Abstract

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most common persistent adverse effects of chemotherapy affecting cancer survivors. Other than the use of duloxetine, no other intervention has a proven benefit for these patients. Here, a patient with multiple myeloma who developed CIPN experienced a significant reduction in their symptoms after the implantation of a spinal cord stimulator.

Case Description: A 64-year-old male with a history of multiple myeloma presented with chronic pain 4 years after chemotherapy, followed by an autologous stem cell transplant. As the patient’s symptoms were refractory to medical management, he underwent placement of a permanent spinal cord stimulator, resulting in 80% relief of calf pain and a 60% improvement in foot paresthesias/pain.

Conclusion: Spinal cord stimulation proved effective in treating CIPN (CIPN following autologous stem cell transplant) in a 64-year-old male treated 4 years ago for multiple myeloma.

Keywords: Chemotherapy, Neuromodulation, Neuropathy, Pain

INTRODUCTION

There are over 18.1 million new cancer cases diagnosed in the United States yearly.[ 20 ] Approximately 30–40% of patients treated with neurotoxic chemotherapy agents for these cancers develop CIPN (i.e., chemotherapy-induced peripheral neuropathy pain characterized by burning, tingling, numbness, and heightened sensitivity to touch).[ 5 , 11 , 13 , 19 , 22 , 24 , 25 ] Mechanistically, CIPN is largely attributed to damage to mitochondria (i.e., impairment of ion channel function), triggering of immunological mechanisms, and disruption of microtubules. Common chemotherapy agents that cause CIPN are paclitaxel and platinum-based agents (i.e., cisplatin and oxaliplatin). Nonchemotherapeutic agents, such as bortezomib, and newer targeted agents, such as enfortumab and vedotin, are also associated with significant CIPN. Medical management of CIPN may include gabapentinoids (gabapentin and pregabalin), while the only oral agent with modest proven clinical benefit is duloxetine. Spinal cord stimulation (SCS) is also approved for treating peripheral neuropathic pain.[ 6 ] Here, a 64-year-old male who underwent a stem cell transplant and chemotherapy 4 years ago for multiple myeloma successfully underwent SCC placement for CIPN.

CASE

Four years ago, a 64-year-old male with multiple comorbidities presented with Stage 1 immunoglobulin G kappa multiple myeloma. He was first treated with chemotherapy that included lenalidomide, bortezomib, and dexamethasone (VRD). This was followed by consolidation treatment involving an autologous stem cell transplant with melphalan conditioning, following which he remained on lenalidomide as maintenance therapy.

Onset of neuropathy

The patient’s neuropathy began between 2 and 3 months after initiating the VRD regimen and progressively worsened throughout his clinical course. Despite pharmacological management with trials of gabapentin, pregabalin, duloxetine, methadone, topiramate, nortriptyline, and lidocaine patches, the patient’s symptoms remained. Physical therapy improved his gait and coordination, but not the paresthesia or pain.

SCS placement 4 years later

Due to the patient’s refractory symptoms despite medical management over the prior 4 years, he underwent an SCS trial. This resulted in a 100% improvement in pain and functionality in his calves and approximately 60% improvement in his feet; it was then converted to a permanent SCS [ Figures 1 and 2 ]. He stopped all pain medication after the placement of the spinal cord stimulator. Eight months after SCS placement, he continues to report >80% pain relief in the calves and > 60% relief of numbness in his feet.

Figure 1:

Procedural fluoroscopy for placement of the patient’s percutaneous spinal cord stimulator trial; the two leads are centered predominantly at the T8 and T9 vertebral levels.

Figure 2:

Intraoperative placement of the paddle leads spinal cord stimulator with a laminectomy at T9 and subsequent placement of the paddle electrode centered at T8.

DISCUSSION

SCS can provide substantive symptom relief for postchemotherapy patients with CIPN [ Table 1 ]. Although there are multiple instances in which patients are successfully treated for CIPN using SCS, there are no clearly established guidelines for SCS utilization. There is also a lack of literature regarding the optimal programming SCS pattern for patients with CIPN; further, studies are warranted to discern clinical differences in low vs. high vs. burst frequencies. Our patient benefited from burst stimulation, which involves closely spaced, high-frequency stimuli delivered to the spinal cord. The stimulus paradigm consists of a 40-Hz burst mode of constant-current stimuli with five spikes at 285–332 Hz/burst, pulse width of 10–500 μs, inter-spike intervals of 3 ms, and amplitude corresponding to 50–70% of the sensitive threshold.[ 15 ]

Table 1:

Literature review summary.

CONCLUSION

SCS effectively reduced CIPN symptoms in a 64-year-old male with 4-year following chemotherapy and stem cell transplant for multiple myeloma.

Ethical approval:

Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

1. Abd-Elsayed A, Gyorfi M, Hughes M. Spinal cord stimulator for treating chemotherapy-induced peripheral neuropathy. Pain Med Case Rep. 2021. 5: 223-6

2. Abd-Elsayed A, Schiavoni N, Sachdeva H. Efficacy of spinal cord stimulators in treating peripheral neuropathy: A case series. J Clin Anesth. 2016. 28: 74-7

3. Abd-Elsayed A, editors. Management of chronic chemotherapy induced peripheral neuropathy using neurostimulation. Proceedings of the regional anesthesia and pain medicine conference: 14th annual pain medicine meeting of the American society of regional anesthesia and pain medicine Miami Beach. FL, USA: (ASRA); 2015. p. 41

4. Braun Filho JL, Braun LM. Spinal cord stimulation in the treatment of refractory painful chemotherapy induced polyneuropathy. Rev Bras Anestesiol. 2007. 57: 533-8

5. Burgess J, Ferdousi M, Gosal D, Boon C, Matsumoto K, Marshall A. Chemotherapy-induced peripheral neuropathy: Epidemiology, pathomechanisms and treatment. Oncol Ther. 2021. 9: 385-450

6. Castelli G, Desai KM, Cantone RE. Peripheral neuropathy: Evaluation and differential diagnosis. Am Fam Phys. 2020. 102: 732-9

7. Cata JP, Cordella JV, Burton AW, Hassenbusch SJ, Weng HR, Dougherty PM. Spinal cord stimulation relieves chemotherapy-induced pain: A clinical case report. J Pain Symptom Manage. 2004. 27: 72-8

8. Chai T, Thakur S, Shroff G. Chemotherapy-induced peripheral neuropathy pain and postmastectomy pain syndrome in a breast cancer patient managed with neurostimulation: A case report. PMR. 2017. 9: S271

9. Grant C, Luke WR, Thompson R, Scribner D. Dual coverage of metastatic ostealgia and cancer-related peripheral neuropathy with a spinal cord stimulator. PMR. 2019. 11: S138

10. Kamdar MM, McCall LW, Saba AM, Wainger BJ. Improvement in neuropathic pain, proprioception, and gait stability after spinal cord stimulator implantation for chemotherapy-induced peripheral neuropathy. Pain Med Case Rep. 2021. 5: 291-5

11. Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. Burst spinal cord stimulation: A clinical review. Pain Med. 2019. 20: S31-40

12. Lopes A, Duarte K, Lins C, Kubota G, Silva V, Galhardoni R. Spinal cord stimulation as a treatment option for refractory chemotherapy-induced peripheral neuropathy: Case report. Arq Bras Neurocir. 2020. 39: 228-31

13. Mattar M, Umutoni F, Hassan MA, Wamburu MW, Turner R, Patton JS. Chemotherapy-induced peripheral neuropathy: A recent update on pathophysiology and treatment. Life (Basel). 2024. 14: 991

14. Michael A, Bruel B. Chronic regional pain syndrome and chemotherapy-induced peripheral neuropathy in a patient with metastatic melanoma. Neuromod Technol Neural Interface. 2020. 23: e84

15. Nishimura KK, Barlogie B, Van Rhee F, Zangari M, Walker BA, Rosenthal A. Long-term outcomes after autologous stem cell transplantation for multiple myeloma. Blood Adv. 2020. 4: 422-31

16. Panchal SJ. Treatment of lower extremities chemotherapy induced allodynia and neuropathic pain with wireless scs: Case study (10693). Neuromod Technol Neural Interface. 2016. 19: e147

17. Sarkar AK. High frequency spinal cord stimulation for neuropathic pain capturing bilateral hands and feet without paresthesia. Neuromod Technol Neural Interface. 2019. 22: e69

18. Sayed D. The increasing utility of spinal cord stimulation for cancer related pain: A case series. Neuromod Technol Neural Interface. 2015. 18: e80

19. Seretny M, Currie GL, Sena ES, Ramnarine S, Grant R, MacLeod MR. Incidence, prevalence, and predictors of chemotherapy-induced peripheral neuropathy: A systematic review and meta-analysis. Pain. 2014. 155: 2461-70

20. Siegel RL, Giaquinto AN, Jemal A. Cancer statistics 2024. CA Cancer J Clin. 2024. 74: 12-49

21. Sisson C, Schittone S. Three cases of high-frequency spinal cord stimulation for painful lower extremity neuropathy of varied etiologies. Neuromod Technol Neural Interface. 2017. 20: e243

22. Staff NP, Grisold A, Grisold W, Windebank AJ. Chemotherapy-induced peripheral neuropathy: A current review. Ann Neurol. 2017. 81: 772-81

23. Wright B, Stovall B. Opioid discontinuation following successful treatment of chemotherapy-induced peripheral neuropathy with dorsal column spinal cord stimulation. Neuromod Technol Neural Interface. 2021. 24: e7

24. Zajaczkowska R, Kocot-Kepska M, Leppert W, Wrzosek A, Mika J, Wordliczek J. Mechanisms of chemotherapy-induced peripheral neuropathy. Int J Mol Sci. 2019. 20: 1451

25. Zhi WI, Baser RE, Kwon A, Chen C, Li SQ, Piulson L. Characterization of chemotherapy-induced peripheral neuropathy using patient-reported outcomes and quantitative sensory testing. Breast Cancer Res Treat. 2021. 186: 761-8