Spinal Cord Stimulator Trial Procedure Note

Date/Time: [Procedure start date/time]

Location: [Facility type and specific location]

Primary Operator: [Name and credentials]

Assistants: [Names and roles] (Omit if none)

Anesthesia Provider: [Name and role] (Omit if local-only without separate provider)

Device Representative: [Company and name] (Omit if not present)

Procedure Performed: Percutaneous epidural spinal cord stimulator trial lead placement, [number] leads

Pre-procedure Diagnosis: [Diagnosis]

Post-procedure Diagnosis: [Diagnosis]

Indication and Patient Selection

[Brief description of chronic pain condition and pain distribution targeted]

• Coverage prerequisites: Chronic intractable pain refractory to conservative therapies; psychological screening [completed on date / unknown]; this is a temporary SCS trial to evaluate candidacy for permanent implantation.
• Functional goals for trial period: [2–4 measurable goals achievable within days, such as walking tolerance, sleep continuity, reduction in breakthrough medication use]

Informed Consent

Informed consent was obtained [prior to sedation / before procedure]. Risks discussed included bleeding, infection, dural puncture, neurologic injury, lead migration, and inadequate relief. Alternatives and opportunity for questions were provided. Consent type: [written / verbal]; documentation location: [location].

Pre-Procedure Safety Assessment

• Allergies: [Allergies including antibiotics, prep agents, contrast, latex, and reaction type / NKDA]
• Anticoagulation/Antiplatelet Status: [Agent, indication, last dose date/time, confirmation of appropriate hold period per protocol] (Required field—if unknown, enter "[REQUIRED—NOT YET DOCUMENTED]" and document rationale to proceed or postpone)
• Infection Screening: [Negative for fever, skin infection at site, systemic infection / positive findings and actions taken]
• Baseline Neurologic Status: [Pre-existing motor and sensory deficits with distribution / no focal deficits]
• Baseline Pain Score: [NRS 0–10 or other validated scale]
• Baseline Function Anchor: [Patient-specific activity metric or validated instrument score]

Time-Out

Time-out performed confirming correct patient, procedure, site/approach, and equipment readiness.

Anesthesia and Monitoring

• Anesthesia type: [Local only / moderate sedation / MAC / general] (If deeper than local, include rationale)
• Monitoring: [Pulse oximetry / NIBP / ECG / capnography] at [interval]
• Medications administered: [Drug, dose, route, time for each medication including sedatives and local anesthetic]
• Patient feedback during mapping: [Yes, able to provide feedback / no / not applicable—paresthesia-free system]
• Intraoperative neurophysiologic monitoring: [Modality and key findings / not used]

Sterility and Antibiotic Prophylaxis

• Skin prep: [Agent and concentration]
• Barrier precautions: Sterile gown, sterile gloves, mask, cap, full body drape; sterile field maintained throughout.
• Antibiotic prophylaxis: [Drug, dose, route, administration time] (Must be prior to needle insertion. If not given, document rationale. If unknown, enter "[REQUIRED—NOT YET DOCUMENTED]")

Positioning and Imaging

• Positioning: [Prone / lateral / other] with [padding and pressure point protection]
• Imaging guidance: Fluoroscopy with AP and lateral views; images saved to PACS: [yes / no]
• Planned epidural entry: [Interspace level] via [right / left / midline] approach (Include rationale if non-standard)

Procedure Narrative

Epidural access: [Needle type and gauge], loss-of-resistance with [air / saline], epidural entry at [interspace level], confirmation by [contrast epidurogram / fluoroscopic signs / other]. [Difficulties encountered and management, or "No difficulties encountered."]

Lead Details

(Document the following for each lead placed. Do not infer position beyond what imaging confirmed.)

• Lead [number]: [Manufacturer/model]; Lot/Serial/UDI: [identifier]; Entry: [right / left] at [interspace level]; Final tip level: [vertebral level]; Contact span: [if documented]; Position: [midline / right lateral / left lateral]; AP and lateral fluoroscopic views confirm dorsal epidural placement.

Stimulation Testing

• System paradigm: [Paresthesia-based / paresthesia-free]
• Mapping results: [Coverage of painful area with qualitative description and percentage, tolerability, positional effects] (For paresthesia-free systems: "Paresthesia mapping not performed; [programs] provided")

Lead Securing and Closure

• Securing method: [Anchor type, suture details, strain relief loop: yes / no]
• External connection: [Cable routing and securing method]; external pulse generator connected and functioning: [yes / no]
• Dressing: [Occlusive dressing type and reinforcement method]
• Final fluoroscopic image after stylet removal: [Obtained / not obtained]

Estimated Blood Loss: [Volume / minimal]

Complications: [None / description of event, timing, management, and current status]

Patient Condition at End of Procedure: [Hemodynamically stable, neurologic status, tolerance of procedure]

Intraoperative Programming

Programming performed [on-table / in recovery] by [clinician and/or device representative]. Stimulation paradigm: [paresthesia-based / paresthesia-free]. [Summary of initial programming outcomes including patient-reported coverage or programs provided.] Reference programming report for detailed parameters. Immediate post-procedure analgesia is not interpreted as trial success due to local anesthetic and procedural confounders.

Post-Procedure Assessment

• Recovery and vitals: [Stable / interventions required]
• Neurologic exam: [Motor and sensory findings compared to baseline; new deficits: yes / no]
• Pain status: [Brief report] (Acknowledge confounding by local anesthetic)
• Disposition: [Discharged home with escort / observation]; warning signs reviewed with patient (fever, drainage, new neurologic symptoms, severe headache)

Trial Evaluation Plan

• Trial duration: Start: [date]; Planned lead removal: [date] (Not to exceed 10 days)
• Measurement plan: Daily pain scores using [same validated scale as baseline]; functional activity tracking for [stated goals]; stimulation usage notes; medication use tracking
• Follow-up: Phone contacts: [dates]; Clinic visit: [date]; Lead removal: [date]
• Success criteria: Pain improvement ≥[50%] on validated scale; functional improvement [tied to stated goals]; medication use [stable or decreased]; patient willingness to proceed to permanent implant (If alternative criteria used, document adjudication process)

(For any required field that is missing—device identifiers, final lead tip levels, antibiotic prophylaxis details, or anticoagulation status—enter "[REQUIRED—NOT YET DOCUMENTED]" rather than omitting.)