This video demonstrates the development of and clinical use of the retrograde approach for percutaneous lead placement for chronic tibial nerve stimulation. This technique can be done under local anesthesia in the office setting. The technological advance of wireless stimulation allows placement of the lead in a smaller area where historically a pulse generator would not fit.  An implantable tibial nerve technology with wireless energy delivery allows programmable nerve stimulation to previously difficult to access targets. Patient controlled home stimulation can also provide longer, daily stimulation time and more rapid clinical improvement.

We review the cadaver anatomy of the tibial nerve at the ankle and then demonstrate the retrograde percutaneous approach for a tibial nerve lead in several patients in the office setting. The technique was developed to place the lead percutaneously with the guidance of a combination of bony landmarks   and resulted in lead placement consistently more parallel to the nerve.  The video then shows placement in the office under local anesthesia in several patients.

The retrograde approach, starting at the level of the medial malleolus, about 1 finger breadth behind (in general about 1/3 the distance from the medial malleolus to Achilles tendon) penetrates the fascia of the lower leg to enter the space adjacent to the tibial nerve.  Testing of the finder needle for motor and sensory response guides lead placement.  Wireless lead stimulation is demonstrated.

We demonstrate the development and use of a safe retrograde method of percutaneous tibial nerve lead placemen that is done is the office under local anesthesia.  The retrograde approach, starting posterior to the medial malleolus, was easier and reproducibly placed a lead parallel to the tibial nerve that may optimize stimulation.