Spinal cord stimulation for intractable visceral pain due to sphincter of oddi dysfunction

Spinal Cord Stimulation for Intractable Visceral Pain Originating from the Pelvic and Abdominal Region: A Narrative Review on a Possible New Indication for Patients with Therapy-Resistant Pain

Aim

Visceral pain, characterized by pain that is diffuse and challenging to localize, occurs frequently and is difficult to treat. In cases where the pain becomes intractable despite optimal medical management, it can affect patients' Quality of Life (QoL). Spinal Cord Stimulation (SCS) has emerged as a potential solution for intractable visceral pain.

Purpose

In this narrative review, we collected all evidence regarding the efficacy of SCS for visceral pain across various underlying conditions.

Methods

A comprehensive literature search was conducted in PubMed, Embase, and Web of Science in which articles published from October 1st, 1963 up to March 7th, 2023 were identified.

Results

Seventy articles were included in this review of which most were retrospective cohort studies, case series and case reports. The studies, often with a small number of participants, reported on SCS for chronic pancreatitis, anorectal pain and bowel disorders, gynaecological diagnoses, visceral pelvic pain, urological disorders and finally general visceral pain. They found positive effects on pain and/or symptom relief, opioid consumption, anxiety and depression and QoL. Complications occurred frequently but were often minor and reversible.

Conclusion

Better screening and selection criteria need to be established to optimally evaluate eligible patients who might benefit from SCS. A positive outcome of a sympathetic nerve block appears to be a potential indicator of SCS effectiveness. Additionally, women receiving SCS for endometriosis had a better outcome compared to other indications. Finally, SCS could also relief functional symptoms such as voiding problems and gastroparesis. Complications could often be resolved with revision surgery. Since SCS is expensive and not always covered by standard health insurance, the incorporation of cost-analyses is recommended. In order to establish a comprehensive treatment plan, including selection criteria for SCS, rigorous prospective, possibly randomized and controlled studies that are diagnosis-oriented, with substantial follow-up and adequate sample sizes, are needed.

Spinal cord stimulation for visceral pain associated with medullary sponge kidney

Chronic pain is a common reason for which people in the USA seek medical care. It is linked to opioid consumption, anxiety and a reduction in quality of life. Over the past 50 years, spinal cord stimulation (SCS) has evolved as a safe and efficacious treatment for chronic pain etiologies. The authors present the first known case of SCS for pain due to medullary sponge kidney disease. This report adds to the growing body of literature supporting the use of SCS for treating visceral organ pain, while also highlighting the utility of ventral lead placement for treating visceral pain. As SCS utilization increases, it is expected that there will be a decrease in opioid consumption, and this will help us contain the opioid epidemic.

Spinal Cord Stimulation for Visceral Pain: Present Approaches and Future Strategies

INTRODUCTION

The introduction of successful neuromodulation strategies for managing chronic visceral pain lag behind what is now treatment of choice in refractory chronic back and extremity pain for many providers in the United States and Europe. Changes in public policy and monetary support to identify nonopioid treatments for chronic pain have sparked interest in alternative options. In this review, we discuss the scope of spinal cord stimulation (SCS) for visceral pain, its limitations, and the potential role for new intradural devices of the type that we are developing in our laboratories, which may be able to overcome existing challenges.

METHODS

A review of the available literature relevant to this topic was performed, with particular focus on the pertinent neuroanatomy and uses of spinal cord stimulation systems in the treatment of malignant and nonmalignant gastrointestinal, genitourinary, and chronic pelvic pain.

RESULTS

To date, there have been multiple off-label reports testing SCS for refractory gastrointestinal and genitourinary conditions. Though some findings have been favorable for these organs and systems, there is insufficient evidence to make this practice routine. The unique configuration and layout of the pelvic pain pathways may not be ideally treated using traditional SCS implantation techniques, and intradural stimulation may be a viable alternative.

CONCLUSIONS

Despite the prevalence of visceral pain, the application of neuromodulation therapies, a standard approach for other painful conditions, has received far too little attention, despite promising outcomes from uncontrolled trials. Detailed descriptions of visceral pain pathways may offer several clues that could be used to implement devices tailored to this unique anatomy.

The Efficacy of BurstDR Spinal Cord Stimulation for Chronic Abdominal Pain: A Clinical Series

BACKGROUND

Chronic abdominal pain is a debilitating condition known for its multifactorial nature. Outcomes with spinal cord stimulation (SCS) for abdominal pain syndromes are noticeably absent in the literature. To date, there have been no published reports of novel waveforms of SCS for management of chronic abdominal pain. We assessed the efficacy and durability of BurstDR SCS in reducing abdominal pain and analgesic consumption.

CASE DESCRIPTION

We performed a retrospective review of medical records from 3 patients with different etiologies of abdominal pain (postherniorrhaphy pain syndrome, Crohn disease, abdominal neuropathy). All patients underwent thoracic laminectomy for BurstDR SCS paddle lead and pulse generator placement after a successful trial stimulation period. Data were collected with a telephone survey after a minimum duration of >24 months following implantation. Pain scores were measured using a numeric rating scale. Two of 3 patients were entirely pain-free and reported Patient Global Impression of Change scores of 7 after a minimum follow-up of >24 months. While the third patient continued to have chronic as well as episodic abdominal pain, he was able to discontinue all narcotic pain medications and experienced a 33% decrease in frequency and 60% decrease in severity of monthly pain exacerbations. He reported satisfaction and a Patient Global Impression of Change of 6.

CONCLUSIONS

BurstDR SCS is a new programming modality, and long-term follow-up is necessary to determine its durability. Despite varying etiologies of abdominal pain, this series suggests BurstDR SCS sustained for >2 years might be effective as a treatment for abdominal pain syndromes. Future studies of SCS would benefit from standardized abdominal pain scores and high-powered studies using global patient registries.

Spinal Cauda Equina Stimulation for Alternative Location of Spinal Cord Stimulation in Intractable Phantom Limb Pain Syndrome: A Case Report

Phantom limb pain is a phenomenon in which patients experience pain in a part of the body that no longer exists. In several treatment modalities, spinal cord stimulation (SCS) has been introduced for the management of intractable post-amputation pain. A 46-year-old male patient complained of severe ankle and foot pain, following above-the-knee amputation surgery on the right side amputation surgery three years earlier. Despite undergoing treatment with multiple modalities for pain management involving numerous oral and intravenous medications, nerve blocks, and pulsed radiofrequency (RF) treatment, the effect duration was temporary and the decreases in the patient's pain score were not acceptable. Even the use of SCS did not provide completely satisfactory pain management. However, the trial lead positioning in the cauda equina was able to stimulate the site of the severe pain, and the patient's pain score was dramatically decreased. We report a case of successful pain management with spinal cauda equina stimulation following the failure of SCS in the treatment of intractable phantom limb pain.