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Эберхард Фетц (Eberhard Fetz) и его коллеги из университета Вашингтона (University of Washington) построили систему, при помощи которой обезьяна научилась управлять мышцами своей руки, не имевшей прямой связи с головным мозгом. Опыт открывает заманчивые перспективы для парализованных пациентов с повреждениями позвоночного столба.

Ранее некоторые научные группы показывали возможность снятия сигналов с моторной коры головного мозга, которые затем управляли манипулятором робота. Другие демонстрировали возможность функциональной электростимуляции определённых мышц, под управлением компьютера (без участия мозга). Но впервые, как сообщает PhysOrg.com, оба этих подхода были совмещены.

Treatment of chronic intractable atypical facial pain using peripheral subcutaneous field stimulation

Alexander E. Yakovlev, MD, Beth E. Resch, APNP


Introduction: Atypical facial pain (ATFP) is challenging to manage and there are fewproven therapies available.We present a case
report describing application of peripheral subcutaneous field stimulation (PSFS) to a patient with chronic intractable ATFP which
conventional treatment failed to ameliorate.
Methods: The patient underwent an uneventful PSFS trial with percutaneous placement of two temporary eight-electrode leads
(Medtronic Inc, Minneapolis, MN, USA) placed subdermally over the left mandible.
Results: After experiencing excellent pain relief over the next two days, the patient was implanted with permanent leads and
rechargeable generator two and a half weeks later and reported sustained pain relief at 12-month follow-up visit.
Discussion: Peripheral subcutaneous field stimulation provides an effective treatment option for patients suffering from chronic
ATFP who have failed conservative treatment. PSFS may provide pain relief with advantages over conservative treatments and
more invasive techniques.
Conclusion: Peripheral subcutaneous field stimulation offers an alternative treatment option to select patients with intractable
ATFP.
Keywords: Atypical facial pain, electric stimulation, intractable jaw pain, pain, peripheral subcutaneous field stimulation, trigeminal
neuralgia
Conflict of interest: The authors reported no conflicts of interest.

INTRODUCTION

Atypical facial pain (ATFP) represents a wide group of facial pain
problems which have many different causes but present with
common symptoms. Some studies postulate a low-grade infectious
and inflammatory process occurring over a long period can result in
nerve damage and be the triggering factor for ATFP. Dental or physical
trauma also is linked to ATFP. Malignant neoplasms invading the
base of the skull and traumatizing branches of the trigeminal nerve
and even benign tumor of the trigeminal nerve or meninges can
lead to ATFP (1). There was report of facial sarcoidosis presenting as
ATFP (2). In some of the patients no etiologic factors can be found
and patients in this group tend to have significant psychopathology
(3). Successful treatment of the patients with ATFP is rare because of
the variety of etiologies of this syndrome.


Atypical facial pain differs from trigeminal neuralgia (TN) in every
respect. The ATFP is reported as continuous but can fluctuate in
intensity. This pain described as burning, aching or cramping, pinching,
pulling, often in the region of trigeminal nerve and can extend
into the upper neck or back of scalp. TN is characterized by paroxysms
of severe, lancinating, electric-like bouts of pain restricted to
the distribution of trigeminal nerve. The pain may last from several
seconds to minutes. Attacks are often triggered by eating, brushing
teeth, and washing. Between the paroxysms the patients are free of
symptoms but report experiencing the fear of an impending attack.
Sufferers go out of their way to avoid any contact to trigger areas (4).
This disorder of the sensory division of the trigeminal nerve may be
due to degenerative, fibrotic changes in the gasserian ganglion or
due to tortuous blood vessels compressing the trigeminal root as it
exits the brain stem, as can occur in the patients with MS. Other
causes of TN include tumor growth, bony abnormalities, and other
vascular conditions. Interventional treatments included in the management
algorithm for patients with TN include microvascular
decompression (MVD) and percutaneous stereotactic radiofrequency
(PSR) rhizotomy. MVD and PSR rhizotomy have comparable
rates of pain relief that are highest among available options and can
approach 77% in seven years for MVD and 75% in six years for PSR
rhizotomy (5).


Traditional treatment options for ATFP include anticonvulsants,
antidepressants, baclofen, triptans, non-steroidal antiinflammatory
medications, and opioids. ATFP is challenging to
manage and there are few proven therapies available. Treatment
with these medications is often ineffective and wrought with intolerable
side-effects. Surgical procedures such as MVD generally are
not successful with ATFP patients. Peripheral nerve stimulation has
been used to treat a variety of neuropathies (6), including ilioinguinal
(7), occipital (8–11), post-herpetic (12), and stimulation of
trigeminal branches was reported for treatment of trigeminal postherpetic
neuralgia and trigeminal post-traumatic neuropathic
pain(13–16) with excellent relief of pain. Treatment of ATFP, including
trigeminal neuropathic pain using peripheral subcutaneous
field stimulation (PSFS) can lead to decreased reports of pain as
well as a reduced need for oral pain medications.

Figure 1. Subdermal placement of two eight-electrode leads showing the electrodes placed over the left mandible.

CASE REPORT

A 72-year-old woman was referred to our clinic with a history of left
jaw pain, previously diagnosed as TN. Her pain had begun more
than three years ago. She was followed by an oral surgeon and
orthodontist for jaw pain and temporomandibular joint disorder.
Tooth extractions and trigger point injections inside the left lower
gum were unsuccessful at treating her pain. She had been seen by a
pain physician two years before treatment in our clinic who had
performed a trigeminal nerve block which provided several hours of
relief. Subsequently, the patient underwent stereotactic radiofrequency
ablation of the gasserian trigeminal ganglion for the second
and third trigeminal nerve division. The patient received no relief
from this procedure. The patient was evaluated by neurosurgeons
and was not considered to be a candidate for gamma-knife radiosurgery
and MVD.


Previous conservative therapy had included trileptal, pregabalin,
darvocet, oxycodone, fentanyl patch, gabapentin, nonsteroidal antiinflammatory
medications, and topical ointments, none of which
provided the patient relief. Upon presentation to our clinic the
patient’s chronic pain medication regimen included long and short
acting oxycodone and ibuprofen. The patient described her pain as
aching, burning, rarely sharp in character and lasting all day and
night. The pain could get better with sleep. Distribution of the pain
was over left mandible and mastoid process. On physical examination
we found allodynia over the left proximal mandible; multiple
teeth were removed on the left. In our opinion the patient had a
clinical presentation of ATFP but not a classic TN. A trigeminal nerve
block performed in our clinic provided three weeks of pain relief.
The patient was counseled on treatment options including continued
treatment with oral pain medications, or peripheral nerve
stimulator therapy. The patient elected to proceed with peripheral
nerve field stimulator therapy.


The patient underwent successful two-day trial of percutaneous
placement of two eight-electrode leads (Medtronic Inc., Minneapolis,
MN, USA) after passing a psychological evaluation for an implantable
device. Leads were placed subdermally over the left mandible
(Fig. 1). During the PSFS trial, she reported greater than 50%
improvement in pain and rated her pain as a 2 on the visual analog
scale (VAS) compared with a 9 on the VAS before trial leads were
placed. Two and a half weeks later the patient underwent implantation
with permanent leads and a RestoreUltra (Medtronic Inc.,
Minneapolis, MN, USA) rechargeable generator. Preoperatively we
discussed with the patient location of the generator and she chose
supragluteal area because of cosmetic concerns. The patient had a
previously placed Port-a-catheter for chemotherapy and did not
want new scars over the chest. The procedure was performed in an
ambulatory surgery center with intravenous sedation and local
anesthesia administered by the surgeon. We chose right lateral
decubitus position for easy access to left side of the face, neck, and
back. Two permanent eight-electrode standard Octad leads were
inserted subdermally along left mandible through vertical 1.5 cm
incision 2 cm anterior to the tragus of the left ear. The leads were
passed through slightly bent 14 Gauge Tuohy needles to follow the
curvature of the mandible. Both leads were anchored in the wound
to fibroaponeurotic tissue with 2-0 nonabsorbable suture of braided
polyester (Ethibond) and Titan anchors (Medtronic Inc., Minneapolis,
MN, USA). The leads were tunneled over and behind the ear to
the second incision created over the upper posterior neck where
they were connected to extensions. Extensions were finally brought
by use of a 60-cm tunneling tool into the left supragluteal area to
the subcutaneous pocket created for the generator and were connected
to a RestoreUltra (Medtronic Inc., Minneapolis, MN, USA)
rechargeable generator. The post-operative course was uneventful.
Initiation of use of RestoreUltra rechargeable generator was
uneventful during the post-operative period.


The stimulator was programmed using a guarded electrode configuration
with a pulse width of 450 msec and a rate of 60 Hz. The
amplitude use ranged from 1.5 to 2.3 V. The patient reported that
the stimulation covered 100% of her painful areas following the
initial programming. After implant surgery the patient was weaned
off all opioids. The patient has been using her PSFS 24 hours per day,
adjusting stimulation intensity for changes in intensity of pain with
good pain relief. She continued to report excellent pain relief at her
12-month follow-up visit.

DISCUSSION

The PSFS alleviates pain by subdermal stimulation of the peripheral
fibers, which may prevent transmission of painful impulses to the
central nervous system. The neuromodulating effects of electrical
stimulation are based on the tenets of the “gate-control theory” of
pain proposed by Melzack and Wall in 1965 (17). Based on this
theory, it is hypothesized that PSFS “closes the gate” to pain transmission
by activating large-diameter afferent fibers via application
of an electric field. PSFS may also alter local blood flow, cause
release of endorphins, affect neurotransmitters and axonal conduction,
and may block cell membrane depolarization (18). The mechanism
of action of PSFS and neuromodulation in general continues to
be investigated as there may be a multitude of ways in which neuromodulation
affects pain transmission. PSFS can be effective in
treating painful areas, such as the face, which are very difficult to
target with epidural stimulation.Peripheral subcutaneous field stimulation is an alternative treatment
option for patients suffering fromchronic ATFP. PSFS has many
advantages over many conservative treatments as well as more
invasive techniques. There are no side-effects created by PSFS as
there are with many medications. There is a high rate of success with
permanent implant due to the fact that a trial is performed during
which the patient evaluates the efficacy of the device. The therapy is
completely reversible if for some reason therapy becomes contraindicated
or is no longer needed. Patient programmers permit
patients to control the level of stimulation they feel based on their
degree of pain. This enables patients to take a more active role in
their pain management.

SUMMARY

We present a single case of intractable ATFP which was refractory to
conventional treatment but successfully treated with PSFS. This
technique may be a safe and effective treatment for patients who
have failed to find relief with more conservative measures or who
are not appropriate candidates for more invasive interventional
pain or surgical procedures based on their comorbid health conditions.
PSFS has provided our patient with satisfactory pain relief
without the side-effects of previous medication therapy. In our
opinion, PSFS offers a safe and effective treatment method that is
completely reversible should a patient lose its pain-alleviating
effect. This case study provides support for PSFS as an alternative
treatment option for patients with intractable jaw pain and will
inspire interest in prospective studies comparing peripheral nerve
stimulation with other therapies.

REFERENCES

  1. Yonas H, Jannetta PJ. Neurinoma of trigeminal root and atypical trigeminal neuralgia: their commonality. Neurosurgery 1980;6:273–277.
  2. Smith L, Osborne RF. Facial sarcoidosis presenting as atypical facial pain. Ear Nose Throat J 2006;85:574, 578.
  3. Weddington WW, Blazer D. Atypical facial pain and trigeminal neuralgia: comparison study. Psychosomatics 1979;20:348–349.
  4. Bagheri S, Farhidvash F, Percciantte V. Diagnosis and treatment of patients with trigeminal neuralgia. J Am Dent Assoc 2004;135:1713–1717.
  5. Miller JP,Acar F, Burchiel KJ.Classification of trigeminal neuralgia: clinical, therapeutic, and prognostic implications in a series of 144 patients undergoing microvascular decompression. J Neurosurg 2009;111:1231–1234. [Epub ahead of print] PMID: 19392593.
  6. Novak CB, Mackinnon SE. Outcome following implantation of a peripheral nerve stimulator in patients with chronic nerve pain. Plast Reconstr Surg 2000;105:1967–1972.
  7. Stinson LW Jr, Roderer GT, Cross NE, Davis BE. Peripheral subcutaneous electrostimulation for control of intactable post-operative inguinal pain: a case reportseries. Neuromodulation 2001;4:99–104.
  8. Slavin KV, Nersesyan H,Wess C. Peripheral neurostimulation for treatment of intractable occipital neuralgia. Neurosurgery 2006;58:112–119.
  9. Johnstone CS, Sundaraj R.Occipital nerve stimulation for the treatment of occipital neuralgia-eight case studies. Neuromodulation 2006;9:41–47.
  10. Oh MY, Ortega J, Bellotte JB, Whiting DM,Alу K. Peripheral nerve stimulation for the treatment of occipital neuralgia and transformed migraine using a C1-2-3 subcutaneous paddle style electrode: a technical report. Neuromodulation 2004;7:103–112.
  11. Weiner RL, Reed KL. Peripheral neurostimulation for control of intractable occipital neuralgia. Neuromodulation 1999;2:217–221.
  12. Yakovlev A, Peterson A. Peripheral nerve stimulation in treatment of intractable postherpetic neuralgia—a case report. Neuromodulation 2007;10:373–375.
  13. Johnson MD, Burchiel KJ. Peripheral stimulation for treatment of trigeminal postherpetic neuralgia and trigeminal posttraumatic neuropathic pain: a pilot study.Neurosurgery 2004;55:135–141.
  14. Dunteman E. Peripheral nerve stimulation for unremitting opthalmic postherpetic neuralgia. Neuromodulation 2002;5:32–37.
  15. Slavin KV, Wess C. Trigeminal branch stimulation for intractable neuropathic pain: technical note. Neuromodulation 2005;8:7–13.
  16. Oberoi J, Sampson C, Ross E. Head and neck peripheral stimulation for chronic pain report of three cases. Neuromodulation 2008;11:272–276.
  17. Melzack R,Wall PD. Pain mechanisms: a new theory. Science 1965;150:971–979.
  18. Paicius RM, Bernstein CA, Lempert-Cohen C. Peripheral nerve field stimulation for the treatment of chronic low back pain: preliminary results of long-term follow-up: a case series. Neuromodulation 2007;10:279–290.

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