1402 - Peripheral Nerve Stimulation as Salvage Therapy for Intractable Neuropathic Foot Pain Following Crush Injury: A Case Report

Case Diagnosis: Focal neuropathic plantar foot pain following crush injury, successfully managed with peripheral nerve stimulation (PNS).

Case Description: 42-year-old male presented with intractable focal left plantar foot pain, requesting elective below-knee amputation 8 months following a workplace accident causing pelvic ring fractures and post-traumatic stress disorder. He met Budapest criteria for complex regional pain syndrome. Symptoms were refractory to membrane stabilizers, opioids, physical therapy, and neuromodulatory modalities. Electrodiagnostics revealed isolated chronic reinnervation changes in the left tibial nerve, impacting selective fibers at and below the knee. High-resolution nerve ultrasound showed no evidence of entrapment or focal enlargement. Lumbar spine MRI was unremarkable.
A 60-day percutaneous PNS trial 12 months post injury targeting the tibial nerve distal to its bifurcation led to marked pain relief and improved mood, allowing discontinuation of opioids and neuropathic medications. However, symptoms returned upon device removal. Given the favorable response, a permanent PNS system is planned.

Discussions: This case highlights PNS can provide significant analgesic and functional benefits for focal neuropathic pain, even when imaging or electrodiagnostics are inconclusive. Tibial nerve targeting is appropriate for plantar foot pain and may serve as a less invasive alternative to spinal cord stimulation or amputation. Temporary systems, such as the 60-day PNS trial, function as both treatment and assessment for permanent implantation. In addition, psychological comorbidities may delay access to interventional therapies; trauma-informed mental health support early in the treatment pathway is essential. This case supports PNS as a salvage strategy for refractory neuropathic pain and highlights the importance of a multidisciplinary approach in complex presentations.

Conclusions: PNS can offer substantial functional and analgesic benefits in chronic neuropathic pain syndromes, serving both as a therapeutic modality and a trial platform for permanent implantation. In carefully selected patients, it may restore quality of life and avert irreversible surgical decisions such as amputation.