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Neuromodulation for Headaches—Sphenopalatine Ganglion Stimulation

Introduction The primary headache disorders, migraine and the trigeminal autonomic cephalalgias (TACs), are severely disabling neurologic conditions and constitute a therapeutic challenge. Each of these disorders now has strict and validated criteria for diagnosis, promulgated in the International Classification of Headache Disorders, third edition (ICHD-3), beta version (Headache Classification Committee of the International Headache Society (IHS), 2013). The sphenopalatine ganglion (SPG), also called the pterygopalatine ganglion,…

Occipital Nerve Stimulation for Treatment of Intractable Headache Syndromes

Introduction Occipital nerve stimulation (ONS) has matured significantly over the past 40 years in terms of a better understanding of the indications for its use and implant techniques necessary for a successful outcome. Picaza et al. in reported placing coiled electrodes around dissected exposed occipital nerves, with favorable results in controlling occipital neuralgia pain. Following the publication of initial data and a technique description using percutaneously placed…

Peripheral Nerve Field Stimulation for Intractable Pain

Introduction Peripheral nerve field stimulation (PNfS) is a new and exciting area of neurostimulation. It belongs to the general category of electrical stimulation of the peripheral nervous system. However, instead of stimulating a well-defined nerve trunk, the stimulation is applied to the small terminal branches of one or more peripheral nerves. The target area for stimulation is the subcutaneous tissue, where the small nervous endings of…

Percutaneous Peripheral Nerve Stimulation for the Management of Postoperative Pain

Acknowledgments This work was supported in part by the National Institute on Aging (1R44AG052196-01). The content of this chapter is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging. Postoperative pain is often severe, not easily treated with existing analgesics, which might produce undesirable side-effects, and may increase the risk of persistent (“chronic”) pain lasting…

Combined Spinal Cord Stimulation and Peripheral Nerve Field Stimulation for the Treatment of Chronic Back and Neck Pain

Introduction The concept of using neuromodulation for treatment of chronic axial pain (back and neck) is not new—as a matter of fact, chronic back pain was one of the earliest indications for spinal cord stimulation (SCS) when this modality was introduced into clinical practice in the 1960s ( ). SCS is a popular approach for contemporary pain management, and has been widely used for treatment of…

Peripheral Nerve Stimulation for Facial Pain

Introduction Facial pain is a common condition that affects approximately 10%–25% of the worldwide adult population ( ). It is a serious health problem, and significantly affects the daily functioning of patients. The main types of facial pain are trigeminal neuralgia (TN), trigeminal neuropathic pain (TNP), and persistent idiopathic facial pain ( ). It has been reported that the lifetime prevalence of TN and persistent idiopathic…

Peripheral Nerve Stimulation for Pain Suppression

Disclosures Joseph Boggs, PhD, is an employee of and owns equity in SPR Therapeutics. John Chae, MD, ME, is a consultant to and owns equity in SPR Therapeutics. Maria Bennett, MS, is an employee of and owns equity in SPR Therapeutics. Introduction It is common for electrical stimulation of named peripheral nerves to produce consistently high success rates in achieving pain relief (60%–80%) in well-selected patients…

Anatomy and Physiology Related to Peripheral Nerve Stimulation

The mammalian nerve is comprised of a core or axon surrounded by an axolemma that is contained within a complex sheath which varies in diameter and is either dependent or not on the presence of myelin. Myelinated fibers are made up of many laminae called internodes that, depending on the nerve fiber, are interrupted at variable distances. This myelin sheath is contained within a membrane termed…

A Review of Spinal Cord Stimulation Cost Studies

Introduction General Considerations About Spinal Cord Stimulation Cost Studies A cost-effective therapy is not necessarily the most inexpensive available; rather, cost-effective choices provide clinical benefits that exceed those offered by other therapies and often reduce the consumption of healthcare resources sufficiently to offset and even exceed the cost of the therapy. Because other therapies are available for conditions treated by SCS, clinicians must produce compelling evidence…

Ten Kilohertz (10kHz) High-Frequency Spinal Cord Stimulation

Introduction One of the major technological advancements over recent years in spinal cord stimulation (SCS) therapy comes from the introduction of a novel 10 kHz high-frequency (HF) waveform to treat severe chronic pain with seemingly greater effectiveness than traditional paresthesia-producing SCS, providing broader applicability of this treatment. While traditional low-frequency SCS has been proven as a safe, effective, and cost-effective treatment, wider acceptance of this therapy…

Dorsal Root Ganglion Stimulation for Pain Control

Acknowledgments The author thanks Allison Foster, PhD, an independent medical writer on the author’s staff, for her intellectual contribution to the drafting of the manuscript. Conflict of Interest Statement Dr. Verrills is a shareholder of Clinical Intelligence Pty Ltd., and a peer-to-peer teacher and consultant to both Nevro Corp. and St. Jude Medical Inc. Dorsal Root Ganglion Stimulation: The Intervention The pain management perspective for treating…

Clinical Aspects of Burst Stimulation for Pain Control

Disclosure S. Schu is a consultant for St. Jude Medical Inc. for training and education. T. Vancamp reports no conflict of interest. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Introduction Neuromodulation has gained significant acceptance as…

Complications of Spinal Cord Stimulation

Introduction The use of neurostimulation to change the perception of pain and modulate neural responses has become an important part of the pain treatment continuum. Advocates herald neurostimulation as an important part of this continuum for intractable neuropathic and mixed-pain syndromes. Recent level-one studies have supported this optimistic view, but adverse events subsequent to this therapy must be recognized, addressed, and mitigated when possible. This chapter…

Spinal Cord Stimulation for the Treatment of Low Back Pain

Introduction Since the 1970s, when spinal cord stimulation (SCS) first came into widespread clinical use, its most common application has been management of persistent pain following low back surgery, commonly known as the failed back surgery syndrome (FBSS). It was asserted at that time ( ), and has been accepted previously, that covering the topography of pain with stimulation paresthesia, at subjectively comfortable or tolerable stimulation…

Spinal Cord Stimulation for Peripheral Neuropathic Pain

Overview In Western countries neuromodulation is increasingly used for peripheral neuropathic pain (PNP). To know the indications for neuromodulation therapies and understand how to diagnose PNP disorders, one must be familiar not only with the principles of the techniques, but also with (the basics of) the nervous system and its diseases. Detailed information about the relevant anatomy of the nervous system can be found in Chapter 3…

Neurostimulation for the Treatment of Complex Regional Pain Syndrome

Introduction Much has occurred since the 2009 edition of this book was published. Terms like causalgia, described by Mitchell in 1864 ( ), and reflex sympathetic dystrophy (RSD), coined by , were replaced with the umbrella taxonomy of complex regional pain syndrome (CRPS) by Stanton-Hicks in , and laid the foundation for symptoms and signs that describe this syndrome. CRPS, which embodies Type I and Type…

The Development of Algorithms for Pain Care Including Neuromodulation Therapies: Introducing the SAFE Principles

Introduction Algorithms provide a set of general rules or instructions to solve a specific problem in a particular instance. In contrast to mathematical or engineering algorithms, where a rigid workflow provides a precise prediction, medical algorithms for appropriate interventions for a particular disease need more flexibility to accommodate the needs and perspectives of the physician and patient and incorporate psychosocial constraints, efficacy, and cost considerations (both…

Functional Magnetic Resonance Imaging in the Neuromodulation of Pain

Introduction Physical pain is a leading cause of healthcare spending, work-related disability, and morbidity in the United States ( ). According to a 2008 Medical Expenditure Panel Survey, the direct and indirect costs of chronic pain were found to range from $560 to $635 billion annually ( ). From a neurosurgical perspective, acute and chronic pain are specific indications for surgical intervention for a variety of…

History of Spinal Cord Stimulation

Acknowledgments The authors are grateful for recollections contributed by personal communication with: Donlin M. Long, MD, PhD, retired Director and Professor, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD. Thomas J. Mortimer, PhD, Professor Emeritus of Biomedical Engineering, Case Western Reserve University, Cleveland, OH. Surgical Procedures for Pain Control Surgical procedures for pain control may be considered as falling into one of three…

Management Strategies for Chronic Pain

Introduction The prevalence of chronic pain in the United States is variable; however, the burden is substantial and continues to grow. Chronic pain is defined as pain that lasts longer than 3 months or past the time of normal tissue healing. Most recently, analysis of data from the 2012 National Health Interview Study showed that 11.2% of adults report having daily pain ( ). Pain is…