Progress in neurological surgery
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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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Peripheral nerve stimulation and, recently, peripheral nerve field stimulation are excellent options for the control of extremity pain in instances where conventional methods have failed and surgical treatment is ruled inappropriate. New techniques, ultrasound guidance, smaller generators, and task-specific neuromodulatory hardware and leads result in increasingly safe, stable and efficacious treatment of pain in the extremities. Peripheral nerve stimulation has shown to be an increasingly viable option for many painful conditions with neuropathic and possibly nociceptive origins. This chapter focuses on the historical use of neuromodulation in the extremities, technical tasks associated with implant, selection of candidates, and potential pitfalls of and solutions for implanting devices around the peripheral nervous system for extremity pain.
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Peripheral nerve stimulation (PNS) has been used for the treatment of various neuropathic pain disorders, including occipital neuralgia, for the patients who failed less-invasive therapeutic approaches. Several different mechanisms of pain relief were proposed when PNS is used to treat occipital neuralgia and clinical studies using various types of electrical leads suggested largely positive clinical responses in patients with mostly refractory, severe neuropathic pain. ⋯ Those include patients who experienced repeated migration of cylindrical lead as paddle lead may provide greater stability, who are experiencing unpleasant recruitment of surrounding muscle and/or motor nerve stimulation and for cases where skin erosions were caused by a cylindrical lead. However, disregarding the type of lead used, multiple clinical advantages of this minimally invasive, easily reversible approach include relatively low morbidity and a high treatment efficacy.
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Occipital nerve stimulation may provide pain relief for patients with otherwise refractory primary headache disorders. While this treatment modality remains an off-label use of spinal cord stimulator technology, a growing body of literature documents surgical techniques, stimulation parameters, complications, and outcome of this novel form of neuromodulation. ⋯ A discussion of stimulation parameters used for occipital stimulation will be included. Prospective, blinded studies of occipital nerve stimulation may clarify the role of occipital stimulation in chronic headache management.
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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.