Spinal Cord Stimulator Implant Procedure Note

Procedure Date: [Date]; Start Time: [Time]; End Time: [Time]

Facility/Location: [Facility or OR/Procedure Room]

Proceduralist: [Name, credentials]

Assistant(s): [Name(s), credentials] (Omit line if none)

Anesthesia Provider: [Name, credentials]; Anesthesia Type: [MAC / general anesthesia / local with sedation]

Device Representative: [Name, company] (Omit line if none)

Pre-Procedure

Preoperative Diagnosis: [Diagnosis describing underlying pain condition and indication for SCS]

Postoperative Diagnosis: [Diagnosis] (State "same as preoperative" if unchanged)

[Indication for permanent implant] (Summarize underlying pain condition, trial outcome including percent pain relief, functional improvements, and trial duration. Include rationale for selected system configuration only if clinically relevant.)

[Informed consent] (State that informed consent was obtained. List only the material risks actually discussed, such as infection, bleeding, neurologic injury, lead migration, device malfunction, need for revision, and dural puncture/CSF leak. Do not list risks that were not discussed.)

[Time-out confirmation] (Document that procedural time-out was performed verifying correct patient, procedure, implant site/side, target spinal levels, equipment availability, and perioperative antibiotic administration including agent, dose, and timing relative to incision.)

Anticoagulant/Antiplatelet Management: [Agent(s) held, last dose timing, resumption plan] (Required for neuraxial access; do not omit)

Allergies and Infection Status: [Relevant allergies including prep agents, antibiotics, adhesives, implant materials; confirmation of no active infection at incision sites]

Positioning and Preparation: [Patient positioning: prone / lateral decubitus / supine], pressure points padded, [skin prep agent], sterile draping performed

Procedure Details

[Anesthesia approach] (Describe anesthesia used and implications for intraoperative testing—awake paresthesia mapping vs. device-based testing under general anesthesia. Document local anesthetic infiltration at planned incision sites.)

[Fluoroscopy] (State fluoroscopy utilized and views obtained. Note if images were saved to PACS. Include total fluoroscopy time if tracked.)

[Lead placement narrative] (Include only if new permanent leads were placed during this procedure; omit entirely if IPG-only with previously placed leads. Describe epidural access including entry level, side, and needle technique. Specify lead type, final lead position on imaging including vertebral levels and midline vs. lateral positioning; for bilateral leads, specify right vs. left. Describe anchoring method including anchor type and fixation to fascia. Document any complications during access such as dural puncture or bleeding.)

[IPG pocket creation] (Document pocket location with side and anatomy, tissue plane, hemostasis technique, and irrigation. If an antimicrobial envelope was used, document here.)

[Tunneling and connections] (Describe tunneling from lead anchor site to IPG pocket. Document lead-to-IPG connection including set screw security, strain relief, and lead coiling. Note if extensions were used.)

[Intraoperative testing] (Document impedance check results—all within expected range or specify abnormalities by contact with corrective actions. Describe stimulation testing approach and outcomes. If initial programming was performed, record active contacts, amplitude, pulse width, and frequency; otherwise reference separate programming note.)

[Wound closure] (Document closure by layers: deep layer closure method/material and skin closure method. State dressing type applied and whether pressure dressing was placed over pocket.)

[Counts and drains] (Include sponge/needle/instrument counts if required by facility policy. Document drains only if placed. Omit if not applicable.)

Implanted Devices

• Implantable Pulse Generator (IPG):

  Manufacturer: [Manufacturer]

  Model/Catalog #: [Model]

  Serial #: [Serial number or "not available"]

  Lot #: [Lot number or "not available"]

  UDI: [UDI or "not available"]

  Implant Location: [Location, e.g., left posterior flank pocket]

• Lead 1: (Include only if implanted)

  Type: [Percutaneous cylindrical / Paddle]

  Manufacturer: [Manufacturer]

  Model/Catalog #: [Model]

  Serial #: [Serial number or "not available"]

  Lot #: [Lot number or "not available"]

  UDI: [UDI or "not available"]

  Implant Location: [Location, e.g., epidural, tip at T8, midline]

• Lead 2: (Include only if implanted)

  Type: [Percutaneous cylindrical / Paddle]

  Manufacturer: [Manufacturer]

  Model/Catalog #: [Model]

  Serial #: [Serial number or "not available"]

  Lot #: [Lot number or "not available"]

  UDI: [UDI or "not available"]

  Implant Location: [Location, e.g., epidural, tip at T8–T9, right of midline]

• Extension(s): (Include only if used)

  Manufacturer: [Manufacturer]

  Model/Catalog #: [Model]

  Serial #: [Serial number or "not available"]

  Lot #: [Lot number or "not available"]

  UDI: [UDI or "not available"]

  Implant Location: [Course from lead anchor site to pocket]

• Anchor(s): (Include only if used)

  Manufacturer: [Manufacturer]

  Model/Catalog #: [Model]

  Lot #: [Lot number or "not available"]

• Antimicrobial Envelope: (Include only if used)

  Manufacturer: [Manufacturer]

  Model/Catalog #: [Model]

  Lot #: [Lot number or "not available"]

(If identifiers were not captured, state "not available" rather than leaving blank. Missing identifiers may be added via dated addendum when obtained.)

Explanted Devices

(Include this section only if trial leads, externalized extensions, or other hardware were removed during this procedure; otherwise omit entirely)

• Component Type: [Trial lead / externalized extension / other]

  Manufacturer: [Manufacturer if known]

  Model: [Model or "not available"]

  Condition on Removal: [Removed intact / fragment retained with rationale and follow-up plan]

Findings and Complications

Findings: [Lead positioning confirmation on imaging, impedance status, adequacy of stimulation coverage]

Estimated Blood Loss: [EBL in mL] (Include if applicable or required by policy)

Complications: [No complications] (If complications occurred, describe event, timing, immediate management, patient status, and follow-up plan)

Post-Procedure Status and Plan

Disposition: [Condition and destination, e.g., transferred to PACU in stable condition / discharged home in stable condition]

Wound Care: [Dressing type, removal timing, incision care instructions]

Activity Restrictions: [Limits on bending, twisting, lifting; driving restrictions; duration of restrictions to reduce lead migration risk]

Medications: [Analgesic regimen; antibiotics if prescribed; anticoagulant/antiplatelet resumption timing]

Follow-Up: [Wound check timing, programming visit, postoperative imaging if planned]

Red-Flag Symptoms Reviewed: [Fever, wound drainage or swelling, severe headache, new neurologic deficits, loss of stimulation, worsening pain] (Document symptoms actually discussed with patient)