Case Reports: Case Report
It is very important that pain medicine physicians respect vetted clinical protocols for the application of advanced pain management modalities and for nonpain medicine physicians to appreciate the methodical, intellectual, and clinical processing that is the foundation most likely to lead to success when sophisticated techniques are used. Okparete et al.,1 provide such a lesson in their report of a 42-year-old man who had ankylosing spondylitis and then developed complex regional pain syndrome, manifested as femoral nerve neuropathy after total hip replacement. The patient failed to improve after a number of conservative therapeutic interventions, targeting the complex regional pain syndrome. When the authors considered spinal cord stimulation (SCS), they obtained a pain psychology evaluation. This essential component of the patient’s preprocedure evaluation is vital, because it helps to document that the patient has no major psychosocial barriers to improvement. Forthright information, including the potential for failure, was apparently presented to the patient so that one can believe that the informed consent process was genuine. A 7-day trial with the percutaneous system resulted in substantial, clinically relevant improvements in the patient’s functional capabilities and medication need. Thus, he qualified for the placement of permanent electrode arrays that were intentionally multielectrode in design so that therapy could continue even if future adjustments to the stimulation pattern were necessary when the electrodes migrated.
The patient’s ankylosing spondylitis had resulted in the classic “bamboo spine” changes that severely impeded the authors’ attempts to access the spine for SCS at the traditional lumbar levels. Thus, the decision was logically made to use the patent sacral hiatus. Although sacral hiatus is not new,2 the passage of leads to the thoracic level is creative and novel. In addition, the authors did this not once but twice and on the right and the left side, as the patient progressed from the trial to the permanent placement. The authors followed classic patient management in working through a variety of treatment possibilities. It is fascinating, although not fully explained as to mechanism, that both of the patient’s pain generators were successfully diminished by the SCS therapy. The patient’s ultimate result fulfilled anyone’s best expectations: the quality of life was enhanced, his functional capacity markedly improved, and his need for potent analgesic decreased. Because of the systematic and versatile approach taken by the authors, the patient’s safety was optimized throughout.
John Rowlingson, MD
Department of Anesthesiology
University of Virginia Health System
1. Okparete I, Young AC, Amin S. Spinal cord stimulator placement in a patient with complex regional pain syndrome and ankylosing spondylitis: a novel approach with dual benefits. A & A Case Reports. 2014;2:117–20
2. Park CH, Kim BI. Sacral nerve stimulation through the sacral hiatus. Korean J Pain. 2012;25:195–7