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■ РЕКОНСТРУКТИВНАЯ И МИКРОСОСУДИСТАЯ ХИРУРГИЯ
ПЕРИФЕРИЧЕСКАЯ НЕЙРОСТИМУЛЯЦИЯ В ЛЕЧЕНИИ ПОСТЛАМИНЭКТОМИЧЕСКОГО СИНДРОМА
ДЛЯ КОРРЕСПОНДЕНЦИИ
Alexander Yakovlev, Comprehensive Pain Management of the Fox Valley, SC, 820 East Grant Street, Suite 335, Appleton, WI 54911, USA E-mail: aeyakovlev@yahoo.com
Ключевые слова:
электрическая стимуляция, боль в спине, боль, периферическая нейростимуляция, спинальная стимуляция
А. Яковлев, А. Тимченко, С. Орлов, Н. Шабалина
Отделение комплексного лечения болевого синдрома в Фокс Вэлли, Аплтон, Висконсин, США
Хроническая боль в спине у пациентов с постламинэктомическим синдромом плохо поддается консервативной терапии и общепринятым минимально инвазивным методам лечения, в том числе спинальной доставкой лекарственных препаратов и центральной нейростимуляцией. Наш опыт включает 98 пациентов с хронической болью в спине и нижних конечностях, возникшей вследствие постламинэктомического синдрома, которым была проведена имплантация систем для периферической нейростимуляции. Стимуляция осуществлялась путем подкожной имплантации двух 8-контактных электродов в поясничной области. У большинства пациентов мы наблюдали отчетливый противоболевой эффект в течение 2-дневной тестовой стимуляции. Через 2-4 нед проводилась имплантация постоянных систем для периферической нейростимуляции с использованием подзаряжающихся и неподзаряжающихся генераторов. Через 12 мес 84 пациента (85,7%) отмечали выраженный противоболевой эффект (более 75% уменьшение интенсивности боли по УДБ-шкале). Таким образом, по нашим данным, периферическая нейростимуляция является эффективным методом лечения пациентов с постламинэктомическим синдромом, у которых продолжается некурабельная боль в спине, несмотря на консервативную терапию. Периферическая нейростимуляция обеспечивает более эффективный контроль боли в сравнении с консервативным лечением, спинальной стимуляцией и целевой доставкой лекарственных препаратов. Периферическая стимуляция может быть рекомендована как приоритетная методика для обсуждаемой нозологической группы. Клин. и эксперимент. хир. Журн. им. акад. Б.В. Петровского. - 2015. - № 1. - С. 52-56.
Peripheral nerve field stimulation in the treatment of postlaminectomy syndrome
A. Yakovlev, A. Timchenko, S. Orlov, N. Shabalyna
Comprehensive Pain Management of the Fox Valley, Appleton, WI, USA
Keywords:
electric stimulation, failed back syndrome, low back pain, pain, peripheral nerve field stimulation, postlaminectomy syndrome, spinal cord stimulation
Chronic low back pain in the patients with postlaminectomy syndrome (PLS) is challenging to treat despite conservative therapy and available interventional pain procedures including spinal cord stimulation (SCS) and intrathecal (IT) therapies. Many interventional pain specialists describe difficulty achieving adequate coverage of pain in the lumbosacral area during the SCS trial or maintaining adequate axial low back pain control over the long term after implantation of SCS for patients with PLS. Peripheral Nerve Field Stimulation (PNFS) may represent an alternative option for these patients when conventional treatment failed to ameliorate intractable low back pain. These report reviews, 98 patients who were evaluated between September 2005 and May 2012, with chronic low back and lower extremity pain associated with postlaminectomy syndrome that underwent PNFS placement. These patients underwent an uneventful PNFS trial with percutaneous placement of two temporary eight-electrode leads (Medtronic Inc., Minneapolis, MN) placed subcutaneously over the lumbar area. After experiencing excellent pain relief over two trial days, patients were implanted with permanent leads and rechargeable or non-rechargeable generator two to four weeks later. At twelve month follow-up visit 84 patients (85.7%) reported significant pain relief (>75% reduction in VAS) with permanent stimulator. PNFS provides an effective treatment option for patients with postlaminectomy syndrome suffering from chronic low back pain who have failed conservative treat-
А. Яковлев, А. Тимченко, С. Орлов, Н. Шабалина ■ ПЕРИФЕРИЧЕСКАЯ НЕЙРОСТИМУЛЯЦИЯ В ЛЕЧЕНИИ _ПОСТЛАМИНЭКТОМИЧЕСКОГО СИНДРОМА
ment. PNFS may provide pain relief with advantages over conservative treatments, spinal cord stimulation, and intrathecal therapies. Peripheral nerve field stimulation, rather than SCS, may more effectively treat intractable low back pain for selected patients with postlaminectomy syndrome.
Clin. Experiment. Surg. Petrovsky J. - 2015. - N 1. - Р. 52-56.
Postlaminectomy syndrome (PLS) occurs in patients who underwent spinal operations for such conditions as spinal instability, disc herniation, or spinal stenosis. There are multiple causes of PLS including spinal instability, disc herniation or epidural fibrosis and arachnoiditis [1-2]. The management of chronic low back and lower extremity pain associated with postlaminectomy syndrome can be difficult in clinical practice. Spinal cord stimulation (SCS) has been effective to control radicular pain, but not as consistently beneficial in management of axial low back pain [3-10]. Recent advances in SCS technology allows for better control of low back pain [11] but it remains a challenge in the treatment of patient with PLS. After implantation of SCS, patients may continue to experience significant low back pain, requiring frequent interventional pain procedure including epidural and facet blocks, trigger point and sacroiliac joint injections, and continued use of different pain medications and oral opioids. Some of these patients undergo implantation of intrathecal pumps.
Many interventional pain specialists describe difficulty achieving adequate coverage of pain in the lumbosacral area during the SCS trial or maintaining adequate axial low back pain control over the long term after implantation of SCS for patients with PLS. During the SCS trial the patients may experience uncomfortably strong stimulation in the legs, flanks, abdomen or even chest wall while attempting to obtain adequate stimulation in low back [3, 12]. This problem can contribute to the trial failure. At present time there is no clear understanding regarding the mechanism by which, in the absence of lead migrations, changes in the patterns of stimulation SCS over time becomes ineffective for control of low back pain [13].
Peripheral nerve field stimulation (PNFS) has been used to treat a variety of neuropathies [14], including ileoinguinal [15], occipital [16-19], post-herpetic [20], intercostals [21], for treatment of trigeminal postherpetic neuralgia and trigeminal posttraumatic neuropathic pain [22-25] with excellent relief of pain and reduced need for oral pain medications. Recent reports describing treatment of low back pain by using stimulation through the leads placed subcutaneously in areas with localized pain [3, 6, 13, 26, 27] demonstrated good efficacy, simplicity and low morbidity of this novel technique.
Methods
Between September 2005 and May 2012, 98 patients with chronic low back and lower extremity pain associated with postlaminectomy syndrome underwent PNFS placement. Sixty one of them were males and thirty seven were females. Patient gender distribution was 62.2% male, 37.8% female with mean age 57 years, ranging from 32 to 90 years. Most patients, 89.8%, had over 12 months of previous pain duration. In this group, 36 (37%) patient already had implanted SCS and eleven (11%) patients had preexisting intrathecal pumps but continued suffering from intractable low back pain. No patients were involved in active litigation. All patients failed conservative therapy and had short lasting pain relief after different injections.
Following psychological evaluation and clearance for advanced interventional pain procedures, patients underwent successful trial of percutaneous placement of two 8-electrode standard Octad Leads subcutaneously (Medtronic Inc., Minneapolis, MN). After local infiltration of 1% lidocaine, the leads were inserted through 14 gauge Touhy needles (Fig. 1). The leads were placed vertically, parallel and lateral to postoperative scar in the area of maximum pain (Fig. 2). Both leads were connected to temporary extension cable and to a temporary external stimulator. During the 2 day PNFS trial the patients reported greater than 50% improvement in pain. Stimulator parameters programmed for amplitude between 1.8 and 3.2 volts, pulse width 350 to 450 microseconds, and frequency 40-50 Hz. Two to four weeks later the patients underwent implantation with permanent leads through small perpendicular to midline incisions made in the paraspinal areas of the lumbar region (Fig. 3). The leads were passed through slightly bent 14 Gauge Tuohy needles to follow the curvature in lumbar area. Positioning of the leads was done with C-arm guidance (Fig. 4) to assure proper placement and to avoid potential damage of existing electrodes in the group of patient with previously implanted SCS or prevent laceration of intrathecal catheter for the patients with IT pumps. Both leads were anchored in the wound to fibroaponeurotic tissue with 2-0 nonabsorbable suture of braided polyester (Ethibond) and Titan Anchors (Medtronic Inc., Minneapolis, MN). The leads were tunneled to the left or right supragluteal
Fig. 1. Two 14 gauge Touhy needles placed subdermally in the paraspinal area of the lumbar region parallel to postoperative scar
Fig. 2. Percutaneous placement of two 8-electrode standard Octad leads (Medtronic Inc., Minneapolis, MN) subcutaneously during the trial
Fig. 3. The incisions made in paraspinal areas of lumbar region for placement of the leads during permanent implantation
i i b h ' ■ f^B л il»; , ' «¿i f
areas where the subcutaneous pocket was created for the generator. Leads were then connected to a rechargeable Restore (Medtronic Inc., Minneapolis, MN) or non-rechargeable generators Restore Ultra (Medtronic Inc., Minneapolis, MN). All procedures for permanent implantation were performed with conscious sedation and local anesthesia. The postoperative course was uneventful. The stimulator was programmed using a guarded electrode configuration with a pulse width of 450 microseconds and a rate of 60 Hz. The amplitude use ranged from 1.5 to 2.3 volts.
Electrode polarities were set as follow:
First lead: 0(+) l(-) 2(+) 3(-) 4(+) 5(-) 6(+) 7(-)
Second lead: 8(-) 9(+) 10(-) 11(+) 12(-) 13(+) 14(-) 15(+)
The patient reported that the stimulation covered at least ninety percent of her painful areas following the initial programming.
Results
One patient developed postoperative wound infection and subsequently underwent removal of the generator with two leads. Seventy six patients had reprogramming of PNFS in the first 6 weeks after the surgery. Sixteen patients needed additional teaching sessions about use of their recharging devices postoperatively.
At twelve month follow-up visit 84 patients (85.7%) reported significant pain relief (>75% reduction in VAS) with permanent stimulator. Stimulator parameters were in the same range like during PNFS trial. Seventeen patients (47%) in the group with preexisting SCS systems continued to use PNFS only. In the group of patients with implanted intrathecal pumps four patients (36%) asked to stop their intrathecal devices. Patients were weaned off intrathecal medications and these devices were subsequently filled with normal saline. 84 patients (85.7%) who benefited from PNFS were able to decrease or discontinue use of pain medications. Patients also reported other positive outcomes including the ability to return to social and educational activities.
Discussion
The treatment of chronic low back pain in the group of patient with PLS is a challenge for the patients and as well as for physicians treating them. Many therapies including advanced interventional pain procedures like SCS show mixed results. Some patients with SCS have lead revisions or even explanation because of failure to control low back pain.
PNFS alleviates pain by subcutaneous 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 of the «gate-control theory» of pain proposed by Melzack and Wall in 1965 [28]. Based on this theory, it is hypothesized that PNFS «closes the gate» to pain transmission by activating large-diameter afferent fibers via application of an electric
А. Яковлев, А. Тимченко, С. Орлов, Н. Шебалина ■ ПЕРИФЕРИЧЕСКАЯ НЕЙРОСТИМУЛЯЦИЯ В ЛЕЧЕНИИ _ПОСТЛАМИНЭКТОМИЧЕСКОГО СИНДРОМА
field. PNFS may also alter local blood flow, cause release of endorphins, affect neurotransmitters and axonal conduction, and may block cell membrane depolarization [14]. 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 effects pain transmission. PNFS works on the painful areas of the low back which is sometimes very difficult to target with epidural stimulation. In our experience, the patients had better coverage of the pain areas with vertical positioning of the leads because greater involvement of the endings posterior primary division of lumbar spinal nerves which emerging almost perpendicular to subcutaneously placed leads. We believe this technique of lead placement allows for the stimulation of more dermatomal nerves, capturing the broadest possible zone corresponding to the area of low back pain and positively influencing outcomes of trials and final implant procedures.
PNFS provides a safe, effective, and convenient treatment option for patients with PLS suffering from chronic intractable low back pain. PNFS has many advantages over many conservative treatments as well as more invasive techniques. There are no side effects created by PNFS as there are with many medications. There is a high rate of success with permanent implant due to 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.
Conclusion
Presented in this report is the data on patients with PLS implants that suffered from intractable, refractory-to-conventional-treatment low back pain and were successfully treated with PFNS. This technique may be a safe and effective treatment for patients who have not found relief with conservative measures or who are not appropriate candidates for more invasive interventional pain or surgical procedures based on their co-morbid health conditions. This technique is easier to
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Recommendations for future studies
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