The authors report on 2 cases of delayed compression of the cervical spinal cord by dense scar tissue forming around epidural electrodes implanted for spinal cord stimulation (SCS). This complication has not been previously reported.Myelopathy developed in 2 patients 5 and 16 years after the surgical placement of a cervical epidural electrode. Prior to myelopathy, both patients experienced a tolerance phenomenon. Magnetic resonance imaging in both cases showed severe compression of the spinal cord by the electrode. At surgery, thick scar tissue surrounding the electrode and compressing the posterior aspect of the cord was discovered. Both patients experienced a full recovery following the removal of both scar tissue and the electrode.Medical and paramedical staff dealing with SCS should be aware of this severe and delayed complication. In addition, the development of epidural fibrosis can explain the occurrence of tolerance.
CT is useful in showing an entrapped epidural catheter and the mechanisms of entrapment. Surgery should be considered when gentle traction fails to retrieve the catheter. CT allows the clinician to localize the catheter with accuracy, thus facilitating surgical follow-up.
Background
Since the development and publication of diagnostic criteria for pudendal nerve entrapment (PNE) syndrome in 2008, no comprehensive work has been published on the clinical knowledge in the management of this condition. The aim of this work was to develop recommendations on the diagnosis and the management of PNE.
Methods
The methodology of this study was based on French High Authority for Health Method for the development of good practice and the literature review was based on the PRISMA method. The selected articles have all been evaluated according to the American Society of Interventional Pain Physicians assessment grid.
Results
The results of the literature review and expert consensus are incorporated into 10 sections to describe diagnosis and management of PNE: (1) diagnosis of PNE, (2) patients advice and precautions, (3) drugs treatments, (4) physiotherapy, (5) transcutaneous electrostimulations (TENS), (6) psychotherapy, (7) injections, (8) surgery, (9) pulsed radiofrequency, and (10) Neuromodulation. The following major points should be noted: (i) the relevance of 4+1 Nantes criteria for diagnosis; (ii) the preference for initial monotherapy with tri‐tetracyclics or gabapentinoids; (iii) the lack of effect of opiates, (iv) the likely relevance (pending more controlled studies) of physiotherapy, TENS and cognitive behavioural therapy; (v) the incertitudes (lack of data) regarding corticoid injections, (vi) surgery is a long term effective treatment and (vii) radiofrequency needs a longer follow‐up to be currently proposed in this indication.
Conclusion
These recommendations should allow rational and homogeneous management of patients suffering from PNE. They should also allow to shorten the delays of management by directing the primary care.
Significance
Pudendal nerve entrapment (PNE) has only been known for about 20 years and its management is heterogeneous from one practitioner to another. This work offers a synthesis of the literature and international experts' opinions on the diagnosis and management of PNE.
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