Title: Cervical Spinal Cord Stimulation for Chronic Pan-Brachial Plexopathy and Spinal Cord Injury: A Case Report
Background:
•Brachial plexus avulsion (BPA) is a traction injury that disrupts the preganglionic fibers of the plexus nerve roots originating from the spinal cord leading to significant neuropathic pain, functional impairment, stress, and poor quality of life [1,2].
•Dorsal root entry zone (DREZ) lesioning, a surgical technique that destroys afferent sensory neurons in the dorsal horn to inhibit nociception [3].
Purpose:
•To describe cervical spinal cord stimulation (cSCS) as a possible neuromodulation treatment for refractory neuropathic pain for brachioplexopathy once no other procedures or surgeries are indicated.
Case Description:
•Presentation: A 39-year-old male complete T6 spinal cord injury and complete left brachial plexus avulsion (BPA) injury from a 2008 motorcycle accident, presented with chronic, burning, left palm pain.
•Failed interventions: physical therapy, neuropathic and anti-inflammatory medications, opioids, epidurals, and peripheral nerve blocks.
•Surgery: not a candidate for nerve and muscle transfer and dorsal root entry zone (DREZ) lesioning.
•Physical examination: flaccid paralysis, muscle atrophy, and patches of numbness or allodynia throughout the entire left upper extremity.
•Imaging: XR with inferior displacement of humerus (Figure 1)
•Electrodiagnostic studies: absent recruitable motor units in brachial plexus innervated muscles and absent or very low amplitude sensory nerve action potentials in terminal branch nerves (Table 1).
Results
•cSCS trial was successful with 70% reduction (Figure 2).
•Permanent cSCS implant was performed epidurally via interlaminar, right paramedian approach, at the C7-T1 interspace, and two duals leads terminating at the middle of the C4 and the bottom of the C5 vertebral body levels, respectively (Figure 3).
•At 1-month follow-up, 70% pain reduction, significant activity tolerance improvement more than 1 hour with ADL’s, and opioid use reduction.
Discussion
•Few cases have reported cervical SCS efficacy for treating BPA-related pain.
•Case 1: 85% pain relief after cervical SCS after 1 year with complete cessation of gabapentinoids, occasional use of anti-inflammatory drugs, and return to full-time work [4].
•Case 2: 41 patients with a mean visual analog score reduction of 4.0 post-cSCS implantation, in which two cases reported 60-80% and 30-35% pain relief with functional improvement at 5 months and 8 months post-implantation, respectively [5].
•This case reports similar pain reduction and functional recovery
References
1.Parry WCB. Pain in avulsion lesions of the brachial plexus: Pain. 1980;9(1):41-53. doi:10.1016/0304-3959(80)90027-5
2.Choi PD, Novak CB, Mackinnon SE, Kline DG. Quality of life and functional outcome following brachial plexus injury. The Journal of Hand Surgery. 1997;22(4):605-612. doi:10.1016/S0363-5023(97)80116-5
3.Ferraresi S, Basso E, Maistrello L, Scerrati A, Di Pasquale P. Dorsal root entry zone lesion: nuances of the technique and long-term results. Neurosurgical Focus: Video. 2020;3(2):V13. doi:10.3171/2020.7.FOCVID2031
4.Ramnarayan R, Easwaran R. Spinal Cord Stimulation for Brachial Plexus Injury Pain: A Case Report and Review of Literature. Neurology and Neurorehabilitation. 2020;2(4). Accessed June 13, 2024. https://www.iomcworld.org/abstract/spinal-cord-stimulation-for-brachial-plexus-injury-pain-a-case-report-and-review-of-literature-59663.html
5.Dombovy-Johnson ML, Hagedorn JM, Wilson RE, Canzanello NC, Pingree MJ, Watson JC. Spinal Cord Stimulation for Neuropathic Pain Treatment in Brachial Plexus Avulsions: A Literature Review and Report of Two Cases. Neuromodulation: Technology at the Neural Interface. 2020;23(5):704-712. doi:10.1111/ner.13128
