Strategies for Difficult Fluoroscopic Landmarking During Sacral Neuromodulation Lead Placement

Douglas Luchristt*, Cindy L. Amundsen

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Objectives: Fluoroscopic guidance is a key tool used in combination with sensory and motor testing to ensure optimal sacral neuromodulation lead placement. The objectives of this video are to briefly review bony landmarks for fluoroscopic imaging and provide strategies to overcome common obstacles during fluoroscopic mapping for sacral neuromodulation lead placement. Methods: Our video is divided into 2 parts. First, we review anatomic landmarks in anterior-posterior (AP) fluoroscopic imaging for identification of the sacrum and the medial edge of the bilateral sacral foramina. We then provide a series of nonideal fluoroscopic images, explaining the cause of the difficult interpretation and strategies to overcome these obstacles. In the second half, we similarly review the identification of S3 and optimal needle angle trajectory during lateral fluoroscopic imaging. We again provide a series of nonideal imaging examples to highlight strategies for needle placement in difficult cases. Results: We provide an overview of normal fluoroscopic landmarks for both AP and lateral fluoroscopic imaging during sacral neuromodulation lead placement, along with a series of 6 nonideal examples. Strategies for overcoming barriers to identification of bony anatomy on fluoroscopy are provided in the context of these examples. Conclusion: While appropriate patient preparation and positioning are important to optimize fluoroscopic guidance during sacral neuromodulation lead placement, patient anatomy and other factors often obscure or distort expected anatomic landmarks. We demonstrate our approach to overcoming common fluoroscopic obstacles and provide strategies for improvement of operative efficiency. These strategies can be combined with other intraoperative information such as tactile feedback, additional fluoroscopic views, and intraoperative complex nerve mapping to help optimize sacral neuromodulation lead placement and improve operative efficiency.

Original languageEnglish (US)
Pages (from-to)218-220
Number of pages3
StatePublished - Apr 2023

ASJC Scopus subject areas

  • Urology


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