Dorsal root ganglion stimulation for the treatment of joint pain with predominantly nociceptive characteristics: A case series

Abstract

Introduction Dorsal root ganglion stimulation (DRG‐S) has recently emerged as a novel therapy in neuromodulation that demonstrated a higher rate of success than spinal cord stimulation (SCS) in a prospective, head‐to‐head randomized comparative trial to treat complex regional pain syndrome (CRPS) and causalgia. In contrast to SCS, DRG‐S also shows promise in treating conditions that are not purely neuropathic such as axial low back pain, which has a prominent nociplastic pain component. It is not known to what extent the effectiveness of DRG‐S for such indications is due to effective treatment of the neuropathic pain component versus the effects of DRG‐S on mechanical pain. Although rarely studied, reporting outcomes of DRG‐S to treat predominantly mechanical/nociceptive pain may help point toward expanding the utility of this therapy. Here, we present five cases of refractory mechanical pain treated with DRG‐S. Methods A retrospective analysis of all patients who underwent a successful DRG‐S trial and implant between September 2017 and September 2021 at our institute was performed. Patients who had intractable joint pain without strong evidence of neuropathic pain were included in this case series. The Budapest criteria for CRPS, the Douleur Neuropathique 4 Questions (DN4) survey, or a definable nerve injury were used to determine the presence of neuropathic pain. Baseline assessments for pain (Numeric Rating Scale [NRS]), function (Oswestry Disability Index [ODI]), quality of life (EuroQol‐5 Dimension [EQ‐5D]), and other applicable joint surveys were extracted from pre‐trial baseline and follow‐up appointments. Results Five patients were identified and included. Patient diagnoses consisted of refractory joint pain of the hip, knee, or ankle. Mean NRS pain scores improved by 74% from 9.2 at baseline to 2.4 at the last follow‐up (mean = 28 months post‐implant). From baseline to the last follow‐up, mean ODI scores improved by 65% from 66 to 23 and EQ‐5D scores more than doubled from an average of 0.371 to 0.797. Conclusion This clinical report illustrates the potential utility DRG‐S has in treating pain that clinically presents as predominantly refractory mechanical joint pain without a significant neuropathic component. The physiological reasons for our observations may be that DRG‐S is able to directly influence the conduction of nociceptive signaling at the DRG and within the spinal cord. Further investigations are warranted to determine if DRG‐S is a potential treatment option for chronic mechanical pain.

Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience

“…Post-surgical joint pain or causalgia of the post-surgical joint is a PSPS that has garnered little attention with SCS compared with DRG-S. [118][119][120] There have been 2 prospective studies, 1 retrospective, 1 case series, 3 case reports, and 1 subset analysis of the ACCURATE study representing 66 patients with post joint replacement pain. 99,102,104,[121][122][123][124] The evidence DRG-S has demonstrated in post-surgical joint pain/causalgia compared to SCS places DRG-S as the authors' preferred neuromodulatory option in refractory post-surgical joint pain/causalgia.…”

“…A recent case series and a case report by Chapman et al, totaling 5 patients, reported on joint pain deemed not primarily neuropathic in nature treated with DRG-S. 123 Joints included the hip, knee, and ankle. There were impressive improvements in VAS, quality of life as measured by the EQ-5, as well as joint-specific testing.…”

“…Use radiofrequency (RF) sensory mapping or periradicular infiltration to locate most affected areas prior to trial 88,103,135,235 Discogenic pain L2 9,77,82 or T12 2,3,8,125 Post-knee replacement syndrome L 2,3,4 12,81,102,104,121,123 Pudendal neuralgia L1 and S2 144 Postherpetic neuralgia At level DRG, or above and below affected dermatome 136,137,142,236 Post-thoracotomy syndrome At the affected level(s) 136,142,236 Post-herniorrhaphy syndrome L1 followed by T12 and L2 104,105,236,237 Abdominal and abdominal wall pain Dermatomal distribution 97,[115][116][117]147 Sacroiliac joint pain/adjacent segment syndrome of the SI joint T12 and L1 or S1 8,104 Region of Body Hand and elbow C5/6/7/8 14,121,136 Hip joint T12/L1, L4, and S1 81,123 Breast T3-T7 137,238 Knee L2, L3, and L4 81,…”

Blocking Aδ- and C-fiber neural transmission by sub-kilohertz peripheral nerve stimulation

“…Blocking the afferent neural transmission to the spinal cord has been extensively applied in the clinic for managing various sensory-related disorders, especially many types of chronic pain arising from sensitized afferent input from peripheral tissues ( Epstein and Palmieri, 2012 ; Verrills et al, 2016 ). In particular, patients suffering from nociceptive pain, postherpetic neuralgia, peripheral neuropathy, musculoskeletal pain, and visceral pain report significant pain relief from treatments that block afferent drives from the spinal nerves ( Eldabe et al, 2018 ; Huygen et al, 2020 ; Berger et al, 2021 ; Kim et al, 2021 ; Chapman et al, 2023 ). Migraines and headaches can also be managed by blocking afferent drives from the trigeminal ganglia pathway ( Messlinger and Russo, 2019 ).…”

Treatment of joint pain using dorsal root ganglion stimulation

“…Patients reported improvement in pain from 9.2 to 2.4 on Numeric Rating Scale (NRS) with 65% improvement in Oswestry Disability Index (ODI) and improvement in quality of life as reported by EuroQol‐5 Dimension (EQ‐5D). Readers can find more details on the topic in cited article 1 …”