Percutaneous Neurostimulation for Management of Chronic Neuropathic Pain Post-Cholecystectomy: A Case Report
Pain following cholecystectomy is not uncommon and can have a number of etiologies: hematoma, infection, hernia, and psychogenic causes. Intraoperative nerve crushing during tissue retraction and nerve entrapment due to fibrosis throughout the healing phase have also been reported as possible causes. This chronic post-surgical pain is a major clinical problem which could lead to impaired physical function and reduced quality of life. For that reason, peripheral nerve stimulation has been applied to the treatment of painful conditions throughout the body, beginning with the major nerves of the extremities and culminating today in precise subcutaneous field stimulation targeted to specific areas of neuropathic pain.
Case of a 42-year-old male who was evaluated at the Pain Management Clinic of the University of Puerto Rico due to a constant itching-burning pain localized to the right upper quadrant of his abdomen. Patient reported that six months prior to the onset of symptoms he underwent an open cholecystectomy due to symptomatic gallbladder disease. With regards to his ongoing symptoms, patient reported the presence of mild inflammation 2 cm around the surgical scar accompanied by pruritus and a itching-burning pain fluctuating from moderate to severe in terms of intensity. Before being evaluated by our service, the patient was initially managed using gabapentinoids, TCAs, NSAIDs, acetaminophen, and topical agents. Besides this pharmacological regimen, three subcutaneous injections using steroids and local anesthetics and two sono-guided transversus abdominis plane blockages were performed; all with mild improvement for a limited period of one week. Due to failure of achieving proper pain management; the pain became intractable. It was decided to perform a trial of peripheral neurostimulation. Under conscious sedation and local anesthetic, two electrodes were placed around the right upper quadrant of the abdomen. For one week the patient reported an improvement of above 80%. For this reason, it was decided to place the neurostimulator definitely. Under general anesthesia and after applying local anesthetics to the designated area, the electrodes were placed above and below the surgical scar and the IPG was localized to the right lower quadrant. Two weeks later, with a clean wound and no sign of infection, the neurostimulation was initiated with excellent results. On follow up for approximately one year, the patient reported a significant decrease of pain and for this reason the analgesic drugs and gabapentin dose were reduced to a minimum.
Patients with difficult pain control due to postsurgical neuralgia after a cholecystectomy procedure often suffer significantly compromise on their quality of life. Multiple therapies have been used with partial results in the short and long term. It has been shown and proven that using peripheral nerve stimulation could be an excellent option in the adequate management of pain in this type of patients.