●Informed consent was obtained from patient in this case report

●Exempted from IRB review given lack of identifiable patient information per university policy

●58-year-old  female with past medical history of HIV on HAART, communicating hydrocephalus managed with VP shunt/revision, chronic facet arthropathy, and depression who presented with refractory lower back pain radiating to bilateral buttocks

●Started 9 years ago without inciting trauma or preceding events

●Described as 8/10, “aching,” “burning,” and “throbbing” pain

●Exacerbated by walking and standing, and relieved by lumbar extension

●Notable for a positive bilateral Kemp’s test

●Treated by a prior pain specialist with physical therapy, medications (NSAIDs, Tylenol, muscle relaxants, neuropathic pain medications) and interventional techniques (medial branch blocks, epidural steroid injections) without improvement and with significant side effects

●Lumbosacral radiographs with bilateral L3-S1  facet arthropathy and lumbar MRI with severe facet arthrosis without central canal or foraminal stenosis

●Averse to trying alternative agents

●After discussion, psychological evaluation, and surgical clearance, patient elected to proceed with SCS trial

●Bilateral octopolar 10kHz SCS leads placed percutaneously into posterior epidural space using fluoroscopic guidance and connected to external pulse generator

●Left lead placed at mid-point of T7, and right lead placed at superior endplate of T8

 

●Leads remained in place for 7 days

●Experienced significant pain relief that decreased to 1/10 rating

●Significant functional improvement after trial

●No adverse effects or consequences to include infection or compromised neural function noted

●Plans to proceed with permanent implant

●Identifying appropriate inclusion and exclusion criteria for neuromodulation can be challenging

●Guidelines suggest screening for psychiatric conditions like psychosis that could negatively impact treatment response

●Spinal canal entry in patients with VP shunts are associated with increased risk of infection

●Also, there is greater risk of acute spinal canal pressure increases, compromising spinal cord perfusion

●Consider short course of post-operative antibiotics in addition to prophylaxis during SCS placement for these patients

●Consistently evaluate for acute ICP increases from potential shunt kinking during prone positioning for this procedure

●Consider local anesthetics to prioritize early detection of shunt failure or changes in spinal perfusion pressure