Peripheral Field Stimulation Research Articles

Peripheral Field Stimulation for the Management of Facial Pain

Peripheral nerve field stimulation (PNFS) is a tool in the armamentarium of treatment options for trigeminal pain; however, the efficacy of this modality in mitigating trigeminal pain remains unclear. The aim of the present study was to examine the existing literature on PNFS and elucidate outcomes associated with its use in patients with trigeminal pain.

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.

Commentary: Management of Refractory Pain After Total Joint Replacement

Chronic refractory pain after total joint replacement is debilitating and a source of dissatisfaction for patients. The management of pain following total joint replacement varies during the acute postoperative period compared to the 3 months postoperative at which point the pain is considered chronic pain. Acute postoperative pain relief programs have seen promising results with multimodal pain control through the use of combinations of opioids, acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids and ketamine. The addition of regional blocks to the multimodal regimen has improved acute postoperative pain control following total joint replacements. On the other hand, chronic pain can be successfully managed with options including genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). While there is still minimal data on chronic pain relief regimens, meta-analyses and case reports have demonstrated the effectiveness and promising outcomes. This paper aims to evaluate the current medications and treatment options for managing refractory pain following TJA.

Management of Refractory Pain After Total Joint Replacement.

Chronic pain after total joint replacement (TJA), specifically total knee replacement (TKA), is becoming more of a burden on patients, physicians, and the healthcare system as the number of joint replacements performed increases year after year. The management of this type of pain is critical, and therefore, understanding the various modalities physicians can use to help patients with refractory pain after TJA is essential. The modalities by which chronic pain can be successfully managed include genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). Meta-analyses and case reports have demonstrated the effectiveness of these treatment options in improving pain and functional outcomes in patients with chronic pain after TKA. The purpose of this paper is to review and synthesize the current literature investigating the different ways that refractory pain is managed after TJA, with the goal being to provide treatment recommendations for providers treating these patients.

Peripheral Nerve Stimulation in Pain Management: A Systematic Review

Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. To assess the clinical evidence of PNS in the treatment of acute or chronic pain. A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data syntheses: 227 studies met inclusion criteria and were included in qualitative synthesis. Evidence synthesis based on randomized controlled trials (RCTs) and observational studies showed Level I and II evidence of PNS in chronic migraine headache; Level II evidence in cluster headache, postamputation pain, chronic pelvic pain, chronic low back and lower extremity pain; and Level IV evidence in peripheral neuropathic pain, and postsurgical pain. Peripheral field stimulation has Level II evidence in chronic low back pain, and Level IV evidence in cranial pain. Lack of high-quality RCTs. Meta-analysis was not possible due to wide variations in experimental design, research protocol, and heterogeneity of study population. The findings of this systematic review suggest that PNS may be effective in managing chronic headaches, postamputation pain, chronic pelvic pain, and chronic low back and lower extremity pain, with variable levels of evidence in favor of this technique.

Electric Field Stimulation for the Functional Assessment of Isolated Dorsal Root Ganglion Neuron Excitability.

Genetically encoded calcium indicators have proven useful for characterizing dorsal root ganglion neuron excitability in vivo. Challenges persist in achieving high spatial-temporal resolutions in vivo, however, due to deep tissue imaging and motion artifacts that may be limiting technical factors in obtaining measurements. Here we report an ex vivo imaging method, using a peripheral neuron-specific Advillin-GCaMP mouse line and electric field stimulation of dorsal root ganglion tissues, to assess the sensitivity of neurons en bloc. The described method rapidly characterizes Ca2+ activity in hundreds of dorsal root ganglion neurons (221 ± 64 per dorsal root ganglion) with minimal perturbation to the in situ soma environment. We further validate the method for use as a drug screening platform with the voltage-gated sodium channel inhibitor, tetrodotoxin. Drug treatment led to decreased evoked Ca2+ activity; half-maximal response voltage (EV50) increased from 13.4V in untreated tissues to 21.2, 23.3, 51.5 (p < 0.05), and 60.6V (p < 0.05) at 0.01, 0.1, 1, and 10µM doses, respectively. This technique may help improve an understanding of neural signaling while retaining tissue structural organization and serves as a tool for the rapid ex vivo recording and assessment of neural activity.

Proceedings #49: Management of Trigeminal Autonomic Cephalgia with Cranial Peripheral Nerve and Peripheral Field Stimulation

Proceedings #49: Management of Trigeminal Autonomic Cephalgia with Cranial Peripheral Nerve and Peripheral Field Stimulation

Stimulus-Driven Cortical Hyperexcitability in Individuals with Charles Bonnet Hallucinations

Throughout the lifespan, the cerebral cortex adapts its structure and function in response to changing sensory input [1, 2]. Whilst such changes are typically adaptive, they can be maladaptive when they follow damage to the peripheral nervous system, including phantom limb pain and tinnitus [3, 4]. An intriguing example occurs in individuals with acquired ocular pathologies-most commonly age-related macular degeneration (MD) [5]-who lose their foveal vision but retain intact acuity in the peripheral visual field. Up to 40% of ocular pathology patients develop long-term hallucinations involving flashes of light, shapes, or geometric patterns and/or complex hallucinations, including faces, animals, or entire scenes, a condition known as Charles Bonnet Syndrome (CBS) [6, 7, 8]. Though CBS was first described over 250 years ago [9, 10], the neural basis for the hallucinations remains unclear, with no satisfactory explanation as to why some individuals develop hallucinations, while many do not. An influential but untested hypothesis for the visual hallucinations in CBS is that retinal deafferentation causes hyperexcitability in early visual cortex. To assess this, we investigated electrophysiological responses to peripheral visual field stimulation in MD patients with and without hallucinations and in matched controls without ocular pathology. Participants performed a concurrent attention task within intact portions of their peripheral visual field, while ignoring flickering checkerboards that drove periodic electrophysiological responses. CBS individuals showed strikingly elevated visual cortical responses to peripheral field stimulation compared with patients without hallucinations and controls, providing direct support for the hypothesis of visual cortical hyperexcitability in CBS.

Sandwich technique, peripheral nerve stimulation, peripheral field stimulation and hybrid stimulation for inguinal region and genital pain

Objective: Ilioinguinal neuralgia (IG) and genitofemoral (GF) neuralgia following inguinal hernia repair is a chronic and debilitating neuropathic condition. Recently, peripheral nerve stimulation has become an effective and minimally invasive option for the treatment of refractory pain. Here we present a retrospective case series of six patients who underwent placement of peripheral nerve stimulation electrodes using various techniques for treatment of refractory post-intervention inguinal region pain.Methods: Six patients with post-intervention inguinal, femoral or GF neuropathic pain were evaluated for surgery. Either octopolar percutaneous electrodes or combination of paddle and percutaneous electrodes were implanted in the area of their pain. Pain visual analog scores (VAS), surgical complication rate, preoperative symptom duration, degree of pain relief, preoperative and postoperative work status, postoperative changes in medication usage, and overall degree of satisfaction with this therapy was assessed.Results: All six patients had an average improvement of 62% in the immediate post-operative follow-up. Four patients underwent stimulation for IG, one for femoral neuralgia, and another for GF neuralgia. Peripheral nerve stimulation provided at least 50% pain relief in all the six patients with post-intervention inguinal region pain. 85% of patients indicated they were completely satisfied with the therapy overall. There was one treatment failure with an acceptable complication rate.Conclusion: Peripheral nerve or field stimulation for post-intervention inguinal region pain is a safe and effective treatment for this refractory and complex problem for patients who have exhausted other management options.

Some Non‐FDA Approved Uses for Neuromodulation: A Review of the Evidence

Neuromodulation, including spinal cord stimulation and peripheral nerve field stimulation, has been used with success in treating several painful conditions. The FDA approved the use of neuromodulation for a few indications. We review evidence for neuromodulation in treating some important painful conditions that are not currently FDA approved. This review included an online web search for only clinical trials testing the efficacy of neuromodulation in treating coronary artery disease, peripheral vascular disease (PVD), headache, and peripheral field stimulation. Our systematic literature search found 10, 6, and 3 controlled studies relating to coronary artery disease, PVD, and headache, respectively. Our review also included 5 noncontrolled studies relating to peripheral field stimulation, as no controlled studies had been completed. This review article shows compelling evidence based on clinical trials that neuromodulation can be of benefit for patients with serious painful conditions that are not currently approved by the FDA.

Peripheral field stimulation for thoracic post herpetic neuropathic pain

ObjectivePost herpetic neuralgia is a chronic, debilitating pain with very few management options and is often refractory to treatment. We present our experience with a series of 4 patients who underwent subcutaneous peripheral field stimulation for treatment of thoracic post herpetic neuropathic pain. MethodsFour patients with intractable thoracic post herpetic neuropathic pain were operated after maximum medical treatment and a neuropsychological evaluation. Multiple percutaneous electrodes were placed in the subcutaneous plane in the region of pain for a 7-day trial. Following a successful trial (more than 50% reduction of pain), the electrodes were then internalized and attached to a pulse generator. Visual analog scores (VAS) were studied during the preoperative, immediate postoperative and last follow-up visits. Long-term treatment results were determined by retrospective review of medical records. Average follow-up period was 28.2 months. ResultsAll 4 patients showed persistent improvement in their VAS pain scores with an average improvement of more than 75%. There were no treatment failures and no complication requiring re-operation was reported. ConclusionPeripheral field stimulation for the treatment of post herpetic neuropathic pain is a safe and effective method for pain relief for an extremely complex problem with very few solutions. Patient selection and proper lead placement is most important for the success of treatment.

Lumbar Subcutaneous Peripheral Field Stimulation in Eleven Patients with Chronic Low Back Pain and/or Post Laminectomy Syndrome

Lumbar Subcutaneous Peripheral Field Stimulation in Eleven Patients with Chronic Low Back Pain and/or Post Laminectomy Syndrome

Brief Report: Preliminary Evidence of Reduced Sensitivity in the Peripheral Visual Field of Adolescents with Autistic Spectrum Disorder

A number of studies have demonstrated atypical perception in individuals with ASD. However, the majority of these studies have presented stimuli to central vision. The aim of the study presented here was to test the sensitivity of peripheral vision in ASD. This was achieved by asking participants to detect brief flashes of light presented between 30 and 85 degrees away from fixation. We found that participants with ASD detected fewer ligh-flashes than the control participants. This deficit was more pronounced in the nasal hemifield than the temporal hemifield. We suggest that the imbalance between nasal and temporal hemifield sensitivity may contribute to the peripheral-field stimulation and lateral glances that are observed in ASD.

Triangular Stimulation Method Utilizing Combination Spinal Cord Stimulation With Peripheral Subcutaneous Field Stimulation for Chronic Pain Patients: A Retrospective Study

This retrospective data collection study aims to evaluate the responses of patients who have been implanted with a neuromodulation system using a combination of spinal cord stimulation (SCS) and peripheral subcutaneous field stimulation (PSFS) leads for chronic intractable pain. Forty patients with chronic, intractable pain implanted with both SCS and PSFS leads were enrolled in a retrospective data collection study. Pre-implant data (demographics, pain levels, pain location, and medication use) and post-implant data (pain levels, medication use, and device programming reports) were compared to measure short- and long-term improvements in pain for a period of approximately six months. Device system use and parameter data were collected. The majority of patients experienced immediate and short-term pain relief and reduction in oral pain medications as a result of combination SCS/PSFS therapy. The improvements were maintained for some, but not all patients by six months. Patients cycled through multiple programs over follow-up; the use of triangular stimulation was consistent over time, and by six months, patients preferred this program over others. Limitations of the retrospective chart review included missing data and variable follow-up times, and may have made determinations of long-term efficacy difficult. This study demonstrates that combination SCS and PSFS therapy is potentially a beneficial treatment option for reducing pain levels and oral pain medication compared with baseline in previously resistive chronic pain patients. There is a need for further study of this therapy in a greater number of subjects and in a prospective, controlled setting. In the author's general experience, triangular stimulation is very effective for treating isolated low back pain, because it covers larger topographic areas of the lower back than flow or field stimulation. An investigational device exemption study will be necessary for subcutaneous field stimulation indicated for focal isolated pain to be adequately investigated and utilized by physicians in the future.

Atlas of Implantable Therapies for Pain Management

This book is edited and half written by a widely published anaesthesiologist and has contributions from 111 North American and one European specialist implanters, half of whom are anaesthesiologists and half neurosurgeons. It has 28 chapters in just under 200 pages and is divided into four parts: 1) spinal cord stimulation, 2) peripheral nerve and peripheral field stimulation, 3) neurostimulation of the cranium and head and 4) intrathecal drug delivery. This book covered a lot of ground within the field of implantable therapies. Being an Atlas it is a technical vade mecum and the focus is on how to do the implantation procedures and the pitfalls to avoid. It does not set out the place of such implantation therapies amongst the gamut of pain relieving treatments. Nor does it set out the adjunctive treatments that may be critical in obtaining the best results from the employment of such therapies. It is thus left up to the reader to decide when and if such expensive and invasive therapies are indicated and which other treatment modalities may need to coexist for the optimum outcome. It therefore assumes a prior understanding of the subject. It is written from a very North American perspective. It makes scant reference to the European experience and research in this field and thus for me lacked balance. There were some inconsistencies. For example the programming chapter deals with a tripole and yet in the surgically implanted lead chapter there are bipoles to the new penta lead with five parallel arrays that straddle the posterior columns and thus provide theoretically greater programming possibilites. There is considerable variation in chapter layouts and the font sizes are too small. Illustrations are not centred with the text, their size is too small, and many are crowded together. Fewer larger illustrations would have been clearer and more instructive. The references quoted which informed the text were taken mostly from the North American medical literature and missed out on a wealth of European research and experience. A lot of the references quoted cohort studies, often quite old, which were not controlled studies and offered weak evidence at best. Generally the book endeavoured to cover a lot of ground but it lacked clarity at times because of insufficient detail. There was a significant omission of discussion of high frequency neuromodulation in relation to conventional neuromodulation but there was a chapter devoted to EMG/ SSEP for the positioning of a particular tripolar lead which many practitioners would consider an unnecessary extra expense with little proven value. For the practitioner new to the field of implantable therapies this book shows the scope of this particular branch of pain medicine. It is full of good advice on techniques and how to avoid complications. It is sadly let down by the layout and the brevity of the chapters. For the experienced practitioner it is frustrating in its lack of detail. One is left with the feeling that if it contained half the number of illustrations and that the text dealt with the subject matter in more detail quoting worldwide experience and research that it would be a very useful addition to the pain management library.

Subcutaneous Target Stimulation or Peripheral Subcutaneous Field Stimulation: That Is the Question

Subcutaneous Target Stimulation or Peripheral Subcutaneous Field Stimulation: That Is the Question

Subcutaneous Target Stimulation–Peripheral Subcutaneous Field Stimulation in the Treatment of Refractory Angina: Preliminary Case Reports

Spinal cord stimulation is now established as an effective treatment for refractory angina. We present the use of an alternative approach to neuromodulation of anginal pain using subcutaneous leads placed at the site of pain. In this case series, five patients with refractory angina received successful treatment with subcutaneous target stimulation-peripheral subcutaneous field stimulation. This technique was able to provide good analgesia in two patients that had had poor pain relief from existing spinal cord stimulators. All five patients achieved significant pain relief with a reduction in symptoms and a decrease in the use of pain medication.

Rethinking Algorithms of Pain Care: The Use of the S.A.F.E. Principles

In 1996, Krames, trying to make sense out of therapeutic choice for pain management of chronic noncancer-related pain problems wrote that “because there are multiple choices, both interventional and noninterventional for the management of pain, the treating physician should choose one therapy over another in a rational manner …”[1] Because, at the time there was little information to mine for decision-making, the only variables accessible to the treating physician for choosing one therapy over another were levels of invasiveness and “up-front” costs of the therapy. Krames suggested an algorithm of choosing that was based on the time-honored medical principle, the KISS principle, or “Keep It Sweet and Simple.” This algorithm based on the KISS principle listed least invasive and less “up-front” costly therapies first and more invasive and more costly therapies, later in the algorithm. He also suggested that some therapies could be used in series, some in parallel, abandoning those that do not work and trying more invasive therapies and more costly therapies until the algorithm (choices) was exhausted. Based on this algorithm, implantable technologies for pain, stimulation therapies, and implantable drug delivery systems (IDDS) were relegated to last resort therapy. While this approach was appropriate for the time, today, a review of the literature allows us to make more rational choices between pain therapies based on variables other than invasiveness and up-front costs. Today, it may not be in the best interest of a patient, or even the third party payer, to wait until all less costly and less invasive, but not effective, treatment options have failed before initiating more invasive therapies including nerve-blocking procedures, epidural steroid injections, facet injections/neurolysis, or therapies of neuromodulation, such as spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), peripheral subcutaneous field stimulation (PSFS), or intrathecal therapies via IDDS. If a given …

The Effect of Central and Peripheral Field Stimulation on the Rise Time and Gain of Human Optokinetic Nystagmus

We wished to examine the spatial (gain) and temporal (rise time) properties of human optokinetic nystagmus (OKN) as a function of stimulus velocity and field location. Stimuli were either M-scaled random dots or vertical stripes that moved at velocities between 20-80 deg s(-1). Three field conditions were examined: full field; a 20 deg central field; and a 12.5 deg central-field mask. OKN gain was found to be significantly affected by stimulus velocity and stimulus location, with the higher stimulus velocities and the 12.5 deg central-field mask giving lower gains. Steady-state gains for all three field conditions were not found to be affected by prior adaptation to stationary or moving stimuli. The 63% rise time was found to be significantly affected by the stimulus velocity, whereas this was not the case for the 90% rise time. Neither rise time was found to be significantly affected by the field location. These results indicate that, although the effectiveness (gain) of peripheral retina is lower than that of the central retina during optokinetic stimulation, the peripheral retina has access to common mechanisms responsible for the fast component of OKN.

Neither Spinal γ-Aminobutyric Acid-A nor Strychnine-Sensitive Glycine Receptor Systems Are the Sole Mediators of Halothane Depression of Spinal Dorsal Horn Sensory Neurons

Inhaled anesthetics depress the response of spinal dorsal horn low-threshold (LT) neurons to peripheral receptive field stimulation. Part of that depression may be mediated by anesthetic interactions with gamma-aminobutyric acid type A (GABA(A)) and strychnine-sensitive glycine inhibitory neurotransmitter systems. In this electrophysiological study, we attempted to antagonize halothane depression of LT neurons by administering bicuculline (a competitive GABA(A) antagonist) and/or strychnine (a competitive glycine antagonist) systemically, alone or in combination, to decerebrate, spinal cord-transected rats. We observed that both bicuculline and strychnine, alone or in combination, significantly but only partially reversed halothane depression of LT neuronal responses to receptive field stimulation. The inability of bicuculline and strychnine, alone or in combination, to completely reverse halothane depression suggests that although GABA(A) and glycine systems are involved in the observed halothane depression, additional mechanisms of action are also required for halothane depression of LT spinal sensory neurons. The results of this study support the hypothesis that halothane depression of spinal sensory neurons is mediated, but not completely, by the anesthetic effects on gamma-aminobutyric acid type A and strychnine-sensitive glycine neurotransmitter systems.