LETTER TO THE EDITOR
An Unexpected Weight Loss in a Morbid Obese Patient with Spinal
Cord Stimulation Therapy for Chronic Neuropathic Pain
Serbülent Gökhan Beyaz1 &Burak Kaya2
Received: 7 May 2021 / Revised: 7 May 2021 / Accepted: 13 May 2021
# The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
Dear Editor:
Obesity is a multifactorial and complex disease that occurs due to the interaction of genetic and environmental factors. It has been reported that 7% of the adult population globally and 27% of the American population are obese [1]. Obesity is associated with myocardial infarction, cerebrovascular dis-eases, and sudden death among cardiovascular diseases and increasingly affects the young population. Chronic back, low-er back, and leg pain is common in obese patients, and many weight loss methods are used for obesity treatment [2]. Treatments are applied widely, from diet and herbal therapies to sleeve gastrectomy surgery, one of the most popular methods recently. Obesity responds to diet, although main-taining weight loss in the long term is challenging. Diets can sometimes be excessive, and this has been known to cause adverse health effects. Although bariatric surgeries are a re-markably effective method in maintaining weight loss in mor-bidly obese patients, complications may differ depending on the type of surgery performed. Generally, anastomotic leak, infections due to this leak, nausea or vomiting, and dumping syndrome are early period complications. Late complications include absorption disorders including protein, iron, vitamin B12, phosphate, calcium, fat-soluble vitamins (A, D, E, K) and other vitamins, incisional hernia, cholelithiasis, and renal diseases [3]. In addition to these treatments, few articles show that neuromodulation may effectively treat obesity [4]. We aimed to present a case with chronic pain due to failed back surgery and severe weight loss in the follow-up after spinal cord stimulator (SCS) implantation.
All procedures performed in studies involving human par-ticipants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or com-parable ethical standards. Written consent was obtained from this patient to write and publish this study. The patient was 35 years old, 110 kg in weight, and 154 cm in height (body mass index, BMI: 46,38 kg/m2) woman with a history of interver-tebral disc hernia and chronic lower back bilateral leg pain. She had been undergone multiple operations with no relief of symptoms. She also had no relief from physiotherapy and multiple oral and systemic analgesics. We planned and ap-plied SCS (Boston Scientific Corporation, Valencia, CA) for T8–T12 levels. In her follow-ups, she had significant pain relief, and she ceased using all of her analgesics and pregabalin. Her functional capacity was improved, and she became physically active. After successful trials of the SCS-off period, we decided to remove the SCS system. Simultaneous with our follow-ups, the patient had lost 30 kg of weight (new BMI: 33.73 kg/m2). She also stated that her appetite is reduced in addition to her pain-free physical activ-ities. There was no intervention to diet and lifestyle of the patient by us.
While 6–12 months after SCS implantation, each unit in-crease in body mass index has been shown to dein-crease the effectiveness of SCS by 2%, it has been reported that chronic pain patients with high BMI experience more severe pain than patients with low BMI [2,5]. These publications took their place as studies showing that obesity may affect the potential success of SCS in patients with chronic pain. However, there is no study showing the effectiveness of SCS alone in the treatment of obesity. Various neuromodulation methods have been tried in the treatment of obesity. Sobocki et al. reported that C1–C2 occipital stimulation (vagal neurostimulation) with the help of electrodes implanted subcutaneously on five obese patients concluded that it reduced body mass and im-proved body composition, and significantly increased the ac-tivity of the autonomic nervous system [4]. Criticism has also * Serbülent Gökhan Beyaz
sgbeyaz@gmail.com
1
Department of Anesthesiology and Reanimation, Pain Medicine, Istinye University Faculty of Medicine, Istanbul, Turkey
2 Department of Anesthesiology, Akyazı Goverment Hospital,
Sakarya, Turkey Obesity Surgery
been made about whether vagal stimulation is non-invasive or invasive, the effectiveness, and ease of this application [6]. Based on the creation of a somatic-autonomic reflex, percuta-neous electro-neurostimulation (PENS) developed for the treatment of urinary and fecal incontinence by stimulating the posterior tibial nerve, it has been reported that stimulation of the sensory nerve terminations localized in the T6 derma-tome causes the development of a reflex that ends in the vagal nerve branches that stimulate the gastric wall, similar to the gastric pacemaker [7]. Therefore, they showed that all patients who received diet (1200 kcal/day) and PENS experienced decreased appetite and significant weight loss. We think that comparative randomized controlled studies are needed to de-cide whether SCS will effectively treat obese patients with spinal pain since the result cannot be reached with a single case.
Author’s Contribution Serbülent Gökhan Beyaz: study design, manu-script data collection, preparing, writing, and editing. Burak Kaya: Translating and editing.
Declarations
Disclosure of benefit is a declaration that the authors have no conflicting interests, not supported or funded by any Drug Company.
References
1. Cheah MH, Kam PC. Obesity: basic science and medical aspects relevant to anaesthetists. Anaesthesia. 2005;60(10):1009–21.
https://doi.org/10.1111/j.1365-2044.2005.04229.x.
2. Marola O, Cherala R, Prusik J, et al. BMI as a predictor of spinal cord stimulation success in chronic pain patients. Neuromodulation. 2017;20(3):269–73.https://doi.org/10.1111/ner.12482. Epub 2016 Aug 5
3. Khwaja HA, Bonanomi G. Bariatric surgery: techniques, outcome and complications. Curr Anaesth Crit Care. 2010;21:31–8. 4. Sobocki J, Her man RM, Frac zek M. Oc cipit al C1-C2
neuromodulation decreases body mass and fat stores and modifies activity of the autonomic nervous system in morbidly obese patients—a pilot study. Obes Surg. 2013;23(5):693–7.
5. Mekhail N, Mehanny D, Armanyous S, et al. The impact of obesity on the effectiveness of spinal cord stimulation in chronic spine-related pain patients. Spine J. 2019;19(3):476–86.https://doi.org/ 10.1016/j.spinee.2018.08.006. Epub 2018 Aug 22
6. Kassir R, Barthelemy JC, Roche F, et al. Comments on the article: occipital C1-C2 neuromodulation decreases body mass and fat stores and modifies activity of the autonomic nervous system in morbidly obese patients–a pilot study. Obes Surg. 2016;26(2):384–5.https:// doi.org/10.1007/s11695-015-1965-3.
7. Ruiz-Tovar J, Oller I, Diez M, et al. Percutaneous electrical neurostimulation of dermatome T6 for appetite reduction and weight loss in morbidly obese patients. Obes Surg. 2014;24(2):205–11.
https://doi.org/10.1007/s11695-013-1091-z.
Publisher’s Note Springer Nature remains neutral with regard to jurisdic-tional claims in published maps and institujurisdic-tional affiliations.
