Spinal cord stimulator 

Make sure you know the history of all previous spine surgeries-- especially previous lamis. Look at the imaging. 

MAC anesthesia

Prone with back as flat as possible where you plan to enter. 

- C-arm in AP view, go live and move it around until you see the interlaminar spaces clearly 

- Go in two levels below where you plan to enter -- Put the coude needle on the skin and use xray to localize.  

i.e. if you want to enter T12-L1 interlaminar space, put needle in near pedicle of L2 (red), dock on lamina of L1 (blue), and enter the T12-L1 interlaminar spac (green) 

- needle goes in bevel UP

Ways to determine you are in the epidural space

- using your hands to get the haptic feedback of popping through ligamentum flavum, stop after you feel that. Downside: requires skill and experience. 

- syringe full of air that you periodically push against until you reach loss of resistance. Downside: air does not conduct, if you inject too much into the epidural space you won't be able to trial the electrodes during the case. 

- syringe full of water that you periodically push against until water starts to enter. Downside: if clear fluid comes out of needle, you won't know if its water that you injected epidurally or CSF

- Aim for direct midline placement

- Plug the electrode into the white box then extension leads. Wake up the patient intraop. The reps trial different settings and figure out if the pain area is covered. 

- Pull the coude needle out, tape the leads onto the skin and