Percutaneous Peripheral Nerve Stimulation of the Medial Branch Nerves for the Treatment of Chronic Axial Back Pain in Patients After Radiofrequency Ablation

Abstract

Objective Lumbar radiofrequency ablation is a commonly used intervention for chronic back pain. However, the pain typically returns, and though retreatment may be successful, the procedure involves destruction of the medial branch nerves, which denervates the multifidus. Repeated procedures typically have diminishing returns, which can lead to opioid use, surgery, or implantation of permanent neuromodulation systems. The objective of this report is to demonstrate the potential use of percutaneous peripheral nerve stimulation (PNS) as a minimally invasive, nondestructive, motor-sparing alternative to repeat radiofrequency ablation and more invasive surgical procedures. Design Prospective, multicenter trial. Methods Individuals with a return of chronic axial pain after radiofrequency ablation underwent implantation of percutaneous PNS leads targeting the medial branch nerves. Stimulation was delivered for up to 60 days, after which the leads were removed. Participants were followed up to 5 months after the start of PNS. Outcomes included pain intensity, disability, and pain interference. Results Highly clinically significant (≥50%) reductions in average pain intensity were reported by a majority of participants (67%, n = 10/15) after 2 months with PNS, and a majority experienced clinically significant improvements in functional outcomes, as measured by disability (87%, n = 13/15) and pain interference (80%, n = 12/15). Five months after PNS, 93% (n = 14/15) reported clinically meaningful improvement in one or more outcome measures, and a majority experienced clinically meaningful improvements in all three outcomes (i.e., pain intensity, disability, and pain interference). Conclusions Percutaneous PNS has the potential to shift the pain management paradigm by providing an effective, nondestructive, motor-sparing neuromodulation treatment.

Non-Spinal Neuromodulation of the Lumbar Medial Branch Nerve for Chronic Axial Low Back Pain: A Narrative Review

“…Percutaneous PNS of the LMBN is a relatively new modality, and to date, there are 10 human, clinical studies focusing on nonspinal neuromodulation for chronic axial LBP (16)(17)(18)(19)(20)(21)(22)(23)(24)(25). Kapural et al (25) was the first to publish clinical data using the SPRINT device.…”

“…Low-frequency pulse train stimulation of the LMBN terminal branches activates both sensory afferents and muscle efferent fibers, producing proprioceptive signals in large diameter fibers that convergently directly activate sensory afferents engaging in the spinal cord gating mechanism. Data are limited but have demonstrated sustained results, even after cessation of 60-day temporary stimulation for patients with multifactorial chronic axial low back pain, including degenerative disc disease, lumbar spondylosis, lumbar facet arthropathy, discogneic pain, etc (17,(20)(21)(22)(23)25). The permanently implanted restorative LMBN PNS system, on the other hand, has a more regimented minimally invasive technique.…”

Peripheral Nerve Stimulation for Chronic Pain: A Systematic Review of Effectiveness and Safety

“…However, it is important to comment that long-term follow-up at 12 months demonstrated that 67% of enrolled subjects endorsed a 63% reduction in low back pain intensity after a 30-day trial of the externalized wearable stimulator, irrespective of etiology of low back pain. Deer et al’s subsequent study using the same methodology was also excluded because the enrolled population was too small and because of the extent of industry involvement [ 140 ]. However, these findings are supported by several other reports of simulation of other nerves which are of interest even though they did not meet the inclusion criteria.…”

Treatment of chronic axial back pain with 60‐day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study

“…Abbreviation: PNS, peripheral nerve stimulation. a One superficial infection at a lead exit site was resolved with removal of lead 1 week prior to end of treatment and an oral antibiotic (first reported in Deer et al 44 ).…”