Neuroaugmentation in the management of pelvic pain syndromes

The management of pelvic pain usually represents a challenge; neuroaugmentation of the sacral segmental nerves roots is probably one of the last options that pain physicians resort to. In properly selected patients, it can provide satisfactory results. In this article, we have reviewed some aspects relevant to pelvic pain and their treatment with this technique. Two techniques of neuroaugmentation are described: a transacral approach has been used extensively with good results for pelvic pain and urinary bladder dysfunction. A retrograde electrode placement technique from rostral lumbar segments has been published by some authors. It appears to be a reasonable and acceptable route to treat pelvic pain. The most common indications for sacral neuroaugmentation are: interstitial cystitis, vulvodynia, male chronic pain syndrome, and in some cases, sacroiliac joint pain. The mechanism of action of neuroaugmentation has not been defined; however, it seems that neuroaugmentation can induce release of inhibitory neurotransmitters in the spinal cord, in particular glycine and GABA; there is also evidence that substance P and other peptides may participate. It has also been proposed that neuroaugmentation may decrease the release of excitatory neurotransmitters like glutamate. The most unlikely mechanism to explain the analgesia of neuroaugmentation is endorphin release, since naloxone does not antagonize the effects of neuroaugmentation.