Authors:
Loy Daniel Strawn, Jr., MD, Resident
Kyle Glasser, MD, Fellow
Alethia Sellers, MD, CMQ, Associate Professor
Department of Anesthesiology and Perioperative Medicine
The University of Alabama at Birmingham, Heersink School of Medicine
Introduction:
The human nervous system is divided into central and peripheral components. Noxious stimuli are transmitted from the peripheral nervous system to the central nervous system.1 Painful stimuli are transmitted along peripheral A-delta and C nociceptive nerve fibers to the central nervous system, and then via descending pathways to the dorsal horn of the spinal cord.1 While detection of nociceptive stimuli serves an important purpose in human physiology, persistent nociception (e.g., due to peripheral nerve dysfunction) may result in the development of chronic pain.2 Chronic pain of the low back is an increasingly recognized cause of morbidity across the world, affecting approximately 7.5% of the global population.3 The underlying cause of nearly 10% of chronic pain may be due to pathology involving the peripheral nervous system.4
Treatment options for chronic pain secondary to peripheral nerve pathology include conservative measures such as physical therapy, and more novel therapies such as peripheral nerve stimulation. 2 Peripheral nerve stimulation (PNS) is defined as the application of an electrical field to a nerve or group of nerves including and/or distal to the dorsal root or trigeminal ganglion.5 The mechanistic foundation of PNS is rooted in the gate control theory, which posits that the activation of inhibitory interneurons results in the inhibition of nociceptive afferent input from C fibers.2 PNS is increasingly being utilized in the treatment of chronic low back pain. Methods of PNS for the treatment of low back pain include restorative stimulation of the multifidus muscles, stimulation of the lumbar medial branch nerves, and peripheral nerve field stimulation.3 We report a case in which a patient with chronic facetogenic low back pain was successfully treated with PNS.
Case Report:
Our patient is a 62-year-old female with a past medical history of chronic low back pain secondary to lumbar spondylosis. She was referred to the University of Alabama at Birmingham Pain Clinic for treatment of refractory low back pain. Previously, she underwent bilateral lumbar facet joint injections and bilateral lumbar radiofrequency ablations of the medial branch nerves and dorsal rami with initial, but short-lived relief of pain. These treatments were no longer providing meaningful pain relief. PNS was proposed as a treatment option, and she elected to proceed. Using fluoroscopic guidance, a PNS lead was placed near the left L4 medial branch nerve. Proper positioning of the lead was confirmed with paresthesia in the distribution of her normal pain and multifidus muscle twitching. At her 60-day follow-up, she reported 80% improvement in her pain and a better quality of life.
Discussion:
Chronic low back pain affects millions of individuals worldwide, with facetogenic pain being responsible for 15-45% of cases.6 PNS is increasingly considered as a treatment option for these individuals with relatively low risk of side effects, however evidence has been limited to level II or III currently.7 Eldabe et al completed the first randomized control trial comparing PNS with optimized medical management (OMM).8 They studied 116 patients from 21 centers and found that the addition of PNS to OMM is more effective than OMM alone in relieving low back pain at up to 9 months.8 Similarly, Cohen et al conducted a case series involving 9 patients. They found that PNS provided clinically and statistically significant improvements of low back pain, along with improved quality of life and lower opioid / non-opioid analgesic medication usage.9 Other studies have been completed, with many demonstrating that PNS provides significant reductions in low back pain, but further high-quality trials are needed before this promising treatment modality can be considered standard of care.
Conclusion:
PNS can provide meaningful pain relief. Our case demonstrates this, particularly in patients with chronic facetogenic low back pain that is refractory to other standard pain treatments.
REFERENCES
- Bourne S, Machado A, Nagel S. Basic Anatomy and Physiology of Pain Pathways. Neurosurgery Clinics of North America, 2014;25(4):629-638. doi:10.1016/j.nec.2014.06.001
- Deer TR, Naidu R, Strand N, et al. A review of the bioelectronic implications of stimulation of the peripheral nervous system for chronic pain conditions. Bioelectron Med. 2020;6:9. Published 2020 Apr 24. doi:10.1186/s42234-020-00045-5
- D’Souza RS, Jin MY, Abd-Elsayed A. Peripheral Nerve Stimulation for Low Back Pain: A Systematic Review. Curr Pain Headache Rep. 2023;27(5):117-128. doi:10.1007/s11916-023-01109-2
- Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4):287-333. doi:10.1016/j.ejpain.2005.06.009
- Abejón D, Pérez-Cajaraville J. Peripheral nerve stimulation: definition. Prog Neurol Surg. 2011;24:203-209. doi:10.1159/000323052
- Perolat R, Kastler A, Nicot B, et al. Facet Joint Syndrome: From Diagnosis to Interventional Management. Insights Imaging. 2018 Oct;9(5):773-789. doi: 10.1007/s13244-018-0638-x. Epub 2018 Aug 8. PMID: 30090998; PMCID: PMC6206372.
- Xu, J., Sun, Z., Wu, J., et al. (2021, March 19). Peripheral Nerve Stimulation in Pain Management: A Systematic Review. Pain Physician. 2021;24(2):E131-E152.
- Eldabe SS, Taylor RS, Goossens S, et al. A Randomized Controlled Trial of Subcutaneous Nerve Stimulation for Back Pain Due to Failed Back Surgery Syndrome: The SubQStim Study. Neuromodulation. 2019;22(5):519-528. doi:10.1111/ner.12784
- Cohen S, Gilmore C, Kapural L, et al. Percutaneous Peripheral Nerve Stimulation for Pain Reduction and Improvements in Functional Outcomes in Chronic Low Back Pain [published correction appears in Mil Med. 2019 Dec 1;184(11-12):e954]. Mil Med. 2019;184(Suppl 1):537-541. doi:10.1093/milmed/usy31