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Oswald J, Shahi V, Chakravarthy KV. Prospective case series on the use of peripheral nerve stimulation for focal mononeuropathy treatment. Pain Manag 2019; 9:551-558. [PMID: 31686589 DOI: 10.2217/pmt-2019-0028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Jessica Oswald
- Department of Anesthesiology & Pain Medicine, University of California San Diego Health Sciences, San Diego, CA 92037, USA
| | - Varun Shahi
- Department of Emergency Medicine, University of California, Oakland, CA 90095, USA
| | - Krishnan V Chakravarthy
- Department of Anesthesiology & Pain Medicine, University of California San Diego Health Sciences, San Diego, CA 92037, USA.,VA San Diego Healthcare System, San Diego, CA 92161, USA
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Abstract
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.
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Liu A, Jiao Y, Ji H, Zhang Z. Unilateral occipital nerve stimulation for bilateral occipital neuralgia: a case report and literature review. J Pain Res 2017; 10:229-232. [PMID: 28176938 PMCID: PMC5268330 DOI: 10.2147/jpr.s125271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Aijun Liu
- Department of Neurosurgery, First Affiliated Hospital of PLA General Hospital, Beijing, People's Republic of China
| | - Yongcheng Jiao
- Department of Neurosurgery, First Affiliated Hospital of PLA General Hospital, Beijing, People's Republic of China
| | - Huijun Ji
- Department of Neurosurgery, First Affiliated Hospital of PLA General Hospital, Beijing, People's Republic of China
| | - Zhiwen Zhang
- Department of Neurosurgery, First Affiliated Hospital of PLA General Hospital, Beijing, People's Republic of China
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Mekhail NA, Estemalik E, Azer G, Davis K, Tepper SJ. Safety and Efficacy of Occipital Nerves Stimulation for the Treatment of Chronic Migraines: Randomized, Double-blind, Controlled Single-center Experience. Pain Pract 2016; 17:669-677. [PMID: 27779368 DOI: 10.1111/papr.12504] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/22/2016] [Accepted: 07/08/2016] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Nagy A Mekhail
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Emad Estemalik
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Gerges Azer
- Evidence Based Pain Medicine Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Kristina Davis
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Stuart J Tepper
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, U.S.A
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Deer TR, Mekhail N, Petersen E, Krames E, Staats P, Pope J, Saweris Y, Lad SP, Diwan S, Falowski S, Feler C, Slavin K, Narouze S, Merabet L, Buvanendran A, Fregni F, Wellington J, Levy RM. The appropriate use of neurostimulation: stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:551-70; discussion 570. [PMID: 25112890 DOI: 10.1111/ner.12215] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 04/17/2014] [Accepted: 05/13/2014] [Indexed: 11/28/2022]
Abstract
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.
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Lerman IR, Chen JL, Hiller D, Souzdalnitski D, Sheean G, Wallace M, Barba D. Novel High-Frequency Peripheral Nerve Stimulator Treatment of Refractory Postherpetic Neuralgia: A Brief Technical Note. Neuromodulation 2015; 18:487-93; discussion 493. [PMID: 25832898 DOI: 10.1111/ner.12281] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 01/14/2015] [Accepted: 01/21/2015] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
| | | | - David Hiller
- University of California San Diego, San Diego, CA, USA
| | | | | | - Mark Wallace
- University of California San Diego, San Diego, CA, USA
| | - David Barba
- University of California San Diego, San Diego, CA, USA
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Dach F, Éckeli ÁL, Ferreira KDS, Speciali JG. Nerve block for the treatment of headaches and cranial neuralgias - a practical approach. Headache 2015; 55 Suppl 1:59-71. [PMID: 25644836 DOI: 10.1111/head.12516] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2014] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Fabíola Dach
- Headache Clinic, University Hospital of School of Medicine, University of Sao Paulo, Ribeirao Preto, SP, Brazil
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Reverberi C, Dario A, Barolat G, Zuccon G. Using Peripheral Nerve Stimulation (PNS) to Treat Neuropathic Pain: A Clinical Series. Neuromodulation 2014; 17:777-83; discussion 783. [DOI: 10.1111/ner.12157] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 09/07/2013] [Accepted: 12/20/2013] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Giancarlo Barolat
- Neuroscience Division; St. Luke Presbyterian Hospital; Denver CO USA
| | - Giulia Zuccon
- Barolat Neuroscience; Presbyterian/St Lukes Medical Center; Denver CO USA
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Freeman JA, Trentman TL. Clinical utility of implantable neurostimulation devices in the treatment of chronic migraine. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2013; 6:195-201. [PMID: 24348076 PMCID: PMC3838759 DOI: 10.2147/mder.s27109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- John A Freeman
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Terrance L Trentman
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
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10
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Reed KL. Peripheral neuromodulation and headaches: history, clinical approach, and considerations on underlying mechanisms. Curr Pain Headache Rep 2013; 17:305. [PMID: 23274677 PMCID: PMC3548086 DOI: 10.1007/s11916-012-0305-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Ken L Reed
- Reed Migraine Centers, Dallas, TX 75243, USA.
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Johnstone CSH, Sundaraj R. Occipital nerve stimulation for the treatment of occipital neuralgia-eight case studies. Neuromodulation 2012; 9:41-7. [PMID: 22151592 DOI: 10.1111/j.1525-1403.2006.00041.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Charlotte S H Johnstone
- Nepean Pain Management Center, Nepean Hospital, Division of University of Sydney, Kingswood, New South Wales, Australia
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12
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Verrills P, Vivian D, Mitchell B, Barnard A. Peripheral Nerve Field Stimulation for Chronic Pain: 100 Cases and Review of the Literature. PAIN MEDICINE 2011; 12:1395-405. [DOI: 10.1111/j.1526-4637.2011.01201.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chan I, Brown AR, Park K, Winfree CJ. Ultrasound-guided, percutaneous peripheral nerve stimulation: technical note. Neurosurgery 2010; 67:ons136-9. [PMID: 20679937 DOI: 10.1227/01.neu.0000383137.33503.eb] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Isaac Chan
- Columbia University Medical Center, New York, New York, USA
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Slavin KV, Vannemreddy PSSV. Repositioning of supraorbital nerve stimulation electrode using retrograde needle insertion: a technical note. Neuromodulation 2010; 14:160-3; discussion 163-4. [PMID: 21992205 DOI: 10.1111/j.1525-1403.2010.00315.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Simopoulos T, Bajwa Z, Lantz G, Lee S, Burstein R. Implanted Auriculotemporal Nerve Stimulator for the Treatment of Refractory Chronic Migraine. Headache 2010; 50:1064-9. [DOI: 10.1111/j.1526-4610.2010.01694.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Keller T, Krames ES. “On the Shoulders of Giants”: A History of the Understandings of Pain, Leading to the Understandings of Neuromodulation. Neuromodulation 2009; 12:77-84. [DOI: 10.1111/j.1525-1403.2009.00196.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Reverberi C, Bonezzi C, Demartini L. Peripheral Subcutaneous Neurostimulation in the Management of Neuropathic Pain: Five Case Reports. Neuromodulation 2009; 12:146-55. [DOI: 10.1111/j.1525-1403.2009.00201.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Stuart RM, Winfree CJ. Neurostimulation Techniques for Painful Peripheral Nerve Disorders. Neurosurg Clin N Am 2009; 20:111-20, vii-viii. [DOI: 10.1016/j.nec.2008.07.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weiner RL, Alo’ KM. Occipital Neurostimulation for Treatment of Intractable Headache Syndromes. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Trentman TL, Zimmerman RS. Occipital Nerve Stimulation: Technical and Surgical Aspects of Implantation. Headache 2008; 48:319-27. [DOI: 10.1111/j.1526-4610.2007.01023.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
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.
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Affiliation(s)
- Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois 60612, USA.
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23
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Park CH, Huh BK. Permanent Peripheral Nerve Stimulation for Chronic Occipital Neuralgia: Case reports. Korean J Pain 2008. [DOI: 10.3344/kjp.2008.21.2.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Chan Hong Park
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Billy K Huh
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Slavin KV. Peripheral nerve stimulation for the treatment of neuropathic craniofacial pain. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:115-20. [PMID: 17691366 DOI: 10.1007/978-3-211-33079-1_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- K V Slavin
- Department of Neurosurgery, University of Illinois, Chicago 60612, USA.
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Slavin KV, Colpan ME, Munawar N, Wess C, Nersesyan H. Trigeminal and occipital peripheral nerve stimulation for craniofacial pain: a single-institution experience and review of the literature. Neurosurg Focus 2006; 21:E5. [PMID: 17341049 DOI: 10.3171/foc.2006.21.6.8] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Konstantin V Slavin
- Department of Neurosurgery, University of Illinois, Chicago, Illinois 60612, USA.
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Kapural L, Mekhail N, Hayek SM, Stanton-Hicks M, Malak O. Occipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neuralgia: a pilot study. Anesth Analg 2005; 101:171-4, table of contents. [PMID: 15976227 DOI: 10.1213/01.ane.0000156207.73396.8e] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Leonardo Kapural
- Pain Management Center, The Cleveland Clinic Foundation, 9500 Euclid Ave., Desk C25, Cleveland, OH 44195, USA.
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Eisenberg E, Waisbrod H, Gerbershagen HU. Long-Term Peripheral Nerve Stimulation for Painful Nerve Injuries. Clin J Pain 2004; 20:143-6. [PMID: 15100589 DOI: 10.1097/00002508-200405000-00003] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Elon Eisenberg
- Pain Relief Unit, Rambam Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa Pain Research Group, Israel.
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Abstract
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.
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Affiliation(s)
- Daniel M Doleys
- Pain and Rehabilitation Institute, 720 Montclair Road, Suite 204, Birmingham, AL 35213, USA.
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