Ultrasound-guided percutaneous peripheral nerve stimulation for analgesia following total knee arthroplasty: a prospective feasibility study

Abstract

BackgroundPeripheral nerve stimulation has been used for decades to treat chronic pain but has not been used for postoperative analgesia due to multiple limitations, beginning with invasive electrode placement. With the development of small-diameter/gauge leads enabling percutaneous insertion, ultrasound guidance for accurate introduction, and stimulators small enough to be adhered to the skin, neurostimulation may now be provided in a similar manner to continuous peripheral nerve blocks. Here, we report on the use of ultrasound-guided percutaneous peripheral nerve stimulation to treat postoperative pain.Materials and methodsSubjects within 60 days of a total knee arthroplasty with pain insufficiently treated with oral analgesics had a 0.2-mm-diameter electrical lead (pre-loaded into a 20 gauge needle) introduced percutaneously using ultrasound guidance with the tip located approximately 0.5–1.0 cm from the femoral nerve (a second lead was inserted approximately 1.0–3.0 cm from the sciatic nerve for posterior knee pain). An external stimulator delivered current. Endpoints were assessed before and after lead insertion and the leads subsequently removed. Due to the small sample size for this pilot/feasibility study, no statistics were applied to the data.ResultsLeads were inserted in subjects (n = 5) 8–58 days postoperatively. Percutaneous peripheral nerve stimulation decreased pain an average of 93% at rest (from a mean of 5.0 to 0.2 on a 0–10 numeric rating scale), with 4 of 5 subjects experiencing complete resolution of pain. During passive and active knee motion pain decreased an average of 27 and 30%, respectively. Neither maximum passive nor active knee range-of-motion was consistently affected.ConclusionsUltrasound-guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postoperative pain following orthopedic surgical procedures, and further investigation appears warranted.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study

“…Previous investigations involving the same helically coiled lead used in the current study have reported a 7.5% average incidence of fracture deep to the skin during removal (none occurred in the subjects of the current study) . All previous lead remnants have been left in situ with no negative sequelae reported in up to a one year period of assessment . Importantly, magnetic resonance imaging may be performed safely in patients with retained lead fragments at 1.5 Tesla .…”

“…One lead of the current investigation broke exterior to the subject where the lead met the connection block, which has not yet been reported . Previous investigations involving the same helically coiled lead used in the current study have reported a 7.5% average incidence of fracture deep to the skin during removal (none occurred in the subjects of the current study) .…”

In Vitro Magnetic Resonance Imaging Evaluation of Fragmented, Open-Coil, Percutaneous Peripheral Nerve Stimulation Leads

“…Accordingly, the medical professional should inform the patient regarding these matters and make a notation in the patient's medical records. It should be noted that the rate of lead fracture (as determined by visual inspection of the removed lead) associated with lead removal has been reported to be 7.5% . Notably, there were no reports of infectious or neurologic complications related to the presence of lead fragments in situ , nor any reports of indwelling leads fracturing during therapy .…”

“…No serious device‐related adverse events have occurred across all studies and, for the adverse events that did occur, these required little or no medical treatment . In addition, there have been no reports of induced sensory, motor, or proprioception deficits during use of this unique means of applying PNS, thus, enabling percutaneous PNS to be utilized during physical rehabilitation (e.g., during the immediate postoperative period) and activities of daily living .…”

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation for Postoperative Analgesia

“…[32][33][34] In 2 of these abstracts, 32,33 a total of 10 individuals were included who experienced postoperative knee pain difficult to control with oral analgesics between 6 and 97 days after surgery. Using ultrasound guidance, a femoral and/or sciatic nerve electrical lead was inserted, depending on where most of the pain originated (anterior vs posterior).…”