scsparaplegia.pdf

Case Study 2: Pain Relief in the Patient With Traumatic Paraplegia Sanjay S. Sastry, MD

Alyn L. Benezette, DO

Kristina H. Berger, MD

Director of Pain Management Coastal Pain Center South Daytona, Florida

Medical Director Coastal Pain Center South Daytona, Florida

Lake Mary Family Practice Lake Mary, Florida

The authors have nothing to disclose.

Case Description The patient is a 62-year-old man who initially presented in January 2009 with complaints of chronic low back pain. He is a disabled, wheelchair-bound construction worker. He sustained a crushing injury to the spine resulting in spinal cord transection at the level of T12-L1 after falling off a roof while at work in 2002. He described constant, severe, bilateral low back pain that was dull, aching, spasmodic, more right-sided, and worse at night. It is aggravated by sitting for long periods and relieved by sleep, rest, and medication. The patient was referred by his neurologist for interventional pain control. He stated that he was “sick and tired” of taking pain medication daily. His goal was to reduce, if not eliminate, all use of pain medication. The patient’s daily visual analog scale (VAS) pain score was 6 out of 10.

Objective To alleviate the chronic, intractable, daily pain of a patient who suffers from traumatic spinal cord injury (SCI) resulting in transection of the spinal cord at T12-L1.

Figure 1. Octrode lead placed toward T3-4 region. Above the level of lesion (A-P view).

Pa i n M e d i c i n e N e w s Sp e c i a l E d i t i o n   •  D e c e m b e r 2 0 1 2

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Treatment of Patient The patient had numerous regional blocks performed without any pain relief. Proposition for a trial placement of a spinal cord stimulator (SCS) using dual Octrode lead placements was discussed. The patient consented. The trial procedure was performed in an office setting, whereas the subsequent permanent implant was completed in an outpatient hospital setting. The trial placement of the stimulator was done using dual Octrode percutaneous cylindrical leads. The first Octrode lead was placed midline to right paramedian to the spinous process of the T3-4 epidural space region after gaining entry to the epidural space from the T5-6 area (Figure 1). The second Octrode lead was placed via the L3-4 epidural space, placing the lead midline to the right paramedian to the spinous process of the L1-2 region (Figure 2). Subsequently, intraoperative stimulation testing was done. The severity of the scoliosis can be seen in Figure 3. The patient had excellent pain relief. He was subsequently taken to the recovery room where further stimulation and programming of the leads were provided. After 3 days, the trial leads were pulled. The patient stated that he had greater than 80% pain relief. The patients VAS pain score during the stimulation of the SCS was 1 to 2 out of 10. After placement of the permanent SCS, the patient said that he had 70% to 75% overall pain relief in the low back region and legs. The patient was followed up 3 years later and reported that he had greater than 60% ongoing pain relief from the SCS.

Figure 2. Octrode placed at L1-2 region, below level of the lesion (lateral view).

Challenges Patients with traumatic SCIs often experience persistent, unrelenting chronic pain. The injury to the cord often presents both physiologic and anatomic challenges. These patients are not considered candidates for an SCS trial due to the disruption of the neural pathways and anatomic challenges. In many cases, it is thought that the injury itself prevents the ability for the patient to obtain paresthesias from the SCS device. In this case, the patient also had extensive levoscoliosis of his spine. Very little has been published on the use of SCS for chronic pain associated with traumatic SCI. Further research should be encouraged.

Conclusion Patients with traumatic SCI resulting in chronic pain may benefit from a trial with an SCS. Further studies are warranted.

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I n d e p e n d e n t ly d e v e l o p e d b y M c M a h o n P u b l i s h i n g

Figure 3. Severity of scoliosis. A-P view.