Occipital peripheral nerve stimulation in the management of chronic intractable occipital neuralgia in a patient with neurofibromatosis type 1: a case report.

INTRODUCTION: Occipital peripheral nerve stimulation is an interventional pain management therapy that provides beneficial results in the treatment of refractory chronic occipital neuralgia. Herein we present a first-of-its-kind case study of a patient with neurofibromatosis type 1 and bilateral occipital neuralgia treated with occipital peripheral nerve stimulation. CASE PRESENTATION: A 42-year-old Caucasian woman presented with bilateral occipital neuralgia refractory to various conventional treatments, and she was referred for possible treatment with occipital peripheral nerve stimulation. She was found to be a suitable candidate for the procedure, and she underwent implantation of two octapolar stimulating leads and a rechargeable, programmable, implantable generator. The intensity, severity, and frequency of her symptoms resolved by more than 80%, but an infection developed at the implantation site two months after the procedure that required explantation and reimplantation of new stimulating leads three months later. To date she continues to experience symptom resolution of more than 60%. CONCLUSION: These results demonstrate the significance of peripheral nerve stimulation in the management of refractory occipital neuralgias in patients with neurofibromatosis type 1 and the possible role of neurofibromata in the development of occipital neuralgia in these patients.

A novel technique for pudendal nerve block.

Pudendal nerve block is performed to confirm the diagnosis of pudendal neuralgia. Many physicians and patients are hesitant to pursue diagnostic nerve blocks to confirm the diagnosis of pudendal neuralgia secondary to significant patient discomfort, the need for special equipment, and the risk in the traditionally described approach. OBJECTIVE: To describe a novel technique for pudendal nerve block with minimal risk and decreased patient discomfort. DESCRIPTION OF THE TECHNIQUE: With the patient in the prone position, the C-arm is projected in the anteroposterior position until the pelvic inlet is visualized. Subsequently, the ischial spine is highlighted by 5 to 15 degree ipsilateral oblique angulation of the fluoroscope. A 25-gauge 3.5 cm needle is advanced to the tip of the ischial spine where the pudendal nerve transiently leaves the pelvis. The pudendal nerve block is performed at this level. CONCLUSION: We described a new and novel technique to block pudendal nerve under fluoroscopic visualization safely with increased patient comfort.

Management of chronic limb pain with spinal cord stimulation.

BACKGROUND: Spinal Cord Stimulation (SCS) is a treatment option for chronic pain patients. The most common indication for SCS is the failed back syndrome with leg pain. In the last decade, advances in our understanding of appropriate stimulation programming, lead placement and the physiology of SCS, have led to changes in multi-site stimulation, and stimulation with differing programs. In the past, low back, axial neuropathic type pain was not responsive to SCS. With dual electrode arrays, and dual stimulation with alternating programs of stimulation, steering of stimulation paresthesia, and versatile programmable stimulation parameters, SCS has become a more versatile form of analgesia. PURPOSE: To describe the current treatment rational for SCS and the results of that treatment. RESULTS: The SCS is most efficient in patients with neuropathic pain of the extremities and less efficacious in patients with axial pain. CONCLUSION: SCS is the most effective treatment for limb pain not amenable to surgical decompression. The success of SCS in this chronic pain group is 80% successful in treatment of leg pain, and much less effective in treatment of axial pain.