title: Spinal cord stimulation in conjunction with peripheral nerve field stimulation for the treatment of low back and leg pain: a case series.
abstract: Background.  The treatment of chronic low back and leg pain remains a difficult medical challenge, particularly for patients with postlaminectomy syndrome. While spinal cord stimulation (SCS) has been a significant addition to the available options, it is often inadequate in relieving both the back and leg pain components. We hypothesized that for some patients the combination of SCS with peripheral nerve field stimulation (PNFS) would be a safe, effective alternative that would be more effective than either modality alone. Objective.  Our objective was to demonstrate the efficacy of PNFS used in combination with SCS for the treatment of chronic pain syndromes involving the lower back and legs. Study Design.  Case series. Methods.  A total of 20 patients with chronic low back and leg pain syndromes who had failed conventional therapies underwent implantation of a combination of traditional SCS and PNFS. Leads were placed in the epidural space, as well as superficially in the subcutaneous tissues of the lower back, directly in the region of maximum pain. Patients initially underwent a trial of stimulation to assess response, and a permanent system was implanted if patients reported greater than 50% pain relief during the trial. For some patients, a combination was used at the time of the initial trial. In other cases, the decision to proceed with the combination was made later, either at the time of permanent implant, or later on, after SCS alone failed to adequately control pain. Results.  In each case, PNFS was used in combination with traditional SCS for patients with chronic lower back and lower extremity pain. While not all of these patients ultimately proceeded with the combination of SCS and PNFS to control their pain, the majority of patients found the combination better in controlling their overall pain than either modality alone. In addition, using a combined approach at the time of trial provided a noninvasive and effective method of comparing the efficacy of each method, allowing patients to identify the best form of neuromodulation for their particular pain. Conclusions.  Due to the availability of 16 contact capacity generators, neurostimulation with multiple leads in various combinations-including both epidural and peripheral nerve field stimulation simultaneously-can be applied safely and effectively. The availability of this combined approach for a trial of stimulation prior to implant allows patients to compare SCS to PNFS and to indicate a preference for one over the other or for the combination. We conclude that PNFS may be used in combination with SCS as a safe and effective alternative treatment for patients with chronic low back and leg pain, and further suggest that the combined approach should be considered as a treatment option for this population.
authors.affiliation: Coast Pain Management, Newport Beach, CA, USA;              Newport Beach Headache and Pain Institute, Newport Beach, CA, USA;              Anesthesiology and Pain Medicine, University of California, Irvine, 101 The City Drive South Orange, CA, USA.
authors.forename: Clifford A
authors.initials: CA
authors.lastname: Bernstein
authors.forename: Richard M
authors.initials: RM
authors.lastname: Paicius
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Barkow
authors.forename: Cheryl
authors.initials: C
authors.lastname: Lempert-Cohen