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ORIGINAL ARTICLE
Surgical Aspects of the Possover LION Procedure: An

Emerging Procedure for Recovery of Visceral Functions and

Locomotion in Paraplegics

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Uffe S Løve 1 , Soren B Elmgreen , Axel Forman , Ivan Arsic , Marc Possover , Anette B Jønsson , Helge Kasch 7
AbstrAct
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.
Keywords: Laparoscopy, Neurostimulation, Possover LION procedure, Traumatic spinal cord injury.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1450

IntroductIon 1 Department of Surgery, Hospitalsenhed Midt, Viborg, Denmark
Spinal cord injury (SCI) is frequent. The World Health Organization 2 Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
estimates an annual incidence of 250,000 to 500,000 cases. 3 Department of Obstetrics and Gynecology, Aarhus University
Individuals living with the consequences of SCI face numerous Hospital, Aarhus, Denmark
medical complications and reduced life expectancy as a direct or 4 Department of Radiology, Hospitalsenhed Midt, Viborg, Denmark
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indirect result of their disability. Detrusor overactivity and sphincter 5
dyssynergy are encountered in 85% of cases, and improved control 6 Possover International Medical Center, Zürich, Switzerland
of micturition and defecation closely follows the restoration Department of Neurology, Spinal Cord Injury Center of Western
of ambulation as primary rehabilitation goals of patients with Denmark, Viborg, Denmark
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SCI. Inpatient rehabilitation entails training and to some extent Department of Neurology, Hospitalsenhed Midt, Viborg, Denmark
restoration of body functions via conventional physiotherapy and Corresponding Author: Uffe S Løve, Department of Surgery,
occupational therapy augmented by electrical stimulation, be it Hospitalsenhed Midt, Viborg, Denmark, Phone: +78446496, e-mail:
either neuromuscular or functional. Nevertheless, recovery after the skovloeven@gmail.com
initial inpatient rehabilitation is at best modest, and the conversion How to cite this article: Løve US, Elmgreen SB, Forman A, et al. Surgical
rate of the American Spinal Injury Association Impairment Scale Aspects of the Possover LION Procedure: An Emerging Procedure for
3,4
grade remains poor for grades A and B. Likewise, the rate of Recovery of Visceral Functions and Locomotion in Paraplegics. World
motor improvement declines over time, leaving many patients with J Lap Surg 2021;14(2):75–80.

permanent motor, sensory, and autonomic deficits. After 12 months Source of support: Nil
from the sustained injury, a majority of SCI persons have essentially Conflict of interest: None
exhausted their possibility of further recovery. 4,5

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