Hf-scs (10 khz) for the management of neuropathic pain and autonomic dysfunction secondary to iatrogenic conus medullaris injury: A case report

Introduction. Iatrogenic spinal cord injuries secondary to spinal puncture are rare complications, frequently associated with severe neuropathic pain and autonomic dysfunction. When the clinical presentation is refractory to conventional treatments, spinal cord stimulation (SCS) represents a crucial therapeutic resource (Kapural et al., 2015). Conus medullaris lesions require targeted strategies to address both the painful component and the sacral parasympathetic pathways (Deer et al., 2014). Recently, high-frequency spinal cord stimulation (HF-SCS) has also demonstrated efficacy in managing neurogenic sphincter disorders (Schieferdecker et al., 2019).Methods. We report the case of a patient with a spinal cord injury secondary to a spinal puncture. Contrast-enhanced lumbosacral MRI revealed a T2-hyperintense area posterior to the conus medullaris (L1-L2). EMG of the lower limbs showed marked neurogenic compromise with denervation features in the left medial gastrocnemius muscle and severe compromise of the left tibial nerve. Clinically, the patient presented with severe neuropathic pain in the left L4 territory (great toe), perineal hypoesthesia, severe sphincter deficit (frequent/weak urinary stream, fecal incontinence), and sexual dysfunction (absence of erection and ejaculation), all refractory to medications (including cannabis) and pulsed radiofrequency of the L4 dorsal root ganglion. Baseline scores were NRS 10, DN4 8/10, and SF-12: PCS12 23.39, MCS12 17.10. A 10-kHz SCS system was implanted using two octpolar leads (one lead with the first distal electrode at T8 and the other lead with the first distal electrode at T10). Clinical follow-up was performed at 6 months, with a 12-month follow-up planned.Results. Activation of 10-kHz stimulation resulted in immediate symptomatic relief and restoration of autonomic functions: regular urinary stream, bowel control, and recovery of erection and eiaculation. At the 6-month follow-up, a drastic reduction in pain was documented (NRS 4, DN4 4). SF-12 scores demonstrated a sharp increase in quality of life (PCS12: 37.95; MCS12: 29.23). No complications were recorded. Further clinical improvement was hypothesized by optimizing target mapping through waveform programming adjustments.Conclusions. This case demonstrates that dual-lead HF-SCS can be a safe and effective therapeutic option for the management of complex neuropathic pain as well as severe sphincter and sexual dysfunctions secondary to iatrogenic conus medullaris injuries.