Perineuromal stimulation in the treatment of occipital neuralgia: a case study

Prospective case series on the use of peripheral nerve stimulation for focal mononeuropathy treatment

Aim: This case series looks at outcomes in 39 patients implanted using the Bioness Stimrouter system on various isolated mononeuropathies. Patients & methods: A case series of 39 patients with a total of 42 implants were enrolled starting August 2017 at various pain management centers. Results: Of 39 patients studied, 78% of the participants noticed an improvement in their pain. There was a 71% reduction in pain scores with the average preprocedure score of 8 improving to 2 post-implant. Participants noted on average a 72% improvement in activity with the greatest observed in the brachial plexus (80%) and suprascapular nerve (80%) and smallest in the intercostal nerve (40%). Approximately 89% of those implanted with a peripheral nerve stimulator experienced a greater than 50% reduction in opioid consumption. Conclusion: Peripheral nerve stimulators are a new, minimally invasive neuromodulation modality that shows promising early results in our 39-patient case series.

Occipital Nerve Stimulation

Although the first publications on clinical use of peripheral nerve stimulation for the treatment of chronic pain came out in the mid-1960s, it took 10 years before this approach was used to stimulate the occipital nerves. The future for occipital nerve stimulation is likely to bring new indications, devices, stimulation paradigms, and a decrease in invasiveness. As experience increases, one may expect that occipital nerve stimulation will eventually gain regulatory approval for more indications, most likely for occipital neuralgia, migraines and cluster headaches. This process may require additional studies, at least for approval from the US Food and Drug Administration.

Unilateral occipital nerve stimulation for bilateral occipital neuralgia: a case report and literature review

Objectives

The aim of this study is to present a case of successful relief of bilateral occipital neuralgia (ON) using unilateral occipital nerve stimulation (ONS) and to discuss the possible underlying mechanisms.

Materials and methods

We present the case of a 59-year-old female patient with severe bilateral ON treated with unilateral ONS. We systematically reviewed previous studies of ONS for ON, discussing the possible mechanisms of ONS in the relief of ON.

Results

The patient reported complete pain relief after consistent unilateral ONS during the follow-up period. The underlying mechanisms may be linked to the relationship between pain and several brain regions, including the pons, midbrain, and periaqueductal gray.

Conclusion

ONS is an effective and safe option for treating ON. Future studies will be required to clarify the mechanisms by which unilateral occipital stimulation provided relief for bilateral neuralgia in this case.

Safety and Efficacy of Occipital Nerves Stimulation for the Treatment of Chronic Migraines: Randomized, Double-blind, Controlled Single-center Experience

BACKGROUND

A recent multicenter study presented 52-week safety and efficacy results from an open-label extension of a randomized, sham-controlled trial for patients with chronic migraine (CM) undergoing peripheral nerve stimulation of the occipital nerves. We present the data from a single center of 20 patients enrolled at the Cleveland Clinic's Pain Management Department.

METHODS

In this single center, 20 patients were implanted with a neurostimulation system, randomized to an active or control group for 12 weeks, and received open-label treatment for an additional 40 weeks. Outcomes collected included number of headache days, pain intensity, Migraine Disability Assessment (MIDAS), Zung Pain and Distress (PAD), direct patient reports of headache pain relief, quality of life, satisfaction, and adverse events (AEs).

RESULTS

Headache days per month were reduced by 8.51 (±9.81) days (P < 0.0001). The proportion of patients who achieved a 30% and 50% reduction in headache days and/or pain intensity was 60% and 35%, respectively. MIDAS and Zung PAD were reduced for all patients. Fifteen (75%) of the 20 patients at the site reported at least one AE. A total of 20 AEs were reported from the site.

CONCLUSION

Our results support the 12-month efficacy of 20 CM patients receiving peripheral nerve stimulation of the occipital nerves in this single-center trial.

The appropriate use of neurostimulation: stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation Appropriateness Consensus Committee

INTRODUCTION

The International Neuromodulation Society (INS) has identified a need for evaluation and analysis of the practice of neurostimulation of the brain and extracranial nerves of the head to treat chronic pain.

METHODS

The INS board of directors chose an expert panel, the Neuromodulation Appropriateness Consensus Committee (NACC), to evaluate the peer-reviewed literature, current research, and clinical experience and to give guidance for the appropriate use of these methods. The literature searches involved key word searches in PubMed, EMBASE, and Google Scholar dated 1970-2013, which were graded and evaluated by the authors.

RESULTS

The NACC found that evidence supports extracranial stimulation for facial pain, migraine, and scalp pain but is limited for intracranial neuromodulation. High cervical spinal cord stimulation is an evolving option for facial pain. Intracranial neurostimulation may be an excellent option to treat diseases of the nervous system, such as tremor and Parkinson's disease, and in the future, potentially Alzheimer's disease and traumatic brain injury, but current use of intracranial stimulation for pain should be seen as investigational.

CONCLUSIONS

The NACC concludes that extracranial nerve stimulation should be considered in the algorithmic treatment of migraine and other disorders of the head. We should strive to perfect targets outside the cranium when treating pain, if at all possible.

Novel High-Frequency Peripheral Nerve Stimulator Treatment of Refractory Postherpetic Neuralgia: A Brief Technical Note

OBJECTIVES

The study aims to describe an ultrasound (US)-guided peripheral nerve stimulation implant technique and describe the effect of high-frequency peripheral nerve stimulation on refractory postherpetic neuralgia.

MATERIALS AND METHODS

Following a cadaver pilot trial using US and confirmatory fluoroscopic guidance, a 52-year-old man with refractory left supraorbital neuralgia underwent combined US and fluoroscopic-guided supraorbital peripheral nerve stimulator trial. The patient was subsequently implanted with a percutaneous lead over the left supraorbital and supratrochlear nerve utilizing a high-frequency stimulation paradigm.

RESULTS

At 9 months follow-up, the pain intensity had declined from a weekly average of 8/10 to 1/10 on the pain visual analog scale (VAS). After implant, both nerve conduction and blink reflex studies were performed, which demonstrated herpetic nerve damage and frequency-specific peripheral nerve stimulation effects. The patient preferred analgesia in the supraorbital nerve distribution accomplished with high-frequency paresthesia-free stimulation (HFS) at an amplitude of 6.2 mA, a frequency of 100-1200 Hz, and a pulse width of 130 μsec, to paresthesia-mediated pain relief associated with low-frequency stimulation.

CONCLUSION

We report the implant of a supraorbital peripheral nerve stimulating electrode that utilizes a high-frequency program resulting in sustained suppression of intractable postherpetic neuralgia.

Nerve block for the treatment of headaches and cranial neuralgias - a practical approach

BACKGROUND

Several studies have presented evidence that blocking peripheral nerves is effective for the treatment of some headaches and cranial neuralgias, resulting in reduction of the frequency, intensity, and duration of pain.

OBJECTIVES

In this article we describe the role of nerve block in the treatment of headaches and cranial neuralgias, and the experience of a tertiary headache center regarding this issue. We also report the anatomical landmarks, techniques, materials used, contraindications, and side effects of peripheral nerve block, as well as the mechanisms of action of lidocaine and dexamethasone.

CONCLUSIONS

The nerve block can be used in primary (migraine, cluster headache, and nummular headache) and secondary headaches (cervicogenic headache and headache attributed to craniotomy), as well in cranial neuralgias (trigeminal neuropathies, glossopharyngeal and occipital neuralgias). In some of them this procedure is necessary for both diagnosis and treatment, while in others it is an adjuvant treatment. The block of the greater occipital nerve with an anesthetic and corticosteroid compound has proved to be effective in the treatment of cluster headache. Regarding the treatment of other headaches and cranial neuralgias, controlled studies are still necessary to clarify the real role of peripheral nerve block.

Clinical utility of implantable neurostimulation devices in the treatment of chronic migraine

Chronic migraine is a disabling disorder that is costly to individuals and society. Occipital nerve stimulation has been used to treat refractory cases of primary headache disorders including drug-resistant chronic cluster headaches and chronic migraine. The Food and Drug Administration (FDA) off-labeled application of equipment used for peripheral nerve (occipital) stimulation is borrowed from FDA-labeled spinal cord stimulation. Manufacturer-sponsored randomized trials include a feasibility study (ONSTIM-Medtronic) and a safety and efficacy study (St Jude). A non-industry sponsored prospective, randomized crossover study by Serra and Marchiotretto suggests improved quality of life and a significant reduction in medication use. Though preliminary studies suggest occipital nerve stimulation is safe and efficacious in treating chronic migraine headache, complication rates, including lead migration, lead fracture, and surgical site infections remain high. Further studies are needed to demonstrate long-term outcomes, while improved surgical techniques and site-specific equipment are needed to minimize complications.

Peripheral neuromodulation and headaches: history, clinical approach, and considerations on underlying mechanisms

Implantable peripheral neurostimulation was introduced in 1969 as a potential treatment for certain neuropathic pain syndromes, primarily involving the limbs. While a few early studies included implants for occipital neuralgia, serious interest in its potential as a treatment for head pain came only after our 1999 report of positive findings in a series of patients with occipital neuralgia. Subsequent investigators confirmed these initial findings, and then extended the application to patients with various primary headache disorders, including migraine. While most found a therapeutic response, the degree of that response varied significantly, and analysis suggests that the issue of paresthesia concordancy may be central, both in explaining the data, as well as providing direction for future endeavors. Therefore, while at present peripheral neurostimulation is gaining increasing acceptance as a treatment for chronic headaches, the precise clinical indications and procedures, as well as the underlying neurophysiological mechanisms, are still being worked out.

Occipital nerve stimulation for the treatment of occipital neuralgia-eight case studies

Objective.  The aim of this study was to examine the hypothesis that subcutaneous occipital stimulation influences pain due to occipital neuralgia. Materials and Methods.  Between 2001 and 2004 eight patients with intractable occipital neuralgia were referred to our center. Their records were reviewed. Each patient was interviewed over the telephone. They were all offered a trial of stimulation using a percutaneous lead over 1 week. If they achieved 50% pain reduction a permanent lead was implanted. The impact of occipital stimulation was measured by pain score, analgesic requirements, and employment status. Results.  Seven proceeded to a permanent stimulator. There was a reduction in the visual analog score postimplantation in five of the seven patients. The total quantity of opiates taken after implantation showed a marked reduction. Of the seven who had a permanent implant two acquired full-time employment. Conclusion.  Occipital neuralgia is a useful and reversible treatment for intractable occipital neuralgia.

Ultrasound-guided, percutaneous peripheral nerve stimulation: technical note

BACKGROUND

Peripheral nerve stimulation is a form of neuromodulation that applies electric current to peripheral nerves to induce stimulation paresthesias within the painful areas.

OBJECTIVE

To report a method of ultrasound-guided, percutaneous peripheral nerve stimulation. This technique utilizes real-time imaging to avoid injury to adjacent vascular structures during minimally invasive placement of peripheral nerve stimulator electrodes.

MATERIAL AND METHODS

We describe a patient that presented with chronic, bilateral foot pain following multiple foot surgeries, for whom a comprehensive, pain management treatment strategy had failed. We utilized ultrasound-guided, percutaneous tibial nerve stimulation at a thigh level to provide durable pain relief on the right side, and open peripheral nerve stimulation on the left.

RESULTS

The patient experienced appropriate stimulation paresthesias and excellent pain relief on the plantar aspect of the right foot with the percutaneous electrode. On the left side, we were unable to direct the stimulation paresthesias to the sole of the foot, despite multiple electrode repositionings. A subsequent, open placement of a left tibial nerve stimulator was performed. This revealed that the correct electrode position against the tibial nerve was immediately adjacent to the popliteal artery, and was thus not appropriate for percutaneous placement.

CONCLUSION

We describe a method of ultrasound-guided peripheral nerve stimulation that avoids the invasiveness of electrode placement via an open procedure while providing excellent pain relief. We further describe limitations of the percutaneous approach when navigating close to large blood vessels, a situation more appropriately managed with open peripheral nerve stimulator placement. Ultrasound-guided placement may be considered for patients receiving peripheral nerve stimulators placed within the deep tissues, and not easily placed in a blind fashion.

Repositioning of supraorbital nerve stimulation electrode using retrograde needle insertion: a technical note

INTRODUCTION

With growing interest and acceptance of peripheral nerve stimulation (PNS) approach, there is now an increasing need in developing clear procedural details to resolve frequent complications and minimize associated tissue injury. Migration and suboptimal positioning of PNS electrodes are one of the most commonly observed complications of PNS approach.

MATERIALS AND METHODS

We present a simple technique for repositioning a supraorbital electrode using retrograde insertion of introducer needle that allows one to place percutaneous (cylindrical) PNS electrode into appropriate anatomical location with minimal additional injury to surrounding tissues.

RESULTS

This approach has been successfully used in multiple cases. An illustrative case of electrode revision with proposed technique is described in detail.

CONCLUSION

This technically simple approach to repositioning of cylindrical supraorbital electrodes using retrograde needle insertion eliminates the need for a more elaborate and invasive procedure. The technique can be used for electrode repositioning in most PNS applications.

Peripheral nerve stimulation for neuropathic pain

Peripheral nerve stimulation (PNS) has been used for treatment of neuropathic pain for more than 40 years. Recent resurgence of interest to this elegant surgical modality came from the introduction of less invasive implantation techniques and the wider acceptance of neuromodulation as a treatment of medically refractory cases. This article reviews the literature on the use of PNS for neuropathic pain and describes current indications and hardware choices in frequent use. Published experience indicates that neuropathic pain responds to PNS in many patients. PNS works well in both established indications, such as post-traumatic and postsurgical neuropathy, occipital neuralgia, and complex regional pain syndromes, and in relatively new indications for neuromodulation, such as migraines and daily headaches, cluster headaches, and fibromyalgia. Future research and growing clinical experience will help in identifying the best candidates for PNS, choosing the best procedure and best hardware for each individual patient, and defining adequate expectations for patients and pain specialists.

Peripheral nerve stimulation for the treatment of neuropathic craniofacial pain

Treatment of neuropathic pain in the region of head and face presents a challenging problem for pain specialists. In particular, those patients who do not respond to conventional treatment modalities usually continue to suffer from pain due to lack of reliable medical and surgical approaches. Peripheral nerve stimulation (PNS) has been used for treatment of neuropathic pain for many decades, but only recently it has been systematically applied to the craniofacial region. Here we summarize published experience with PNS in treatment of craniofacial pain and discuss some technical details of the craniofacial PNS procedure.

Trigeminal and occipital peripheral nerve stimulation for craniofacial pain: a single-institution experience and review of the literature

OBJECT

Treatment of chronic neuropathic pain in the region of the head and face presents a challenge for pain specialists; patients who do not respond to conventional treatment modalities usually continue to suffer from pain due to the lack of reliable medical and surgical approaches. Peripheral nerve stimulation (PNS) has been used to treat neuropathic pain for many decades, but only recently has it been applied systematically to the craniofacial region. To advance the study of this treatment option, the authors present their initial experience with this approach, summarize published data on the use of PNS in treatment of craniofacial pain, and discuss some technical details of the craniofacial PNS procedure.

METHODS

A review of prospectively collected data in 30 patients who underwent PNS surgery for craniofacial pain was performed. The pain location, duration, cause, and previous treatments were analyzed, along with the surgical details, initial and long-term results, complications, and repeated operations. Stimulated nerves in this group included supraorbital (seven patients), infraorbital (six), and occipital (21); in 19 patients more than one nerve was stimulated. Twenty-two patients proceeded with implantation of a permanent system after the trial. Of these, at the time of the latest evaluation (mean follow-up duration 35 months), in two patients the devices had been removed because of pain improvement over time, in three the devices were removed due to loss of effectiveness (two cases) or late infection (one), and the rest are enjoying either complete (15 patients) or partial (two patients) pain relief. Three patients underwent repeated operation due to lead erosion, infection, or migration.

CONCLUSIONS

Peripheral nerve stimulation appears to be a safe and effective approach in the treatment of craniofacial neuropathic pain. The growing body of literature supports a wider acceptance of this approach in the field of pain surgery.

Occipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neuralgia: a pilot study

Persistent occipital neuralgia can produce severe headaches that may not be controllable by conservative or surgical approaches. We describe a case series of 6 patients who had chronic headaches over an average of 4.9 yr who underwent occipital nerve electrical stimulation lead implantation using a modified midline approach. The patients had received conservative and surgical therapies in the past including oral antidepressants, membrane stabilizers, opioids, occipital nerve blocks, and radiofrequency ablations. Significant decreases in pain visual analog scale (VAS) scores and drastic improvement in functional capacity were observed during the occipital stimulation trial and during the 3-mo follow-up after implantation. The mean VAS score changed from 8.66 +/- 1.0 to 2.5 +/- 1.3 whereas pain disability index improved from 49.8 +/- 15.9 to 14.0 +/- 7.4. Our midline approach has several advantages compared with the submastoid approach used elsewhere. There is only one small midline incision over the upper neck and the strain on the lead extension occurs only with flexion and is minimal with lateral flexion and rotation, which contributes to overall stability of this system.

Long-Term Peripheral Nerve Stimulation for Painful Nerve Injuries

BACKGROUND

Although peripheral nerve stimulation (PNS) has been used in the treatment of pain since 1965, only a few follow-up studies have been published. The aim of the present retrospective study was to carefully assess the long-term efficacy and safety of PNS in the treatment of painful nerve injuries.

METHODS

Patients suffering from intractable pain due to peripheral nerve injuries underwent PNS after careful selection. Long-term results were evaluated based upon patients' reports of pain intensity on a visual analog scale (VAS) and their consumption of analgesics. Two categories of results were chosen: good, referring to 50% or more relief of pain with abstinence from analgesic medications; and poor, with less than 50% improvement.

RESULTS

Of 154 referred patients, 46 (26 women and 20 men) were found suitable for PNS. Four etiologic factors were identified, the most common being nerve lesion following an operation in the region of the hip or knee. Other etiologies included entrapment neuropathy, pain following nerve graft, and painful neuropathy following a traumatic injection. The follow-up period was 3-16 years. Of the 46 patients who underwent surgery, the results were classified as good in 36 (78%) patients and as poor in 10 (22%) patients. Overall, pain intensity dropped from a VAS of 69 +/- 12 before surgery to 24 +/- 28 postoperatively (P < 0.001).

CONCLUSIONS

PNS can produce good pain relief in the majority of carefully selected patients suffering from isolated painful neuropathies.

Psychological aspects of interventional therapy

This discussion is not, nor could it hope to be, an exhaustive examination of all of the various interventional therapies. Instead, it is intended to highlight the potential contribution of psychosocial factors. These factors may vary to some degree or another depending on the specific procedure, but clearly play a role whenever the desired outcome involves a reduction in subjective pain, alteration in the adaptiveness with which the patient responds to the experience of pain, and quality of life. Many notables, including Dr. Michael Cousins, have echoed the importance of incorporating interventional therapies into an interdisciplinary approach. Yet, there seems to be a preponderance of "block shops". Even when used for diagnostic or prognostic purposes, the impact of psychosocial variables and the potential relevance of a meaningful behavioral or psychologic evaluation cannot be overstated. It is easy to understand how the reader might conclude that immersing oneself in the minutiae of all these variables could lead to a feeling of intellectual paralysis when it comes to evaluating the data and arriving at a conclusion or diagnosis. However, ignoring these psychosocial variables and their complex interaction does not constitute a solution. This is particularly true in considering discography where, depending on the criteria applied, the percent of "false positives" can vary from 0% to as much as 40%. The implication for the performing of "unnecessary" spine surgery is obvious. The thoughtful practitioner will be mindful of the role of psychosocial variables in so far as they are thought to be relevant in a particular case. The overall contribution of psychosocial variables to the application of interventional therapies for the diagnosis and treatment of pain can be overlooked and ignored, but not denied. A certain percentage of patients will respond in a predictable, desirable or positive fashion purely on a statistical basis. Historically, and there seems to be no reason to believe this will change in the immediate future, the degree to which the psychosocial variables are considered is left up to the interventionalist. Some are content to perform a directed procedure or therapy concerned only, and sometimes to a less than sufficient degree, with the technical adequacy of the procedure. Others will appreciate the role of human factors including those of the practitioner and patient alike, and strive not only for a statistically derived outcome but the best possible outcome for a given patient. Psychosocial factors can sometimes take on the character of "nuisance variables". However, it is hard not to wonder how much care each would want to have given to these factors if one were on the other end of the needle.