Cervical spinal cord stimulation for neuropathic pain after brachial plexus avulsion injury: case report

Abstract

Brachial plexus avulsion is a rare and debilitating condition frequently associated with severe, intractable neuropathic pain. Treatment modalities include dorsal root entry zone lesioning, stellate ganglion blockade, and neuromodulation. We present a case of a 42 year old female with left upper extremity brachial plexopathy and complex regional pain syndrome (CRPS) type 2 following a motor vehicle accident. Her pain report consisted of constant “crushing” pain, radiating from the left shoulder into her entire left upper extremity. Additionally, she reported muscle spasms, and constant sensations of burning, numbness, and tingling. On physical examination, she presented with gross atrophy from the left shoulder girdle distally. Motor control was limited to trace movements in her distal 4th and 5th digits. She exhibited increased temperature of > 3°C; localized swelling; and violaceous color tone as compared to her unaffected limb. Palpation to light touch revealed allodynia and hyperalgesia. MRI of the cervical spine was negative for obvious spinal cord or root pathology. MRI of her brachial plexus was unremarkable; however, electrophysiologic studies demonstrated upper and middle trunk lesions. Previous unsuccessful interventions included repeated stellate ganglion blockade, transcutaneous electrical nerve stimulation (TENS), and opioid medication. Present pain medications included Gralise® 600 mg TID, tramadol 50 mg PRN, and baclofen 10 mg BID. On these medications, her average pain level was consistently 9/10. After a successful trial of cervical spinal cord stimulator leads, she went on to an uneventful permanent implantation procedure. The left and right leads were positioned with their cephalad-most contacts at the C2-3 and C4-5 levels respectively. At two-week follow up her mood and sleep were both 90% improved and her average pain report decreased to 1/10. Spinal cord stimulation is an effective treatment for neuropathic pain secondary to brachial plexopathy refractory to pharmacotherapy and conventional interventional attempts to modulate pain.