Techniques for optimizing lead placement during sacral neuromodulation

We present a video describing technical considerations for optimizing lead placement for sacral neuromodulation. A 56-year-old female presented with urinary urgency incontinence refractory to behavioral modification, physical therapy, and oral pharmacotherapy. An Interstim device had been placed 3 years prior by another provider, but the patient did not find it beneficial and had uncomfortable stimulation despite reprogramming. After counseling, she opted for device revision. The S3 foramen is identified using fluoroscopy in anterior-posterior and lateral views; a needle is advanced through the cephalad and medial aspect of the foramen and tested for bellows and toe responses. After the directional guide is placed, the introducer is advanced until it is midway through the bony table. The lead, with a curved stylet, is advanced for repeat testing prior to deployment. It should have a cephalad-to-caudad appearance and curve laterally. Motor responses are tested and optimally should be < 2 V with all electrodes. The lead is then advanced fully, deployed, and retested. The patient’s daytime frequency improved to 6 per day from 11 per day at baseline; her urgency incontinence and the uncomfortable stimulation resolved. Optimization of lead placement for sacral neuromodulation is crucial for improving clinical results.