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NEUROMODULATION FOR THE SACRAL AND COCCYGEAL SPACE

NEUROMODULATION FOR THE SACRAL AND COCCYGEAL SPACE. Kenneth M. Alo`, M.D. Mohammad I. Hirzallah, M.D. Erich Richter, M.D. Methodist Hospital Research Institute, The Texas Medical Center Ministry of Health Hospitals, Amman, Jordan LSU Health Science Center, New Orleans Louisiana

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NEUROMODULATION FOR THE SACRAL AND COCCYGEAL SPACE

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  1. NEUROMODULATION FOR THE SACRAL AND COCCYGEAL SPACE Kenneth M. Alo`, M.D. Mohammad I. Hirzallah, M.D. Erich Richter, M.D. • Methodist Hospital Research Institute, The Texas Medical Center • Ministry of Health Hospitals, Amman, Jordan • LSU Health Science Center, New Orleans Louisiana Alo` K, Hirzallah M, Richter E. Technical Note: Percutaneous Cephalocaudal Peripheral Nerve Stimulation for Coccygodynia. NeurosurgicalReview.com. 2011.

  2. OUTCOMES • Urge incontinence (80%) --- S3 • Fecal Incontinence (84%) --- S4 • Urgency-frequency disorders (70%) --- S2/3 • Vulvodynia (60%) --- S 2+3 • Pudendal neuralgia/neuropathies (60%) --- S 2+3(4) • Interstitial Cystitis (30-50%) --- S2+3(4) • Coccygodynia (?) --- S4+5

  3. ACCESS OPTIONS • Retrograde (Cephalocaudal) Technique • Anterograde Trans-hiatus Technique • Transforaminal Technique (Interstim) • Epidural technique with laminotomy • Percutaneous Cephalocaudal/Retrograde PNS

  4. Retrograde (Cephalocaudal) Technique Alo`KM. Select Nerve Root Stimulation: Facilitating the Cephalocaudal “Retorgrade” Method of Electrode Insertion. In: Atlas of Implantable Therapies for Pain Management. Deer T, ed. Chapter16. New York, NY: Springer:2011;107-114.

  5. Anterograde Trans-Hiatus Technique Deer T. Sacral Nerve Root Stimulation for the Treatment of Pelvic and Rectal Pain. In: In: Atlas of Implantable Therapies for Pain Management. Deer T, ed. Chapter16. New York, NY: Springer:2011;95-99.

  6. Transforaminal S3 Technique (Interstim) Steinberg AC, Oyama IA, Whitmore KE. Bilateral S3 stimulator in patients with interstitial cystitis. Urology. 2007;69(3):441-443.

  7. Epidural Laminotomy Techniques (Sacral Pathologies) • Alo` KM, Hirzallah MI, Richter EO. Technical Note: Percutaneous Cephalocaudal Peripheral Nerve Stimulation for Coccygodynia. JNR. 2011. NeurosurgicalReview.com

  8. Percutaneous PNS - Cephalocaudal Alo` K, Hirzallah MI, Richter E. Technical Note: Percutaneous Cephalocaudal Peripheral Nerve Stimulation for Coccygodynia. JNR. 2011. NeurosurgicalReview.com

  9. Percutaneous PNS - Cephalocaudal Alo` K, Hirzallah MI, Richter E. Technical Note: Percutaneous Cephalocaudal Peripheral Nerve Stimulation for Coccygodynia. JNR. 2011. NeurosurgicalReview.com

  10. Summary • Percutaneous access to S4 and S5 • Simple placement with low morbidity • Away from the painful coccyx and hiatus • Limited infection away from rectum • Less dehiscence risk • Easy to trial and implant permanently • Low migration risk • Less technically demanding than alternatives • Easily removed • Option for an underserved patient population

  11. Suggested Reading • Alo` KM. Select Nerve Root Stimulation: Facilitating the Cephalocaudal “Retrograde” Method of Electrode Insertion. In: Atlas of Implantable Therapies for Pain Management. Deer T, ed. Chapter16. New York, NY: Springer:2011;107-114. • Richter, EO, Abramova, MV, Sure, D, Alo`, KM. Nerve root, sacral, and pelvic stimulation.  In: Deer, T, Levy, R, and Hayek, S, eds. Neurostimulation for the Treatment of Chronic Pain: Interventional and Neuromodulatory Techniques for Pain Management.In press.  • Alo` K, Alo` K Hirzallah MI, Richter E. Technical Note: Percutaneous Cephalocaudal Peripheral Nerve Stimulation for Coccygodynia. JNR. 2011. NeurosurgicalReview.com • Deer T. Sacral Nerve Root Stimulation for the Treatment of Pelvic and Rectal Pain. In: In: Atlas of Implantable Therapies for Pain Management. Deer T, ed. Chapter16. New York, NY: Springer:2011;95-99.

  12. Suggested Reading - 2 • Uludağ Ö, Melenhorst J, Koch SMP, Van Gemert WG, Dejong CHC, Baeten CGMI. Sacral neuromodulation: long term outcome and quality of life in patients with faecal incontinence. Colorectal Disease. 2010. • Steinberg AC, Oyama IA, Whitmore KE. Bilateral S3 stimulator in patients with interstitial cystitis. Urology. 2007;69(3):441-443. • Alo` KM, McKay E. Selective nerve root stimulation (SNRS) for the treatment of intractable pelvic pain and motor dysfunction: a case report. Neuromodulation. 2001;4(1):19-23. • McDonald JS, Alo`KM. Bonica’s Management of Pain, 3rd Edition. In: Loeser J, ed. Section E: Pain in Pelvis, Perineum, and Genitalia: Chapter 73, Pain of Urogenital Origin. Philadelphia, PA: Lippinncott, Williams & Wilkins: 2001: 1448-1461. 12 12

  13. Suggested Reading - 3 • Alo` KM, Gohel R, Corey CL. Sacral nerve root stimulation for the treatment of urge incontinence and detrusor dysfunction utilizing a cephalocaudal intraspinal method of lead insertion: a case report. Neuromodulation. 2001;4(2):53-58. • Alo` KM, Yland MJ, Redko V, Feler C, Naumann C. Lumbar and sacral nerve root stimuation (NRS) in the treatment of chronic pain: a novel anatomic approach and neurostimulation technique. Neuromodulation. 1999;2:23-31. • Feler CA, Whitworth LA, Brookoff D, Powell R. Recent advances: Sacral nerve root stimulation using a retrograde method of lead insertion for the treatment of pelvic pain due to interstitial cystitis. Neuromodulation. 1999;2:211-216. 13

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