Best Practices for Peripheral Nerve Stimulation

Dec 2, 2018, 00:00 AM by Porter McRoberts, MD

By Porter McRoberts, MD
Medical Director of Pain Medicine
Holy Cross Hospital
Fort Lauderdale, FL

Peripheral nerve stimulation (PNS) is an excellent and robust modality for the treatment of chronic or refractory neuropathic pain. Its use differs from spinal cord stimulation (SCS) in that it is more specific: it is easier to target small watersheds of neuropathic pain, and it does not violate the CNS, but it does require a robust understanding of peripheral neuroanatomy and the techniques and tools used to implant in the periphery. Two subtypes of PNS exist: direct PNS stimulation of a peripheral nerve and peripheral nerve field stimulation (PNfS) where the target is the terminal, sensory, cutaneous nerve fibers in a local area.

Generally speaking, PNS is warranted when following circumstances exist: 1) SCS is unsuitable for any reason, such as the central neuro-axis is difficult to access or alterations and coagulation are unmitigatable, or 2) a situation better suits peripheral nerve stimulation than SCS. Those situations are nuanced. Often times, direct nerve trauma and the resulting painful conditions such as CRPS type II or causalgia responds very robustly to direct stimulation of the peripheral nerve proximal to the injury. A good test is to see if a local anesthetic injection at the intended stimulation site relieves the pain.

Several established targets for PNS and PNfS placement exist.

Reasonable Targets for PNS and PNfS Placement

Disease State	Nerve Target
Occipital neuralgia	Post ganglionic, C2 fibers at the posterior occiput
Facial pain	Supra- and infra-orbital nerves, temporo-auricular, trigeminal divisions
Upper extremity pain	Median, ulnar, radial, axillary, suprascapular
Pain of torso	Intercostal, cluneal, lateral branches of sacral nerves, dorsal cutaneous nerves of cervical, thoracic and lumbar spines
Pain of pelvis	Ilioinguinal, iliohypogastric, genitofemoral
Pain of lower extremity	Common peroneal, superficial peroneal, deep peroneal, lateral femoral cutaneous, tibial, saphenous, sciatic, femoral

Hybrid stimulation, concordant and communicating stimulation of both the spinal cord and attendant peripheral nerve, additionally provides significant and possibly greater relief than either modality alone.

Combination Targets for Hybrid Stimulation

Pain Location	Spinal Lead Location	Peripheral Lead Location
Axial back/neck	Corresponding cord level	Cluneal or PNfS near cutaneous dorsal rami serving pain location.
Thoracic radicular	Corresponding thoracic level	Intercostal or PNfS near pain location
Facial	Cervical (nucleus caudalis)	Corresponding nerve of the face
Shoulder	Cervical or high thoracic	Axillary n. or suprascapular n.
Abdominal	Mid to higher thoracic T5, T6	Ilioinguinal, hypogastric, or PNfS near pain
Flank	Corresponding thoracic level	PNfS near pain location

In addition, reach out to established peripheral nerve implanters they too are an excellent resource.

Bibliography

Cairns KD, McRoberts WP, Peripheral Nerve Stimulation for Truncal Pain, IN: Slavin K, (ed) Prog Neurol Surg 2011;24:58-69. Epub 2011 Mar 21

McRoberts WP, Cairns KD, Peripheral Nerve and Peripheral Nerve Field Stimulation for the Painful Extremity, IN: Slavin K, (ed) Prog Neurol Surg. 2011;24:156-70. Epub 2011 Mar 21.

McRoberts WP, Deer TR, Abejon D, Barolat G. (2016) Stimulation of the Extraspinal Peripheral Nervous System. In T.R. Deer, J.E. Pope (Eds.) Atlas of Implantable Therapies for Pain Management (pp 171-183). New York, NY: Springer Science.

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