Trigeminal and Occipital Peripheral Nerve Stimulation for Craniofacial Pain: A Single-institution Experience and Review of the Literature

Konstantin V. Slavin, MD; M. Efkan Colpan, MD; Naureen Munawar, MD; Christian Wess, MD; Hrachya Nersesyan, MD, PhD

Disclosures

Neurosurg Focus. 2006;21(6) 

In This Article

Summary and Introduction

Summary

Object: Treatment of chronic neuropathic pain in the region of the head and face presents a challenge for pain specialists; patients who do not respond to conventional treatment modalities usually continue to suffer from pain due to the lack of reliable medical and surgical approaches. Peripheral nerve stimulation (PNS) has been used to treat neuropathic pain for many decades, but only recently has it been applied systematically to the craniofacial region. To advance the study of this treatment option, the authors present their initial experience with this approach, summarize published data on the use of PNS in treatment of craniofacial pain, and discuss some technical details of the craniofacial PNS procedure.
Methods: A review of prospectively collected data in 30 patients who underwent PNS surgery for craniofacial pain was performed. The pain location, duration, cause, and previous treatments were analyzed, along with the surgical details, initial and long-term results, complications, and repeated operations.
Stimulated nerves in this group included supraorbital (seven patients), infraorbital (six), and occipital (21); in 19 patients more than one nerve was stimulated. Twenty-two patients proceeded with implantation of a permanent system after the trial. Of these, at the time of the latest evaluation (mean follow-up duration 35 months), in two patients the devices had been removed because of pain improvement over time, in three the devices were removed due to loss of effectiveness (two cases) or late infection (one), and the rest are enjoying either complete (15 patients) or partial (two patients) pain relief. Three patients underwent repeated operation due to lead erosion, infection, or migration.
Conclusions: Peripheral nerve stimulation appears to be a safe and effective approach in the treatment of craniofacial neuropathic pain. The growing body of literature supports a wider acceptance of this approach in the field of pain surgery.

Introduction

The idea of using PNS to treat craniofacial pain is not new. The interest in this modality has been increasing over the last few years, but the original applications date back to the 1960s. When Wall and Sweet[19] tried to find a new approach to suppress neuropathic pain, they inserted an electrode into their own infraorbital foramina and obtained a decrease in pain perception during the entire episode of electrical stimulation.[23] Moreover, in the first article dedicated to the idea of PNS with implantable devices (even before spinal cord stimulation was introduced),[19] one of the eight patients with neuropathic pain presented with severe facial pain, and in this patient an electrode was inserted deep into the infraorbital foramen. The stimulation resulted in lasting pain suppression as long as the stimulator was on. Later, in an other patient a system was applied to the temporal area, delivering stimulation aimed at the branches of the mandibular nerve.[23] At approximately the same time, Shelden[12] implanted electrodes wrapped around the mandibular nerve itself in three patients and stimulated the nerves through an implanted receiver at 14,000 Hz, thus achieving temporary pain relief.

The use of PNS for craniofacial neuropathic pain was rediscovered in 1999 with the publication of an article by Weiner and Reed[22] in which they described percutaneous electrode insertion in the vicinity of the occipital nerves. Soon after publication of that pioneering paper, we began using the PNS approach in both the occipital and trigeminal regions.[13,14] Many other publications detailing the experience in many centers and describing different PNS techniques and applications have appeared over the last several years.[1,2,3,4,5,6,7,8,9,10,11,15,16,17,20,21]

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