Occipital Nerve PNS

[Nonphysiologic]

Hey All,

Has anyone here done a peripheral nerve stimulator for Occipital Neuralgia? I have a patient who has done every medical and almost every interventional option for his occipital neuralgia as well as seen tons of academic headache specialists. Nothing has worked. The only thing that has worked are Occipital nerve blocks at the ridge which provide temporary but profound relief (on the order of days to weeks). TON C3/4 Rhizotomies/blocks haven't worked either. So the other day I trialed a PNS stimulator and placed the leads at the bilateral occipital ridges kind of like this picture below (not my actual patient's picture).

It went very well. The patient had >95% relief for one week of the trial and tells me he still feels like he has some residual benefit from the trial. He was so happy. He was in tears at the follow up post op. He is really looking forward to the implant.

The problem is the company I'm using has a small IPG that I have to figure out where to put and how to tunnel it. I have several concerns and because of these concerns I may refer out or just refer to a neurosurgeon who does this but he puts the stimulator at C2 (NOT where I trialed and had major success), or maybe send to surgery for decompression.

1. I've never done one of these but it seemed easy enough to trial. I am a little concerned about the implant because I don't know a good place to place the IPG (albiet being tiny and thing. It is with mainly with this company because this is the only one my ASC approved). I am concerned about lead migration because its in the neck- an area with so much mobility.
2. It is technically considered "off-label" use of the device and I have never done one before. I don't really know anyone in my area who does much of this. I am concerned that in the event something goes wrong both of those situations can be used against me. I would like to see one being done but I don't know anyone else near me that does this.
3. The skin near the occipital ridge and the superior neck does not have much fat and so I think tunneling might be difficult.
4. Should I just NOT do this with this company and wait till my ASC approves the PNS company that does not have an IPG to tunnel to (Like StimWave)?

My main two concerns are IPG placement/tunneling as well as the technical off label use.

I really want this to work out for this patient because he is desperate has been dealing with this since being a teenager and he tells me he felt alive for the first time in a long time during the trial.

Thanks.

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[Nodolor]

"I really want this to work out for this patient because he is desperate has been dealing with this since being a teenager and he tells me he felt alive for the first time in a long time during the trial."

This pt is destined for failure

 

[lobelsteve]

we did a lot of these in my fellowship training but mostly because we could not because they were needed. I’ve got one in private practice that’s been there for seven or eight years and it’s helping significantly. The IPG is in the posterior axilla and the tunneling is quite simple.

 

[Laryngospasm]

My former partner used to do this a lot. Lots of issues with the leads but some success.

 

[Agast]

Hindsight is 2020, but I would not trial a patient unless I had a plan for the implant. I would definitely not switch gears to a decompression or lead placement in an area that was not trialed. I've seen IPG that was tunneled to mid back.

I'm not sure how the Stimwave would be much better. Is he going to wear the receiver on the back of his head on a band? How does that work.

 

[Orin]

Done a few in fellowship and since. Technically not challenging but the need for revisions due to migration/fracture of the leads is the problem.

Stimwave and Nalu don't fix the lead fracture issue, although the PNS barbs may help the migration. The Stimrouter lead should fix the fracture and migration issue but the external patch positioning makes it a challenge. There was a poster for a suboccipital placement that looked promising, but haven't tried that yet. You could try the temporary Sprint PNS lead if you can't get the implant done.

I agree though, good to have an implanter lined up if you can't/won't do it.

 

[callmeanesthesia]

A local neurosurgeon did occipital neurectomies - she would send me patients for diagnostic block sometimes. She claimed a very high success rate. Would probably eliminate the option of PNS though with the scar tissue.

 

[gdub25]

Agree with having surgeon clip the nerve. It fixes the problem for good. Patient ends up with numbness in the area supplied by the occipital nerve but any patient who gets this far down the treatment algorithm is happy to have that as a trade off.

 

[Taus]

Agree with having surgeon clip the nerve. It fixes the problem for good. Patient ends up with numbness in the area supplied by the occipital nerve but any patient who gets this far down the treatment algorithm is happy to have that as a trade off.

You talking about at GON or c2 ganglionectomy? A neurosurgeon at my fellowship institution did the latter and referred us the diagnostic blocks. I reviewed literature Around that time and although it was limited was overall fairly positive from my recollection

 

[gdub25]

C2 ganglionectomy.

 

[callmeanesthesia]

You talking about at GON or c2 ganglionectomy? A neurosurgeon at my fellowship institution did the latter and referred us the diagnostic blocks. I reviewed literature Around that time and although it was limited was overall fairly positive from my recollection

I think the surgeon in my area was doing GON - she described just a small incision on the back of the scalp.

 

[Baron Samedi]

Also did several in fellowship, also did several revisions for lead migration.

 

[bedrock]

A local neurosurgeon did occipital neurectomies - she would send me patients for diagnostic block sometimes. She claimed a very high success rate. Would probably eliminate the option of PNS though with the scar tissue.

we did a lot of these in my fellowship training but mostly because we could not because they were needed. I’ve got one in private practice that’s been there for seven or eight years and it’s helping significantly. The IPG is in the posterior axilla and the tunneling is quite simple.

My former partner used to do this a lot. Lots of issues with the leads but some success.

I've done about 10 cases in my decade of PP. I've seen some great outcomes but agree that lead migration can be PITA. Agree with steve that the tunneling is simple.

Regarding surgery I've seen it work well, but also sometime worsen symptoms. This you should discuss in detail with the patient ahead of time. stim has less risk, but they have to deal with a device, lead breakage, IPG replacement, etc.

Basically it comes down to your local area and how rural you are.

If you are urban and have a good local neurosurgeon that does this at least a couple times a year, I'd go that route.
If you are rural or have no surgeon within a few hours who can do the surgery and manage the patient afterwards, then I would stim, or if a patient wouldn't consider surgery at all, I would give them the option of stim.

 

[SC Tian]

Does anyone in this group encounter the denial from insurance for this type of occipital nerve stimulation? I used to do it in large non-profit group, now switched to a private group, anyone can share your experiences of insurance authorization situation for occipital stim.
As far as migration, Years ago the techniques of double anchoring from Mayo Clinic seems to work for me, Thanks for your help.

 

[painfree23]

Hey All,

Has anyone here done a peripheral nerve stimulator for Occipital Neuralgia? I have a patient who has done every medical and almost every interventional option for his occipital neuralgia as well as seen tons of academic headache specialists. Nothing has worked. The only thing that has worked are Occipital nerve blocks at the ridge which provide temporary but profound relief (on the order of days to weeks). TON C3/4 Rhizotomies/blocks haven't worked either. So the other day I trialed a PNS stimulator and placed the leads at the bilateral occipital ridges kind of like this picture below (not my actual patient's picture).
View attachment 338057
It went very well. The patient had >95% relief for one week of the trial and tells me he still feels like he has some residual benefit from the trial. He was so happy. He was in tears at the follow up post op. He is really looking forward to the implant.

The problem is the company I'm using has a small IPG that I have to figure out where to put and how to tunnel it. I have several concerns and because of these concerns I may refer out or just refer to a neurosurgeon who does this but he puts the stimulator at C2 (NOT where I trialed and had major success), or maybe send to surgery for decompression.

1. I've never done one of these but it seemed easy enough to trial. I am a little concerned about the implant because I don't know a good place to place the IPG (albiet being tiny and thing. It is with mainly with this company because this is the only one my ASC approved). I am concerned about lead migration because its in the neck- an area with so much mobility.
2. It is technically considered "off-label" use of the device and I have never done one before. I don't really know anyone in my area who does much of this. I am concerned that in the event something goes wrong both of those situations can be used against me. I would like to see one being done but I don't know anyone else near me that does this.
3. The skin near the occipital ridge and the superior neck does not have much fat and so I think tunneling might be difficult.
4. Should I just NOT do this with this company and wait till my ASC approves the PNS company that does not have an IPG to tunnel to (Like StimWave)?

My main two concerns are IPG placement/tunneling as well as the technical off label use.

I really want this to work out for this patient because he is desperate has been dealing with this since being a teenager and he tells me he felt alive for the first time in a long time during the trial.

Thanks.

Why not occipital nerve rf or decompression instead of implanting something?

 

[SC Tian]

 

[SC Tian]

this lady has significant left sided occipital pain, imo, rf of occipital nerve with mainly skin innervation, causing more dysesthesia that can be very unpleasant to patients.

 

[MitchLevi]

this lady has significant left sided occipital pain...

Does she???

That sucks and it hurts me to see that image.

We don't all get the same experience on Earth.

 

[lobelsteve]

History please. Xray unrevealing for what was done surgically.

 

[SC Tian]

Oh, this is a poor 80 plus lady with C1-2 spinal stenosis from pannus formation posterior to dens resulting in compression myelopathy, did decompression and fusion occiput to C6, recovered slowly, with very significant neck, arm pain and headache, did cervical epidural twice, moderate improvement in arms symptoms, need Some helps to know if we can get approved for the occipital nerve stim? Thanks.

 

[bedrock]

This lady definitely deserves an occipital stimulator.

Migration won't be a major issue as I'm sure there isn't much movement.

 

[lobelsteve]

This lady definitely deserves an occipital stimulator.

Migration won't be a major issue as I'm sure there isn't much movement.

Much = none

 

[MitchLevi]

Migration won't be a major issue as I'm sure there isn't much movement.

Good point.