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

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

Severe Pain in a Leiomyoma with Twin Pregnancy- An Analgesic Dilemma

BACKGROUND: Pain is the most common complication of fibroids in pregnancy and can be difficult to treat. The choices of pain relief in pregnancy are limited due to myriad risks including miscarriage, teratogenicity, premature birth, and low birth weight. CASE REPORT: This paper describes the analgesic challenges faced when managing severe pain in the antepartum period for a woman pregnant with twins who also suffered from uterine leiomyomas. Multiple analgesic regimens were trialled over the course of the pregnancy with large doses of opioids required for long periods. Ultimately the patient underwent a laparotomy and myomectomy at 25 weeks gestation in an attempt to alleviate her pain. CONCLUSION: There should be early discussions and planning around the choice of analgesic agents and their planned duration, with the risks and benefits weighed in each instance. A multidisciplinary approach with obstetricians, neonatologists, anesthetists, and pain specialists is likely to result in the most benefit while limiting the risk to the fetus

High Frequency Spinal Cord Stimulation in a Patient with Bilateral Cochlear Implants

BACKGROUND: High-frequency spinal cord stimulation (HF-SCS) has become very popular in the management of chronic pain worldwide. As it relies on generating high-frequency electrical impulses, there is a risk of interference with other devices such as cochlear implants that utilize similar principles. A literature search did not reveal any case reports of HF-SCS implantation in a patient with cochlear implants. CASE REPORT: A 75-year-old White woman with a history of bilateral cochlear implants (Cochlear Americas Nucleus® with cp910 processor) for severe sensorineural hearing loss presented to our chronic pain clinic with lumbosacral radiculopathy. The patient underwent a HF-SCS trial with entry point at the L1-L2 space and the leads positioned at the top and bottom of T8. The patient did not experience any auditory interference with her Cochlear implant at triple the average SCS stimulation strength. During the follow-up visit the next week, the patient reported nearly 80% symptomatic pain relief and significant functional improvement. There was no change in her hearing and no evidence of interference. The patient ultimately underwent percutaneous SCS paddle electrode placement and at 3 months, continues to have excellent pain relief without any auditory interactions. CONCLUSION: We successfully implanted a HF-SCS at the thoracic level in a patient with bilateral cochlear implants without any auditory interference. KEY WORDS: Cochlear implant, lumbar radiculopathy, spinal cord stimulation

Complex Regional Pain Syndrome Type II After Cervical Interlaminar Epidural Injection

BACKGROUND: Complex regional pain syndrome (CRPS) is a pain condition associated with autonomic and inflammatory features and is characterized by pain that is disproportionate in magnitude to the typical pain after similar injuries. The pathophysiology of CRPS is poorly understood, and many events have been implicated as causative factors. CASE REPORT: There are 2 previously documented case reports of CRPS after epidural steroid injections (ESI). This case report details the development of CRPS symptoms in a patient after receiving a cervical ESI. The precipitating event could have been trauma to a nerve root, nerve root irritation from the injectate, or contrast media reaction. Treatment focused on physical therapy and early intervention with a stellate ganglion block. The patient had complete resolution of her symptoms after 10 months. CONCLUSIONS: Although rare, CRPS due to direct nerve root injury or nerve root irritation can develop after an ESI; early diagnosis and treatment may result in a better outcome. KEY WORDS: Complex regional pain syndrome, CRPS, epidural steroid injections, TFESI, ILESI

A Retrospective, Single-Center Study Investigating the Effects of a Novel Miniature Wireless Spinal Cord Stimulation System for the Treatment of Chronic Back and Leg Pain

BACKGROUND: Tietze syndrome is believed to be a result of recurrent microtrauma and characterized by painful localized inflammation and swelling of the chest wall. Chronic inflammatory changes may infiltrate surrounding tissues, leading to nerve root irritation and subsequent neuralgia. Resultant chronic neuropathy has been historically treated with conservative therapies and local nerve blocks, but the role of implantable neurostimulators have not been well described. CASE REPORT: A 73-year-old woman presented with chronic pain in the left paracentral chest area with episodes of burning and tingling, which radiated to the left shoulder, left arm, and left upper side of the jaw and face. Following the implantation of a permanent neurostimulator, the patient reported a near complete resolution of her pain symptoms. CONCLUSION: The role of implantable neurostimulators in the treatment of chronic neuropathy in the setting of Tietze syndrome is promising and their use may become a mainstay option in the future. KEY WORDS: Tietze Syndrome, neuromodulation, spinal cord nerve stimulation, pain management, neuralgia, implantable spinal cord stimulator

Spontaneous Intracranial Hypotension (SIH) Pain Relief with Lumbar Epidural Blood Patch (EBP) in a Patient with Cancer: A Case Report

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a challenging chronic headache pain condition that can severely debilitate patients. It can be caused by any etiology in which intracranial cerebrospinal fluid (CSF) outflow surpasses CSF production. Conservative first-line therapy typically involves caffeine, hydration, medications, bed rest, and/or abdominal binding. Refractory cases involve epidural blood patch and surgical repair. To date, there have been no published studies or case reports on the treatment of SIH using epidural blood patch (EBP) in patients with cancer. We present a case demonstrating the utility of EBP in the treatment of refractory SIH in a patient with cancer. CASE REPORT: A 65-year-old woman with lung adenocarcinoma presented with refractory SIH of 2 years. She failed conservative first-line therapies and was evaluated by multiple services without relief. She then received an EBP with 75% relief of symptoms, and 100% relief of all symptoms with a repeat EBP. CONCLUSIONS: Given its overall safety and effectiveness, EBP should be considered as a treatment option in patients with cancer who present with SIH. KEY WORDS: Cancer, cerebrospinal fluid, chronic pain, epidural blood patch, headache, oncology, spontaneous intracranial hypotension

Dramatic Response to Lidocaine Infusion for Pain from Brachial Plexus Avulsion Injury

BACKGROUND: Traumatic brachial plexus avulsion injury (tBPI) can cause a severe chronic pain syndrome that is very difficult to treat. Though lidocaine has been shown to be effective for other pain syndromes, effectiveness in tBPI has not previously been reported. CASE REPORT: A 55-year-old man with tBPI had severe pain and minimal relief with numerous analgesic agents. He was able to access intravenous lidocaine as he was being treated at a cancer center, and had a sustained response to 7 mg/kg given over an hour. CONCLUSION: There is potential for a single bolus intravenous lidocaine infusion to provide good pain control sustained over many months in patients with traumatic brachial plexus injury. An adequate serum concentration of lidocaine is required for analgesic effect. If initial doses of lidocaine are tolerated but ineffective, higher doses may still be beneficial. KEY WORDS: Brachial plexus avulsion, lidocaine, lignocaine, pain management, palliative care, therapeutics, trauma

Spinal Cord Stimulator for Treating Chemotherapy-induced Peripheral Neuropathy

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is not only one of the most common adverse experiences of cancer survivors, but it is also one which has the greatest effect on quality of life. Ultimately, CIPN can lead to unwanted modification of treatment such as chemotherapy dose reductions or termination of treatment altogether. CASE REPORT: We present a case of a 47-year-old man with severe bilateral CIPN resistant to conservative management, who was successfully treated with spinal cord stimulation. CONCLUSION: Spinal cord stimulation can be an effective treatment for CIPN resistant to conservative management. KEY WORDS: Spinal cord stimulator, chemotherapy induced neuropathy, peripheral neuropathy

The Use of Thoracic Epidural for Rapid Opioid Taper

BACKGROUND: Inflammatory Bowel Disease (IBD) is often associated with significant abdominal pain that can be challenging to control. Although controversial, opioids are often prescribed for the management of abdominal pain in patients with IBD. There have been several methods described for the rapid taper of patients on long-term, high-dose opioids. However, to date, there have been no reported cases using epidural analgesia for rapid opioid taper. CASE REPORT: We present a case of a 36-year-old man with ulcerative colitis and recurrent bowel obstructions on a high-dose transdermal fentanyl patch whose opioid consumption was rapidly tapered during inpatient hospitalization utilizing thoracic epidural analgesia. CONCLUSION: The potential role of epidural analgesia in rapid opioid taper has yet to be explored. In patients with chronic pain and inflammatory bowel disease or recurrent bowel obstructions, epidural analgesia may be particularly helpful to improve gastrointestinal motility while also being used to rapidly taper opioid dosage. KEY WORDS: Inflammatory bowel disease, ulcerative colitis, Crohn’s disease, epidural, opioids, rapid opioid taper, fentanyl patch

Exposed Hardware: A True Contraindication for a Spinal Cord Stimulator? A Case Report and Review of the Literature

BACKGROUND: Infection is one of the most common complications of spinal cord stimulator (SCS) implantation and causes severe morbidity for the patients and is costly for the health system and insurance. Every effort to minimize the risk of infection Post-SCS implantation has to be made. CASE REPORT: A 55-year-old man suffered right arm brachial plexus avulsion and subdural hematoma requiring a craniotomy and subsequently a cranioplasty with a metal mesh in 1998. Over the years he developed significant neuropathic pain which was controlled with a combination medication regimen until recently. In our clinic, a trial of cervical SCS showed significant improvement of pain. The consulting neurosurgeon, while evaluating his skull, noticed a very small skin defect, exposing a metal plate with no signs of infection. Based on that, he refused to implant the SCS. The patient is now seeking alternative treatment methods. CONCLUSION: Well-designed animal/human studies investigating the effects of exposed hardware for seeding infection to remote implants in the body are required to scientifically extrapolate if exposed hardware is a true contraindication for implanting an SCS or other devices in the body. KEY WORDS: Spinal cord stimulator, brachial plexus injury, complex regional pain syndrome, exposed hardware, surgical infection