Indications
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Peripheral nerve stimulation (PNS) is indicated for patients with chronic, medically refractory, severe neuropathic pain that involves distribution of the nerve to be stimulated.
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Occipital nerve stimulation (ONS) is indicated primarily for treatment of occipital neuralgia, including posttraumatic and postsurgical pain in the occipital nerve distribution.
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Supraorbital nerve stimulation (SNS) is indicated for patients with trigeminal neuropathic pain, mainly secondary to posttraumatic or postsurgical supraorbital neuralgia or neuropathy (e.g., after operations on frontal sinuses, after frontal craniotomies).
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ONS and SNS have been used for treatment of migraines and cluster headaches in research studies.
Contraindications
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PNS is contraindicated in patients with complete sensory loss (e.g., in cases of anesthesia dolorosa).
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Patients with unfavorable psychological evaluation results.
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Patients with anticoagulation or who are receiving antiplatelet therapy.
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Patients with active infection.
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Failed trial of stimulation.
Planning and positioning
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Patients are positioned supine, with attention given to the electrode insertion point, the entire area where the electrode will be located, an anchoring incision, and the generator pocket (for internalization procedures). The entire area is shaved and prepared, and the planned location of electrodes is drawn on the skin with fluoroscopic assistance (i.e., with the C-arm positioned around the patient’s head).
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For ONS implants, a gel roll is placed under the patient’s ipsilateral shoulder, and the patient’s head is turned into the lateral position. The insertion point for the ipsilateral electrode is placed behind the mastoid process, with the goal of reaching the midline with the needle along the radiographic level of the arch of C1. The contralateral electrode is inserted through a small incision at the midline aiming at the contralateral mastoid process; this electrode is tunneled backward so that both electrodes, in case of bilateral insertion, exit behind same ear.
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For supraorbital electrode insertion, the patient may be positioned supine, but the shoulder roll and head turning are needed for the second stage of surgery so that the electrodes may be anchored in the retromastoid region and then tunneled toward the generator pocket.
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A generator pocket for craniofacial PNS is planned in the infraclavicular region with an incision drawn 1 to 2 cm below the clavicle.
Figure 44-1:
Line of incision for anchoring the bilateral ONS electrodes with electrode direction drawn. Note the “X” mark through which temporary electrodes exit the skin during the trial period; it is placed a few centimeters away from the incisions for permanent implantation.
Figure 44-2:
A, Direction for insertion of the right supraorbital nerve stimulation electrode and the right auriculotemporal nerve stimulation electrode. Direction for insertion is from lateral to medial. B, Location of anchoring incision behind the ipsilateral ear. “X” marks indicate exit sites for temporary (trial) electrodes.Related posts:
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