Stimulation of Dorsal Root Ganglia for the Management of Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is a pain disorder associated with dysregulation of the central nervous system and autonomic nervous system resulting in functional loss, impairment, and disability. It mostly involves the extremities and often worsens over time. It is usually initiated after an injury, surgery, or vascular accident, although spontaneous development is also described.

 

Neuro-modulation has been shown to be an effective intervention for CRPS but is hampered by technical challenges associated with directing stimulation to distal extremities. Van Buyten et al. (2015) suggest that dorsal root ganglia (DRG) may be more effective as a physiological target for electrical modulation due to recruitment of the primary sensory neurons that innervate the painful distal anatomical regions.

 

DRG is a gateway to transmission of sensory signals to the spine. It is an active rather than passive neural structure in the development of neuropathic pain with anatomical and physiological changes. DRG stimulation has been shown to reduce DRG neuron hyper-excitability in nerve injury models.

 

Van Buyten et al identified 11 subjects diagnosed with uni- or bilateral lower-extremity CRPS and placed quadripolar epidural leads near lumbar DRG using conventional percutaneous techniques. Neurostimulators were trialed with 8 being successful and therefore permanently implanted and programed to achieve optimal pain–paresthesia overlap.

 

A degree of pain relief and subjective functional improvements were seen in all eight participants. There was significant 62% reduction in average self-reported pain from baseline values and pain relief was achieved through a 12 month period in most subjects. Some participants also experienced improvements in function and CRPS-associated oedema and trophic skin changes. Locations typically difficult to target with traditional spinal cord stimulation showed excellent pain-paraesthesia concordance with DRG neurostimulation, and the area of pain distributions was also reduced.

 

While subject numbers are low, the study by Van Buyten et al. have demonstrated that neuromodulation of the DRG appears to be a promising option for relieving chronic pain and other symptoms associated with CRPS. The capture of discrete painful areas such as the feet, combined with stable paresthesia intensities independent of body position, suggests this stimulation modality may allow more selective and consistent targeting of painful areas than traditional spinal cord stimulation.

 

An additional recent study published in the Pain Management Research Review 24 (2015) indicates that patient satisfaction has improved with the introduction of DRG stimulation. For example, there is reduced position-dependent lead movement hence stable pain-paraesthesia concordance, and more focal coverage and less energy requirement for stimulation.

 

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Van Buyten J, Smet I, Liem L, Russo M, Huygen, F. (2015) Stimulation of Dorsal Root Ganglia for the Management of Complex Regional Pain Syndrome: A Prospective Case Series. Pain Practice Volume 15, Issue 3, pages 208–216, Pain Management Research Review, Issue 24 2015

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The comments above are the implicit advice of Workplace Physiotherapy. The views expressed are based on current evidence-based research and accepted best practice approaches. Unless otherwise stated, these comments are not the view of WorkCover NSW or any other professional body. No reproduction or forwarding of this advice is permitted without the consent of the author.

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