Tibial Nerve Mononeuropathy Post Covid-19: Successful Management with Peripheral Nerve Stimulation

Sri Harsha Kanuri, MD*; Luis Miguel Escano Volquez, MD; Roger Haddad MD
Henry Ford Health, Detroit, Michigan /Department of Anesthesiology, Pain Management & Perioperative Medicine

Introduction

• The COVID-19 pandemic, has had profound impacts on global health, primarily targeting the respiratory system.

• Emerging evidence suggests a significant neurological component, including headaches to severe complications like stroke and encephalitis.

• Peripheral nerve injuries, including mononeuropathies, present unique diagnostic and therapeutic challenges (1).

• We present a case of tibial nerve mononeuropathy as a consequence of COVID-19, highlighting the novel application of Peripheral Nerve Stimulation (PNS) for effective management.

Case Presentation

• 43-year-old female, history of hypertension, diabetes, depression, and anxiety, presented with persistent neuropathic pain in her right foot following a severe COVID-19 infection in 2020.

• Pain: 7/10 along the plantar surface of the right foot, extending to all five toes and the interdigital spaces. Constant paresthesia. Worsened by standing, walking, or wearing enclosed footwear.

• Diagnosis: No history of trauma, casting or hypovitaminosis. Well controlled DM with A1C 5.5%. Negative Lumbar MRI, EMG showing sensory>motor polyneuropathy. Symptoms not attributable to other physical injuries.

• Medication management: Gabapentin, Duloxetine, Tramadol, Memantine

• Interventional approaches: Lidocaine and ketamine infusion, capsaicin cream application, and a right posterior tibial nerve block), the patient

  experienced only limited and temporary relief.

• A trial with a Spinal Cord Stimulator was attempted but failed to offer significant pain relief.

Percutaneous Nerve Stimulation for Refractory Neuropathy Pain

Trial of Posterior tibial nerve percutaneous stimulation, a novel approach given her refractory pain status.
Trial: Placed under fluoroscopic and ultrasound guidance
Permanent implant: Ultrasound assisted placement

Results

>75% pain reduction after 7 day trial period

Activities that were once painful and challenging have become more manageable, allowing return to a more normal and active lifestyle.
Following the success of trial, Patient opted for permanent PNS placement

Conclusions

Peripheral nerve stimulation (PNS) proved effective for this type of refractory neuropathic pain post-severe COVID-19 (2).

There is limited data on the literature of this use of PNS.

This innovative approach is useful for complex cases refractory to traditional therapies, highlighting the need for personalized pain management strategies.

The case underlines the long-term neuropathic complications from COVID-19, advocating for continued research in targeted therapies like PNS for chronic pain conditions.

References

1. Carberry N, Badu H, Ulane CM, Beckley A, Rosenberg SJ, Brenner K, et al. Mononeuropathy Multiplex After COVID-19. J Clin Neuromuscul Dis [Internet]. 2021 Sep 1 [cited 2023 Dec 19];23(1):24–30.

2. Finsterer J, Scorza FA, Scorza CA, Fiorini C. Peripheral neuropathy in COVID-19 is due to immune-mechanisms, pre-existing risk factors, anti-viral drugs, or bedding in the Intensive Care Unit. Arq Neuropsiquiatr [Internet]. 2021 [cited 2023 Dec 19];79(10):924–8. Available from: https://pubmed.ncbi.nlm.nih.gov/34287509/