Neuromodulation: Technology at the Neural Interface Received: August 12, 2013
Revised: October 1, 2013
Accepted: October 31, 2013
(onlinelibrary.wiley.com) DOI: 10.1111/ner.12144
LETTER TO THE EDITOR
Spinal Cord Stimulation and Sacral Nerve Stimulation for Postlaminectomy Syndrome With Significant Low Back Pain To the Editor: Should a back surgery fail to achieve all of its desired outcomes, the result is known as postlaminectomy syndrome (PLS) or sometimes called failed back surgery syndrome (FBSS). Common symptoms of PLS include diffuse, dull, achy, burning sharp, pricking, stabbing pain in the back or extremities, after undergoing surgical intervention (1). About 500,000 spine surgeries are performed in the United States each year, and yet up to 20% of Americans who undergo spine surgery each year still have some degree of persistent back or leg pain afterward. Repeat spinal surgery after one operation that has been unsuccessful has a rather high incidence of also being unsuccessful (2). The most common indication for spinal cord stimulation (SCS) in the United States is FBSS (3). SCS has been found to be more cost-effective than reoperation in the treatment of FBSS (4). SCS is widely accepted as a treatment for FBSS; however, oftentimes the SCS fails to control axial low back pain while providing a reasonable control of the radicular pain. Several studies on SCS have failed to achieve sustained low back pain resolution (5). There are several reasons for this phenomenon, both anatomical and technical (6). To this date, the amount of publications of the treatment of low back pain with SNS is very limited. SCS is widely accepted as an effective treatment for neuropathic pain (7). At the same time, there are case reports where the SNS has been successful at treating pain of nociceptive origin. For instance, Kim and Moon report the use of neurostimulation for management of the sacroiliac (SI) joint pain (8). The axial low back pain represents a pain syndrome with nociceptive and neuropathic components that both could potentially respond to neurostimulation.
CASE DESCRIPTION
www.neuromodulationjournal.com
Address correspondence to: Alexander E. Yakovlev, MD, Comprehensive Pain Management of the Fox Valley, 100 Theda Clark Medical Plaza, Suite 252, Neenah, WI 54956, USA. Email: [email protected] No financial support to report. For more information on author guidelines, an explanation of our peer review process, and conflict of interest informed consent policies, please go to http:// www.wiley.com/bw/submit.asp?ref=1094-7159&site=1 Conflict of Interest: The authors reported no conflict of interest.
© 2014 International Neuromodulation Society
Neuromodulation 2014; 17: 763–765
763
The patient is a 29-year-old female with history of lumbar degenerative disk disease, lumbar spondylosis, lumbar facet arthropathy, bilateral sacroiliitis, low back myofascial pain, and lumbar radiculopathy who underwent an L3-4 decompression and a year later an L4-5 decompression through microdiscetomy. She presented with complaints of low back pain and bilateral leg pain, despite previous surgical intervention. She initially was treated with conservative therapy that included medications (pregabalin, amitriptyline, acetaminophen, ibuprofen, cyclobenzaprine, methylprednisolone, oxycodone, hydrocodone), physical therapy with transcutaneous electrical nerve stimulation trial, and chiropractic care. Several pain interventions were performed, including lumbar
epidural steroid injections, and bilateral SI joint injections with steroids were performed and provided the patient limited relief. Diagnostic lumbar facet injections were not effective. She describes her pain as constant, aching, sharp sensation in the low back with radiation in L5-S1 dermatomal distribution to bilateral legs and feet. This patient was not considered to be candidate for any further spine surgery. After all applicable conservative management options and injection options were tried with no success, the decision was made to proceed with thoracic epidural stimulation trial. During a trial, two 8-electrode leads were introduced into the epidural space at the high lumbar level and then advanced cranially in posterior epidural space to reach the level of T8, T9, and T10. The appropriate settings for neurostimulation were selected in order to provide coverage for bilateral leg pain and low back pain. During the three-day trial, the patient logged over 80% relief of the pain in both legs and low back. The decision was made to proceed with implantation of permanent spinal cord stimulator and spinal cord stimulator leads. Implantation and postoperative recovery period were uneventful. The patient proceeded to return to the clinic on an as-needed basis, utilizing her SCS solely for pain control. Nearly a year later, the patient returned to clinic with reports of low back pain not covered by current SCS. She returned to clinic on several occasions when different neurostimulation settings were tried. The fluoroscopy was performed and unchanged lead position was found at the level of T8, T9, and T10. The neurostimulation settings that were providing the axial low back pain relief resulted in uncomfortable paresthesia and muscle twitching in the abdomen and bilateral flank areas. At the same time, the patient on neurostimulation reported excellent radicular pain relief. Several interventional procedures were attempted to help alleviate the low back pain. However, a series of lumbar epidural steroid injections and SI joint injection provided only a short-lived pain relief.
YAKOVLEV ET AL.
Figure 1. Two 8-electrode leads were introduced into the epidural space through the sacrococcygeal ligament and advanced to level S1-S4.
Despite the fact that the low back pain persisted, the patient was very satisfied with the radicular pain relief and did not want to consider a revision of implanted neurostimulator. The sacral nerve stimulation (SNS) trial was suggested and patient agreed to explore this opportunity. During the trial, two 8-electrode leads were introduced into the epidural space through the sacrococcygeal ligament and advanced to level S1-S4 (Fig. 1). The patient reported 100% coverage of the pain areas in the low back and both buttocks with trial neurostimulation, and was very satisfied with this coverage with the following SNS parameters: Lead 1: electrode 2 (+), 3 (−), 4 (+) Lead 2: electrode 10 (−), 11 (+), 12 (−) Rate range: 60 hZ Amplitude (v): varies per patient preference, range 01–10.5 v Pulse width: 300 μsec During the three-day trial, the patient reported excellent coverage of both her low back and leg pain, with both the SCS implant and the temporary sacral neurostimulation. Later, we proceeded with implantation of the sacral neurostimulator with permanent leads positioned between S1 and S4. Implantation and postoperative recovery period were uneventful. At sixth-month follow-up visit, the patient reported significant pain relief (over 90% reduction in visual analog scale [VAS] pain scores) with permanent stimulators which later allowed the patient to decrease her opioid requirements. Twelve-month follow-up demonstrated continued reduction in pain scores (VAS reduction from 6–7/10 to 2/10). As permanent placement of both devices, over one year ago, the patient is reporting sustained pain relief in both her low back and both legs without unpleasant stimulation in her flank or abdomen. The patient uses both devices 24 hours a day.
DISCUSSION
764
Although the exact mechanism of SNS remains undetermined, this treatment is predominantly theorized similar to SCS. SCS has www.neuromodulationjournal.com
been used to effectively treat chronic pain of various origins. It is most commonly used for pain secondary to PLS, complex regional pain syndrome, angina pectoris, peripheral vascular disease (3). SCS alleviates pain by stimulating nerve fibers in the spinal cord. The resulting impulses in the fibers inhibit the conduction of pain signals to the brain. The inhibition of pain transmission may be explained by the “gate-control theory” introduced by Melzack and Wall in 1965. This theory proposes that large diameter afferent fibers via application of an externally applied electric field“closes the gate” of pain transmission. SCS causes somatic afferent inhibition of sensory processing in the spinal cord; it has shown to downregulate the effect on central nervous system excitability and involves several mechanisms. The neuromodulation effect of electrical stimulation may also alter local blood flow, cause release of endorphins, affect neurotransmitters and axonal conduction, and block cell membrane depolarization. Stimulation of the dorsal column increases release of γ-amino butyric acid and decreases the release of excitatory amino acid glutamate of the dorsal horn of rats with neuropathic pain (10). SCS has also been shown to inhibit sympathetic activity, reducing vasoconstriction, and releasing agents from sensory fibers to cause vasodilation (3). The effects of SNS on pain pathways are similar to that mentioned previously for SCS. SNS has been used since the 1980s to treat various dysfunctions of abdominal organs and pelvic pain. This form of neuromodulation has been successful in the management of patients with fecal incontinence (11), voiding dysfunction, irritable bowel syndrome, and intractable pelvic pain (9). By the mid-1990s, sacral root electrical neuromodulation was widely used by urologists for urinary voiding dysfunction (12). There are several published reports describing the use of SNS for management of anal pain and modification of function of pelvic organs. As a proven treatment for urinary incontinence, SNS has recently been found effective in the treatment of interstitial cystitis, a disorder that involves hyperreflexia of the urinary sphincter. SNS is also used to treat pelvic or urinary pain as well as fecal incontinence. Recent publication of SNS has been successful at treating pain related to SI joint dysfunction (8). It can be difficult to obtain consistent and sustainable relief of low back pain with SCS. Low back pain can be hard to target for several reasons, both anatomical and technical (6). The dorsal column is made of white matter, which has very poor electrical conductivity, much like fat. In order to obtain current into the dorsal column, the amplitude must be turned up. By doing this, the current runs through highly conductive cerebrospinal fluid and around the sides to the dorsal root. At which point, the patient typically experiences stimulation into their back and anterior leg, but also into the abdomen, usually felt as cramping. High amplitudes of stimulation can evoke motor responses (6). In order to stimulate low back fibers, stimulation needs to take place deeper in the dorsal column without overstimulating the dorsal roots. In the past, one lead midline or two leads placed right and left of midline, with multicontact programming, these fibers have been accessible (4). Dorsal root stimulation produces paresthesia only in the distribution of the dermatome stimulated (6). The low back dermatomes have a lot of anterior leg coverage. Nearly 80% of the lumbar dermatomes cover the legs, primarily anterior portions. Based on a dermatome chart, to cover low back pain, one would predominantly want to cover L2-5 dermatomes; however, most common practice is to place the lead at T9 in order to obtain low back coverage. Anatomically, this is because the spinal cord is shorter than the vertebral column; the spinal cord terminates at the T12-L1 level. From this
© 2014 International Neuromodulation Society
Neuromodulation 2014; 17: 763–765
LETTER TO THE EDITOR point, the caudal equine nerve roots extend caudally. Vertebral level of the lead will not match the dermatomes that are desired to be stimulated. Another anatomical factor that contributes to the difficulty of low back stimulation is the curvature of the spine. With thoracic kyphosis, the spinal cord is closer or farther away from the dorsal epidural space depending on what vertebral level (6). The diameter of the spinal cord also varies; the smallest diameter of the spinal cord is thoracic around T7-8 effecting the cerebral spinal flow, and thus far stimulation. SCS is widely accepted as a treatment for PLS, but many times SCS can control leg pain reasonably, but can fail to control low back pain. A prospective study from Barolat et al. examined 60 patients with low back and leg pain that were implanted with a 16-electrode paddle lead anywhere from T7 to T10 with a laminotomy technique. This study revealed that at one year, 88.2% of the patients reported fair to excellent relief in the legs and only 68.8% of the patients reported fair to excellent relief in the low back (13). Though this result had more promising results than others, the patient’s primary complaint is low back pain.
CONCLUSION Our case demonstrated that SNS represents an alternative therapeutic option for patients with axial low back pain who either failed to respond to epidural stimulation trial or developed poor coverage for the low back with time. Long-term, prospective, controlled studies are needed to evaluate this finding more rigorously, but presented here is a single case of FBSS with intractable low back and leg pain that was successfully treated with a dual system of SCS and SNS. Alexander E. Yakovlev, MD; Alexander A. Timchenko, MD; Angela M. Parmentier, MSN, APNP Comprehensive Pain Management of the Fox Valley, Neenah, WI, USA
Ethical Approval For this case study, informed consent was obtained from the patient.
Authorship Statement Dr. Yakovlev performed trial and implantation for this case study. Patient recruitment, data collection, data analysis, and patient follow-up were performed by Drs. Timchenko, Parmentier, and Yakovlev in collaboration. Dr. Parmentier prepared the manuscript draft with important intellectual input from Drs. Timchenko and Yakovlev. All authors approved the final manuscript. Comprehensive Pain Management of the Fox Valley provided funding for the study.
REFERENCES 1. North R, Kumar K, Wallace M et al. Spinal cord stimulation versus re-operation in patients with failed back surgery syndrome: an international multicenter randomized controlled trial. Neuromodulation 2010;14:330–336. 2. Krames E, Monis S, Poree L, Deer T, Levy R. Using the SAFE principles when evaluating electrical stimulation therapies for the pain of failed back surgery syndrome. Neuromodulation 2011;14:299–311. 3. Epstein L, Palmieri M. Managing chronic pain with spinal cord stimulation. Mt Sinai J Med 2012;79:123–132. 4. North RB, Ewend MG, Lawton MT, Kidd DH, Piantadosi S. Failed back surgery syndrome: 5-year follow-up after spinal cord stimulator implantation. Neurosurgery 1991;28:692–699. 5. Law JD. Clincal and technical results from spinal stimulation for chronic pain of diverse pathophysiologies. Stereotact Funct Neurosurg 1992;59:21–24. 6. Oakley J. Spinal cord stimulation in axial low back pain: solving the dilemma. Pain Med 2006;7:58–63. 7. Yakovlev AE. Treatment of multifocal pain with spinal cord stimulation. Neuromodulation 2012;15:210–213. 8. Kim YH, Moon DE. Sacral nerve stimulation for the treatment of sacroiliac joint dysfunction: a case report. Neuromodulation 2010;13:306–310. 9. Abdel-Halim M, Crosbie J, Engledow A, Windsor A, Cohen CR, Emmanuel AV. Temporary sacral nerve stimulation alters rectal sensory function: a physiological study. Dis Colon Rectum 2011;54:1134–1140. 10. Cui JG, Meyerson BA, Sollevi A, Linderoth B. Effect of spinal cord stimulation on tactile hypersensitivity in mononeuropathic rats is potentiated by GABA (B) and adenosine receptor activation. Neurosci Lett 1998;247:183–186. 11. George AT, Kalmar K, Goncalves J, Nicholls RJ, Vaizey CJ. Sacral nerve stimulation in the elderly. Colorectal Dis 2011;14:200–204. 12. Falletto E, Masin A, Lolli P et al. Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain? Dis Colon Rectum 2009;52:456–462. 13. Barolat G, Oakley JC, Law JD et al. Epidural spinal cord stimulation with multiple electrode paddle leads is effective in treating intractable low back pain. Neuromodulation 2001;4:59–66.
Keywords: Failed back surgery syndrome, implantation, low back pain, neurostimulation, sacral nerve stimulation, spinal cord stimulation
765
www.neuromodulationjournal.com
© 2014 International Neuromodulation Society
Neuromodulation 2014; 17: 763–765
Revised: October 1, 2013
Accepted: October 31, 2013
(onlinelibrary.wiley.com) DOI: 10.1111/ner.12144
LETTER TO THE EDITOR
Spinal Cord Stimulation and Sacral Nerve Stimulation for Postlaminectomy Syndrome With Significant Low Back Pain To the Editor: Should a back surgery fail to achieve all of its desired outcomes, the result is known as postlaminectomy syndrome (PLS) or sometimes called failed back surgery syndrome (FBSS). Common symptoms of PLS include diffuse, dull, achy, burning sharp, pricking, stabbing pain in the back or extremities, after undergoing surgical intervention (1). About 500,000 spine surgeries are performed in the United States each year, and yet up to 20% of Americans who undergo spine surgery each year still have some degree of persistent back or leg pain afterward. Repeat spinal surgery after one operation that has been unsuccessful has a rather high incidence of also being unsuccessful (2). The most common indication for spinal cord stimulation (SCS) in the United States is FBSS (3). SCS has been found to be more cost-effective than reoperation in the treatment of FBSS (4). SCS is widely accepted as a treatment for FBSS; however, oftentimes the SCS fails to control axial low back pain while providing a reasonable control of the radicular pain. Several studies on SCS have failed to achieve sustained low back pain resolution (5). There are several reasons for this phenomenon, both anatomical and technical (6). To this date, the amount of publications of the treatment of low back pain with SNS is very limited. SCS is widely accepted as an effective treatment for neuropathic pain (7). At the same time, there are case reports where the SNS has been successful at treating pain of nociceptive origin. For instance, Kim and Moon report the use of neurostimulation for management of the sacroiliac (SI) joint pain (8). The axial low back pain represents a pain syndrome with nociceptive and neuropathic components that both could potentially respond to neurostimulation.
CASE DESCRIPTION
www.neuromodulationjournal.com
Address correspondence to: Alexander E. Yakovlev, MD, Comprehensive Pain Management of the Fox Valley, 100 Theda Clark Medical Plaza, Suite 252, Neenah, WI 54956, USA. Email: [email protected] No financial support to report. For more information on author guidelines, an explanation of our peer review process, and conflict of interest informed consent policies, please go to http:// www.wiley.com/bw/submit.asp?ref=1094-7159&site=1 Conflict of Interest: The authors reported no conflict of interest.
© 2014 International Neuromodulation Society
Neuromodulation 2014; 17: 763–765
763
The patient is a 29-year-old female with history of lumbar degenerative disk disease, lumbar spondylosis, lumbar facet arthropathy, bilateral sacroiliitis, low back myofascial pain, and lumbar radiculopathy who underwent an L3-4 decompression and a year later an L4-5 decompression through microdiscetomy. She presented with complaints of low back pain and bilateral leg pain, despite previous surgical intervention. She initially was treated with conservative therapy that included medications (pregabalin, amitriptyline, acetaminophen, ibuprofen, cyclobenzaprine, methylprednisolone, oxycodone, hydrocodone), physical therapy with transcutaneous electrical nerve stimulation trial, and chiropractic care. Several pain interventions were performed, including lumbar
epidural steroid injections, and bilateral SI joint injections with steroids were performed and provided the patient limited relief. Diagnostic lumbar facet injections were not effective. She describes her pain as constant, aching, sharp sensation in the low back with radiation in L5-S1 dermatomal distribution to bilateral legs and feet. This patient was not considered to be candidate for any further spine surgery. After all applicable conservative management options and injection options were tried with no success, the decision was made to proceed with thoracic epidural stimulation trial. During a trial, two 8-electrode leads were introduced into the epidural space at the high lumbar level and then advanced cranially in posterior epidural space to reach the level of T8, T9, and T10. The appropriate settings for neurostimulation were selected in order to provide coverage for bilateral leg pain and low back pain. During the three-day trial, the patient logged over 80% relief of the pain in both legs and low back. The decision was made to proceed with implantation of permanent spinal cord stimulator and spinal cord stimulator leads. Implantation and postoperative recovery period were uneventful. The patient proceeded to return to the clinic on an as-needed basis, utilizing her SCS solely for pain control. Nearly a year later, the patient returned to clinic with reports of low back pain not covered by current SCS. She returned to clinic on several occasions when different neurostimulation settings were tried. The fluoroscopy was performed and unchanged lead position was found at the level of T8, T9, and T10. The neurostimulation settings that were providing the axial low back pain relief resulted in uncomfortable paresthesia and muscle twitching in the abdomen and bilateral flank areas. At the same time, the patient on neurostimulation reported excellent radicular pain relief. Several interventional procedures were attempted to help alleviate the low back pain. However, a series of lumbar epidural steroid injections and SI joint injection provided only a short-lived pain relief.
YAKOVLEV ET AL.
Figure 1. Two 8-electrode leads were introduced into the epidural space through the sacrococcygeal ligament and advanced to level S1-S4.
Despite the fact that the low back pain persisted, the patient was very satisfied with the radicular pain relief and did not want to consider a revision of implanted neurostimulator. The sacral nerve stimulation (SNS) trial was suggested and patient agreed to explore this opportunity. During the trial, two 8-electrode leads were introduced into the epidural space through the sacrococcygeal ligament and advanced to level S1-S4 (Fig. 1). The patient reported 100% coverage of the pain areas in the low back and both buttocks with trial neurostimulation, and was very satisfied with this coverage with the following SNS parameters: Lead 1: electrode 2 (+), 3 (−), 4 (+) Lead 2: electrode 10 (−), 11 (+), 12 (−) Rate range: 60 hZ Amplitude (v): varies per patient preference, range 01–10.5 v Pulse width: 300 μsec During the three-day trial, the patient reported excellent coverage of both her low back and leg pain, with both the SCS implant and the temporary sacral neurostimulation. Later, we proceeded with implantation of the sacral neurostimulator with permanent leads positioned between S1 and S4. Implantation and postoperative recovery period were uneventful. At sixth-month follow-up visit, the patient reported significant pain relief (over 90% reduction in visual analog scale [VAS] pain scores) with permanent stimulators which later allowed the patient to decrease her opioid requirements. Twelve-month follow-up demonstrated continued reduction in pain scores (VAS reduction from 6–7/10 to 2/10). As permanent placement of both devices, over one year ago, the patient is reporting sustained pain relief in both her low back and both legs without unpleasant stimulation in her flank or abdomen. The patient uses both devices 24 hours a day.
DISCUSSION
764
Although the exact mechanism of SNS remains undetermined, this treatment is predominantly theorized similar to SCS. SCS has www.neuromodulationjournal.com
been used to effectively treat chronic pain of various origins. It is most commonly used for pain secondary to PLS, complex regional pain syndrome, angina pectoris, peripheral vascular disease (3). SCS alleviates pain by stimulating nerve fibers in the spinal cord. The resulting impulses in the fibers inhibit the conduction of pain signals to the brain. The inhibition of pain transmission may be explained by the “gate-control theory” introduced by Melzack and Wall in 1965. This theory proposes that large diameter afferent fibers via application of an externally applied electric field“closes the gate” of pain transmission. SCS causes somatic afferent inhibition of sensory processing in the spinal cord; it has shown to downregulate the effect on central nervous system excitability and involves several mechanisms. The neuromodulation effect of electrical stimulation may also alter local blood flow, cause release of endorphins, affect neurotransmitters and axonal conduction, and block cell membrane depolarization. Stimulation of the dorsal column increases release of γ-amino butyric acid and decreases the release of excitatory amino acid glutamate of the dorsal horn of rats with neuropathic pain (10). SCS has also been shown to inhibit sympathetic activity, reducing vasoconstriction, and releasing agents from sensory fibers to cause vasodilation (3). The effects of SNS on pain pathways are similar to that mentioned previously for SCS. SNS has been used since the 1980s to treat various dysfunctions of abdominal organs and pelvic pain. This form of neuromodulation has been successful in the management of patients with fecal incontinence (11), voiding dysfunction, irritable bowel syndrome, and intractable pelvic pain (9). By the mid-1990s, sacral root electrical neuromodulation was widely used by urologists for urinary voiding dysfunction (12). There are several published reports describing the use of SNS for management of anal pain and modification of function of pelvic organs. As a proven treatment for urinary incontinence, SNS has recently been found effective in the treatment of interstitial cystitis, a disorder that involves hyperreflexia of the urinary sphincter. SNS is also used to treat pelvic or urinary pain as well as fecal incontinence. Recent publication of SNS has been successful at treating pain related to SI joint dysfunction (8). It can be difficult to obtain consistent and sustainable relief of low back pain with SCS. Low back pain can be hard to target for several reasons, both anatomical and technical (6). The dorsal column is made of white matter, which has very poor electrical conductivity, much like fat. In order to obtain current into the dorsal column, the amplitude must be turned up. By doing this, the current runs through highly conductive cerebrospinal fluid and around the sides to the dorsal root. At which point, the patient typically experiences stimulation into their back and anterior leg, but also into the abdomen, usually felt as cramping. High amplitudes of stimulation can evoke motor responses (6). In order to stimulate low back fibers, stimulation needs to take place deeper in the dorsal column without overstimulating the dorsal roots. In the past, one lead midline or two leads placed right and left of midline, with multicontact programming, these fibers have been accessible (4). Dorsal root stimulation produces paresthesia only in the distribution of the dermatome stimulated (6). The low back dermatomes have a lot of anterior leg coverage. Nearly 80% of the lumbar dermatomes cover the legs, primarily anterior portions. Based on a dermatome chart, to cover low back pain, one would predominantly want to cover L2-5 dermatomes; however, most common practice is to place the lead at T9 in order to obtain low back coverage. Anatomically, this is because the spinal cord is shorter than the vertebral column; the spinal cord terminates at the T12-L1 level. From this
© 2014 International Neuromodulation Society
Neuromodulation 2014; 17: 763–765
LETTER TO THE EDITOR point, the caudal equine nerve roots extend caudally. Vertebral level of the lead will not match the dermatomes that are desired to be stimulated. Another anatomical factor that contributes to the difficulty of low back stimulation is the curvature of the spine. With thoracic kyphosis, the spinal cord is closer or farther away from the dorsal epidural space depending on what vertebral level (6). The diameter of the spinal cord also varies; the smallest diameter of the spinal cord is thoracic around T7-8 effecting the cerebral spinal flow, and thus far stimulation. SCS is widely accepted as a treatment for PLS, but many times SCS can control leg pain reasonably, but can fail to control low back pain. A prospective study from Barolat et al. examined 60 patients with low back and leg pain that were implanted with a 16-electrode paddle lead anywhere from T7 to T10 with a laminotomy technique. This study revealed that at one year, 88.2% of the patients reported fair to excellent relief in the legs and only 68.8% of the patients reported fair to excellent relief in the low back (13). Though this result had more promising results than others, the patient’s primary complaint is low back pain.
CONCLUSION Our case demonstrated that SNS represents an alternative therapeutic option for patients with axial low back pain who either failed to respond to epidural stimulation trial or developed poor coverage for the low back with time. Long-term, prospective, controlled studies are needed to evaluate this finding more rigorously, but presented here is a single case of FBSS with intractable low back and leg pain that was successfully treated with a dual system of SCS and SNS. Alexander E. Yakovlev, MD; Alexander A. Timchenko, MD; Angela M. Parmentier, MSN, APNP Comprehensive Pain Management of the Fox Valley, Neenah, WI, USA
Ethical Approval For this case study, informed consent was obtained from the patient.
Authorship Statement Dr. Yakovlev performed trial and implantation for this case study. Patient recruitment, data collection, data analysis, and patient follow-up were performed by Drs. Timchenko, Parmentier, and Yakovlev in collaboration. Dr. Parmentier prepared the manuscript draft with important intellectual input from Drs. Timchenko and Yakovlev. All authors approved the final manuscript. Comprehensive Pain Management of the Fox Valley provided funding for the study.
REFERENCES 1. North R, Kumar K, Wallace M et al. Spinal cord stimulation versus re-operation in patients with failed back surgery syndrome: an international multicenter randomized controlled trial. Neuromodulation 2010;14:330–336. 2. Krames E, Monis S, Poree L, Deer T, Levy R. Using the SAFE principles when evaluating electrical stimulation therapies for the pain of failed back surgery syndrome. Neuromodulation 2011;14:299–311. 3. Epstein L, Palmieri M. Managing chronic pain with spinal cord stimulation. Mt Sinai J Med 2012;79:123–132. 4. North RB, Ewend MG, Lawton MT, Kidd DH, Piantadosi S. Failed back surgery syndrome: 5-year follow-up after spinal cord stimulator implantation. Neurosurgery 1991;28:692–699. 5. Law JD. Clincal and technical results from spinal stimulation for chronic pain of diverse pathophysiologies. Stereotact Funct Neurosurg 1992;59:21–24. 6. Oakley J. Spinal cord stimulation in axial low back pain: solving the dilemma. Pain Med 2006;7:58–63. 7. Yakovlev AE. Treatment of multifocal pain with spinal cord stimulation. Neuromodulation 2012;15:210–213. 8. Kim YH, Moon DE. Sacral nerve stimulation for the treatment of sacroiliac joint dysfunction: a case report. Neuromodulation 2010;13:306–310. 9. Abdel-Halim M, Crosbie J, Engledow A, Windsor A, Cohen CR, Emmanuel AV. Temporary sacral nerve stimulation alters rectal sensory function: a physiological study. Dis Colon Rectum 2011;54:1134–1140. 10. Cui JG, Meyerson BA, Sollevi A, Linderoth B. Effect of spinal cord stimulation on tactile hypersensitivity in mononeuropathic rats is potentiated by GABA (B) and adenosine receptor activation. Neurosci Lett 1998;247:183–186. 11. George AT, Kalmar K, Goncalves J, Nicholls RJ, Vaizey CJ. Sacral nerve stimulation in the elderly. Colorectal Dis 2011;14:200–204. 12. Falletto E, Masin A, Lolli P et al. Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain? Dis Colon Rectum 2009;52:456–462. 13. Barolat G, Oakley JC, Law JD et al. Epidural spinal cord stimulation with multiple electrode paddle leads is effective in treating intractable low back pain. Neuromodulation 2001;4:59–66.
Keywords: Failed back surgery syndrome, implantation, low back pain, neurostimulation, sacral nerve stimulation, spinal cord stimulation
765
www.neuromodulationjournal.com
© 2014 International Neuromodulation Society
Neuromodulation 2014; 17: 763–765
