Terrence L Trentman

Mayo Foundation for Medical Education and Research, Jacksonville, FL, United States

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Publications (42)183.5 Total impact

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    ABSTRACT: To describe use of bilateral temporal and occipital stimulator leads for a refractory headache disorder. A 31-year-old female had a 10-year history of chronic, severe occipital and temporal region headaches. The patient underwent permanent implant of an occipital stimulator system that resulted in sustained, compete resolution of her occipital pain. However, she continued to suffer disabling (10/10) temporal region headaches and was bedbound most days of the week. Therefore, bilateral temporal stimulator leads were implanted and tunneled to her internal pulse generator. At 12-month follow-up, the patient enjoyed sustained improvement in her pain scores (8/10) and marked increase in her level of functioning. Taking into account increased activity level, she rated her overall improvement at 50%. Unfortunately, infection and erosion of her right temporal lead necessitated temporal stimulator removal. Headache disorders may require stimulation of all painful cephalic regions. However, our success in this case must be considered in light of the technical challenges and expense of placing stimulator leads subcutaneously around the head and neck, including the risk of infection, lead breakage, erosion, and migration.
    Medical Devices: Evidence and Research 01/2014; 7:55-9.
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    ABSTRACT: To investigate the sensitivity of MRI of the spine compared with CT myelography (CTM) in detecting CSF leaks. Between July 1998 and October 2010, 12 patients with orthostatic headache and a CTM-confirmed spinal CSF leak underwent an MRI of the spine with and without contrast. Using CTM as the gold standard, we retrospectively investigated the sensitivity of spinal MRI in detecting a CSF leak. Eleven of 12 patients with a CSF leak documented by CTM also had extradural fluid collections on spinal MRI (sensitivity 91.7%). Six patients with extradural fluid collections on spinal MRI also had spinal dural enhancement. When compared with the gold standard of CTM, MRI of the spine appears to be a sensitive and less invasive imaging modality for detecting a spinal CSF leak, suggesting that MRI of the spine should be the imaging modality of first choice for the detection of spinal CSF leaks.
    Neurology 10/2013; · 8.25 Impact Factor
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    ABSTRACT: OBJECTIVES: Patient satisfaction is tied to outcome, but there is scant literature on the relationship of patient perceived outcome and attributes of the pain clinic visit, including the patient interaction with the pain management specialist. The primary purpose of this study is to identify attributes of the patient-provider interaction most strongly associated with patient perceived outcome of their clinic visit. The secondary aim is to correlate patient perceived outcome with patient self-rated overall health. METHODS: A patient satisfaction survey conducted via phone approximately 3 weeks after the patient's pain clinic visit. RESULTS: The response rate was 60.2%; 987 patient surveys collected between 2006 and 2010 were used in the analysis. Four factors were significantly associated with the outcome: (1) Explanations by the physician of the patient's condition and treatment, (2) clear instructions regarding post-appointment activities, (3) knowing the patient as a person, and (4) the patient's self-rated health. In terms of the secondary objective, those who answered very good/excellent regarding their self-rated health had an 87% increased odds of better (very good/excellent) outcome of their pain clinic visit (or 1.87 times the odds of better outcome) compared with those who answered poor/fair/good. CONCLUSIONS: Our results suggest that pain physicians may positively impact patient perceived outcomes of clinic visits by explaining the patient's condition and treatment, providing instructions, and taking the time to understand the patient and their values.
    Pain Practice 05/2013; · 2.61 Impact Factor
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    ABSTRACT: OBJECTIVES: Patient perception of healthcare quality is of growing interest. It has been shown that patient satisfaction is associated with compliance with medical advice and clinical outcome. The 3-fold purpose of this study was to identify which attributes of the patient-physician interaction most strongly correlated with patients' perceptions of provider quality of care, to identify key drivers that move patients' perception of overall provider quality from "very good" to "excellent," and to identify features of the pain clinic experience that were most important to patients but were simultaneously perceived as lacking. METHODS: Randomized patient satisfaction survey conducted via telephone approximately 3 weeks after the patient's pain clinic visit. RESULTS: A total of 999 patients participated in the survey over 5 years (estimated response rate 60.2%). Thoroughness, listening, and time spent with the provider were the 3 attributes most strongly associated with the patients' perceptions of provider quality of care, while thoroughness, listening, punctuality, and clear instructions were the drivers of "very good" vs. "excellent" patient perceived overall provider quality. Areas identified for clinic improvement include thoroughness, providing adequate explanations and instructions, and including patient preferences in decision making. CONCLUSIONS: These results may guide pain clinic physicians as they seek to improve patient perceptions of their care and ultimately patient outcomes.
    Pain Practice 10/2012; · 2.61 Impact Factor
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    ABSTRACT: OBJECTIVE: To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. PATIENTS AND METHODS: A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. RESULTS: The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). CONCLUSION: Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.
    Mayo Clinic Proceedings 10/2012; · 5.79 Impact Factor
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    ABSTRACT: Background:Chronic migraine (CM) is a debilitating neurological disorder with few treatment options. Peripheral nerve stimulation (PNS) of the occipital nerves is a potentially promising therapy for CM patients.Methods:In this randomized, controlled multicenter study, patients diagnosed with CM were implanted with a neurostimulation device near the occipital nerves and randomized 2:1 to active (n = 105) or sham (n = 52) stimulation. The primary endpoint was a difference in the percentage of responders (defined as patients that achieved a ≥50% reduction in mean daily visual analog scale scores) in each group at 12 weeks.Results:There was not a significant difference in the percentage of responders in the Active compared with the Control group (95% lower confidence bound (LCB) of -0.06; p = 0.55). However, there was a significant difference in the percentage of patients that achieved a 30% reduction (p = 0.01). Importantly, compared with sham-treated patients, there were also significant differences in reduction of number of headache days (Active Group = 6.1, baseline = 22.4; Control Group = 3.0, baseline = 20.1; p = 0.008), migraine-related disability (p = 0.001) and direct reports of pain relief (p = 0.001). The most common adverse event was persistent implant site pain.Conclusion:Although this study failed to meet its primary endpoint, this is the first large-scale study of PNS of the occipital nerves in CM patients that showed significant reductions in pain, headache days, and migraine-related disability. Additional controlled studies using endpoints that have recently been identified and accepted as clinically meaningful are warranted in this highly disabled patient population with a large unmet medical need.Trial registration:Clinical trials.gov (NCT00615342).
    Cephalalgia 10/2012; · 3.49 Impact Factor
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    ABSTRACT: The objective of our study was to review the clinical utility of digital subtraction myelography for the diagnosis of spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH) and those with superficial siderosis. Procedure logs from 2007 to 2011 were reviewed to identify cases in which digital subtraction myelography was performed to diagnose spinal CSF leaks. Electronic medical records were reviewed to obtain information regarding diagnosis and outcome. For patients to be included in the study, preprocedural spinal MRI had to show an extradural fluid collection spanning more than one vertebral level and postmyelographic CT had to confirm the presence of an active CSF leak. If digital subtraction myelography successfully showed the site of the CSF leak, the location was documented. Eleven patients (seven men and four women; mean age, 49.0 years) underwent digital subtraction myelography during the study period. Six patients had SIH and five patients had superficial siderosis. The extradural fluid collection on spinal MRI averaged a length of 15.5 vertebral levels. Digital subtraction myelography successfully showed the site of the CSF leak in nine of the 11 patients, and all of the dural tears were located in the thoracic spine between T3 and T11. Digital subtraction myelography is a valuable diagnostic tool for the localization of rapid spinal CSF leaks and should be considered in patients who are clinically suspected to have a dural tear that is accompanied by a longitudinally extensive extradural fluid collection on spinal MRI.
    American Journal of Roentgenology 09/2012; 199(3):649-53. · 2.90 Impact Factor
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    ABSTRACT: Introduction:  Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-term ONS outcomes. Methods:  The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records. Results:  Twenty-nine patients underwent a trial of ONS during the 8.5-year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-eight percent of patients required at least one lead revision. Discussion:  These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. Conclusions:  Randomized controlled long-term studies in specific, intractable, primary headache disorders are indicated.
    Neuromodulation 08/2012; · 1.19 Impact Factor
  • Anesthesiology 05/2012; 117(1):212-5. · 5.16 Impact Factor
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    ABSTRACT: Occipital nerve stimulation can be effective therapy for recalcitrant headache disorders. Lead migration remains the primary technical adverse event associated with this therapy. Revision surgery for occipital nerve stimulator leads sometimes requires exposure of all components including internal pulse generator, extension cables, connectors, and leads with multiple incisions. However, minimizing the invasiveness of revision surgery reduces the time, infection risk, and discomfort associated with the procedure. We describe two techniques that attempt to minimize the extent of revision surgery necessary for lead migration. We describe two minimally invasive revision techniques. One uses a 14-gauge Tuohy needle converted to a slotted needle. The other uses a standard Tuohy needle inserted subcutaneously into the anchor site along the desired course of the lead. Both techniques allow replacement of a migrated occipital nerve stimulator lead while eliminating the need to access connector or battery sites with multiple incisions. Conclusions:  When migration occurs, the techniques described can simplify lead revision while minimizing the invasiveness of the procedure.
    Neuromodulation 12/2011; 15(4):387-91. · 1.19 Impact Factor
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    ABSTRACT: To determine patients' opinions regarding the person, method, and timing for disclosure of postoperative visual loss (POVL) associated with high-risk surgery. On the basis of findings of a pilot study involving 219 patients at Mayo Clinic in Florida, we hypothesized that at least 80% of patients would prefer disclosure of POVL by the surgeon, during a face-to-face discussion, before the day of scheduled surgery. To test the hypothesis, we sent a questionnaire to 437 patients who underwent prolonged prone spinal surgical procedures at Mayo Clinic in Rochester, MN, or Mayo Clinic in Arizona from December 1, 2008, to December 31, 2009. Among the 184 respondents, 158 patients gave responses supporting the hypothesis vs 26 with at least 1 response not supporting it, for an observed incidence of 86%. The 2-sided 95% confidence interval is 80% to 91%. At least 80% of patients prefer full disclosure of the risk of POVL, by the surgeon, during a face-to-face discussion before the day of scheduled surgery. This finding supports development of a national patient-driven guideline for disclosing the risk of POVL before prone spinal surgery.
    Mayo Clinic Proceedings 09/2011; 86(9):865-8. · 5.79 Impact Factor
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    ABSTRACT: Hypotension is common in patients undergoing surgery in the sitting position under general anesthesia, and the risk may be exacerbated by the use of antihypertensive drugs taken preoperatively. The purpose of this study was to compare hypotensive episodes in patients taking antihypertensive medications with normotensive patients during shoulder surgery in the beach chair position. Medical records of all patients undergoing shoulder arthroscopy during a 44-month period were reviewed retrospectively. The primary endpoint was the number of moderate hypotensive episodes (systolic blood pressure ≤ 85 mmHg) during the intraoperative period. Secondary endpoints included the frequency of vasopressor administration, total dose of vasopressors, and fluid administered. Values are expressed as mean (standard deviation). Of 384 patients who underwent shoulder surgery, 185 patients were taking no antihypertensive medication, and 199 were on at least one antihypertensive drug. The antihypertensive medication group had more intraoperative hypotensive episodes [1.7 (2.2) vs 1.2 (1.8); P = 0.01] and vasopressor administrations. Total dose of vasopressors and volume of fluids administered were similar between groups. The timing of the administration of angiotensin-converting enzyme inhibitors and of angiotensin receptor antagonists (≤ 10 hr vs > 10 hr before surgery) had no impact on intraoperative hypotension. Preoperative use of antihypertensive medication was associated with an increased incidence of intraoperative hypotension. Compared with normotensive patients, patients taking antihypertensive drugs preoperatively are expected to require vasopressors more often to maintain normal blood pressure.
    Canadian Anaesthetists? Society Journal 08/2011; 58(11):993-1000. · 2.31 Impact Factor
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    ABSTRACT: Electronic medical records (EMR) may increase the safety and efficiency of healthcare. Anesthesia care is a significant component of the perioperative period, yet little is known about the adoption of anesthesia information management systems (AIMS) by US anesthesiologists, particularly in non-academic settings. Herein, we report the results of a survey of US anesthesiologists regarding adoption of AIMS and anesthesiologist-perceived advantages and barriers to AIMS adoption. Using the e-mail database of the American Society of Anesthesiologists, we solicited randomly selected US anesthesiologists to participate in a survey of their AIMS adoption, perceived advantages and barriers to AIMS. Two and then 3 weeks after the initial mailing, a follow-up e-mail was sent to each anesthesiologist. The study was closed 4 weeks after the initial mailing. Five thousand anesthesiologists were solicited; 615 (12.3%) responses were received. Twenty-four percent of respondents had installed an AIMS, while 13% were either installing a system now or had selected one, and an additional 13% were actively searching. Larger anesthesiology groups with large case loads, urban settings, and government affiliated or academic institutions were more likely to have adopted AIMS. Initial cost was the most frequently cited AIMS barrier. The most commonly cited benefit was more accurate clinical documentation (79%), while unanticipated need for ongoing information technology support (49%) and difficult integration of AIMS with an existing EMR (61%) were the most commonly cited problems. There were no barriers cited significantly more often by non-adopters than adopters. At least 50% of our survey respondents were currently using, installing, planning to install, or searching for an AIMS. However, the strength of any conclusion is undermined by a low survey response rate and potential bias as respondents using or searching for an AIMS may be more likely to participate. Nonetheless, challenges exist for anesthesiologists considering AIMS adoption including cost. Furthermore, important questions remain regarding payment for anesthesia services and the relationship of AIMS and "meaningful use" as defined by the Centers for Medicare & Medicaid Services.
    International Journal of Clinical Monitoring and Computing 04/2011; 25(2):129-35.
  • Terrence L Trentman, Richard S Zimmerman, David W Dodick
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    ABSTRACT: 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. This chapter will review occipital nerve stimulation, including surgical techniques and complications noted in the literature. 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.
    Progress in neurological surgery 01/2011; 24:96-108.
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    ABSTRACT: To investigate sedation and anesthesia trends and practice patterns for procedures in the cardiac electrophysiology laboratory (EPL). A survey distributed by e-mail. US teaching hospitals with a training program in cardiac electrophysiology. Cardiologists involved in procedures in the electrophysiology laboratory of academic electrophysiology programs. A survey was e-mailed to the selected programs. The survey questions included the use of anesthesia professional (MD/CRNA) and nonanesthesia professional (RN) services, medications administered, commonly performed airway interventions, satisfaction with anesthesia services, and reasons that anesthesia professionals are not used when RNs administer sedation. Of the 95 academic electrophysiology programs surveyed, there were 38 responses (40%). The majority (71%) of respondents used a combined model of care with both anesthesia professional care and nonanesthesia professional (RN) sedation, although there were EPLs that had exclusively anesthesia professional (n = 6) and exclusively nonanesthesia professional coverage (n = 5); 26.3% of respondents answered that care by an anesthesia professional was warranted most (>50%) of the time regardless of their current care model. The main reasons cited for having RN-administered sedation were the lack of availability of anesthesia professionals, difficulty with scheduling, and increased operating room suite turnover times. Programs using exclusively RN sedation (13%) reported all levels of anesthesia including general anesthesia (patient unarousable to repeated deep stimulation). This survey suggested that sedation for EPL procedures was sometimes allowed to progress to deep sedation and general anesthesia and that selection of anesthesia provider frequently was made based on availability, operating room efficiency, and economic reasons before patient safety issues. The implications of the survey must be explored further in a larger-scale sample population before more definitive statements can be made, but results suggested that sedation in the EPL is an area that would benefit from updated guidelines specific to the current practice as well as attention from the anesthesia community to address the deficiency in provision of anesthesia care.
    Journal of cardiothoracic and vascular anesthesia 01/2011; 25(4):647-59. · 1.06 Impact Factor
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    ABSTRACT: Chronic cluster headache is a severely disabling neurological disorder. Evidence from open-label case series suggest that occipital nerve stimulation may be effective for the treatment of chronic cluster headache. To evaluate the effectiveness of a microstimulator for chronic cluster headache. Prospective, observational feasibility study plus medical record review. Academic medical center. Four patients with medically refractory chronic cluster headache underwent implantation of a unilateral bion microstimulator. In-person follow-up was conducted for 12 months after implantation, and a prospective follow-up chart review was carried out to assess long term outcome. Three of the participants returned their headache diaries for evaluation. The mean duration of chronic cluster headache was 14.3 years (range 3 to 29 years). Pain was predominantly or exclusively retroocular/periocular. One participant demonstrated a positive response (> 50% reduction in cluster headache frequency) at 3 months post-implant, while there were 2 responders at 6 months. At least one of the participants continued to show > 60% reduction in headache frequency at 12 months. A chart review showed that at 58-67 months post-implant, all 3 participants reported continued use and benefit from stimulation. No side-shift in attacks was noted in any participant. Adverse events were limited to 2 participants with neck pain and/or cramping with stimulation at high amplitudes; one required revision for a faulty battery. Small patient population without control group. Not blinded or randomized. Unilateral occipital nerve stimulation, using a minimally invasive microstimulator, may be effective for the treatment of medically refractory chronic cluster headache. This benefit may occur immediately after implantation, remain sustained up to 5 years after implantation, and occur despite the anterior location of the pain. Prospective, randomized controlled trials of occipital nerve stimulation in chronic cluster headache should proceed.
    Pain physician 01/2011; 14(5):435-40. · 10.72 Impact Factor
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    ABSTRACT: In 2005, the authors' ambulatory surgery center (ASC) was closed, and the breast operations performed there were integrated into the hospital. This change allowed a comparison of perioperative time intervals for patients undergoing these procedures at an outpatient facility versus a hospital. The records of 92 patients who underwent breast operations at the ASC between January 2004 and December 2005 were compared with those of 92 patients who underwent outpatient breast operations at the hospital starting January 2006. Anesthetic techniques, recovery room events, and perioperative time intervals were analyzed. Age and recovery room times were similar. Complications were negligible at both facilities. The preoperative, operating room entry to incision, and total facility time intervals significantly increased when breast cases were moved back to the hospital setting. These data demonstrate significantly shorter perioperative time intervals at the ASC. Incorporating time-saving practices from the outpatient setting could contribute to greater hospital productivity.
    American journal of surgery 07/2010; 200(1):64-7. · 2.36 Impact Factor
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    ABSTRACT: Occipital nerve stimulation is a form of peripheral nerve stimulation used to treat refractory headache disorders. Various techniques have been described for occipital nerve stimulator implantation; these include midline cervical or retromastoid lead insertion with internal pulse generator placement in the infraclavicular, gluteal or low abdominal regions. Lead migration is one of the most common complications of occipital nerve stimulators. Implantation approaches that include remote battery sites may contribute to mechanical stress on the components, as the leads or extensions may traverse highly mobile body regions. In this technical report, we describe an occipital stimulator implantation technique that may be advantageous in terms of patient positioning, ease of surgical approach and minimization of mechanical stress on components.
    Stereotactic and Functional Neurosurgery 02/2010; 88(2):121-5. · 1.46 Impact Factor
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    ABSTRACT: Occipital nerve stimulation is a modality reserved for refractory headache disorders. Leads (wires) are inserted subcutaneously in the occipital region to stimulate the distal C1-3 nerves; lead migration may result from repeated mechanical forces on the lead associated with patient movement. The primary aim of this study was to determine implantation pathways associated with the least pathway length change secondary to body movement in an in vitro model of an occipital stimulator system. After institutional review board approval, 10 volunteers were recruited. The expected pathway of an occipital stimulator system was identified and measured externally, and then changes in pathway length were measured during various volunteer movements, including neck and low back flexion, extension, rotation, and lateral flexion. The pathways studied included those that connect internal pulse generators in the gluteal, low abdominal, and infraclavicular regions to occipital leads inserted via a cervical or retromastoid approach. The flexion/extension pathway length changes associated with midline occipital and retromastoid sites to the infraclavicular site were significantly less than those pathways to the periscapular site. Also, the abdominal site was associated with less pathway length change during flexion/extension than the gluteal site. Internal pulse generators in sites other than the buttock, including infraclavicular or low abdomen, may be associated with lower lead migration risk. There are many considerations when selecting insertion sites and lead pathways for occipital nerve stimulation. Implanters and patients may consider these results when contemplating surgical approaches to this challenging form of peripheral nerve stimulation.
    Pain Practice 10/2009; 10(1):42-8. · 2.61 Impact Factor
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    ABSTRACT: Anesthesiologists support nerve stimulator insertion procedures, including occipital nerve stimulator placement for refractory headache disorders. Sedation during these cases can be challenging on account of variable surgical stimuli and surgery positioning that contribute to neck flexion, potentially compromising the airway. Greater patient comfort and safety may be found in performing permanent occipital stimulator placement procedures entirely under general anesthesia, assuming that appropriate stimulation patterns can be achieved in patients who are unable to provide intraoperative feedback. The purpose of this study is to describe our initial experience with occipital nerve stimulator placement performed entirely under general anesthesia and the resulting stimulation patterns, and to review the medical literature regarding the anesthetic techniques used during these novel neurosurgical procedures. After institutional review board approval, we reviewed the records of 5 patients who underwent permanent occipital nerve stimulator placement under general anesthesia. Appropriateness of the postoperative stimulation patterns was noted in addition to complications. The medical literature was searched for occipital stimulation surgery studies that also described the anesthetic technique. We found that all 5 patients underwent uncomplicated general anesthetics. Postoperative occipital stimulation was nonpainful and symmetrical for all. The literature search provided little information on the anesthetic technique; most procedures were performed at least in part under local anesthesia with sedation. On the basis of this small case series, we conclude that the occipital nerve stimulator systems can be successfully placed under general anesthesia while still achieving the desired occipital region stimulation. Further studies are needed to correlate occipital nerve stimulator placement under general anesthesia and long-term headache control.
    Journal of neurosurgical anesthesiology 10/2009; 22(2):158-62. · 2.41 Impact Factor