Permanent percutaneous splanchnic nerve neuromodulation for management of pain due to chronic pancreatitis: a case report

Abstract

Introduction: The management of pain in chronic benign pancreatitis is complex. Celiac plexus neurolysis provides pain relief of variable duration. Neuromodulation of splanchnic nerves with electrodes and an implantable pulse generator system is an alternative to producing long-term pain relief with minimal complications in selected cases.

Methods: A 36-year-old lady with intractable abdominal pain for five years from chronic benign pancreatitis presented to our pain clinic. Multiple pharmacotherapy regimens, surgery, and interventions produced temporary pain relief of variable duration and intensity. Following a successful trial of celiac plexus stimulation, neuromodulation of the splanchnic nerves was achieved with two permanently implanted octopolar leads at the T11/T12 area connected to an implantable pulse generator.

Results: Eighteen months following the implant, the patient continues to derive satisfactory pain relief without any device related complications. Her opiate use is significantly reduced from 225 (486 mg morphine per day) to 12.5 (27 mg morphine per day) micrograms/h fentanyl patches and the fentanyl lozenges were stopped with an increase in appetite and of more than 8 kg in weight gain. The initial pain score visual analogue scale (VAS) 8-9/10 was reduced to VAS 0/10 since implantation.

Discussion: The pain of chronic pancreatitis has both visceral and somatic components as evidenced by the lack of complete pain relief from celiac plexus block alone and the knowledge that in chronic disease, the pathology extends to extra pancreatic somatic tissues, particularly the retro-peritoneum. We postulate that the electrical field generated by the dual octrode system extends to include splanchnic nerves and other somatic innervation of the pancreas.

Conclusion: In our opinion, this is the first case of a successful long-term neuromodulation of splanchnic nerves with a permanently implanted device. The potential exists for its use in visceral abdominal pain of varied etiology, once more experience is obtained with this technique.