Transcutaneous Peripheral Nerve Stimulation for the Treatment of Neuropathic Pain in the Upper Limb

Background: A small number of patients develop intractable peripheral nerve pain following injury or surgery to the upper limb that is refractory to pharmacological treatment. This study reports our results of using transcutaneous peripheral nerve stimulation (TPNS), a non-invasive form of neuromodulation, to treat this difficult problem. Methods: Seventy-two patients were treated for intractable pain in the upper limb using this technique. Electrical current was delivered transcutaneously through a handheld probe, placed on the skin overlying the affected peripheral nerve proximal to the site of pain. Pain severity was determined before and immediately after treatment by subjective patient self-assessment using a visual analogue pain scale. Pre-post treatment changes in pain severity were analysed by Student's test for paired data. Outcome in respect of overall effectiveness of this treatment, was graded according to the maximum duration of pain relief achieved. Results: Overall, TPNS reduced pain intensity from 8.4 (SD 1.6) before treatment to 4.2 (SD 3.5) immediately after treatment, a highly significant effect ([Formula: see text]). The treatment achieved cure in 8/72 (11%) of our patients and a useful therapeutic outcome (pain relief ≥ 1 day) in 27/72 (38%). The treatment failed in 37/72 (51%). Conclusions: TPNS warrants consideration as a therapy for neuropathic pain in the upper limb after drug treatment has failed and before offering surgery or spinal root stimulation.

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One Year Follow-up of a Randomized, Double-Blind, Placebo-Controlled Trial of Percutaneous Peripheral Nerve Stimulation for Chronic Neuropathic Pain Following Amputation

Neurosurgery ◽

10.1093/neuros/nyz310_144 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Joshua M Rosenow ◽

Christopher Gilmore ◽

Brian M Ilfeld ◽

Sean Li ◽

Mehul J Desai ◽

...

Keyword(s):

Neuropathic Pain ◽

Pain Relief ◽

Peripheral Nerve ◽

Nerve Stimulation ◽

Peripheral Nerve Stimulation ◽

Pain Interference ◽

Controlled Study ◽

Double Blind ◽

Double Blind Placebo

Abstract INTRODUCTION Over 85% of patients experience residual limb (RLP) and/or phantom limb (PLP) pain following amputation. Peripheral nerve stimulation (PNS) is a non-opioid approach to relieve postamputation neuropathic pain. A recent multicenter, randomized, double-blind, placebo-controlled study using a novel percutaneous PNS system demonstrated clinically and statistically significant improvements in pain and pain interference with PNS compared to placebo (Gilmore et al, 2019). This work presents prospective 1-yr follow-up to assess durability of pain relief and functional improvements. METHODS Over 85% of patients experience residual limb (RLP) and/or phantom limb (PLP) pain following amputation. Peripheral nerve stimulation (PNS) is a non-opioid approach to relieve post-amputation neuropathic pain. A recent multicenter, randomized, double-blind, placebo-controlled study using a novel percutaneous PNS system demonstrated clinically and statistically significant improvements in pain and pain interference with PNS compared to placebo (Gilmore et al, 2019). This work presents prospective one-year follow-up to assess durability of pain relief and functional improvements. RESULTS A significantly greater proportion of subjects who completed the 12-mo visit reported = 50% pain relief on the BPI-SF (5/8, 63%; average pain relief = 73% among responders) compared to the placebo group at the time of crossover (0/14, 0%, P = .003; average pain relief = 23%). A majority of subjects also reported = 50% reductions in pain interference at 12 mo (5/8, 63%). Two of 13 (15%) subjects in the placebo group reported sustained improvements in pain interference (P = .06). Average reduction in pain interference among responders in the PNS group was 87%. CONCLUSION This work suggests that PNS delivered over 60 d may provide clinically significant and enduring pain relief, enabling improved function and potentially reducing the need for a permanently implanted system.

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Percutaneous peripheral nerve stimulation for the treatment of chronic neuropathic postamputation pain: a multicenter, randomized, placebo-controlled trial

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2018-100109 ◽

2019 ◽

Vol 44 (6) ◽

pp. 637-645 ◽

Cited By ~ 10

Author(s):

Christopher Gilmore ◽

Brian Ilfeld ◽

Joshua Rosenow ◽

Sean Li ◽

Mehul Desai ◽

...

Keyword(s):

Neuropathic Pain ◽

Pain Relief ◽

Peripheral Nerve ◽

Nerve Stimulation ◽

Peripheral Nerve Stimulation ◽

Pain Interference ◽

Controlled Study ◽

Chronic Neuropathic Pain ◽

Postamputation Pain

Background and objectivesChronic neuropathic pain is a common challenging condition following amputation. Recent research demonstrated the feasibility of percutaneously implanting fine-wire coiled peripheral nerve stimulation (PNS) leads in proximity to the sciatic and femoral nerves for postamputation pain. A multicenter, double-blinded, randomized, placebo-controlled study collected data on the safety and effectiveness of percutaneous PNS for chronic neuropathic pain following amputation.MethodsTwenty-eight lower extremity amputees with postamputation pain were enrolled. Subjects underwent ultrasound-guided implantation of percutaneous PNS leads and were randomized to receive PNS or placebo for 4 weeks. The placebo group then crossed over and all subjects received PNS for four additional weeks. The primary efficacy endpoint evaluated the proportion of subjects reporting ≥50% pain reduction during weeks 1–4.ResultsA significantly greater proportion of subjects receiving PNS (n=7/12, 58%, p=0.037) demonstrated ≥50% reductions in average postamputation pain during weeks 1–4 compared with subjects receiving placebo (n=2/14, 14%). Two subjects were excluded from efficacy analysis due to eligibility changes. Significantly greater proportions of PNS subjects also reported ≥50% reductions in pain (n=8/12, 67%, p=0.014) and pain interference (n=8/10, 80%, p=0.003) after 8 weeks of therapy compared with subjects receiving placebo (pain: n=2/14, 14%; pain interference: n=2/13, 15%). Prospective follow-up is ongoing; four of five PNS subjects who have completed 12-month follow-up to date reported ≥50% pain relief.ConclusionsThis work demonstrates that percutaneous PNS therapy may provide enduring clinically significant pain relief and improve disability in patients with chronic neuropathic postamputation pain.Trial registration numberNCT01996254.

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Novel technique for trialing peripheral nerve stimulation: ultrasonography-guided StimuCath trial

Neurosurgical FOCUS ◽

10.3171/2016.12.focus16475 ◽

2017 ◽

Vol 42 (3) ◽

pp. E5 ◽

Cited By ~ 8

Author(s):

Chandan G. Reddy ◽

Oliver E. Flouty ◽

Marshall T. Holland ◽

Leigh A. Rettenmaier ◽

Mario Zanaty ◽

...

Keyword(s):

Neuropathic Pain ◽

Pain Relief ◽

Peripheral Nerve ◽

Nerve Stimulation ◽

Relative Effectiveness ◽

Peripheral Nerve Stimulation ◽

Insurance Companies ◽

Peripheral Nerve Stimulator ◽

Vas Score

OBJECTIVE Peripheral nerve stimulation (PNS) has been used for the treatment of neuropathic pain for many decades. Despite the specific indications for PNS, clinicians often have difficulty screening for candidates likely to have a good or fair outcome. Given the expense of a permanent implant, most insurance companies will not pay for the implant without a successful PNS trial. And since PNS has only recently been approved by the US Food and Drug Administration, many insurance companies will not pay for a conventional trial of PNS. The objective of this study is to describe a short low-cost method for trialing and screening patients for peripheral nerve stimulator implantation. Additionally, this study demonstrates the long-term efficacy of PNS in the treatment of chronic neuropathic pain and the relative effectiveness of this novel screening method. METHODS The records of all patients who had undergone trialing and implantation of a PNS system for chronic refractory pain at the authors' institution over a 1-year period (August 1, 2012–July 31, 2013) were examined in this retrospective case series. The search revealed 17 patients, 13 who had undergone a novel in-office ultrasonography-guided StimuCath screening technique and 4 who had undergone a traditional week-long screening procedure. All 17 patients experienced a successful PNS trial and proceeded to permanent PNS system implantation. Patients were followed up for a mean duration of 3.0 years. Visual analog scale (VAS) pain scores were used to assess pain relief in the short-term (< 6 weeks), at 1 year, and at the last follow-up. Final outcome was also characterized as good, fair, poor, or bad. RESULTS Of these 17 patients, 10 were still using their stimulator at the last follow-up, with 8 of them obtaining good relief (classified as ≥ 50% pain relief, with an average 81% reduction in the VAS score) and 2 patients attaining fair relief (< 50% relief but still using stimulation therapy). Among the remaining 7 patients, the stimulator had been explanted in 4 and there had been no relief in 3. Excluding explanted cases, follow-up ranged from 14 to 46 months, with an average of 36 months. Patients with good or fair relief had experienced pain prior to implantation for an average of 5.1 years (range 1.8–15.2 years). A longer duration of pain trended toward a poorer outcome (bad outcome 7.6 years vs good outcome 4.1 years, p = 0.03). Seven (54%) of the 13 patients with the shorter trial experienced a good or fair outcome with an average 79% reduction in the VAS score; however, all 4 of the bad outcome cases came from this group. Three (75%) of the 4 patients with the longer trial experienced a good or fair outcome at the last follow-up, with an average 54% reduction in the VAS score. There was no difference between the trialing methods and the proportion of favorable (good or fair) outcomes (p = 0.71). CONCLUSIONS Short, ultrasonography-guided StimuCath trials were feasible in screening patients for permanent implantation of PNS, with efficacy similar to the traditional week-long screening noted at the 3-year follow-up.

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Peripheral Nerve Stimulation for Trigeminal Neuropathic Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/27 ◽

2012 ◽

Vol 1;15 (1;1) ◽

pp. 27-33 ◽

Cited By ~ 1

Author(s):

David A. Stidd

Keyword(s):

Neuropathic Pain ◽

Peripheral Nerve ◽

Nerve Stimulation ◽

Medical Management ◽

Facial Pain ◽

Case Series ◽

Peripheral Nerve Stimulation ◽

Intractable Pain ◽

Safe Procedure ◽

Trigeminal Neuropathic Pain

Facial pain is a complex disease with a number of possible etiologies. Trigeminal neuropathic pain (TNP) is defined as pain caused by a lesion or disease of the trigeminal branch of the peripheral nervous system resulting in chronic facial pain over the distribution of the injured nerve. First line treatment of TNP includes management with anticonvulsant medication (carbamazepine, phenytoin, gabapentin, etc.), baclofen, and analgesics. TNP, however, can be a condition difficult to adequately treat with medical management alone. Patients with TNP can suffer from significant morbidity as a result of inadequate treatment or the side effects of pharmacologic therapy. TNP refractory to medical management can be considered for treatment with a growing number of invasive procedures. Peripheral nerve stimulation (PNS) is a minimally invasive option that has been shown to effectively treat medically intractable TNP. We present a case series of common causes of TNP successfully treated with PNS with up to a 2 year follow-up. Only one patient required implantation of new electrode leads secondary to electrode migration. The patients in this case series continue to have significant symptomatic relief, demonstrating PNS as an effective treatment option for intractable TNP. Though there are no randomized trials, peripheral neuromodulation has been shown to be an effective means of treating TNP refractory to medical management in a growing number of case series. PNS is a safe procedure that can be performed even on patients that are not optimal surgical candidates and should be considered for patients suffering from TNP that have failed medical management. Key words: Trigeminal neuropathic pain, peripheral nerve stimulation, neuromodulation, intractable pain, facial trauma, postherpetic neuralgia

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Peripheral Nerve Stimulation of Brachial Plexus Nerve Roots and Supra-Scapular Nerve for Chronic Refractory Neuropathic Pain of the Upper Limb

Neuromodulation Technology at the Neural Interface ◽

10.1111/ner.12573 ◽

2017 ◽

Vol 20 (7) ◽

pp. 684-689 ◽

Cited By ~ 9

Author(s):

Bénédicte Bouche ◽

Marie Manfiotto ◽

Philippe Rigoard ◽

Jean Lemarie ◽

Véronique Dix-Neuf ◽

...

Keyword(s):

Neuropathic Pain ◽

Peripheral Nerve ◽

Brachial Plexus ◽

Upper Limb ◽

Nerve Stimulation ◽

Peripheral Nerve Stimulation ◽

Nerve Roots ◽

Stimulation Of

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Ultrasound Guided Peripheral Nerve Stimulation Implant for Management of Intractable Pain after Inguinal Herniorrhaphy

January 2018 - Pain Physician ◽

10.36076/ppj/2015.18.e31 ◽

2015 ◽

Vol 18;1 (1;1) ◽

pp. E31-E38 ◽

Cited By ~ 2

Author(s):

Foad Elahi

Keyword(s):

Inguinal Hernia ◽

Pain Relief ◽

Peripheral Nerve ◽

Nerve Stimulation ◽

Case Series ◽

Peripheral Nerve Stimulation ◽

Intractable Pain ◽

Ultrasound Guided ◽

Inguinal Herniorrhaphy ◽

Significant Pain

Background: Inguinal hernia repair is one of the most common operations performed worldwide. Intractable pain following this operation is a potential debilitating complication. The exact etiology of this complex pain is unknown and the treatment of chronic pain after inguinal herniorrhaphy can be a difficult task for both the patient and the clinician. Objectives: The objectives of this study are to identify the ability of peripheral nerve electrical stimulation to decrease post inguinal herniorrhaphy pain, increase patients’ functionality, and decrease pain medication use. Study Design: Three patients with intractable pain after inguinal herniorrhaphy were included in this case series. Two patients had right-sided inguinal repair and one had a leftsided repair. Pain in these patients all began after the inguinal repair and had an average pain duration of 3.4 years after surgery. All 3 patients had been treated with multiple pain management modalities without significant pain improvement. We will describe the clinical course of these patients who presented with chronic intractable pain. After a period of failed conservative medical management and repetitive successful nerve blocks, we decided to proceed with utilizing electrical nerve stimulation as a treatment modality. Setting: This retrospective study was done at the university hospital and has an IRB assigned number. Results: After careful consideration of the patients’ history and physical examination and a thorough psychological assessment, we proceeded with a temporary percutaneous electrical neurostimulation that provided significant pain relief. Ultrasound guided permanent percutaneous electrical neurostimulation implant was shown to provide significant pain relief at 12-month follow-ups. We reviewed all existing pertinent medical literature related to the management of post herniorrhaphy pain. This case series adds to our current knowledge for chronic intractable post herniorrhaphy pain management. Limitations: This study is a retrospective assessment of a new technique that was applied to a limited number of cases. It remains to be determined whether this technique is superior to the classical open surgical technique in the future. Our findings warrant further studies on the utilization of peripheral nerve stimulation with chronic post herniorrhaphy pain. Key words: Peripheral nerve stimulation, ilioinguinal nerve, iliohypogastric nerve, nerve block, inguinal hernia repair, ultrasound guided procedure

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Chronic post-traumatic neuropathic pain of brachial plexus and upper limb: a new technique of peripheral nerve stimulation

Neurosurgical Review ◽

10.1007/s10143-014-0523-0 ◽

2014 ◽

Vol 37 (3) ◽

pp. 473-480 ◽

Cited By ~ 13

Author(s):

Giorgio Stevanato ◽

Grazia Devigili ◽

Roberto Eleopra ◽

Pietro Fontana ◽

Christian Lettieri ◽

...

Keyword(s):

Neuropathic Pain ◽

Peripheral Nerve ◽

Brachial Plexus ◽

Upper Limb ◽

Nerve Stimulation ◽

Peripheral Nerve Stimulation ◽

New Technique ◽

Post Traumatic ◽

A New Technique

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Peripheral Nerve Stimulation for Treatment of Painful Osteoarthritis of the Knee: A Case Report

Pain Management Case Reports ◽

10.36076/pmcr.2021.5.201 ◽

2021 ◽

pp. 201-204

Keyword(s):

Case Report ◽

Pain Relief ◽

Peripheral Nerve ◽

Knee Pain ◽

Nerve Stimulation ◽

Short Form ◽

Pain Modulation ◽

Peripheral Nerve Stimulation ◽

Osteoarthritis Of The Knee ◽

Osteoarthritic Knee

BACKGROUND: Osteoarthritic knee (OAk) pain is common, yet the standard of care often yields unsatisfactory pain relief. There remains a role for novel treatment options. Percutaneous motor peripheral nerve stimulation (mPNS) of the knee is a novel minimally invasive procedure that stimulates motor end points leading to muscle contraction associated with the painful joint. Pain relief is hypothesized to be achieved through central pain modulation. CASE REPORT: We report the case of a patient who experienced refractory osteoarthritic knee pain after 9 months of conservative care. Following 7 weeks of mPNS treatment, the patient achieved improvement in OAk pain relief and activities of daily living as measured by notable improvements in the Brief Pain Inventory-Short Form and Knee Injury and Osteoarthritis Outcome Score at 8- and 12-weeks postimplant. The Patient Global Impression of Change at the end of stimulation was much improved. CONCLUSION: Motor PNS may offer a safe and effective treatment alternative for chronic refractory pain related to OAk. KEY WORDS: Osteoarthritis, knee, pain, peripheral nerve stimulation

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