Spinal Cord Stimulation as Alternative Treatment for Chronic Post-Herniorrhaphy Pain
Alexander E. Yakovlev, MD*, Mazin Al Tamimi, MD † , Giancarlo Barolat, MD ‡ , Sergey A. Karasev, MD § , Yuri A. Merkulov, MD ¶ , Beth E. Resch, APNP *, Victoria E. Yakovleva, BA *
Objective: Our goal was to determine the efficacy of spinal cord stimulation for patients with intractable post-herniorrhaphy pain which conventional treatment failed to ameliorate.
Procedure: The patients underwent an uneventful spinal cord stimulator (SCS) trial with percutaneous placement of two eight-electrode epidural leads (Medtronic Inc, Minneapolis, MN, USA) to level T7-T8-T9.
Results: Upon experiencing excellent pain relief over the next two days during the trial, the patients were implanted with permanent leads and rechargeable or non-rechargeable generators two to four weeks later and reported sustained pain relief during following 12 months after implantation.
Conclusion: We conclude that SCS offers an alternative treatment option for intractable post-herniorrhaphy pain. This type of treatment should be considered for use in a select group of patients when all conventional treatments failed.
Keywords: Abdominal pain, dorsal column stimulation, electric stimulation, pain, post-herniorrhaphy pain, spinal cord stimulation
Conflict of Interest: The authors reported no conflict of interest.
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INTRODUCTION
Abdominal wall hernias occur commonly, with a prevalence of 1.7% for the general population and 4% for those over the age of 45years (1). Seventy-five percent of abdominal wall hernias are inguinal hernias. Repair of inguinal hernias is performed at an annual rate of 2800 per million population in the United States and Europe, with the majority of patients being male (2). Aasvang and Kehlet report the risk of chronic pain following inguinal herniorrhaphy at 12%, with nerve damage being the most important pathogenic factor for chronic pain state. Other factors which may contribute to chronic pain state following inguinal herniorrhaphy include the type of surgical repair performed, patient age, gender, preoperative pain intensity, recurrence of hernia, and sexual dysfunction (3). Use of peripheral nerve stimulation for the treatment of chronic groin pain is documented (4). Use of spinal cord stimulator (SCS) to interrupt pain transmission from the viscera to the spinal cord has been documented to benefit patients with chronic abdominal pain. The first documented case report of SCS for treatment of visceral pain syndrome was in a patient with pain and diarrhea from irritable bowel syndrome (5). Subsequently, reports have been published describing use of SCS for treating pain related to chronic non-alcoholic pancreatitis, generalized abdominal pain, abdominal wall neuromas, and posttraumatic splenectomy (6,7). The SCS is reversible, safe, and cost-effective treatment (8).
MATERIALS AND METHODS
Between March 2007 and April 2008, 15 consecutive patients from three treatment centers suffering from intractable chronic postoperative groin pain underwent SCS placement. Eleven of them were male and four were female. Patient gender distribution was 73.3% male and 26.7% female with mean age 38 years and range from 29 to 71 years. Most of the patients, 86.6%, had more than 12 months’ pain duration. No patients were involved in active litigation. In total, 13.3% of patients had distant history of drug and alcohol abuse. All patients had at least one re-exploration of surgical site and no further surgeries were indicated. The patients failed conservative therapy which included medical management with anticonvulsants including gabapentin and pregabalin, opioids, tricyclic antidepressants (TCAs), topical medications like lidocaine patches, physical therapy, and TENs unit. All patients experienced short lasting pain relief which they rated as less than 50% after ilioinguinal, iliohypogastric, and genitofemoral nerve blocks. This degree of pain relief did not make them candidates for neuroablative procedures. Five patients had long history of neuropathic low back pain treated conservatively in the past. All the patients had psychological evaluation and clearance for advanced interventional pain procedures. All underwent successful trial of percutaneous placement of two eight-electrode epidural leads (Medtronic Inc., Minneapolis, MN, USA). Epidural access was gained at the T12/L1 or L1/L2 with final leads positioned atT7-T8-T9 (Fig. 1). Both leads were connected to a temporary extension cord and to an external stimulator. During the two-day SCS trial, which is customary in our clinics, the patients reported greater than 50% improvement in pain. In the group of five patients with low back pain we also were able to cover areas of low back pain. Stimulator parameters programmed for amplitude between 1.8 and 3.2 V, pulse width 350–450 msec, and frequency 40–50 Hz. Two to four weeks later the patients underwent implantation with permanent leads placed through small incision made in upper lumbar area and RestorePRIME non-rechargeable or RestoreULTRA (Medtronic Inc., Minneapolis, MN) rechargeable generators were placed in a subcutaneous pocked created through an incision in the left or right supragluteal areas (Fig. 2). All procedures were performed with conscious sedation and local anesthesia. Initiation of generator use was uneventful during the post-operative period.
Figure 1. Thoracic epidural placement of two eight-electrode epidural leads showing the electrodes in a staggered position at T7-T8-T9.
Figure 2. Incision and pocket for the generator made in the right supragluteal area.
RESULTS
At12-month follow-up visit all the patients reported significant pain relief (>75% reduction in visual analog scale)with permanent stimulator. Stimulator parameters were in the same range of the trial.The
patients with groin pain and previous history of low back pain also reported sustained relief of their multi-focal pain. All patients were able to decrease or discontinue use of pain medications (Table 1). Patients also reported other positive outcomes including the ability to return to family, social, and educational activities. There was no post-implant device or procedure-related complications. Nine patients required reprogramming of SCS in the first six weeks after the surgery. Two patients needed additional teaching sessions about use of their recharging devices postoperatively.
DISCUSSION
Post-herniorrhaphy pain is complex in nature, with superimposed neuroplastic changes within the peripheral and central nervous system (9). According to the proposed classification for post-herniorrhaphy pain, neuropathic pain is more common than non-neuropathic pain or pain related to the spermatic cord (10). The underlying pathophysiological mechanisms of post-herniorrhaphy pain include direct intraoperative nerve injury, tension on the ilioinguinal, iliohypogastric, genitofemoral, femoral, and lateral femoral cutaneous nerves, and an inflammatory reaction to implanted mesh with possible subsequent nerve injury. The combination of nerve injury and chronic inflammation may increase the excitability of nociceptors in the dorsal root ganglion, subsequently causing the development of hyperalgesia and pain (11). For this reason, we felt SCS was the therapeutic approach most likely to be effective with this patient population.
For patients with chronic post-herniorrhaphy pain, conservative treatment includes therapeutic and diagnostic procedures aimed at identifying a definite diagnosis related to a specific neuralgia or identification of a clear pattern of pain along a particular nerve distribution. Conservative treatment of the patients included in this study revealed no definitive diagnosis related to specific neuralgia or identification of specific nerve distribution involvement. The challenge of treating these patients can possibly be explained by the complex innervation of the groin by the ilioinguinal, iliohypogastric, genitofemoral, femoral, and lateral femoral cutaneous nerves further complicated by dermatomal overlap of these nerves. Previous studies support our findings that peripheral nerve blocks with local anesthetics and steroids may provide temporary pain relief and cryoanalgesia offers mixed outcomes. These findings may also be explained by the complicated innervation and contralateral over lapping innervation of the groin areas (12,13). For these reasons, wedid not believe that peripheral nerve field stimulation would be beneficial because the patients’ wide distribution of pain with no definitive localization of pain over a certain nerve. It has been suggested that post-herniorrhaphy pain may originate from the deep muscle layers, which are innervated by nerves other than the iliohypogastric, ilioinguinal, or genitofemoral nerves (14).
Spinal cord stimulator therapy represents an alternative treatment option other than repeated surgical exploration and is a relatively easy-to-perform, effective, and safe procedure. The therapy is reversible should patients lose its pain-alleviating effect or if abdominal pain resolves. These patient are relatively young, well-motivated, not involved in litigation processes and have favorable spine anatomy because no previous back surgeries or advanced degenerative changes in the vertebral column allow for easier lead placement in the absence of epidural fibrosis, which is common in patients who have had spine surgery. All of the above mentioned advantages may have contributed to the positive outcomes for this patient group in regard to the pain relief experienced following their SCS procedures and perioperative morbidity.
CONCLUSION
Spinal cord stimulator may be a therapeutic alternative for patients with chronic post herniorrhaphy groin pain who in the past exhausted all available treatments. The preliminary data from this small group of patients with groin pain will provide groundwork for further prospective studies including comparison with other less invasive interventions to control chronic post-herniorrhaphy groin pain.
Authorship Statements
Drs. Alexander Yakovlev and Mazin Al Tamimi designed and conducted the study, including patient recuritment, data analysis. Dr. Giancarlo Barolat designed the study, prepared the manuscript draft with important intellectual input. Dr. Sergey A. Karasev designed and conducted the study. Dr.Yuri A. Merkulev conducted the study. Beth E. Resch drafted the manuscript and conducted the study. Viktoria E. Yakovleva conducted the study and drafted the manuscript. All authors approved the final manuscript. We would like to thank Dr. Barolat for his editorial support.
How to Cite this Article:
Yakovlev A.E., Al Tamimi M., Barolat G., Karasev S.A., Merkulov Y.A., Resch B.E., Yakovleva V.E. 2010. Spinal Cord Stimulation as Alternative Treatment for Chronic Post-Herniorrhaphy Pain. Neuromodulation 2010; 13: 288–291
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COMMENTS
Comments added after online publication February 24, 2010. In this article,Yarkovlev et al. provide a helpful summary of the course of 15 patients treated for post-herniorrhaphy pain with SCS. They appropriately point to the limitations of conventional conservative therapy for a significant number of patients. Given the ubiquity of the procedure, this represents a considerable problem, though their estimate that 12% suffer long term pain may be somewhat aggressive. A review of the literature demonstrates a range of reported long term pain syndromes from 0.7% to 36.7%; severe chronic pain is reported in 3% of cases [1]. As they point out, this treatment has been reported on before, both by Rauchwerger et al. [2] as they mention, but also in two casesby Elias in this journal in 2000[3]. It is important that we continue to accumulate information on specific applications such as this in order to reliably identify those disorders that would warrant further investigation. It appears that postherniorrhaphy pain is an excellent candidate for spinal cord stimulation when conservative measures have failed. This would be an important area for further investigation, particularly with a randomized controlled trial.
Kenneth Aló, MD
Director
River Oaks Pain Management
Houston, TX, USA
Director, Section of Neuro-Cardiology
Associate Professor, Institute of Cardiology and Vascular Medicine
Monterrey Technical University, Monterrey Mexico (Instituo de Cardiologia
y Medicina Vascular del TEC de Monterrey)
Erich O. Richter, MD.
Assistant Professor of Neurosurgery
Department of Neurosurgery
LSU Health Sciences Center, New Orleans
New Orleans, LA, USA
***
This paper is interesting for many as it demonstrates an option to patient sthought to be beyond improvement. The paper is well written, has good visuals (photos, x-rays, and graphs), and describes a technique that is valuable.The paper does not focus on the failures that are seen with the same approach in patients with pain patterns that resemble that described in this manuscript. A prospective study is needed to determine the best lead placement for this pain syndrome, and what patient factors may impact outcomes.
Timothy R. Deer, MD
Clinical Professor of Anesthesiology
West Virginia University School of Medicine
Charleston, WV, USA
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