Abstract

RODRIGO, M. D. et al. C2-C3 Invasive Electrical Stimulation for the Treatment of Cephalic and Facial Pain: Occipital Neuralgia. Transformed Migraine. Cluster Headache. Facial Algias. Rev. Soc. Esp. Dolor [online]. 2008, vol.15, n.6, pp.382-391. ISSN 1134-8046.

Introduction. The peripheral cervical-occipital extraspinal electrical stimulation with an implanted system, is a little aggressive technique that can achieve good results in patients with refractory neurophatic pain localized in the cephalic and facial región. Thirty four patients with long-evolving, persistent, severe, uncontrolled pain of different ethiologies, localized in the cervical facial región, for whom other therapy options were exhausted, were treated with unilateral or bilateral cervical occipital electrical stimulation in the pain unit of the Zaragoza Clinic Hospital. Material and Method. Thirty four patients were treated from June 2002 to February 2008, fourteen of which were diagnosed with transformed migraine; two suffered from cluster headache and eighteen had occipital and/or trigeminal neuralgia. Before the neurostimulation system was implanted, an occipital nerve block was performed with local anesthetic to establish the cervicogenic component in the pain. The surgical procedure was performed in two stages. The treatment effectiveness assessment was made on the basis of the variation of the following parameters before and after the implant: ongoing pain, pain during the crisis, number of crisis events, overnight rest, functioning, social and laboral activity, patient satisfaction, drug therapy reduction and emotional status. Results. The participants were 25 female patients and 9 male patients with an average age of 51,2 (R. 29-80). They suffered from ongoing pain, and 27 of them also experienced crisis events with a very severe agudization of symptoms. All the patients needed pharmacological treatment with analgesics (average of 4,4 drugs per patient). Other treatment options had failed in all these patients. The mean time of pain evolution was 98,9 months (R. 5-360). The test stimulation period, with the lead/s implanted in external phase, was satisfactory in 32 patients, with an overall improvement of over 50%. These patients were implanted with the definitive system. The mean treatment time with cervical occipital electrical stimulation was 22,8 months. (R. 1-67). The ongoing pain has disappeared and the number of crisis events and their severity has decreased in most of our patients. Pharmacological treatment was withdrawn in 17 patients, and the overall average of drugs per patient has decreased from 4,3 to 1. 88,2% of patients on sick leave (15 out of 17), has returned to work. The overall result ratings have been as follows: 32 patients with the definitive implant, Very Good outcome in 20 patients (62,5), Good outcome in 11 (34,3) and Bad otucome in 1 (3,2%). The treatment effectiveness rate according to the diagnosis has been: - Transformed migraine: 13 patients have received the definitive implant. The outcome results are: 9 of them Very Good and 4 Good. - Occipital trigeminal neuralgia: 17 patients have received the definitive implant. The outcome results are: 11 of them Very Good, 5 Good and 1 of them Bad. - Cluster headache: 2 definitve implanted with Good results in both. The reported complications were as follows: - Lead migration occured in two occassions, which required surgical replacement. - The intermediate extension had to be replaced in another patient, due to a fracture six months after the definitive implant. - A painful stimulation was experienced in two cases, both of them already resolved. - Three infection cases occurred, one of which lead to the system explantation. - One case of painful temporal inflamation around the pocket zone, at the gluteus region. Conclussions. The occipital stimulation overall patient outcome has been either very good or good. The benefit from occipital stimulation for facial area pain, reinforces the relevant therapeutic interest the hipotetical cervical-trigeminal functional connection has. It is necessary to determine the type of cervical-trigeminal connection, in order to be able to define which kind of facial algia could benefit from the cervical occipital electrical stimulation therapy. For the treatment of facial algias, refractory to conventional treatments, we recommend to assess the cervicogenic component, with the mayor and minor occipital nerves anesthesic. This can be specially useful, towards occipital stimulation therapy, in patients with severe and invalidating pain syndromes localized in the facial area.

Keywords : Invasive occipital peripheric electrical stimulation; occipital-trigeminal neuralgia; transformed migraine; facial algias.

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