Bilateral Peripheral Nerve Field Stimulation for Intractable Coccygeal Pain: A Case Study Using Dual Lead Intercommunication

Abstract

Coccygeal pain is a difficult chronic pain problem with mixed response to various treatments. This is a report of a case of coccygeal pain that after failing various conservative and interventional procedures over five years was evaluated with a temporary peripheral sacral fascial lead followed by implantation of bilateral sacral paramedian leads for peripheral nerve field stimulation (PNFS). This resulted in marked pain control and resumption of full activity. The visual analog scale (VAS) pain score improved from eight pre-implant to one after implant and has remained at that level in follow-up. Peripheral nerve field stimulation has been reported for axial chronic back pain, post-laminectomy pain and sacroiliac joint pain either alone or in conjunction with epidural spinal cord stimulation. Both single and parallel leads have been used to provide wider stimulation but differences in location have not been examined. This is the first case report of the use of PNFS for treatment of intractable chronic coccygeal pain. The effectiveness of PNFS was established for this patient by using a prolonged 10-day temporary trial period followed by a 30-day interval without stimulation during which the pain returned to the pre-trial level before proceeding with permanent implantation, it was clear that in this case, PNFS was effective for pain control. Interestingly, the trial and permanent leads were both in the posterior sacral fascia but not in identical positions yet equally effective for pain control. The observation of the effectiveness of different positions may indicate that at least for peripheral field stimulation there may be significant current spread in the fascia. Two and three months after the implant, we examined the effect of different lead settings and the effect of unilateral stimulation compared with bilateral stimulation with and without interlead communication. The patient feedback in this case provides some understanding of the effect of field stimulation with different lead placements. A trial of a deep peripheral fascial lead for sacral and coccygeal field stimulation is a simple option and may be a reasonable approach to consider in the range of treatments for chronic coccygeal pain.

Considerations in permanent implantation of peripheral nerve stimulation (PNS) for chronic neuropathic pain: An international cross‐sectional survey of implanters

“…These results would suggest that the majority of providers are either targeting single nerves or only targeting two nerves simultaneously for less than half of their cases. One case study found marked pain control from bilateral peripheral nerve field stimulation (PNfS) in intractable coccygeal pain 25 but the PNS data for a comparison between efficacy of dual‐lead implants and single‐lead implant is limited. Further, additional studies are needed to distinguish between physician perception of clinical efficacy from dual‐lead implants that target unilateral versus bilateral limbs.…”

<p>Peripheral nerve field stimulation to the preauricular area for intractable chronic migraine: a case report</p>

“…D’Ammando et al28 employed PNFS on 22 patients with chronic refractory neuropathic pain and found that the clinical effect of PNFS was better on craniofacial postherpetic neuropathy (PHN) than on upper limb PHN; and of failed back surgery syndrome (FBSS) patients, pain in lumbosacral area achieved better analgesic effects than in perineal area. Granville et al29 used temporary bilateral sacral PNFS in the treatment of intractable coccyx pain and achieved good results.…”

Current Innovations in Peripheral Nerve Stimulation

“…PNS has been shown to be efficacious in several chronic pain conditions including trigeminal neuropathic pain [ 12 – 16 ], episodic cluster headache (supraorbital nerve stimulation) [ 17 , 18 ], chronic migraine/headache disorders (occipital nerve stimulation) [ 19 , 20 ], fibromyalgia (C2 area stimulation) [ 21 , 22 ], postherpetic neuralgia [ 23 – 26 ], complex regional pain syndrome type I [ 4 , 27 ] and type II [ 28 ], isolated peripheral neuropathy [ 29 ], ilioinguinal, iliohypogastric, and lateral femoral cutaneous neuralgia [ 30 ], back pain [ 31 ], foot pain (tibial nerve stimulation) [ 32 ], and coccydynia [ 21 , 33 ].…”