Burst or Conventional Peripheral Nerve Field Stimulation for Treatment of Neuropathic Facial Pain

Abstract

Background Trigeminal Neuropathic Pain (TNP) is a chronic facial pain syndrome caused by a lesion or disease affecting one or more branches of the trigeminal nerve. It may, for example, result from accidental injury to a branch of the trigeminal nerve by trauma or during surgery; it may also be idiopathic. TNP is typically constant, in contrast to most cases of the commoner trigeminal neuralgia. In some cases, pain may be refractory to pharmacological treatment. Peripheral nerve field stimulation is recognized as an effective minimally invasive surgical treatment option for this debilitating condition. To date, stimulation has used conventional tonic waveforms, which generate paraesthesia in the stimulated area. This is the first report of the use of paraesthesia‐free burst pattern stimulation for TNP. Methods Seven patients were treated at the John Radcliffe Hospital for TNP from 2016 to 2018. Mean duration of preoperative symptoms was five years. All patients had exhausted pharmacological measures to limited effect. The initial three patients had tonic stimulation with the subsequent four having burst stimulation. Outcome was assessed using the numeric pain rating scale preoperatively and postoperatively at three and six months and one year. Side‐effects and complications were also assessed as well as reduction in analgesic medication use. Results All patients achieved pain reduction of at least 50% at 6 months (range 50–100%, mean 81%, p = 0.0082). Those in the burst stimulation group were paraesthesia free. One patient developed a postoperative infection for which the system had to be removed and is awaiting reimplantation. There were no other complications in either group. Conclusion Burst stimulation conferred similar pain control to tonic stimulation in our small cohort, and there were similar reductions in pain medication use. An additional benefit of burst stimulation is freedom from paraesthesia. Larger scale studies are needed to further evaluate burst stimulation and compare its efficacy with that of tonic stimulation.

Clinical outcomes and complications of peripheral nerve field stimulation in the management of refractory trigeminal pain: a systematic review and meta-analysis

“…Only 2 studies reported the median number of failed pain medications, which was 3 for both studies. 1,7 Nine studies treated cohorts consisting of mixed diagnoses. The most common diagnoses were persistent idiopathic facial pain (PIFP; n = 26) and trigeminal neuropathic pain (TNP; n = 25), followed by postherpetic neuralgia (PHN; n = 19), symptomatic trigeminal neuralgia (STN; n = 14), trigeminal neuralgia type 2 (TN2; n = 12) and type 1 (TN1; n = 8), and trigeminal deafferentation pain (TDP; n = 5).…”

“…Evidence supporting the utility of PNFS for treating trigeminal pain is based solely on uncontrolled retrospective and prospective observational studies. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Until the results of high-quality RCTs become available, we argue that a meta-analysis of reported outcomes provides the strongest support for the use of PNFS for trigeminal pain. In this paper, we identify studies that report on outcomes of PNFS for trigeminal pain and perform a meta-analysis of the outcomes to estimate efficacy.…”

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PeriPheral nerve field stimulation (PNFS) has been used for the treatment of trigeminal pain, but its efficacy has yet to be established. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] This therapeutic modality involves subcutaneous electrode implantation in the vicinity of trigeminal nerve branches and application of electrical current using a permanently implanted pulse generator. 9 Similar to other forms of neuromodulation, PNFS is nonablative, reversible, adjustable, and ABBREVIATIONS BNI = Barrow Neurological Institute; IPG = implantable pulse generator; MVD = microvascular decompression; NRS = numeric rating scale; PGP = percutaneous gasserian ganglion procedure; PHN = postherpetic neuralgia; PIFP = persistent idiopathic facial pain; PNFS = peripheral nerve field stimulation; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis; RCT = randomized controlled trial; SRS = stereotactic radiosurgery; STN = symptomatic trigeminal neuralgia; TDP = trigeminal deafferentation pain;

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A review of the bioelectronic implications of stimulation of the peripheral nervous system for chronic pain conditions

“…In general, low frequency tonic stimulation to activate either motor or sensory fibers, has been the standard for PNS waveform selection. Recently, higher frequencies (1 to 10 KHz) and novel waveforms, burst therapy, have influenced the spinal cord in unique ways (Amirdelfan et al, 2018;North et al, 2016;Manning et al, 2019). Novel high frequencies have been applied to PNS resulting in a blockade of nerve conduction using 10Khz frequency (Gilmore et al, 2019b).…”

“…Despite the lack of correlating evidence between the block and PNS some benefits of the local anesthetic block exist. First, the block may determine appropriate targets to apply electrical activity (Manning et al, 2019). This may include an understanding of anatomy surrounding the nerve, especially if ultrasound is used.…”