Percutaneous Peripheral Nerve Stimulation Research Articles

Peripheral Nerve Stimulation of the Shoulder: A Technical Primer.

Scapulalgia or shoulder pain accounts for 16% of all musculoskeletal complaints in the healthy adult population and becomes more common as we age. When this pain exceeds 3 months in duration, it is deemed to be chronic, and typically treated in an escalating manner. Spanning a continuum of conservative and non-conservative measures, chronic shoulder pain treatments range from rest and physical therapy to surgery. Since each patient presents with a unique spectrum of symptoms a customized treatment plan is often required. Over the lifetime of many of these patients, a variety of treatment options are required. One of these treatment options, peripheral nerve stimulation (PNS), is a minimally invasive procedure in which an electrical impulse is delivered through a percutaneously implanted, small caliber electrode to a peripheral nerve proximal to the lesion which interferes with the pain signals. Over the past several years, significant growth of PNS in the treatment of chronic neuropathic pain has been observed. However, the procedural techniques have not been well described. The foundation of long-term, minimally invasive percutaneous PNS in patients with chronic shoulder pain, and procedural techniques for stimulating the suprascapular and axillary nerves using fluoroscopy or ultrasonography will be described in this report.

Structural and Functional Changes in Supraspinatus Tendinopathy through Percutaneous Electrolysis, Percutaneous Peripheral Nerve Stimulation and Eccentric Exercise Combined Therapy: A Single-Blinded Randomized Clinical Trial.

Shoulder tendinopathies produce pain and reduce functionality. The aim of this randomized clinical trial was to analyze the effects of Percutaneous electrolysis (PE), Percutaneous peripheral Nerve Stimulation (PNS) and eccentric exercise (EE) on pain (NPRS), strength, electromyographic activity, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and functionality (DASH and SPADI) in individuals with supraspinatus tendinopathy. Participants (n = 50) were divided into two groups; they received 4 treatment sessions, 1 per week, of PE and PNS (n = 25) or 10 treatment sessions of TENS and US (n = 25). Both groups performed the EE program consisting of 3 sets of 10 repetitions of each of the 3 exercises, twice a day, during the 4 weeks. Follow-up was carried out at 4, 12 and 24 weeks after the start of the intervention. There are statistically significant differences in the analysis between groups (p < 0.001) in the post-treatment and follow-up measurements favorable to the PE+PNS+EE treatment on pain (NPRS), strength, supraspinatus electromyographic amplitude, ultrasound characteristics of the tendon (echogenicity, thickness and hypervascularization) and DASH and SPADI questionnaires. The combined treatment with PE, PNS and EE is an effective option in the clinical management of tendinopathies, with positive results in the short and long term on the variables studied.

Novel Implantation Technique for Thoracoabdominal Peripheral Nerve Stimulation via a Transversus Abdominal Plane Approach for Treatment of Chronic Abdominal Pain.

Chronic abdominal pain (CAP) is a common and challenging to treat condition with a global prevalence of up to 25%. Despite extensive evaluation, approximately 40% of patients with CAP have an unknown diagnosis. Medications may be ineffective, and surgery is rarely indicated. Interventional treatment including sympathetic blocks, sympathetic neurolysis, and transversus abdominal plane (TAP) blocks may be an option, but their efficacy can wane over time. Neuromodulation has emerged as an option for these patients, as there is evidence of success with dorsal column spinal cord and dorsal root ganglion (DRG) stimulation. Peripheral nerve stimulation (PNS) may be an alternative option, particularly in higher risk patients or in patients for whom neuraxial access may be unsafe or too technically challenging. Thoracoabdominal nerve peripheral nerve stimulation via a TAP approach may be more specifically targeted in comparison to dorsal column or DRG stimulation. In this short report, we detail a technique that the authors have successfully used for thoracoabdominal nerve PNS via a TAP approach for management of CAP. This article describes a novel medial to lateral ultrasound guided thoracoabdominal nerve PNS via a TAP approach technique for lead placement and implantation. A medial to lateral ultrasound guided TAP approach as described to successfully implant percutaneous thoracoabdominal nerve PNS leads for management of CAP. The thoracoabdominal nerve PNS via a TAP approach lead placement technique noted in this report has been used as a means for management of CAP utilizing peripheral neuromodulation. Here, we present a short report detailing a potential technique for PNS utilization for management of CAP. Further studies are needed to validate the safety and efficacy of this therapy modality, although the authors have found it to be a viable management option for patients with medically refractory neuropathic CAP.

Percutaneous peripheral nerve stimulation (PNS) in post-amputation pain management: A comprehensive review

A new percutaneous Peripheral Nerve Stimulation (PNS) device is described in this paper as a potential treatment for amputation-related neuropathic pain and functional impairment in military service members and veterans. Recent advances have made it feasible to inject thin wire-coiled PNS leads percutaneously under ultrasound guidance, allowing doctors to get around the problems and invasiveness of traditional PNS systems. Avoiding the femoral and sciatic nerves may minimize the hazards associated with these leads. Phantom limb pain (PLP) is experienced by an estimated 40% - 80% of amputees. This article provides a concise summary of current studies that examine the impact of PNS technological advancements on neuromodulation. This research aimed to provide healthcare providers with up-to-date, evidence-based suggestions for alleviating post-amputation discomfort.

Use of Temporary Percutaneous Peripheral Nerve Stimulation in an Oncologic Population: A Retrospective Review

ObjectivesPatients with an underlying cancer diagnosis may experience pain from many sources. Temporary, percutaneous peripheral nerve stimulation (PNS) is a minimally invasive procedure that can control pain in those who have failed conservative management. The purpose of this retrospective review is to show the use of PNS in managing pain in the oncologic setting. Materials and methodsTemporary, percutaneous PNS was placed under fluoroscopic or ultrasound guidance for 15 patients at a cancer pain facility. Cases were grouped by subtypes of cancer pain (ie, tumor-related, treatment-related, cancer-associated conditions, and cancer-independent). Before PNS, patients were refractory to medical management or previous interventional treatments. Patients were observed with routine clinic visits to monitor pain levels via visual analog scale (VAS) and quality-of-life measures. PNS was removed after the indicated 60-day treatment period. ResultsThis retrospective review presents ten successful cases of oncologic-related pain treated with PNS. Patients with subtypes of pain that were tumor related, from cancer-associated conditions, and cancer independent all experienced a similar degree of pain relief. However, patients with cancer-treatment–related pain experienced the least analgesia from PNS. We also present six cases in which PNS did not provide adequate pain relief. ConclusionPNS is an emerging technology in neuromodulation that may be useful in managing pain, especially in the oncologic population. Patients with cancer-related and non–cancer-related pain localized to a specific nerve distribution should be considered appropriate candidates for PNS. Further research is needed to optimize patient selection and indications for PNS in the population with cancer.

Blood flow effects of percutaneous peripheral nerve stimulation. A blinded, randomized clinical trial.

The vasculature function is mainly regulated by the autonomic nervous system. Importantly, the sensory-motor nervous system also innervates peripheral vessels and has the capacity to modulate vascular tone. Here we investigated the effects of electrical stimulation of a mixed nerve trunk on blood flow in deep arteries and muscle perfusion. Our hypothesis is that stimulation of a mixed nerve can modify blood flow. Twenty-nine healthy participants were included into a randomized-crossover and blinded clinical trial. Each subject received a placebo and two percutaneous peripheral nerve stimulation (pPNS) protocols on the median nerve: Pain Threshold continuous Low Frequency (PT-cLF) and Sensory Threshold burst High Frequency (ST-bHF). Blood flow was then assessed bilaterally using Power Doppler Ultrasonography at the main arteries of the arm, and blood perfusion at the forearm muscles. Afterwards, blood flow was quantified using a semi-automatized software, freely shared here. Placebo, consisting in needle insertion, produced an immediate and generalized reduction on peak systolic velocity in all arteries. Although nerve stimulation produced mainly no effects, some significant differences were found: both protocols increased the relative perfusion area of the forearm muscles, the ST-bHF protocol prevented the reduction in peak systolic velocity and TAMEAN of the radial artery produced by the control protocol and PT-cLF produced a TAMEAN reduction of the ulnar artery. Therefore, the arterial blood flow in the arm is mainly impervious to the electrical stimulation of the median nerve, composed by autonomic and sensory-motor axons, although it produces mild modifications in the forearm muscles perfusion.

The Emerging Role of Peripheral Nerve Stimulation in Postoperative Analgesia.

Though peripheral nerve stimulation has long been utilized in the field of chronic pain management, its use in acute pain management in the postoperative period is relatively novel and warrants further consideration. In the postsurgical period, peripheral nerve stimulation may offer an additional low-risk, opioid-sparing analgesic option, which is particularly pertinent in the setting of the ongoing opioid epidemic, as inadequate postsurgical analgesia has been shown to increase the risk of developing persistent or chronic postsurgical pain. In this review, we discuss the current literature that illustrate the emerging role of peripheral nerve stimulation as an effective treatment modality in the postoperative period for the management of acute pain, as various studies have recently been conducted evaluating the feasibility of utilizing percutaneous peripheral nerve stimulation as an adjunct in postsurgical analgesia. Nonetheless, future studies are necessary to continue to elucidate the short- and long-term impacts of peripheral nerve stimulation use in acute postsurgical analgesia.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation of C2 Dorsal Root Ganglion for the Treatment of Refractory Atypical Facial Pain: A Technical Report and Case Series

BackgroundChronic craniofacial pain can be difficult to manage clinically. This technical report documents the peripheral nerve stimulation of the C2 dorsal root ganglion as an effective modality to treat refractory atypical facial pain. Materials and MethodsIn this case series, three patients with chronic refractory atypical facial pain and p >50% pain relief following diagnostic C2 dorsal root ganglion blockade underwent ultrasound-guided percutaneous placement of a peripheral nerve stimulator adjacent to the C2 dorsal root ganglion. Patients were then observed clinically and monitored for improvement in symptoms and adverse events. ResultsThree patients underwent peripheral nerve stimulator placement. At follow-up, there were no reported adverse events, and all patients reported satisfactory improvement in pain. ConclusionThe neuromodulation of C2 dorsal root ganglion via ultrasound-guided percutaneously implanted peripheral nerve stimulator is a novel and potentially effective approach for the management of chronic refractory craniofacial pain.

ID: 207032 Durability of Relief Following 60-day Percutaneous Medial Branch PNS Treatment for Chronic Low Back Pain

For patients with chronic axial low back pain (LBP), there is often clinical evidence of central nervous system sensitization and finding a clear source of nociceptive input or damage to the somatosensory system can be challenging. Conventional therapies that mask the pain can fail to address centrally-mediated, underlying causes of pain. Sixty-day percutaneous peripheral nerve stimulation (PNS) applied to medial branch nerves offers a non-opioid, non-destructive, and non-surgical treatment designed to restore the balance of peripheral inputs to the central nervous system and reverse maladaptive changes in central pain processing, which can be applied earlier in the treatment continuum than permanently-implanted neurostimulation systems. The objective of this large multicenter clinical trial was to characterize the responses to medial branch PNS in a prospective multicenter case series study in patients recalcitrant to multiple non-surgical treatments. Additional goals of the clinical trial were to determine which low back pain patient phenotypes may be more or less likely to respond to PNS.

ID: 205775 Open-Coil Percutaneous Peripheral Nerve Stimulation Leads Facilitate Tissue Ingrowth to Enable Implantation up to 60-days

Open-coil leads used to deliver 60-day percutaneous peripheral nerve stimulation (PNS) are designed to encourage tissue integration following percutaneous implantation, reducing “pistoning” at the skin to inhibit the ingress of contaminants and thereby reducing infection risk. A previous meta-analysis of coiled and non-coiled percutaneous leads found the infection risk of coiled leads to be approximately 25-times lower than non-coiled leads. The present study evaluated open-coil percutaneous PNS leads in a porcine model over the course of a 60-day implant period to assess the timeline and extent of tissue ingrowth.

ID: 217178 Percutaneous Stimulation of Suprascapular Nerve Improves Pain And Pain-Related Impairment Associated With Rotator Cuff Arthropathy

Treatment of rotator cuff arthropathy begins with conservative measures. Surgery is considered when pain progresses, and shoulder function deteriorates. Recently, percutaneous peripheral nerve stimulation (PNS) offers another non-surgical option for treating pain. Below is a case of chronic shoulder pain from rotator cuff damage that was successfully treated via percutaneous PNS stimulation with long term pain relief.

ID: 206983 Retrospective Review of Real-World Outcomes Following 60-Day PNS of the Cervical Medial Branch Nerves

Axial neck pain is a prevalent and often debilitating pain condition with conventional treatment options that commonly lack efficacy or are neurodestructive (e.g., radiofrequency ablation). Sixty-day percutaneous peripheral nerve stimulation (PNS) has emerged as a potential non-destructive treatment for axial neck pain that targets efferent fibers in the cervical medial branch nerves to secondarily produce comfortable, cycling tension in core cervical musculature (e.g., multifidus). The present work is a retrospective review of outcomes from patients receiving 60-day PNS treatment targeting the cervical medial branch nerves in routine clinical practice.

ID: 207021 Significant and Sustained Relief of Shoulder Pain Following 60-day PNS Treatment: A Real-World Retrospective Review

Chronic shoulder pain commonly results in disability and reduced quality of life, with frequent causes including post-surgical pain, inoperable musculoskeletal injury or joint degeneration, and stroke. Temporary percutaneous peripheral nerve stimulation (PNS) has demonstrated significant and sustained relief of chronic shoulder pain in previous clinical trials. This study presents the first real-world, retrospective review of patient outcomes through up to 6 months following the start of a 60-day PNS treatment for chronic shoulder pain.

ID: 221650 Successful Peripheral Nerve Stimulation for Tarsal Tunnel Syndrome - Case Report

Tarsal Tunnel Syndrome (TTS) occurs with injury to the tibial nerve due to entrapment underneath the retinaculum, fracture, previous ankle injury, or an iatrogenic etiology etc. Surgical treatment has been the mainstay of TTS, but failure of a tarsal tunnel release has been reported to be as high as 40-60% and as low as 5% [1]. The literature on therapeutic options for TTS is sparse [2,3]. We present a novel case of percutaneous peripheral nerve stimulation (PNS) of the tibial nerve to treat refractory TTS / tibial neuropathy.

ID: 209649 Peripheral Nerve Stimulation: A New Horizon for Traumatic Brachial Plexus Injury

A traumatic insult to the brachial plexus can result in a wide range of symptoms including numbness, pain, paresthesia, and weakness. [1] While surgical intervention has historically been the standard of care and can undoubtedly improve symptoms, it is not without risk. [2] The use of temporary percutaneous peripheral nerve stimulation (PNS) (SPRINT® PNS system, SPR Therapeutics) has emerged as a minimally invasive potential alternative to surgical intervention. We present a case of ballistic trauma to the brachial plexus with multilevel plexal involvement treated with a SPRINT® PNS system.

Peripheral Nerve Stimulation for Back Pain in Patients With Multiple Myeloma as Bridge Therapy to Radiation Treatment: A Case Series

ObjectivesPatients with spinal lesions or vertebral compression fractures from multiple myeloma often present with back pain that restricts their ability to lie flat and prevents them from undergoing cancer treatment. Temporary, percutaneous peripheral nerve stimulation (PNS) has been described for cancer pain secondary to oncologic surgery or neuropathy/radiculopathy from tumor invasion. The purpose of this case series is to show the use of PNS as an analgesic bridge therapy to treat myeloma-related back pain and allow patients to complete their course of radiation. Materials and MethodsTemporary, percutaneous PNS was placed under fluoroscopic guidance for four patients with unremitting low back pain secondary to myelomatous spinal lesions. Before PNS, the patients had pain refractory to medical management and were unable to tolerate radiation mapping and treatment owing to low back pain while supine. Patients were followed with routine clinic visits to monitor pain and progression through cancer therapy. PNS was removed after approximately 60 days or after completion of radiation. ResultsThis case series presents four successful cases of PNS to treat low back pain from myelomatous spinal lesions and associated vertebral compression fractures. PNS targeted the medial branch nerves to treat both nociceptive and neuropathic low back pain. All four patients successfully completed radiation therapy with PNS in place. ConclusionsPNS can effectively treat low back pain secondary to myeloma-related spinal lesions as a bridge therapy to radiation. The use of PNS is a promising option for back pain from other primary or metastatic tumors. Further research is needed into the use of PNS for cancer-related back pain.

Durable patient-reported outcomes following 60-day percutaneous peripheral nerve stimulation (PNS) of the medial branch nerves

BackgroundChronic low back pain (CLBP) is often associated with clinical evidence of central nervous system sensitization and finding a clear source of nociceptive input can be challenging. Conventional therapies targeting peripheral spinal pain structures can fail to address centrally-mediated, underlying causes of pain. Sixty-day percutaneous peripheral nerve stimulation (PNS) applied to the lumbar medial branch nerves is a non-surgical, non-opioid treatment that may restore the balance of peripheral inputs to the central nervous system and reverse maladaptive changes in central pain processing. As a minimally invasive, non-destructive treatment, percutaneous PNS was designed to be used earlier in the treatment continuum than radiofrequency ablation or permanently-implanted neurostimulation systems. ObjectiveThe objective of this clinical trial was to characterize the durability of responses to medial branch PNS in a prospective multicenter case series study of CLBP patients recalcitrant to multiple non-surgical treatments. DesignProspective, multicenter clinical trial. PopulationAdults with CLBP without radicular leg pain who had previously failed multiple types of conventional treatments. InterventionSixty-day percutaneous PNS applied to the lumbar medial branch nerves. MethodsPercutaneous PNS leads were implanted under image guidance (ultrasound and/or fluoroscopy) and treatment was applied for up to 60 days, after which the leads were removed. Participants were followed through 14 months (12 months after the 2-month PNS treatment). Prospectively-defined endpoints included assessments of pain intensity, disability, pain interference, health-related quality of life, depression, and patient global impression of change. ResultsTreatment of CLBP with 60-day percutaneous PNS treatment produced clinically meaningful improvements in average pain intensity, disability, and/or pain interference for a majority of participants through the entire 14 month follow up period without requiring permanent system implantation. The proportion of participants experiencing clinically meaningful improvement in at least one outcome (pain intensiy, disability, pain interference) with PNS was 91% after 2 months, 79% at 5 months, 73% at 8 months, 75% at 11 months, and 77% at 14 months. There were no serious or unanticipated study-related adverse events. ConclusionThis prospective multicenter clinical trial demonstrates the clinical utility of percutaneous PNS when applied to the medial branch nerves for the treatment of chronic low back pain recalcitrant to non-surgical treatments. Given the minimally invasive nature of percutaneous PNS and the significant benefits experienced by participants, percutaneous PNS provides a safe and effective first-line neuromodulation treatment for patients with CLBP that may obviate the need for neuroablative procedures or permanent neurostimulation system implantation.

Efficacy of Peripheral Nerve Stimulation with a High Frequency Electromagnetic Coupled (HF-EMC) Powered Implanted Receiver in Treating Different Pain Targets/Neuralgias.

Chronic pain is a significant global public health problem. Peripheral nerve stimulation (PNS) has been gaining popularity in recent years as it is effective, safe and less invasive than surgery for the treatment of chronic pain. The authors aimed to document and share a collection of patient-reported pain scores before and after implanting a percutaneous PNS lead/s with an external wireless generator at various target nerves. The authors designed a retrospective study, reviewing electronic medical records. Statistical analysis was performed using SPSS 26; p-value ≤ 0.05 was considered significant. The mean baseline pain scores of 57 patients have reduced significantly after the procedure at different follow-up durations. Target nerves included genicular nerves, superior cluneal nerves, posterior tibial nerve ± sural nerve, middle cluneal nerves, radial and ulnar nerves and right common peroneal nerve. In the one-month follow-up group, mean pain score was reduced from 7.44 ± 1.48 pre-procedure to 1.6 ± 1.49, from 7.42 ± 1.5 pre-procedure to 1.6 ± 1.5 7.42 at 3 months, from 7.52 ± 1.5 to 1.72 ± 1.57 at 6 months, from 7.41 ± 1.53 to 1.7 ± 1.55 at 9 months, from 7.41 ± 1.58 to 1.76 ± 1.63 at 12 months, from 7.38 ± 1.59 to 1.69 ± 1.56 at 15 months and from 7.5 ± 1.7 to 1.45 ± 1.57 at 24 months (p ≤ 0.001). Patients also reported significant reduction in morphine milliequivalent, pre-procedure MME 47.75 ± 452.5 to 37.92 ± 43.51 at 6 months (p = 0.002, N = 57), pre-procedure MME 42.72 ± 43.19 to 30.38 ± 41.62 at 12 months (p = 0.003, N = 42), and pre-procedure MME 41.2 ± 46.12 to 21.19 ± 40.88 at 24 months (p ≤ 0.001, N = 27). The only complications occurred post procedure with 2 patients receiving an explant and 1 patient receiving a lead migration. PNS has been shown to be safe and effective in treating chronic pain at different sites with sustained pain relief for up to 24 months. This study is unique in providing long-term follow-up data.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation for Chronic Refractory Neuropathic Pain - A Successful Series of 5 Challenging Cases

Percutaneous peripheral nerve stimulation (PNS) has progressed significantly over the last decade. From the proof of concept that ultrasound-guided (USG), percutaneous implantation was possible to advances in waveforms, and development of several definitive and temporary implantation systems, the field has been rapidly evolving. In this clinical series, we document 5 of the most challenging cases treated at the Department of Pain Medicine at Mayo Clinic (Florida) in 2021.

Ultrasound-guided percutaneous peripheral nerve stimulation for chronic refractory neuropathic pain: a unique series.

During the last two decades, with the advent of recent technology, peripheral nerve stimulation has become an appealing modality at the forefront of pain management. In this case series, we document the clinical rationale and technical considerations on three of the most challenging cases, refractory to previous interventions, that were treated by our team with an ultrasound-guided percutaneous peripheral nerve stimulator targeting the musculocutaneous, bilateral greater occipitaland subcostal nerves. At the6-month follow-up, all patients experienced greater than 50% relief of baseline pain, with a near-complete resolution of pain exacerbations. Furthermore, to our knowledge, this is the first report of an ultrasound-guided percutaneous technique of a peripheral nerve stimulator targeting the musculocutaneous and subcostal nerves.