Therapy resistant lower back and pelvic pain resulting from previous surgery, represents one of the most common indication for the chronic epidural spinal cord stimulation. Rarely, as a consequence of concomitant surgery-related injury, the patient may additionally suffer from voiding dysfunction also amenable to neurostimulation treatment. We present a combined spiinal cord stimulation (SCS) and sacral nerve stimulation (SNS) in small cohort of patients suffering from voiding dysfunction accompanied by neuropathic back/leg/pelvic pain.

Patients failing the conservative treatment were referred through an interdisciplinary pelvic floor center. The implantation was performed in 4 patients suffering from low back/leg/ pelvic floor pain combined with void dysfunction. To target both of these symptoms, a SCS electrode and two S3 SNS electrodes were placed percutaneously for the trial period and connected to external stimulator in order to assess the efficacy of the stimulation. The trial lasted between 6 and 14 days, incorporated testing of various waveforms (tonic, microburst, FAST, Contour) and was followed by the implantation of a neurostimulator upon successful trial. Neurostimulator was able to deliver a distinct waveform to each electrode. Follow-up ranged from 1 to 3 months including pain intensity score and urodynamic examination.

All 4 patients had a successful trial and were subsequently implanted with a neurostimulator. Under tonic stimulation, all of them reported over 90% reduction neuropathic pain (median VAS 8/10 preoperatively and 1.5/10 postoperatively). Two of these patients suffered previously from bladder emptying problems with the necessity of self-catheterization. SNS restored normal bladder function with no need of further self-catheterization. 1 patient suffered from stress-incontinence which completely disappeared. The uro-dynamic exams showed no residual urine. To note, patients prefered paresthesia-free stimulation for lower back/leg pain and tonic stimulation for void dysfunction combined with tonic sacral stimulation.

In this cohort of patients, we observed an significant response of pain-incontinence syndrome to the combined SCS/SNS therapy with pain reduction and restoration of bladder function. The application of concomitant waveforms broadens the therapeutic spectrum of complex pain-void dysfunction syndromes. The examination of lager cohort of patients is warranted.