Surgical Aspects of the Possover LION Procedure: An Emerging Procedure for Recovery of Visceral Functions and Locomotion in Paraplegics

Background: Traumatic spinal cord injury (SCI) may be a devastating life event. Motor and sensory recovery after 6 months post-injury is sparse, despite intensive neurorehabilitation. Long-term disabling consequences may further reduce self-supportiveness and the quality of life. A new surgical intervention, the Possover LION procedure (Laparoscopic Implantation of Neuroprosthesis), may improve long-term perspectives providing the patient with an implantable pulse generator (IPG), and leads to pelvic situated nerves (sciatic and femoral nerves) to regain substantial motor and sensory functions in lower extremities. Objective: To report from the surgical point of view, the experience of implementing an IPG system for direct nerve stimulation of pelvic nerves in a series of chronic traumatic SCI patients. Methods: From two substudies, a feasibility study and a controlled clinical study, data from 21 SCI patients with severe paraplegia who had undergone the Possover LION procedure were obtained. The Possover LION procedure was implemented in a surgical department with skilled surgeons in close collaboration with neurological expertise. The developer of the procedure performed the first operations and afterward provided guidance and collaboration. Results: Twenty patients (F = 3, M = 17, age = 36.9 ± 9.0, ISCNSCI AIS A = 19, AIS B = 1) with lesion between Th3 and L1 had IPG and four leads implanted. One patient had a “frozen pelvis” and could not be operated. During operation, severe bleeding was seen in one patient that could be stopped using on-site applied hemostats, with no need of transfusion. One patient had initial normalization of infection parameters postoperatively, but developed Staphylococcus aureus infection near the IPG, removal of IPG and leads was needed. Clinically significant dislocation of leads was seen in two patients and dislocation/tilting of IPG in one patient. Hardware problems with possible lead breakage were observed in one patient. Conclusion: Posttraumatic SCI patients with paraplegia can be elected for the LION procedure by a specialist team of neurorehabilitation experts (neurologists, PTs), and skilled surgeons in the neuro-pelvic area, with Possover LION expertise. Complication rates for the Possover LION procedure are comparable to or better than those seen with spinal cord stimulation, and the procedure is generally safe. We recommend the monitoring of implanted leads and IPG using CT abdomen.