Neuromodulation: Technology at the Neural Interface
Received: July 27, 2012 Revised: November 28, 2012 Accepted: January 3, 2013
(onlinelibrary.wiley.com) DOI: 10.1111/ner.12030
LETTER TO THE EDITOR
Peripheral Nerve Field Stimulation for Sacroiliac
Joint Pain
To the Editor:
Low back pain (LBP) is the fifth most common complaint for all
doctor visits (1). Studies have shown that LBP is often not confined
to the spine and that sacroiliac (SI) joint is involved in 25% of the
patients with complaints of back pain (2). The diagnosis of SI joint
pain can be difficult because there is a significant overlap between
LBP, radicular pain, and SI joint pain. Oftentimes, successful treat-
ment of SI joint pain itself serves as a diagnostic tool (3). Some of the
causes of SI joint pain include trauma, infection, metabolic causes,
fracture, inflammatory processes, and arthritic processes (2,4). Con-
servative treatments for SI joint pain include the following: pain
medications, nonsteroidal anti-inflammatory drugs, steroid injec-
tion (5), physical therapy (6), and exercise program. Surgical proce-
dures include the following: radiofrequency ablation of the SI joint
(7,8), lumbar and sacral radiofrequency neurotomy (9,10), and
fusion (11,12). In a large study, the success for SI joint fusion has
been found to be between 60% and 75% (7).
Peripheral nerve stimulation (PNS) has been used to treat chronic
pain for the last 40 years and offers a minimally invasive surgical
treatment option for many different areas of pain (13). The benefits
from the PNS system are based on the gate control theory of pain
proposed by Melzack and Wall in 1965; this theory hypothesizes that
the electric field “closes the gate” to pain transmission (14). Theories
on how the PNS works also propose that PNS alters endogenous
endorphins and ultimately alters the pain threshold, thus providing
subjective benefit in pain (1). PNS has been used for treatment of
pain occipital, ilioinguinal, trigeminal, and postherpetic neuralgias
(10). More recently, investigators have placed electrodes in the sub-
cutaneous tissue in the area of the pain without targeting a specific
nerve to stimulate nerve endings in these areas to give pain relief.
This technique has been called by some as “peripheral nerve field
stimulation” (PNFS) (15). It has fewer side-effects than many medi-
cations and less risk than more invasive surgeries. It is also a good
alternative to treating areas of pain that cannot be treated with the
use of a spinal cord stimulator (SCS) (16) and also has been used in
conjunction with SCS and was beneficial for patients with back and
lower extremity pain (17). It gives the patient freedom to adjust the
device in accordance with their pain and thus allows the patient to
play an active role in his or her treatment. Because PNFS has been
successfully used to treat LBP (15), its use, specifically for SI joint
pain, though logical, has not been previously addressed. In this
paper, therefore, we present our initial experience with PNFS for the
treatment of SI joint pain as a pilot study.
MATERIAL AND METHODS
This study looked retrospectively at ten patients who underwent
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PNS complete system implantation for treatment of SI joint pain and
www.neuromodulationjournal.com © 2013 International Neuromodulation Society
have at least one-year follow-up. The ages ranged from 44 to 92
years, with median of 72.5 years. Four patients were female and six
were male. Patients presented in this paper have a follow-up of
14–29 months, with a median of 24 months. Because the group is
heterogeneous and small, statistical analysis could not be done. The
study is therefore limited to clinical outcomes and complications.
All ten patients presented with pain in the SI joint(s). Eight patients
had pain bilaterally and two had pain unilaterally. Prior treatment and
evaluation included the following: physical therapy, nonsteroidal
anti-inflammatory drugs, trigger-point injections, SI joint injections,
and psychologic evaluation. Four patients also had prior treatment
with radiofrequency ablation, which did give patients some relief;
however, the effect disappeared after several months. SI joint injec-
tion was done with 3 mL of 0.5% Marcaine (bupivacaine) (Hospira
Worldwide Inc., Lake Forest, IL, USA) with 20–40 mg of Depo-medrol
(methylprednisolone) (Pfizer, New York, NY, USA). A total of at least
two injections were done. A good relief of pain was considered diag-
nostic. Usually, the effect lasted between two weeks to two to three
months. Physical therapy included the use of heel lift when leg-length
discrepancy was detected. Those who failed conservative therapy
and were deemed motivated to improve (based on psychologic
evaluation) were considered candidates for PNFS trial. Those who
reported significant improvement in pain after the trial stimulation
for four to five days received permanent PNFS implant. Degree of pain
was assessed by asking the patients to rate the pain on a scale of 1–10,
with 10 being the worst.
Trial Electrode Implant
The procedure was done using sterile technique and local anes-
thetics. Fluoroscopic guidance was used during the lead implant.
Focal pressure was applied on the SI joint and areas around it to
mark the painful spots. Through a Touhy needle, the trial lead, with
eight contacts, electrode diameter of 1.3 mm and length of 3 mm,
and interelectrode distance of 6 mm, was inserted into the subcu-
taneous tissue to place the proximal one or two electrodes around
the most painful part of the SI joint and the most distal electrode at
midline. The external part of the lead wire was sutured to the skin
with a strain-relief loop. The insertion site was covered with sterile
dressing. Stimulation studies were done at the time of implantation
to confirm that the patients had good response from stimulation. If
There are no sources of financial support to report.
The content of this manuscript represents the authors’ work/opinions and not
those of the sponsoring agent.
There are no conflicts of interest to report.
Neuromodulation 2014; 17: 98–101

Figure 1. Bilateral lead placement.
the response was unsatisfactory, the lead was repositioned. The
external part of the lead wire was then connected to an external
pulse generator and the latter was programmed to produce pares-
thesia in the painful area. The patient was then instructed on adjust-
ment of the pulse generator depending on the pain level. An
antibiotic was prescribed for the duration of the trial to prevent
infection. After five to six days of trial stimulation, the electrodes
were removed. If the patient reported satisfactory improvement in
pain, he or she was referred for permanent implantation of PNFS.
Permanent Implant of PNFS
Three different permanent implant stimulator systems were uti-
lized (Medtronic, Minneapolis, MN, USA; Boston Scientific, Natick,
MA, USA; and St. Jude Medical, Plano, TX, USA) based on the refer-
ring pain physicians’ preferences. The implantation of the perma-
nent system was done under local anesthesia with sedation. The
leads were inserted through small incisions using the same tech-
nique as that used for trial lead implant under fluoroscopic guid-
ance to place them over the same area as the trial leads. When
unilateral lead was indicated, it was inserted from lateral to medial.
When bilateral leads were indicated, the second lead was inserted
through the midline with medial to lateral lead placement (Fig. 1).
Intraoperative stimulation studies were done to confirm that it
covered the painful areas and that it was adequate to control the
pain without unpleasant sensation. If the testing showed problems,
the lead was removed and reinserted at slightly different depth
within the subcutaneous tissue and retested to make sure that sat-
isfactory results were obtained. The lead wire was then anchored to
the underlying fascia by silk suture. Another incision was made in
the flank area through which a subcutaneous pocket was created.
The pocket was not more than a centimeter deep to allow proper
charging of the battery. The ideal pocket location was not too super-
ficial as to avoid erosion and not too large as to avoid movement
of the generator. The connecting wires of the leads were then
www.neuromodulationjournal.com © 2013 International Neuromodulation Society
LETTER TO THE EDITOR
tunneled to this incision and connected to the pulse generator. The
latter was then placed in the subcutaneous pocket. The integrity of
the system was then tested. The incisions were then closed.
Eight patients had bilateral leads and two patients had a unilat-
eral lead implanted. The pulse generator was usually programmed
the day after the surgery. Different combinations of stimulation
parameters were used with different combinations of bipolar lead
arrangements until optimal results were obtained. Generally,
voltage between 1 and 8, median pulse width of 360, and frequency
of 40 ⫾ 10 Hz were used.
During the follow-up, the patient was asked to rate the pain the
same way it was done during preoperative evaluation. This rating
was focused solely on the SI joint area of pain, which was the surgi-
cal target. If there was 50% or greater relief of pain over the treated
region, the improvement was considered significant. The pain medi-
cation usage and effect on sleep also was evaluated and compared
with preoperative needs.
RESULTS (TABLE 1)
The follow-up is 14–29 months, with a median of 24 months. Six
out of ten patients (60%) had significant relief of pain (improvement
of pain score by 50% or more), of which two were completely free of
pain, two (20%) had between 20% and 30% improvement in pain,
and two (20%) did not benefit from the operation. Furthermore, the
need for pain medications was reduced in six out of ten patients and
four out of ten reported improved sleep pattern. Complications
included flipped pulse generator (one patient) and migrated lead
(one patient), which had to be repositioned. No specific pattern in
the history or physical examination was noted in two patients who
had unsatisfactory response; except that, both these patients had
rated their pain as 10/10.
DISCUSSION
Treatment of SI joint pain is often very challenging. Even after the
trial of extensive conservative treatment, some patients continue to
have disabling pain. In such situations, more aggressive treatment
options can be considered. Such options include radiofrequency
ablation or fusion of the SI joint (7,11). Though these procedures
have shown promising results, they are still being evaluated. There-
fore, another procedure that is minimally invasive was sought. PNFS
implantation is a minimally invasive procedure that does not violate
the SI joint. It has been used successfully in the treatment of
regional pain. In addition, it has the ability to change the stimulation
parameters so that if the benefits slowly fade away they can be
changed to rejuvenate the stimulation. Therefore, patients who had
failed conservative treatment were treated with this method.
Psychologic evaluation is an important step in preoperative
evaluation of a patient for PNFS implant. It helps to rule out soma-
tization, untreated depression, and tendency to seek gain that may
adversely affect the results. It therefore helps the treating physician
to determine the likelihood of benefit to the patient from the pro-
cedure and covey that information to the patient (13).
The stimulating electrodes were placed over the SI joint, the
midline area at the level of SI joint, and the area between the two.
The midline area was included in the coverage because most
patients had pain in this area, in addition to the SI joint. The nerve
endings covered by the electrodes were therefore, most probably,
the dorsal rami of first two or three sacral nerve roots.
The trial stimulation was useful to determine the likelihood
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of benefit to the patient from the procedure. When there was a
Neuromodulation 2014; 17: 98–101
 PATIL ET AL.

Table 1. Patient results.

Patient # Age Sex Unilateral Change in Pain scale Sleep pattern Complications
or bilateral medications Before After after surgery
after surgery surgery surgery
1 73 M Bilateral Decreased 7 0 Unchanged None
2 48 M Bilateral Unchanged 9 7 Improved None
3 80 F Bilateral Decreased 8 0 Improved None
4 74 F Bilateral Increased 10 10 Worsened No longer using system
5 68 M Unilateral Decreased 7 5 Unchanged None
6 88 M Unilateral Unchanged 10 10 Unchanged Pulse generator flipped—this was corrected surgically
7 52 F Bilateral Decreased 10 5 Improved Lead migration—this was corrected surgically
8 58 F Bilateral Decreased 9 4 Unchanged None
9 92 M Bilateral Unchanged 7 1 Unchanged None
10 44 M Bilateral Decreased 8 2 Improved None
F, female; M, male.

positive result from the trial study, permanent implant was done.
Therefore, to replicate the results of the trial study, it is important to
place the permanent electrodes in the same location as those
during the trial studies. Therefore, intraoperative fluoroscopic
images were obtained during permanent electrode placement and
compared with those obtained with trial leads to make sure that
they were in the same location as those as the trial leads. In addition,
lead placement was done under local anesthesia and intraoperative
stimulation studies were done, so that feedback could be obtained
from the patient regarding the adequacy of pain relief and absence
of unpleasant sensation during stimulation.
The procedure for implanting PNFS is straightforward and mini-
mally invasive outpatient procedure that is performed under local
anesthesia with minimal sedation. The patients first receive a trial
lead placement. This trial gives them and the treating physician a
good indication of the likely outcome. Because the leads are placed
in the subcutaneous tissue, the SI joint is not violated, thus signifi-
cantly reducing the risk of joint infection or injury (13). The lead can
be inserted to the target though a Touhy needle, without the need
for tissue dissection. Furthermore, because the lead is placed in the
subcutaneous tissue, there is no major risk of stimulation causing
serious side-effects. Because patients could change some of their
stimulation parameters, they could adjust them based on their
need. In order to prevent risk of infection, new electrodes were used
for permanent implant and an interval of several weeks kept
between the two procedures. In addition, excessive injection of
local anesthesia was avoided because the local anesthetic could
travel along the electrode, making it difficult to do intraoperative
testing. In this series, the pulse generator pockets were in the flank
area because most patients preferred it and it is easy for patients to
reach it for recharging or for making minor changes in the stimula-
tion parameters.
Though the number of patients is small and the follow-up is rela-
tively short, the results are encouraging as 80% of patients achieved
improvement in pain, with 60% receiving significant improvement.
These results are encouraging because the patients treated in this
series had failed all other form of conservative treatments. In addi-
tion, these results are very similar to those obtained in fusion pro-
cedure (7). Like all other implants, there are risks of infection,
hardware breakage, migration of the leads, or flipping of the pulse
generator. Fortunately, because the implants are in the subcutane-
ous tissue, the risk of serious complication is remote and often
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excellent pain control are free of pain medication or have improve-
ment in sleep. The reason for this finding is that they had pain in
other areas too. There was nothing in the history or physical findings
that was unusual about those patients that failed this for treatment
except that they had the highest pain ratings. This may suggest that
those with very severe pain are less likely to improve.
CONCLUSION
PNFS implant for SI joint pain is a simple and minimally invasive
procedure to treat chronic disabling SI joint pain. Though the
number of patients in this series is small and the follow-up is rela-
tively short to draw any conclusion, the result of the present series is
encouraging. Eighty percent of the patients benefited from the pro-
cedure and 60% have significant improvement. By the very nature
of the procedure, the likelihood of serious complication is negli-
gible. This procedure therefore may be worth pursuing for patients
who have failed conservative treatment and want a less invasive
surgical procedure.
Authorship Statements
Drs. Patil and Otto wrote the manuscript. Ms. Otto also collected
the data. Dr. Raikar conducted the trial procedures and also helped
to collect the data.
Arun Angelo Patil, MD*, DeeAne Otto, APRN*,
Soubrata Raikar, MD†
*Division of Neurosurgery, University of Nebraska Medical Center,
Omaha, NE, USA; and†Fremont, NE, USA
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