Neuromodulation via cervical stimulation is often utilized to control neck and upper extremity pain. In order to obtain coverage in the neck and upper extremity, an upper cervical vertebral body is typically targeted. However, some authors’ enthusiasm for cervical spinal cord stimulation is tempered by the challenge of securing an electrode in this inherently more flexible region [30]. Unsurprisingly, there is reportedly a higher rate of lead migration in the cervical spine than the thoracic spine [31]. Additionally, preoperative imaging with cervical MRI is more critical in this region leading some authors to uniformly recommend it preoperatively [32]. The authors always obtain an MRI prior to paddle implant in order to assess canal diameter so an appropriately sized paddle may be selected. The authors perform the procedure under general anesthesia with the head stabilized in a Mayfield head frame so as to obtain maximum flexion and temporary reversal of the cervical lordosis. However, there are reports in the literature of this procedure being done under conscious sedation with good results [33].

Two options exist for the passage of a paddle electrode in this spinal segment. Anterograde cervical epidural paddle electrode placement is possible only after laminotomy or laminectomy. Placing a high cervical epidural paddle in the cephalad direction certainly offers benefits in terms of operative ease [29]. Fluoroscopy is used to plan the skin incision which is generally about 5 cm in length. Typically, the laminotomy is performed at the C4/5 or C5/6 interspace depending on paddle length. The electrode is then advanced under fluoroscopic guidance to the planned level. If any epidural resistance hinders electrode placement, additional laminotomies are performed and a more extensive epidural dissection is carried out so adhesions can be separated under direct visualization [33].

If a retrograde paddle placement is desired, the patient is positioned prone in pins with capital flexion. Two techniques have been described for retrograde paddle placement. The most frequently reported technique involves placement at C1/C2, while newer reports demonstrate feasibility of placement at C0/C1 [32–34]. Incision is made from the occiput down to C2 or C3. At that point either a laminotomy at C1 to expose the epidural plane for C1/2 retrograde passage or blunt dissection of the posterior occipito-atlantic membrane to find the dural plane superior to the level of C1 is performed. Subsequently, the spinal cord electrode is then advanced in a retrograde fashion under fluoroscopy to its ideal position.

Given the flexion in the region special attention is typically paid to securing the electrode in place. Most authors strongly suggest a sizeable stress relaxation loop in the cervical region [27, 32–34]. Some recommend anchor placement with suture to the paraspinal musculature [32]. Papahill reports a 0 % lead migration rate with “several” strain relief loops of electrode placed deep to the subfascial with no additional anchoring [33]. The authors tend to place sizeable stress relaxation loops in both the cervical region and at the battery insertion site as to alleviate any points of increased strain along the system. Care is taken to ensure the leads are tunneled out of the cervical spine in a submuscular and subfascial manner. Given the higher rates of migration in the cervical spine, utilizing good surgical technique at implant date almost certainly decreases the rate of postoperative lead migration.