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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Neuromodulation practitioners increasingly recognize the potential for peripheral nerve field stimulation (PNfS) to treat pain originating from the trunk. Conditions resulting in truncal pain that may respond to PNfS include cervical and lumbar postlaminectomy syndrome, inguinal neurapraxia, post-herpetic neuralgia, and post-thoracotomy pain. The focus of this chapter is to review the mechanism of action in PNfS, patient selection factors, programming strategies, and technical considerations.
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Recently, there has been a tremendous evolution in the field of neurostimulation, both from the technological point of view and from development of the new and different indications. In some areas, such as peripheral nerve stimulation, there has been a boom in recent years due to the variations in the surgical technique and the improved results documented by in multiple published papers. ⋯ The confusion arises when attempting to describe peripheral nerve stimulation and subcutaneous stimulation. Peripheral nerve stimulation, in its pure definition, involves implanting a lead on a nerve, with the aim to produce paresthesia along the entire trajectory of the stimulated nerve.
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Since its inception in the 1970s, peripheral neuromodulation has become an increasingly common procedure to treat chronic neuropathic disorders. Historically, peripheral nerve stimulation (PNS) originated with the placement of large surface cuff electrodes, which was refined by the introduction of functional nerve mapping with circumferential electrical stimulation. This substantially improved the targeting of sensory fascicles. ⋯ To further refine functional mapping for the placement of these percutaneous electrodes, radiofrequency needle probes have more recently been employed to elicit paresthesias in awake patients to map the pain generators and guide treatment. In this chapter, we provide a description of the development and basic mechanisms of peripheral nerve stimulation, as well as a more detailed description of the two most commonly employed forms of peripheral nerve stimulation: occipital nerve stimulation for occipital neuralgia, and subcutaneous peripheral nerve field stimulation to stimulate free nerve endings within the subcutaneous tissue when the pain is limited to a small, well-localized area. The closely related ideas of internal and external targeted subcutaneous stimulation are also discussed.