Peripheral Nerve Stimulation for the 21st Century: Sural, Superficial Peroneal, and Tibial Nerves

Objective. Peripheral nerve stimulation (PNS) of the lower extremity has progressed significantly over the last decade. From the proof of concept that ultrasound-guided, percutaneous implantation was possible to advances in waveforms, the field has been rapidly evolving. While most nerves in the lower extremity can be PNS targets, consideration must be given to the ergonomics of pulse generator placement, patient comfort, and avoidance of lead migration. For this paper, we examine some of the conditions amenable to lower extremity PNS, review the evidence and history behind PNS for these conditions, and describe approaches for the tibial, sural, and superficial peroneal nerves. Methods. A literature search was conducted using PubMed. Search terms used were "peripheral nerve stimulation," "lower extremity entrapment neuropathies," "sural nerve," "superficial peroneal nerve," "tibial nerve," and "tarsal tunnel syndrome." Emphasis was placed on randomized controlled studies, anatomical dissections, and comprehensive review articles. Approaches to nerves and ultrasound images were based on anecdotal PNS cases from an experienced implanter (SP). Conclusions. The development of ultrasound as a viable method of image guidance for percutaneous peripheral nerve stimulation has led to an exponential growth in the field. Lower extremity percutaneous lead placement is both feasible and an appropriate treatment modality for certain pain conditions.