Peripheral Nerve Stimulation for the 21st Century: Sural, Superficial Peroneal, and Tibial Nerves

Abstract

Objective Peripheral nerve stimulation (PNS) of the lower extremity has progressed significantly over the last decade. From the proof of concept that ultrasound-guided, percutaneous implantation was possible to advances in waveforms, the field has been rapidly evolving. While most nerves in the lower extremity can be PNS targets, consideration must be given to the ergonomics of pulse generator placement, patient comfort, and avoidance of lead migration. For this paper, we examine some of the conditions amenable to lower extremity PNS, review the evidence and history behind PNS for these conditions, and describe approaches for the tibial, sural, and superficial peroneal nerves. Methods A literature search was conducted using PubMed. Search terms used were “peripheral nerve stimulation,” “lower extremity entrapment neuropathies,” “sural nerve,” “superficial peroneal nerve,” “tibial nerve,” and “tarsal tunnel syndrome.” Emphasis was placed on randomized controlled studies, anatomical dissections, and comprehensive review articles. Approaches to nerves and ultrasound images were based on anecdotal PNS cases from an experienced implanter (SP). Conclusions The development of ultrasound as a viable method of image guidance for percutaneous peripheral nerve stimulation has led to an exponential growth in the field. Lower extremity percutaneous lead placement is both feasible and an appropriate treatment modality for certain pain conditions.

Peripheral Nerve Stimulation for Lower Extremity Pain

“…The common peroneal nerve is a branch of the sciatic nerve and provides sensation to the anterior and lateral parts of the leg and foot [ 50 ]. The nerve then branches to the superficial peroneal (SPN), which can be injured after ankle fractures and surgeries due to its superficial nature [ 53 ]. This superficial nature also makes it a desirable target for PNS therapy.…”

“…Posterior tibial neuralgia, also known as tarsal tunnel syndrome, is a compression neuropathy that can result in significant foot pain when the tibial nerve and its branches are compressed by the flexor retinaculum [ 53 ]. Two studies describe improvement in this condition with PNS.…”

Peroneal nerve palsy (injury) in fibullar tunnel syndrome

“…Электроды имплантируются в области нерва проксимальнее латеральной лодыжки. Использование ультразвукового контроля интраоперационно увеличивает точность установки электродов [23,24].…”

An Update on Peroneal Nerve Entrapment and Neuropathy

“…28 The superficial course of the SPN <1 cm deep to the dermis makes it particularly susceptible to injury and compression; nonetheless, it also makes it a candidate for peripheral nerve stimulation (PNS). 29 Consequently, percutaneous PNS is an alternative minimally invasive treatment method for certain pain manifestations of peroneal neuropathy. A common target for SPN lead placement is in the distal leg, just proximal to the lateral malleolus.…”

“…Although large studies reporting outcomes from treatment with this modality are lacking, the development of new percutaneous PNS systems and the use of ultrasound for lead implantation have rapidly expanded and offered a potential treatment option. 29…”