Thank you very much, and I'm going to let Dr. Flasky tell you about the next therapies now. How do I end this? Now it's showing up on your screen. Okay. All right, thank you. All right, well, good morning, everyone, and thanks for coming to the course. Jen and I have actually been running this course together now for probably about five years, and it's interesting to see how sometimes we cycle through the anatomy of this course, and this is going to be the first year we're doing it without cadavers, so it's going to be mostly didactics and then using some simulators as well. The one thing I want to build up before I even get up into my talk is, for those who don't know, spinal cord stimulation and neuromodulation is exploding in this country. If you look back five years ago, neuromodulation was a $1 billion healthcare expenditure. You fast forward five years, we're now $5 billion, and they estimate by 2020, so next year we will be $20 billion. That's how fast we are growing. We just released a quarterly report that basically said they believe spinal cord stim will surpass spinal surgery as for virgin backs. Highmark, one of the biggest insurance carriers in the world, basically just announced they're running a study, multi-center randomized controlled trial, directly comparing spinal cord stim versus fusion as your primary treatment, so virgin back. And the reason being is the numbers that we are getting now, the technology, the innovation has grown so rapidly, and we're producing level one evidence, studies that just have amazing results. And to put it, there's a great quote in the Morgan Stanley quarterly report. They averaged out all studies that they could find. Given this is not a scientific render to this, but they basically said, if you had a first-time spinal surgery, your chance of success was 50% to 70% and a 30% chance of chronic pain. Your chance of success with a minimally invasive safe procedure like spinal cord stim was greater than 80%. So they said, why would you ever start with a spinal surgery? That was the quarterly report from Morgan Stanley. So I like to just build with that because I like people to know I'm very passionate about this space for those who know me, and I want people to realize why this is growing. And I think, you know, if you're not on the train, you're kind of getting left behind. So I always say it's time to jump on board. So for the next 20 minutes, I get to talk to you about the implantation, some of the techniques involved for spinal cord stimulation. So I kind of try to narrow it down because right now in the United States, about 30% of the implants are going in by neurosurgeons, and about 70% are going in by interventional pain physicians. The majority of the implants that go in by neurosurgeons are done by an open surgical technique or paddles, but there are still about 20% to 25% of neurosurgeons who do only percutaneous techniques. So I'm going to kind of dive into both. These are my disclosures. I work for a lot of companies. I guess technically have no loyalty to any of them because I like to just advance the field, product development, education. I do a lot of society engagement. So start off with this idea of a trial. One of the things I always tell my patients is there's no other surgery that you get to try out first before you would ever have it, and that's what we do with spinal cord stimulation. I do think trials are getting kind of antiquated. And when I say that, I mean the reason we always did trials was you wanted to gauge how well the patient did and to see if they liked the stimulation. The idea was some patients didn't tolerate prior seizures. They didn't tolerate that tingling sensation. Most of the waveforms on the market, which Dr. Roslin is going to talk about next, are paresthesia-free. Patients don't feel anything. And we have success rates that are approaching over 80%. So the question is, is it worth actually even trialing patients anymore? There's going to be a big study that's launched actually looking at this, going direct to implant versus trialing. If you think about it, when we do vagal nerve stimulation, we don't trial the patients. When we do other forms of surgery, neurosurgery, we don't trial the patients. And there's not many things we can quote that have the success rates we do. But essentially right now in the United States, the one thing insurance companies love to see is a trial and that you can document in your paperwork that they have greater than 50% pain relief. I would tell you in true practice, sometimes you have patients who have 80% pain relief and they're just not happy. But you can give 30% pain relief, 40% pain relief to somebody, but they went to the mall with their grandkids, so they're super happy. So a lot of it, I base it in my practice on functional outcomes as well. What happened during the week of the trial? Did you increase your activity? Did you do things that you normally couldn't do? Did this make you happy? But ultimately, insurance companies love the 50% rule. So what makes a spinal cord stimulator successful? So if you're going to put these devices in, these are some of the pointers I thought of that would be very important to make sure you're going to succeed with the stimulator. The first thing is paresthesia mapping or physiologically mapping. Even though the majority of the waveforms on the market now are paresthesia-free, every single one of them except for one still has to be physiologically mapped to make sure that you're on the midline of the spinal cord. And one of the things that always drives me nuts is I run a very high-volume spinal cord stim practice. I create a massive referral networking area, so I see everything that happens with spinal cord stim. And one of the things that drives me nuts is when a neurosurgeon puts in a paddle electrode and it's sitting all the way on the side of the canal. When you put in a pedicle screw, you don't get it in the vicinity of the pedicle. You know, when you're doing an MVD, you don't get in the vicinity of the nerve, right? You put it right where it's supposed to go. And paddle electrodes or electrodes are meant to be on the midline of the spinal cord. So I always say as neurosurgeons, we have to take our time, no matter how long it takes, to get the electrode in where it's supposed to go. If you take pride in these cases, the patients do better. And I always tell people, you know, we have a lot of level one evidence studies that are building. For 50 years, spinal cord stim relied on two studies. Now we have over 12 level one evidence studies, either run by industry or physician initiated. If you want to match the data that comes from these big studies, part of it is actually taking the time to do it right. The other one is the preciseness of stimulation. You want to confine the stimulation to the target area. This is where things like DRG stimulation comes into place because now you can target it to dermatomal coverage for focal pain patterns. Rechargeable is non-rechargeable. In the 90s and the early 2000s, everything in spinal cord stim became about rechargeable generators. Like the companies thought it would take it by storm and that was going to always be the future. What's funny is now is we're starting to see a flip back. Patients don't want to maintain their systems. They don't want to recharge their batteries. Technology is changing so rapidly now that most patients are not going to make it nine years with the battery before they ask for the new technology to be implanted. So there's a big push now for non-rechargeable generators. In addition, sometimes older patients, they don't understand technology. I always remember having an 80-year-old lady with peripheral neuropathy who was in excruciating pain, could not walk. I gave her a spinal cord stimulator. She had 100% pain relief. But the rep had to go to her house every week for the first three months to charge a device. And eventually the rep said, I can't do this anymore. So the patient just let the therapy die because they refused to learn how to charge a device. So we've got to remember with technology and the way things change, certain things are not for everybody. So it's good to have these options. And then the sustainability of the therapy. This is really important because insurance companies now, with the growth that we're experiencing in neuromodulation, are looking at everything. They don't want to see explants. They don't want to see failures. They don't want to see patients moving on to having a ton of other procedures done. So we as physicians have to take a lot of pride in doing this well and keeping the patients engaged. And if that means bringing them back every three months for programming adjustments, then we should do it. Everything should be about sustaining this therapy. And there's a lot of research now looking at how to get these therapies to continue moving. One of those things now is for the last three years, companies have developed adapters. So what that means is one company's battery can hook up to another company's electrode. So now let's say somebody has the therapy in for five years and they were doing great. They come back and say it's no longer working for me. If that happened, like if you had high blood pressure and you came in to the doctor and said the blood pressure medication is no longer working, does your doctor say you failed medication? No, they try a different class. They try a different dose. So the idea now is you can try a different class of neuromodulation. So you can leave the electrode in the spine, not have to put them through a spinal procedure, and just change the battery to a different company's technology with all the different waveforms on the market and give them a shot of recapturing them. This is the idea of sustainability of therapy. So here we go. The ongoing debate that's always existed, percutaneous versus paddle. Actually, I know the neurosurgery faculty in the room very well. And about half of us start directly with a paddle and about half of us start with a percutaneous lead. So this is a very hot debate that has not gone away for probably 20 years. The question is, though, do neurosurgeons really need to learn these techniques? I will tell you, I had the privilege in my training working with somebody who did a lot of spinal cord stimulation and introduced me to it. I came out of training knowing I wanted to be a functional neurosurgeon who did spinal cord stimulation. Not everyone has that luxury. If you don't have an attending in your training that does this, you don't get a good exposure to it. I also were never taught as a neurosurgeon how to do epidural access. The only time I ever stuck a needle in somebody's spine in training was to get CSF with a lumbar puncture. So the thought of not getting fluid back was kind of a foreign concept to me. And I always say the first time I ever did a percutaneous implant, I was petrified. I was truly scared that I was going to hurt the patient. But yet, who actually understands the anatomy better than a neurosurgeon who sees it every single day? And the truth of the matter is one day I just booked a patient for a percutaneous implant. And I booked it for literally three times the amount I normally would book for a spinal cord stim. And I just did it really slow, and everything went perfect. So the point is that we may not be trained on this in our training, but we can do this, and we can be very good at doing it. And what we have to break is that cycle, whereas neurosurgeons or even orthopedic spine surgeons, we don't see it in our training. And we have a very poor understanding of it. When you actually get to see the data, I mean, literally, level one evidence, multicenter, randomized control trials, that have greater than 80% success rates with what is considered a minimally invasive outpatient procedure. I mean, this is important for us to know. So here's just some of the pros and cons of percutaneous versus paddle. I'm one of the people who favor putting in paddles right from the get-go. I think that they're more stable. I think they last longer. I think they have more programming capabilities. They're highly more energy efficient because the signal is directly right to the spinal cord. But there are benefits to percutaneous as well. It's much less surgical trauma because it's all put in through a needle, less setup time. It used to be that some people thought the complication rates were lower with percutaneous versus paddle. The truth of the matter is now there's several studies that come out that show that they're actually equal. And I can tell you as a neurosurgeon who does both, I can do both in the same amount of time. So it doesn't matter if I do an open surgical and do a small laminectomy or I do a percutaneous approach, they take me about the same amount of time regardless. So I think a lot of these things for the benefits, the pros and cons, are kind of starting to merge together. It used to be that you only put in paddle electrodes because you didn't want them to migrate. So you only did a paddle electrode when a percutaneously migrated two times. The truth of the matter is now a lot of physicians are getting so good at anchoring and positioning percutaneously that they don't migrate either. So you have to do it for other reasons. What I think about is the energy efficiency of sending a signal in all directions. The programming capabilities of having four or five columns of contacts across a paddle, to me, tells me that for years to come I'm not going to run out of the ability to program this patient. So a percutaneous technique, it's all done through a 2E needle. You usually get access with a shallow approach, less than 45 degrees, your paraspinal, and you get epidural access. Some people will introduce a guide wire. Some people do loss of resistance technique either with air or saline. I do loss of air when I do it. So my technique is I actually hit the spinous process, follow the needle onto the lamina, and then just bounce off the lamina until I get that first pop. And that's the epidural space for me. For the most part, I only start shooting fluoro once I actually get to that lamina and I'm about to pop in. A lot of people just do fluoro right from the get-go, but that's just my technique for doing it. And then what you do is once you know you're in the epidural space, you can start introducing the electrode up. I always recommend shooting both an AP and lateral, especially when you're first getting started, because the one thing you don't want to do is go dorsal, and the one thing you don't want to mistake yourself for doing is going in the sac and actually putting this in intrathecal. So that's very unlikely to happen. It's very rare to happen, but I highly recommend the first cases that you're doing. You always flip AP and lateral and make sure you're in the dorsal epidural space. For paddle leads, essentially these go in through a laminectomy. There's different approaches for doing this. You can either do a midline approach with a small laminectomy. This is the approach I like to do. So I take down the interspinous ligament. I take down a little bit of the spinous process. I usually just do it, honestly, in one bite with a ronjour. I just line my ronjour up right in the interspinous ligament. I take one big bite, which takes all the ligament out. It takes a little bit of the inferior portion of the spinous process out. At that point, you're now looking at ligamentum flavum, and I drill just a small trough, midline, and kind of go out, usually about half a centimeter on each side. So that way your opening is about a centimeter. Some people prefer to do hemi-laminectomies. They just come in on one side. They keep the interspinous ligament intact, and then they put the paddle in from an angle. I would say in my hands, that takes a little bit longer to do. It's a little bit more of a fuss factor, and we are talking about the thoracic spine, so there is no concern of loss of stability by taking down one level or even two or three levels of interspinous ligament. So I prefer just to do the midline approach. You're going to advance the paddle electrode superior. That's the most common way to do this as opposed to retrograde. I always say plan your procedure so that the base of your paddle sits right at the laminectomy site. And the reason I say that is one of the things that's, and this is one of the cons of putting in a paddle electrode in an open approach is it's going to be a lot harder to revise that. Percutaneously, it just pulls right out. You don't have to open anything up. It's just going to slip right out of the tissue. That's not going to happen with a paddle because we're doing open surgery. So one of my recommendations is plan out your surgery. So whatever level you want to put the paddle at, plan out the surgery so that the base of the paddle sits right at the opening of your laminectomy site. So if you ever have to come back in and revise it, you can literally trace the wire right to the epidural space and you won't hit dura because the paddle is protecting you from doing it. If you shove it up past your laminectomy opening, now you can't get to it. So now you follow the wire directly into the epidural space and you're going to have to drill off bone to get to the base of the paddle. So that's why I always plan it so that the base is right there at the opening. We're going to go through some of the advanced techniques too. I put a lot of thought process into even how I place the batteries. I've written actually a paper on this with Ashwini Charan from Jefferson. We designed the spot to put it in the buttock area. It's in the upper lateral buttock. What I always tell physicians is just put some thought process into it. Don't put it in the midline of their lower back because every time they lay down they're gonna lay on it. Don't put it in the medial aspect of the bottom of the butt, which is also a favorite place for people, and they sit on it every time they need to go to sit in a chair. So we chose this location because, I mean, these are three landmarks to use to find it, but it ends up being that the battery sits right below the belt line and it's just enough off the side that you can't roll on it so you can still sleep on your side, but it's not enough to the back that you actually lay on it or sit on it. So it's kind of in this perfect location where it's not gonna bother the patient because one of the things we see is about in a lot of the papers that come out about 5% of the people talk about battery site pain or battery site discomfort, and that's part of the reason is I think a lot of physicians don't put a lot of thought process into where they put the battery. The other favorite spot is is the flank. People love to put it in the flank. The problem is every time you sit down it jabs you in the bottom of the rib if you don't position it properly. So just put a little thought into where you put the battery. So these are some of the advanced techniques that I'll go through, kind of try to avoid some of the complications or the most common complications that can happen. So for years the most common complication we had in spinal cord stimulation, whether it was percutaneous or paddle, was always lead migration. Part of it was we didn't really have really good anchors for physicians putting in paddles especially to didn't know exactly how to get it on the midline, how to secure it well down. And percutaneous leads too were not being anchored properly so they were migrating a lot. These numbers have dramatically decreased on a lot of the follow-up studies that have been done and the level one evidence studies and multi-center trials that have been done that follow patients for two years. This rate has dramatically decreased but the reason it's dramatically decreased is because we've done a lot of research and techniques to get this number down. So I'm going to go through some of them. The first one is regardless of whether you put in a percutaneous lead or a paddle electrode, the lead wire should be paraspinal. Do not put the lead wire in between the spinous processes directly in the midline. One is you create an environment where the spinous processes are going to keep banging on the electrode every time you flex and extend your back. The companies, the engineers, work on actually flexing and extending these leads over and over again in machines. The average human being will flex and extend the lead 10,000 times a day. So if you have a bone, if it's coming in between two bones and you're flexing extending that bone onto it every single day 10,000 times, you're eventually going to fracture it or you're going to pull it out. The other thing is that you have the soft tissue and the muscle but then the hardest part is the fascia that lays on top of the muscle. Do not create a kink point right where the electrode comes out of the fascia because that's the stiffest point. So every time you flex and extend your back the fascia wants a kink, the electrode. So if you do a soft angle, shallow angle coming out paraspinal, that helps. If you use anchors, don't put the anchor, which shows here in the picture, right on top of the fascia so that the lead just comes out right into the fascia because now you have a stiff anchor holding it in place and then the lead does a 90-degree turn through the fascia and it just keeps kinking. And all it's going to do is eventually break the lead or pull it out. So my recommendation is if you use anchors, put the anchor across the fascia because now the anchor is taking the stress of the stiff fascia around it. The other one, it actually matters where you put the battery. So the two most common locations are usually either in the abdomen or the buttocks. The problem with putting it in the abdomen means you either have to position the patient lateral, which if you're doing a laminectomy that's not fun but I've done it in my training, or you're gonna have to put the electrode in and then undrape, flip them over, re-drape, and then do an abdomen incision. So for that, because of that, most physicians prefer to do it in the buttock area, which is where I prefer. There's a great paper by Henderson that showed that if you place, so if you put a thoracic lead in, run the wire down to the buttock area, you need nine centimeters of lead to accommodate for flexing and extending your back. So if you tighten everything down really tight and the wires just hold snug in between that battery and your spine, what's gonna happen when you start flexing and extending your back? You put all the pressure on either pulling it out of the battery or pulling it out of the spine. So what I do is I actually create, which in the next few slides, I create a strain relief loop right where I put the electrode in, and then what I do is I loosely coil the extra wire behind the battery and then put it in the pocket. And basically you have a whole coil there that can now flex and extend and open and close every time you bend your back. If you place it in the abdomen, one of the benefits of the abdomen is it's only side rotation, so you don't actually have to accommodate for nine centimeters. I think Henderson showed it was something like three or four centimeters. But it does make a difference where you put the battery, how much lead you need. What I always suggest is just put a lot of extra lead in the battery pocket, coil behind the battery. And then this is a paper also from Henderson looking at strain relief loops. These are all the things that physicians realized over the last 10 to 15 years how to stop this problem with electrode migration and fractures. So this is a, you place a strain relief loop where it comes out of the spine. So if you think about it, you have a loop where every time you flex and extend your back, the electrode slides through the loop. So there's no actually tension point on it. This is what I prefer to do. Some people will do this with an anchor. I happen to do this just without an anchor, but you can do either way. This basically shows that by creating this loop, you take a lot of the tension off the electrode. Now this is one of the last ways I guess we consider advanced techniques. For those who know me, I'm very passionate about placing spinal cord stimulators asleep. If you're gonna put them in asleep, you can't lose your safety aspect and you can't lose the ability that you need to test where the electrode is. There is a difference between anatomic midline and physiological midline. This was a great paper by Holstheimer that showed 40% of the time the spinal cord is not in the midline. So if you put an electrode in under x-ray and don't test it and it looks great on x-ray, 40% of the time you're not going to get the right coverage. Now what's interesting is it was a great paper by somebody in the room, Dr. Early, who looked at if you place a five column paddle electrode, so imagine that that's spanning across the entire spinal cord and place it just on x-ray without testing, 20% of the time you will not be able to get the proper coverage. So imagine that. So if you're placing a percutaneous lead, that's one of those five columns, and you place it on anatomic midline, the chance that you're gonna be wrong is pretty high. So I either say the patient has to be awake and you have to test where it is, or you can use neuromonitoring to physiologically map out the spinal cord. I prefer neuromonitoring because I always joke as a, I talk to a lot of pain physicians, so my going joke is I'm a neurosurgeon, I don't like to talk to my patients, so we put them all asleep. This is some of the protocols that were published. There's been several papers now that have come out looking at awake versus asleep with neuromonitoring. Dr. Roslyn and I are doing a point counterpoint on Tuesday during the pain section of whether you should do it awake or asleep. The, what I can tell you is, first is for awake placement, it is the standard of care, especially with pain physicians. There's not been a single study that has ever looked at placing a spinal cord stimulator awake, not one, but it's accepted as a standard of care. There are now numerous studies that are out looking at asleep with neuromonitoring, whether you do percutaneous or permanent implants. The last one just came out last year, I was the PI multi-center trial directly comparing the two. Asleep with neuromonitoring actually blew it out of the water. In every scenario it was 25% faster, it had a fifth of the adverse events, and it was almost twice as accurate. So there's a lot of benefits to doing it. The NAC guidelines, which are our guidelines for neuromodulation that get redone every two years, in 2016 when they released the guidelines they said there's only two ways to place spinal cord stimulators, either completely awake or asleep with neuromonitoring, and there shouldn't be anything in between. So I tell this to both pain physicians and neurosurgeons, you know, as a neurosurgeon you would never operate on the thoracic spinal cord without neuromonitoring. Why would you do a laminectomy and shove a paddle on someone's spinal cord without some type of aspect of safety, which is neuromonitoring. A lot of neurosurgeons like to put these in without doing anything, just completely asleep. And you know what, 99.9% of the time, because you know you're very skilled, you're gonna be completely fine. The problem is that 0.01% of the time when something happens you're not gonna know. And so I always recommend that. The other thing is when you put it in asleep, you know, that safety aspect is one. The other just as important aspect is making sure that the lead is in the right location. If you know it's gonna be off 40% of the time just by putting it on x-ray, I mean, you don't want that to happen, right? We don't, just like I kind of made the joke before, you don't put a pedicle screw around the pedicle. No, you put it precisely where it prolongs. So I think mapping out the spinal cord with it is very useful. Yes, exactly. I didn't want to get too much into it because it's the aspect of time. No, that's exactly, but I'm very passionate about neuromoderns. I love talking about it. But basically we use EMG responses to do it. And you can, based on the EMG responses of left and right and their amplitudes, you can tell how far left or how far right you are. And the testing is literally within seconds. You can put it in and test in 10 seconds. Yes. Yeah, so the wire goes off the field. Normally your rep would just hook up to test impedances, but they can send the signal through and then the neuromodern technician watches the EMGs. I don't know if everyone heard what she said. So there's two ways you can actually use neuromodern. One is you can use EMG, where when you turn on the stimulation, you get EMG responses. The idea is it's what they call the H reflex. If you touch a hot stove, you pull your hand back. It's because the sensory input was so big you get a spinal cord reflex. That happens before your brain even knows. So you can get a muscle to contract. That's what we do to test the lead. So you turn up the stimulation high enough that, say, your quad contracts. If your quadriceps is contracting, we know we're generating paresthesias in the front of your thigh. So that's what you can use. The other way, what Jen was saying, we can use what's called SSEP collision, so sensory collision. So you're always monitoring sensory as a safety aspect for the dorsal column. When you turn on stimulation, your sensory signal should drop out because it's blocking. That's how stimulation works with paresthesias. You overload the sensory nerve so they're no longer sensing. So what you do is when you turn up the stimulation, you see does the left side or the right side or both drop out with sensory. It's another quick way to do it. The problem with it is it's not as accurate as EMG. With EMG, I can tell you I'm 60% on the left, 40% on the right. With SSEP, I can just tell you, you know, I can see the signal dropping out on the left, I can see it dropping out on the right, but I don't know exactly where I am. But if you're only getting signals dropping out on the right, you know you're not in the midline because you're not getting the left. So it's a myotomal marker of dermatome. That's exactly it. We can talk if anybody wants to. I have all the papers I can send you, PDFs, a lot of the studies I publish too. I'm very passionate about it. We can absolutely talk about it afterward. These are the last few slides. So what's going to make you successful putting in percutaneous leads? One is you want to be below T12, L1, so you want to be below the conus. It's very helpful usually because the one thing you don't want to do is put pressure on the spinal cord when you're putting this in and it's creating that angle, so that's usually very helpful. What you want to do is actually you want to pump up the abdomen to take away their lumbar lordosis, almost try to make their spine straight because it opens up the space between the lamina. You want to come in paraspinal with a very shallow approach, so minimize your angle as much as you can. With paddle placement, try to keep a small laminectomy. One of the ways I said was design it so that the base of your paddle sits right at your laminectomy site. Don't do wide laminectomies and get out into the facet joints because when you put the paddle in, you end up putting pressure on the nerve roots and stuff, so you can end up getting abdominal pain that may be transient, but you don't want to go too wide with your laminectomy. You can do things like strain relief loops, go for a midline placement. I always tell people it doesn't matter if it takes me 30 minutes in the OR or 3 hours, that patient will not leave the operating room until that electrode is sitting directly on the midline. The last thing you want to do is, this was treated as a last resort therapy for so many years and we're not given proper training during our residency on it and we have really bad understanding of how it works. If you go in there and you don't try your best to put this thing on the midline and you put it lateral, it's going to fail, so it's that self-fulfilling cycle of oh, well, spinal cord stim doesn't work. No, it works if you take the time to do it right. You're going to give your patient the best chance of success if you take the time to put it on the midline. Sometimes it's easy, it goes right in for a shot. Other times you're going to sit there for an hour dealing with some kind of midline adhesion that you have no idea why it's even there. But I will tell you that you have the best chance of success if you take the time to do it. And this is the last two slides. So even for neurosurgeons, I know a lot of neurosurgeons who are really good at doing spinal cord stimulation, but they only do paddles. There are devices that are coming out on the market now that are only percutaneous approaches. If you don't do the percutaneous approach, you're going to lose access to gaining those patients. So one is DRG stimulation, which is where we place the electrode directly on a DRG and can treat focal pain, things like CRPS. This is really gaining a lot of traction over the last few years, and if you don't do the percutaneous approach, you're not going to be able to do it. And then the other one was when HF10 high frequency stimulation first launched, it was only percutaneous leads. When you look back literally five years ago, there were three companies on the market, and those three companies battled it out for over 20 years. It was Abbott, Medtronic, and Boston Scientific. You fast forward five years, right now there are eight companies on the market. There are two more that are launching this year, and there's more coming. So not every company is going to have the ability to give everyone a paddle and everything. So percutaneous approaches are going to be important if you want to gain access to those patients. Last slide. I always say think outside the box. This was a 75-year-old lady. She didn't even have back pain. All she had was right leg pain. So there was a surgeon who actually did a laminoframenotomy on her at like L45. Her pain went away for six weeks and then came right back. Obviously you can tell why. I cannot tell you, she went to literally five spine surgeons who all told her the same thing. We confuse you from like T2 to the sacrum. She didn't even have back pain. So what I did is, obviously the idea of trial lead, putting a percutaneous lead up here and fishing it up, this scoliosis is pretty difficult. So what I did is, this was an outpatient procedure. It took me about an hour and a half. I did a small laminectomy where my entry site was, and I did a mini laminectomy above it, and I just kind of curled the paddle to her scoliosis, and I sent her home for a trial with the paddle. She came back one week later, and I just directly hooked up the battery. She's now over three years out, and she's doing fantastic. Her leg pain is gone. It's all just what's considered a minimally invasive outpatient procedure as opposed to a T2 to S1 fusion. So sometimes you can think outside the box, and STEM works really well. Okay. Thank you.

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