Использование периферической нейростимуляции в лечении затылочной невралгии

Резюме

Затылочная невралгия - это редкая форма головной боли, которую можно лечить медикаментозно, блокадами нервов и методами абляций. Хроническую некупируемую затылочную невралгию, резистентную к медикаментозной терапии, можно успешно контролировать путем периферической нейростимуляции в течение длительного времени.

Хроническая боль при затылочной невралгии имеет нейропатический компонент, резистентный к лечению опиоидами. Интервенционные методы играют все более значительную роль в лечении хронических болевых синдромов, включая использование периферической нейростимуляции для купирования затылочной невралгии.

Методы. Пациенты с хронической некурабельной затылочной невралгией подверглись неосложненной пробной периферической нейростимуляции с установкой одного или двух временных 8-контактных электродов, введенных подкожно в области большого и малого затылочных нервов (Medtronic Inc., Миннеаполис, Миннесота).

Результаты. Все пациенты отмечали выраженный клинический эффект на фоне временной нейростимуляции, после чего в течение 2-4 нед им были имплантированы постоянные электроды и подзаряжаемый генератор. В течение 12 мес после имплантации у всех пациентов регистрировался выраженный аналгезирующий эффект.

Заключение. Периферическая нейростимуляция является эффективным альтернативным методом лечения узкой группы пациентов с хронической болью, не курабельной традиционными методами.

Ключевые слова:электрическая стимуляция, боль, затылочная невралгия, периферическая нейростимуляция

Клин. и эксперимент. хир. Журн. им. акад. Б.В. Петровского. 2016. № 3. С. 106-110.

Статья поступила в редакцию: 15.02.2016. Принята в печать: 16.04.2016.

Occipital neuralgia (ON) is a lancinating, sharp, throbbing, electric shock-like pain in the cutaneous distribution of the greater and lesser occipital nerves or the third occipital nerve [1]. Diagnostic criteria include tenderness over the affected nerve which is temporarily alleviated by nerve block. No data are available about the prevalence or incidence of this condition. ON can be caused by irritation of nerve roots from mechanical trauma [2] including deceleration injuries, whiplash, infection, or entrapment-compression related to temporal arteritis [3], neurosyphilis [4], vascular compression [5], herpetic neuralgia, arthrosis of the C1-2 facet joint [6-7], and scarring from previous surgeries in the area.

Initial conservative treatment includes heat, rest, anti-inflammatory medications, and muscle relaxants. Neuromodulators, tricyclic antidepressants and opioids may also alleviate the pain. Patients with persistent symptoms may be treated with occipital nerve blocks for diagnostic and therapeutic purposes, possibly providing permanent pain relief. Other treatment options include botulinum toxin A injection [8-11], percutaneous neurolysis of the C2 nerve root using ethyl alcohol [12] and surgical treatment including microvascular decompression of include the C2 nerve root, ganglion or postganglionic nerve, ablation of the ON, and peripheral stimulation of the ON [13-16].

Neuropathic pain is known to respond favorably to neuromodulation therapy and poorly to opioids. Peripheral nerve field stimulation (PNFS) and ONS have been used to treat a variety of neuropathies [17], including ileoinguinal [18], occipital [19-22], post-herpetic [23], intercostals [24], trigeminal postherpetic neuralgia and trigeminal posttraumatic neuropathic pain [25-28], headaches [29] and back pain [30-35] with excellent relief of pain and reduced need for oral pain medications.

Material and methods

between May 2009 and April 2012, 19 patients suffering from intractable chronic occipital neuralgia underwent temporary ONS lead placement. Seven patients had unilateral ON and twelve patients had bilateral ON. All patients had previously failed conservative therapies including anti-inflammatory medications, muscle relaxants, neuromodulators including tricyclic antidepressants and anti-seizure medications. Some patients had trial opioid pain medications with poor pain relief. Some patients had undergone diagnostic cervical facet median branch nerve injections and RFA cervical facet median branch nerve, botulinum toxin A injections, or cryoablation of the bilateral lesser and greater occipital nerve blocks with less than 50% improvement in pain or short lasting relief. All patients had undergone bilateral lesser and greater occipital nerve blocks with greater than 50% improvement in pain for less than 2 weeks duration. Eleven patients were males (57.9%) and eight were female (42.1%) aged from 28 to 75 years (mean age - 49 years). All patients had over 12 months pain duration. No patients were involved in active litigation. A distant history of drug and alcohol abuse was noted in 15.8% of patients.

Patients described their pain as intermittent or continuous lancinating, sharp, throbbing, electric shock-like pain originating in the occipital area and radiating in the cutaneous distribution of the greater and lesser occipital nerves. All patients had tenderness on palpation over the affected nerves and had temporarily pain relief following bilateral less and greater occipital nerve blocks. Chronic pain medication regimens had included neuromodulators including gabapentin, pregabalin, amitriptyline, muscle relaxants including tizanidine, cyclobenzaprine, methocarbamol, opioid pain medications including darvocet, oxycodone, hydrocodone, morphine, hydro- morphone, fentanyl patch, nonsteroidal anti-inflammatory medications, lidocaine patches, and topical ointments, none of which provided the patients significant pain relief. Each of the patients was counseled on treatment options including continuing with current treatment, or ONS therapy. The patients elected to proceed with ONS therapy.

All patients underwent successful 2 day trial of percutaneous placement of two 8-electrode Octade Leads (Medtronic Inc., Minneapolis, MN) after passing a psychological evaluation for an implantable device. After local infiltration of 1% lidocaine, two 14 gauge Touhy needles were advanced in the subcutaneous tissue from medial to lateral on the level C1 in the left and right occipital region along the nuchal line, perpendicular to the occipital nerves towards mastoid process. The Touhy needles were bent to follow the occipital curvature. Leads were advanced through the Touhy needles and then the needles were removed while leads were maintained in position (Fig. 1). Leads were then connected to a temporary external stimulator via an extension cord. During the 2 day ONS trial the patients reported greater than 50% improvement in pain. Two to four weeks later the patients underwent im- plantation with permanent leads and RestorePRIME non-rechargeable or RestoreULTRA (Medtronic Inc., Minneapolis, MN) rechargeable generators. Preop- eratively we discussed with the patients the op- tions for location of the implanted generator and they chose the right or left supragluteal area. Each of the two permanent leads were anchored to fibroaponeurotic tissue in the wound created along upper cervical region with 2-0 non-absorbable suture of braided polyester (Ethibond) and Titan Anchors (Medtronic Inc., Minneapolis, MN). The leads were tunneled to the left or right supragluteal areas where the subcutaneous pocket was created (Fig. 2) for the generator. Leads were then connected to RestorePRIME non-rechargeable or RestoreUltra (Medtronic Inc., Minneapolis, MN) rechargeable generator. The procedures were performed in an am- bulatory surgery center with intravenous sedation and local anesthesia administered by the surgeon. The post-operative courses were uneventful for each patient. The initiation of OMS therapy after implantation was uneventful.

The implanted stimulators were programmed us- ing an alternating electrode configuration with a pulse width of 270 to 450 microseconds and a rate of 40 to 60 Hz. The amplitude use ranged from 0.5 to 2.8 Volts. The patients each reported that the stimulation covered one-hundred percent of their painful areas following the initial programming.

Results

7 patients had unilateral and twelve patients had bilateral lead placements to cover affected occipital regions. No complications were reported during the ONS trial. After implantation of permanent generator and leads no wound infection was encountered. 15 patients had reprogramming of ONS in the first 6 weeks after the surgery. 6 patients needed additional teaching sessions about use of their recharging devices postoperatively. One patient needed revision of ONS lead because the skin erosion over the tip of the lead in lateral aspect of occipital region.

At 12 month follow-up visit all patient reported significant pain relief (>50% reduction in VAS) with permanent stimulator. Stimulator parameters were in the same range like during ONS trial. 13 (68.4%) patients were using the ONS 24 hours per day, adjusting stimulation intensity for changes in intensity of pain with good pain relief. The other 6 (31.6%) patients were turning on the ONS only during the day hours. All patients were able to decrease or discontinue use of pain medications. 2 patients continued to use tizanidine and pregabalin. Patients also reported other positive outcomes including the ability to return to social and educational activities.

Discussion

the occipital nerves originated from the medial branch of the posterior C2 and C3 primary sensory division of the cervical nerves and emerge between C1 and C2, ascending through the semispinalis and trapezius muscles near their attachment on the occipital area of the skull medial to the occipital artery to innervate the posterior scalp [36-37]. By placing stimulating leads in a transverse fashion across the occipital nerves, ONS alleviates pain by subdermal stimulation of the peripheral fibers, which may prevent transmission of painful impulses to the central nervous system. The neuromodulating effects of electrical stimulation are based on the tenets of the “gate-control theory” of pain proposed by Melzack and Wall in 1965 [38]. Based on this theory, it is hypothesized that NOS “closes the gate” to pain transmission by activating large-diameter afferent fibers via application of an electric field. ONS may also alter local blood flow, cause release of endorphins, affect neurotransmitters and axonal conduction, and may block cell membrane depolarization [34]. The mechanism of action of ONS and neuromodulation in general continues to be investigated as there may be a multitude of ways in which neuromodulation affects pain transmission. ONS and PNFS works on the painful areas of the head which are very difficult to target with epidural stimulation.

ONS provides a safe, effective, and convenient treatment option for patients suffering from chronic intractable ON. ONS has advantages over conservative treatments as well as more invasive techniques. There are no side effects created by ONS as there are with many medications. There is a high rate of success with permanent implant due to the fact that a trial is performed during which the patient evaluates the efficacy of the device. The therapy is completely reversible if for some reason therapy becomes contraindicated or is no longer needed. Patient programmers permit patients to control the level of stimulation they feel based on their degree of pain. This enables patients to take a more active role in their pain management.

Conclusion

We present the treatment of chronic intractable ON successfully treated with ONS. This technique may be a safe and effective treatment for patients who have failed to find relief with more conservative measures. ONS has provided our patients with satisfactory pain relief without the side effects of previous medication therapy. In our opinion, ONS offers a safe and effective treatment method that is completely reversible should a patient lose its pain-alleviating effect. These patient outcomes provide support for ONS as an alternative treatment option for patients with ON and will hopefully inspire interest in prospective studies comparing ON to other therapies.

Литература

1. Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders: 2nd ed. Cephalalgia. 2004; Vol. 24 [Suppl 1]: 1-160.

2. Hunter C.R., Mayfield FH: Role of the upper cervical roots in the production of pain in the head. Am J Surg. 1949; Vol. 78: 743-51.

3. Jundt J.W., Mock D. Temporal arteritis with normal erythrocyte sedimentation rates presenting as occipital neuralgia. Arthritis Rheum. 1991; Vol. 34: 217-9.

4. Smith D.L., Lucas L.M., Kumar K.L. Greater occipital neuralgia: an unusual presenting feature of neurosyphilis. Headache. 1987; Vol. 27: 552-4.

5. Hildebrandt J., Jansen J. Vascular compression of the C2 and C3 roots - yet another cause of chronic intermittent hemicrania? Cephalalgia. 1984; Vol. 4: 167-70.

6. Ehni G., Benner B. Occipital neuralgia and C1-C2 arthrosis. N Engl J Med. 1984; Vol. 310: 127.

7. Hammond S.R., Danta G. Occipital neuralgia. Clin Exp Neurol. 1978; Vol. 15: 258-70.

8. Blumfeld A.M., Dodick D.W., Silberstein S.D. Botulinum neurotoxin for the treatment of migraine and other primary headache disorders. Dermatol Clin. 2004; Vol. 22 (2): 167-75.

9. Loder E., Biondi D. Use of botulinum toxins for chronic headaches: a focused review. Clin J Pain. 2002; Vol. 18 (6 Suppl): S169-76.

10. Ondo W.G., Vuong K.D., Derman H.S. Botulinum toxin A for chronic daily headache: a randomized placebocontrolled, parallel design study. Cephalalgia. 2004; Vol. 24 (1): 60.

11. Freund B.J., Schwartz M. Use of botulinum toxin in chronic whiplash-associated disorder. Clin J Pain. 2002; Vol. 18 (6 Suppl): S163-8.

12. Koch D., Wakhloo A.K. CT-guided chemical rhizotomy of the C1 root for occipital neuralgia. Neuroradiology. 1992; Vol. 34: 451-2.

13. Dubuisson D. Treatment of occipital neuralgia by partial posterior rhizotomy at C1-3. J Neurosurg. 1995; Vol. 82 (4): 581-6.

14. Kapoor V., Rothfus W.E., Grahovac S.Z., Amin Kassam S.Z., Horowitz M.B. Refractory occipital neuralgia: preoperative assessment with CT-guided nerve block prior to dorsal cervical rhizotomy. Am J Neuroradiol. 2000; Vol. 24 (10): 2105-10.

15. Park C.H., Jeon E.Y., Chung J.Y., Kim B.I., Roh W.S., Cho S.K. Application of pulsed radiofrequency for 3rd occipital neuralgia: A case report. J Korean Pain Soc. 2004; Vol. 17 (1): 63-5.

16. Gille O., Lavignolle B., Vital J.M. Surgical treatment of greater occipital neuralgia by neurolysis of occipital nerve and sectioning of the inferior oblique muscle. Spine. 2004; Vol. 29 (7): 828-32.

17. Van Buyten J.-.P, Van Zundert J., Milbouw G. Treatment of failed back surgery syndrome patients with low back and leg pain: a pilot study of a new dual lead spinal cord stimulation system. Neuromodulation. 1999; Vol. 2: 258-65.

18. Stinson L.W. Jr., Roderer G.T., Cross N.E., Davis B.E. Peripheral subcutaneous electrostimulation for control of intactable post-operative inguinal pain: a case report series. Neuromodulation. 2001; Vol. 4: 99-104.

19.Slavin K.V., Nersesyan H., Wess C. Peripheral neurostimulation for treatment of intractable occipital neuralgia. Neurosurgery. 2006; Vol. 58: 112-9.

20. Johnstone C.S., Sundaraj R. Occipital nerve stimulation for the treatment of occipital neuralgia-eight case studies. Neuromodulation. 2006; Vol. 9: 41-7.

21. Oh M.Y., Ortega J., Bellotte J.B., Whiting D.M., Alo K. Peripheral nerve stimulation for the treatment of occipital neuralgia and transformed migraine using a C1-2-3 subcutaneous paddle style electrode: a technical report. Neuromodulation. 2004; Vol. 7: 103-12.

22. Weiner R.L., Reed K.L. Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation 1999; Vol. 2: 217-21.

23. Yakovlev A., Peterson A. Peripheral nerve stimulation in treatment of intractable postherpetic neuralgia- a case report. Neuromodulation. 2007; Vol. 10: 373-5.

24. Tamimi M.A., Davids H.R., Langston M.M., Krutsch J.P., Yakovlev A., Barolat G. Successful treatment of chronic neuropathic pain with subcutaneous peripheral nerve stimulation. Neuromodulation . 2009; Vol. 12: 210-4.

25. Johnson MD, Burchiel KJ. Peripheral stimulation for treatment of trigeminal postherpetic neuralgia and trigeminal posttraumatic neuropathic pain: a pilot study. Neurosurgery 2004; 55: 135-41.

26. Dunteman E. Peripheral nerve stimulation for unremitting opthalmic postherpetic neuralgia. Neuromodulation. 2002; Vol. 5: 32-7.

27. Slavin K.V., Wess C. Trigeminal branch stimulation for intractable neuropathic pain: technical note. Neuromodulation. 2005; Vol. 8: 7-13.

28. Oberoi J., Sampson C., Ross E. Head and Neck Peripheral Stimulation for Chronic Pain Report of Three Cases. Neuromodulation. 2008; Vol. 11: 272-6.

29. Yakovlev A.E., Resch B.E. Peripheral nerve stimulation (PNS) for treatment of intractable headaches associated with lyme disease. Pain Med. 2009; Vol. 10 (1): 224.

30. Yakovlev A.E., Resch B.E. Peripheral nerve field stimulation for treatment of pain related to spine deformities. Pain Med. 2009; Vol. 10 (1): 223.

31. Yakovlev A.E., Resch B.E. Peripheral nerve field stimulation (PNFS) for treatment of postlaminectomy syndrome in patients with implanted intrathecal pain pumps. Pain Med. 2009; Vol. 10 (1): 221-2.

32. Krutsch J.P., McCeney M.H., Barolat G., Tamimi M.A., Smolenski A. A case report of subcutaneous peripheral nerve stimulation for the treatment of axial back pain associated with postlaminectomy syndrome. Neuromodulation. 2008; Vol. 11: 112-5.

33. Bernstein C.A., Paicius R.M., Barkow S.H., Lempert-Cohen C. Spinal cord stimulation in conjunction with peripheral nerve field stimulation for the treatment of low back and leg pain: case series. Neuromodulation. 2008; Vol. 11: 116-23.

34. Paicius R.M., Bernstein C.A., Lempert-Cohen C. Peripheral nerve field stimulation for the treatment of chronic low back pain. Preliminary results of long term follow-up: a case series. Neuromodulation. 2007; Vol. 10: 279-90.

35. Ordia J., Vaisman J. Subcutaneous peripheral nerve stimulation with paddle lead for treatment of low back pain: case report. Neuromodulation. 2009; Vol. 12: 205-9.

36. Groen G.J., Baljet B., Drukker J. Nerves and nerve plexuses of the human vertebral column. Am J Anat. 1990; Vol. 188: 282-96.

37. Becser N, Bovim G, Sjaastad O. Extracranial nerves in the posterior part of the head: anatomic variations and their possible clinical significance. Spine. 1998; Vol. 23: 1435-41.

38. Melzack R., Wall P.D. Pain mechanisms: a new theory. Sciencе. 1965; Vol. 150: 971-9.

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ГЛАВНЫЙ РЕДАКТОР
ГЛАВНЫЙ РЕДАКТОР
Дземешкевич Сергей Леонидович
Доктор медицинских наук, профессор (Москва, Россия)

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