Spinal cord stimulation for treatment of pain in a patient with post thoracotomy pain syndrome.

Post Thoracotomy Pain Syndrome (PTPS) is defined as pain that occurs or persists in the area of the thoracotomy incision for at least 2 months following the initial procedure.  The true incidence of PTPS is hard to define as literature reports a wide range of occurrence from 5% to 90%.  Thoracotomy is associated with a high risk of severe chronic postoperative pain.  Presenting symptoms include both neuropathic pain in the area of the incision, as well as myofascial pain commonly in the ipsilateral scapula and shoulder.  Pain management can be challenging in these patients.  Multiple treatments have been described including conservative treatments with oral nonsteroidal anti-inflammatory drugs (NSAIDs); topically applied, peripherally acting drugs; neuromodulating agents; physical therapy; transcutaneous electrical nerve stimulation as well as more invasive treatments including intercostal nerve blocks, trigger point steroid injections, epidural steroid injections, radiofrequency nerve ablation, cryoablation, and one case report of spinal cord stimulation.  Unfortunately, a portion of these patients will have persistent pain in spite of multiple treatment modalities, and in some cases will experience worsening of pain. This case report describes the novel utility and complete resolution of symptoms with spinal cord stimulation (SCS) in treatment of a patient with persistent PTPS. In the operating room, a percutaneous octet electrode lead was placed using sterile technique under fluoroscopic guidance and loss-of-resistance technique.  The octet electrode lead was subsequently advanced with the aid of fluoroscopy to the level of the T3 superior endplate just right of midline.  The patient's pain distribution was captured optimally with stimulation at this level.  With the assistance of a neurosurgeon, the lead was anchored, tunneled, and connected to a generator, which was implanted over the right iliac crest.  The patient tolerated the procedure well with no complications. We report the successful use of SCS as well as complete resolution of symptoms at 4 months follow-up, in a patient with persistent PTPS, which was resistant to other modalities. In conclusion, studies designed to evaluate the effectiveness of SCS for PTPS may be warranted.