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Lin T, Gargya A, Singh H, Sivanesan E, Gulati A. Mechanism of Peripheral Nerve Stimulation in Chronic Pain. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:S6-S12. [PMID: 32804230 PMCID: PMC7828608 DOI: 10.1093/pm/pnaa164] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION With the advancement of technology, peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. Its origin is based on the gate control theory postulated by Wall and Melzack in 1965. However, the exact mechanism behind PNS' analgesic effect is largely unknown. In this article, we performed a comprehensive literature review to overview the PNS mechanism of action. DESIGN A comprehensive literature review on the mechanism of PNS in chronic pain. METHODS Comprehensive review of the available literature on the mechanism of PNS in chronic pain. Data were derived from database searches of PubMed, Scopus, and the Cochrane Library and manual searches of bibliographies and known primary or review articles. RESULTS Animal, human, and imaging studies have demonstrated the peripheral and central analgesic mechanisms of PNS by modulating the inflammatory pathways, the autonomic nervous system, the endogenous pain inhibition pathways, and involvement of the cortical and subcortical areas. CONCLUSIONS Peripheral nerve stimulation exhibits its neuromodulatory effect both peripherally and centrally. Further understanding of the mechanism of PNS can help guide stimulation approaches and parameters to optimize the use of PNS.
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Affiliation(s)
- Tiffany Lin
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Akshat Gargya
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Harmandeep Singh
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Eellan Sivanesan
- Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, USA
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Pedersen JL, Barloese M, Jensen RH. Neurostimulation in cluster headache: A review of current progress. Cephalalgia 2013; 33:1179-93. [DOI: 10.1177/0333102413489040] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose of review Neurostimulation has emerged as a viable treatment for intractable chronic cluster headache. Several therapeutic strategies are being investigated including stimulation of the hypothalamus, occipital nerves and sphenopalatine ganglion. The aim of this review is to provide an overview of the rationale, methods and progress for each of these. Latest findings Results from a randomized, controlled trial investigating sphenopalatine ganglion stimulation have just been published. Reportedly the surgery is relatively simple and it is apparently the only therapy that provides relief acutely. Summary The rationale behind these therapies is based on growing evidence from clinical, hormonal and neuroimaging studies. The overall results are encouraging, but unfortunately not all patients have benefited. All the mentioned therapies require weeks to months of stimulation for a prophylactic effect to occur, suggesting brain plasticity as a possible mechanism, and only stimulation of the sphenopalatine ganglion has demonstrated an acute, abortive effect. Predictors of effect for all modes of neurostimulation still need to be identified and in the future, the least invasive and most effective strategy must be preferred as first-line therapy for intractable chronic cluster headache.
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Brewer AC, Trentman TL, Ivancic MG, Vargas BB, Rebecca AM, Zimmerman RS, Rosenfeld DM, Dodick DW. Long-term outcome in occipital nerve stimulation patients with medically intractable primary headache disorders. Neuromodulation 2012; 16:557-62; discussion 563-4. [PMID: 22882274 DOI: 10.1111/j.1525-1403.2012.00490.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-term ONS outcomes. METHODS The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records. RESULTS Twenty-nine patients underwent a trial of ONS during the 8.5-year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-eight percent of patients required at least one lead revision. DISCUSSION These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. CONCLUSIONS Randomized controlled long-term studies in specific, intractable, primary headache disorders are indicated.
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Affiliation(s)
- Ann Chang Brewer
- College of Medicine, University of Arizona, Phoenix, AZ, USA; Department of Anesthesiology, Mayo Clinic in Arizona, Phoenix, AZ, USA; Department of Neurology, Mayo Clinic in Arizona, Phoenix, AZ, USA; Department of Plastic and Reconstructive Surgery, Mayo Clinic in Arizona, Phoenix, AZ, USA; and Department of Neurosurgery, Mayo Clinic in Arizona, Phoenix, AZ, USA
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Van Buyten JP, Linderoth B. Invasive neurostimulation in facial pain and headache syndromes. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.eujps.2011.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zimmerman RS, Rosenfeld DM, Freeman JA, Rebecca AM, Trentman TL. Revision of Occipital Nerve Stimulator Leads: Technical Note of Two Techniques. Neuromodulation 2011; 15:387-91. [DOI: 10.1111/j.1525-1403.2011.00413.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Piquet M, Balestra C, Sava SL, Schoenen JE. Supraorbital transcutaneous neurostimulation has sedative effects in healthy subjects. BMC Neurol 2011; 11:135. [PMID: 22035386 PMCID: PMC3261828 DOI: 10.1186/1471-2377-11-135] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 10/28/2011] [Indexed: 11/23/2022] Open
Abstract
Background Transcutaneous neurostimulation (TNS) at extracephalic sites is a well known treatment of pain. Thanks to recent technical progress, the Cefaly® device now also allows supraorbital TNS. During observational clinical studies, several patients reported decreased vigilance or even sleepiness during a session of supraorbital TNS. We decided therefore to explore in more detail the potential sedative effect of supraorbital TNS, using standardized psychophysical tests in healthy volunteers. Methods We performed a double-blind cross-over sham-controlled study on 30 healthy subjects. They underwent a series of 4 vigilance tests (Psychomotor Vigilance Task, Critical Flicker Fusion Frequency, Fatigue Visual Numeric Scale, d2 test). Each subject was tested under 4 different experimental conditions: without the neurostimulation device, with sham supraorbital TNS, with low frequency supraorbital TNS and with high frequency supraorbital TNS. Results As judged by the results of three tests (Psychomotor Vigilance Task, Critical Flicker Fusion Frequency, Fatigue Visual Numeric Scale) there was a statistically significant (p < 0.001) decrease in vigilance and attention during high frequency TNS, while there were no changes during the other experimental conditions. Similarly, performance on the d2 test was impaired during high frequency TNS, but this change was not statistically significant. Conclusion Supraorbital high frequency TNS applied with the Cefaly® device decreases vigilance in healthy volunteers. Additional studies are needed to determine the duration of this effect, the underlying mechanisms and the possible relation with the stimulation parameters. Meanwhile, this effect opens interesting perspectives for the treatment of hyperarousal states and, possibly, insomnia.
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Affiliation(s)
- Maxime Piquet
- Environmental, Occupational and Ageing Physiology Laboratory, DAN Europe Research, Haute Ecole Paul Henri Spaak, I.S.E.K., Brussels, Belgium.
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Mammis A, Gudesblatt M, Mogilner AY. Peripheral Neurostimulation for the Treatment of Refractory Cluster Headache, Long-Term Follow-Up: Case Report. Neuromodulation 2011; 14:432-5; discussion 435. [DOI: 10.1111/j.1525-1403.2011.00386.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Magis D, Gerardy PY, Remacle JM, Schoenen J. Sustained Effectiveness of Occipital Nerve Stimulation in Drug-Resistant Chronic Cluster Headache. Headache 2011; 51:1191-201. [DOI: 10.1111/j.1526-4610.2011.01973.x] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Magis D, Bruno MA, Fumal A, Gérardy PY, Hustinx R, Laureys S, Schoenen J. Central modulation in cluster headache patients treated with occipital nerve stimulation: an FDG-PET study. BMC Neurol 2011; 11:25. [PMID: 21349186 PMCID: PMC3056751 DOI: 10.1186/1471-2377-11-25] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 02/24/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occipital nerve stimulation (ONS) has raised new hope for drug-resistant chronic cluster headache (drCCH), a devastating condition. However its mode of action remains elusive. Since the long delay to meaningful effect suggests that ONS induces slow neuromodulation, we have searched for changes in central pain-control areas using metabolic neuroimaging. METHODS Ten drCCH patients underwent an 18FDG-PET scan after ONS, at delays varying between 0 and 30 months. All were scanned with ongoing ONS (ON) and with the stimulator switched OFF. RESULTS After 6-30 months of ONS, 3 patients were pain free and 4 had a ≥ 90% reduction of attack frequency (responders). In all patients compared to controls, several areas of the pain matrix showed hypermetabolism: ipsilateral hypothalamus, midbrain and ipsilateral lower pons. All normalized after ONS, except for the hypothalamus. Switching the stimulator ON or OFF had little influence on brain glucose metabolism. The perigenual anterior cingulate cortex (PACC) was hyperactive in ONS responders compared to non-responders. CONCLUSIONS Metabolic normalization in the pain neuromatrix and lack of short-term changes induced by the stimulation might support the hypothesis that ONS acts in drCCH through slow neuromodulatory processes. Selective activation in responders of PACC, a pivotal structure in the endogenous opioid system, suggests that ONS could restore balance within dysfunctioning pain control centres. That ONS is nothing but a symptomatic treatment might be illustrated by the persistent hypothalamic hypermetabolism, which could explain why autonomic attacks may persist despite pain relief and why cluster attacks recur shortly after stimulator arrest. PET studies on larger samples are warranted to confirm these first results.
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Abstract
PURPOSE OF REVIEW Conventional management options in medically intractable chronic-headache syndromes, such as chronic migraine, chronic cluster headache and hemicrania continua, are often limited. This review summarizes the current concepts, approaches and outcome data of invasive device-based neurostimulation approaches using occipital-nerve stimulation and deep-brain stimulation. RECENT FINDINGS Recently, there has been considerable progress in neurostimulation approaches to medically intractable chronic-headache syndromes. Previous studies have analysed the safety and efficacy of suboccipital neurostimulation in drug-resistant chronic-headache syndromes such as in chronic migraine, chronic cluster headache and hemicrania continua. The studies suggest suboccipital neurostimulation can have an effect even decades after onset of headaches, thus representing a possible therapeutic option inpatients that do not respond to any medication. Similarly, to date over 50 patients with cluster headaches underwent hypothalamic deep-brain stimulation. From these, an average of 50-70% did show a significant positive response. SUMMARY These findings will help to further elucidate the clinical potential of neurostimulation in chronic headache.
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Franzini A, Messina G, Leone M, Broggi G. Occipital nerve stimulation (ONS). Surgical technique and prevention of late electrode migration. Acta Neurochir (Wien) 2009; 151:861-5; discussion 865. [PMID: 19430723 DOI: 10.1007/s00701-009-0372-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Accepted: 04/08/2009] [Indexed: 11/28/2022]
Abstract
Occipital nerve stimulation (ONS) is an emerging procedure for the treatment of cranio-facial pain syndromes and headaches refractory to conservative treatments. The aim of this report is to describe in detail the surgical intervention and to introduce some useful tricks that help to avoid late displacement and migration of the suboccipital leads. The careful description of the surgical steps may contribute to a standardization of the procedure and make the interpretation of results easier even if obtained in series of patients operated on by different authors.
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Affiliation(s)
- Angelo Franzini
- Department of Neurosurgery, Istituto Nazionale Neurologico "Carlo Besta", Milan, Italy
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Current World Literature. Curr Opin Neurol 2009; 22:321-9. [DOI: 10.1097/wco.0b013e32832cf9cb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tepper SJ, Rezai A, Narouze S, Steiner C, Mohajer P, Ansarinia M. Acute treatment of intractable migraine with sphenopalatine ganglion electrical stimulation. Headache 2009; 49:983-9. [PMID: 19486173 DOI: 10.1111/j.1526-4610.2009.01451.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND We report preliminary results of a novel acute treatment for intractable migraine. The sphenopalatine ganglion (SPG) has sensorimotor and autonomic components and is involved in migraine pathophysiology. METHODS In 11 patients with medically refractory migraine, the sphenopalatine fossa was accessed with a 20-gauge needle using the standard infrazygomatic transcoronoid approach under fluoroscopy. Patients underwent temporary unilateral electric stimulation of the SPG with a Medtronic 3057 test stimulation lead after induction of full-blown migraine. Both sham and active stimulations with different settings were carried out for < or =60 minutes, and then the lead was removed. RESULTS In 11 evaluations, 2 patients were pain-free within 3 minutes of stimulation. Three had pain reduction; 5 had no response; 1 was not stimulated. Five patients had no pain relief. Stimulation settings: mean amplitude of 1.2V, mean pulse rate of 67 Hz, mean pulse width of 462 micros. Lack of headache relief appeared linked to suboptimal lead placement, poor physiologic sensory response to localization stimulation, and diagnosis of medication overuse headache. CONCLUSION This study suggests a possible role for SPG stimulation in the treatment of refractory migraine headaches.
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Affiliation(s)
- Stewart J Tepper
- Center for Headache and Pain, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave. T33, Cleveland, OH 44195, USA
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