Combined spinal cord and peripheral nerve stimulation in severe neuropathic pain syndrome

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Abstract

Introduction. Chronic severe neuropathic pain syndrome (NPS) refractory to conservative and surgical treatments remains a significant clinical challenge. Chronic electrical stimulation of a single neural structure often proves insufficiently effective, highlighting the need for innovative approaches such as combined neuromodulation. This article aims to present a clinical case of combined spinal cord and peripheral nerve stimulation. A case report. A 32-year-old female with iatrogenic injury to the sural nerve following surgical intervention presented with refractory NPS (8 points on VAS). Failed conservative therapy (gabapentin, duloxetine) and surgical management (neuroma excision) led to chronic spinal cord stimulation, achieving 30% pain reduction. Subsequent ultrasound-guided peripheral nerve electrode implantation combined with chronic electrical stimulation resulted in complete pain area coverage and pain intensity reduction to 1–2 points on VAS.

Conclusion. Technical challenges associated with combined neuromodulation should not preclude its clinical application. Electrode proximity does not significantly affect system performance. Combined neuromodulation demonstrated synergistic effects in pain management by enhancing analgesia through simultaneous modulation of central and peripheral pain mechanisms. Large-scale studies evaluating the safety and efficacy of this combined approach are required for routine clinical implementation.

About the authors

Viktor P. Kondratyev

N.N. Burdenko National Scientific and Practical Center for Neurosurgery

Author for correspondence.
Email: vstenv@gmail.com
ORCID iD: 0000-0003-3272-8699
SPIN-code: 9705-3018

postgraduate student, 6th Neurosurgical department (craniofacial neurosurgery) with the group “Functional neurosurgery”

Russian Federation, Moscow

Emil D. Isagulyan

N.N. Burdenko National Scientific and Practical Center for Neurosurgery

Email: emisagulyan@gmail.com

Cand. Sci. (Med.), senior researcher, 6th Neurosurgical department (craniofacial neurosurgery) with the group “Functional neurosurgery”

Russian Federation, Moscow

Alexey A. Tomskiy

N.N. Burdenko National Scientific and Practical Center for Neurosurgery

Email: alexey_tomskiy@mail.ru
ORCID iD: 0000-0002-2120-0146

Cand. Sci. (Med.), Assoc. Prof., Department of neurosurgery with courses in neuroscience, senior researcher, 6th Clinical department, neurosurgeon, Head, Functional neurosurgery group

Russian Federation, Moscow

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2. Fig. 1. Radiographic image of the implanted electrode in the posterior epidural space at the T10–T12 vertebral levels.

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3. Fig. 2. Intraoperative photograph. Ultrasound-guided electrode implantation on the sural nerve (n. suralis).

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4. Fig. 3. Ultrasound image of the implanted electrode. Left: transverse scan. The electrode runs along the trunk of the sural nerve (n. suralis) at a distance of less than 1 mm from it. Right: longitudinal scan. Aligning the electrode and n. suralis in the same plane is extremely challenging due to their spatial relationship, but the electrode shadow and epineurium of n. suralis can be visualized.

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5. Fig. 4. Photograph of postoperative wounds on day 3 after surgery. Several hematomas were observed in the loop pocket bed, but they had no clinically significant effect and resolved spontaneously within several weeks.

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6. Fig. 5. Changes of pain intensity (VAS scores) over time depending on the treatment method.

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Copyright (c) 2025 Kondratyev V.P., Isagulyan E.D., Tomskiy A.A.

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