CC BY-NC-ND 4.0 · Asian J Neurosurg
DOI: 10.1055/s-0044-1779338
Case Report

Retrograde Epidural Spinal Cord Stimulation for the Treatment of Intractable Neuropathic Pain Following Spinal Cord and Cauda Equina Injuries: A Case Report and Literature Review

Chun Lin Lee
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
2   Department of Neurosurgery, Penang General Hospital, Pulau Penang, Malaysia
3   Department of Biomedical Science (International Program), Faculty of Science, Mahidol University, Bangkok, Thailand
4   Excellent Center for Drug Discovery (ECDD), Faculty of Science, Mahidol University, Bangkok, Thailand
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
5   Siriraj Pain Management Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Sukunya Jirachaipitak
5   Siriraj Pain Management Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
6   Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Prajak Srirabheebhat
1   Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
› Author Affiliations
Funding None.


Spinal cord stimulation (SCS) offers an alternative treatment for refractory pain resulting from various etiologies. Generally, SCS electrodes are inserted in an anterograde fashion, moving from caudal to rostral direction. However, there are instances where anterograde placement is unfeasible due to technical limitations. We present the use of retrograde surgical electrode placement in SCS for a patient with extensive epidural fibrosis at the site intended for electrode insertion. A 48-year-old female suffering from refractory neuropathic pain caused from injuries to the conus medullaris and cauda equina opted for SCS. During the SCS trial procedure, challenges emerged when attempting percutaneous electrode insertion at the site of a prior T12 laminectomy. However, the trial stimulation resulted in significant pain relief. For the permanent placement of the stimulator, utilizing a surgical electrode centered at T11 vertebral level, a considerable amount of epidural fibrosis was encountered at the entry of the spine, particularly at the T12 vertebral level. To avoid dural injury and ensure accurate electrode positioning, a retrograde technique for surgical electrode was employed via partial laminectomies at the T9-T10 level. The final electrode positioning was in accordance with the preoperative plan, well-centered at the T11 vertebral level. The patient experienced sustained relief from neuropathic pain over the long term. Retrograde epidural SCS is a suitable option for cases characterized by extensive epidural fibrosis resulting from a previous spinal surgery or when the anterograde placement of the electrode is unattainable due to aberrant vertebral anatomy.

Ethical Approval Statement

For only a single case report, ethical approval was not required by the Ethics Committee of the Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand. The patient's data in this case report retained full confidentiality in compliance with the Declaration of Helsinki.

Authors' Contributions

L.C.L. contributed in writing, reviewing, editing, and approval of the final manuscript. S.S. helped in reviewing and approval of the final manuscript. B.S. has contributed in conceptualization, supervision, editing, and approval of the final manuscript. S.J. and P.S. reviewed and approved the final manuscript.

Publication History

Article published online:
26 February 2024

© 2024. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965; 150 (3699): 971-979
  • 2 Jensen MP, Brownstone RM. Mechanisms of spinal cord stimulation for the treatment of pain: still in the dark after 50 years. Eur J Pain 2019; 23 (04) 652-659
  • 3 Lee AW, Pilitsis JG. Spinal cord stimulation: indications and outcomes. Neurosurg Focus 2006; 21 (06) E3
  • 4 Piyawattanametha N, Sitthinamsuwan B, Euasobhon P. Excellent pain relief by using spinal cord stimulation after failed bilateral stereotactic anterior cingulotomy in a patient with intractable neuropathic pain of the lower extremities following surgery of Tarlov cyst. J Med Assoc Thai 2017; 100 (Suppl. 04) S196-S202
  • 5 Huang Q, Duan W, Sivanesan E. et al. Spinal cord stimulation for pain treatment after spinal cord injury. Neurosci Bull 2019; 35 (03) 527-539
  • 6 Rascón-Ramírez FJ. Spinal cord stimulation and cauda equina syndrome: could it be a valid option? A report of two cases. Neurocirugia (Astur Engl Ed) 2022; 33 (02) 90-94
  • 7 Murnion BP. Neuropathic pain: current definition and review of drug treatment. Aust Prescr 2018; 41 (03) 60-63
  • 8 Scholz J, Finnerup NB, Attal N. et al; Classification Committee of the Neuropathic Pain Special Interest Group (NeuPSIG). The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain 2019; 160 (01) 53-59
  • 9 Campbell JN, Meyer RA. Mechanisms of neuropathic pain. Neuron 2006; 52 (01) 77-92
  • 10 Colloca L, Ludman T, Bouhassira D. et al. Neuropathic pain. Nat Rev Dis Primers 2017; 3: 17002
  • 11 Sampson JH, Cashman RE, Nashold Jr BS, Friedman AH. Dorsal root entry zone lesions for intractable pain after trauma to the conus medullaris and cauda equina. J Neurosurg 1995; 82 (01) 28-34
  • 12 Sindou M. Surgery in the DREZ for refractory neuropathic pain after spinal cord/cauda equina injury. World Neurosurg 2011; 75 (3-4): 447-448
  • 13 Piyawattanametha N, Sitthinamsuwan B, Euasobhon P, Zinboonyahgoon N, Rushatamukayanunt P, Nunta-Aree S. Efficacy and factors determining the outcome of dorsal root entry zone lesioning procedure (DREZotomy) in the treatment of intractable pain syndrome. Acta Neurochir (Wien) 2017; 159 (12) 2431-2442
  • 14 Sitthinamsuwan B, Khumsawat P, Phonwijit L, Nunta-Aree S, Nitising A, Suksompong S. The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity. Spinal Cord Ser Cases 2017; 3: 17033
  • 15 Saris SC, Iacono RP, Nashold Jr BS. Dorsal root entry zone lesions for post-amputation pain. J Neurosurg 1985; 62 (01) 72-76
  • 16 Falci S, Best L, Bayles R, Lammertse D, Starnes C. Dorsal root entry zone microcoagulation for spinal cord injury-related central pain: operative intramedullary electrophysiological guidance and clinical outcome. J Neurosurg 2002; 97 (2, Suppl): 193-200
  • 17 Falci S, Indeck C, Barnkow D. Spinal cord injury below-level neuropathic pain relief with dorsal root entry zone microcoagulation performed caudal to level of complete spinal cord transection. J Neurosurg Spine 2018; 28 (06) 612-620
  • 18 Sdrulla AD, Guan Y, Raja SN. Spinal cord stimulation: clinical efficacy and potential mechanisms. Pain Pract 2018; 18 (08) 1048-1067
  • 19 Moens M, De Smedt A, Brouns R. et al. Retrograde C0-C1 insertion of cervical plate electrode for chronic intractable neck and arm pain. World Neurosurg 2011; 76 (3-4): 352-354 , discussion 268–269
  • 20 Perper Y. Retrograde spinal cord stimulator lead placement for right L5 radiculopathy. Pain Med 2012; 13 (05) 733-734
  • 21 De Andres J, Perotti L, Villaneuva-Perez VL, Asensio-Samper JM, Fabregat-Cid G. Role of lumbosacral retrograde neuromodulation in the treatment of painful disorders. Pain Physician 2013; 16 (02) 145-153
  • 22 Taghva A. Anterograde and retrograde epidural paddle placement through a single laminotomy for the treatment of back and lower extremity pain using spinal cord stimulation: case reports and technical note. Neuromodulation 2014; 17 (08) 766-770
  • 23 Abd-Elsayed A, Lee S, King C. Retrograde placement of spinal cord stimulator leads for treating resistant pelvic pain. Saudi J Anaesth 2017; 11 (03) 366-367
  • 24 van Helmond N, Kardaszewski CN, Chapman KB. Cervical retrograde spinal cord stimulation lead placement to treat failed back surgery syndrome: a case report. A A Case Rep 2017; 8 (12) 334-336
  • 25 Oosterbos C, Vanvolsem S, Duyvendak W. et al. Retrograde placement of high cervical electrodes: a technical refinement and case series. Neuromodulation 2018; 21 (08) 755-761
  • 26 Haddad HW, Elkersh MA, Hankey PB, Kaye MD. Spinal cord stimulation of the sacral region as a treatment for intractable coccygodynia: a case study. Pain Med Case Rep 2021; 5 (06) 319-323