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Objective A heightened and organized understanding of sacral anatomy could potentially lead to a more effective and safe method of dorsal root ganglion stimulation (DRG-S) lead placement. The aim of this technical note is to describe a standardized access method for S1 DRG-S lead placement. Design Technical note. Methods The described approach utilizes alignment of the lumbosacral prominence and is measurement-based, allowing for standardized sacral access, even when visualization is suboptimal. The medial-to-lateral needle trajectory is designed to limit interaction with the sensitive neural structures and allows for a more parallel orientation of the lead to the DRG and nerve root. Conclusions The described technique potentially improves the safety of S1 DRG-S lead placement. The parallel lead orientation to the DRG may also increase efficacy while lowering energy requirements.

Study design Case report. Objective To describe the presentation, management, and autopsy findings in a case of a fatal intraoperative cardiac arrest after application of an absorbable hemostatic agent into a bleeding iliac bone screw defect. Summary of background data To the authors' knowledge, this represents the first reported complication of intraoperative death associated with Surgifoam (Ethicon) thromboembolization to the heart and lung microcirculation after its application into a bleeding bone defect. Methods A 56-year-old male was undergoing revision fusion surgery for pseudarthrosis after multilevel thoracolumbosacral fusion with pelvic fixation for degenerative scoliosis. Intraoperatively, upon removal of the right iliac screw, heavy venous bleeding was encountered, which was stopped after application of 10 mL of Surgifoam into the screw defect. Approximately 5 minutes later, the patient's end tidal CO2 dropped, and his pulse was lost. Epinephrine was administered and the patient was immediately turned to supine position and cardiopulmonary resuscitation initiated. Cardiopulmonary resuscitation was performed unsuccessfully for 30 minutes at the end of which the patient was pronounced dead. Results Autopsy findings revealed angulated particles of hemostatic agent with entrapped red blood cells partially to completely occluding small-to-medium-sized vessels of the heart and lungs. The cause of death was pulmonary and cardiac embolization of foreign material from the surgical screw defect to the vessels of the heart and lungs, significantly compromising respiration and blood flow causing sudden death. Conclusion Although Surgifoam is an excellent hemostatic agent for use in spinal surgery, it must be used with extreme caution in the setting of heavily bleeding bone defects after pedicle cannulation or removal of instrumentation. In cases when brisk venous bleeding is encountered, signifying potential compromise of an emissary vein, use of other hemostatic agents such as bone wax may be a safer option. Level of evidence N/A.