Peripheral subcutaneous stimulation for the treatment of intractable postherpetic neuralgia: two case reports and literature review

Peripheral Nerve Stimulation for Neuropathic Pain Management: A Narrative Review

This narrative review examines the therapeutic efficacy of peripheral nerve stimulation (PNS) in the treatment of neuropathic pain (NP), a type of pain arising from lesions or diseases of the somatosensory system with a global prevalence ranging from 6.90% to 10.00%. Traditional pharmacological interventions often fall short for many persons, highlighting the need for alternative treatments such as PNS, which has demonstrated significant promise with minimal side effects. The review summarizes the effectiveness of PNS in various NP conditions, including trigeminal neuralgia and postherpetic neuralgia, and underscores the need for further research to refine treatment approaches. The mechanism of PNS is discussed, involving the activation of non-nociceptive Aβ fibers and modulation of neurotransmitters, and offering pain relief through both peripheral and central pathways. Despite the proven efficacy of PNS, challenges remain, including the need for randomized controlled trials and the optimization of stimulation parameters. The review concludes that PNS is a promising treatment modality for NP, warranting additional high-quality trials to solidify its role in clinical practice.

Intercostal Neuralgia Successfully Managed With Peripheral Nerve Stimulation

Intercostal neuralgia is characterized by neuropathic pain along the distribution of the intercostal nerve, which can cause debilitating pain and interfere with daily activities. The literature is extremely limited in assessing the use of neuromodulation to treat trauma-induced intercostal neuralgia. This case reports a 40-year-old patient who presented with decades of refractory, long-standing thoracic pain. The pain ranged from a four out of 10 to a nine out of 10 on the numeric rating scale (NRS). The patient failed pharmacologic therapy, physical therapy, chiropractic care, injection therapy, transcutaneous electrical nerve stimulation (TENS), and spinal cord stimulation (SCS). The patient underwent a 60-day peripheral nerve stimulation (PNS) trial, which temporarily relieved the pain until it was explanted. The patient subsequently underwent placement of a permanent PNS implant, which provided between 80-100% daily pain relief at a six-month follow-up. At the two-year follow-up, the patient continued to experience sustained pain relief, had weaned from opioid medications, and returned to all desired daily activities. This case suggests that minimally invasive PNS can effectively manage pain for patients with intercostal neuralgia who fail conservative measures. Further, to our knowledge, this two-year follow-up is the longest-reported outcome in the literature for using PNS for intercostal neuralgia after traumatic injury.

Digital subtraction angiography-guided peripheral nerve stimulation via the foramen rotundum for refractory trigeminal postherpetic neuralgia: a case report and literature review

Postherpetic neuralgia (PHN) is a debilitating complication of varicella-zoster virus infection. This case report presents a novel approach to treating refractory trigeminal maxillary postherpetic neuralgia using digital subtraction angiography (DSA)-guided peripheral nerve stimulation via the foramen rotundum. A 72-year-old female with severe, treatment-resistant pain underwent this intervention. The results demonstrated the disappearance of tactile allodynia, a significant reduction in oral analgesic requirements, and no observed complications or side effects during a 3-year follow-up period. This case highlights the potential effectiveness of DSA-guided peripheral nerve stimulation using a new dorsal root ganglion (DRG) stimulator as an alternative therapy for refractory trigeminal postherpetic neuralgia (TPHN).

Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain

The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.

Subcutaneous Peripheral Nerve Stimulation for Treatment of Acute/Subacute Herpes Zoster-related Trigeminal Neuralgia: A Retrospective Research

OBJECTIVES

The purpose of this study was to observe the effect of subcutaneous stimulation of the peripheral nerve on acute or subacute zoster occurring in trigeminal nerve branches, and to evaluate the preventive effect of prior temporary implant of a peripheral stimulation electrode in the acute or subacute phase of herpes zoster (HZ) (from 30 to 90 d after zoster onset) before postherpetic neuralgia (PHN) presents.

METHODS AND MATERIALS

A total of 26 patients' medical records were analyzed. All of patients had received temporary subcutaneous peripheral nerve stimulation (PNS). The clinical efficacy of treatment was evaluated on a visual analog scale (VAS), and dosages of pain medication were recorded before and at 1 to 6 months after the temporary stimulation. The rate of PHN was reevaluated at a 6 months follow-up.

RESULTS

There was a significant decrease in VAS values after PNS. Medication doses decreased significantly after TPNS. The rate of clinically meaningful PHN (VAS >3) dropped below 4%.

DISCUSSION

This study revealed that PNS is an effective treatment for trigeminal herpetic neuralgia following acute or subacute HZ. As a extend neuromodulation method, subcutaneous peripheral nerve-field stimulation might be a useful option to reduce the progression of neuropathic changes caused by persistent transmission of pain signals in the trigeminal nerve branches after the acute or subacute phase of HZ.

Peripheral Nerve Stimulation for Chronic Pain: A Systematic Review of Effectiveness and Safety

Peripheral nerve stimulation (PNS) was the first application of neuromodulation. Widespread application of PNS was limited by technical concerns. Recent advances now allow the percutaneous placement of leads with ultrasound or fluoroscopic guidance, while the transcutaneous powering of these leads removes the need for leads to cross major joints. This systematic review was written to assess the current status of high-quality evidence supporting the use of PNS for pain conditions treated by interventional pain physicians. The available literature on PNS, limited to conditions treated by interventional pain physicians, was reviewed and the quality assessed. Literature from 1966 to June 2021 was reviewed. The outcome measures were pain relief and functional improvement. One hundred and two studies were identified. Five randomized controlled trials (RCT) and four observational studies, all case series, met the inclusion criteria. One RCT was of high quality and four were of moderate quality; all four case series were of moderate quality. Three of the RCTs and all four case series evaluated peripheral nerve neuropathic pain. Based upon these studies, there is level II evidence supporting the use of PNS to treat refractory peripheral nerve injury. One moderate-quality RCT evaluated tibial nerve stimulation for pelvic pain, providing level III evidence for this indication. One moderate-quality RCT evaluated surgically placed cylindrical leads for cluster headaches, providing level III evidence for this indication. The evidence suggests that approximately two-thirds of patients with peripheral neuropathic pain will have at least 50% sustained pain relief. Adverse events from PNS are generally minor. A major advantage of PNS over spinal cord stimulation is the absence of any risk of central cord injury. The study was limited by the paucity of literature for some indications. No studies dealt with joint-related osteoarthritic pain.

Neuromodulation in Postherpetic Neuralgia: Case Reports and Review of the Literature

Objective

Postherpetic neuralgia (PHN) is common in the United States. Current treatment options for PHN are fairly limited. Spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) are considered mostly experimental and still rarely performed in patients with PHN.

Design

Two case reports and a review of the literature.

Setting

Tertiary academic medical center.

Methods

1) Pubmed, Ovid, and EBMR databases were searched for all reports that had the following key words: postherpetic neuralgia, spinal cord stimulation, and peripheral nerve stimulation. 2) A retrospective chart review was performed for all the patients that underwent PNS for PHN at Mayo Clinic Florida (MCF).

Results

There were 20 original reports that described 309 patients with PHN who were treated with SCS. Sixteen reports had a permanent implantation of SCS, with a total of 255 patients, out of which 120 had long-term pain relief. There were six reports of subcutaneous PNS for PHN (in a thoracic area). Four reports provided data on success rates where all five patients received complete pain relief. In our practice, two patients underwent subcutaneous PNS for PHN (in the thoracic area) with good pain relief for 10 months and 2.5 years, respectively.

Conclusions

Based on our review of the literature and the two cases at MCF, subcutaneous PNS seems to be a promising intervention in the treatment of PHN.

Nerve Stimulation for Pain

Nerve stimulation is a reversible technique that is used successfully for the treatment of traumatic neuropathic pain, complex regional pain syndrome, and craniofacial neuropathic pain. Nerve field stimulation targets painful regions rather than a single nerve and has expanded indications, including axial low back pain. Appropriate patient education and motivation are crucial prior to surgery. Ongoing research is necessary to provide high-level evidence for the use of nerve stimulation. Most electrodes are primarily designed for spinal cord stimulation, hence the need to develop nerve electrodes dedicated for nerve stimulation.

Ultrasound-guided peripheral nerve stimulation for neuropathic pain after brachial plexus injury: two case reports

Brachial plexus injury (BPI) often causes severe neuropathic pain that becomes chronic and difficult to treat pharmacologically or surgically. Here, we describe two cases of successful treatment of BPI with peripheral nerve stimulation (PNS). Both patients had experienced severe neuropathic pain after incomplete BPI for a long time (32 and 17 years) and did not response to medication, radiofrequency neuroablation, or spinal cord stimulation. After PNS using ultrasound, their pain was relieved by more than 50% over the course of 1 year. Both patients were satisfied with their improved sleep and quality of life. We conclude that PNS could be an alternative therapeutic modality for neuropathic pain after BPI as it provides direct nerve stimulation, has few complications, and is easy to perform.

Concordant occipital and supraorbital neurostimulation therapy for hemiplegic migraine; initial experience; a case series

INTRODUCTION

Hemiplegic migraine is a particularly severe form of the disease that often evolves to a debilitating chronic illness that is resistant to commonly available therapies. Peripheral neurostimulation has been found to be a beneficial therapy for some patients among several diagnostic classes of migraine, but its potential has not been specifically evaluated for hemiplegic migraine.

MATERIALS AND METHODS

Four patients with hemiplegic migraine were treated with concordant, combined occipital and supraorbital neurostimulation over periods ranging 6-92 months. The clinical indicators followed included assessments of headache frequency and severity, frequency of hemiplegic episodes, functional impairment, medication usage, and patient satisfaction.

RESULTS

All reported a positive therapeutic response, as their average headache frequency decreased by 92% (30 to 2.5 headache days/month); Visual Analog Score by 44% (9.5 to 5.3); frequency of hemiplegic episodes by 96% (7.5 to 0.25 hemiplegic episodes/month); headache medication usage by 96% (6 to 0.25 daily medications); and Migraine Disability Assessment score by 98% (249 to 6). All were satisfied and would recommend the therapy, and all preferred combined occipital-supraorbital neurostimulation to occipital neurostimulation alone.

CONCLUSIONS

Concordant combined occipital and supraorbital neurostimulation may provide effective therapy for both the pain and motor aura in some patients with hemiplegic migraine.

The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee

INTRODUCTION

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications.

METHODS

The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar.

RESULTS

Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medication-related side effects and has enduring effect. Device-related complications are not uncommon; however, the incidence is becoming less frequent as technology progresses and surgical skills improve. Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated.

CONCLUSIONS

Appropriate neurostimulation is safe and effective in some chronic pain conditions. Technological refinements and clinical evidence will continue to expand its use. The NACC seeks to facilitate the efficacy and safety of neurostimulation.

Complications of varicella zoster virus reactivation

OPINION STATEMENT

Varicella zoster virus (VZV) is an exclusively human neurotropic alphaherpesvirus. Primary infection causes varicella (chickenpox), after which virus becomes latent in ganglionic neurons along the entire neuraxis. With advancing age or immunosuppression, cell-mediated immunity to VZV declines and virus reactivates to cause zoster (shingles), which can occur anywhere on the body. Skin lesions resolve within 1-2 weeks, while complete cessation of pain usually takes 4-6 weeks. Zoster can be followed by chronic pain (postherpetic neuralgia), cranial nerve palsies, zoster paresis, meningoencephalitis, cerebellitis, myelopathy, multiple ocular disorders and vasculopathy that can mimic giant cell arteritis. All of the neurological and ocular disorders listed above may also develop without rash. Diagnosis of VZV-induced neurological disease may require examination of cerebrospinal fluid (CSF), serum and/ or ocular fluids. In the absence of rash in a patient with neurological disease potentially due to VZV, CSF should be examined for VZV DNA by PCR and for anti-VZV IgG and IgM. Detection of VZV IgG antibody in CSF is superior to detection of VZV DNA in CSF to diagnose vasculopathy, recurrent myelopathy, and brainstem encephalitis. Oral antiviral drugs speed healing of rash and shorten acute pain. Immunocompromised patients require intravenous acyclovir. First-line treatments for post-herpetic neuralgia include tricyclic antidepressants, gabapentin, pregabalin, and topical lidocaine patches. VZV vasculopathy, meningoencephalitis, and myelitis are all treated with intravenous acyclovir.

Spinal cord stimulation in the treatment of postherpetic neuralgia in patients with chronic kidney disease: a case series and review of the literature

BACKGROUND

Postherpetic neuralgia (PHN) is usually managed pharmacologically. It is not uncommon for patients with chronic kidney disease (CKD) to suffer from PHN. It is difficult to prescribe a sufficient dose of anticonvulsants for intractable pain because of the decreased glomerular filtration rate. If the neural blockade and pulsed radiofrequency ablation provide only short-term amelioration of pain, spinal cord stimulation (SCS) with a low level of evidence may be used only as a last resort. This study was done to evaluate the efficacy of spinal cord stimulation in the treatment of PHN in patients with CKD.

METHODS

PHN patients with CKD who needed hemo-dialysis who received insufficient relief of pain over a VAS of 8 regardless of the neuropathic medications were eligible for SCS trial. The follow-up period was at least 2 years after permanent implantation.

RESULTS

Eleven patients received percutaneous SCS test trial from Jan 2003 to Dec 2007. Four patients had successfully received a permanent SCS implant with their pain being tolerable at a VAS score of less than 3 along with small doses of neuropathic medications.

CONCLUSIONS

SCS was helpful in managing tolerable pain levels in some PHN patients with CKD along with tolerable neuropathic medications for over 2 years.