Progress in neurological surgery
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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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Peripheral nerve stimulation (PNS) has been used for the treatment of neuropathic pain for more than 40 years. Recent interest in the utilization of this technique stems from the many modifications of the original procedure and the refinement of the available hardware. This rendered the procedure less traumatic and more effective, and thus more widely accepted as a neuromodulation technique for the treatment of various chronic pain syndromes including post-traumatic and postsurgical neuropathy, occipital neuralgia, and complex regional pain syndromes, and in relatively new indications for neuromodulation, such as migraines and daily headaches, cluster headaches. ⋯ We review the protocol of our approach including the surgical nuances for our implantation technique. Collaborative efforts in future research will lead to a growth in our clinical experience with the utilization of PNS and will help in identifying the best candidates for it. This, along with the development and refinement of the available hardware would lead to a more specific patient selection for each modality of treatment, increasing the efficacy and success of the intended treatment.
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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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Although commonly used in clinical practice, peripheral nerve stimulation (PNS) for treatment of chronic pain is performed mainly with devices developed and marketed for spinal cord stimulation applications. This may be one of the reasons why PNS approach is marked by a very high complication rate, as the anatomy of peripheral nerves and the surrounding soft tissues is quite different from epidural spinal space for which the current devices are designed. ⋯ Based on the literature data and the analysis of the author's experience with PNS procedures it appears that although the rate of complications is relatively high, the morbidity associated with PNS approach is very minor and most problems may be resolved with simple re-operations, usually on outpatient basis. The reduction in complication rate is expected to occur when the hardware used in PNS procedures is appropriately adapted for PNS applications.
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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.