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Pritzlaff SG, Latif U, Rosenow JM, Chae J, Wilson RD, Huffman WJ, Crosby ND, Boggs JW. A review of prospective studies regarding percutaneous peripheral nerve stimulation treatment in the management of chronic pain. Pain Manag 2024; 14:209-222. [PMID: 38939963 PMCID: PMC11234914 DOI: 10.1080/17581869.2024.2352398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/03/2024] [Indexed: 06/29/2024] Open
Abstract
Conventionally, peripheral nerve stimulation (PNS) for treatment of chronic pain has involved a two-stage process: a short-term (e.g., 7 days) trial and, if significant pain relief is achieved, a permanent PNS system is implanted. A percutaneous PNS treatment is now available where a coiled lead may be implanted for up to 60 days with the goal of producing sustained relief. In the present review, published prospective trials using percutaneous PNS treatment were identified and synthesized. The collected evidence indicates that percutaneous PNS treatment for up to 60 days provides durable clinically significant improvements in pain and pain interference. Similar efficacy across diverse targets and etiologies supports the broad applicability for use within the chronic pain population using this nonopioid technology.
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Affiliation(s)
- Scott G Pritzlaff
- Department of Anesthesiology & Pain Medicine, University of California Davis Health, Sacramento, CA 95817, USA
| | - Usman Latif
- Department of Anesthesiology, Pain & Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS 66103, USA
| | - Joshua M Rosenow
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - John Chae
- MetroHealth Rehabilitation Institute, The MetroHealth System, Cleveland, OH 44109 ,USA
- Department of Physical Medicine & Rehabilitation, Case Western Reserve University, Cleveland, OH 44109, USA
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Richard D Wilson
- MetroHealth Rehabilitation Institute, The MetroHealth System, Cleveland, OH 44109 ,USA
- Department of Physical Medicine & Rehabilitation, Case Western Reserve University, Cleveland, OH 44109, USA
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2
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Fiala KJ, Martens JM, Abd-Elsayed A. Medial branch neurostimulator trial. NEUROMODULATION TECHNIQUES FOR THE SPINE 2024:120-124. [DOI: 10.1016/b978-0-323-87584-4.00023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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3
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Gargya A, Zats A, Lake T. Peripheral Nerve Stimulation for the Management of Pediatric Neuropathic Pain. Pediatrics 2023; 152:e2023061843. [PMID: 37946580 DOI: 10.1542/peds.2023-061843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 11/12/2023] Open
Abstract
The management of neuropathic pain in children poses an enormous challenge for pediatricians and pain management physicians. Current treatment options include physical therapy and medication management. Peripheral nerve stimulation/neuromodulation is a novel and minimally invasive treatment that can be initiated and monitored in an outpatient setting. This new technology can be a useful tool for treating pain secondary to pediatric neuropathy and chronic refractory pain after conservative management. Our case report describes the use of a peripheral nerve stimulator in the successful management of pediatric neuropathic leg pain.
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Affiliation(s)
- Akshat Gargya
- Department of Anesthesiology, Division of Interventional Pain, The University of Vermont Health Network, South Burlington, Vermont
| | - Alan Zats
- Department of Anesthesiology, Division of Interventional Pain, The University of Vermont Health Network, South Burlington, Vermont
| | - Tiffini Lake
- Department of Anesthesiology, Division of Interventional Pain, The University of Vermont Health Network, South Burlington, Vermont
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D'Souza RS, Jin MY, Abd-Elsayed A. Peripheral Nerve Stimulation for Low Back Pain: A Systematic Review. Curr Pain Headache Rep 2023; 27:117-128. [PMID: 37060395 DOI: 10.1007/s11916-023-01109-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE OF REVIEW Low back pain (LBP) is a prevalent condition that is associated with diminished physical function, poor mental health outcomes, and reduced quality of life. Peripheral nerve stimulation (PNS) is an emerging modality that has been utilized to treat LBP. The primary objective of this systematic review is to appraise the level of evidence on the efficacy of PNS for treatment of LBP. RECENT FINDINGS Twenty-nine articles were included in this systematic review, consisting of 828 total participants utilizing PNS as the primary modality for LBP and 173 participants using PNS as salvage or adjunctive therapy for LBP after SCS placement. Different modalities of PNS therapy were reported across studies, including conventional PNS systems stimulating the lumbar medial branch nerves, peripheral nerve field stimulation (PNFS), and restorative neuromuscular stimulation of the multifidus muscles. All studies consistently reported positive modest to moderate improvement in pain intensity with PNS therapy when comparing baseline pain intensity to each study's respective primary follow-up period. There was a very low GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) quality of evidence supporting this finding. Inconsistency was present in some comparative studies that demonstrated no difference between PNS therapy versus control cohorts (sham or SCS therapy alone), which therefore highlighted the potential for placebo effect. This systematic review highlights that PNS, PNFS, and neuromuscular stimulation may provide modest to moderate pain relief in patients with LBP, although evidence is currently limited due to risk of bias, clinical and methodological heterogeneity, and inconsistency in data.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Max Y Jin
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA.
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Lee MT, Mackie K, Chiou LC. Alternative pain management via endocannabinoids in the time of the opioid epidemic: Peripheral neuromodulation and pharmacological interventions. Br J Pharmacol 2023; 180:894-909. [PMID: 34877650 PMCID: PMC9170838 DOI: 10.1111/bph.15771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 11/23/2021] [Accepted: 11/27/2021] [Indexed: 01/18/2023] Open
Abstract
The use of opioids in pain management is hampered by the emergence of analgesic tolerance, which leads to increased dosing and side effects, both of which have contributed to the opioid epidemic. One promising potential approach to limit opioid analgesic tolerance is activating the endocannabinoid system in the CNS, via activation of CB1 receptors in the descending pain inhibitory pathway. In this review, we first discuss preclinical and clinical evidence revealing the potential of pharmacological activation of CB1 receptors in modulating opioid tolerance, including activation by phytocannabinoids, synthetic CB1 receptor agonists, endocannabinoid degradation enzyme inhibitors, and recently discovered positive allosteric modulators of CB1 receptors. On the other hand, as non-pharmacological pain relief is advocated by the US-NIH to combat the opioid epidemic, we also discuss contributions of peripheral neuromodulation, involving the electrostimulation of peripheral nerves, in addressing chronic pain and opioid tolerance. The involvement of supraspinal endocannabinoid systems in peripheral neuromodulation-induced analgesia is also discussed. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
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Grants
- MOST 108-2321-B-002-005 Ministry of Science and Technology, Taiwan
- MOST 107-2811-B-002-008 Ministry of Science and Technology, Taiwan
- R01 DA041229 NIDA NIH HHS
- MOST 107-2321-B-002-010 Ministry of Science and Technology, Taiwan
- R01 DA047858 NIDA NIH HHS
- 107M4022-3 Ministry of Education, Taiwan
- MOST 106-2321-B-002-019 Ministry of Science and Technology, Taiwan
- NHRI-EX111-11114NI National Health Research Institutes, Taiwan
- FRGS/1/2021/WAB13/UCSI/02/1 Ministry of Higher Education, Malaysia
- R21 DA042584 NIDA NIH HHS
- REIG-FPS-2020/065 UCSI University Research Excellence and Innovation Grant, Malaysia
- NHRI-EX109-10733NI National Health Research Institutes, Taiwan
- MOST 104-2745-B-002-004 Ministry of Science and Technology, Taiwan
- MOST 109-2320-B-002-042-MY3 Ministry of Science and Technology, Taiwan
- MOST 107-2811-B-002 -008 Ministry of Science and Technology, Taiwan
- MOST 108-2320-B-002-029-MY3 Ministry of Science and Technology, Taiwan
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Affiliation(s)
- Ming Tatt Lee
- Department of Pharmacology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur 56000, Malaysia
| | - Ken Mackie
- Gill Center for Biomolecular Research, Indiana University, Bloomington, Indiana 47405, USA
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana 47405, USA
| | - Lih-Chu Chiou
- Department of Pharmacology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 40402, Taiwan
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6
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Gilmore CA, Deer TR, Desai MJ, Hopkins TJ, Li S, DePalma MJ, Cohen SP, McGee MJ, Boggs JW. Durable patient-reported outcomes following 60-day percutaneous peripheral nerve stimulation (PNS) of the medial branch nerves. INTERVENTIONAL PAIN MEDICINE 2023; 2:100243. [PMID: 39239603 PMCID: PMC11372989 DOI: 10.1016/j.inpm.2023.100243] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 09/07/2024]
Abstract
Background Chronic low back pain (CLBP) is often associated with clinical evidence of central nervous system sensitization and finding a clear source of nociceptive input can be challenging. Conventional therapies targeting peripheral spinal pain structures can fail to address centrally-mediated, underlying causes of pain. Sixty-day percutaneous peripheral nerve stimulation (PNS) applied to the lumbar medial branch nerves is a non-surgical, non-opioid treatment that may restore the balance of peripheral inputs to the central nervous system and reverse maladaptive changes in central pain processing. As a minimally invasive, non-destructive treatment, percutaneous PNS was designed to be used earlier in the treatment continuum than radiofrequency ablation or permanently-implanted neurostimulation systems. Objective The objective of this clinical trial was to characterize the durability of responses to medial branch PNS in a prospective multicenter case series study of CLBP patients recalcitrant to multiple non-surgical treatments. Design Prospective, multicenter clinical trial. Population Adults with CLBP without radicular leg pain who had previously failed multiple types of conventional treatments. Intervention Sixty-day percutaneous PNS applied to the lumbar medial branch nerves. Methods Percutaneous PNS leads were implanted under image guidance (ultrasound and/or fluoroscopy) and treatment was applied for up to 60 days, after which the leads were removed. Participants were followed through 14 months (12 months after the 2-month PNS treatment). Prospectively-defined endpoints included assessments of pain intensity, disability, pain interference, health-related quality of life, depression, and patient global impression of change. Results Treatment of CLBP with 60-day percutaneous PNS treatment produced clinically meaningful improvements in average pain intensity, disability, and/or pain interference for a majority of participants through the entire 14 month follow up period without requiring permanent system implantation. The proportion of participants experiencing clinically meaningful improvement in at least one outcome (pain intensiy, disability, pain interference) with PNS was 91% after 2 months, 79% at 5 months, 73% at 8 months, 75% at 11 months, and 77% at 14 months. There were no serious or unanticipated study-related adverse events. Conclusion This prospective multicenter clinical trial demonstrates the clinical utility of percutaneous PNS when applied to the medial branch nerves for the treatment of chronic low back pain recalcitrant to non-surgical treatments. Given the minimally invasive nature of percutaneous PNS and the significant benefits experienced by participants, percutaneous PNS provides a safe and effective first-line neuromodulation treatment for patients with CLBP that may obviate the need for neuroablative procedures or permanent neurostimulation system implantation.
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Affiliation(s)
| | - Timothy R Deer
- Spine & Nerve Centers of the Virginias, Charleston, WV, USA
| | - Mehul J Desai
- International Spine, Pain & Performance Center, Washington, DC, USA
| | | | - Sean Li
- Premier Pain Centers, Shrewsbury, NJ, USA
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7
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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8
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Tieppo Francio V, Westerhaus BD, Rupp A, Sayed D. Non-Spinal Neuromodulation of the Lumbar Medial Branch Nerve for Chronic Axial Low Back Pain: A Narrative Review. FRONTIERS IN PAIN RESEARCH 2022; 3:835519. [PMID: 35295793 PMCID: PMC8915554 DOI: 10.3389/fpain.2022.835519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic low back pain remains highly prevalent, costly, and the leading cause of disability worldwide. Symptoms are complex and treatment involves an interdisciplinary approach. Due to diverse anatomical etiologies, treatment outcomes with interventional options are highly variable. A novel approach to treating chronic axial low back pain entails the use of peripheral nerve stimulation to the lumbar medial branch nerve, and this review examines the clinical data of the two different, commercially available, non-spinal neuromodulation systems. This review provides the clinician a succinct narrative that presents up-to-date data objectively. Our review found ten clinical studies, including one report of two cases, six prospective studies, and three randomized clinical trials published to date. Currently, there are different proposed mechanisms of action to address chronic axial low back pain with different implantation techniques. Evidence suggests that peripheral nerve stimulation of the lumbar medial branch nerve may be effective in improving pain and function in patients with chronic axial low back pain symptoms at short and long term follow up, with good safety profiles. Further long-term data is needed to consider this intervention earlier in the pain treatment algorithm, but initial data are promising.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS, United States
| | - Benjamin D. Westerhaus
- Cantor Spine Center at the Paley Orthopedic and Spine Institute, Ft. Lauderdale, FL, United States
| | - Adam Rupp
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS, United States
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS, United States
- *Correspondence: Dawood Sayed
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9
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Gilmore CA, Desai MJ, Hopkins TJ, Li S, DePalma MJ, Deer TR, Grace W, Burgher AH, Sayal PK, Amirdelfan K, Cohen SP, McGee MJ, Boggs JW. Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study. Pain Pract 2021; 21:877-889. [PMID: 34216103 PMCID: PMC9290596 DOI: 10.1111/papr.13055] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/01/2021] [Accepted: 06/24/2021] [Indexed: 12/18/2022]
Abstract
Background The objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single‐center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments. Materials & Methods Participants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long‐term for 12 months after the 2‐month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow‐up visits thereafter in progress. Results Clinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy‐three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2‐month percutaneous PNS treatment (n = 54/74). Whereas prospective follow‐up is ongoing, among those who had already completed the long‐term follow‐up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment. Conclusion Given the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first‐line neurostimulation treatment option for patients with chronic axial back pain.
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Affiliation(s)
| | - Mehul J Desai
- International Spine, Pain, and Performance Center, Washington, DC, USA
| | | | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | | | - Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | - Warren Grace
- The Spine and Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | | | - Puneet K Sayal
- International Spine, Pain, and Performance Center, Washington, DC, USA
| | | | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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10
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San-Emeterio-Iglesias R, Minaya-Muñoz F, Romero-Morales C, De-la-Cruz-Torres B. Correct Sciatic Nerve Management to Apply Ultrasound-Guided Percutaneous Neuromodulation in Patients With Chronic Low Back Pain: A Pilot Study. Neuromodulation 2021; 24:1067-1074. [PMID: 33876885 DOI: 10.1111/ner.13396] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/05/2021] [Accepted: 03/15/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND The 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 METHODS Thirty 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). RESULTS All 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. CONCLUSIONS The 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.
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11
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Moman RN, Olatoye OO, Pingree MJ. Temporary, Percutaneous Peripheral Nerve Stimulation for Refractory Occipital Neuralgia. PAIN MEDICINE 2021; 23:415-420. [PMID: 33823015 DOI: 10.1093/pm/pnab128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Rajat N Moman
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Oludare O Olatoye
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew J Pingree
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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12
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Deer TR, Gilmore CA, Desai MJ, Li S, DePalma MJ, Hopkins TJ, Burgher AH, Spinner DA, Cohen SP, McGee MJ, Boggs JW. Percutaneous Peripheral Nerve Stimulation of the Medial Branch Nerves for the Treatment of Chronic Axial Back Pain in Patients After Radiofrequency Ablation. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:548-560. [PMID: 33616178 PMCID: PMC7971467 DOI: 10.1093/pm/pnaa432] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Lumbar radiofrequency ablation is a commonly used intervention for chronic back pain. However, the pain typically returns, and though retreatment may be successful, the procedure involves destruction of the medial branch nerves, which denervates the multifidus. Repeated procedures typically have diminishing returns, which can lead to opioid use, surgery, or implantation of permanent neuromodulation systems. The objective of this report is to demonstrate the potential use of percutaneous peripheral nerve stimulation (PNS) as a minimally invasive, nondestructive, motor-sparing alternative to repeat radiofrequency ablation and more invasive surgical procedures. DESIGN Prospective, multicenter trial. METHODS Individuals with a return of chronic axial pain after radiofrequency ablation underwent implantation of percutaneous PNS leads targeting the medial branch nerves. Stimulation was delivered for up to 60 days, after which the leads were removed. Participants were followed up to 5 months after the start of PNS. Outcomes included pain intensity, disability, and pain interference. RESULTS Highly clinically significant (≥50%) reductions in average pain intensity were reported by a majority of participants (67%, n = 10/15) after 2 months with PNS, and a majority experienced clinically significant improvements in functional outcomes, as measured by disability (87%, n = 13/15) and pain interference (80%, n = 12/15). Five months after PNS, 93% (n = 14/15) reported clinically meaningful improvement in one or more outcome measures, and a majority experienced clinically meaningful improvements in all three outcomes (i.e., pain intensity, disability, and pain interference). CONCLUSIONS Percutaneous PNS has the potential to shift the pain management paradigm by providing an effective, nondestructive, motor-sparing neuromodulation treatment.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
| | | | - Mehul J Desai
- International Spine Pain and Performance Center, George Washington University, School of Medicine, Washington, DC, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | | | | | | | | | - Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Deer TR, Eldabe S, Falowski SM, Huntoon MA, Staats PS, Cassar IR, Crosby ND, Boggs JW. Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. J Pain Res 2021; 14:721-736. [PMID: 33737830 PMCID: PMC7966353 DOI: 10.2147/jpr.s297091] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is an effective tool for the treatment of chronic pain, although its efficacy and utilization have previously been significantly limited by technology. In recent years, purpose-built percutaneous PNS devices have been developed to overcome the limitations of conventional permanently implanted neurostimulation devices. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period, outcomes that have not previously been observed with conventional permanently implanted neurostimulation devices. This narrative review summarizes mechanistic processes that contribute to chronic pain, and the potential mechanisms by which selective large diameter afferent fiber activation may reverse these changes to induce a prolonged reduction in pain. The interplay of these mechanisms, supported by data in chronic pain states that have been effectively treated with percutaneous PNS, will also be discussed in support of a new theory of pain management in neuromodulation: Peripherally Induced Reconditioning of the Central Nervous System (CNS).
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Steven M Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Marc A Huntoon
- Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Mainkar O, Singh H, Gargya A, Lee J, Valimahomed A, Gulati A. Ultrasound-Guided Peripheral Nerve Stimulation of Cervical, Thoracic, and Lumbar Spinal Nerves for Dermatomal Pain: A Case Series. Neuromodulation 2020; 24:1059-1066. [PMID: 33314509 DOI: 10.1111/ner.13334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES With the development of percutaneously inserted devices, peripheral nerve stimulation (PNS) has been gaining attention within chronic pain literature as a less invasive neurostimulation alternative to spinal column and dorsal root ganglion stimulation. A majority of current PNS literature focuses on targeting individual distal nerves to treat individual peripheral mononeuropathies, limiting its applications. This article discusses our experience treating dermatomal pain with neurostimulation without needing to access the epidural space by targeting the proximal spinal nerve with peripheral nerve stimulation under ultrasound-guidance. MATERIALS AND METHODS A temporary, percutaneous PNS was used to target the proximal spinal nerve in 11 patients to treat various dermatomal pain syndromes in patients seen in an outpatient chronic pain clinic. Four patients received stimulation targeting the lumbar spinal nerves and seven patient received stimulation targeting the cervical or thoracic spinal nerves. RESULTS The case series presents 11 cases of PNS of the proximal spinal nerve. Seven patients, including a majority of the patients with lumbar radiculopathy, had analgesia during PNS. Four patients, all of whom targeted the cervical or thoracic spinal nerves, did not receive analgesia from PNS. CONCLUSION PNS of the proximal spinal nerve may be an effective modality to treat dermatomal pain in patients who are not candidates for other therapies that require access to the epidural space. This technique was used to successfully treat lumbar radiculopathy, post-herpetic neuralgia, and complex regional pain syndrome.
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Affiliation(s)
- Ojas Mainkar
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Harmandeep Singh
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Akshat Gargya
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Jane Lee
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Ali Valimahomed
- Advanced Orthopedics and Sports Medicine Institute, Freehold, NJ, USA
| | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, Department of Anesthesiology, New York, NY, USA
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Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain. Anesthesiology 2020; 133:1127-1149. [PMID: 32898231 DOI: 10.1097/aln.0000000000003532] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
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16
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Gilmore CA, Patel J, Esebua LG, Burchell M. A Review of Peripheral Nerve Stimulation Techniques Targeting the Medial Branches of the Lumbar Dorsal Rami in the Treatment of Chronic Low Back Pain. PAIN MEDICINE 2020; 21:S41-S46. [PMID: 32804229 DOI: 10.1093/pm/pnaa084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The lumbar medial branch nerve has historically been a focus for ablative techniques in the treatment of chronic low back pain (CLBP) of facetogenic origin. Recent developments in the field of neuromodulation have been employed to target these nerves for analgesia and/or functional restoration in broader populations of CLBP patients. The objective of this article was to provide an introductory review of procedural techniques and devices employed for peripheral nerve stimulation (PNS) of the lumbar medial branch of the dorsal ramus for the treatment of CLBP. METHODS A literature search via PubMed.gov was performed through September 2019 with key words focusing on peripheral nerve stimulation for chronic low back pain. This was refined to include only those articles that focused specifically on stimulation of the lumbar medial branch of the dorsal ramus. References within selected articles and unpublished data currently in the peer review process were also utilized. RESULTS Ninety articles from PubMed.gov were obtained. Two approaches to PNS of the medial branch of the dorsal ramus were identified. CONCLUSIONS Our review of the current literature regarding techniques for neuromodulation of the medial branch of the dorsal ramus revealed two dominant methods: a temporarily implanted percutaneous coiled-lead approach and a permanently implanted system. The two techniques share some similarities, such as targeting the medial branch of the dorsal ramus, and also have some differences, such as indwelling time, stimulation parameters, duration of treatment, image guidance, and degrees of invasiveness, but they are both demonstrating promising results in clinical trials.
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Affiliation(s)
- Christopher A Gilmore
- Carolinas Pain Institute, Winston-Salem, North Carolina, USA.,Center for Clinical Research, Winston-Salem, North Carolina, USA
| | - Janus Patel
- Department of Anesthesiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Lasha-Giorgi Esebua
- Department of Anesthesiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Michael Burchell
- Department of Anesthesiology, Wake Forest University, Winston-Salem, North Carolina, USA
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17
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Cohen SP, Gilmore CA, Rauck RL, Lester DD, Trainer RJ, Phan T, Kapural L, North JM, Crosby ND, Boggs JW. Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Pain Following Amputation. Mil Med 2020; 184:e267-e274. [PMID: 31111898 PMCID: PMC6614808 DOI: 10.1093/milmed/usz114] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/02/2019] [Accepted: 04/18/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction Chronic pain and reduced function are significant problems for Military Service members and Veterans following amputation. Peripheral nerve stimulation (PNS) is a promising therapy, but PNS systems have traditionally been limited by invasiveness and complications. Recently, a novel percutaneous PNS system was developed to reduce the risk of complications and enable delivery of stimulation without surgery. Materials and Methods Percutaneous PNS was evaluated to determine if stimulation provides relief from residual and phantom limb pain following lower-extremity amputation. PNS leads were implanted percutaneously to deliver stimulation to the femoral and/or sciatic nerves. Patients received stimulation for up to 60 days followed by withdrawal of the leads. Results A review of recent studies and clinical reports found that a majority of patients (18/24, 75%) reported substantial (≥50%) clinically relevant relief of chronic post-amputation pain following up to 60 days of percutaneous PNS. Reductions in pain were frequently associated with reductions in disability and pain interference. Conclusions Percutaneous PNS can durably reduce pain, thereby enabling improvements in quality of life, function, and rehabilitation in individuals with residual or phantom limb pain following amputation. Percutaneous PNS may have additional benefit for Military Service members and Veterans with post-surgical or post-traumatic pain.
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Affiliation(s)
- Steven P Cohen
- Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD
| | | | - Richard L Rauck
- Center for Clinical Research, 145 Kimel Park Dr, Suite 330, Winston-Salem, NC
| | - Denise D Lester
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA
| | - Robert J Trainer
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA
| | - Thomas Phan
- Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA
| | - Leonardo Kapural
- Center for Clinical Research, 145 Kimel Park Dr, Suite 330, Winston-Salem, NC
| | - James M North
- Center for Clinical Research, 145 Kimel Park Dr, Suite 330, Winston-Salem, NC
| | - Nathan D Crosby
- SPR Therapeutics, 22901 Millcreek Blvd, Suite 110, Cleveland, OH
| | - Joseph W Boggs
- SPR Therapeutics, 22901 Millcreek Blvd, Suite 110, Cleveland, OH
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Mainkar O, Solla CA, Chen G, Legler A, Gulati A. Pilot Study in Temporary Peripheral Nerve Stimulation in Oncologic Pain. Neuromodulation 2020; 23:819-826. [PMID: 32185844 PMCID: PMC7496167 DOI: 10.1111/ner.13139] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/07/2020] [Accepted: 02/07/2020] [Indexed: 12/15/2022]
Abstract
Objectives Temporary, percutaneous peripheral nerve stimulation (PNS) has been shown to provide analgesia for acute postoperative pain, postamputation pain, and low back pain. The implanted device stimulates the neural target for up to 60 days at which point the leads are extracted. Patients have demonstrated prolonged analgesia continuing after extraction of the leads. The purpose of this case series is to demonstrate peripheral neural targets that could feasibly be used to treat various pain syndromes prevalent in the oncologic population. Materials and Methods A temporary, percutaneous PNS was implanted under ultrasound guidance in 12 oncologic chronic pain patients seen in an outpatient pain clinic who had failed medical and/or interventional management. The device was implanted for up to 60 days. Clinical progress of pain and functional capacity was monitored through regular clinical visits. Results The case series presents seven successful cases of implementation of the PNS to treat oncologic pain. Three of these cases demonstrate targeting of proximal spinal nerves to treat truncal neuropathic pain and lumbar radicular pain. The four remaining cases demonstrate successful targeting of other peripheral nerves and brachial plexus. We also share five failed cases without adequate pain relief with PNS. Conclusions PNS has potential uses in the treatment of oncologic pain. Further high‐quality studies should be designed to further elucidate use of the PNS to treat oncologic pain.
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Affiliation(s)
- Ojas Mainkar
- Department of Anesthesiology, New York Presbyterian Hospital, New York, NY, USA
| | | | - Grant Chen
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aron Legler
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Gilmore CA, Kapural L, McGee MJ, Boggs JW. Percutaneous Peripheral Nerve Stimulation (PNS) for the Treatment of Chronic Low Back Pain Provides Sustained Relief. Neuromodulation 2018; 22:615-620. [DOI: 10.1111/ner.12854] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 12/23/2022]
Affiliation(s)
| | - Leonardo Kapural
- Center for Clinical ResearchCarolinas Pain Institute Winston Salem NC USA
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20
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Current Innovations in Peripheral Nerve Stimulation. PAIN RESEARCH AND TREATMENT 2018; 2018:9091216. [PMID: 30302288 PMCID: PMC6158945 DOI: 10.1155/2018/9091216] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/08/2018] [Accepted: 08/19/2018] [Indexed: 12/17/2022]
Abstract
Peripheral nerve stimulation has been used in the treatment of several chronic pain conditions including pain due to peripheral nerve dysfunctions, complex regional pain syndrome, and cranial neuralgias. It has been shown to be effective for chronic, intractable pain that is refractory to conventional therapies such as physical therapy, medications, transcutaneous electrical stimulations, and nerve blocks. Recently, a new generation of peripheral nerve stimulation devices has been developed; these allow external pulse generators to transmit impulses wirelessly to the implanted electrode, and their implantation is significantly less invasive. In this review, we discuss the history, pathophysiology, indications, implantation process, and outcomes of employing peripheral nerve stimulation to treat chronic pain conditions.
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Ilfeld BM, Ball ST, Gabriel RA, Sztain JF, Monahan AM, Abramson WB, Khatibi B, Said ET, Parekh J, Grant SA, Wongsarnpigoon A, Boggs JW. A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty. Neuromodulation 2018; 22:653-660. [PMID: 30024078 PMCID: PMC6339601 DOI: 10.1111/ner.12790] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Scott T Ball
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Amanda M Monahan
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jesal Parekh
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Stuart A Grant
- Duke University Medical Center, Duke University, Durham, NC, USA
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