RESUMO
Sacroiliac joint pain (SIJP) has been difficult to properly manage in the medical field. Patients are initially managed with medications and physical therapy but may require further interventions including intra-articular corticosteroid injections, radiofrequency ablation, and sacroiliac joint fusion. Although peripheral nerve stimulation (PNS) and peripheral field nerve stimulation (PFNS) have been used with varying success, subcutaneous spinal cord stimulation (SCS) has not yet been utilized. We present the case of a patient with bilateral SIJP who had successful resolution with the use of subcutaneously-implanted SCS electrode leads. A 74-year-old female patient with a history of lumbar stenosis status post epidural steroid injection and minimally invasive lumbar decompression presented with year-long chronic low back pain (LBP) with unsuccessful pain relief from medical management and physical therapy. On physical exam, pain elicited with tenderness over both sacroiliac joints with positive Patrick's and Gaenslen's test bilaterally. After successful pain relief from a diagnostic SI joint injection, the patient underwent an SCS trial. Trial SCS leads were placed epidurally at T7 and subcutaneously next to bilateral SI joints. Epidural stimulation provided no pain relief after three days. Stimulation was then changed to the subcutaneous leads, with subsequent 90% pain relief. The patient then underwent a permanent implant with subcutaneous lead placement without complications. She reported pain relief ongoing for two years. SIJP is a difficult condition to treat despite various modalities. Recent advances in neuromodulation have shown anecdotal success with PNS. SCS involves electrode leads placed in the epidural space to provide axial back and radicular pain coverage. In this case, however, SCS leads were placed subcutaneously with excellent pain relief. Our case showcases the successful use of subcutaneous-implanted SCS which can provide another viable minimally invasive treatment option in the management of this pain source.
RESUMO
Chronic pancreatitis represents an inflammatory condition occurring from repetitive pancreatic inflammation episodes ultimately causing patients intractable pain alongside pancreatic insufficiency and as a result, reduced quality of life. In addition to alcohol and smoking cessation, patients with chronic pancreatitis are treated conservatively with anti-depressants, anti-convulsant and analgesic medications including paracetamol and celecoxib - with limited success. Alternative to surgical resection, patients can opt for endoscopic treatment options including sphincterotomy or removal of calculi which have shown limited success. Celiac plexus blocks have had positive outcomes as well, however, are not long-lasting and carry significant risks, such as gastroparesis or organ damage. Evidence has shown alterations in the peripheral and central nervous system which causes these patients to often experience dysfunctional and neuropathic pain. The advent of this knowledge has introduced neuromodulation into the field with successful cases of spinal cord stimulation treating the pain associated with chronic pancreatitis. Dorsal root ganglion stimulation is similarly based upon the gate theory of pain but with more precision as it strictly targets the dorsal root ganglion. There have been no cases reported in the literature of this form of stimulation in treating chronic pancreatitis. We present a case of a patient with chronic pancreatitis who obtained 80% abdominal pain relief for two years after undergoing dorsal root ganglion stimulation.
RESUMO
OBJECTIVE: Chronic rectal pain secondary to radiation-induced proctitis is fast-becoming a leading cause of chronic pain, especially for prostate cancer survivors. Currently, many elderly patients resort to increased opioid intake to alleviate the pain. However, this increase in opioid consumption often leads to constipation and further aggravates the anorectal pain, thus leading to a perpetual, vicious cycle. We reasoned that blocking the ganglion impar could attenuate this sympathetically maintained pain, which would lead to a reduction in the consumption of opioids, lessen constipation, and lead to an improvement in the patient's quality of life. STUDY DESIGN: Case report. SETTING: An academic tertiary pain management clinic. RESULTS: The authors report the case of a 73-year-old African American man with a history of prostate cancer who presented to the pain management clinic for evaluation and treatment of his chronic anorectal pain secondary to radiation-induced proctitis. The patient underwent a ganglion impar block, using the transcoccygeal technique, and consequently reported excellent pain relief with little or no use for opioid pain medications at a 2-month follow-up. Ultimately, this approach led to improved mobility and an increase in the patient's quality of life. CONCLUSIONS: Based on this case's success, a prospective study or randomized control trial evaluating the efficacy of the ganglion impar block as a treatment option for chronic anorectal pain secondary to radiation-induced proctitis appears warranted.
