Neuromodulation: A Novel Treatment for the Pain of Charcot Foot
Alexander Yakovlev, MD; Angela Parmentier, APNP; Lynda Fields, APNP • Comprehensive Pain Management of the Fox Valley, SC
820 East Grant Street, Suite 335 • Appleton, Wisconsin, USA
INTRODUCTION
Charcot-Marie-Tooth disease (CMT) is one of the most common inherited neurological disorders, affecting approximately 1 in 2,500 people in the United States. In general, people with CMT have weakness and decreased sensation in the lower part of their legs, and they have problems with their feet, such as high arches and toes that bend up at the middle joint, numbness in the foot, or being
unable to feel where the foot is placed. There is no cure for CMT, but physical therapy, occupational therapy, braces and other orthopedic devices, possible orthopedic surgery to reverse foot and joint
deformities, and use of opioid medications can help control the severe pain and disability.
METHODS
We report successful spinal cord stimulator trial and permanent implantation in a 42-year-old-male patient with bilateral foot pain diagnosed with Charcot foot as a result of an inherited trait from CMT disease.
RESULTS
A 42-year-old male presenting to our clinic two years after the diagnosis of Charcot foot with bilateral foot pain (left greater than right). He had seen several orthopedic specialists who indicated no surgical intervention was indicated. He was encouraged to continue with conservative methods including wears a brace and shoe orthotics on the left and orthotic insert on the right foot. He was dependent on orthopedic braces and special adaptive shoes prior to getting out of bed in the morning, as ambulation without them was quite painful. The patient worked as a manager for a restaurant and is on his feet all day. Initially patient underwent several sympathetic nerve blocks, which he sustained mild pain relief for several hours following injection, without long-lasting relief. He was facing permanent disability due to the pain despite the use of ibuprofen 800 mg three times daily, Gabapentin 1200 mg three times daily, and Vicodin 5/500. After conservative therapy failed, neuromodulation was considered. During the trial, one, 14-gauge Tuohy needle was advanced into the T12-L1 intervertebral space, and second Tuohy needle was advanced into L1-L2 intervertebral space. Using loss of resistance to air technique, the epidural space was identified and confirmed with C-arm on AP and lateral views. Two, 8-electrode leads were inserted through the Tuohy needles and were positioned in the posterior epidural space. One lead was rested on the level of T11, T12, L1, and second lead was rested on the level of T10, T11, T12. With 100% coverage of his feet pain during SCS trial, patient underwent SCS permanent implant. Two weeks post-operative, stimulation parameters were the following: frequency 60, pulse width 450-840, amplitude 6.3 voltz, and rate of 45-65
CONCLUSIONS
Although peripheral neuropathy has been well-studied and treated with spinal cord stimulation, using it for treatment of foot pain related to Charcot foot is novel. Further studies should be done to evaluate treatment of Charcot foot pain with spinal cord stimulation.
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