Cryoneurolysis and Peripheral Nerve Stimulation: Comment.

Abstract

We read the excellent review “Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain”1 with a particular interest in the potential application of neuromodulation for acute pain management. With the accelerating drive for early mobilization and hospital discharge, there is a need to explore alternative pain management strategies in addition to the traditional loco-regional techniques using chemical means to interrupt nerve conduction. Loco-regional analgesic techniques may often result in undesirable effect of motor weakness hindering mobilization or physiotherapy. The infusion of local anesthetics has additional concerns of sterility of the infused solution and the temporal limitation of the duration of infusion. We concur with the authors that analgesic effects with neuromodulation opens a new avenue in augmenting the quality of analgesia while minimizing the risk of motor blockade. Rather than selecting one modality over another, we proposed that there is a case to be made to integrate both loco-regional analgesia with early neuromodulation, the novel concept of “hybrid regional technique.”By utilizing local anesthesia in the acute phase perioperatively, and transition with concomitant neuromodulation, the hybrid technique of conduction blockade complemented by neuromodulation of unblocked fibers via gate-control theory2,3 may offer patients with the “best of both worlds” and can potentially smoothen the course of acute postoperative pain transition. The concept of multimodal analgesia4,5 has its roots in the idea that different analgesic techniques target different pain pathways or the mechanisms of pain causation. The principle of integrating loco-regional conduction blockade with electrical neuromodulation aligns along the basic tenet of multimodal analgesia in that each modality complements the other.The authors also appropriately highlighted that the cost of currently employed specialized peripheral nerve stimulator systems may discourage its general adoption. Additional procedures in placing these delicate catheters and its paraphernalia may need special expertise or resources and hence may impede its widespread use. Thus, further work is essential to investigate the possibility to safely amalgamate electrical analgesia technique to the traditional continuous regional analgesic block as a single procedure with suitable catheter and its associated equipment. Nevertheless, peripheral nerve block catheters used in regional anesthetic block have been successfully used for neuromodulation trialing6 and may serve as a precedent to integrate the dual modalities in the arena of acute pain management.The authors declare no competing interests.