Poster Abstracts
Shivana Ramsingh, MBBS
Physician
United Spine and Pain
Pensacola, Florida
Ryan Ramsook, MD
CEO
United Spine & Pain
Tallahassee, Florida
Single Level S1 Dorsal Root Ganglion Stimulation (DRG-S) for Painful Diabetic Peripheral Approximately 50% of patients with Diabetes Mellitus (DM) develop Diabetic Peripheral Neuropathy (DPN) within 25 years, and 40-50% will experience severe, uncontrollable pain1. A few studies have demonstrated Spinal Cord Stimulation (SCS) as an effective treatment for DPN2. SCS is a neuromodulation technique that uses a mild electric current to block the electrical impulses sent to the brain from pain fibers. One study showed that SCS for DPN treatment showed significant pain relief in 63% of patients at one-year post-SCS implantation2. A systematic review done by Deer et al. 3 showed that there was a moderate level of evidence to support the use of Dorsal Root Ganglion Stimulation (DRG-S), another type of neuromodulation with more precise targeting of affected nerves, in treating chronic focal neuropathic pain. A case report by Chapman et al. 4 showcased DRG-S use specifically for DPN at the T12 and S1 levels, with significant pain relief. However, there were no reports in the literature of DRG-S with single lead placement at the S1 level only, which might provide the same alleviation. The benefit of DRG-S done only at the S1 level is that it offers a reduced risk of dural puncture and subsequent complications compared to DRG-S done at a higher vertebral level. Our case report aimed to fill this knowledge gap by demonstrating the therapeutic efficacy of single-level S1 DRG-S for painful DPN. Adding to our rationale for doing a single-level S1 DRG-S was a case series5 demonstrating single lead implantation at the S1 level for CRPS providing complete foot coverage, with therapeutic efficacy lasting at the six-month follow-up. Traditional spinal cord stimulation has previously been used to treat DPN with significant pain alleviation. However, with the advent of DRG-S, a neuromodulation technique that targets affected nerves more precisely, the painful dermatomes of DPN could be more effectively treated. The patient gave written informed consent after extensive discussion of the benefits and risks of DRG-S for the publication of this case. This case report describes a 62-year-old diabetic man presenting with chronic, diabetic peripheral neuropathic pain. He rated his pain as 9.5/10 on the Numeric Rating Scale (NRS) in both lower extremities, with paresthesia greater in his feet than in his legs. His chronic pain was uncontrolled despite being on an opioid regimen. It caused significant functional limitation, resulting in a decline in quality of life and age-appropriate impairment in Activities of Daily Living (ADL) activities. After failing conservative treatment, which included different medications (acetaminophen, NSAIDs, muscle relaxants, Gabapentin, Pregabalin, Duloxetine), physical therapy, and a physician-guided home exercise program, the patient was offered a 7-day trial of DRG-S at the S1 level. The patient was placed prone, exposing the lower back, which was cleaned and draped. Next, the skin and surgical trajectory were anesthetized with 1% lidocaine. Subsequently, under fluoroscopic guidance, two single leads were placed into each of the S1 foramina, and correct placement was confirmed with fluoroscopy in the anteroposterior (Figure 1) and lateral views (Figure 2). The DRG-S trial resulted in considerable pain alleviation after seven days. His bilateral, neuropathic foot pain was reduced by 95%, indicating high therapeutic efficacy. Furthermore, during the trial, all opioids were discontinued entirely, and the patient reported considerable improvements in ADL, mood, and sleep.
Neuropathy: A Case Report
Background:
We report the use of DRG-S at a single S1 level for pain management of a case of DPN that has failed all conservative therapies.
Purpose/Objectives:
Method:
Results:
Conclusions: Our case study provides evidence for DRG-S at the S1 level as an effective treatment option for diabetic peripheral neuropathy of the feet that has failed conservative management.
This case report demonstrates that single-level S1 DRG-S may be considered an effective neuromodulatory option for painful Diabetic Peripheral Neuropathy, with the added benefit of avoiding the risk of dural puncture and subsequent complications seen with DRG-S done at a higher vertebral level.
References: 1. Veves A, Backonja M, Malik RA. Painful diabetic neuropathy: Epidemiology, natural history, early diagnosis, and treatment options. OUP Academic. Pain Medicine. 2008;9(6):660–674. Accessed April 1, 2023. https://doi.org/10.1111/j.1526-4637.2007.00347.x.
2. Review: Electrical spinal cord stimulation in painful diabetic polyneuropathy, a systematic review on treatment efficacy and safety. European Journal of Pain. 2011;15(8):783-788. Accessed April 1, 2023. https://onlinelibrary.wiley.com/doi/pdf/10.1016/j.ejpain.2011.01.010.
3. Deer TR, Hunter CW, Mehta P, et al. Systematic literature review of dorsal root ganglion neurostimulation for the treatment of pain. OUP Academic. Pain Medicine. 2020;21(8):1581–1589. Accessed April 1, 2023. https://doi.org/10.1093/pm/pnaa005.
4. Chapman KB, Van Roosendaal B W, Van Helmond N, et al. (September 30, 2020) Unilateral Dorsal Root Ganglion Stimulation Lead Placement With Resolution of Bilateral Lower Extremity Symptoms in Diabetic Peripheral Neuropathy. Cureus. 12(9):e10735. Accessed April 1, 2023, https://doi.org/10.7759/cureus.10735
5. Skaribas IM, Peccora C, Skaribas E. Single S1 dorsal root ganglia stimulation for intractable complex regional pain syndrome foot pain after lumbar spine surgery: A case series. Neuromodulation. 2019;22(1):101-107. Accessed April 1, 2023. https://doi.org/10.1111/ner.12780.