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McCullough M, Kenney D, Curtin C, Ottestad E. Peripheral nerve stimulation for saphenous neuralgia. Reg Anesth Pain Med 2024; 49:455-460. [PMID: 38050145 DOI: 10.1136/rapm-2023-104538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/15/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Injury to saphenous nerve branches is frequent during knee surgery and can result in chronic pain. This saphenous neuralgia remains challenging to treat. Peripheral nerve stimulation (PNS) is a new potential non-pharmacologic treatment option. We present our outcomes experience using this technology in 12 patients. METHODS We retrospectively reviewed PNS placement for saphenous neuralgia between 2000 and 2022 at a single institution. Demographic information was collected as well as response to the device. Four-question short-form Patient-Reported Outcome Measurement Information System (PROMIS) Scores were collected before and 2 weeks, 6 weeks, and 6 months postprocedure. Specific scores included pain interference and behavior, functional mobility, depression, anxiety, and sleep impairment. Change in pain interference measured by the short-form PROMIS tool at 6 months was chosen as the primary outcome. RESULTS Twelve patients met inclusion criteria, with 10 patients having the full 6-month follow-up. In these 10 patients, the mean change from baseline in the short-form adjusted pain interference score (greater difference means improved pain) at 6 months was 5.8 (SD 6.5). Among all patients, average follow-up was 11.5 months (range 3-35 months). Most patients' symptoms developed after knee surgery (84%). Prior to PNS, patients underwent other treatments including cryoablation (8%), radiofrequency ablation (16%), saphenous neurectomy (16%), or surgical release of adjacent nerves (25%). Ten patients (83%) reported any improvement in symptoms while two reported no benefit. Complications occurred in four patients (33%). Two patients had the device removed and a third discontinued use. PROMIS Scores for pain, functional mobility, mood, and sleep impairment all improved. DISCUSSION Limited effective treatments exist for saphenous neuralgia. Our case series demonstrates the potential of PNS as a treatment for saphenous neuralgia. Comparative effectiveness studies are warranted to assess whether our effect size is clinically relevant.
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Affiliation(s)
- Meghan McCullough
- Surgery, Plastic and Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deborah Kenney
- Orthopedic Surgery, Stanford University, Palo Alto, California, USA
| | - Catherine Curtin
- Surgery, Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Einar Ottestad
- Anesthesiology and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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2
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Goree JH, Grant SA, Dickerson DM, Ilfeld BM, Eshraghi Y, Vaid S, Valimahomed AK, Shah JR, Smith GL, Finneran JJ, Shah NN, Guirguis MN, Eckmann MS, Antony AB, Ohlendorf BJ, Gupta M, Gilbert JE, Wongsarnpigoon A, Boggs JW. Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement. Neuromodulation 2024:S1094-7159(24)00064-3. [PMID: 38739062 DOI: 10.1016/j.neurom.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.
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Affiliation(s)
- Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Stuart A Grant
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Yashar Eshraghi
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Sandeep Vaid
- Better Health Clinical Research, Newnan, GA, USA
| | | | - Jarna R Shah
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - G Lawson Smith
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Nirav N Shah
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Maged N Guirguis
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Maxim S Eckmann
- Department of Anesthesiology, University of Texas San Antonio, San Antonio, TX, USA
| | | | - Brian J Ohlendorf
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Mayank Gupta
- Neuroscience Research Center, Overland Park, KS, USA
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3
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Vu PD, Gul F, Robinson CL, Chen GH, Hasoon J. Peripheral Nerve Stimulation After Total Knee Arthroplasty and Non-Operable Patella Fracture. Orthop Rev (Pavia) 2024; 16:115599. [PMID: 38586247 PMCID: PMC10994825 DOI: 10.52965/001c.115599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/01/2024] [Indexed: 04/09/2024] Open
Abstract
Chronic knee pain, affecting over 25% of adults in the United States, has surged by 65% over the past two decades leading to rising functional deficits, mobility problems, and a diminished quality of life. While conservative management with pharmacologic and minimally invasive injections are pursued early in the disease process, total knee arthroplasty for refractory osteoarthritis of the knee is often considered. This procedure usually improves pain and functionality within the first three months. However, a significant portion of patients often suffer from postoperative pain that can become chronic and debilitating. We detail the case of a patient with a previous TKA as well as a non-operable patella fracture who obtained significant relief with PNS despite prior conservative and minimally invasive management.
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Affiliation(s)
- Peter D Vu
- Department of Physical Medicine & Rehabilitation The University of Texas Health Science Center at Houston
| | | | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine Beth Israel Deaconess Medical Center
| | - Grant H Chen
- Department of Anesthesiology, Critical Care, and Pain Medicine The University of Texas Health Science Center at Houston
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine The University of Texas Health Science Center at Houston
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4
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Abd-Elsayed A, Henjum LJ, Shiferaw BT, Yassa PE, Fiala KJ. Infrapatellar Branch of the Saphenous Nerve: Therapeutic Approaches to Chronic Knee Pain. Curr Pain Headache Rep 2024; 28:279-294. [PMID: 38294640 DOI: 10.1007/s11916-024-01217-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE OF REVIEW The infrapatellar branch of the saphenous nerve (IPS) is an under-investigated nerve that can be a source of chronic knee pain. This literature review aims to deliver an up-to-date review of chronic pain transmitted via the IPS along with therapeutic approaches available for pain refractory to conservative measures. RECENT FINDINGS Knee pain transmitted via the IPS can arise from several etiologies. Damage to the IPS is often iatrogenic and develops following total knee arthroplasty, anterior cruciate ligament reconstruction, and other knee surgical procedures. Other causes of IPS-derived pain include entrapment of the nerve, neuromas, Schwannomas, and pain from knee osteoarthritis transmitted through the IPS.This article investigated therapeutic approaches to pain derived from the IPS. Common approaches included radiofrequency ablation, neuroma excisions, Schwannoma excision, nerve blocks, surgical exploration, surgical release of an entrapped nerve, cryoablation, and peripheral nerve stimulation. Pain scores, duration of pain relief, adverse events, and secondary outcomes were all included in this review. A subset of the patient population experiences chronic pain deriving from the IPS that is refractory to conservative treatment measures. This review aims to evaluate the etiologies and therapeutic approaches for chronic pain arising from the IPS refractory to conservative treatments.
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Affiliation(s)
- Alaa Abd-Elsayed
- Anesthesiology Department, University of Wisconsin, 600 Highland Avenue, Madison, WI, B6/319 CSC, USA.
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5
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Amirianfar E, Rosales R, Logan A, Doshi TL, Reynolds J, Price C. Peripheral nerve stimulation for chronic knee pain following total knee arthroplasty: a systematic review. Pain Manag 2023; 13:667-676. [PMID: 37937468 DOI: 10.2217/pmt-2023-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Chronic knee pain following total knee arthroplasty (TKA) affects a subset of patients that is refractory to pharmacological and non-pharmacological modalities. Peripheral nerve stimulation (PNS) has been used in patients with chronic knee pain following TKA and has shown some efficacy. Methods: Comprehensive search of Ovid Medline, Elsevier Embase, Cochrane Central Register of Controlled Trials, CINAHL Plus with Full Text, Scopus, SPORTDiscus with Full Text and the Web of Science platform. From inception to August 2022, for studies using PNS to treat chronic knee pain following TKA. Primary outcomes included pain scores, functional status and medication usage. Results: Nine studies were extrapolated with all demonstrating effectiveness of PNS for patients with chronic knee pain following TKA. Discussion: PNS for chronic knee pain following TKA has been shown to be an efficacious treatment modality. The level of evidence is low and more research is needed to assess its safety and effectiveness.
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Affiliation(s)
- Edwin Amirianfar
- Jackson Memorial Health Systems/University of Miami, Department of Physical Medicine & Rehabilitation, Miami, FL 33136, USA
| | - Richard Rosales
- Jackson Memorial Health Systems/University of Miami, Department of Physical Medicine & Rehabilitation, Miami, FL 33136, USA
| | - Andrew Logan
- Jackson Memorial Health Systems/University of Miami, Department of Physical Medicine & Rehabilitation, Miami, FL 33136, USA
| | - Tina L Doshi
- Johns Hopkins University School of Medicine, Department of Anesthesiology & Critical Care Medicine, Baltimore, MD 21205, USA
| | - John Reynolds
- Louis Calder Memorial Library, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Chane Price
- University of Miami, Department of Physical Medicine & Rehabilitation, Miami, FL 33136, USA
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Früh A, Sargut TA, Hussein A, Muskala B, Kuckuck A, Brüßeler M, Vajkoczy P, Bayerl S. Peripheral nerve stimulation for the treatment of chronic knee pain. Sci Rep 2023; 13:15543. [PMID: 37730812 PMCID: PMC10511698 DOI: 10.1038/s41598-023-42608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/12/2023] [Indexed: 09/22/2023] Open
Abstract
The average age of our population is increasing, resulting in a high incidence of chronic degenerative knee pathologies. Several treatment options, including surgical procedures are available to help mitigate these pathologies. However, the percentage of subjects with chronic post-surgical knee pain is still estimated at 16-20%. Neuromodulation techniques such as spinal cord stimulation and dorsal root ganglion stimulation (DRGS) are treatment options for subjects with chronic knee pain. The evidence for peripheral nerve stimulation (PNS) is minimal due to a limited number of neuromodulation systems capable of targeting the distal part of the lower limbs. This study aimed to investigate the safety and efficacy externally powered PNS systems for the treatment of chronic intractable knee pain targeting the saphenous nerve. Patients suffering from chronic intractable post-surgical knee pain received landmark-guided peripheral nerve stimulation of the branches of the saphenous nerve. All implants were performed with an externally powered PNS system to avoid lead migration as a result of cross-joint lead positions tunneling towards an Implantable Pulse Generator to the trunk. Data were collected retrospectively. Subject-reported outcome was measured via numerical rating scale values on a 10-point scale measuring pain intensity at rest and in motion. Additional data were collected for the subjects treated at the Charité location, including quality of life with the SF-36 form, quality of sleep with the Pittsburgh Sleep Quality Index and mood states with the short form of the General Depression Scale. Thirty-three patients received direct to permanent implant, landmark-guided peripheral nerve stimulation of the saphenous nerve branches. Six (18.2%) subjects reported non-sufficient initial benefit from the therapy and were explanted. Two subjects were explanted due to wound infections. The total study population reported included 25 patients. These subjects reported significant improvements related to pain, quality of life, mood quality, and quality of sleep. Additionally, subjects were able to reduce their opioid medication significantly after PNS therapy. Externally powered PNS at the saphenous nerve branches is a straightforward, selective and safe technique for patients with chronic knee pain. The landmark-guided implantation technique is less invasive than classical neuromodulation techniques such as spinal cord or DRGS and complication rates remain low. Short-term results are promising and show considerable reductions in pain scores and opioid intake. Long-term results are pending.
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Affiliation(s)
- Anton Früh
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health, BIH Academy, Junior Digital Scientist Program, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tarik Alp Sargut
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany
| | | | | | - Anja Kuckuck
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany
| | | | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Simon Bayerl
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany.
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7
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Chow RM, Lee RY, Rajput K. Peripheral Nerve Stimulation for Pain Management: A Review. Curr Pain Headache Rep 2023; 27:321-327. [PMID: 37523121 DOI: 10.1007/s11916-023-01143-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW Peripheral nerve stimulation has seen a recent upsurge in utilization for various chronic pain conditions, specifically from a neuropathic etiology, where a single peripheral nerve can be pinpointed as a culprit for pain. RECENT FINDINGS There is conflicting evidence about the efficacy and long-term outcomes of peripheral nerve stimulation for chronic pain, with most studies being small sized. The focus of this article is to review available evidence for the utilization of peripheral nerve stimulation for chronic pain syndromes as well as upcoming evidence in the immediate postoperative realm. The indications for the use of PNS have expanded from neuropathic pain such as occipital neuralgia and post-amputation pain, to more widespread disease processes such as chronic low back pain. Percutaneous PNS delivered over a 60-day period may provide significant carry-over effects including pain relief, potentially avoiding the need for a permanently implanted system while enabling improved function in patients with chronic pain.
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Affiliation(s)
- Robert M Chow
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT, TMP306510, USA
| | - Ryan Yesung Lee
- Medical Student-3, Yale University School of Medicine, New Haven, USA
| | - Kanishka Rajput
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT, TMP306510, USA.
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Gullapalli PA, Javed S. Multidisciplinary chronic pain management strategies in patients with Ehlers-Danlos syndromes. Pain Manag 2023; 13:5-14. [PMID: 36305215 DOI: 10.2217/pmt-2022-0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Ehlers-Danlos syndromes (EDS) are a group of disorders characterized by abnormal connective tissue affecting several organ systems. Patients with the hypermobile type of EDS (hEDS) commonly experience chronic pain which can present as musculoskeletal pain, fibromyalgia, neuropathic pain or abdominal pain. The effective management of chronic pain in hEDS patients is a challenge. This study reviews two cases of chronic pain in hEDS patients and the multimodal treatment regimen used along with peripheral nerve stimulation for shoulder and knee pains, never before reported in hEDS patients. Since hEDS associated chronic pain is multifactorial in origin, treatment requires a multidisciplinary approach which includes physical therapy, psychotherapy, pharmacotherapy and interventional pain procedures such as trigger point injections, peripheral nerve block, radiofrequency ablation and peripheral nerve stimulation.
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Affiliation(s)
| | - Saba Javed
- Department of Anesthesiology, University of Texas at Houston, Division of Chronic Pain Medicine, Houston, TX 77030, USA
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Chitneni A, Hasoon J, Urits I, Viswanath O, Berger A, Kaye A. Peripheral Nerve Stimulation for Chronic Shoulder Pain Due to Rotator Cuff Pathology. Orthop Rev (Pavia) 2022; 14:37494. [DOI: 10.52965/001c.37494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chronic shoulder pain affects millions of patients each year. Various conditions can result in shoulder pain ranging from rotator cuff injury, subacromial impingement, post-surgical pain, bursitis, adhesive capsulitis, and osteoarthritis. Typically, rotator cuff pathology is diagnosed by physical exam maneuvers along with advanced imaging modalities. Initial treatment for rotator cuff injury typically consists of physical therapy, NSAIDs, and possible injections depending on the extent of the injury. If conservative measures fail or the injury is too substantial, surgery is typically the appropriate treatment for healthy patients. For patients who are not surgical candidates or refuse surgery, peripheral nerve stimulation (PNS) can be considered. With the use of PNS, the suprascapular and axillary nerves can be targeted to provide pain relief for a variety of chronic shoulder pain issues. We describe the use of PNS in 2 patients with significant rotator cuff pathology who were not surgical candidates.
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Affiliation(s)
- Ahish Chitneni
- Department of Physical Medicine & Rehabilitation, New York-Presbyterian (Columbia/Cornell), New York, NY
| | - Jamal Hasoon
- UTHealth McGovern Medical School, Department of Anesthesia and Pain Medicine, Houston, TX
| | - Ivan Urits
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Omar Viswanath
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Amnon Berger
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alan Kaye
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, LA
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Peripheral Nerve Stimulation for Lower Extremity Pain. Biomedicines 2022; 10:biomedicines10071666. [PMID: 35884969 PMCID: PMC9313008 DOI: 10.3390/biomedicines10071666] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 11/22/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is rapidly increasing in use. This interventional pain treatment modality involves modulating peripheral nerves for a variety of chronic pain conditions. This review evaluated its use specifically in the context of chronic lower extremity pain. Studies continue to elucidate the utility of PNS and better define indications, contraindications, as well as short- and long-term benefits of the procedure for the lower extremity. While large, prospective evidence is still lacking, the best available evidence suggests that improvements may be seen in pain scores, functionality, and opioid consumption. Overall, evidence synthesis suggests that PNS for the lower extremities may be a viable option for patients with chronic lower extremity pain.
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