Ultrasound imaging and occipital nerve stimulation

https://doi.org/10.1111/j.1525-1403.2009.00254.xGet rights and content

Objectives

Occipital nerve stimulation (ONS) is a peripheral nerve stimulation (PNS) technique that has been used with success in the management of intractable chronic daily headaches (CDHs) and occipital neuralgia (ON). The technique involves the placement of a stimulating surgical or percutaneous electrode over the occipital nerves within the subcutaneous tissues at the skull base. Until recently, procedures involving the occipital nerves were based on identifying bony or arterial landmarks with direct palpation or fluoroscopy. Although universally accepted as an imaging technique, fluoroscopy does not provide real-time imaging of the occipital nerves or vessels. Furthermore, therapeutic efficacy of ONS is directly related to the ability of the stimulating electrode to produce peripheral nerve dermatomal paresthesia, emphasizing the need for precision placement.

Materials and Methods

A total of six patients, diagnosed with refractory CDH and ON, after failing extensive medical management, were diagnosed as potential candidates for ONS. Subsequently, all underwent successful percutaneous trials of bilateral octopolar (Advanced Neuromodulation Systems, Plano, TX, USA) ONS under ultrasound guidance, followed by permanent surgical implantation.

Results

In this case series, ultrasound provided accurate, real-time placement of introducer needles and stimulating electrodes by allowing visualization of tissue planes (epidermis, dermis, subcutaneous fat, and trapezious muscle), as well as vessels and nervous structures.

Conclusions

Ultrasound imaging has been used increasingly for peripheral nerve blockade in surgical anesthesia and in chronic pain management as it allows real-time localization of both nervous and vascular structures (color flow Doppler) and, thus, a method for increasing blockade precision and safety. As an adjunct to ONS, the position of the introducer needles and electrodes can be visualized in relation to the occipital nerves and vasculature. This reproducible positioning allows accurate depth of placement (assuring production of the prerequisite PNS dermatomal paresthesia required for ONS efficacy) and limits the risk of injury to the occipital artery or nerve(s). In this case series, ultrasonography provided real-time, safe, and reliable placement of ONS electrodes. It also allowed identification of nervous and vascular structures unable to be seen with fluoroscopy, The portable nature of modern ultrasound machines, together with an ever improving pixelation of the Doppler color flow images/real-time measurements, and a lack of radiation exposure make this technology an attractive emerging modality in the field of Neuromodulation.

Section snippets

INTRODUCTION

Chronic daily headache (CDH) syndromes represent a major health issue worldwide in terms of lost workdays and revenue (1., 2., 3.). Diagnoses include migraine, atypical migraine, cluster, transformed migraine, and cervicogenic headaches, as well as occipital and facial hemicranias, or any combination of the above. Many of these patients are totally disabled, having failed conservative and pharmacologic treatments (4,5).

Occipital neuralgia (ON), however, is described by the National Institute of

METHODS

A total of six patients, diagnosed with refractory CDH and ON, were referred from the neurology service. After failing extensive medical management (biofeedback, physical therapy, massage, acupuncture, narcotics, NSAID’s, tricycle antidepressants, anticonvulsants, tryptans, beta blockers), they were diagnosed as potential candidates for ONS after positive anesthetic phase response to occipital nerve blockade. Subsequently, all underwent successful percutaneous trials of bilateral octopolar

DISCUSSION

Ultrasound guidance in regional anesthesia and pain medicine was first described in 1978 (27). A Doppler ultrasound blood flow detector was used to localize the third division of the subclavian artery, rendering the supraclavicular approach to the brachial plexus safer and highly successful. The ultrasound-guided applications have emerged not only as an alternative to regional anesthesia neurostimulating techniques (21,22) but also as an alternative to radiation emitting fluoroscopic techniques

CONCLUSION

In this case series, ultrasonography provided real-time, safe, and reliable placement of ONS electrodes. It also allowed identification of nervous and vascular structures unable to be seen with fluoroscopy. The portable nature of modern ultrasound machines, together with an ever-improving pixelation of the Doppler color flow images/real-time measurements, and a lack of radiation exposure make this technology an attractive emerging modality in the field of neuromodulation. Future prospective

REFERENCES (29)

  • EversS et al.

    Recent advances in the treatment of headaches

    Curr Opin Anaesthesiol

    (2005)
  • AshkenaziA et al.

    Review: greater occipital nerve block for migraine and other headaches: is it useful?

    Curr Pain Headache Rep

    (2007)
  • NavaniA et al.

    A case of pulsed radiofrequency lesioning for occipital neuralgia

    Pain Med

    (2006)
  • TaylorM et al.

    Botulinum toxin type-A (BOTOX) in the treatment of occipital neuralgia: a pilot study

    Headache

    (2008)
  • Cited by (0)

    For more information on author guidelines, an explanation of our peer review process, and conflict of interest informed consent policies, please go to http://www.wiley.com/bw/submit.asp?ref=1094-7159&site=1

    View full text