Introduction
We present a case of a 32-year-old female with severe chronic abdominal and pelvic pain due to endometriosis. After significant pain relief from an intraoperative bilateral quadratus lumborum (QL) block, a trial of QL peripheral nerve stimulation (PNS) for 60 days was trialed for sustained relief.
Methods
This case report is exempt from Institutional Review Board (IRB) review as per DHMC policy, as it contains no patient-identifiable information
Results
A 32-year-old female with chronic visceral endometriosis pain, extending from the abdomen to the right hip, experienced worsening pain during menses, leading to severe pain, vomiting, and inability to eat. On 9/14/22, she had diagnostic laparoscopy and hysteroscopy, receiving an intraoperative QL block that resulted in 100% pain relief for two days. She consulted the DHMC pain clinic to explore neurolysis/ablation or spinal cord stimulation (SCS). A confirmatory QL block in the clinic also provided 100% relief. After discussing this success, she agreed to trial QL PNS.
During the procedure, she was placed supine under monitored anesthesia care (MAC). Using ultrasound guidance, the fascial plane between the internal oblique and quadratus lumborum muscles was identified, and injected saline confirmed plane separation. A stimulating probe and introducer replaced the echogenic needle, verified with ultrasound. After placing a percutaneous lead, lead impedance was confirmed normal, and it was anchored and connected. Upon lead removal, she reported a 40% pain reduction. The lead was removed early at her request due to an upcoming vacation
Discussion/Conclusion
• Endometriosis occurs when endometrial glands and stroma grow outside the uterus, typically in the pelvis but also in areas like the bowel or diaphragm. This nonmalignant, estrogen-dependent condition can cause dysmenorrhea, dyspareunia, chronic pain, and infertility, with symptoms ranging from mild to severe. It affects females across various hormonal stages.
• QL blocks provide pain relief for both somatic and visceral analgesia, addressing pain from both the muscles and deeper organs. They are frequently used for abdominal and hip surgeries.
• Peripheral nerve stimulation (PNS) is an emerging method in pain management with increasing evidence supporting its effectiveness in treating various chronic pain conditions. Stimulators used temporarily or permanently.
• To our knowledge, no other cases of PNS QL block for chronic endometriosis pain have been documented.
References
• Vercellini, P., Viganò, P., Somigliana, E., & Fedele, L. (2014). Endometriosis: pathogenesis and treatment. Nature Reviews, 10(5), 261–275. https://doi.org/10.1038/nrendo.2013.255
• Hickey, M., Ballard, K., & Farquhar, C. (2014). Endometriosis. BMJ: British Medical Journal, 348. https://doi.org/10.1136/bmj.g1752
• Willard, F. H., Vleeming, A., Schuenke, M. D., Danneels, L., & Schleip, R. (2012). The thoracolumbar fascia: anatomy, function and clinical considerations. Journal of Anatomy, 221(6), 507–536. https://doi.org/10.1111/j.1469-7580.2012.01511.x
• Ong Sio LC, Hom B, Garg S, Abd-Elsayed A. Mechanism of Action of Peripheral Nerve Stimulation for Chronic Pain: A Narrative Review. Int J Mol Sci. 2023 Feb 25;24(5):4540. doi: 10.3390/ijms24054540. PMID: 36901970; PMCID: PMC10003676.