Peripheral Nerve Stimulation in Treatment of Intractable Postherpetic Neuralgia
Alexander E. Yakovlev, MD* • Andrea T. Peterson, DO†
*Interventional Pain Management and† Physical Medicine, Marshfield Clinic, Marshfield, WI, USA
ABSTRACT
Objective. This case report presents an application of peripheral nerve stimulation to a patient with intractable postherpetic neuralgia that conventional treatment failed to ameliorate.
Methods. The patient underwent an uneventful peripheral nerve stimulator trial with placement of two temporal eight-electrode percutaneous leads (Octrode leads, Advanced Neuromodulation Systems, Plano, TX, USA) into the right subscapular and right paraspinal area of the upper thoracic region.
Results. Upon experiencing excellent pain relief over the next two weeks, the patient underwent implantation of permanent leads two weeks later and reported sustained pain relief.
Conclusion. Peripheral nerve stimulation offers an alternative treatment option for intractable pain associated with postherpetic neuralgia, especially for elderly patients where treatment options are limited due to existing comorbidities. Further studies are warranted.
KEY WORDS: Pain, peripheral nerve stimulation, postherpetic neuralgia, spinal cord stimulation.
Introduction
Postherpetic neuralgia represents a common neuropathic pain syndrome following an acute outbreak of herpes zoster that is frequently unresponsive to all available conventional treatment modalities. The pharmacologic treatment of postherpetic neuralgia has limited success because of its potential ineffectiveness and potential side-effects (1,2). Different surgical procedures, such as dorsal root entry zone coagulation (3), deep brain stimulation (4), and spinal cord stimulation (5), have been used to treat postherpetic neuralgia, but unfortunately to date show mixed or even limited efficacy.
Most affected patients are advanced in age and almost 50% of patients who are over 70 years of age are still experiencing pain at one year (6,7). These patients exhibit a range of comorbidities including diabetes and various malignancies, especially lymphoproliferative disorders, which contribute to the failure of treatment (8–10). Older patients respond less favorably to spinal cord stimulation than younger postherpetic neuralgia patients (11) because of the age-related loss of large myelinated nerve fibers involved in pain modulation. The severity of the pain in postherpetic neuralgia often negatively impacts the quality of life of patients and complicates the nature of coexisting diseases.
Peripheral nerve stimulation has been used to treat patients with injuries to a specific nerve (12), including application to occipital (13–16), ilioinguinal (17), supraorbital (18,19), and trigeminal neuralgia (20). However, no reports in the medical literature to date describe the use of subcutaneous stimulation of branches of peripheral nerves for the treatment of postherpetic neuralgia.
Case Report
An 81-year-old, 75 kg, 160 cm, woman was referred to the pain clinic with the diagnosis of intractable postherpetic neuralgia. The patient presented with complaints of severe burning pain over the posterior aspect of the right shoulder and right upper posterior chest wall along the segmental distribution from the right first to seventh intercostal nerves for the past three months. The patient tried
different pain medications, including tramadol, ultracet, oxycontin, vicodin, morphine, and gabapentin, that did not alleviate the pain and caused many adverse side-effects. Therapy utilizing a transcutaneous electrical nerve stimulation unit made her pain worse.
The patient’s medical history was significant for hypertension, hypothyroidism, hypercholesterolemia, chronic hepatitis C with abnormal liver function tests, azotemia, osteoporosis, severe and diffuse osteoarthritis, recurrent urinary tract infections, chronic urinary incontinence, deep vein thrombosis and pulmonary embolism, Raynaud’s phenomenon, and multiple joint and abdominal surgeries. The patient was on a chronic pain medication regimen, including gabapentin 600 mg every eight hours, sustained release morphine 15 mg every 12 hours, lidocaine topical 5% patch with three patches worn 12 hours on, 12 hours off to affected areas. The patient was treated in our pain clinic for four months prior to peripheral nerve stimulator placement with subcutaneous injection of steroids, thoracic epidural steroid injections, and a spinal cord stimulator trial, which failed to provide any pain relief.
The patient was offered placement of a peripheral nerve stimulator and she agreed to this procedure. This decision was based on the failure of extensive treatment and the patient’s decline to go ahead with the intrathecal pump placement. In April 2006, she underwent an uneventful peripheral nerve stimulator trial with placement of two temporal eight-electrode percutaneous leads (Octrode leads, Advanced Neuromodulation Systems, Plano, TX, USA) under the skin along the fascial layer into the right subscapular and right paraspinal area of the upper thoracic region. One lead rested across and the second lead was located parallel to the intercostal nerves forming an imaginary triangle around the pain area. The stimulation parameters used by the patient during the trial were amplitude 3 mA and pulse width of 450 microseconds at a frequency of 60 Hz.
During the trial, the patient reported excellent coverage of her usual pain using temporal leads and had excellent pain control. Two weeks later, the patient underwent implantation of permanent leads (Fig. 1) and an Eon rechargeable generator (Advanced Neuromodulation Systems). The procedure was performed in the ambulatory surgery center and the postoperative course was uncomplicated. The stimulation parameters used by the patient after the surgery were the same as during the trial. After surgery, the patient stated that her pain abated 100%. She used peripheral nerve stimulator continuously. When the patient came back for follow-up six months after surgery, she had stopped use of all pain medications and reported improvement of her sleep and functional status.
FIGURE 1. Subcutaneous electrode placement in the right subscapular
and right paraspinal area of the upper thoracic region.
Discussion
Peripheral nerve stimulation was introduced into clinical practice in the 1960s and was developed in parallel with spinal cord stimulation. Scientific groundwork for peripheral nerve stimulation and spinal cord stimulation was provided by the gate-control theory of pain proposed by Melzack and Wall in 1965 (21). According to this theory, activation of large myelinated nerve fibers can interrupt the transmission of nociception to the central nervous system.
In 1967, Wall and Sweet implanted electrodes on peripheral nerves (22), introducing a new era of neuromodulation whose applications continue to expand to and offer relief to patients with chronic intractable pain. In the past, peripheral nerve stimulation required an open surgical approach during the trial, but is now performed with less invasive percutaneous placement of the leads. During the final placement of the permanent electrical stimulator and leads, nonsurgical leads can be utilized that require less extensive intraoperative dissection and result in decreased procedure time. Significant technological advances and new indications for peripheral nerve stimulation have increased its value as a preferred treatment option for physicians practicing pain management. Reports regarding the application of peripheral targeted neuromodulation within recent history have demonstrated its safety, efficacy, and cost-effectiveness in managing a variety of painful conditions including, but not limited to, occipital neuralgia (13), shoulder pain (23,24), atypical trigeminal neuralgia (20), intractable facial pain (25), cervicogenic headache (26), migraine (27), chronic regional pain control (28), and chronic abdominal pain (29), among other conditions and applications.
The case of intractable postherpetic neuralgia successfully treated with peripheral nerve stimulation has been presented. This minimally invasive technique represents a different therapeutic approach for the patients who in the past have failed all available treatments or who are at increased risk of potential complications from more advanced interventional pain or surgical procedures. This information may be useful in the care of difficult patients with postherpetic neuralgia and stimulate interest in design of a prospective study in which peripheral nerve stimulation is compared to other treatments, including spinal cord stimulation for the treatment of intractable pain associated with postherpetic neuralgia.
Acknowledgments
The authors thank Marshfield Clinic Research Foundation for its support through the assistance of Linda Weis and Alice Stargardt in the preparation of this manuscript.
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