Chronic post-traumatic neuropathic pain of brachial plexus and upper limb: a new technique of peripheral nerve stimulation

Abstract

The aim of the study was to evaluate the effect on pain relief in patients with peripheral neuropathic pain after brachial plexus injuries using an implanted peripheral nerve stimulator applied directly to the nerve branch involved into the axillary cavity. Seven patients with post-traumatic brachial plexus lesions or distal peripheral nerve complaining of severe intractable chronic pain were enrolled in a single-centre, open-label trial. Conventional drugs and traditional surgical treatment were not effective. Patients underwent careful neurological evaluation, pain questionnaires and quantitative sensory testing (QST). Surgical treatment consists of a new surgical technique: a quadripolar electrode lead was placed directly on the sensory peripheral branch of the main nerve involved, proximally to the site of lesion, into the axillary cavity. To assess the effect, we performed a complete neuroalgological evaluation and QST battery after 1 week and again after 1, 6 and 12 weeks. All patients at baseline experienced severe pain with severe positive phenomena in the median (5) and/or radial (2) territory. After turning on the neuro-stimulator system, all patients experienced pain relief within a few minutes (>75 % and >95 % in most), with long-lasting pain relief with a reduction in mean Numerical Rating Scale (NRS) of 76.2 % after 6 months and of 71.5 % after 12 months. No significant adverse events occurred. We recommend and encourage this surgical technique for safety reasons; complications such as dislocation of electrocatheters are avoided. The peripheral nerve stimulation is effective and in severe neuropathic pain after post-traumatic nerve injuries of the upper limbs.

The Neurostimulation Appropriateness Consensus Committee (NACC) Safety Guidelines for the Reduction of Severe Neurological Injury

“…There were no reports of neurological injury. Stevanato et al recently reported an enhanced implantation technique for patients with post‐traumatic brachial plexus injury or distal peripheral nerve lesions with chronic severe intractable neuropathic pain . The authors report that by implanting quadripolar leads proximal to the site of injury and close to the axilla, there was no lead migration or any other complication at 12‐month follow‐up in all seven patients studied.…”

Treatment of Neuropathic Pain in Brachial Plexus Injuries

“…Peripheral nerve stimulation provides 50-83% pain relief in 65-80% of the patients [116][117][118][119][120], and the affected limb preserves the residual function remaining after the injury [121]. Allodynia and neuropathic pain are controlled with mild improvement in the sensory function [116,118].…”

Peripheral Nerve Stimulation of Brachial Plexus Nerve Roots and Supra-Scapular Nerve for Chronic Refractory Neuropathic Pain of the Upper Limb

“…In a recent study, Stevanato implanted surgically paddle leads in the axillary cavity in seven patients suffering from chronic post‐traumatic neuropathic pain of BP and upper limb. All the patients reported a pain relief ≥50%, with a mean pain severity improving from nine before surgery to 2.6 at the 12‐month follow‐up . In 2002, Goroszeniuk was the first to implant percutaneously a PNS cylindrical lead in the BP with good results .…”

“…Among neuromodulation techniques, both cervical spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) have been proposed (1,2). Since its first description by Wall and Sweet in 1967 (3), PNS efficacy for chronic neuropathic pain of the upper limbs has been suggested in few isolated cases or short pioneering series reporting variable but encouraging results (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15). A combination of peripheral and central mechanisms might explain the analgesic effect induced by low-frequency PNS which preferentially excites large myelinated fibers: modulation of peripheral nociceptors (16), blockade of afferent nociceptive inputs by continuous stimulation (6), modulation of nociception in the dorsal horn of the spinal cord (17).…”