title: Ultrasound-guided percutaneous peripheral nerve stimulation for analgesia following total knee arthroplasty: a prospective feasibility study.
abstract: BACKGROUND
  Peripheral nerve stimulation has been used for decades to treat chronic pain but has not been used for postoperative analgesia due to multiple limitations, beginning with invasive electrode placement. With the development of small-diameter/gauge leads enabling percutaneous insertion, ultrasound guidance for accurate introduction, and stimulators small enough to be adhered to the skin, neurostimulation may now be provided in a similar manner to continuous peripheral nerve blocks. Here, we report on the use of ultrasound-guided percutaneous peripheral nerve stimulation to treat postoperative pain.
  
  
  METHODS
  Subjects within 60 days of a total knee arthroplasty with pain insufficiently treated with oral analgesics had a 0.2-mm-diameter electrical lead (pre-loaded into a 20 gauge needle) introduced percutaneously using ultrasound guidance with the tip located approximately 0.5-1.0 cm from the femoral nerve (a second lead was inserted approximately 1.0-3.0 cm from the sciatic nerve for posterior knee pain). An external stimulator delivered current. Endpoints were assessed before and after lead insertion and the leads subsequently removed. Due to the small sample size for this pilot/feasibility study, no statistics were applied to the data.
  
  
  RESULTS
  Leads were inserted in subjects (n = 5) 8-58 days postoperatively. Percutaneous peripheral nerve stimulation decreased pain an average of 93% at rest (from a mean of 5.0 to 0.2 on a 0-10 numeric rating scale), with 4 of 5 subjects experiencing complete resolution of pain. During passive and active knee motion pain decreased an average of 27 and 30%, respectively. Neither maximum passive nor active knee range-of-motion was consistently affected.
  
  
  CONCLUSIONS
  Ultrasound-guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postoperative pain following orthopedic surgical procedures, and further investigation appears warranted.
authors.affiliation: Department of Anesthesiology, University of California San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA, 92103-8770, USA. bilfeld@ucsd.edu.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Ilfeld
authors.affiliation: Department of Anesthesiology, Wake Forest University Baptist Medical Center, 145 Kimel Park Drive, Ste 330, Winston-Salem, NC, 27103, USA.|The Center for Clinical Research, Winston-Salem, NC, USA.|Carolinas Pain Institute, Winston-Salem, NC, USA.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Gilmore
authors.affiliation: Department of Anesthesiology, Duke University Medical Center, DUMC 3094, Durham, NC, 27710, USA.
authors.forename: Stuart A
authors.initials: SA
authors.lastname: Grant
authors.affiliation: Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Dr. #5216, Durham, NC, 27710, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Bolognesi
authors.affiliation: Department of Orthopedic Surgery, University of North Carolina, 3147 Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7055, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Del Gaizo
authors.affiliation: SPR Therapeutics, LLC, 22901 Millcreek Blvd, Suite 110, Cleveland, OH, 44122, USA.
authors.forename: Amorn
authors.initials: A
authors.lastname: Wongsarnpigoon
authors.affiliation: SPR Therapeutics, LLC, 22901 Millcreek Blvd, Suite 110, Cleveland, OH, 44122, USA.
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Boggs
mesh_terms: D000368:Aged; D000698:Analgesia / Q000295:instrumentation / Q000379:methods*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D001340:Autonomic Nerve Block / Q000295:instrumentation / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy*; D011446:Prospective Studies; D018084:Ultrasonography, Interventional / Q000295:instrumentation / Q000379:methods*
keywords: Acute pain; Neuromodulation; Neurostimulation; Orthopedic surgery; Peripheral nerve stimulation; Postoperative analgesia; Total knee arthroplasty; Total knee replacement; Ultrasound-guided analgesia; Ultrasound-guided percutaneous peripheral nerve stimulation