Retrograde placement of spinal cord stimulator leads for treating resistant pelvic pain

Sir,

Spinal cord stimulators (SCSs) have been used since 1967 to successfully treat many chronic pain conditions. The Food and Drug Administration (FDA) has approved the use of SCS for the treatment of multiple chronic pain conditions including chronic pain of the trunk and limbs, complex regional pain syndrome, and intractable low back pain, leg pain, and pain from failed back surgery syndrome.[1] In addition, the use of neuromodulation technologies has been emerging for alternate indications. Chronic pelvic pain is continuous or intermittent pain that occurs in the lower abdomen or pelvic area, and it causes a functional limitation in activities of daily living or reduced quality of life. The etiology of pelvic pain is often multifactorial, and its pathophysiology is complex and incompletely understood.[2] Even when the pathology is defined, evidence-based management options for chronic pelvic pain is limited, and few therapeutics have shown meaningful clinical efficacy.[3] We present a patient with intractable pelvic pain successfully treated with spinal cord stimulation.

A 56-year-old female presented to our clinic with pelvic pain that had been present since she was a teenager. The patient was involved in three motor vehicle accidents in the 1990s, which aggravated her pain. She has tried several modalities including multiple types of opioids, antidepressants, anti-seizure medications, steroid injections, and physical therapy as well as seeing a chiropractor and pain psychologist. The patient's severe pelvic pain remained unresponsive to treatment, and after discussion of the benefits and side effects, we decided to proceed with SCS trial. After passing the psychological evaluation, the patient underwent an SCS trial where we placed two Octad leads in a retrograde fashion to be placed into the sacral canal. The patient experienced approximately 80% improvement in her pain during the trial week. We then moved forward with the permanent implant by placing two Octad leads in a retrograde fashion; the leads were entered at the L3–L4 space and advanced to the S3 level bilaterally. The patient continued to have pain improvement at 1-year follow-up.

The drive for technology advancement within medicine is often fueled by suboptimal results within patient outcomes. Over time, new indications for the current technology may emerge and offer clinicians further options to optimize patient care. The FDA has currently approved the use SCS for multiple indications. We present a novel use of SCS in the treatment of chronic pelvic pain. Chronic pelvic pain refers to noncyclical pain occurring below the umbilicus for a duration of at least 6 months, which is severe enough to cause functional disability or require treatment.[4] A single source is rarely identified, and management can be vexing for both the patient and physician. Currently, medications are often central to the management of chronic pelvic pain. However, randomized clinical trials have shown that they are not proven to be clearly superior to placebo. In addition, side effects may limit the doses that can be used for therapeutic effect.[5] A multimodal approach is clearly optimal with simultaneous treatment of anatomic, musculoskeletal, functional bowel and bladder, and psychological factors when indicated.[6] We have introduced a case when SCS was used to successfully treat severe pelvic pain that was resistant to other therapeutic options. In cases when chronic pelvic pain is resistant to conservative measures, SCS may be considered as an effective option in the treatment of this condition.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Abd-Elsayed is a consultant for Medtronic, Halyard, Axsome, Ultimaxx Health, Innocol and spine Loop.