PERIPHERAL NERVE STIMULATION IN SEVERE NEUROPATHIC UPPER EXTREMITY PAIN IN A PATIENT WITH AMYOTROPHIC LATERAL SCLEROSIS

Abstract Background Complex regional pain syndrome (CRPS) is a chronic disabling painful disorder with limited options to achieve therapeutic relief. CRPS type I which follows trauma, may not show obvious damage to the nervous structures and remains dubious in its pathophysiology and also its response to conservative treatment or interventional pain management is elusive. Spinal cord and dorsal root ganglion stimulation (SCS, DRGS) provide good relief, mainly for causalgia or CRPS I of lower extremities but not very encouraging for upper extremity CRPS I. we reported earlier, a case of CRPS I of right arm treated successfully by wireless peripheral nerve stimulation (WPNS) with short term follow up. Here we present 1-year follow-up of this patient. Objective To present the first case of WPNS for CRPS I with a year follow up. The patient had minimally invasive peripheral nerve stimulation (PNS), without implantable pulse generator (IPG) or its accessories. Case report This was a case of refractory CRPS I after blunt trauma to the right forearm of a young female. She underwent placement of two Stimwave electrodes (Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1) in her forearm under intraoperative electrophysiological and ultrasound guidance along radial and median nerves. This WPNS required no IPG. At high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA), patient had shown remarkable relief in pain, allodynia and temperature impairment. At 5 months she started driving without opioid consumption, while allodynia disappeared. At 1 year follow up she was relieved of pain [visual analogue scale (VAS) score of 4 from 7] and Kapanji Index (Score) improved to 7–8. Both hands look similar in color and temperature. She never made unscheduled visits to the clinic or visited emergency room for any complications related to the WPNS. Conclusions CRPS I involving upper extremity remain difficult to manage with conventional SCS or DRGS because of equipment related adverse events. Minimally invasive WPNS in this case had shown consistent relief without any complications or side effects related to the wireless technology or the technique at the end of 1 year. Implications This is the first case illustration of WPNS for CRPS I, successfully treated and followed up for 1 year.

Download Full-text

Abstract TMP31: Peripheral Nerve Stimulation Paired with Constraint-Induced Therapy to Enhance Post-Stroke Upper Extremity Motor Performance

Stroke ◽

10.1161/str.44.suppl_1.atmp31 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Cheryl Carrico ◽

KC Chelette ◽

Laurie Nichols ◽

Lumy Sawaki

Keyword(s):

Peripheral Nerve ◽

Upper Extremity ◽

Motor Function ◽

Nerve Stimulation ◽

Motor Performance ◽

Motor Recovery ◽

Peripheral Nerve Stimulation ◽

Motor Deficit ◽

Motor Training ◽

Post Stroke

Research has shown that peripheral nerve stimulation (PNS) can enhance motor learning following cortical lesions. Studies have also shown that intensive upper extremity motor training can significantly enhance post-stroke motor performance. Constraint-induced therapy (CIT) is a form of intensive training that restricts use of the non-paretic upper extremity during repetitive, task-oriented motor training of the paretic extremity. Extensive evidence has validated the effectiveness of CIT for enhancing post-stroke upper extremity motor recovery. No studies have evaluated how PNS may modulate the effects of CIT. Therefore, we conducted a pilot study of PNS paired with CIT and hypothesized that in subjects with stroke, pairing CIT with active PNS would lead to significantly more improved motor function in the paretic upper extremity than CIT paired with sham PNS. Outcome measures included the Fugl-Meyer Assessment Scale (FMA; primary outcome measure), the Wolf Motor Function Test (WMFT), and the Action Research Arm Test (ARAT). Nineteen chronic stroke subjects with mild to moderate upper extremity motor deficit received 2 hours of either active (n=10) or sham (n=9) PNS preceding 4 hours of CIT for 10 consecutive weekdays. Changes in FMA, WMFT, and ARAT were analyzed using factorial ANOVA. Results showed significant (p<0.05) change in all measures at completion evaluation compared with baseline (FMA (p=0.005); WMFT (p=0.030); ARAT (p=0.020)) as well as 1-month follow-up compared with baseline (FMA (p=0.048); WMFT (p=0.045); ARAT (p=0.047)). These results highlight the enormous potential for PNS paired with CIT to enhance post-stroke upper extremity motor recovery more effectively than CIT alone.

Download Full-text

Peripheral Nerve Stimulation of Complex Upper Extremity Amputation Pain May Be Variable

A & A Practice ◽

10.1213/xaa.0000000000001441 ◽

2021 ◽

Vol 15 (4) ◽

pp. e01441

Author(s):

Michael J. Jung ◽

Scott G. Pritzlaff

Keyword(s):

Peripheral Nerve ◽

Upper Extremity ◽

Nerve Stimulation ◽

Peripheral Nerve Stimulation ◽

Extremity Amputation ◽

Stimulation Of

Download Full-text

Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: a case illustration introducing a novel technology

Scandinavian Journal of Pain ◽

10.1515/sjpain-2018-0014 ◽

2018 ◽

Vol 18 (3) ◽

pp. 555-560 ◽

Cited By ~ 8

Author(s):

Daniel Herschkowitz ◽

Jana Kubias

Keyword(s):

Minimally Invasive ◽

Peripheral Nerve ◽

Complex Regional Pain Syndrome ◽

Upper Extremity ◽

Nerve Stimulation ◽

Pain Syndrome ◽

Peripheral Nerve Stimulation ◽

Therapeutic Modality ◽

Invasive Technique ◽

Type I

AbstractBackgroundComplex regional pain syndrome (CRPS) is a debilitating painful disorder, cryptic in its pathophysiology and refractory condition with limited therapeutic options. Type I CRPS with its variable relationship to trauma has often no discernible fractures or nerve injuries and remains enigmatic in its response to conservative treatment as well as the other limited interventional therapies. Neuromodulation in the form of spinal cord and dorsal root ganglion stimulation (SCS, DRGS) has shown encouraging results, especially of causalgia or CRPS I of lower extremities. Upper extremity CRPS I is far more difficult.ObjectiveTo report a case of upper extremity CRPS I treated by wireless peripheral nerve stimulation (WPNS) for its unique features and minimally invasive technique. The system does not involve implantation of battery or its connections.Case reportA 47 year old female patient presented with refractory CRPS I following a blunt trauma to her right forearm. As interventional treatment in the form of local anesthetics (Anesthesia of peripheral branches of radial nerve) and combined infusions of ketamine/lidocaine failed to provide any significant relief she opted for WPNS treatment. Based on the topographic distribution, two electrodes (Stimwave Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1), were placed along the course of radial and median nerves under ultrasonography monitoring and guided by intraoperative stimulation. This procedure did not involve implantation of extension cables or the power source. At a frequency of 60 Hz and 300 μs the stimulation induced paresthesia along the distribution of the nerves. Therapeutic relief was observed with high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA) reducing her pain from a visual analogue scale (VAS) score of 7–4 postoperatively. Three HF stimulations programs were provided at the time of discharge, as she improved in her sensory impairment to touch, pressure and temperature at her first follow up visit. At 5-months she was able to drive, did not require opioids and allodynia disappeared.ConclusionsIn a case with difficult CRPS I involving upper extremity, a minimally invasive WPNS of radial and median nerves provided good symptomatic relief. The procedure was tolerated well and both electrodes remained in place without any adverse events.ImplicationsIn view of the very limited options currently available to manage CRPS, WPNS can be a promising therapeutic modality.

Download Full-text

Techniques for Peripheral Nerve Stimulator Implantation of the Upper Extremity

Pain Medicine ◽

10.1093/pm/pnaa185 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

pp. S27-S31

Author(s):

Vinita Singh ◽

Diya Sandhu ◽

Nan Xiang

Keyword(s):

Peripheral Nerve ◽

Upper Extremity ◽

Nerve Stimulation ◽

Pulse Generator ◽

Technical Note ◽

Peripheral Nerve Stimulation ◽

Nerve Stimulator ◽

Peripheral Nerve Stimulator ◽

Academic Center ◽

Technical Details

Abstract Objective To present a technical note on how to perform upper extremity peripheral nerve stimulators for three major nerves: median, ulnar, and radial. Design Literature review and expert opinion. Setting Single academic center. Results Peripheral nerve stimulation has recently become popular with the development and availability of peripheral nerve stimulators with an external pulse generator. Here, we describe ultrasound anatomy and technical details for peripheral nerve stimulation in the upper extremity for three major nerves: median, ulnar, and radial. Conclusions Upper extremity peripheral nerve stimulation can be considered as an option for refractory neuropathic upper extremity pain.

Download Full-text