The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Best Practices for Cervical Neurostimulation

IntroductionThe International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on the use of neurostimulation in the cervical region to improve outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for an often-overlooked area of neurostimulation practice.Materials and MethodsAuthors were chosen based upon their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to the present. Identified studies were graded using the US Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.ResultsThe NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.ConclusionsThe NACC recommends best practices regarding the use of cervical neuromodulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be utilized as a guide to assist decision making when clinically appropriate.     

Dutch Consensus Paper: A Consensus View on the Place of Neurostimulation Within the Treatment Arsenal of Five Reimbursed Indications for Neurostimulation in The Netherlands

IntroductionAfter an interpretation trajectory, the Dutch Quality of Healthcare Institute recommended that for five indications, spinal cord stimulation, dorsal root ganglion stimulation, or occipital nerve stimulation, together referred to as neurostimulation, can be considered effective and be reimbursed in the Netherlands. These five indications are the well and largely studied, accepted neurostimulation indications in scientific literature.As an extension of this, all the scientific societies involved in the Netherlands were required to reach a consensus about the diagnosis and treatment of these five formulated indications to describe the place of neurostimulation within the treatment algorithm. This article describes the development process and content of the consensus paper.Materials and MethodsA scientific committee, consisting of three anesthesiologists/pain physicians (one of whom acted as the working group’s chair), a neurosurgeon, a neurologist, a rehabilitation physician, and three nurse practitioners, participated. A quality advisor of the Knowledge Institute of the Dutch Federation of Medical Specialists supported the committee. The committee participated on behalf of their various scientific and professional societies. Three sessions were organized during which the place of neurostimulation in the treatment algorithm of the five relevant indications was discussed extensively. A narrative literature review and experts’ opinions formed the basis of decision-making in the process.ResultsFor all five diagnoses, general and diagnosis-specific treatment requirements, conservative treatments, and minimally invasive treatments are listed. These treatments should be considered in the chronic pain management algorithm before eventually proceeding to neurostimulation.Discussion/ConclusionThe content of this consensus view was discussed and compared with other literature on cost-effectiveness and the place in the algorithm of treating chronic pain. This Dutch consensus paper could ultimately contribute to the maintenance or expansion of neurostimulation and the reimbursement.     

Spinal‐Peripheral Neurostimulation (SPN) for Bilateral Postherniorrhaphy Pain: A Case Report

Objective: Postherniorrhaphy pain is a not uncommon, and difficult to treat, pain condition. Success with different methods of neurostimulation has been reported in the literature in the last decade. We assess the use of a new modality of neuromodulation—spinal‐peripheral neurostimulation (SPN). Materials and Methods: We report the results of treatment of a patient with bilateral, intractable postherniorrhaphy pain with SPN. Results: Significant reduction in pain and decrease in opioid consumption have been achieved. Conclusion: SPN can be an effective treatment for postherniorrhaphy pain resistant to conservative management.     

Successful Peripheral Nerve Field Stimulation for Thoracic Radiculitis Following Brown-Sequard Syndrome

Objective: The objective of this study is to present a novel approach to the treatment of thoracic radiculitis following Brown‐Sequard syndrome with peripheral nerve field stimulation (PNFS). Furthermore, we endeavor to discuss the role of PNFS in the management of refractory neuropathic pain conditions including post‐traumatic and post‐surgical neuropathy particularly with regards to the post‐surgical spine. Materials and Methods: Presented is a 57‐year‐old man with history of thoracic microdiscectomy resulting in Brown‐Sequard syndrome presented with chronic post‐operative thoracic radicular pain radiating to the abdomen, refractory to conservative management. The patient underwent three intercostal nerve blocks from T7 to T9 with transient symptomatic relief. The patient's options were limited to chemomodulation, neuromodulation, or selective intercostal nerve surgical neurectomy. He subsequently underwent a PNFS trial and reported >75% pain reduction. Permanent percutaneous PNFS electrodes were implanted subcutaneously over the right T7 and T9 intercostal nerves and replicated the trial results. Results: Neuromodulation produced pain relief with >90% improvement in pain compared with baseline both during the trial and following permanent implantation of the PNFS system. Conclusion: Chronic radicular pain may be difficult to manage in the post‐surgical patient and often requires the use of multiple therapeutic modalities. In this case, we successfully utilized PNFS as it demonstrated greater technical feasibility when compared with dorsal column stimulation and repeat surgery; therefore, it may be considered for the management of post‐surgical neuropathy. Further controlled studies are needed to evaluate the efficacy of PNFS as a treatment option.     

Prospective,Two-part Study of the Interaction Between Spinal Cord Stimulation and Peripheral Nerve Field Stimulation in Patients with Low Back Pain: Development of a New Spinal-Peripheral Neurostimulation Method

Objective: The goal of the study was to assess the efficacy of interaction between spinal cord stimulation (SCS) and peripheral nerve field stimulation (PNFS) and to evaluate a new spinal‐peripheral neuromodulation method for low back pain. Materials and Methods: The prospective two‐part study included patients with low back pain due to failed back surgery syndrome and/or spinal stenosis. In the first part 20 patients were implanted with SCS and PNFS. They selected the best program out of three: SCS alone, PNFS alone, or both together. In the second part another 20 patients with the same implanted leads were selecting between three programs: SCS and PNFS separately, SCS as anode and PNFS as cathode, or in reverse. Results: In the first part 79% of the patients selected simultaneous use of SCS and PNFS. The overall success of the trials was 85%. In the second part communication between SCS and PNFS provided wider coverage of axial pain. The overall success of the trials was 90%. Conclusion: Simultaneous use of SCS and PNFS increase efficacy of both methods for axial back pain. The new SPN method showed great potential in providing coverage for back pain.     

Peripheral Neurostimulation for the Treatment of Refractory Cluster Headache,Long-Term Follow-Up: Case Report

Introduction: Cluster headache is a headache syndrome characterized by periodic episodes of intense headache with spontaneous remission. There are recent reports utilizing occipital nerve stimulation for the successful management of medically refractory cases of cluster headache. Methods: The case of an 18‐year‐old boy with chronic, refractory, recurrent cluster headaches is presented. He was treated surgically with combined occipital, supraorbital, and infraorbital nerve stimulation. Results: Prior to operation, the patient suffered three to four episodes of cluster headache per day, for four years. After implantation of occipital, supraorbital, and infraorbital nerve stimulators, the patient averages at most three to four headaches per month, at 36‐month follow‐up. Conclusion: Peripheral neurostimulation is safe and efficacious in the management of chronic, medically refractory cluster headache syndrome. The efficacy of treatment was found to be persistent after three years.     

EFNS guidelines on neurostimulation therapy for neuropathic pain

Pharmacological relief of neuropathic pain is often insufficient. Electrical neurostimulation is efficacious in chronic neuropathic pain and other neurological diseases. European Federation of Neurological Societies (EFNS) launched a Task Force to evaluate the evidence for these techniques and to produce relevant recommendations. We searched the literature from 1968 to 2006, looking for neurostimulation in neuropathic pain conditions, and classified the trials according to the EFNS scheme of evidence for therapeutic interventions. Spinal cord stimulation (SCS) is efficacious in failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) type I (level B recommendation). High-frequency transcutaneous electrical nerve stimulation (TENS) may be better than placebo (level C) although worse than electro-acupuncture (level B). One kind of repetitive transcranial magnetic stimulation (rTMS) has transient efficacy in central and peripheral neuropathic pains (level B). Motor cortex stimulation (MCS) is efficacious in central post-stroke and facial pain (level C). Deep brain stimulation (DBS) should only be performed in experienced centres. Evidence for implanted peripheral stimulations is inadequate. TENS and r-TMS are non-invasive and suitable as preliminary or add-on therapies. Further controlled trials are warranted for SCS in conditions other than failed back surgery syndrome and CRPS and for MCS and DBS in general. These chronically implanted techniques provide satisfactory pain relief in many patients, including those resistant to medication or other means.