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Neuromodulation for Headache & Craniofacial Pain: 50 Consecutive Cases. Paul Verrills MD , David Vivian MD, Bruce Mitchell MD and Adele Barnard PhD Metro Spinal Clinic, Melbourne. Dr Paul Verrills Musculoskeletal Physician MBBS FAFMM GDMM(Hons) MPainMed FIPP.

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Neuromodulation for Headache & Craniofacial Pain: 50 Consecutive Cases

Paul Verrills MD, David Vivian MD, Bruce Mitchell MD and Adele Barnard PhD

Metro Spinal Clinic, Melbourne

Dr Paul Verrills Musculoskeletal PhysicianMBBS FAFMM GDMM(Hons) MPainMed FIPP

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Disclosure StatementNo funds have been received in support of this studyRoyalties: NILStock Options: NILTeaching – Consultant (adhoc peer-peer) - St. Jude Medical - Arthrocare - Mundipharma - Medtronic - Boston ScientificResearch Grant: NILTravel Support: NIL

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Chronic Craniofacial Pain

Treatment of chronic neuropathic pain in the region of the head, neck and face presents a challenge for pain specialists.

Peripheral nerve field stimulation (PNFS) is evolving as a treatment for neuropathic pain

Increase in the number of cases of PNFS for the craniofacial region since the publication of Richard Weiner’s study in 1999.

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Supraorbital

Occipital

Occipital and Supraorbital Leads – Unilateral Chronic Daily headache

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PNFS for headache and craniofacial pain: Patient Selection

Chronic Daily Headache / Occipital Neuralgia / ‘Migraine’

Neuropathic or combined somatic (nociceptive) & neuropathic pain component.

Failure to respond to other conservative treatments

Red flags excluded

Psychological clearance

Successful trial phase (eg. >50% pain relief)

Informed consent

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PNFS for headache and craniofacial pain: Study Design

  • Data collected over 4 years
  • 50 consecutive implant patients
  • Follow up rate of 100%
  • Assessments
    • Questionnaires, along with patients’ histories were used to assess
    • Pain (11-point numerical rating scale)
    • Analgesic use
    • Depression (Zung Depression Index)
    • Disability (Neck Disability Index)
  • Follow up of mean 10.8 ± 6.5 months (range 1-36 months)
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PNFS for headache and craniofacial pain: Decrease in Pain

Average pain reduction of 4.8± 2.4 NRS (p ≤ 0.05)

Average pain relief of 62.6 ± 26.4%

Pain Relief

88% of patients achieved ≥ 25%

76% of patients achieved ≥ 50%

43% of patients achieved ≥ 75%

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PNFS for headache and craniofacial pain: High patient satisfaction rate

82% of patients were satisfied with their treatment outcome

61% of patients were either very or completely satisfied

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PNFS for headache and craniofacial pain: Reduced Analgesic use

77% of patients reported a reduction in analgesic use

66% of patients reported a moderate to extreme decrease

Reduction in analgesic use inversely correlated with pain relief (r = 0.75, p ≤0.05) patient satisfaction (r = 0.69, p ≤0.05)

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PNFS for headache and craniofacial pain: ReducedDisability (NDI)

Degree of disability following

80% of patients reported reductions in their disability following implantation (p ≤ 0.05)

Median NDI reduced by 8.2 ± 8.6%

Implantation

100

80

62.1

60

56.7

Neck Disability Index (%)

40

20

0

Pre Implant

Post Implant

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Depression following Implantation

80

60

Zung Depression SDS Index (%)

40

20

0

Pre Implant

Post Implant

PNFS for occipital/craniofacial pain:Reduced Depression

70% of patients reported reductions in their depression index following implantation

(p ≤ 0.05)

Median Zung reduced by 9.2 ± 9.9%

55.1

47.0

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PNFS for occipital/craniofacial pain:Sustained Pain Relief

Pain relief achieved initially following implantation was sustained at follow up intervals of ≥12 months.

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PNFS for occipital/craniofacial pain:Complications

Two thirds of patients achieved favorable outcomes following reposition and/or re-implantation

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pverrills@metrospinal.com.auwww.metrospinal.com.au

PNFS for occipital/craniofacial pain: Summary

Average pain reduction of 4.9± 2.5 VAS (p ≤ 0.05)

Average pain relief of 63.1 ± 27.0%.

Reduced disability, analgesic use and depression was observed following PNFS

Reduction in analgesic use inversely correlated with pain relief and patient satisfaction

This study demonstrates that this reversible, safe and effective treatment is a promising pain relief strategy for an otherwise intractable condition.