A Case of Successful Treatment of Neuropathic Pain After a Scapular Fracture Using Subcutaneous Targeted Neuromodulation

Subcutaneous targeted neuromodulation is one part of the wider new peripheral neuromodulation development in the treatment of neuropathic pain. Although it has not received wider acceptance, there are many reports in the literature of successful use of this technique.     

Permanent Percutaneous Splanchnic Nerve Neuromodulation for Management of Pain due to Chronic Pancreatitis: A Case Report

Introduction: The management of pain in chronic benign pancreatitis is complex. Celiac plexus neurolysis provides pain relief of variable duration. Neuromodulation of splanchnic nerves with electrodes and an implantable pulse generator system is an alternative to producing long‐term pain relief with minimal complications in selected cases. Methods: A 36‐year‐old lady with intractable abdominal pain for five years from chronic benign pancreatitis presented to our pain clinic. Multiple pharmacotherapy regimens, surgery, and interventions produced temporary pain relief of variable duration and intensity. Following a successful trial of celiac plexus stimulation, neuromodulation of the splanchnic nerves was achieved with two permanently implanted octopolar leads at the T11/T12 area connected to an implantable pulse generator. Results: Eighteen months following the implant, the patient continues to derive satisfactory pain relief without any device related complications. Her opiate use is significantly reduced from 225 (486 mg morphine per day) to 12.5 (27 mg morphine per day) micrograms/h fentanyl patches and the fentanyl lozenges were stopped with an increase in appetite and of more than 8 kg in weight gain. The initial pain score visual analogue scale (VAS) 8‐9/10 was reduced to VAS 0/10 since implantation. Discussion: The pain of chronic pancreatitis has both visceral and somatic components as evidenced by the lack of complete pain relief from celiac plexus block alone and the knowledge that in chronic disease, the pathology extends to extra pancreatic somatic tissues, particularly the retro‐peritoneum. We postulate that the electrical field generated by the dual octrode system extends to include splanchnic nerves and other somatic innervation of the pancreas. Conclusion: In our opinion, this is the first case of a successful long‐term neuromodulation of splanchnic nerves with a permanently implanted device. The potential exists for its use in visceral abdominal pain of varied etiology, once more experience is obtained with this technique.     

Lower Urinary Tract and Bowel Disorders and Multiple Sclerosis: Role of Sacral Neuromodulation: A Preliminary Report

Objective. In the present study we wanted to determine whether sacral neuromodulation benefits patients with bladder and bowel symptoms caused by multiple sclerosis (MS). Methods. At our Institute, five patients with MS underwent unilateral implantation of a sacral neuromodulation system, InterStim (Medtronic Inc., Minneapolis, Minnesota, USA), between April 2001 and June 2002; the mean follow‐up was 30.4 months (range 24–38). The following parameters were evaluated before and after implant of the neurostimulator device: number of daily voidings, number of incontinent episodes, residual urine, Wexner score, quality of life (QoL), and psychological impact. Results. There was an overall 81.4% decrease of urgency and frequency with a significant decrease in the number of upper urinary tract infections and fever; there was a slight improvement in bowel function; there was an overall 51.8% improvement in the QoL and a discernible improvement emotional well‐being. Conclusions. Unilateral chronic sacral neuromodulation can be a valuable treatment for neurogenic bladder and bowel disorders associated with MS.     

Use of Peripheral Subcutaneous Field Stimulation for the Treatment of Axial Neck Pain: A Case Report

Objective. To present a novel technique of neuromodulation for the treatment of axial neck pain. Materials and Methods. A case of a patient with history of long‐standing axial neck pain with previous cervical spine operation and confirmed discogenic pain is presented. Traditional treatment measures did not provide adequate pain relief. A trial of peripheral subcutaneous field stimulation (PSFS) was performed. Following an excellent response during a week‐long trial, a permanent PSFS system was implanted. The patient was followed for nine months after internalization. Results. Seven‐day trial of PSFS resulted in complete relief of the patient's pain. This 100% relief of pain continued after the implantation of permanent PSFS system consisting of two quadripolar electrodes, one placed over the paraspinal muscles parallel to midline, and the other positioned horizontally over the ipsilateral trapezius muscle. The patient was gradually weaned off of all opioid medications and continues to report 100% reduction in pain intensity at the nine‐month follow‐up. Conclusion. PSFS represents a new and promising modality in treatment of axial neck pain. Exact mechanism of the pain relief remains unclear.     

Utility of Electrical Neuromodulation for Treating Chronic Pain Syndromes in the Pediatric Setting: A Systematic Review

ObjectivesChronic pain syndromes in children can carry significant threats to psychological well-being, opioid overuse, functional impairments, and severe disability. While several high-level studies, almost exclusively in adults, have demonstrated the utility of implantable electrical neuromodulation systems for treating various chronic pain syndromes, there exists a paucity of pediatric-specific evidence. Unfortunately, evidence and practice patterns established from adults may not be fully translatable to children given differences in disease manifestations and anatomical variances.Materials and MethodsWe performed a systematic review using conventional PRISMA methodology to identify studies reporting use of implantable electrical neuromodulation systems in children. The primary outcome parameters collected were analgesic relief and functional benefits. Additionally, previous interventions attempted, neuromodulation parameters, and limitations were collected as reported.ResultsA total of 11 studies was identified, which described 19 patients who were refractory to multidisciplinary pain management strategies. The cohort was mostly adolescent (18/19), suffered from CRPS (14/19), and received SCS (17/19). Nearly all patients, both those with CRPS (13/14) and non-CRPS conditions (4/4), reported significant pain relief and functional recovery following neuromodulation. There were no severe complications reported; limitations included suboptimal benefit or loss of analgesia (3/19), lead or device revision (3/19), and subcutaneous infection (1/19), all of which were congruent with adult outcomes.ConclusionThere exist children with chronic pain refractory to standard of care approaches who could be considered for neuromodulation interventions. The existing data, which was limited and from a low tier of evidence, suggest that these interventions are relatively safe and provide meaningful pain reduction and functional improvements. While not previously reported, we recommend careful consideration of the pubertal growth spurt prior to device lead placement—if reasonable and appropriate—given the possibility of inferior lead migration with physiologic growth in patients with SCS devices or foraminal extrusion in patients with dorsal root ganglion stimulation devices.     

Sacral Insufficiency Fracture, Usually Overlooked Cause of Lumbosacral Pain

Sacral insufficiency fractures are usually known to develop in elderly patients with osteoporosis without definite trauma history. It is difficult to diagnose the sacral insufficiency fracture at an early stage because lower lumbar diseases, concurrently or not, may also be presented with similar symptoms and signs. We report a rare case of sacral insufficiency fracture who was not diagnosed initially but, instead, showed progressively worsening of clinical symptoms and radiological findings after decompression surgery for upper level lumbar stenosis.     

Lumbar Sympathetic Chain Neuromodulation with Implanted Electrodes for Long‐Term Pain Relief in Loin Pain Haematuria Syndrome

Introduction. Loin pain‐hematuria syndrome (LPHS) is a rare clinical entity causing unilateral or bilateral intractable flank and loin pain with hematuria. The etiology is poorly understood, and the diagnosis is made by exclusion of urological and nephrological conditions. The management is mainly symptomatic aiming for pain relief with nonopioid and opioids analgesics, and interventions such as capsaicin infusion into the renal pelvis, percutaneous regional nerve blocks, and laparoscopic or open surgical procedures, none of them providing lasting pain relief. Methods. We describe four cases of LPHS in which long‐term pain relief was achieved successfully by neuromodulation of lumbar sympathetic plexus with implanted electrodes. All patients underwent an initial successful trial of neuromodulation with Stimulong monoelectrode (Pajunk, GmbH, Geisingen, Germany) inserted percutaneously to lie adjacent to L3–L4 vertebral bodies followed by permanent implantation of the stimulation system using four contact electrodes (Medtronic Inc, Minneapolis, Minnesota, USA) in two patients with excellent long‐term pain relief. Results. All our patients had significant reductions in visual analog scale scores and analgesic consumption for the duration of the monoelectrode trial and in one patient beyond six months. Of the two patients who had full implants, pain relief is excellent with minimal analgesic consumption and one has resumed employment. There were no complications. Discussion. LPHS is very difficult to treat with some experts maintaining it is mainly psychological. Conservative treatments are often unsatisfactory and radical measures not reliable. Peripheral stimulation of nerves and plexuses has been successful as shown from case reports. All our patients preferred low‐frequency stimulation although its precise mode of action is uncertain. Conclusion. Our experience shows that lumbar sympathetic chain neuromodulation in intractable LPHS not amenable to conservative therapy is a reasonable alternative before radical interventions. More experience is needed in multiple centers before its recommendation for refractory LPHS.     

Reprogramming Sacral Neuromodulation for Sub-Optimal Outcomes: Evidence and Recommendations for Clinical Practice

ObjectivesIn some patients treated for urinary or fecal incontinence with sacral neuromodulation (SNM) persistence of symptoms, a reduction in efficacy or adverse effects of stimulation can occur. In such situations, further programming of the SNM device can help resolve problems. Infrequently hardware failure is detected. This article aims to provide practical guidance to solve sub-optimal outcomes (troubleshooting) occurring in the course of SNM therapy.Materials and MethodsA systematic literature review was performed. Collective clinical experience from an expert multidisciplinary group was used to form opinion where evidence was lacking.ResultsCircumstances in which reprogramming is required are described. Actions to undertake include changes of electrode configuration, stimulation amplitude, pulse frequency, and pulse width. Guidance in case of loss of efficacy and adverse effects of stimulation, developed by a group of European experts, is presented. In addition, various hardware failure scenarios and their management are described.ConclusionsReprogramming aims to further improve patient symptoms or ensure a comfortable delivery of the therapy. Initial changes of electrode configuration and adjustment of stimulation parameters can be performed at home to avoid unnecessary hospital visits. A logical and stepwise approach to reprogramming can improve the outcome of therapy and restore patient satisfaction.     

The Association Between Bodily Functions and Cognitive/Emotional Factors in Patients With Chronic Pain Treated With Neuromodulation: A Systematic Review and Meta-Analyses

ObjectivesTo date, pain relief in general continues to be the most prominent outcome measurement in daily routine care and clinical research. Nevertheless, the awareness of a shift toward more functional outcomes and/or emotional and cognitive outcomes has been raised. The interplay between bodily functions (such as pain intensity) and emotional or cognitive factors, however, has not yet been fully elucidated. The aim of this study was to systematically review the evidence for associations between bodily functions and cognitive and emotional factors in patients with chronic pain who are treated with neuromodulation.Materials and MethodsFour data bases were consulted for this systematic literature review: PubMed, Web of Science, Scopus, and Embase. The Downs and Black Checklist (modified) was used to assess the risk of bias. The study protocol was prospectively registered at the International prospective register of systematic reviews (PROSPERO, CRD42021226803). If two or more studies reported correlation coefficients for a specific association, a meta-analysis based on correlation coefficients was performed for that specific association.ResultsThe initial data base search identified a total of 1432 studies, of which 19 studies were eventually included in the systematic review. Evidence was found for two associations: 1) a positive correlation between pain intensity and anxiety (r = 0.42; 95% CI, 0.34 to 0.50) and 2) a positive correlation between pain intensity and depression (r = 0.32; 95% CI, 0.10 to 0.51). The association between pain intensity and catastrophizing was not statistically significant (r = 0.23; 95% CI, ?0.36 to 0.69).ConclusionsOn the basis of the associations between pain intensity and anxiety/depression, a biopsychosocial approach might be the most suitable in clinical practice to properly address all aspects of the International Classification of Functioning, Disability, and Health framework in patients who are treated with neuromodulation.     

Correct Sciatic Nerve Management to Apply Ultrasound-Guided Percutaneous Neuromodulation in Patients With Chronic Low Back Pain: A Pilot Study

BackgroundThe objectives of this study were to evaluate the effects of an ultrasound (US)-guided percutaneous neuromodulation (PNM) intervention on the sciatic nerve, regarding pain, hip range of motion (ROM), balance, and functionality in patients with chronic low back pain (LBP); and to determine the optimal anatomical location of sciatic nerve stimulation to obtain therapeutic benefits in such patients.Materials and MethodsThirty patients with chronic LBP were recruited and divided randomly into three groups. All patients received a single percutaneous electrical stimulation intervention on the sciatic nerve, with a different anatomical application location for each group (proximal, middle, and distal). Level of pain, hip passive ROM, dynamic balance, and Oswestry disability index were analyzed. All variables were calculated before the intervention, immediately postintervention, 48 hours and one week after the intervention, except the LBP questionnaire (before, and 48 hours and one week after the intervention).ResultsAll interventions decreased the level of pain and increased the ROM, balance, and functionality. Besides, these therapeutic effects were maintained during one week, regardless of the anatomical location of application.ConclusionsThe choice of an anatomical location of application of the US-guided PNM on the sciatic nerve by the physiotherapist does not influence the improvement of pain, ROM, balance, and function in patients with chronic LBP.