Basic Trial (PNE Trial/Peripheral Nerve Evaluation)

Part 6 - Lead Connections & Impedance Check

1. Connect PNE Grounding Pad and Basic Trial Cable, placing the pad on the skin close to the Tegaderm, not over it, on the patient's side, orientating port numbers 1 and 2 inwards. 2. Connect PNE leads ensuring silver connector pins are completely inside the ports ('1' Teal = Left, '2' Purple = Right). (Note: if only 1 lead is used it MUST be connected to the Teal port for stim to work). 3. Connect Basic Trial Cable to ETS and check impedances (warn patient that they may feel stim when connecting to CP).

Part 7 - Strain Relief and Dressing

1. Create Basic Trial Cable strain relief and cover with medium Tegaderm. 2. Use large Tegaderm to cover connections and cover any exposed leads. Use remaining gauze as required to avoid skin irritation from cables. 3. Secure ETS to patient with Tegaderm or use belt. 4. Disconnect ETS from CP.

Part 2 - Patient Marking

1. Identify spinous process of the lower lumbar vertebrae or the median crest of the sacrum and draw vertical midline. 2. Measure 9cm cephalad from the tip of the coccyx for horizontal crosshair mark. Alternatively, some doctors like to feel for the sacrococcygeal junction and measure 7cm cephalad to the level of S3. (Note: some doctors also like to feel for the sciatic notches, which will confirm the level of S3). 3. Foramen needle entry point is 2cm lateral of midline and 2cm cephalad of the horizontal mark.

Part 4 - Needle Testing

1. Once in foramen, clip j-hook on uninsulated portion of needle (below needle hub and above the 3 dash marks). 2. Deliver test stim to evaluate sensory and/or motor responses to confirm location. (Note: perineal sensation at <2 mA stim with anal bellows occurring at a lower mA than the great toe flexion is preferred but not required for PNE). 3. If motor response is not obtained initially, confirm patient's comfort with increasing stim to try and elicit a motor response. If stim gets uncomfortable and there's no motor response, just sensory response is acceptable, and you can proceed. 4. Turn stim off. 5. Advance need .5cm - 1cm 6. Deliver test stim again to confirm coverage is maintained. (Note: if motor response is obtained initially on step 3, there is no need to increase stim to try to elicit a motor response every time the needle is advanced). 7. Turn stim off 8. Repeat advancing needle up to as much as 2cm if response is maintained in order to locate the deepest location that still elicits a response to reduce impact of potential lead migration. 9. If response is lost, pull back on needle until slight response is obtained again. (Note: it may be necessary to increase mA to 4-5 mA during this process, and that's acceptable). 10. Place a second needle on contralateral side using first needle as guidance (approx. 4cm medial from first needle). 11. Repeat steps 7-12, ensuring correct second needle placement and responses.

Part 1 - Procedure Preparation

1. Place ground pad on patient's calf/foot. 2. Connect ground pad and black j-hook stimulation cable to the CP.

Procedure Parts

1. Procedure Preparation 2. Patient Marking 3. Needle Placement 4. Needle Testing 5. PNE Lead Placement 6. Lead Connections & Impedance Check 7. Strain Relief and Dressing

Part 5 - PNE Lead Placement

1. Remove foramen needle stylet from first needle. 2. Place the lead through the first foramen needle and advance lead until the appropriate marker reaches the needle hub. (Note: 1st marker = short 3.5in needle, 2nd marker = long 5in needle). 3. Clip j-hook on the silver connector pin, which is the uninsulated portion of lead. 4. Deliver test stim to confirm sensory and/or motor responses are maintained. 5. Stabilize lead and carefully withdraw needle from skin (and no further). Lay the foramen needle down on the patient's back and re-test the lead. If response is maintained, continue to withdraw needle and stylet. 6. If response has changed or been lost, with stylet still in lead, the lead can be pulled back slightly to try and regain response. If response has been completely lost, you can carefully withdraw the PNE lead and stylet, along with needle from the patient. Carefully remove the needle from the lead (NOT over the lead to remove stylet, but down the lead), and then you can re-use the PNE lead. You will need to start from the beginning to replace the foramen needle and re-test the needle and lead. 7. Once lead is deployed, re-test lead to ensure original response has been maintained. 8. Repeat steps 1-7 on the contralateral side. 9. Use liquid adhesive on skin around the leads where the Tegaderm will be placed over the leads. 10. Coil leads and place 2x2cm gauze over each, securing leads to skin with small Tegaderm. Ensure sufficient lead is outside of the dressing for connection to the Basic Trial Cable.

Part 3 - Needle Placement

1. Use local anesthetic at foramen needle entry point. 2. Insert foramen needle with bevel up (black marker), at approximately a 60-degree angle. 3. The needle trajectory should be parallel to the midline. (Note: if using x-ray, needle placement should be visualized targeting the superior medial aspect of the S3 foramen).