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Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia following Hallux Valgus Surgery
Session: MP-04a
Thurs, April 19, 3:30-5:00 pm
Shubert (Shubert Complex), 6th floor

Please note, medically challenging cases are removed three months after the meeting and scientific abstracts after three years.

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Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of

the Sciatic Nerve for Postoperative Analgesia following Hallux Valgus Surgery

 

Ilfeld BM, Gabriel RA, Said ET, Monahan AM, Sztain JF, Abramson WB, Khatibi B,

Finneran JJ, Jaeger PT, Schwartz AK, Ahmed SS


University California San Diego


Introduction

Percutaneous peripheral nerve stimulation (pPNS) or “neuromodulation” is

an analgesic modality involving the insertion of an electrical lead through an

introducing needle—obviating the requirement of a surgical incision for

placement—followed by the introduction of electric current

Neuromodulation is based on “gate control theory”, in which electric current

stimulates large-diameter afferent nerve fibers that subsequently interrupt

communication (the “gate”) from small-diameter pain fibers to the central

nervous system at the level of the spinal cord.

This therapy has multiple theoretical benefits over existing analgesic

modalities: a lack of systemic side effects (e.g., opioid-induced nausea,

respiratory depression), diversion and abuse potential, local anestheticinduced

sensory, motor, and proprioception deficits, and significant foreign

body infection risk

•The US FDA has cleared an available

lead and stimulator for the treatment

of acute pain for use up to 60 days

•Percutaneous PNS has been used to

treat chronic pain and post-operative

pain following knee arthroplasty

•The purpose of this feasibility study

was to explore the possibility of

providing analgesia following painful

ambulatory foot surgery with pPNS

 

 

Materials & Methods

The protocol was prospectively registered (NCT02898103), approved by the local IRB,

and all subjects provided written informed consent. Lead insertion occurred within 2

weeks prior to unilateral hallux valgus osteotomy.

A helically-coiled, insulated electrical lead was percutaneously inserted 1-2 cm posterior

to the sciatic nerve between the popliteal fossa and subgluteal region using a short-axis,

in-plane ultrasound-guided approach.

A general anesthetic was administered during surgery and a pulse generator

(“stimulator”) was connected to the lead and initiated in the recovery room (SPRINT, SPR

Therapeutics, Cleveland, Ohio).

Rescue analgesia was provided with opioids and—if needed—a ropivacaine 0.2%

perineural infusion via a popliteal catheter during the first three days. Subjects were

discharged home and followed daily by telephone.

Subjects returned to the clinic for lead removal with simple traction by an investigator

between POD 14-28.

Subjects (n=7) reported both minimal pain and opioid requirements in the first two

postoperative weeks (Figures). 50% triggered their CPNB POD 2-3.

One subject experienced adequate analgesia in the PACU, but complained of foot

cramping with stimulation that evening and withdrew from study.

One subject’s lead was dislodged the day after surgery, replaced two days later, and

subsequently fractured on POD 7.

One subject’s lead fractured during removal. Retained fragments are not surgically

removed and have not previously produced any complications when left in situ.

This proof-of-concept study demonstrates that pPNS is feasible for ambulatory surgery;

and suggests that this modality both provides analgesia and decreases reliance on

opioids following hallux valgus procedures.

 

Results & Conclusion

Subjects (n=7) reported both minimal pain and opioid requirements in the first two

postoperative weeks (Figures). 50% triggered their CPNB POD 2-3.

One subject experienced adequate analgesia in the PACU, but complained of foot

cramping with stimulation that evening and withdrew from study.

One subject’s lead was dislodged the day after surgery, replaced two days later, and

subsequently fractured on POD 7.

One subject’s lead fractured during removal. Retained fragments are not surgically

removed and have not previously produced any complications when left in situ.

This proof-of-concept study demonstrates that pPNS is feasible for ambulatory surgery;

and suggests that this modality both provides analgesia and decreases reliance on

opioids following hallux valgus procedures.

 

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