Нейромодуляция в лечении хронической боли у пациента с синдромом Элерса-Данло и имплантированным электрокардиостимулятором

Введение. Мы сообщаем об успешном случае лечения упорной боли у пациентки с синдромом Элерса-Данло и имплантированным электрокардиостимулятором (ЭКС). Интенсивная боль в поясничной области, связанная с постламинэктомическим синдромом, у женщины 56 лет была купирована методом периферической нейростимуляции.

Методы. 56-летней женщине с синдромом Элерса-Данло и некупируемой консервативным лечением болью в пояснице, развившейся вследствие постламинэктомического синдрома, была проведена успешная пробная периферическая нейростимуляция с использованием четырехконтактных подкожных электродов (Medtronic Inc, Minneapolis, MN), позиционированных в поясничной области. Ранее пациентке был имплантирован постоянный двухкамерный ЭКС (St.Jude, SJM, Inc, Plano, TX) в связи с синдромом слабости синусового узла и клинически значимыми эпизодами брадикардии (синкопальные состояния).

Результаты. Во время тестовой периферической нейростимуляции не отмечалось дисфункций в работе нейростимулятора и ЭКС. Пациентка отметила более чем 75% снижение интенсивности боли во время тестовой стимуляции. Временные электроды были удалены, и через 2 нед пациенке были имплантированы неподзаряжаемый генератор и электроды для постоянной нейростимуляции. Обсуждение. До недавнего времени пациентам с имплантированными ЭКС методика нейростимуляции считалась противопоказанной в связи с возможным нежелательным взаимодействием обоих устройств. Учитывая увеличение доли пожилых людей в популяции, все более актуальными становятся вопросы совместного использования методик нейромодуляции и кардиостимуляции, что требует дальнейшего изучения по мере накопления клинического опыта.

Заключение. Cовместное использование постоянной нейростимуляции и электрокардиостимуляции является безопасной методикой. Ранее имплантированный ЭКС не лимитирует применение методов нейростимуляции в лечении хронических болевых синдромов, некурабельных традиционными способами.

Treatment of chronic conditions using functional neurosurgical therapies is a rapidly expanding field. Neurostimulation is a widely accepted therapy for treating chronic pain with spinal cord stimulation (SCS) and peripheral nerve field stimulation (PNFS), for treating movement disorders such as Parkinsons Disease (PD) with deep brain stimulation (DBS), for treating gastric emptying disorders with vagus nerve stimulation, and for treating urinary dysfunction using sacral nerve stimulation (SNS). Previously, treatment with neurostimulators was considered generally contraindicated in patients with cardiovascular implantable electronic devices (CIEDs) because of concerns regarding potential device interactions [1]. These interactions include potential interference between devices such as inappropriate shock delivery via implantable cardiac defibrillator (ICD), permanent pacemaker (PPM) dysfunction, or reset of neurostimulator or implanted pulse generator (IPG) following shock delivery by an ICD [2].

As use of neurostimulation therapies increases in an aging population widely treated with CIEDs, feasibility and safety of simulataneous use of these therapies has warranted further attention. We report a case study of a patient with a previously implanted CIED successfully treated with PNFS for intractable low back pain related to postlaminectomy syndrome (PLS).

Postlaminectomy syndrome (PLS) refers to chronic back and/or leg pain which occurs in patients after spinal operations. Of the 200,000 patients in the United States who undergo spine surgery each year, 20% to 40% experience persistent or recurrent pain [3] which may be refractory to conservative therapies. Peripheral nerve field stimulation (PNFS) has been used to treat a variety of neuropathies [4], including ileoinguinal [5], occipital [6-9], post-herpetic [10], intercostals [11], for treatment of trigeminal postherpetic neuralgia, trigeminal posttraumatic neuropathic pain [12-15], atypical facial pain [16], chronic pelvic pain [17], and hip pain after total hip arthroplasty or greater trochanteric bursectomy [18] with excellent relief of pain and reduced need for oral pain medications. Recent reports describing treatment of low back pain by using stimulation through the leads placed subcutaneously in areas with localized pain [19-22] demonstrated good efficacy, simplicity and low morbidity.

Methods

An 56 year-old female with a history of intractable low back pain experienced poor pain control utilizing conservative therapies. He had a long history of low back pain related to lumbar spinal stenosis and 7 years prior to presenting for treatment in our pain clinic had undergone lumbar decompression and spinal fusion which actually worsened his pain. She had trialed over-the-counter NSAIDS, acetaminophen with minimal improvement in the pain level and numerous opioids, tramadol, neuromodulators, muscle relaxants, and antidepressants commonly used to treat chronic pain but did not tolerate them due to central nervous system sedating side effects. The pa- tient had no lower extremity pain but reported 100% of her pain in the low back exacerbated by rising from bed in the morning, standing and walking. She reported no pain when seated or lying down. The patient had undergone no interventional procedures prior to surgical intervention. After beginning treatment in our pain clinic she underwent a series of 3 caudal epidural injections which gave her no improvement in the pain. The patient was diagnosed with Ehlers- Danlos syndrome and had a previously implanted St. Jude (SJM, Inc, Plano, TX) dual chamber permanent pacemaker (PPM) because of sick sinus syndrome. Prior to offering the patient PNFS trial to cover the area of pain in his lumbar spine, we contacted St. Jude Medical, Inc for information regarding safety and recommendations regarding use of neurostimulation therapy with PPM. It was recommended that the neurostimulator be tested for possible interactions such as inhibition of pacing, asynchronous pacing or noise reversion after implantation by programming the neurostimulator to its highest output and the pacemaker to its most sensitive setting and monitoring the patient on an EKG to determine of the neurostimulator was causing over sensing that may interfere with the function of the PPM [23]. The risks, benefits and alternatives of PNFS trial to cover the area of pain over the lumbar spine were discussed with the patient, including the potential effects of neurostimulation causing interference with his PPM and he decided to proceed.

After local infiltration of 1% lidocaine, the leads were inserted through 15 gauge Touhy needles. The leads were placed vertically, parallel and lateral to postoperative scar in the area of maximum pain. Two leads were inserted superiorly and inferiorly in the each paraspinal area in the lumbar region. All four leads were attached to connecting leads then to temporary extension cable and to a temporary external stimulator. During the procedure the patient reported 75% coverage of painful areas with the settings as follows: pulse width 450 μsec, Pulse rate 60 Hertz, and amplitude 5 Volts. During intraoperative testing the amplitude was increased to the maximum intensity of 10.5 Volts while the patient was being monitored on EKG and no PMM interference was noted. During the 3 day PNFS trial the patient reported greater than 75% improvement in pain. Temporary leads were removed and 2 weeks later the patient underwent implantation with permanent leads through small parallel to midline incisions made in the paraspinal areas of the lumbar region (Fig. 1). The leads were passed through slightly bent 15 Gauge Tuohy needles to follow the curvature in lumbar area (Fig. 2). Two 4-electrode leads were inserted subdermally in superior and inferior direction through each incision vertically and parallel to each other. Total four 4-electrode leads were left in place (Fig. 3). During intraoperative testing the patient again reported 75% coverage of painful areas. Recommended intraoperative testing was again repeated, with the amplitude increased to the maximum intensity of 10.5 Volts while the patient was being monitored on EKG. Again, no PMM interference was noted. The leads were anchored in the each of two wounds to fibroaponeurotic tissue with 2-0 nonabsorbable suture of braided polyester (Ethibond) and Titan Anchors (Medtronic Inc., Minneapolis, MN). The leads were attached to connecting leads which then were tunneled to the left or right supragluteal areas where the subcutaneous pocket was created for the generator (Fig. 4). Leads were then affixed to a non- rechargeable generators PrimeADVANCED (Medtronic Inc., Minneapolis, MN). The procedure for permanent implantation was performed with conscious sedation and local anesthesia. The post-operative course was uneventful. The stimulator was programmed using a guarded electrode configuration with a pulse width of 450 μsec, pulse rate of 60 Hertz and amplitude use ranging from 2.1 to 5.7 Volts.