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

Neuropathic pain is a rampant disease exacting a significant toll on patients, providers, and health care systems around the globe. Neuromodulation has been successfully employed to treat many indications including failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), phantom limb pain (PLP), radiculopathies, and intractable pelvic pain, among many others. Recent studies have also demonstrated efficacy for cancer-related pain and chemotherapy induced neuropathy with these techniques. Spinal cord stimulation (SCS) is the most commonly employed technique and involves implantation of percutaneous or paddle leads targeting the dorsal columns of the spinal cord with the goal of disrupting the pain signals traveling to the brain. Tonic, high frequency, and burst waveforms have all been shown to reduce pain and disability in chronic pain patients. Closed-loop SCS systems that automatically adjust stimulation parameters based on feedback (such as evoked compound action potentials) are becoming increasingly used to help ease the burden placed on patients to adjust their programming to their pain and position. Additionally, dorsal root ganglion stimulation (DRGS) is a newer technique that allows for dermatomal coverage especially in patients with pain in up to two dermatomes. Regardless of the technique chosen, neuromodulation has been shown to be cost-effective and efficacious and should be given full consideration in patients with chronic pain conditions.

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Spinal Cord Stimulation Therapy for the Treatment of Concomitant Phantom Limb Pain and Critical Limb Ischemia

Annals of Vascular Surgery ◽

10.1016/j.avsg.2015.10.015 ◽

2016 ◽

Vol 32 ◽

pp. 131.e11-131.e14 ◽

Cited By ~ 8

Author(s):

Giovanni De Caridi ◽

Mafalda Massara ◽

Raffaele Serra ◽

Claudia Risitano ◽

Massimiliano Giardina ◽

...

Keyword(s):

Spinal Cord ◽

Critical Limb Ischemia ◽

Spinal Cord Stimulation ◽

Phantom Limb Pain ◽

Limb Ischemia ◽

Phantom Limb ◽

Limb Pain

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Mirror therapy for Complex Regional Pain Syndrome (CRPS)—A literature review and an illustrative case report

Scandinavian Journal of Pain ◽

10.1016/j.sjpain.2013.06.002 ◽

2013 ◽

Vol 4 (4) ◽

pp. 200-207 ◽

Cited By ~ 9

Author(s):

Samaa Al Sayegh ◽

Tove Filén ◽

Mats Johansson ◽

Susanne Sandström ◽

Gisela Stiewe ◽

...

Keyword(s):

Case Report ◽

Complex Regional Pain Syndrome ◽

Reflex Sympathetic Dystrophy ◽

Phantom Limb Pain ◽

Pain Syndrome ◽

Signs And Symptoms ◽

Physical Rehabilitation ◽

Phantom Limb ◽

Mirror Therapy ◽

Limb Pain

AbstractBackground and purposeThis case of a 42 year old woman with lower extremity Complex Regional Pain Syndrome (CRPS) after a twisting injury of the ankle, effectively treated with the addition of mirror therapy to a rehabilitation programme, prompted a literature review of both CRPS and mirror therapy. Mirror therapy is a newer adjunct to other forms of pain control and functional restoration for treatment of CRPS as well as other difficult clinical problems. This was a required group project as part of a university based course in chronic pain for healthcare workers.Materials and methodsThe PubMed database up to September 26,2012 was reviewed using four search word groups: “CRPS mirror therapy”, “mirror CRPS”, “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror” and “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror + RCT”. Nine studies from PubMed met the criteria that this working group had chosen for inclusion in the analysis of mirror therapy as treatment. These references were supplemented by others on CRPS in order to generate an adequate review of both the syndrome CRPS and mirror therapy itself. Some references were specific for mirror therapy in the treatment of CRPS but others described mirror therapy for the treatment of phantom limb pain, brachial plexus avulsion pain, for physical rehabilitation of stroke related paresis and for rehabilitation after hand surgery.ResultsCriteria for the diagnosis of CRPS including the International Association for the Study of Pain criteria and the Budapest criteria are reviewed with an emphasis on the specificity and sensitivity of the various criteria for clinical and research purposes. The signs and symptoms of CRPS are a part of the criteria review.The main treatment strategy for CRPS is physical rehabilitation for return of function and mirror therapy is one of many possible strategies to aid in this goal.The patient in this case report had failed many of the adjunctive therapies and rehabilitation had been unsuccessful until the addition of mirror therapy. She then could progress with physical rehabilitation and return to a more normal life. Mirror therapy techniques are briefly described as part of a discussion of its success with relationship to signs and symptoms as well as to the duration of CRPS (and other syndromes). Some discussion of the theories of the central effects of both CRPS and phantom limb pain and how these are affected by mirror therapy is included.An analysis of the 9 most relevant articles plus a critique of each is present in table form for review.ConclusionsThere appears to be a clear indication for the use of mirror therapy to be included in the multidisciplinary treatment of CRPS types 1 and 2 with a positive effect on both pain and motor function. There is also evidence that mirror therapy can be helpful in other painful conditions such as post stroke pain and phantom limb pain.ImplicationsCRPS is often overlooked as an explanation for obscure pain problems. Prompt diagnosis is essential for effective treatment. Mirror therapy is a newer technique, easy to perform and can be a useful adjunct to aid physical rehabilitation and decrease pain in this population. Much further prospective research on mirror therapy in CRPS is ongoing and is needed to systematize the technique, to clarify the effects and to define the place of this therapy in the multidisciplinary management of CRPS.

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