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In January, Bea Fiala and her husband drove eight hours through a blizzard from their home in Grand Island, Nebraska, to Rochester, Minnesota, in search of answers.
Bea had spent three years with terrible pain in her right thigh that began several months after knee replacement surgery. At first, it felt like a needling, tingling pain, but the pain got progressively worse. She had consults with specialists, including two local pain management physicians. And she tried several treatments to find some relief, but the pain persisted.
A stand-up comedian for 18 years, Bea had to stop performing because her pain was too distracting.
"The pain came when I stood for more than 15 minutes," Bea says. "I took Tylenol. I tried massage, lidocaine patches, capsaicin, medications used for nerve pain, physical therapy and acupuncture, but I couldn't find anything to relieve the pain. Most of the doctors I saw thought the pain was coming from my back."
After several steroid injections in her back and one aimed at the nerve in her thigh, which only provided a few days of relief, Bea underwent a spinal stimulator trial. "It made things worse," Bea says. "I felt I couldn't keep living with this horrible pain. I was at my wit's end."
In August 2017, Bea underwent spinal fusion surgery. But, as she suspected, her thigh pain was not coming from her back, and the surgery did not reduce the pain. At that point, she decided she had to go to a facility that could identify and treat the true cause of her chronic pain.
"I knew something was wrong and thought, 'I need to go somewhere where they'll find me an answer,'" Bea says.
Family members had had good experiences at Mayo Clinic, so Bea asked her primary care doctor to make a referral. During her first visit to Mayo Clinic in Rochester, she underwent electromyography, or EMG, which showed she had an old, inactive irritation of the nerve root at the L5 level of her spine in her lower back.
"In most cases, pain from an L5 nerve root irritation would have been radiating to her buttock, calf and foot, not the anterior thigh," says Matthew Pingree, M.D., a Mayo Pain Medicine physician. "The EMG findings encouraged us to look for other causes of her pain beyond her back."
"I knew something was wrong and thought, 'I need to go somewhere where they'll find me an answer.'"Bea Fiala
Following consults with specialists in Neurology and Sports Medicine, Bea learned that her leg pain was coming from the lateral femoral cutaneous nerve in her thigh and was most consistent with a condition known as meralgia paresthetica. The disorder, which is more common in women, is characterized by tingling, numbness and burning pain in the outer thigh. It's caused by compression of the nerve that supplies sensation to the skin surface of the thigh.
Tight clothing, obesity or weight gain, and pregnancy are common causes of meralgia paresthetica. However, the condition can also be due to local trauma or a disease, such as diabetes. In Bea's case, the cause was unknown.
After reviewing her multidisciplinary evaluation and examining her during an appointment in April, Dr. Pingree gave Bea an injection of local anesthesia around her lateral femoral cutaneous nerve.
"Mrs. Fiala had greater than 50% reduction of her pain within the first 15 minutes after the injection, which helped us predict that peripheral nerve stimulation of the lateral femoral cutaneous nerve would have a high likelihood of reducing her pain," Dr. Pingree says.
Nerve stimulation for pain relief is not new. One common form of nerve stimulation, which Bea had already tried and failed, is dorsal column or spinal stimulation. It works by blocking pain signals as they travel from the nerves in the arm or leg through the spinal cord. A newer treatment option, peripheral nerve stimulation blocks pain signals by stimulating a specific nerve in the arm or leg.
"It's a more targeted and less invasive treatment placed near the nerve in the arm or leg rather than in the spinal canal," Dr. Pingree says.
Bea underwent the minimally invasive procedure to implant the stimulator in June. The peripheral nerve stimulating lead was placed close to her lateral femoral cutaneous nerve.
Although the procedure is performed in an operating room, it doesn't require an overnight hospital stay. "No incision is made. Instead, ultrasound is used to visualize the nerve, and the needle is used to place the lead," Dr. Pingree says. "In most cases, the system can be turned on the same day of the procedure."
While other peripheral nerve stimulation systems are available, the one chosen for Bea uses a 15-centimeter flexible lead that has the thickness and consistency similar to that of a wet spaghetti noodle.
"On one end of the lead are three contacts that provide electrical stimulation, and a plastic flexible anchor that keeps the lead in place. At the other end is a receiver that communicates with the removable, rechargeable battery that's worn externally by the patient," Dr. Pingree says. "In most cases, patients can feel the stimulation as a small buzzing sensation."
When she got home after the procedure, Bea found that she could go about her daily activities pain-free. For the first two months after it was placed, she had the stimulator turned on all day. Now she only needs it for four hours a day.
"Before the stimulator, I was very limited in what I could do. I had to stop teaching chair yoga, which I loved," Bea says. "The pain debilitated my entire life."
"Being part of the team that helped her have such a positive outcome is very satisfying and one of the reasons I practice pain medicine."Matthew Pingree, M.D.
In addition to being able to go about her daily activities without pain, Bea has been able to return to the stage. "When I'm on stage, it alleviates everything. It's like getting all this adrenalin," Bea says of her stage act "Bea Funny." "This is what I'm supposed to be doing. It's a natural gift God gave me to make people laugh."
She performs for senior expos, church groups and conventions. "It gives me a personal high to know I've made someone feel good," Bea says. "I'm not in it to make a million. I'm in it to make a million people laugh."
"It was a real pleasure treating Mrs. Fiala. She always kept us laughing," Dr. Pingree says. "Dealing with chronic pain can be very frustrating for patients. Being part of the team that helped her have such a positive outcome is very satisfying and one of the reasons I practice pain medicine."