Cycling Sacral Root Neuromodulation: Pilot Study to Assess the Effectiveness of This Mode in Neuromodulator Programming for the Treatment of Chronic Pelvic Pain Syndrome

Abstract

Aim: There is lack of evidence of the role of sacral root neuromodulation (SNM) in the management of chronic pelvic pain syndrome (CPPS). We evaluated the effectiveness of cycling sacral root neuromodulation (CSNM) in the management of CPPS in patients non responders to conservative treatment. Methods:A prospective, single center, cohort study was carried out on all patients with CPPS refractory to conventional treatment, who underwent test stimulation using the tined lead between February 2012 and March 2016. During test stimulation the tine lead was positioned along the third sacral nerve, on the side where they reported more pain. Success was defined as >50% improvement of pain and concurrent urinary symptoms. After a successful SNM test period of 4 weeks, patients received a permanent implant. We also included 9 more patients already with a permanent implant and partial responders to continuous mode in neuromodulator programming. To assess pain and quality of life, all patients filled-in a VAS scale and SF-36 and McGill questionnaires, at baseline, after the 4-week test period ad after the permanent implant.Results: Overall 22 consecutive adult patients were suitable to undergo a cycling test stimulation; 19 out of them (86.3%) underwent a permanent implant after a satisfactory test phase, using a codified cycling mode of programming. Eighteen naive patients out of nineteen (94.7%) maintained the benefits of the test stimulation at a mean follow up of 21.3 months. VAS scale, McGill and SF-36 questionnaires scores improved significantly in all domains with a 95% satisfaction rate; 7 out of the 9 already implanted patients (77.7%) significantly improved their pain control.Conclusion: CSRN appears to be effectiveness in treating CPPS in both naïve and previous implanted partial responder patients.

Sacral neuromodulation in the management of chronic pelvic pain: A systematic review and meta‐analysis

“…Eleven studies assessed patients’ QoL all of which reported improvements in various QoL domains. Eight studies employed the RAND SF‐36 health survey questionnaire and six reported individual domains 12,14,18,20,29,31,34 . All six studies reported improvements in bodily pain domain.…”

“…33 Cyclical compared to continuous stimulation may also lengthen battery life. 31 Current lead implantation is completed either by a caudal approach via the sacral hiatus, which carries a risk of lead migration, a transforaminal approach via S3 foramen, or the retrograde approach which may have a higher failure rate and inadequate electrode insertion. 45 more invasive, but allows for precise nerve-specific lead placement with a clear view of the sacral nerves.…”

Reprogramming Sacral Neuromodulation for Sub-Optimal Outcomes: Evidence and Recommendations for Clinical Practice

“…The authors demonstrated that high-frequency stimulation (40 Hz) more effectively reinforces afferent signal transmission to the central nervous system than lower frequencies (21 Hz) (59). Even higher frequencies have been described for SNM in the treatment of chronic pelvic pain with a similar conclusion although it seems difficult to find a single frequency that works best for every patient in this population (60).…”

Programming Algorithms for Sacral Neuromodulation: Clinical Practice and Evidence—Recommendations for Day-to-Day Practice

“…Since the early days of SNM, the standard pulse frequency has been 14-16 Hz (22,26) for both urological and bowel dysfunctions. Nevertheless, it has been shown that frequency changes can lead to significant clinical improvements (27)(28)(29)(30)(31). Two double-blind studies with random parameter selection investigated the impact of changing the frequency or the pulse width in patients with fecal incontinence (28,29).…”

“…Although it has been shown that frequency changes can lead to significant clinical improvements (27–31), 10–14 Hz remains the most frequently used pulse rate range for basic programming (32).…”