CE ArticlePain Management -- Beyond the Basics:

[NRSKarenRN, BSN, RN]

pain management -- beyond the basics: neurostimulation and pain control

in 1995, a 45-year-old man injured his back in a work-related accident. he was diagnosed with a herniated nucleus pulposus of the l5-s1 vertebrae and right foraminal stenosis at l5. at clinical examination, he reported low back pain and radicular pain that radiated down his right lower extremity to the foot. the pain was unrelieved with bed rest and physical therapy.

a course of 3 epidural steroid injections provided temporary relief, with the last injection affording less than a week of 30% relief. subsequent selective nerve root blocks provided 100% relief for 24 hours. a pulsed radiofrequency (rf) procedure performed transforaminally at l5 provided 2 months relief, after which the pain completely returned.

medications included methadone 10 mg 3 times daily gabapentin 600 mg 4 times daily, and amitriptyline 75 mg every night at bedtime. these medications reduced the visual analogue score (vas) from 8-9 to 6-7, but other medication trials did not further enhance pain relief. in 1997, the patient underwent a l5-s1 laminectomy with relief of the pain for 26 months. the patient returned to work as a plant foreman at a furniture factory.

the patient returned after a subsequent injury with minimal complaint of back pain but excruciating right lower extremity pain. his physical exam was consistent with a recurrent l5 radiculopathy. a repeat mri showed postoperative changes, no herniated disc, but a significant scar surrounding the l5 nerve root. a repeat selective nerve root block, transforaminal epidural steroid injection, and lysis of adhesions provided minimal relief for 3 days.

given this patient's complicated history and current level of pain, would a neurostimulation technique prove effective in the management of his condition? we return to this case study near the conclusion of this activity.

introduction

indications

technique/types of scs/pns

complications and risks

conclusion

references

http://www.medscape.com/viewprogram/3465?src=mp

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