Brief Commentary Hypodermis Tension Loop: A New Preventative Measure for Lead Migration in the Morbidly Obese From: Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY, USA Address Correspondence: Sayed E Wahezi, MD Multidisciplinary Pain Program 1250 Waters Place, Tower #2, Bronx, NY 10461. E-mail swahezi@montefiore.org: Disclaimer: There was no external funding in the preparation of this manuscript. Free full manuscript: www.painphysicianjournal.com Sayed E. Wahezi MD, and Jay M. Shah MD www.painphysicianjournal.com Pain Physician 2015; 18:E1123-E1126 • ISSN 2150-1149 W e present a case of a 40-year-old morbidly obese woman, where lead migration was prevented using a novel technique of hypodermal tension loop creation. Objectives We demonstrated that the amount of lumbosacral subcutaneous tissue directly contributes to the likeli- hood of electrode migration during percutaneous trial implantation . The authors describe the first report of a hypodermis tension loop to prevent lead migration in the morbidly obese. Methods A 43-year-old morbidly obese woman (BMI > 60) with chronic, intractable, lower back pain (LBP) s/p L3 to S1 laminectomy/fusion and failed back surgery syn- drome (FBSS) underwent SCS trial implantation (1). On follow-up imaging, 3 vertebral body lead migration was appreciated despite lead anchoring with anchor/ suture, surgical taping, and standard superficial tension loop (2). SCS leads were placed using standard percu- taneous technique and sutured to the skin using the Medtronic® anchor system. Final electrode placement was verified using fluoroscopy and paresthesia pattern prior to discharge. The patient experienced low back and leg paresthesias for 5 hours following the proce- dure, after which lumbar paresthesias decreased and leg/groin increased. Three level lead migration was identified on follow-up examination where superficial anchor-lead complex was unchanged. Repeat stimula- tor trialing was scheduled due to submaximal pain cov- erage during initial trial. Electrode migration without lead-anchor disruption suggested subdermal or epidur- al cause. The authors surmise the focus of the migration occurred within the hypodermis, because it is the most deformable location within the lead tract (1). A repeat stimulator trial was performed one month after the initial procedure using entry, position, and anchoring techniques indicated above, but a hy- podermal tension loop was created to counteract the compressible nature of the subcutaneous tissue (Fig. 1). Two 14-gauge 7-inch standard introductory Medtron- ic® needles were used to enter the T12/L1 epidural space on opposite sides of the corresponding spinous processes. Sixty cm standard Medtronic ® leads were Electrode migration/displacement is reported to be the most common complication of spinal cord stimulator (SCS) implantation, with the literature reporting incidences from 13.2% to 22.6%. There have been numerous publications describing techniques preventing lead migration, with most involving tying leads to skin and fascia for trial and permanent leads, respectively. However, few have addressed how to prevent migration in the case of hypermobile tissue seen in the morbidly obese. We describe the creation of subcutaneous tension loops to prevent lead migration. Key words: Spinal cord stimulator, trial, lead migration, subcutaneous tissue, hypodermis, tension loop, morbidly obese