NEUROMODULATION FOR THE
SACRAL AND COCCYGEAL SPACE
Kenneth M. Alo`, M.D.
Mohammad I. Hirzallah, M.D.
Erich Richter, M.D.
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Methodist Hospital Research Institute, The Texas
Medical Center
Ministry of Health Hospitals, Amman, Jordan
LSU Health Science Center, New Orleans
Louisiana
Alo` K, Hirzallah M, Richter E. Technical Note: Percutaneous Cephalocaudal Peripheral
Nerve Stimulation for Coccygodynia. NeurosurgicalReview.com. 2011.
OUTCOMES
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Urge incontinence (80%) --- S3
Fecal Incontinence (84%) --- S4
Urgency-frequency disorders (70%) --- S2/3
Vulvodynia (60%) --- S 2+3
Pudendal neuralgia/neuropathies (60%) --- S 2+3(4)
Interstitial Cystitis (30-50%) --- S2+3(4)
Coccygodynia (?) --- S4+5
ACCESS OPTIONS
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Retrograde (Cephalocaudal) Technique
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Anterograde Trans-hiatus Technique
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Transforaminal Technique (Interstim)
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Epidural technique with laminotomy
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Percutaneous Cephalocaudal/Retrograde PNS
Retrograde (Cephalocaudal) Technique
Alo`KM. Select Nerve Root Stimulation: Facilitating the Cephalocaudal “Retorgrade” Method of
Electrode Insertion. In: Atlas of Implantable Therapies for Pain Management. Deer T, ed.
Chapter16. New York, NY: Springer:2011;107-114.
Anterograde Trans-Hiatus Technique
Deer T. Sacral Nerve Root Stimulation for the Treatment of Pelvic and Rectal Pain. In: In: Atlas
of Implantable Therapies for Pain Management. Deer T, ed. Chapter16. New York, NY:
Springer:2011;95-99.
Transforaminal S3 Technique (Interstim)
Steinberg AC, Oyama IA, Whitmore KE. Bilateral S3 stimulator in patients with interstitial
cystitis. Urology. 2007;69(3):441-443.
Epidural Laminotomy Techniques
(Sacral Pathologies)
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Alo` KM, Hirzallah MI, Richter EO. Technical Note: Percutaneous Cephalocaudal Peripheral
Nerve Stimulation for Coccygodynia. JNR. 2011. NeurosurgicalReview.com
Percutaneous PNS - Cephalocaudal
Alo` K, Hirzallah MI, Richter E. Technical Note: Percutaneous Cephalocaudal Peripheral Nerve
Stimulation for Coccygodynia. JNR. 2011. NeurosurgicalReview.com
Percutaneous PNS - Cephalocaudal
Alo` K, Hirzallah MI, Richter E. Technical Note: Percutaneous Cephalocaudal Peripheral Nerve
Stimulation for Coccygodynia. JNR. 2011. NeurosurgicalReview.com
Summary
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Percutaneous access to S4 and S5
Simple placement with low morbidity
Away from the painful coccyx and hiatus
Limited infection away from rectum
Less dehiscence risk
Easy to trial and implant permanently
Low migration risk
Less technically demanding than alternatives
Easily removed
Option for an underserved patient population
Suggested Reading
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Alo` KM. Select Nerve Root Stimulation: Facilitating the
Cephalocaudal “Retrograde” Method of Electrode Insertion.
In: Atlas of Implantable Therapies for Pain
Management. Deer T, ed. Chapter16. New York, NY:
Springer:2011;107-114.
Richter, EO, Abramova, MV, Sure, D, Alo`, KM. Nerve root,
sacral, and pelvic stimulation. In: Deer, T, Levy, R, and
Hayek, S, eds. Neurostimulation for the Treatment of
Chronic Pain: Interventional and Neuromodulatory
Techniques for Pain Management. In press.
Alo` K, Alo` K Hirzallah MI, Richter E. Technical Note:
Percutaneous Cephalocaudal Peripheral Nerve Stimulation for
Coccygodynia. JNR. 2011. NeurosurgicalReview.com
Deer T. Sacral Nerve Root Stimulation for the Treatment of
Pelvic and Rectal Pain. In: In: Atlas of Implantable
Therapies for Pain Management. Deer T, ed. Chapter16.
New York, NY: Springer:2011;95-99.
Suggested Reading - 2
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Uludağ Ö, Melenhorst J, Koch SMP, Van Gemert WG, Dejong
CHC, Baeten CGMI. Sacral neuromodulation: long term outcome
and quality of life in patients with faecal incontinence.
Colorectal Disease. 2010.
Steinberg AC, Oyama IA, Whitmore KE. Bilateral S3
stimulator in patients with interstitial cystitis. Urology.
2007;69(3):441-443.
Alo` KM, McKay E. Selective nerve root stimulation (SNRS) for
the treatment of intractable pelvic pain and motor dysfunction: a
case report. Neuromodulation. 2001;4(1):19-23.
McDonald JS, Alo`KM. Bonica’s Management of Pain, 3rd
Edition. In: Loeser J, ed. Section E: Pain in Pelvis, Perineum,
and Genitalia: Chapter 73, Pain of Urogenital Origin.
Philadelphia, PA: Lippinncott, Williams & Wilkins: 2001: 14481461.
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Suggested Reading - 3
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Alo` KM, Gohel R, Corey CL. Sacral nerve root stimulation
for the treatment of urge incontinence and detrusor
dysfunction utilizing a cephalocaudal intraspinal method of
lead insertion: a case report. Neuromodulation.
2001;4(2):53-58.
Alo` KM, Yland MJ, Redko V, Feler C, Naumann C. Lumbar
and sacral nerve root stimuation (NRS) in the treatment of
chronic pain: a novel anatomic approach and
neurostimulation technique. Neuromodulation. 1999;2:2331.
Feler CA, Whitworth LA, Brookoff D, Powell R. Recent
advances: Sacral nerve root stimulation using a retrograde
method of lead insertion for the treatment of pelvic pain due
to interstitial cystitis. Neuromodulation. 1999;2:211-216.
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