Progress in neurological surgery
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Extremely high prevalence among general population along with the high percentage of treatment-refractory cases makes migraine headaches one of the potentially largest indications for neuromodulation. Cranial peripheral nerve stimulation targeting the occipital nerve(s) alone or in combination with others appears to be both safe and efficacious for the treatment of medically intractable migraine headaches. ⋯ Significant further investigation needs to be performed to optimize our knowledge concerning patient selection, stimulation targets and parameters and device programming, and further improve clinical results. At present, neurostimulation for migraine headache pain is performed in the United States on an 'off-label' basis, but based upon our experience and the increasing evidence in the medical literature, we look forward to its approval by the FDA in the near future so that patients suffering from severe, medically intractable headache pain may gain access to these potentially important therapies.
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Recent research has highlighted the important role of the sphenopalatine ganglion (SPG) in cerebrovascular autonomic physiology and in the pathophysiology of cluster and migraine headaches as well as conditions of stroke and cerebral vasospasm. The relatively accessible location of the SPG within the pterygopalatine fossa and the development of options for minimally invasive approaches to the SPG make it an attractive target for neuromodulation approaches. The obvious advantage of SPG stimulation compared to ablative procedures on the SPG such as radiofrequency destruction and stereotactic radiosurgery is its reversibility and adjustable features. The on-going design of strategies for transient and continuous SPG stimulation on as needed basis using implantable SPG stimulators is an exciting new development which is expected to expand the clinical versatility of this technique.
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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.
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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.