Treatment of Chronic Intractable Hip Pain After Iliac Crest Bone Graft Harvest Using Peripheral Nerve Field Stimulation
Alexander E. Yakovlev, MD, Beth E. Resch, APNP+
Introduction: Autologous iliac crest bone graft (ICBG) harvest is a common procedure performed at the time of many spinal surgical procedures and associated with morbidity incurred at the harvest site, the most troublesome being chronic donor site pain.
Methods: The patient underwent an uneventful peripheral nerve field stimulation (PNFS) trial with percutaneous placement of two temporary eight-electrode leads (Medtronic Inc., Minneapolis, MN, USA) placed in epifascial plane over the left ICBG harvest site.
Results: After experiencing excellent pain relief over the next two days, the patient was implanted with permanent leads and generator two weeks later and reported sustained pain relief at 12-month follow-up visit.
Discussion: Peripheral nerve field stimulation provides an effective treatment option for patients suffering from chronic hip pain after ICBG harvest who have failed conservative treatment. PNFS may provide pain relief with advantages over conservative treatments and more invasive techniques.
Conclusion: Peripheralnervefieldstimulationoffersanalternativetreatmentoptionforselectpatientswithchronichippainafter ICBG harvest.
Keywords: Electric stimulation, hip pain, iliac crest bone graft harvest, pain, peripheral nerve field stimulation, spinal fusion Conflict of Interest: The authors reported no conflicts of interest.
INTRODUCTION
Autologous iliac crest bone graft (ICBG) harvest is a common procedure performed at the time of many spinal surgical procedures. Disadvantages of autograft bone include a high rate of complications, ranging from 6% to 49% (1–14), which include, but are not limitedto,chronic donor site pain. Chronic donor site pain has been reported in up to 33% of patients at one year (15) and 19–26% of patients at two years (14) after bone graft harvesting from the iliac crest. A high occurrence rate of donor site pain has been a strong factor supporting research for alternatives to autograft, such as allograft bone, ceramics, and biologics including recombinant human bone morphogenetic proteins (16), as it appears the only way to eliminate the significant risk of postoperative pain at bone graft harvest site is to avoid autologous bone graft harvest.
Previous studies to identify ways to reduce the occurrence rate of donor site pain following ICBG harvest have explored variations of medication administration at the site and alternative surgical techniques at the time of harvest. These studies have included injections or infusions of local anesthetics with or without narcotics (17–19), which has reduced postoperative pain. Placement of an indwelling catheter for the administration of a continuous infusion of anesthetic in the early postoperative period does not appear to decrease donor site pain and may increase the risk of wound infection at the catheter site (20). Alterations in the technique of ICBG harvesting in an attempt to reduce morbidity by keeping the outer and inner cortical tables intact do not reduce the severity of pain at the donor site (21–23). It has been theorized that the incidence of donor site pain is over-reported because patients may have difficulties in differentiating between residual low back pain and pain originating from the iliac crest (24).
Traditional treatment options for chronic donor site pain following ICBG harvest include non-steroidal anti-inflammatory medications, opioids, sacroiliac joint injections, and trigger point injections. Treatment with medications is often ineffective and wrought with intolerable side-effects. Peripheral nerve field stimulation (PNFS) has been used to treat a variety of neuropathies (25), including ilioinguinal (26), occipital (27–30), postherpetic (31), intercostal (32), for treatment of trigeminal postherpetic neuralgia and trigeminal posttraumatic neuropathic pain (33–36) with excellent relief of pain
and reduced need for oral pain medications. Recent reports describing treatment of pain by using stimulation through the leads placed subdermally in areas with localized pain (37–40) demonstrated
good efficacy, simplicity, and low morbidity of this novel technique. Treatment of chronic donor site pain following ICBG harvest using PNFS can lead to decreased reports of pain as well as a reduced need for oral pain medications.
CASE REPORT
A 73-year-old man five-year status post his third spine surgery, a lumbar decompression, and fusion at L3-4 with left ICBG and hardware. The patient had chronic left hip pain at the bone graft harvest
site which he described as constant, aching, stabbing pain which he rated a 7–10/10 on the visual analog scale (VAS). He reported pain worse with walking, better in the seated position. X-rays of the hip revealed osteoarthritis of the left sacroiliac joint.
Previous therapy had included left sacroiliac joint injections and computed tomography-guided sacroiliac joint injections, which provided temporary relief, radiofrequency ablation of the left sacroiliac joint, left greater trochanteric bursa injections, piriformis injections, gabapentin, hydrocodone, cyclobenzaprine, lidocaine patches, acetaminophen, glucosamine, ice, home exercise program, and multiple sessions of physical therapy, none of which provided him significant relief. He did not try nonsteroidal anti-inflammatory medications because he was on chronic warfarin therapy for patent foramen ovale and history of stroke. Physical examination revealed well-healed scars over the left sacroiliac joint and lumbar spine, tenderness on palpation over the left sacroiliac scar, pain elicited with flexion, abduction, external rotation, and extension on the left, and no allodynia or hyperpathia. Patient was counseled on treatment options including continued treatment with oral pain medications or peripheral nerve field stimulator therapy. The patient elected to proceed with peripheral nerve field stimulator (PNFS) therapy.
The patient underwents a successful two-day trial of percutaneous placement of two eight-electrode leads (Medtronic Inc., Minneapolis, MN, USA) after passing a psychological evaluation for an implantable device. Leads were placed in epifascial plane over the left ICBG scar, which was located 7 cm from midline posteriorly (Fig. 1). During the PNFS trial, he reported greater than 50% improvement in pain and rated his pain as a 0 on the VAS with “0” being no pain and “10” being the worst pain, compared with a 9 on the VAS before trial leads were placed. Two weeks later, the patient underwent implantation with permanent leads and a RestoreUltra rechargeable generator (MedtronicInc., Minneapolis, MN, USA). Preoperatively, we discussed with the patient location of the generator and he chose the left midabdomen. The procedure was performed in an ambulatory surgery center with intravenous sedation and local anesthesia administered by the surgeon. He was positioned in the right lateral decubitus position for easy access to left iliac crease and left abdomen. Two permanent eight-electrode standard Octad (Medtronic Inc., Minneapolis, MN, USA) leads were inserted in the epifascial plane and advanced medially and inferiorly from thepostoperative scar over the left iliac crest through slightly bent 14 gauge Tuohy needles to follow the curvature of the ilium. Both leads were anchored in the wound to fibroaponeurotic tissue with 2-0 nonabsorbable suture of braided polyester and Titan anchors (Medtronic Inc., Minneapolis, MN, USA). The leads were tunneled to the second incision created over the left mid abdomen to the subcutaneous pocket created for the generator and were connected to a RestoreUltra rechargeable generator.The postoperative course was uneventful. Initiation of use of the RestoreUltra rechargeable generator was uneventful during the postoperative period. The stimulator was programmed using a complex electrode configuration with a pulse width of 450 msec and a rate of 60 Hz. The amplitude use ranged from 2.5 to 4.9 volts.
Figure 1. Twoeight-electrode leads inserted in epifascial plane and advanced
medially and inferiorly from the postoperative scar over the left posterior iliac
crest connected to a RestoreUltra rechargeable generator.
Electrode polarities were set as follows:
First lead: 0(+) 1(-) 2(+) 3(-) 4(+) 5(-) 6(+) 7(-)
Second lead: 8(-) 9(+) 10(-) 11(+) 12(-) 13(+) 14(-) 15(+)
The patient reported that the stimulation covered 100% of his painful area following the initial programming. The patient reported using the PNFS 24 hours per day, adjusting stimulation intensity for changes in intensity of pain with good pain relief.
At the patient’s 12-month postoperative visit with the treating physician, he reported 100% coverage of his pain and was using the stimulator 100% of the time. He rated his pain as a 0/10 on the VAS. He continued with some left lower extremity weakness, but reported walking continuously for 30 min daily. He reported increased activity working around his yard and taking on projects including painting, cleaning, and small construction projects. He deferred on repeating physical therapy. He used no oral pain medications except over-the-counter acetaminophen once or twice monthly. He did continue on antidepressants for treatment of depression.
DISCUSSION
Peripheral nerve field stimulation alleviates pain by subdermal stimulation of the peripheral fibers, which may prevent transmission of painful impulses to the central nervous system. The neuromodulating effects of electrical stimulation are based on the tenets ofthe “gate-controltheory” of pain proposed by Melzack and Wall in 1965 (41). Based on this theory, it is hypothesized that paresthesia-producing stimulation “closes the gate” to pain transmission by activating large-diameter afferent fibers via application of an electric field. Electrical neuromodulation may also alter local blood flow, cause release of endorphins, affect neurotransmitters and axonal conduction, and may block cell membrane depolarization (39). The mechanism of action of PNFS and neuromodulation in general continues to be investigated as there may be a multitude of ways in which neuromodulation affects pain transmission.
Peripheral nerve field stimulation provides a safe, effective, and convenient treatment option for patients suffering from chronic donor site pain following ICBG harvest. PNFS has many advantages
over many conservative treatments as well as more invasive techniques. There are no side-effects created by PSFS as there are with many medications. Potential complication of PNFS includes bleeding and infection associated with implant surgery, with the infection rate estimated to be between 3% and 5% (42). Other possible complications are related to hardware, including skin erosion over components, lead migration, breakage or disconnection, and persistent pain near hardware (estimated rate 5%) (42). There is a high rate of success with permanent implants because of the fact that a trial is performed during which the patient evaluates the efficacy of the device. The therapy is completely reversible if for some reason therapy becomes contraindicated or is no longer needed. Patient programmers permit patients to control the level of stimulation they feel based on their degree of pain. This enables patients to take a more active role in their pain management.
SUMMARY
We present a single case of intractable, refractory-to-conventional treatment of iliac crest pain which was successfully treated with PNFS. This technique may be a safe and effective treatment for
patients who have failed to find relief with more conservative measures or who are not appropriate candidates for more invasive interventional pain or surgical procedures based on their comorbid health conditions. PNFS has provided our patient with satisfactory pain relief without the side-effects of previous medication therapy. In our opinion, PNFS offers a safe and effective treatment method that is completely reversible should the patient develop any side-effects from stimulation. This case study provides support for PNFS as an alternative treatment option for patients with intractable hip pain and will hopefully inspire interest in prospective studies comparing peripheral nerve stimulation to other therapies.
Authorship Statement
Dr. Alexander Yakovlev designed the study and drafted the manuscript. Beth Resch analyzed the data. Both authors approved the final manuscript.
How to Cite this Article
Yakovlev A.E., Resch B.E. 2010. Treatment of Chronic Intractable Hip Pain After Iliac Crest Bone Graft Harvest Using Peripheral Nerve Field Stimulation. Neuromodulation 2011; 14: 156–159
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COMMENTS
Chronic pain from bone graft harvest is a common painful syndrome. When more conservative approaches fail to ameliorate the pain, peripheral field stimulation may prove a safe and efficacious therapy. More prospective evidence is needed to further substantiate these encouraging findings.
William McRoberts MD
Holy Cross Hospital
Fort Lauderdale, FL, USA
***
Although well known for development of post-operative pain, iliac crest bone graft (ICBG) harvesting used to be a“gold standard”procedure whenever bone material was needed for spinal fusions. Mainly abandoned today in many centers, it is still used by many experienced spine surgeons, and the issue of post-operative pain, sometimes lasting for decades, remains open.
The authors report a single case of post-ICBG pain successfully managed with peripheral neurostimulation—and I am sure this procedure may be tried in many centers in the future, hopefully with similarly stellar results. The issue, however, remains not the lack of understanding of exact mechanism (even though this issue also is still unanswered) but the more practical concern regarding “off label” use of implanted devices, and, perhaps even more importantly, the lack of dedicated devices for this application.
Development of dedicated electrodes and generators for peripheral neurostimulation should become a priority for device manufacturers, while the job of implanters and researchers should be to design and complete clinical studies to show safety, efficacy and long-term effectiveness of this approach.
Konstantin V. Slavin, MD
Professor of Neurosurgery
University of Illinois at Chicago
Chicago, IL, USA
***
Peripheral nerve field stimulation (PNFS) is a promising technique with many potential applications. [1] This case report invokes not only subdermal (cutaneous nerve) but also epifascial (cluneal nerve) stimulation; indeed, in a slender patient, it might be both. This uncertainty in fact highlights one of the potential advantages of the procedure, namely that it does notr equire localization of named neural structures; in this sense, it can be technically easier to implement than many neuromodulation procedures. Like other neuromodulation procedures it is reversible, incurs minimal risk, and allows a trial to demonstrate efficacy before implantation.
On the other hand, PNFS has the potential disadvantages that it lacks anatomic and physiologic precision, and so it can be difficult to characterize, standardize, and study rigorously. It shares the disadvantages of other neuromodulation procedures that it produces paresthesia, frustrating design of high quality blinded clinical trials. Barriers to clinical implementation are so few as to be not only an advantage but also a disadvantage in terms of quality control, certification and recognition by third party payors. [2]
PNFS is expensive using present technology. It can nonetheless be more effective, and for that matter more cost-effective, than other treatments. This report of a single promising case serves as a reminder that we need to develop higher quality evidence and maintain high standards to support implementation.
Richard B. North, MD
The Sandra and Malcolm Berman Brain & Spine Institute
Professor of Neurosurgery, Anesthesiology and Critical Care Medicine (ret.)
Johns Hopkins University School of Medicine
[1] Barolat, G, “Subcutaneous Peripheral Nerve Field Stimulation for Intractable Pain,” In: Krames, E, Peckham, PH, Rezai, A (eds), Neuromodulation, Elsevier Science, 2009, Chapter 88.
[2] Henderson JM, Levy RM, Bedder MD, Staats, PS, Slavin KV, Poree LR, North RB. NANS training requirements for spinal cord stimulation devices: selection, implantation, and follow-up. Neuromodulation 2009;12(3):171–174.
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