POST-ACTINIC PLEXUS NEUROPATHY TREATED WITH SPINAL CORD STIMULATION IMPLANT

M. Toma, D. Alicino, L. Fiore, G. Pulito | Dept. of Anesthesia and Resuscitation, "Vito Fazzi" Hospital, Lecce

INTRODUCTION
Cervicobrachialgia is a painful condition caused by an inflammation of the nerve roots of the cervical plexus. This pathology has had a progressive increase in the world population with a frequency of 3551 cases per 100,000 inhabitants and an overall increase of 34%¹. The therapeutic management is very complex given the low efficacy of opioids in analgesic management, as demonstrated in literature². In pain management, Spinal Cord Stimulation (SCS) is strongly imposed with a good long-term analgesic response³. Specifically, High Frequency Spinal Cord Stimulation allows: stimulation of the posterior cords of the spinal cord with a pulse frequency of 10000 Hz and an average intensity of 1-5 mA and absence of paresthesia.
METHODS
In September 2024, a 68-year-old female patient presented to our Pain Therapy clinic with significant pain (VAS 8/10) and tactile allodynia, despite medical therapy (informed consent was obtained). Anamnesis: In 2020, recurrence of poorly differentiated breast cancer was diagnosed, subjected to quadrantectomy in 2007, treated with CH + RT. In 2021, paresthesias appeared in the first 3 fingers of the left hand (C8-T1) after RT. In 2023, presence of severe pain with hypoesthesia and functional impotence of the left upper limb up to paralysis of the arm and forearm. Current home therapy: Tramadol 37.5mg + Paracetamol 325mg: 2 tablets x 2 /day, Carbamazepine: 300mg in the morning and 350mg in the evening, Pregabalin: 100 mg /day, Alprazolam: 0.25 mg x 2 /day, Tiobec complex: 1 tablet/day, Assonal PEA: 1 tablet/day, Clonazepam 2,5mg/ml: 4 drops in the evening. On 12/12/2024, cervical SCS was positioned in the operating room with the catheter tip positioned in C5. After 16 days, the definitive SCS was implanted.
RESULTS
At the check-up on 04/01/2024, the patient reported a significant improvement in pain symptoms and a gradual improvement in finger mobility. It was therefore decided to halve the ongoing therapy: Tramadol 37.5 + Paracetamol 325mg: from 2 to 1 tablet/day, Carbamazepine: from 300mg in the morning and 350 mg in the evening to 100mg x 2/day, Pregabalin: from 100 to 50mg/day, Alprazolam suspended. In the following months the SCS placement, vas neck pain and vas upper limb pain went from 7 to 2 while pain relief with treatment had a response of more than 50%. In subsequent checks we found: reduction of ODI SCORE from 84% to 46%, great satisfaction on the part of the patient, no adverse events or complications related to the procedure were reported, however, paralysis of the left arm and forearm persists.
CONCLUSIONS
The case we presented demonstrates how the use of SCS in cervicobrachialgia has opened a new scenario in pharmacological descalation and in improving the patient's quality of life even in situations like ours where the neurological damage is now irreversible. The literature shows us that SCS becomes an irreplaceable ally when conventional pharmacological therapies have not shown good efficacy and it is not possible to reduce the dosages.