A "Hail Mary" Use of Sciatic Peripheral Nerve Stimulation for Intractable Ischemic Limb Pain in Non-Reconstructable PAD 

Authors: Samuel Arroyo-Rivera MD, Rupeng Li MD. 

Emory University School of Medicine, Multidisciplinary Pain Fellowship 

Introduction 

Ischemic pain is complex, involving nociceptive, inflammatory, and neuropathic mechanisms.Spinal cord stimulation has been used to manage pain in critical limb ischemia (CLI), but concurrent use of antiplatelet medication limits interventional optionsdue tobleeding risk. For patient's ineligible for revascularization who decline amputation, pain control becomes a major barrier to discharge and comfort. We present a case of sciatic PNS used as a palliative measure for ischemic pain, resulting in successful short-term relief. 

Materials and Methods 

Per institutional policy on single-patient reports, IRB exemption was granted. Written informed consent was obtained for clinical data use. No investigational device exemption or IND was required for this off-label PNS procedure. 

Case Report 

A 78-year-old man with COPD, hypertension, hyperlipidemia, and a 60-pack-year smoking history presented with severe right foot pain secondary to non-reconstructable critical limb ischemia (CLI). CT angiography demonstrated extensive bilateral lower extremity arterial disease, including complete occlusion of the right common femoral artery. Vascular surgery recommended above-knee amputation (AKA), which the patient declined. Non-surgical management included dual antiplatelet therapy (DAPT) withaspirin and clopidogrel, physical therapy, and pain control.  Medical management with pregabalin and oxycodone provided inadequate relief.Physical activity and rehabilitationwere limited by uncontrolled pain.  

As a palliative intervention, two percutaneous peripheral nerve stimulation (PNS) leads were placed adjacent to the right sciatic nerve under ultrasound guidance: one above the popliteal fossa and a second at the peroneal bifurcation. Intraoperative testing produced paresthesia's in the calf and plantar foot without motor activation. The patient reported ≥50% pain relief, enabling discharge and initiation of physical therapy. 

Ten days later, he returned with recurrent ischemic pain. Examination revealed cold, cyanotic right toes indicative of progression of ischemic disease. PNS leads were found nearly fully dislodged. The leads were removed in preparation forbelow the knee amputation with perioperativedual adductor canal and popliteal nerve blocks. 

Discussion 

PNS has demonstrated efficacy in chronic pain conditions and may offer a viable limb-salvage alternative for CLI patients without revascularization options. While SCS holds promise, its limitations make PNS a more viable patient withconcurrent management withDAPT.This PNS trial showed rapid pain relief and functional improvement. Limited collateral circulation and significant progression of ischemia interrupted the successful trial and placement of a permanent PNS.High-quality evidence is lacking and should be pursued. 

Images 

Fluoroscopic image showing peripheral nerve stimulation (PNS) leads targeting the sciatic nerve. The superior red arrow indicates the lead placement in the proximal sciatic nerve, while the inferior red arrow marks the lead in the distal sciatic nerve. 

References