Raoul et al., J Pain Relief 2016, S4 DOI: 10.4172/2167-0846.S4-003 Research Article Open Access J Pain Relief ISSN: 2167-0846 JPAR, an open access journal Surgical management of pain Peripheral Nerve Stimulation in Refractory Neuropathic Low Back Pain Sylvie Raoul*, Emmanuelle Kuhn, Sylvain Durand, Jean-Paul N’Guyen and Julien Nizard Service de Neurochirurgie, Centre Hospitalier Universitaire de Nantes, Nantes, France Abstract Introduction: Spinal cord stimulation is now a treatment of pain in refractory failed back surgery syndrome. The effect on radiculalgias is quite good but often unsatisfying to treat completely low back pain. Subcutaneous peripheral nerve stimulation is now one of the possibility to rescue chronic low back pain. The aim of this prospective study conducted in our center (Nantes, France) is to evaluate the beneft of the subcutaneous peripheral nerve stimulation on chronic low back pain. Method: 34 patients (aged 44-65, mean value 54.3) with chronic bilateral low back pain were evaluated with VAS Score, Medication quantifcation Scale (MQS), the patient satisfaction, and walking distance before and after stimulation. Stimulation was proposed after failure of multidisciplinary management of the patient with algologist, psychologist and rehabilitation. Electrode stimulation was implanted under local or general anesthesia and a test of 7 days was performed at home. The battery was implanted only if VAS score decreased than more 50%. Mean Follow up was 6 months (range 42 to 3 months). Result: All of 34 patients were implanted with good results: VAS score decreased from 7.5 in preoperative conditions to 2.3 in postop conditions (p ≤ 0.001). 63% of patients estimated than they were very satisfy of the surgery and they could propose that to patients. The MQS decreased from 34 in preoperative to 26 two months after the surgery and to 17 6 months after surgery. Walking distance increase after the surgery (800 meters before surgery and 1700 meters after surgery). We have 1 infection and one migration of electrodes Conclusion: this series shows that subcutaneous stimulation can be beneft to treat refractory low back pain. This surgery was well tolerated, safe. *Corresponding author: Sylvie Raoul, Department of Neurosurgery, Centre Hospitalier Universitaire de Nantes, Bd jacques Monod, Nantes, 44000, France, Tel: 33621873262; Fax: 33240165301; E-mail: sylvie.raoul@chu-nantes.fr Received June 20, 2016; Accepted July 18, 2016; Published July 21, 2016 Citation: Raoul S, Kuhn E, Durand S, N’Guyen JP, Nizard J (2013) Peripheral Nerve Stimulation in Refractory Neuropathic Low Back Pain. J Pain Relief S4: 003. doi: 10.4172/2167-0846.S4-003 Copyright: © 2016 Raoul S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Keywords: Peripheral nerve stimulation, Low back pain, Subcutaneous stimulation, Surgical treatment of low back pain Introduction Chronic low back pain afects approximately 25% of the general population and their direct and indirect costs are a major public health problem. Refractory chronic low back pains are defned by their rebellious character in a multidisciplinary management, including several treatment lines, including strong opioids, co-analgesics, functional and sometimes surgical management. Chronic low back pain are typically of mixed origin: mechanical and neuropathic. According to N. Attal and ID. Beith, neuropathic component of low back pain varies between 8% and 16% for pure lumbago and between 80% and 96% for sciatica [1,2]. According Mimassi Tirty six percent of low back pain refractory supported in the assessment and treatment centers of the pain have a predominant neuropathic component [3]. It is in this context of chronic pain with a neuropathic component, the subcutaneous neurostimulation techniques have developed. Various indications were examined: occipital neuralgia, the face of pain, the abdomen, groin, pelvis and lumbar fnally [4,5]. Tese neurostimulation techniques involve placing electrodes in adipose subcutaneous tissue at the base of the painful area and not in contact with the main nerve innervating the painful area. Te evolution of the electrodes, the cross-priming (cross-talk) and the best electrical conduction into the fatty tissue (100 to 1000 times greater than that of the skin) have increased the surface of stimulated areas, covering several metameric levels [6]. While spinal cord stimulation has proven efective in support of the refractory chronic radicular pain, it remained insufcient for the treatment of chronic low back pain, especially due to difculties in covering several metameres and thus a sufciently large surface [7-9]. Several case studies have reported the efcacy of stimulation lumbar subcutaneous associated with a spinal cord stimulation for chronic lombosciatalgies [10-13]. Others have reported the efcacy of stimulation subcutaneous only in cases of chronic pain postsurgical axial Rebel [14-19]. Methodology Anatomy and physiopathology Several structures are involved in low back pain: intervertebral disc, facet joints, muscles and integument. Te pain is ofen mixed with mechanical low back pain and neuropathic low back pain. Te characteristics of these pains are quite diferent and their treatment will be adapted to the type of back pain. Te intervertebral disc is innervated in part by the sympathetic chain through the sinu-vertebral nerve. Tere is a convergence of the sinu- vertebral nerve L5-S1 levels L4-L5, L3-L4 on the twig from L1-L2 [20]. Tus in pure discogenic low back pain infltration sinu-vertebral nerve in L-L2 may allow resolution of these low back pain. Te other innervation system is linked to the rear branch of the nerve root which supports the articular processes posterior muscles and testa Cf; (Figure 1) if this system is generally metameric there are wide anastomoses the metameres possibly responsible for referred pain. it is this system that is involved in sub lumbar cutaneous stimulation. Indeed as the gate-control theory of Wall Melzach and the stimulation of the large Aα fbers allows the activation of inhibitory collateral to reduce the intensity of pain mediated by small AD fbers and C. Tese fbers have a specifc somatotopy at the spinal cord. Tey are ofen located in contact with the middle line, deep enough and the Journal of Pain & Relief J o u r n a l o f P a i n & R e l i e f ISSN: 2167-0846