PPM ACCESS
Access to the PPM Journal and newsletters is FREE for clinicians.
16 Articles in Volume 20, Issue #5
20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care
A Kratom Primer: Miracle Medicine or Herb of Abuse?
A Pilot Study: Incidence and Prediction of Diversion among Opioid Therapy Patients
Analgesics of the Future: G-Protein Biased Mu-Opioid Receptor Ligands
Application Note: Decellularized Human Placenta in the Treatment of Infracalcaneal Heel Pain
Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results
Ask the PharmD: How to Manage Pain Meds During Pregnancy?
Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors
Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis
Differential Diagnoses: Inflammatory or Non-inflammatory Chronic Back Pain?
Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options
Product Review: Non-Invasive Neuromodulation for the Treatment of the Most Difficult Pain Conditions
Provider Perspective: Carpal Tunnel's Association with Hypothyroidism
Research Insights: Opioid Use During the Peripartum Period – What to Expect
Special Report: Race, Pain Management, and the System
When Patients Become Pregnant: How to Maintain Chronic Pain Management

Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis

The authors found SCS delivered exceptional pain control in this “unruly” disease that often fails medical management and other interventions.

Case Presentation: Herein, the authors report the use of a spinal cord stimulator to treat severe chronic intractable abdominal pain in a patient with an 18-year history of chronic pancreatitis. A stimulator with leads placed midline of T5-T6 was used on a high frequency mode. The visual analog scale (VAS) was reported as a 0/10 and remained that way for 2 years until lead migration was confirmed radiographically. 

 

Background

Chronic pancreatitis is the result of inflammation and fibrosis of the pancreas.1 The incidence and prevalence of chronic pancreatitis are approximately 5/100,000 and 50/100,000, respectively; however, this may be underestimated.1 Risk factors can be recalled by the classification system called TIGARO, which stands for toxic-metabolic, idiopathic, genetic, autoimmune, recurrent acute pancreatitis, and obstructive.1

Pancreatitis is a disease that exists along a continuum, which includes acute, acute relapsing, and chronic stages.1 The differentiation between acute and chronic pancreatitis may be made based on time, pain, enzyme levels, and physical characteristics of the pancreas.

Acute pancreatitisis painful, whereas chronic pancreatitis may not always be painful.

Chronic pancreatitiscan have normal lipase and amylase levels. In addition, patients will have patchy areas of fibrosis whereas acute pancreatitis will have an evenly distributed inflammation of the entire organ. Nevertheless, chronic pancreatitis will often present with abdominal pain and pancreatic insufficiency. The visceral pain associated with chronic pancreatitis travels along A-delta and C-fibers, and the associated spinal level is T5-T6.2 The pain can result in hyperalgesia.2 Symptoms manifest as intractable abdominal pain and steatorrhea.1

Pancreas cross section anatomyThe differentiation between acute and chronic pancreatitis may be made based on time, pain, enzyme levels, and physical characteristics of the pancreas. (Image: iStock)

Treatment Options for Chronic Pancreatitis

The treatment of chronic pancreatitis involves lifestyle modification, replacing pancreatic enzyme, controlling pain, and addressing complications.1,3 Patients should be counseled on smoking and alcohol cessation in addition to dietary modifications.1 Pancreatic enzyme replacement may also help relieve pain by placing less stress on the organ to produce and secrete these3 Other modes of medical analgesia include the use of tricyclics, NSAIDs, pregabalin, and opioids.4 A number of invasive techniques are currently being used to treat pancreatitis pain. These include celiac nerve blocks, endoscopic stenting, extracorporeal shock wave lithotripsy, radiation, surgical decompression, denervation, or resection.5-10 The role for interventions is reserved for those failing medical therapy or in cases of suspected malignancy.

The challenge of chronic pancreatitis for pain management physicians is that, while there is a stepwise approach for the treatment, most patients actually fail medication management.11 In addition to this, interventions such as neuroablation and celiac plexus block lack reproducibility and thus may not be an ideal option.11In one report involving 1,018 patients, only 65% to 86% of patients experienced pain relief with endoscopic interventions.10 Failure of medication management and the lack of efficacy of current interventions make chronic pancreatitis an unruly disease that requires more research into alternative treatments for pain.

Spinal Cord Stimulation

Spinal cord stimulation (SCS) is indicated for failed back syndrome, complex regional pain syndrome, peripheral vascular disease, refractory angina, diabetic peripheral neuropathy, postherpetic neuralgia, intercostal neuralgia, and phantom limb pain.12 While the viscerotomal innervation of the pancreas corresponds to the T5-T6 level, SCS currently has limited application in treating visceral abdominal pain.11,12

The authors used SCS in this case for abdominal pain based on expert experience. SCS has been used to treat intractable abdominal pain associated with chronic pancreatitis with promising results.2,13-15 HIPAA authorization was obtained from the patient.

Case Description

A 41-year-old female presented with a primary complaint of 18-year history of intractable abdominal pain following an uneventful cholecystectomy with a secondary complaint of chronic neck and upper extremity pain.  Her social history was significant for being a social smoker. Her surgical history included an appendectomy, hysterectomy, multiple endoscopic retrograde cholangiopancreatography with stent placement, cervical laminectomy with fusion, and two cervical radiofrequency ablations. She described her abdominal pain as a burning sensation in the periumbilical area rated, on average, as 7/10 on the visual analog scale (VAS). The abdominal pain worsened after eating. Nausea and vomiting were concurrent with her pain symptoms.

Following gastroenterology workup, she was diagnosed with chronic pancreatitis and irritable bowel syndrome. The etiology could have been secondary to smoking, but the patient was unwilling to quit. In addition to her gastrointestinal symptoms, she also had concurrent chronic intractable cervicalgia with right upper extremity pain secondary to cervical laminectomy with cervical fusion. She was diagnosed with failed back syndrome.

Failed medical treatments for pain included ketorolac, tramadol, morphine, and buprenorphine patches. The patient was taking gabapentin, pantoprazole, ranitidine, erythromycin, pancrelipase, morphine, montelukast, tramadol, and buprenorphine when she presented to us. Interventional management included seven endoscopic pancreatic stents over the course of 18 years prior to presenting to us. Cervical radiofrequency ablations temporarily relieved the cervicalgia and upper extremity pain symptoms.

The patient was approved for a trial of a Boston Scientific Wavewriter SCS system with two eight-contact leads. The leads were placed under fluoroscopic guidance midline at the level of C3-C6 and T5-T6 (Figure 1). The battery was placed in the gluteus medius.

 

Figure 1Figure 1. Anterior-posterior fluoroscopic radiographs showing eight-contact midline lead placement at C3-C6 and T5-T6.

The trial was conducted over a 4-day period. During this time, the patient experienced four different programming modes for 1 day each. The trialed modes included a conventional mode, high rate, burst, and combination therapy.

  • The conventional mode utilizes low-frequency tonic waves in the 40 Hz to 80 Hz range to induce a paresthesia.
  • High rate mode (typically over 500 Hz) utilizes higher frequency waves than the conventional mode. These high-frequency waves do not induce paresthesia.
  • Burst mode repeatedly delivers a packet of waves in the 2 Hz to 1,200 Hz range followed by a period of no waveform activity.

Combination therapy allows for the various therapy modes to be layered simultaneously. This patient opted for a high rate mode due to her preference for not wanting to feel paresthesia. This high rate mode also gave the patient optimal analgesia when compared to the other modes. The VAS on this high rate mode during the trial was reported to be 1/10.

Two weeks following the successful trial, a permanent SCS was placed with leads at the same location with subsequent programming on a high-frequency mode. During this interval, the patient began tapering down all analgesic medication. She ultimately had 100% reduction in opioid analgesics consumption and no longer used them within the first week of permanent SCS placement.

On post-operative Day 1, the patient reported diminished nausea and vomiting and regained the ability to sleep on her right side. Her VAS was reported as 0/10 for the abdomen as well as the neck and upper extremity. She experienced a 2-year period of pain relief with an average VAS of 0/10 for the abdomen, neck, and upper extremity following permanent placement. Two years following her surgery, she experienced pain in her abdomen and secondary to radiographically confirmed lead migration to the level of T7-T8 (Figures 2 and 3). After lead revision, this issue resolved and the patient has gone 1 year without any further problems.

Figure 2Figure 2. Anterior-posterior radiograph showing eight-contact midline lead placement at T7-T8.Figure 3Figure 3. Lateral fluoroscopic radiograph showing eight-contact midline lead placement at T7-T8.

Discussion

This pain associated with chronic pancreatitis is often debilitating, recurrent, and resistant to medications and other interventional techniques, such as celiac plexus block. This pain is often permanent. The case presented here and similar cases demonstrate that SCS can be used to successfully treat chronic pancreatitis pain.2,13-15

Our case report is similar to other published studies as outlined in Table I. All of these studies had leads placed between T5 and T9 with a reduction in pain medication usage. The remission time was most frequently greater than one year. Vergani15 had the highest average post-operative VAS point reduction, similar to ours, but none of those patients had complete remission of pain as in our case. Kapural14 started the study with 30 patients but 10 patients dropped out due to a failed trial, infection, lead migration, or failure to follow up.14

 

Our case is notable because we were able to obtain complete remission of pain symptoms (sustained VAS of 0) with sustained discontinuation of previous opiate pain medication in a patient for nearly 2 years without complication. Pain symptoms returned at the 2-year mark with radiographically confirmed lead migration at that time to the level of T7-T8.

It should be noted that the programming of the SCS did not change throughout the 2-year time period. This lead migration level was similar to the intended levels of studies produced by Kim13 and Vergani.15 In our presented case, it was a suboptimal location for pain relief as the patient’s pain was worse when the lead moved away from the intended level of T5-T6. This difference leads us to believe that the patient obtained full remission of pain in part because the leads were placed at the T5-T6 level. The intended lead site placement in our case was most similar to cases presented by Khanand Kapural;14 however, these cases differed in many ways. For example, the actual SCS system utilized was not identical nor was the number of leads placed or specific placement. In addition, it is unknown what programming modes were used. These points of interest could have significant implications, but we are unable to draw any conclusions at this time.

 In summary, we report the successful use of SCS for pain associated with chronic pancreatitis with careful follow-ups to monitor for lead migration. More research will be needed on identifying the optimal SCS system, lead site placement, number of leads, best programming, and strategy for monitoring and managing complications such as lead migration.

 

 

Disclosure: This research was supported (in whole or in part) by HCA Healthcare and/or HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Continue Reading:
Treating Pain in Chronic Pancreatitis
close X
SHOW MAIN MENU
SHOW SUB MENU