Occipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neuralgia: a pilot study.
ABSTRACT Persistent occipital neuralgia can produce severe headaches that may not be controllable by conservative or surgical approaches. We describe a case series of 6 patients who had chronic headaches over an average of 4.9 yr who underwent occipital nerve electrical stimulation lead implantation using a modified midline approach. The patients had received conservative and surgical therapies in the past including oral antidepressants, membrane stabilizers, opioids, occipital nerve blocks, and radiofrequency ablations. Significant decreases in pain visual analog scale (VAS) scores and drastic improvement in functional capacity were observed during the occipital stimulation trial and during the 3-mo follow-up after implantation. The mean VAS score changed from 8.66 +/- 1.0 to 2.5 +/- 1.3 whereas pain disability index improved from 49.8 +/- 15.9 to 14.0 +/- 7.4. Our midline approach has several advantages compared with the submastoid approach used elsewhere. There is only one small midline incision over the upper neck and the strain on the lead extension occurs only with flexion and is minimal with lateral flexion and rotation, which contributes to overall stability of this system.
Article: A case of occipital neuralgia in the greater and lesser occipital nerves treated with neurectomy by using transcranial Doppler sonography: technical aspects.[show abstract] [hide abstract]
ABSTRACT: Occipital neuralgia is usually defined as paroxysmal stabbing pain in the greater or lesser occipital nerve (GON or LON) distribution. In occipital neuralgia patients, surgical considerations are carefully taken into account if medical management is ineffective. However, identification of the occipital artery by palpation in patients with thick necks or small occipital arteries can be technically difficult. Therefore, we established a new technique using transcranial Doppler (TCD) sonography for more accurate and rapid identification. The patient was a 64-year-old man who had undergone C1-C3 screw fixation and presented with intractable stabbing pain in the bilateral GON and LON distributions. In cases in which pain management was performed using medication, physical therapy, nerve block, or radiofrequency thermocoagulation, substantial pain relief was not consistently achieved, and recurrence of pain was reported. Therefore, we performed occipital neurectomy of the bilateral GON and LON by using TCD sonography, which helped detect the greater occipital artery easily. After the operation, the patient's headache disappeared gradually, although he had discontinued all medication except antidepressants. We believe that this new technique of occipital neurectomy via a small skin incision performed using TCD sonography is easy and reliable, has a short operative time, and provides rapid pain relief.The Korean journal of pain 03/2011; 24(1):48-52.
Article: Occipital nerve stimulation in a patient with an intractable chronic headache -A case report-.[show abstract] [hide abstract]
ABSTRACT: Occipital nerve stimulation (ONS) is a form of peripheral nerve stimulation used to treat refractory headaches. The trial of ONS was carried with the midline incision C1-2 level, inserted electrical lead subcutaneously to oblique and cephalad direction followed by trajectory of blunt dissection. We used 8 pole electrical lead to cover lesser occipital nerve, greater occipital nerve, third occipital nerve and great auricular nerve. We anchored the lead at the midline insertion site after confirming the stimulation of the patient. And then we looped and tightened the lead loosely, connected the lead and the extension under right supraspinatus muscle region. After 1 week trial period, we performed the permanent implantation of occipital nerve stimulator. We inserted internal pulse generator under a pocket located at right infraclavicular region. The VAS score dropped from 8/10 to 1-2/10. No serious complications were detected during 1 month follow-up.Korean journal of anesthesiology 04/2011; 60(4):298-301.
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ABSTRACT: Objectives: Occipital nerve stimulation (ONS) is a peripheral nerve stimulation (PNS) technique that has been used with success in the management of intractable chronic daily headaches (CDHs) and occipital neuralgia (ON). The technique involves the placement of a stimulating surgical or percutaneous electrode over the occipital nerves within the subcutaneous tissues at the skull base. Until recently, procedures involving the occipital nerves were based on identifying bony or arterial landmarks with direct palpation or fluoroscopy. Although universally accepted as an imaging technique, fluoroscopy does not provide real-time imaging of the occipital nerves or vessels. Furthermore, therapeutic efficacy of ONS is directly related to the ability of the stimulating electrode to produce peripheral nerve dermatomal paresthesia, emphasizing the need for precision placement. Materials and Methods: A total of six patients, diagnosed with refractory CDH and ON, after failing extensive medical management, were diagnosed as potential candidates for ONS. Subsequently, all underwent successful percutaneous trials of bilateral octopolar (Advanced Neuromodulation Systems, Plano, TX, USA) ONS under ultrasound guidance, followed by permanent surgical implantation. Results: In this case series, ultrasound provided accurate, real-time placement of introducer needles and stimulating electrodes by allowing visualization of tissue planes (epidermis, dermis, subcutaneous fat, and trapezious muscle), as well as vessels and nervous structures. Conclusions: Ultrasound imaging has been used increasingly for peripheral nerve blockade in surgical anesthesia and in chronic pain management as it allows real-time localization of both nervous and vascular structures (color flow Doppler) and, thus, a method for increasing blockade precision and safety. As an adjunct to ONS, the position of the introducer needles and electrodes can be visualized in relation to the occipital nerves and vasculature. This reproducible positioning allows accurate depth of placement (assuring production of the prerequisite PNS dermatomal paresthesia required for ONS efficacy) and limits the risk of injury to the occipital artery or nerve(s). In this case series, ultrasonography provided real-time, safe, and reliable placement of ONS electrodes. It also allowed identification of nervous and vascular structures unable to be seen with fluoroscopy, The portable nature of modern ultrasound machines, together with an ever improving pixelation of the Doppler color flow images/real-time measurements, and a lack of radiation exposure make this technology an attractive emerging modality in the field of Neuromodulation.Neuromodulation 04/2010; 13(2):126-30. · 1.19 Impact Factor