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Content uploaded by T. Goroszeniuk
Author content
All content in this area was uploaded by T. Goroszeniuk on Feb 14, 2020
Content may be subject to copyright.
Content uploaded by T. Goroszeniuk
Author content
All content in this area was uploaded by T. Goroszeniuk on Feb 14, 2020
Content may be subject to copyright.
June 2019 Vol 17 No 2 l Pain News 97
Pain News
2019, Vol 17(2) 97 –100
© The British Pain Society 2019
Informing practice
This is part 2 of a 3-part article on the history, current
practice and future directions of peripheral neuromodulation.
In part 1, we previously covered the theory of peripheral
nerve stimulation.
In part 2, we present the role of peripheral modulation for
specific clinical indications.
Stimulation of nerve plexuses
Brachial plexus stimulation
Neuropathic pain in the upper limb is often difficult to treat
effectively.1 The upper limb is a very good target for
neuromodulation. The peripheral stimulation of the brachial
plexus is not only simpler but also seems to be more effective
compared to SCS, dorsal root ganglion (DRG) stimulation
and deep brain stimulation (DBS).
The first patient who underwent peripheral stimulation of
the brachial plexus had extremely severe neuropathic pain
(10/10) caused by brachial plexus injury; the pain co-occurred
with arm paralysis on the affected side. A preliminary, direct
stimulation of the brachial plexus with low-frequency electric
current (2 Hz) for 5 minutes relieved the pain by 95% for
7 hours.2 Subsequently, the stimulation electrode was inserted
percutaneously into the brachial plexus from posterior access.
Using the electrode in that site, stimulation with electric
current at a frequency from 2 to 10 Hz reduced the pain by
95%, which was similar to the effect of the preliminary
stimulation. Notably, after the treatment with the percutaneous
electrode, allodynia resolved within several hours after the
procedure, and a normal sense of touch returned within
several weeks. The arm function continued to improve slowly
over the next 3 months.2 Currently, insertion of stimulation
electrodes via the medial supraclavicular access under the
guidance of stimulation, ultrasonography or fluoroscopy is the
method of choice.3 This method is effective and much easier
than insertion from the posterior approach. An interesting
variant of the medial approach, which involves ultrasound
guidance, was proposed by Bouche from Nantes, who
successfully gives this treatment to patients who have not
responded to SCS.4 To date, this brachial plexus stimulation
(BPS) has been described in about 50 patients. Preliminary or
trial stimulation, for up to 2–3 weeks, can be performed in
most settings. This stimulation can be achieved with simple,
inexpensive catheters that are typically used for continuous
peripheral anaesthesia. Using brachial plexus
neuromodulation, together with a continuous block to treat
patients with upper limb ischaemia, may be a viable
therapeutic option.5 BPS may be considered as an attractive
alternative method of nerve stimulation in patients with pain of
the upper limb. However, trials to compare the effects of BPS
with those of standard treatment are required.
The following images are of BPS and majority of implants
are for severe neuropathic pain and/or CRPS (Figures 1–3).
Stimulation of the lumbar plexus/paravertebral
stimulation
Stimulation of the lumbar plexus can be beneficial in patients
with intractable pain in the hip and knee joints.
It is relatively simple to insert an electrode percutaneously
into the lumbar plexus from paravertebral access at the L4 level
Peripheral neuromodulation: part 2:
somatosensory, head and facial pain
Teodor Goroszeniuk Interventional Pain Management and Neuromodulation Practice, London, UK
Andrzej Król Department of Anaesthesia and Chronic Pain Service, St George’s University Hospitals NHS Foundation Trust,
London, UK
844951PAN Peripheral Neuromodulation: part 2: somatosensory, head and facial painPeripheral Neuromodulation: part 2: somatosensory, head and facial pain
A doctor demonstrating electrotherapy on a young
woman (from the Wellcome Collection L0012521).
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98 Pain News l June 2019 Vol 17 No 2
Peripheral neuromodulation: part 2: somatosensory, head and facial pain
Informing practice
with continuous diagnostic stimulation (2 Hz) and direct
fluoroscopy or ultrasound guidance. In a small study among
patients with knee pain, stimulation of the lumbar plexus
relieved pain in three quarters of patients, and, in two patients,
pain relief was achieved despite unsuccessful spinal cord
stimulation.6
Paravertebral stimulation at the level of the chest can be a
promising alternative to SCS or DRG stimulation for patients
with unilateral chest pain. Paravertebral stimulation offers good
electrode stability and substantial pain relief. The paravertebral
stimulation is based on the same principle as the standard
techniques of paravertebral anaesthesia.7
Nerve stimulation for headache and facial pain
Of the 15 occipital neuralgia patients of Weiner and Reed,8
eight in fact actually suffered from chronic migraine for which it
also proved successful. It is suggested that occipital nerve
stimulation (ONS) is effective in chronic migraine because the
signals from the trigeminal nerve, dura mater and cervical spinal
nerves converge in the brainstem.9
The activation of the afferent fibres from the caudal portion of
the trigeminal nucleus, at the C2 level, can cause pain in the
trigeminal and cervical distributions. Thus, it is hypothesised
that electrical stimulation modulating the function of occipital
nerves can affect the mechanisms of pain in the areas
innervated by the cervical nerves and the trigeminal nerve.9
The great occipital nerve is a branch of the C2 spinal nerve,
and it is an easy target for stimulation-based treatments. In
patients with chronic migraine who underwent ONS, position
emission tomography (PET) showed increased blood flow in the
areas assumed to mediate pain relief, that is, the posterior
pons, anterior cingulate cortex and cuneus.10
Further series of case reports on the promising effects of
ONS in patients with chronic headaches and migraine
prompted large controlled trials assessing the effectiveness of
this treatment.10–13
A total of 66 patients with drug-resistant migraine were
enrolled in the ONSTIM study assessing the effects of bilateral
ONS. The patients were randomly allocated to receive one of
the three following treatments: variable ONS, fixed ONS and
medical treatment.11 Among the patients who received ONS,
39% responded to the variable ONS, and 6% of patients, to
Figure 2. Brachial plexus stimulation (TG copyright, with
permission).
Figure 3. Brachial plexus stimulation (TG copyright, with
permission).
Figure 1. Brachial plexus neurostimulation trial, mono-
lead. Majority of patients have implants for severe
neuropathic pain and/or CRPS. (TG copyright, with
permission).
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June 2019 Vol 17 No 2 l Pain News 99
Peripheral neuromodulation: part 2: somatosensory, head and facial pain
Informing practice
fixed ONS. Patients who received medications did not
improve.
There may be a large placebo response as indicated in the
PRISM study, when 132 patients were randomly allocated to
undergo either nerve stimulation or sham stimulation.12 The
stimulation was given to patients for 12 weeks. The mean
reduction in the number of days with migraine was 27% in the
patients who received active stimulation, compared to 20% in
those who underwent the sham stimulation, which was not
significant.
In another study, 157 patients with refractory migraine were
randomly allocated to receive either active stimulation or sham
stimulation.13 The results showed there was a significant
difference between the groups that received either active or
sham stimulation in achieving at least a 30% (but not 50%)
reduction of headaches. This difference translated into a
reduction in the number of days with headache by 3 days
during a month and a decrease in the Migraine Disability
Assessment Scale (MIDAS) scores by 44 points.
Cluster headache – ONS
Because the hypothalamus is known to be active during cluster
headaches, it was the target of the first neuromodulation
attempts to treat patients with cluster headaches who did not
respond to medications.14 However, the hypothalamus
stimulation led to complications, and new targets for nerve
stimulation in patients with cluster headaches were tested.15,16
In patients with cluster headaches, PET showed an increased
metabolism in the hypothalamus, pons and midbrain. This
increased metabolism could be reversed by the stimulation of
the occipital nerve.17–21 A randomised, controlled trial comparing
low-frequency and high-frequency paraesthesia is ongoing.22
Cluster headache – stimulation of the
sphenopalatine ganglion
Stimulation of the sphenopalatine ganglion (SPG) is another
neuromodulation target for cluster headache. The SPG lies in
the pterygopalatine fossa, and the post-ganglionic
parasympathetic and sensory fibres originating from the
ganglion run along the blood vessels supplying the face, dura
mater and brain. Initially, blockade and radiofrequency ablation
of the SPG was used to treat patients with cluster headache
who did not improve with standard treatment.23,24 The SPG
was chosen as the target for neuromodulation because, in
animal studies, the electrical stimulation of this ganglion
reversed hypoxia and increased blood flow in the relevant
area.25 A study among 28 patients with chronic cluster
headache resistant to standard treatment tested the effects of
a neurostimulator that was implanted through the mouth, with
the tip of the electrode placed in the pterygopalatine fossa.26
This device was controlled externally via a radiofrequency
transmitter. The treatment with the SPG stimulator alleviated
cluster headaches in 67.1% of patients, and it reduced the
frequency of cluster headaches in 36% of all patients.26 This
improvement in cluster headache symptoms suggests that
stimulation of the SPG is effective during acute episodes of
cluster headache and can be also used in the prophylaxis of
these headaches. Temporary sensory disturbances in the face
were the most common adverse effects of the SPG
stimulation.
Facial pain
Nerve stimulation, in the treatment of patients with facial pain,
involves the stimulation of nerves located in the pain centres
and pathways transmitting pain signals such as the trigeminal
ganglion and its branches.27–29 Clinical indications include
trigeminal neuralgia, post-stroke pain, peripheral nerve injury,
and post-herpetic neuralgia. Interestingly, in a case series, Taub
etal.30 observed that stimulation of the trigeminal ganglion
successfully relieved pain in five of seven patients after stroke,
but it did not improve post-herpetic neuralgia in any patient.
Transcutaneous supraorbital nerve stimulation (tSNS) is
promising, and it may prove to be an effective treatment for
patients with migraine.12,31,32
Acknowledgements
The authors would like to acknowledge that this work is based on
their previous publication Goroszeniuk T and Król A. Peripheral
neuromodulation: An update. Ból 2017: 18(1): 15–27 (The official
journal of Polish Pain Society). T.G. is a developer of ExStim.
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