Progress in neurological surgery
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The effect of peripheral neurostimulation has traditionally been attributed to the activation of non-noxious afferent nerve fibers (Aβ-fibers) thought to modulate Aδ and C-fiber-mediated nociceptive transmission in the spinal cord, compatible with the 'gate control theory of pain'. The concept has been extended since its initial description and more recent experimental evidence suggests that the analgesic effects of peripheral nerve stimulation in pain states such as in chronic headache require an interplay of multiple influences. ⋯ Beyond the concept of neuromodulation--decreasing excitation or increasing inhibition--a prerequisite of this arrangement is the convergence of different types of afferent activity and an intact descending modulatory network. In this review, we focus on the functional anatomy, pathophysiological mechanisms and neurophysiological and pharmacological findings elucidating the central mechanisms of peripheral nerve stimulation.
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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.
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Peripheral subcutaneous stimulation has been utilized for a variety of painful conditions affecting the abdominal wall, including sequelae of hernia repair, painful surgical scars, ilio-inguinal neuritis. It has also occasionally been shown to be effective in patients with intractable abdominal visceral pain. Since this is a very recent modality, no large series or prospective studies exist. The results, however, are promising and certainly warrant further investigation.
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Treatment of chronic back and leg pain in patients with failed back surgery syndrome (FBSS) remains problematic as none of the currently available approaches are universally successful in achieving lasting pain control. Spinal cord stimulation (SCS) is very effective for controlling radicular pain but rarely provides adequate control of pain in the lower back. ⋯ Because PNS does not control neuropathic pain due to lumbosacral radiculopathy involving the lower extremities, we developed a hybrid technique of SCS and PNS that offers potential control of both axial pain in the lumbar area and radicular pain to the lower extremities. This chapter presents our results and the possible mechanisms of action.
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Peripheral nerve stimulation (PNS) is an established neuromodulation approach that has been successfully used for the treatment of various painful conditions since the early 1960s. This review provides a comprehensive summary of relevant publications on PNS dividing its history into three distinct periods. The milestones of the field are related to the development of procedures, equipment and indications. As the most rapidly growing segment of operative neuromodulation, PNS continues to evolve as current and emerging clinical indications become matched by basic and clinical research, technological developments and procedural refinements.