Dorsal root ganglion stimulation provides significant functional improvement from acute debilitating Crohn's disease: A novel use.

Crohn's disease is a chronic inflammatory bowel condition causing symptoms, notably pain, due to ongoing intestinal inflammation or complications like abscesses, strictures, and fistulas, which are common in IBD patients. Abdominal pain affects up to 60 % of IBD patients, irrespective of disease severity, prompting medical attention. Various medications like NSAIDs, antidepressants, antispasmodics, anticonvulsants, and opioids are used to manage pain, but they have limited effectiveness and potential side effects, even during remission. In this case, a 20-year-old Caucasian female college student [height 5'4″, weight 120lbs (54.4 kg)] with juvenile idiopathic arthritis and Crohn's disease experienced severe daily abdominal pain, negatively impacting her life. Despite a multimodal regimen, including gabapentin, nortriptyline, duloxetine, and acetaminophen, her pain persisted, significantly affecting her appetite, sleep, mood, activity level, and overall quality of life (QOL). To address this, dorsal root ganglion (DRG) stimulation was considered. The patient aimed for a 20 % pain reduction and improved QOL. Trial leads were placed along the T10 and T12 DRG, resulting in a 25 % pain reduction (8-6 out of 10) and substantial QOL improvement. She could eat, sleep without interruptions, walk longer distances, and be more active. The T12 lead was more effective than the T10, targeting upper abdomen stimulation. The patient and her mother were highly satisfied and opted for permanent implantation for the T11 and T12 DRG. While DRG stimulation was approved in 2016 for chronic pain, to our knowledge, this is the first reported case of its use in a patient with debilitating Crohn's disease.

Spinal cord stimulation may reduce lumbar radiculopathy in the setting of metastatic colon cancer.

Cancer pain has a substantial impact on the quality of life and functional capacity with a prevalence of up to 70 % in patients with advanced, metastatic, or terminal disease [1]. The WHO pain ladder has been used in practice to guide cancer pain management. A three-step ladder starts with NSAIDs and non-opioids for mild pain, weak opioids for mild to moderate pain and strong opioids for moderate to severe pain with the use of adjuvant medications such as TCAs and muscle relaxants at any stage for optimization (Fallon et al., Dec 2022) [2] We present a case of a patient with metastatic colon cancer who was admitted for intractable pain crisis and right sided L-5 radiculopathy secondary to epidural metastasis (Figs. 1 and 2). The patient's pain left her bedridden, unable to walk and remained refractory to an escalating intravenous opioid regimen and caudal epidural steroids. The patient subsequently underwent spinal cord stimulation (SCS) trial at level T-7 and achieved >80 % pain relief resulting in a markedly decreased opioid requirement and tremendous recovery of ambulatory function (Fig. 3). After sustained results, a permanent implant was placed at T-8 and patient remains discharged with functional restoration and continued pain improvement (Fig. 4). To our knowledge, this is a novel application of SCS for a refractory pain crisis secondary to a metastatic colon cancer induced radiculopathy presenting with severe functional impairment. As we transition away from opioid use, it is imperative as pain physicians, to investigate the potential of current as an alternative means of cancer pain management: a ubiquitous and challenging clinical conundrum.