Peripheral Nerve Stimulation in Painful Conditions of the Upper Extremity-An Overview

Peripheral Nerve Stimulation for Pain Management: A Survey of Clinical Practice Patterns

BACKGROUND

Clinical interest in and utilization of peripheral nerve stimulation (PNS) for treating chronic pain has significantly increased in recent years owing to its potential for providing analgesia and improved function and quality of life in comparison with pharmacologic treatments. However, the relative infancy of PNS-specific systems and limited clinical practice guidance likely contribute to significant variation in PNS utilization patterns.

OBJECTIVES

We sought to conduct a survey study to characterize PNS-specific clinical practices and propose the next steps in standardizing key practices for PNS utilization.

MATERIALS AND METHODS

A 19-question survey exploring PNS-relevant clinical parameters was disseminated online to pain physicians in practice. Descriptive statistics were used to summarize results.

RESULTS

A total of 94 responses were collected. Regarding patient selection, most practitioners would apply PNS to treat nociceptive pain from major joint osteoarthritis (77.7%) and chronic low back pain (64.9%), but not for axial neck pain (50.0%). In contrast, most would apply PNS to treat neuropathic pain from peripheral neuralgia (94.7%), pericranial neuralgia (77.7%), and cancer-related neuropathic pain (64.9%). In treating complex regional pain syndrome, most practitioners would apply PNS before all other forms of neuraxial neuromodulation (>50% for each form). Similarly, for treating nonsurgical low back pain, most would apply PNS before neuraxial neuromodulation (>50% for each form) but not before radiofrequency ablation (19.2%). Most routinely performed nerve blocks before PNS, mainly to confirm anatomical coverage (84.0%), and regarded a 50% to 75% interquartile range as the minimum analgesic benefit required before proceeding with PNS. Regarding nerve target selection for treating complex regional pain syndrome of the wrist/hand or ankle/foot, or knee osteoarthritis, we observed a very wide variance of PNS target locations and discrete nerves. Regarding "minor" adverse events, most reported not changing PNS utilization on encountering skin/soft tissue reactions (85.1%), minor infections (76.6%), or lead migration/loss of efficacy (50.0%). In comparison, most reported reducing PNS utilization on encountering skin erosion (58.5%), major infections (58.5%), or lead fractures (41.5%).

CONCLUSIONS

There is significant practice variation regarding the utilization of PNS across numerous key clinical considerations. Future research that explores the reasons driving these differences might help optimize patient selection, target selection, periprocedural management, and ultimately outcomes.

Peripheral Percutaneous Electrical Nerve Stimulation for Neuropathies: A Systematic Review and Meta-analysis

OBJECTIVE

The main objective of this review is to demonstrate the use of Peripheral Percutaneous Electrical Nerve Stimulation (PENS), together with its most up-to-date protocols, for the treatment of neuropathies.

DESIGN

We conducted a systematic search for randomised clinical trials evaluating the effectiveness of PENS on pain intensity, sleep quality, oral analgesic intake and depression in patients with neuropathic pain.

DATA SOURCES

The search was performed in Pubmed, PEDro and Cochrane databases.

ANALYSIS METHODS

The meta-analysis was conducted using RevMan 5.4 software. The mean difference was applied for variables with the same measurement scale, while the standardized mean difference was used for different scales. The inverse variance method was employed for statistical analysis, with heterogeneity assessed using the I² and Cochrane Q statistics.

RESULTS

Four articles that met the search requirements were included. After qualitative and quantitative synthesis, the results obtained were an improvement in pain intensity (-3.57 [-4.01, -3.13]; p < .05) and sleep quality (2.48 [1.96, 3.00]; p < .05) and a reduction in medication intake (-2.37 [-4.26, -0.47]; p < .05) and depressive behaviours (-1.10 [-1.55, -0.66]; p < .05). The overall methodological quality was rated as moderate and the risk of bias as unclear.

CONCLUSIONS

The scientific evidence found is still limited for the use of PENS in neuropathies. However, this study suggests an encouraging future for the use of this therapy as a treatment tool in physiotherapy.

NURSING PRACTICE IMPLICATIONS

PENS requires nurse education on electrode/needle placement and patient instruction, with documentation of key parameters. This review emphasizes the need for further research to establish standardized protocols and optimal application parameters for different neuropathic pain conditions.

Updates on Common Mononeuropathies

This article provides an overview of the most common mononeuropathies. It includes a description of the neuroanatomy and function of each nerve which allows clinical localization of the lesion. It also describes the clinical presentation, findings in electrodiagnostic studies, updates in imaging including neuromuscular ultrasound and magnetic resonance neurography, and recommended treatment. While mononeuropathies may be part of polyneuropathy, this scenario is beyond the scope of this article. The most common mononeuropathy is carpal tunnel syndrome. Its prevalence in the United States is estimated at 50 per 1,000. The second most common entrapment neuropathy is ulnar neuropathy at the elbow. The incidence was calculated as 20.9% in a 2005 study. The most common compressive neuropathy of the lower extremity is peroneal neuropathy. Other common mononeuropathies included in this article are radial neuropathy, tibial neuropathy, and femoral neuropathy.

A Review of Remote Monitoring in Neuromodulation for Chronic Pain Management

PURPOSE OF REVIEW

Neuromodulation techniques have emerged as promising strategies for managing chronic pain. These techniques encompass various modalities of nerve stimulation, including Spinal Cord Stimulation (SCS), Dorsal Root Ganglion Stimulation (DRG-S), and Peripheral Nerve Stimulation (PNS). Studies consistently demonstrate significant improvements in pain intensity, quality of life, and reduced opioid usage among patients treated with these modalities. However, neuromodulation presents challenges, such as the need for frequent in-person follow-up visits to ensure proper functionality of the implanted device. Our review explored factors impacting compliance in current neuromodulation users and examined how remote monitoring can mitigate some of these challenges. We also discuss outcomes of recent studies related to remote monitoring of neuromodulation.

RECENT FINDINGS

While remote monitoring capabilities for neuromodulation devices is an emerging development, there are promising results supporting its role in improving outcomes for chronic pain patients. Higher patient satisfaction, improved pain control, and reduced caretaker burdens have been observed with the use of remote monitoring. This review discusses the current challenges with neuromodulation therapy and highlights the role of remote monitoring. As the field continues to evolve, understanding the importance of remote monitoring for neuromodulation is crucial for optimizing pain management outcomes.

Needle infiltration assisted explantation technique for peripheral nerve stimulator leads

INTRODUCTION

Peripheral nerve stimulation is a neuromodulation modality that is increasing used to treat chronic pain. The permanent peripheral nerve stimulator systems, while easy to implant, are designed to stay in place and scar at the implantation site. There is a paucity of literature on explantation techniques for peripheral nerve stimulators.

METHODS

In this report, we describe a needle infiltration assisted technique for lead explantation. This novel technique is minimally invasive, cost-effective, and utilizes a combination of fluoroscopy and ultrasound imaging. We describe the successful use of this technique in 3 cases without any adverse events.

CONCLUSION

There are many situations which might require a permanent peripheral nerve stimulator to be explanted such as infection, lead erosion, patient request, or need for the patient to undergo magnetic resonance imaging. In these scenarios, we propose a novel needle infiltration assisted technique of explantation that is safe, effective, and easy to replicate.

The Relevance of Implanted Percutaneous Electrical Nerve Stimulation in Orthopedics Surgery: A Systematic Review

Background: Percutaneous peripheral nerve stimulation (PNS) is a form of neuromodulation that involves the transmission of electrical energy via metal contacts known as leads or electrodes. PNS has gained popularity in orthopedic surgery as several studies have supported its use as a pain control device for patients suffering from pain due to orthopedic pathologies involving the knee, shoulder, and foot. The purpose of this systematic review is to summarize the literature involving peripheral nerve stimulation in orthopedic surgery. The existing body of literature provides support for further research regarding the use of PNS in the management of knee pain, hip pain, shoulder pain, foot pain, and orthopedic trauma. Notably, the evidence for its efficacy in addressing knee and shoulder pain is present. Methods: This study was conducted following PRISMA guidelines. Seven hundred and forty-five unique entries were identified. Two blinded reviewers assessed each article by title and abstract to determine its relevance and categorized them as "include", "exclude", and "maybe". After a preliminary review was completed, reviewers were unblinded and a third reviewer retrieved articles labeled as "maybe" and those with conflicting labels to determine their relevance. Twenty-eight articles were included, and seven hundred and seventeen articles were excluded. Articles discussing the use of PNS in the field of orthopedic surgery in patients > 18 years of age after 2010 were included. Exclusion criteria included neuropathic pain, phantom limb pain, amputation, non-musculoskeletal related pathology, non-orthopedic surgery related pathology, spinal cord stimulator, no reported outcomes, review articles, abstracts only, non-human subjects. Results: A total of 16 studies analyzing 69 patients were included. All studies were either case series or case reports. Most articles involved the application of PNS in the knee (8) and shoulder (6) joint. Few articles discussed its application in the foot and orthopedic trauma. All studies demonstrated that PNS was effective in reducing pain. Discussion: Peripheral nerve stimulation can be effective in managing postoperative or chronic pain in patients suffering from orthopedic pathology. This systematic review is limited by the scarcity of robust studies with substantial sample sizes and extended follow up periods in the existing literature.

Permanent Peripheral Nerve Stimulator for Complex Regional Pain Syndrome of the Forearm and Hand

A 51-year-old woman with diabetes and depression was referred to the anesthesia pain clinic with a 15-year history of complex regional pain syndrome type I of the right forearm and hand in the radial sensory nerve distribution. There was no recognized antecedent trauma and she had failed both medical treatment and radial sensory nerve decompression surgery. An ultrasound-guided local anesthetic block of the radial nerve in the upper arm resulted in partial and temporary improvement in pain. She subsequently underwent trial of a peripheral nerve stimulator (PNS) followed by permanent PNS implant placement over the radial nerve proper proximal to the elbow. Within the first month of use, she endorsed substantially improved pain and strength in her right hand. These improvements were sustained for more than 1 year. Applications of PNS technology for treatment of extremity complex regional pain syndrome and neuropathic extremity pain in general are reviewed.

Peripheral Nerve Stimulation for Pain Management: A Review

PURPOSE OF REVIEW

Peripheral nerve stimulation has seen a recent upsurge in utilization for various chronic pain conditions, specifically from a neuropathic etiology, where a single peripheral nerve can be pinpointed as a culprit for pain.

RECENT FINDINGS

There is conflicting evidence about the efficacy and long-term outcomes of peripheral nerve stimulation for chronic pain, with most studies being small sized. The focus of this article is to review available evidence for the utilization of peripheral nerve stimulation for chronic pain syndromes as well as upcoming evidence in the immediate postoperative realm. The indications for the use of PNS have expanded from neuropathic pain such as occipital neuralgia and post-amputation pain, to more widespread disease processes such as chronic low back pain. Percutaneous PNS delivered over a 60-day period may provide significant carry-over effects including pain relief, potentially avoiding the need for a permanently implanted system while enabling improved function in patients with chronic pain.

Peripheral Nerve Stimulation for Low Back Pain: A Systematic Review

PURPOSE OF REVIEW

Low back pain (LBP) is a prevalent condition that is associated with diminished physical function, poor mental health outcomes, and reduced quality of life. Peripheral nerve stimulation (PNS) is an emerging modality that has been utilized to treat LBP. The primary objective of this systematic review is to appraise the level of evidence on the efficacy of PNS for treatment of LBP.

RECENT FINDINGS

Twenty-nine articles were included in this systematic review, consisting of 828 total participants utilizing PNS as the primary modality for LBP and 173 participants using PNS as salvage or adjunctive therapy for LBP after SCS placement. Different modalities of PNS therapy were reported across studies, including conventional PNS systems stimulating the lumbar medial branch nerves, peripheral nerve field stimulation (PNFS), and restorative neuromuscular stimulation of the multifidus muscles. All studies consistently reported positive modest to moderate improvement in pain intensity with PNS therapy when comparing baseline pain intensity to each study's respective primary follow-up period. There was a very low GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) quality of evidence supporting this finding. Inconsistency was present in some comparative studies that demonstrated no difference between PNS therapy versus control cohorts (sham or SCS therapy alone), which therefore highlighted the potential for placebo effect. This systematic review highlights that PNS, PNFS, and neuromuscular stimulation may provide modest to moderate pain relief in patients with LBP, although evidence is currently limited due to risk of bias, clinical and methodological heterogeneity, and inconsistency in data.