Painful Peripheral Neuropathy
What is painful peripheral neuropathy?
Painful peripheral neuropathy (PPN) is a peripheral nerve disorder with elicitation of pain in the distribution of the affected nerve or nerves.
What causes painful peripheral neuropathy?
Common etiologies of PPN include diabetes mellitus, chemotherapy, and HIV. Other causes include autoimmune diseases, other types of infections, inherited nerve disorders, and metabolic conditions involving the kidneys, liver, or thyroid. However, in many cases, a singular cause cannot be identified and this may be termed idiopathic peripheral neuropathy.
How is painful peripheral neuropathy diagnosed?
Diagnosis of PPN begins with a thorough history and physical examination. Further evaluation may include laboratory testing, electrodiagnostic testing (EMG/NCS), or nerve or skin biopsy.
How is painful peripheral neuropathy treated?
Treatment typically begins with trials of various medications in conjunction with supplementation and/or modification of lifestyle factors when appropriate. Physical therapy can be considered for desensitization as well as maintenance of strength and function. Various nerve blocks can also be considered. Finally, barring failure of more conservative measures, a spinal cord stimulator trial may be recommended to aid in improvement of pain and function.
Spinal Cord Stimulator
A spinal cord stimulator (SCS) is a non-surgical, minimally invasive treatment for painful peripheral neuropathy that uses electrical impulses to block specific nerves of the spinal cord that transmit pain. It consists of a pacemaker-like battery pack called a generator and thin wires called leads. Together, the generator and leads produce electrical signals that stimulate specific nerves of the spinal cord which mask or modify pain signals before reaching the brain, thus greatly diminishing a person’s interpretation and perception of pain.
SCS may be used for patients who have chronic pain conditions despite trials of treatment options such as medications, physical therapy, chiropractic, injections, and even surgery. Indications for use of SCS include chronic low back or neck pain with or without limb pain such as failed back surgery syndrome (post-laminectomy pain syndrome). It may also be used for patients with chronic nerve pain conditions such as complex regional pain syndrome (CRPS), painful peripheral polyneuropathy, or painful diabetic neuropathy. Finally, SCS may be used for those patients with chronic pain who may not be surgical candidates or those who wish to avoid surgery altogether.
If a patient is deemed to be a good candidate for a SCS, Dr. Best will discuss performing a trial first. During a SCS trial, the epidural space is accessed using an introducer needle and x-ray (fluoroscopic) guidance just like an epidural steroid injection. However, rather than instilling steroid through the needle, a very small and thin wire (spinal cord stimulator lead) is inserted into the epidural space and gradually advanced to the mid-thoracic region. The other end of the leads exit the skin at the site oof introducer needle placement and connected to the generator which will be secured to the patient’s flank area during the 5–7-day trial period. During this 5–7-day period, the patient has the opportunity to test out the SCS technology and get a sense of whether it helps to significantly decrease pain and improve function. The patient then returns to Dr. Best’s clinic to discuss the result of the SCS trial. During the follow up visit in clinic, the SCS trial leads are removed and, if successful, the patient may choose to have the spinal cord stimulator permanently placed. When a SCS is placed on a permanent basis, all components of the leads are once again placed in the epidural space and advanced to the mid-thoracic region; however, they are then tunneled under the skin and connected to the generator which is sitting in a subcutaneous pocket created with a small incision.
The common goals when considering the use of SCS include significantly decreasing pain, decreasing need for and use of pain medication, and improvement in overall function.
At a Glance
Dr. Craig Best
- Harvard Fellowship-Trained Interventional Spine & Sports Medicine Specialist
- Double Board-Certified in Physical Medicnie & Rehabilitation and Pain Medicine
- Assistant Professor of Physical Medicine & Rehabilitation and Orthopedic Surgery
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