Wireless Peripheral Nerve Stimulation in the Management of Debilitating Extremity Pain from Meralgia Paresthetica and Complex Regional Pain Syndrome: Report of Two Case Illustrations
Journal Title: Biomedical Journal of Scientific & Technical Research (BJSTR) - Year 2018, Vol 9, Issue 3
Abstract
Peripheral Nerve Stimulation [PNS] is an accepted method of neuromodulation in the management of chronic refractory pain, although there is no specialized equipment available today to be accommodated in the peripheral nerve space. PNS employs the standard spinal cord stimulation [SCS] device that comes with bulky and cumbersome components responsible for several adverse events as well as failures. We describe two chronic debilitating afflictions of peripheral nerves viz. Meralgia Paresthetica [MP] of the lower extremity and complex regional pain syndrome [CRPS] of the upper extremity, treated by wireless peripheral nerve stimulation [WPNS] that requires implantation of a single device, notably without an implantable pulse generator [IPG] or its accessories. Device Description: WPNS is a single implantable neural stimulator that encases a stimulating electrode [with 4 or 8 contacts], a microprocessor and antenna to communicate with pulse generator by wireless access. The external transmitter is in a wearable antenna assembly [WAA] worn by the patient in close proximity to the implant. This device, unlike the conventional PNS equipment, does not require an IPG. Case illustrations: A case of MP was diagnosed after the patient underwent an arthroscopic repair of knee joint which was complicated by infection leading to necrotizing fasciitis. Patient required multiple medications and interventions including neurolysis of femoral cutaneous femoral nerve that gave temporary relief. After multiple non-surgical procedures like nerve blocks, physical therapy and cryo-ablation of the cutaneous nerve patient was taken up for WPNS, using a Freedom stimulator with 4 contacts [Stimwave Technologies, Pompano Beach, FL, USA] implanted along the course of the femoral cutaneous nerve. The second case of CRPS type 1, followed blunt trauma to the right upper extremity resulting in intractable pain with allodynia unresponsive to physical therapy, nerve blocks combined with opioid medications. A diagnosis of refractory CRPS was entertained and the patient received placement of two WPNS electrodes [FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1] along the ulnar and median nerves under image guidance. Both patients during the follow up had shown prompt symptomatic relief without any adverse events and required minimal pain medication. Conclusion: WPNS is minimally invasive, single step procedure involving implantation of a single device providing effective relief in debilitating peripheral nerve conditions like MP and CRPS. It does not require an IPG or its accessories thus minimizing the implant related complications and failures. Chronic intractable pain is one of the most common symptoms necessitating a visit to the medical practitioner [1] and also a leading cause for opioid consumption. SCS has been a time-tested neuromodulation therapy with increasing indications to manage refractory pain [2]. Traditional PNS equipment utilizes the SCS device that has all its components to be implanted inside the patient body: electrodes, battery [IPG] and the connection cables along with the anchoring material. Unfortunately, peripheral nerve space on the extremities, cannot anatomically accommodate this bulky apparatus and eventually PNS has several adverse events including failures of therapy [3]. For example, PNS for the upper extremity requires stimulating electrodes in the vicinity of the peripheral nerve while the IPG is placed either in the axilla or the chest wall. Both these locations have to deal with the highly mobile shoulder joint and result in lead migration or failure of the connecting cables to stay connected. Similarly, a femoral nerve stimulation requires IPG in the anterior abdominal wall or the buttock, in both instances the connection wires need to cross the hip joint, another highly mobile joint. WPNS is a novel wireless neuromodulation approach gaining rapid acceptability owing to its minimalistic approach to treat complex painful conditions like MP and CRPS. WPNS, utilizing nanotechnology, does not require the connection cables or the IPG while the WAA keeps the external power source outside the patient body. Additionally, this wireless neuromodulation has the capabilities to deliver multiple frequency ranges.
Authors and Affiliations
Laura Tyler Perryman, Jana Kubias, Stefan Stockli, Daniel Herschkowitz
Keywords
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- EP ID EP586856
- DOI 10.26717/BJSTR.2018.09.001806
- Views 146
- Downloads 0
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