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Spinal Cord Stimulation Using Multiple Leads to Treat Pain Associated with Lateral Medullary Syndrome


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Spinal Cord Stimulation

 
Spinal Cord Stimulation Using Multiple Leads to Treat Pain Associated with Lateral Medullary Syndrome
Introduction:
Wallenberg syndrome (lateral medullary syndrome) is a rare condition resulting from a stroke involving the vertebral artery or its branch, the posterior inferior cerebral artery. Symptom presentation is variable and may include: cranial nerve palsy, hemi-sensory abnormalities, dysdiadochokinesia, and ataxia. 
Treatment includes stroke risk factor modification, rehabilitation, and medications for symptom palliation.
This is a case report of a patient with intractable right hemi-body pain successfully treated with multi-lead spinal cord stimulation.
Case:
A 55 y.o. male presented to our service with right hemi-body pain.  Two years earlier he presented to his physicians with left facial paresis, palatal weakness, anisocoria, ptosis, gait imbalance, and right hemibody sensory loss.  Neurological evaluation was consistent with lateral medullary syndrome (Figure 1).  He made an uneventful recovery except that his hemi-sensory symptoms progressed to hemi-body painful dysesthesias involving most of the right torso and right extremities.
On exam, extremity motor strength was normal. He reported arm and leg pain greater than torso pain.  He had marked mechanical and thermal allodynia involving his entire right torso and limbs. His NRS was 7/10 on medication.
He was previously treated with physiotherapy, extensive medication trials, and a 3-week comprehensive pain/rehabilitation program.  Medications at the time of consultation included hydromorphone, pregabalin, and milnacipran.
Intervention:
Based on his leg and arm pain being the predominant pains, we opted to try spinal cord       stimulation. After a successful trial, separate cervical and low thoracic 8 contact SCS leads were implanted and connected to a single IPG. 
At 8 month follow-up he reported 70% NRS arm/leg pain reduction (mean NRS 3/10) and significant functional improvement.  On exam, allodynia was significantly reduced.  He reported ongoing significant pain and allodynia of his right chest and abdomen.  He had difficulty wearing clothes and trivial events such as his dog jumping on him provoked marked pain exacerbation.  
On the basis of his excellent response to stimulation for his limb pain, he underwent another trial to address thoracic pain.  This was successful as well. Thus, two separate 8 contact SCS leads were implanted to span the length of nearly the entire right hemithoracic epidural space( figures 2 and 3).
At three months follow-up, he reported marked improvement in his torso pain and allodynia as well as overall functional improvement. 
Conclusion:
A couple of small series have reported successful treatment of post-stroke pain syndromes in patients with thalamic or putamen strokes.  This case report is an example of:
a) successful treatment of post-stoke pain in a patient with lateral medullary syndrome and
 
b) sequential placement of a total of 4 SCS leads (32 total contacts) with marked improvement in pain and function.