2019 FSA Posters

P009: A SUCCESSFUL APPLICATION OF HIGH FREQUENCY SPINAL COLUMN STIMULATOR TRIAL FOR TREATMENT OF RELAPSING-REMITTING MULTIPLE SCLEROSIS WITH COMPLEX REGIONAL PAIN SYNDROME.
Christina Brooks, MD, William Grubb, MD, DS; Rutgers RWJUH

Introduction: High Frequency Spinal Column Stimulation (HF SCS) has been shown to be a beneficial treatment option for patients with Chronic Regional Pain Syndrome (CRPS), however there are limited studies on application of HF SCS for Relapsing-Remitting Multiple Sclerosis (RRMS) with CRPS^1,2,3. In this case a 67-year-old male with RRMS was referred to our service for evaluation of persistent lumbar pain with radiculopathy to the right lower extremity (RLE). Despite surgical intervention, the patient had been diagnosed with CRPS. Our initial evaluation supported the diagnosis and received multiple less invasive procedures with excellent clinical results, however with limited duration. At that time the patient was recommended and scheduled for a HF SCS trial.

A percutaneous six-day trial with HF 10,000 Hz epidural SCS was purposed, implemented, and resulted in a significant result post trial. Patient reported reduced pain, increased function, and overall improvement of posture and range of motion.

The patient elected to proceed with a permanent implanted MRI compatible HF SCS given the need for MRI screenings for RRMS disease surveillance.

Methods: The patient was consented for insertion of HF SCS trial with monitored anesthesia care. The patient was placed in the prone position and sedation was administered by the Anesthesiologist. Vancomycin 1.25 grams was administered and with sterile field and sterile process, HF epidural trial leads were inserted under direct fluoroscopy visualization at level L2-L3 and advanced without eliciting paresthesia with appropriate level of impedance. The final position of the leads was verified with AP and lateral fluoroscopic imaging, as shown in Figures 1A and 1B. The patient returned to clinic for inspection of lead insertion, and later for trial removal.

Results: Six days post insertion of HF SCS trial, patient reported significant overall reduction of pain with improved function of the RLE. The patient reported decreased swelling of the RLE, with improved duration of relief compared to past interventions.

Discussion: We are presenting one of several applications of HF SCS for the treatment of a rare subset of patients with RRMS with CRPS. In a literature review of HF SCS utilization there are limited reports of HF SCS trials and permanent implantation in RRMS patients with CRPS^2,3. A 2008 cohort study showed that RRMS patients are at higher risk of CRPS than the general public², however studies of HF SCS as a treatment modality are limited³. The use of HF paresthesia free therapy has demonstrated to be safely applied for significant relief of CRPS symptoms. However; there are limited reports demonstrating successful utilization of HF SCS trials in RRMS patients with CRPS, making this case unique^4,5.

References:

1. Grabow et al.The Clinical Journal of Pain. 2003
2. Schwatema et al. Pain Physician 2008.
3. Hesham et al. MS Journal. 2017.
4. Kumar et al. Surg Neurol 1998.
5. Deer et al. Neuromodulation 2014.