocnemius or Achilles tendon

Confirmation of

Target

Paresthesia in the toes/painful region.

Notes Mixed nerve. May need to loop or shelf lead layout to fit the 15cm lead distal to calf. Use

spinal needle (EPIMED) to go thru crural fascia that is in lower leg.

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PERONEAL (COMMON FIBULAR) NERVE

Popliteal

Fossa

Fibular

Neck

Tibialis

Anterior

Evertors

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Target

1st Incision

2nd Incision

PERONEAL NERVE US IMAGE (SHORT AND LONG AXIS)

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PERONEAL (COMMON FIBULAR) NERVE

Pathology Trauma, Compression, Surgical Insult, and Athletic injuries.

Relevant

Anatomy

Fibular neck, Anterior Tibialis muscle, Evertor muscle group, Popliteal fossa.

Positioning/App

roach

Patient can be sidelying/hooklying, effected limb on top. Incision distal to target posterior to

fibular neck. Insert lead superiorly towards target. Tunnel the remainder of the lead to a

location where patch placement will be comfortable and not elicit motor activation.

Patch

Placement

Cathode over receiving electrodes, Anode facing towards stimulation electrodes.

Confirmation of

Target

Paresthesia to painful distribution, per patient.

Notes Possible compression sleeve wear, due to impact and velocity of lower leg swing during

gait. Clear presence of fixation hardware.

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INTERCOSTAL NERVES

Sternum

Spine

Ribs

Artery

Intercostal

Muscle

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Target

2nd Incision

1st Incision

ICN ULTRASOUND IMAGE (SHORT AXIS)

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INTERCOSTAL NERVES

Pathology Post-surgical trauma, Compression, and /or Viral infections

Relevant

Anatomy

Ribs, Intercostal veins and arteries, Sternum and Spinal Column, Intercostal muscles

Positioning/Appr

oach

Patient can be sidelying or prone. Incision is made anteriolateral to target. Insert lead

lateral to medial towards spine and towards target. Remainder of lead is tunneled between

ribs or to make patch placement convenient.

Patch

Placement

Cathode over receiving electrodes, Anode facing towards stimulation electrodes.

Confirmation of

Target

Paresthesia to painful distribution, per patient.

Notes Patch placement planning is critical to prevent location on lateral trunk, which can make

the patch prone to being removed with armswing, etc. Remember to stay spinal/central to

region of pain.

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MEDIAN NERVE

Ulna

Radius

Flexor Digitorum Profundus

Flexor Pollicis Longus

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Target

2nd Incision

1st Incision

MEDIAN NERVE US IMAGE (SHORT AND LONG AXIS)

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MEDIAN NERVE

Pathology Trauma, and Entrapment within the carpal tunnel (Carpal Tunnel Syndrome).

Relevant

Anatomy

Distal Ulna and Radius. Forearm flexor muscle group and their tendons. Ulnar Artery and

Radial Artery.

Positioning/App

roach

Patient supine with UE extended and forearm supinated. 1st incision is proximal to carpal

tunnel/target. Insert lead distally towards target. Tunnel remainder of lead proximally up

forearm in same line as implanted lead.

Patch

Placement

Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Distal

placement preference to minimize motor response in flexor group muscles.

Confirmation of

Target

Paresthesia to painful region, in the median nerve distribution (the palmar surface of 1st, 2nd

and 3rd digits, and lateral half of 4th digit).

Notes Loop or shelf of lead may be needed to fit the 15cm lead distal to elbow.

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LATERAL FEMORAL CUTANEOUS NERVE

Inguinal Ligament

Asis

Sartorius

Quads

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Target 1st Incision

2nd Incision

LFC ULTRASOUND IMAGE (SHORT AXIS)

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LATERAL FEMORAL CUTANEOUS NERVE

Pathology Meralgia paresthetica (Tight Jean Syndrome), trauma, compression.

Relevant

Anatomy

Inguinal ligament, ASIS, Sartorius muscle, Quadriceps muscle group.

Positioning/App

roach

Patient supine. Target will be directly inferior of the ASIS/inguinal ligament junction, 1st

incision should be below target. Tunnel remainder of the lead lateral to the 1st incision

towards final patch placement.

Patch

Placement

Cathode over receiving electrodes, Anode facing towards stimulation electrodes. Keep

patch anterior lateral. Keep anterior to the IT band.

Confirmation of

Target

Paresthesia to superior, lateral compartment of the thigh (gun holsters)

Notes Make sure patch placement is not too lateralized that patient is knocking it when sitting.

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PUDENDAL NERVE

Sacrospinous

Sacrotuberous

Piriformis

Sciatic

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Target

1st Incision

2nd Incision

PUDENDAL NERVE

Pathology Pudendal neuralgia, entrapment or compression

Relevant

Anatomy

Sciatic nerve, sacrum, piriformis mm, gluteus maximus mm, sacrospinous and

sacrotuberous ligaments

Positioning/App

roach

Patient in sidelying position with hips flexed, operative side up. 1st incision superior and

medial of sciatic nerve. Lead inserted in an inferiolateral direction towards the target,

lateral of the sacrospinous and sacrotuberous crossing, medial to the sciatic nerve and

inferior of the piriformis.

Patch

Placement

Lead is tunneled for receiver electrode termination on superior medial aspect of the

buttocks

Confirmation of

Target

Paresthesia in the buttocks, external genitals, perineum and/or anus

Notes Difficult procedure but successful in the past when done with proper planning

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RADIAL NERVE

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Musculospiral Groove

Lateral Epicondyle

Triceps

Biceps

Target

2nd Incision

1st Incision

RADIAL NERVE ULTRASOUND IMAGE (SHORT AXIS)

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Pathology Radial Tunnel Syndrome, Injury or fractures of the arm, compression, ischemia

Relevant

Anatomy

Musculo Spiral Groove, Biceps Brachii (Long), Triceps Brachii (Lateral and Medial), Lateral

Epicondyle, Olecranon

Positioning/App

roach

Sidelying with effected limb on top, posterior approach. Target is lateral to biceps and

proximal to elbow. 1st incision proximal to the elbow, and approximately 7cm inferior of the

target. Probe inserted inferior to superior, toward target between the long heads of the

triceps and biceps.

Patch

Placement

2nd incision will be on the back of the arm to keep the receiver in the radial nerve

dermatome distribution (C6-C8), and to ensure arm clearance during swing. Cathode

proximal to elbow over receiver, anode superior toward target.

Confirmation of

Target

Paresthesia in the radial distribution of the hand (back of the hand)

Notes Lead mapping is encouraged pre-op to eliminate the possibility of the lead crossing the

elbow joint and for comfort/ease during donning/doffing

RADIAL NERVE

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GENITOFEMORAL NERVE

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External Obliques

Transverse

Abdominis

Inguinal Ligament

Pubic Bone

ASIS

Target

2nd Incision

1st Incision

Pathology Entrapment, Iatrogenic injury, Chronic Postherniorrhapy Inguinal Pain (CPIP), physcial

injury/trauma to the lower abdominal area

Relevant

Anatomy

ASIS, Pubic bone, Inguinal Ligament and Canal, External Obliques muscle, Transverse

Abdominus muscle

Positioning/App

roach

Patient supine. 1st incision inferiomedial to ASIS, approximately 7-10cm from the genitals.

Lead inserted inferiomedially towards the genitals. Remainder of lead tunneled

superiolateral, depending on patch placement planning.

Patch

Placement

Cathode over receiving electrodes, Anode faces genital stimulating electrodes. Patch sits

on lateral lower abdomen, out of the beltline.

Confirmation of

Target

Paresthesia to genital distribution

Notes Pre-op patch placement will be necessary to ensure comfort and to address any pubic hair,

garment issues, or extra adipose tissue or hernias in area. Pre-op stimulation to determine

tolerance is recommended in this sensitive region.

GENITOFEMORAL NERVE

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ILIOHYPOGASTRIC NERVE

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External Obliques

Transverse

Abdominis

ASIS

Pubic Bone

Inguinal Ligament

Target

2nd Incision

1st Incision

Pathology Entrapment, Iatrogenic injury, Chronic Postherniorrhapy Inguinal Pain (CPIP), physcial

injury/trauma to the lower abdominal area

Relevant

Anatomy

ASIS, Pubic bone, Inguinal Ligament and Canal, External Obliques muscle, Transverse

Abdominus muscle

Positioning/App

roach

Patient supine. 1st incision inferiomedial to ASIS, approximately 7-10cm from the target.

Lead inserted inferiomedially towards the genitals. Remainder of lead tunneled

superiolateral, depending on patch placement planning.

Patch

Placement

In proximity of 2nd incision, Cathode over receiving electrodes, Anode toward genital

stimulating electrodes. Patch sits on lateral lower abdomen, out of the beltline

Confirmation of

Target

Paresthesia to Iliohypogastric distribution (lower abdominal area)

Notes Being one of a group of nerves in the peripheral lumbar plexus, it is important to confirm

with the patient that the paresthesia is distributed in the proper area

ILIOHYPOGASTRIC NERVE

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SUPERIOR CLUNEAL NERVE

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L3

Target

Ilium

Lattisimus Dorsi

Longissimus

Thoracis/Iliocostalis

Multifidus

1st Incision

2nd Incision

Pathology Chronic lower lumbar back pain; spinal stenosis, osteoarthritis, bulging discs, herniated

discs, entrapment, or injury

Relevant

Anatomy

Lumbar Vertebrae (L3), Ilium, Multifidus, Longissimus Thoracis, Iliocostalis, Lattisimus Dorsi

Positioning/App

roach

Patient in a prone position. 1st incision is made 7-10cm superior to target at L3. Insert lead

superior to inferior caudad. Remainder of lead is tunneled laterally to make patch

placement convenient.

Patch

Placement

In proximity of 2nd incision, Cathode over receiving electrodes, Anode toward spine and

stimulating electrodes. Patch sits on lateral lower back, out of the beltline.

Confirmation of

Target

Paresthesia in the Cluneal Nerve distribution (upper buttocks/hip)

Notes Lead mapping pre-op is highly recommended in order to arrive at a donning/doffing site that

the patient can reach

CLUNEAL NERVE

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SURAL NERVE

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Evertors/Perone bros

Achilles Tendon

Target

Soleus

Fibula

Lateral Malleous

2nd Incision

1st Incision

SURAL NERVE ULTRASOUND IMAGE

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Pathology Foot and ankle injuries common in athletes; Jones Fractures. Iatrogenic injury, traction and

entrapments

Relevant

Anatomy

Lateral Malleoulus, Fibula, the Peroneus bros; Fibularis Brevis and Fibularis Longus

muscles, Achilles tendon and Soleus muscles

Positioning/App

roach

Patient in prone position. 1st incision 7-10cm proximal to target. Lead inserted caudad;

superior to inferior, toward target. Remainder of lead is tunneled on lateral lower leg, away

from calf/achilles.

Patch

Placement

2nd incision on lateral aspect to keep user patch in the S1 dermatome. Cathode over

receiver, anode directed toward ankle/target.

Confirmation of

Target

Paresthesia in sural distribution of the foot (heel and side)

Notes Plan the lead pathway with the intention of keeping the user patch off of the

achilles/gastrocnemius to avoid discomfort during stim on.

SURAL NERVE

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REFERENCES

McRoberts et al, Stimulation of the Peripheral Nervous System for

the Painful Extremity,

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REFERENCES

http://www.ikonet.com/en/health/virtual-human-

body/virtualhumanbody.php

WAPMU Lectures 2,3 and 4

Essential Anatomy

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