Progress in neurological surgery
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The field of peripheral nerve stimulation (PNS) is now experiencing a phase of rapid growth in number of patients, number of implanters, number of indications, and procedure types. This, however, appears to be only a beginning of major developments that could revolutionize the field of PNS. It is expected that the progress in PNS will continue simultaneously in several directions as new indications, new stimulation targets and new device designs evolve in the foreseeable future. ⋯ Expanding the number of applications will without question strengthen the field of PNS. The turning point, however, will not occur until sufficient scientific evidence is gathered to unequivocally prove its safety, clinical efficacy and cost-effectiveness, and when PNS applications become officially endorsed through regulatory approval of each indication. Such changes will allow implanters to use approved devices for approved indications--instead of the contemporary 'off-label' use--and at the same time give device manufacturers a chance to market these devices and support education on their appropriate use.
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Cluster headache is well known as one of the most painful primary neurovascular headache. Since 1% of chronic cluster headache patients become refractory to all existing pharmacological treatments, various invasive and sometimes mutilating procedures have been tempted in the last decades. Recently, neurostimulation methods have raised new hope for drug-resistant chronic cluster headache patients. ⋯ Other peripheral nerve stimulation approaches used for this indication are also reviewed in detail. Although available studies are limited to a relatively small number of patients and placebo-controlled trials are lacking, existent clinical data suggest that occipital nerve stimulation should nonetheless be recommended for intractable chronic cluster headache patients before more invasive deep brain stimulation surgery. More studies are needed to evaluate the usefulness of supraorbital nerve stimulation and of vagus nerve stimulation in management of cluster headaches.
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Subcutaneous occipital nerve region stimulation is becoming an important part of the overall treatment regimen for a number of chronic headache syndromes refractory to nonsurgical, medical management. A combination of improved device technology and methodology, further understanding about appropriate indications and achievement of on-label FDA status should support continued use and success of this neuromodulation modality.
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Spinal nerve root stimulation (SNRS) is a neuromodulation technique that is used to treat chronic pain. This modality places stimulator electrode array(s) along the spinal nerve roots, creating stimulation paresthesias within the distribution of the target nerve root(s), thereby treating pain in that same distribution. ⋯ SNRS combines the minimally invasive nature, central location, and ease of placement of spinal cord stimulation with the focal targeting of stimulation paresthesias of peripheral nerve stimulation. This hybrid technique may be an effective alternative for patients in whom other forms of neurostimulation are either ineffective or inappropriate.
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Comparative Study
Occipital neuromodulation for refractory headache in the Chiari malformation population.
Chronic occipital and suboccipital headache is a common symptom in patients with Chiari I malformation (CMI). These headaches may persist despite appropriate surgical treatment of the underlying pathology via suboccipital decompression, duraplasty and related procedures. Occipital stimulation has been shown to be effective in the treatment of a variety of occipital headache/pain syndromes. ⋯ Device-related complications requiring additional surgeries occurred in 31% of patients. Occipital neuromodulation may provide significant long-term pain relief in selected CMI patients with persistent occipital pain. Larger and longer-term studies are needed to further define appropriate patient selection criteria as well as to refine the surgical technique to minimize device-related complications.