Progress in neurological surgery
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Fibromyalgia is a condition marked by widespread chronic pain, accompanied by a variety of other symptoms, including sleep and fatigue disorders, headaches, disorders of the autonomic nervous system, as well as cognitive and psychiatric symptoms. It occurs predominantly in women and is often associated with other systemic or autoimmune diseases. ⋯ Greater occipital nerve stimulation has already been used successfully to treat occipital neuralgia and various primary headache syndromes. Testable hypothetical working mechanisms are proposed to explain the surprising effect of this treatment on widespread bodily pain.
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Peripheral nerve stimulation (PNS) has been used for the treatment of neuropathic pain for more than 40 years. Recent interest in the utilization of this technique stems from the many modifications of the original procedure and the refinement of the available hardware. This rendered the procedure less traumatic and more effective, and thus more widely accepted as a neuromodulation technique for the treatment of various chronic pain syndromes including post-traumatic and postsurgical neuropathy, occipital neuralgia, and complex regional pain syndromes, and in relatively new indications for neuromodulation, such as migraines and daily headaches, cluster headaches. ⋯ We review the protocol of our approach including the surgical nuances for our implantation technique. Collaborative efforts in future research will lead to a growth in our clinical experience with the utilization of PNS and will help in identifying the best candidates for it. This, along with the development and refinement of the available hardware would lead to a more specific patient selection for each modality of treatment, increasing the efficacy and success of the intended treatment.
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Extremely high prevalence among general population along with the high percentage of treatment-refractory cases makes migraine headaches one of the potentially largest indications for neuromodulation. Cranial peripheral nerve stimulation targeting the occipital nerve(s) alone or in combination with others appears to be both safe and efficacious for the treatment of medically intractable migraine headaches. ⋯ Significant further investigation needs to be performed to optimize our knowledge concerning patient selection, stimulation targets and parameters and device programming, and further improve clinical results. At present, neurostimulation for migraine headache pain is performed in the United States on an 'off-label' basis, but based upon our experience and the increasing evidence in the medical literature, we look forward to its approval by the FDA in the near future so that patients suffering from severe, medically intractable headache pain may gain access to these potentially important therapies.
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Although commonly used in clinical practice, peripheral nerve stimulation (PNS) for treatment of chronic pain is performed mainly with devices developed and marketed for spinal cord stimulation applications. This may be one of the reasons why PNS approach is marked by a very high complication rate, as the anatomy of peripheral nerves and the surrounding soft tissues is quite different from epidural spinal space for which the current devices are designed. ⋯ Based on the literature data and the analysis of the author's experience with PNS procedures it appears that although the rate of complications is relatively high, the morbidity associated with PNS approach is very minor and most problems may be resolved with simple re-operations, usually on outpatient basis. The reduction in complication rate is expected to occur when the hardware used in PNS procedures is appropriately adapted for PNS applications.
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Recent research has highlighted the important role of the sphenopalatine ganglion (SPG) in cerebrovascular autonomic physiology and in the pathophysiology of cluster and migraine headaches as well as conditions of stroke and cerebral vasospasm. The relatively accessible location of the SPG within the pterygopalatine fossa and the development of options for minimally invasive approaches to the SPG make it an attractive target for neuromodulation approaches. The obvious advantage of SPG stimulation compared to ablative procedures on the SPG such as radiofrequency destruction and stereotactic radiosurgery is its reversibility and adjustable features. The on-going design of strategies for transient and continuous SPG stimulation on as needed basis using implantable SPG stimulators is an exciting new development which is expected to expand the clinical versatility of this technique.