Updated management of occipital nerve stimulator lead migration: case report of a technical challenge.

Electrode migration is a challenge, even with adequate anchoring techniques, due to the high mechanical stress on components of occipital nerve stimulation (ONS) for headache disorders. When a lead displacement of an ONS implant is diagnosed, there are currently different approaches described for its management. Nevertheless current neuromodulation devices are designed like a continuum of components without any intermediate connector, and if a lead displacement is diagnosed, the solution is the complete removal of the electrode from its placement, and its repositioning through an ex-novo procedure. The described technique can allow ONS leads to be revised while minimizing the need to reopen incisions over the IPG, thus improving patients' intraoperative and postoperative discomfort, shortening surgical time and medical costs, reasonably reducing the incidence of infective postoperative complications.

Peripheral nerve field stimulation successfully manages axial pain after posterior cervical spine surgery: case report.

Axial neck and back pain after cervical spinal surgery is a common postoperative complication and can last for years. It is sometimes refractory to conventional treatments such as pharmacotherapy and spinal cord stimulation (SCS). Peripheral nerve field stimulation (PNFS) was recently introduced as an alternative treatment in the management of axial back pain into the occipital/craniofacial region and trunk in occipital neuralgia, post-herpetic neuralgia, and low back pain after lumbar spine surgery. However, PNFS has not been applied to axial neck pain. The patient suffered from occipital neuralgia and axial back pain after cervical spine surgery. In addition to PNFS of the greater occipital nerves for occipital neuralgia, we subcutaneously implanted two electrodes into the bilateral neck regions parallel with a sequential arrangement of the cervical spine. The electrodes were placed immediately above the trapezius muscles and electrical paresthesia was enhanced by posterior neck muscle twitches, fully covering the areas with axial neck pain. Both electrodes successfully achieved an almost 70% decrease in occipital and axial neck pain. Since axial neck pain after cervical spinal surgery often affects patients' health-related quality of life, neuromodulation in the form of PNFS may have the potential to become a novel alternative to conventional pain treatments for medically refractory axial neck pain.

Outcomes of Occipital Nerve Stimulation for Craniofacial Pain Syndromes.

OBJECTIVES: Occipital nerve regional stimulation (ONS) is reported to improve pain in several studies. We examined long-term pain and functional outcomes of ONS in an open-label prospective study. METHODS: Patients with medically refractory and disabling craniofacial pain were prospectively selected for ONS. Primary outcome was a change in mean daily pain intensity on the numeric pain rating scale (NPRS) at 6 months. Secondary outcomes included changes in NPRS, Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), Pain Disability Index (PDI), Center for Epidemiologic Studies Depression Scale - Revised (CESD-R), and Short Form-36 version 2 (SF36) at last follow-up. RESULTS: Thirteen patients (mean age 49.7 ± 8.4) diagnosed with occipital neuralgia (6), hemicrania continua (2), persistent idiopathic facial pain (2), post-traumatic facial pain (1), cluster headache (1), and chronic migraine (1) were enrolled. Mean NPRS improved by 2.1 ± 2.1 at 6 months and 2.1 ± 1.9 at last follow-up (23.5 ± 18.1 months). HIT-6 decreased by 8.7 ± 8.8, MIDAS decreased by 61.3 ± 71.6, and PDI decreased by 17.9 ± 18. SF36 physical functioning, bodily pain, and social functioning improved by 16.4 ± 19.6, 18.0 ± 31.6, and 26.1 ± 37.3, respectively. Moderate to severe headache days (defined as ≥50% of baseline mean NPRS) were reduced by 8.9 ± 10.2 days per month with ONS. CONCLUSION: ONS reduced the long-term NPRS and moderate-severe monthly headache days by 30% and improved functional outcomes and quality of life. A prospective registry for ONS would be helpful in accumulating a larger cohort with longer follow-up in order to improve the use of ONS.

Occipital Nerve Stimulation and Sphenopalatine Ganglion Stimulation for Treatment of Intractable Headache Syndromes.

Headaches are an increasing cause of disability in the world. Intractable headache syndromes affect all age groups but predominantly the middle-aged, working population. Occipital neuralgia is a frequent comorbidity with intractable migraine headaches. Occipital nerve stimulation at the level of nuchal ridge is a reasonable option for these refractory patients. Ultrasound guidance of occipital nerve stimulation can optimize depth placement of leads. Revision surgeries of occipital nerve stimulation are usually performed using surgical leads. Cluster headaches and trigeminal autonomic cephalagias (TACs) are refractory headache conditions that are mediated by sphenopalatine ganglion. Sphenopalatine ganglion stimulation with infrazygomatic approach and fluoroscopic guidance of percutaneous leads can help alleviate pain from cluster headaches and TACs. Innovation in neurostimulation technologies have brought new optimism to these refractory conditions. Efficient and optimal delivery of neurostimulation for intractable headache syndromes requires a multidisciplinary team-based approach for long term compliance and efficacy.

Craniofacial neuralgias.

While non-headache, non-oral craniofacial neuralgia is relatively rare in incidence and prevalence, it can result in debilitating pain. Understanding the relevant anatomy of peripheral branches of nerves, natural history, clinical presentation, and management strategies will help the clinician better diagnose and treat craniofacial neuralgias. This article will review the nerves responsible for neuropathic pain in periorbital, periauricular, and occipital regions, distinct from idiopathic trigeminal neuralgia. The infratrochlear, supratrochlear, supraorbital, lacrimal, and infraorbital nerves mediate periorbital neuralgia. Periauricular neuralgia may involve the auriculotemporal nerve, the great auricular nerve, and the nervus intermedius. The greater occipital nerve, lesser occipital nerve, and third occipital nerve transmit occipital neuralgias. A wide range of treatment options exist, from modalities to surgery, and the evidence behind each is reviewed.

Peripheral Nerve Stimulation for Occipital Neuralgia.

BACKGROUND: Chronic headaches are the second most prevalent disease and second most common cause for years lived with disability worldwide. Occipital neuralgia can cause headaches or be present in addition to other more prevalent causes of headache. If these headaches fail to respond to conservative and pharmacological therapy, physicians proceed to more invasive treatments, starting with infiltration of the greater occipital nerve with local anesthetic with or without corticosteroids, followed by nerve ablation or stimulation. Occipital nerve stimulation gained more popularity as the technology improved and more pain physicians received training on interventional procedures. METHODS: In this manuscript, we are presenting our experience with ultrasound-guided implant of occipital nerve stimulators using peripheral nerve stimulator systems. After confirming appropriateness of treatment by a successful occipital nerve block (i.e., resulting in >50% relief in patients' pain intensity), we implanted five stimulator systems in three patients (two bilateral). RESULTS: We followed these patients for an average of eight months, and the average pain reduction was ∼50%. We did not observe any adverse events during or immediately after surgery. One patient developed an adverse reaction to the adhesive of the battery transmitter, but it was not severe enough to stop her from using the stimulator. CONCLUSIONS: Considering the ease of implant and minimal side effects, implant of peripheral nerve stimulators to stimulate the occipital nerve is a promising treatment modality for patients with chronic headache who present with features of occipital neuralgia. However, wider use of this treatment modality is subject to further studies.

The effects of acupuncture on occipital neuralgia: a systematic review and meta-analysis.

BACKGROUND: Occipital neuralgia is one of the main causes of occipital pain. This systematic review aims to assess the level of evidence in randomized controlled trials (RCTs) on the effects of acupuncture on occipital neuralgia. METHODS: We searched 11 databases and a journal archive from their inception up to December 2019 for relevant RCTs. We did not place any specific restrictions on patients diagnosed with occipital neuralgia, such as age or gender. We included studies that used an acupuncture intervention group, with or without the control group treatment, and that set a control group receiving active, interventional treatment such as medication. For outcomes, we used visual analogue scale (VAS) and effective rate. RESULTS: We included a total of 11 RCTs. All VAS scores (mean difference [MD] -2.35, 95% confidence interval [CI] -2.84, - 1.86) and effective rate values (odds ratio [OR] 4.96, 95% CI 2.24, 10.96) showed significant differences in effect between acupuncture treatment alone and the control group treatment. Similarly, combined acupuncture treatment with control group treatment also showed significant effects in effective rate (OR 6.68, 95% CI 1.11, 40.37). We performed a subgroup analysis on studies that used acupuncture only as the intervention and reported the effective rate, and found that all acupuncture subgroups showed significant effects compared to the control group treatments. None of the studies reported severe adverse effects. CONCLUSIONS: Although acupuncture only and combined acupuncture treatments showed significant effects compared to medication, the results of this study are inconclusive. Studies with rigorous study design and larger sample sizes are needed to confirm the role of acupuncture in this field. TRIAL REGISTRATION: International prospective register for systematic review (PROSPERO) number CRD42019128050.

Occipital Neuralgia Treated With Acupuncture: A Case Report.

We present a case report of a patient whose occipital neuralgia symptoms were substantially improved after a single acupuncture treatment with complete resolution after only a short course of care. The patient, a 78-year-old woman, presented to our institution's neurology department with symptoms of posterior neck pain and electrical sensations in her head which had been present for more than 1 year. With a desire to avoid pharmacologic intervention or invasive procedures, the patient requested acupuncture treatment. The patient received 5 acupuncture treatments over the course of 8 days with substantial resolution of her head pain after a single treatment. This case is suggestive that acupuncture may be a beneficial treatment for patients with occipital neuralgia.

Occipital Nerve Stimulation.

Although the first publications on clinical use of peripheral nerve stimulation for the treatment of chronic pain came out in the mid-1960s, it took 10 years before this approach was used to stimulate the occipital nerves. The future for occipital nerve stimulation is likely to bring new indications, devices, stimulation paradigms, and a decrease in invasiveness. As experience increases, one may expect that occipital nerve stimulation will eventually gain regulatory approval for more indications, most likely for occipital neuralgia, migraines and cluster headaches. This process may require additional studies, at least for approval from the US Food and Drug Administration.

[Treatment of Occipital Neuralgia by Electroacupuncture Combined with Neural Mobilization].

OBJECTIVE: To observe the effect of electroacupuncture (EA) combined with neural mobilization (NM) in the treatment of occipital neuralgia. METHODS: A total of 62 occipital neuralgia patients were randomized into EA group (19 cases), NM group (22 cases) and EA＋NM group (21 cases). EA was applied at acupoint-pairs as Yuzhen (BL 9)- Tianzhu (BL 10), Fengchi (GB 20)- Wangu (GB 12), etc. NM intervention consisted of occipital muscle group mobilization, C2 spinous process mobilization, cervical joint passive movement management mobilization, etc., was performed at the impaired cervical spine segment. The two methods were used in combination for patients in the EA＋NM group. All the treatment was given once a day for 2 weeks. Before and after treatment, the visual analogue scale (VAS) and the 6-point (1－6 points) behavioral rating scale (BRS-6) of headache were used to assess the severity of pain. The therapeutic effect was evaluated according to the "Criteria for Diagnosis and Cure-Improvement of Clinical Conditions" formulated by State Administration of Traditional Chinese Medicine of the People's Republic of China in 1994. RESULTS: After treatment, both VAS and BRS-6 scores were significantly lower than those before treatment in each of the three groups (P<0.05), and were significantly lower in the EA＋NM group than in the simple EA and simple NM groups (P<0.01,P<0.05). The total effective rates were 78.95% (15/19) in the EA group, 68.18% (15/22) in the NM group, and 90.48% (19/21) in the EA＋NM group, with an obviously better therapeutic effect being in the EA＋NM group relevant to each of the other two treatment groups (P<0.05). CONCLUSION: EA, NM and EA combined with NM can improve symptoms of patients with occipital neuralgia, and EA＋NM has a synergic analgesic effect for occipital neuralgia.

Treatment of Occipital Neuralgia by Electroacupuncture Combined with Neural Mobilization / 针刺研究

OBJECTIVE: To observe the effect of electroacupuncture (EA) combined with neural mobilization (NM) in the treatment of occipital neuralgia. METHODS: A total of 62 occipital neuralgia patients were randomized into EA group (19 cases), NM group (22 cases) and EA＋NM group (21 cases). EA was applied at acupoint-pairs as Yuzhen (BL 9)- Tianzhu (BL 10), Fengchi (GB 20)- Wangu (GB 12), etc. NM intervention consisted of occipital muscle group mobilization, C2 spinous process mobilization, cervical joint passive movement management mobilization, etc., was performed at the impaired cervical spine segment. The two methods were used in combination for patients in the EA＋NM group. All the treatment was given once a day for 2 weeks. Before and after treatment, the visual analogue scale (VAS) and the 6-point (1－6 points) behavioral rating scale (BRS-6) of headache were used to assess the severity of pain. The therapeutic effect was evaluated according to the "Criteria for Diagnosis and Cure-Improvement of Clinical Conditions" formulated by State Administration of Traditional Chinese Medicine of the People's Republic of China in 1994. RESULTS: After treatment, both VAS and BRS-6 scores were significantly lower than those before treatment in each of the three groups (P<0.05), and were significantly lower in the EA＋NM group than in the simple EA and simple NM groups (P<0.01,P<0.05). The total effective rates were 78.95% (15/19) in the EA group, 68.18% (15/22) in the NM group, and 90.48% (19/21) in the EA＋NM group, with an obviously better therapeutic effect being in the EA＋NM group relevant to each of the other two treatment groups (P<0.05). CONCLUSION: EA, NM and EA combined with NM can improve symptoms of patients with occipital neuralgia, and EA＋NM has a synergic analgesic effect for occipital neuralgia.

Retrospective study to identify trigeminal-cervical ocular referred pain as a new causative entity of ocular pain.

PURPOSE: To determine the prevalence and clinical characteristics of trigeminal-cervical (TC) ocular referred pain. METHODS: A retrospective study of 1,680 patients seen during 2002-2010 was performed in an ocular surface specialty center to identify patients with or without TC pain defined as ocular pain with ipsilateral trigger points located at the occipital region. Patients with refractory TC pain despite topical anesthetics and conventional treatments received interventional injection to each trigger point. RESULTS: A total of 81 (4.8%) patients (study group) with TC pain and 241 patients (control group) without TC pain were identified out of the 1,680 patients over an 8 year period. There was no difference in age, gender, prior surgeries, medications, non-pain symptoms, pain laterality, and concomitant ocular diseases between the 2 groups. Multivariate regression analysis showed that patients with TC pain had a significant correlation with persistent deep ocular pain, ipsilateral trigger points (f2=99, p<0.001) but not headaches (f2=0.09, p=0.5). Injection at the trigger points achieved complete or partial pain resolution with a low recurrence rate in 43 of 45 (96%) patients with TC pain. CONCLUSION: TC pain defined herein may be a different entity of ocular pain and can indeed be differentiated from other ocular pain by the referral character so that one may avoid mislabeling it as undetermined or as a reason to unnecessarily overtreat concomitant ocular diseases.

Occipital Nerve Stimulation for the Treatment of Refractory Occipital Neuralgia: A Case Series.

BACKGROUND: Occipital neuralgia is a chronic pain syndrome characterized by sharp, shooting pains in the distribution of the occipital nerves. Although relatively rare, it associated with extremely debilitating symptoms that drastically affect a patient's quality of life. Furthermore, it is extremely difficult to treat as the symptoms are refractory to traditional treatments, including pharmacologic and procedural interventions. A few previous case studies have established the use of a neurostimulation of the occipital nerves to treat occipital neuralgia. OBJECTIVE: The following expands on that literature by retrospectively reviewing the results of occipital nerve stimulation in a relatively large patient cohort (29 patients). METHODS: A retrospective review of 29 patients undergoing occipital nerve stimulation for occipital neuralgia from 2012 to 2017 at a single institution with a single neurosurgeon. RESULTS: Of those 29 patients, 5 were repair or replacement of previous systems, 4 did not have benefit from trial stimulation, and 20 saw benefit to their trial stage of stimulation and went on to full implantation. Of those 20 patients, even with a history of failed procedures and pharmacological therapies, there was an overall success rate of 85%. The average preoperative 10-point pain score dropped from 7.4 ± 1.7 to a postoperative score of 2.9 ± 1.7. However, as with any peripheral nerve stimulation procedure, there were complications (4 patients), including infection, hardware erosion, loss of effect, and lead migration, which required revision or system removal. CONCLUSION: Despite complications, the results suggest, overall, that occipital nerve stimulation is a safe and effective procedure for refractory occipital neuralgia and should be in the neurosurgical repertoire for occipital neuralgia treatment.

Observations on the Efficacy of Xi-Cleft Point Acupuncture plus Surrounding Electroacupuncture in Treating Occipital Neuralgia / 上海针灸杂志

Objective To investigate the clinical efficacy of Xi-Cleft point acupuncture plus surrounding electro- acupuncture in treating occipital neuralgia.Methods Forty-eight patients with occipital neuralgia were randomly allocated to treatment and control groups, 24 cases each. The treatment group received Xi-Cleft point acupuncture plus surrounding electroacupuncture and the control group, surrounding electroacupuncture alone. The VAS score was recorded in the two groups before and after treatment. The clinical therapeutic effects were compared between the two groups.Results There was a statistically significant pre-/post-treatment difference in the VAS score in the two groups (P<0.05). There was a statistically significant post-treatment difference in the VAS score between the treatment and control groups (P<0.05). The total efficacy rate was 95.8% in the treatment group and 83.3% in the control group; there was a statistically significant difference between the two groups (P<0.05).Conclusion Xi-Cleft point acupuncture plus surrounding electroacupuncture is an effective way to treat occipital neuralgia.

A good preoperative response to transcutaneous electrical nerve stimulation predicts a better therapeutic effect of implanted occipital nerve stimulation in pharmacologically intractable headaches.

Occipital nerve stimulation (ONS) is a surgical approach to treat patients with medically intractable chronic headache disorders. However, no preoperative test has been yet validated to allow candidates to be selected for implantation. In this study, the analgesic efficacy of transcutaneous electrical nerve stimulation (TENS) was tested for 1 to 3 months in 41 patients with pharmacologically intractable headache disorders of various origins, using a new technique of electrode placement over the occipital nerve. ONS electrodes were subsequently implanted in 33 patients (occipital neuralgia [n=15], cervicogenic headache [n=7], cluster headache [n=6], chronic migraine [n=5]) who had responded at least moderately to TENS. Assessment was performed up to five years after implantation (three years on average), based on the mean and maximum daily pain intensity scored on a 0-10 visual analogue scale and the number of headache days per month. Both TENS and chronic ONS therapy were found to be efficacious (57-76% improvement compared to baseline on the various clinical variables). The efficacy of ONS was better in cases of good or very good preoperative response to TENS than in cases of moderate response to TENS. Implanted ONS may be a valuable therapeutic option in the long term for patients with pharmacologically intractable chronic headache. Although we cannot conclude in patients with poor or no response to TENS, a good or very good response to TENS can support the indication of ONS therapy. This preoperative test could particularly be useful in patients with chronic migraine, in whom it may be difficult to indicate an invasive technique of cranial neurostimulation.

Improvement in clinical outcomes after dry needling in a patient with occipital neuralgia.

The primary purpose of this case report is to outline the diagnosis, intervention and clinical outcome of a patient presenting with occipital neuralgia. Upon initial presentation, the patient described a four-year history of stabbing neck pain and headaches. After providing informed consent, the patient underwent a total of four dry needling (DN) sessions over a two-week duration. During each of the treatment sessions, needles were inserted into the trapezii and suboccipital muscles. Post-intervention, the patient reported a 32-point change in her neck disability index score along with a 28-point change in her headache disability index score. Thus, it appears that subsequent four sessions of DN over two weeks, our patient experienced meaningful improvement in her neck pain and headaches. To the best of our knowledge, this is the first case report describing DN to successfully improve clinical outcomes in a patient diagnosed with occipital neuralgia.

L'objectif principal de cet exposé de cas est de souligner le diagnostic, l'intervention et le résultat clinique d'un patient souffrant de névralgie cervico-occipitale. Lors de la présentation initiale, la patiente a décrit des antécédents de douleur aiguë dans le cou et de céphalées pendant quatre ans. Après avoir fourni le consentement éclairé, la patiente a subi un total de quatre séances de piqûres sèches sur une période de deux semaines. Au cours de chaque séance de traitement, des aiguilles lui ont été insérées dans le trapèze et les muscles sousoccipitaux. Après l'intervention, la patiente a signalé un changement de 32 points à l'index d'incapacité cervicale avec un changement de 28 points à l'index d'incapacité liée aux céphalées. Par conséquent, il semble qu'à la suite des quatre séances de piqûres sèches réparties sur deux semaines, notre patiente a connu une amélioration remarquable concernant ses douleurs cervicales et ses céphalées. À notre connaissance, il s'agit du premier exposé de cas décrivant des piqûres sèches qui améliorent avec succès les résultats cliniques chez un patient ayant reçu un diagnostic de névralgie cervico-occipitale.

Neurostimulation for neck pain and headache.

Patients with medically refractory headache disorders are a rare and challenging-to-treat group. The introduction of peripheral neurostimulation (PNS) has offered a new avenue of treatment for patients who are appropriate surgical candidates. The utility of PNS for headache management is actively debated. Preliminary reports suggested that 60-80% of patients with chronic headache who have failed maximum medical therapy respond to PNS. However, complications rates for PNS are high. Recent publication of 2 large randomized clinical trials with conflicting results has underscored the need for further research and careful patient counseling. In this review, we summarize the current evidence for PNS in treatment of chronic migraine, trigeminal autonomic cephalagias and occipital neuralgia, and other secondary headache disorders.

Peripheral nerve/field stimulation for neuropathic pain.

Peripheral nerve stimulation and peripheral nerve field stimulation are emerging as a viable neuromodulatory therapy in the treatment of refractory pain. Although the technology of percutaneous stimulation has been available for decades, recent advancements have broadened the number of indications. Success of treatment revolves around identifying the correct patient population, and the selection and placement of the appropriate electrodes and implantable pulse generators. Most results to date have come from case reports and retrospective studies. However, given the promising outcomes in reducing otherwise medically refractory pain, future randomized controlled studies are needed to assess this emerging technology.

Novel use of narrow paddle electrodes for occipital nerve stimulation--technical note.

OBJECTIVES: Occipital nerve stimulation (ONS), an established treatment for medically intractable headache syndromes, has lead migration rates quoted up to 24%. In a series of patients with ideal characteristics for this treatment modality, we describe an operative technique for ONS involving the novel use of narrow paddle electrodes: "S8 Lamitrode" (St. Jude Medical [SJM], St. Paul, MN, USA). MATERIALS AND METHODS: Five patients (occipital neuralgia [ON] = 4; chronic migraine [CM] = 1) were treated with ONS between 2010 and 2011. All patients had a successful trial of peripheral neurostimulation (Algotec Ltd, Crawley, UK) therapy. Operative technique involved the use of a park-bench position, allowing simultaneous exposure of the occipital and infraclavicular regions. Through a retromastoid/occipital incision just beneath the external occipital protruberance, exposing the extrafascial plane, the S8 Lamitrode is implanted to intersect both greater occipital nerves for bilateral pain or unilateral greater and lesser occipital nerves for unilateral ON or with significant component of the pain relating to the lesser occipital nerve. RESULTS: Over the median follow-up of 12 months, there were no episodes of lead migration or revision. There also was significant improvement in symptoms in all patients. CONCLUSIONS: This is the first reported use of S8 Lamitrode electrode for ONS. This narrow electrode is suited for this role leading to minimal trauma during surgical placement, facilitates resolution of problems with lead migration, and optimizes effect with stimulation focused more in direction of the occipital nerves without skin involvement. To date, the SJM Genesis neurostimulation system, with percutaneous electrodes only, is CE mark approved in Europe for peripheral nerve stimulation of the occipital nerves for the management of pain and disability for patients diagnosed with intractable CM. Further developments and studies are required for better devices to suit ONS, thereby avoiding frequently encountered problems and which may clarify the role of paddle leads in ONS.