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Brachial Plexus

Introduction The rapidly expanding field of peripheral nerve stimulation (PNS) brings with it a tremendous, but still evolving, potential for treating chronic upper extremity neuropathic pain that is often refractory to standard therapies and results in significant suffering and impaired quality of life. The brachial plexus arises from the anterior rami of C5 to T1, located in the anterior neck, and supplies both motor and sensory…

Axillary and Suprascapular Nerves

Introduction The limited osseous stability of the shoulder allows for its extensive range of motion but makes the strength of the joint largely dependent on the musculotendinous rotator cuff. The complexity of the ligaments, tendons, and cartilaginous tissue that provide structural support for the shoulder, compensating for the shallowness of the glenoid fossa, creates a great deal of technical difficulty when considering the medical and surgical…

Trigeminal Nerve Peripheral Nerve Stimulation

Introduction Trigeminal neuropathic pain (TNP) is a commonly encountered condition that involves patients of all demographic backgrounds and presents a major burden to patients, their families, treating physicians, and society as a whole. Arising from dysfunction of trigeminal sensory system, TNP differs from trigeminal neuralgia (TN) in both causation and clinical presentation. Whereas TN is frequently caused by vascular compression of the trigeminal nerve root by…

Occipital Nerve Stimulation

Introduction Primary headache disorders are classified mainly as migraine, tension-type headaches, and the trigeminal autonomic cephalgias, which include cluster headaches. “Primary” refers to a lack of clear underlying causative pathology, trauma, or systemic disease. Secondary headaches are usually associated with an underlying abnormality such as, but not limited to, infection, trauma, tumor, or nerve root compression. It is important to correctly diagnose the headache etiology in…

Peripheral Nerve Stimulation Education and Psychological Evaluation

Introduction Peripheral nerve stimulation (PNS) involves placing a small electrical device proximal to peripheral nerves. Prior to proceeding with a PNS trial, it is imperative that the patient receive proper education regarding the device, expectations, and complications, in addition to a thorough psychological evaluation. It is essential to properly select patients who will have the best chance for a successful outcome. This chapter will focus on…

Surgical Techniques For Peripheral Nerve Stimulation

Preoperative Considerations Preoperative work-up for peripheral nerve stimulation (PNS) is similar to that for other advanced implantable procedures such as spinal cord stimulation (SCS). This includes an informed consent discussion with the patient about the different treatment options (including device selection), as well as the long-term consequences of the device itself (i.e., need to charge, use skin electrodes, can/cannot have magnetic resonance imaging [MRI], etc.). From…

Surgical Tools For Peripheral Nerve Stimulation

Peripheral Nerve Stimulator Configurations Peripheral nerves can be nonspecifically and specifically targeted for neuromodulation via a variety of configurations. These range from transcutaneous stimulation to partially implanted systems, to fully implanted electrode/receivers with external generators, to fully implanted electrodes and generators ( Fig. 5.1 ). In general, the more invasive approaches are more durable and require a procedure suite with the option for anesthesia, surgical antisepsis,…

Ultrasound Versus Fluoroscopy

Introduction Peripheral nerve stimulation has been around since the early 1960s. These early stimulators were placed under direct visualization during an open surgical procedure. While the results were promising, the obvious disadvantages of having to place stimulators with open surgery prevented much further growth of the field until percutaneous placements began. Consequently, the first percutaneous placement of a peripheral nerve stimulator (PNS) did not take place…

Mechanism of Action of Peripheral Nerve Stimulation

Introduction The underlying mechanism of peripheral nerve stimulation (PNS) has always been thought to be an extension of the “Gate Theory of Pain,” traditional spinal cord stimulation (SCS) applied to peripheral nerves. While this theory may still hold true, recent studies have shown that the Gate Theory alone cannot solely explain the principles behind PNS. Gate Theory A thorough discussion of neuromodulation first requires an understanding…

Peripheral Nerve Entrapments

Introduction There are many poorly recognized or misrecognized peripheral nerve entrapments associated with clinical pain syndromes. Kopell and Thompson stated that peripheral nerve entrapments occur at anatomic sites where the nerve changes direction to enter a fibrous or fibroosseous tunnel, or where the nerve passes over a fibrous or muscular band, and that entrapment occurs at these sites because mechanically induced irritation is most likely to…

History of Peripheral Nerve Stimulation for Pain

Introduction For more than 5000 years, electrical stimulation has been used to treat pain, among other medical conditions. The King Narmer papyrus from 3100 BC describes the use of the Nile catfish, which has a bioelectric generator, for pain control, and Scribonius Largus reported using the torpedo fish in the first century AD. Methods of generating electricity artificially were developed in the 17th and 18th centuries,…

Gaining and Keeping C-Suite Support for Perioperative Quality Improvement Initiatives

Key Points Understanding the chief executive officer (CEO) mindset and what they worry about helps teams frame performance improvement initiatives in ways that will resonate. Proposed quality improvement projects should ideally have direct ties to an organization's strategic plan or key strategic initiatives. Teams should be candid about “known unknowns” and have plans in place for addressing them. Successful projects include timelines, with milestones and data,…

Environmental Sustainability and Perioperative Quality Improvement

Key Points Sustainable quality improvement (QI) aims to deliver care that maximizes positive health outcomes through best use of environmental, social, and financial resources. Average global temperatures on earth are rising because of human activity. The US healthcare industry produces 8% to 10% of US greenhouse gases, at a rate of 1.51 tCO 2 /capita, which is about twice as high as other nations with advanced…

Certified Registered Nurse Anesthetists and Perioperative Medicine

Key Points Certified registered nurse anesthetists (CRNAs) are well positioned within the perioperative care model to provide high-quality care throughout the surgical continuum. Many areas of practice within the profession of nurse anesthesia, including background, training, and personal care delivery, align with the delivery needs of perioperative medicine. The CRNA's perspective enables them to be effective leaders, champions, and active participants in the organization, planning, and…

Nursing and Perioperative Quality Improvement

Key Points Evidence-based medicine, quality improvement (QI), and clinical research are three cornerstones of perioperative nursing. Nurse education and empowerment is crucial to ensure best practice. Multidisciplinary teamwork is essential for optimal patient care. Communication is key among all perioperative clinicians to ensure safe and patient-centered care. Nurses are central to ensuring personalization of perioperative care. You’re Reading a Preview Become a Clinical Tree membership for…

Provider Resilience and Caring for the Carer

Key Points Resilience is needed, both individually and for an organization. To improve staff resilience, promote a culture of wellness in the organization and include executive buy-in. Developing data on risk of burnout in staff, using validated inventories, can help. A community that enhances support networks is vital. Self-awareness and mindfulness training should be provided to all healthcare workers. Background The term resilience can be defined…

A Case Study: National Emergency Laparotomy Audit

Key Points The National Emergency Laparotomy Audit (NELA) collects perioperative data on patients undergoing emergency bowel surgery (emergency laparotomy) from 179 hospitals across England and Wales (2020 figures). Data are used nationally, providing real time hospital-level benchmarked performance reports and informing quality improvement programs. Outcomes after emergency laparotomy have improved annually since the inception of the audit in 2012. Introduction Approximately 30,000 emergency laparotomies are performed…

Orthopedics and Regional Anesthesia: An Outpatient Total Shoulder Replacement Pathway

Key Points A multidisciplinary group convened to create a standardized protocol for outpatient total shoulder replacement based on available evidence. The use of regional anesthesia and analgesia provides superior postoperative analgesia for total shoulder replacement (TSR) compared with general anesthesia and systemic opioids. By standardizing preoperative, intraoperative, and postoperative management, we aimed for a reduction in variability in clinical care with an initial goal of 60%…

Cardiovascular Disease: Preoperative Testing and Evaluation for Noncardiac Surgery

Key Points More older patients with multiple cardiovascular comorbidities, previous surgery, and other diseases associated with aging are presenting for major surgery. Cardiac risk stratification is key to advise the patient on the risks and benefits of surgery and inform discussions with the operative team about the optimal location and timing of surgery or to consider options other than surgery. Preoperative electrocardiogram (ECG) is unnecessary for…