820 - When surgery is not an option: Wireless High-Frequency Peripheral Nerve Stimulation for Chronic Shoulder Pain in a Morbidly Obese Patient on Chronic Anticoagulation: A Case Report

Case Diagnosis: A 68-year-old morbidly obese male with multiple co-morbidities presenting with refractory osteoarthritic shoulder pain

Case Description:
The patient was not a surgical candidate given his body mass index of 55 Kg.m^-2. His past medical history was significant for ischemic cerebral strokes, coronary artery disease, atrial fibrillation, chronic anticoagulation therapy, type 2 diabetes, hypertension, and cirrhosis. X-ray images of the left shoulder revealed severe osteoarthritis, and the ultrasound scan reported partial tears of supra and infraspinatus ligaments. The patient had restricted range of motion with guarding of the peri-articular muscles. The patient reported no analgesic response to Gabapentin, Lyrica, Voltaren, TENS, and 6 months of physical therapy. Intra-articular steroid injection, suprascapular nerve blocks and pulsed radiofrequency ablation of the suprascapular nerve failed to provide more than a few weeks of analgesia. After undergoing a one-week trial of peripheral nerve stimulation of the left suprascapular nerve with a wireless high-frequency system, the patient reported more than 50% improvement in his shoulder pain.

Discussions: He subsequently underwent a permanent implant. The patient is in his 3rd month of physical therapy for his shoulder pain and reports marked improvement in mobility, strength, and pain. The patient can do his activities of daily living without any assistance.

Surgery is the last resort in the treatment algorithm in patients with osteoarthritic shoulder pain refractory to multimodal therapies. However, a small subset of patients is not considered a good fit for surgery due to significant co-morbidities. The benefits of PNS for shoulder pain include minimal invasiveness, low risk of side effects, and long-term pain relief for many patients.

Conclusions: In a patient with significant comorbidities that preclude shoulder surgery, peripheral nerve stimulation of the suprascapular nerve can be considered a viable analgesic option.