This article is a review of a procedure performed by podiatrist Harold N. Gruber, in June of 2009, at Christiana Care Health System’s Wilmington Hospital, in Wilmington, Delaware. Several years ago, Dr. Harold N. Gruber, of Tri-State Foot and Ankle Center, was presented in his Wilmington office with a 35 year old female patient with a chief complaint of continuous pain, burning, and tingling sensations along her right foot. The patient worked at an assembly plant and noted it was difficult to perform her assigned tasks due to the continued pain, as it had been unremitting for several months. She was initially diagnosed approximately 7 years earlier with a tarsal tunnel entrapment, and underwent surgery to release the nerve. The patient returned to her assembly plant job, yet approximately 4 years after the original procedure was back in the office with complaints of a reoccurring pain from the tarsal tunnel. After a second surgery to release the nerve, her post operative course was unremarkable, and she returned to work. Three years later, the patient came back to the office with complaints of pain in the same area, however, more severe. She was experiencing significant burning and tingling along the plantar aspect of her foot which extended to her toes. She also complained of having trouble sleeping, due to the continuous levels of pain. In addition, her pain was beginning to affect her ability to walk. Complex regional pain syndrome, or, â€CRPSâ€, was ruled out, and with the help of electromyelogram and nerve conduction studies, a diagnosis of recurrent, significant tarsal tunnel entrapment was made. At that time, a decision was made to release the tarsal tunnel once again, however this time, additionally attaching a peripheral nerve stimulator to the nerve. Advancements in research have shown that low levels of stimulation to nerves assist in the regulation and alteration of pain signals, as they are perceived by patients. Using such stimulators, a patient can decide how much of stimulus is comfortable and most beneficial, at which time the unit can be programmed to deliver this level of signal on a continuous basis. Because the treatment is ultimately guided by patient input, it can be likened to a patient directed pain pump, however without the deleterious effects of narcotics, which, when used for chronic pain, can cause dependency, lethargy, weight gain, and which can interfere with other medications patients may require. At the request of Dr. Gruber, the patient returned to the operating room at Christiana Care Health System’s Wilmington Hospital, where the tarsal tunnel dissection was performed. During the surgery, Dr. Gruber observed significant scarring and atrophy of the posterior tibial nerve. Because of this, a Neurogent nerve wrap was applied to the nerve and a Medtronicâ" peripheral nerve stimulator was then attached. A lead (which transmits a stimulus from the unit to the nerve) was implanted within the ankle, exiting in the leg, where it was attached to an external trial battery pack. The patient reported immediate relief of her symptoms, following the surgery. As a result, the trial external device was then converted to a permanent implantable unit, which was ultimately positioned within the patient’s thigh. Six months after the procedure, the patient reported that her pain level was improved overall by approximately 40%. New advancements in this technology will now provide Dr. Gruber with the option to implant the above mentioned nerve stimulator via an injection, as opposed to an open procedure, and benefit patients by reducing their post operative recovery times and expediting their return to normal activities. Implantable nerve stimulators are designed to reduce pain and give patients with a chronic condition an additional option, over narcotics and potential disability. Patients with nerve pain or tarsal tunnel syndrome should be carefully evaluated by an experienced professional, as additional treatments are available.
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