Fluoroscopy-Guided Percutaneous Placement of Peripheral Nerve Stimulator of the Cervical Medial Branches in Patients With Treatment-Refractory Occipital Neuralgia: A Case Series.

Abstract

Background: Pain from occipital neuralgia (ON) stems from the compression of the greater occipital nerve, muscle hypertrophy, or spasm. C2-C3 facet joint pain also is implicated in ON, given the third occipital nerve's innervation of the C2-C3 zygapophysial joint. Percutaneous peripheral nerve stimulation (PNS) has in recent years been popularized as a minimally invasive approach in the management of treatment-resistant ON.

Objective: The study seeks to summarize the various modalities used in percutaneous peripheral nerve stimulator placement for ON in the existing literature and propose a novel fluoroscopic technique for effective peripheral nerve stimulator implantation established through a retrospective institutional case series for treatment of patients with ON.

Materials and methods: MEDLINE was accessed for our literature search, and the time frame of the search was set from data base inception to May 1, 2024. Our institutional retrospective chart review was performed in patients who had undergone new implantation of the SPRINT PNS system (SPR Therapeutics, Inc, Cleveland, OH) from January 2023 to May 2024. Parameters extracted from patients' charts for analysis included patient demographics, pain presentation, prior treatments and injection-based interventions, pain intensity, and opioid medications used.

Results: A total of five articles meeting the inclusion criteria were obtained after screening a total of 74 studies, describing peripheral nerve stimulator placement techniques using ultrasound, fluoroscopy, and a combination of both. Five institutional subjects were assessed in our case series. During active PNS therapy, there was a clinically significant reduction in pain (≥50%) intensity as measured by visual analog scale (VAS) score in all five subjects (N = 5, mean 7.20 vs 1.68, 95% CI [-8.87, -2.17], p = 0.0102). At 60 days, pain relief improved (N = 5, mean 7.20 vs 1.32, 95% CI [-8.97, -2.78], p = 0.0062). After device removal, the VAS score trended lower without attaining significance (n = 4, mean 7.5 vs 3.13, 95% CI [-11.04, 2.29], p = 0.128).

Conclusions: Our fluoroscopic-guided peripheral nerve stimulator placement technique yielded pain relief from therapeutic commencement to up to 18 weeks from device placement, exhibiting an efficacy equivalent to that of existing modalities of lead placement published in literature.