Chapter 62 Peripheral Nerve Stimulation Flashcards Preview

Essentials of Pain Medicine > Chapter 62 Peripheral Nerve Stimulation > Flashcards

Flashcards in Chapter 62 Peripheral Nerve Stimulation Deck (23):
1

PNS used for a wide variety of chronic pain disorders

limb mononeuropathies, complex regional pain
syndrome, cranial neuralgias, headache disorders, and
regional pain not amenable to SCS

2

Theories of pain pathophysiology of how neuromodulation affects
chronic pain

direct effects on peripheral pain fibers through excitation failure, selective release of
pain-modulating neurotransmitters, and changes in cerebral
flow in pain centers.

3

an important
consideration when attempting to stimulate a sensory fascicle

The complex fascicular arrangement of upper extremity nerves

4

peripheral nerve arrangements

will have one to several
internal fascicles that routinely change locations within the
nerve topography.

5

An open neurosurgical approach allows what testing

only motor testing with a nerve stimulator, unless
the operator performs a wake-up test.

6

Ultrasound allows

The key nerves of interest are usually superficial
enough to be seen well under US. US also allows visualization of surrounding key soft tissue structures and in each case, care should be taken to not pierce muscle compartments
or vascular structures along the needle/lead path to the nerve

7

For implantation cases, the lead can be anchored
to

the superficial muscle fascia with a strain relief
loop.

8

redundancy of the number of lead contacts in the vicinity of the desired fascicle is important because

The nerve will normally translate within the neurovascular
compartment as much as several millimeters. This
means that a normal nerve may move up to several millimeters
between the muscle and surrounding fascia with
flexion, extension, and rotation of the extremity

9

The radial nerve is very close to the lateral surface of the humerus at a point

10 to 14 cm proximal to the lateral epicondyle

10

RADIAL NERVE PNS technique

Ultrasound scanning usually begins at the
elbow and, with the probe in a transverse orientation to the arm, continues proximally until the desired approach
is identified. The needle can be advanced
from posterolateral to anteromedial to lie between nerve and humerus.

11

RADIAL NERVE PNS indications

Potential patients could include those with posterior interosseous neuropathies or
resistant lateral epicondylitis (tennis elbow) patients.

12

Solution of problems with lead migration

Subsequent radial nerve placements have utilized
more than one electrode, and a 4-week period of soft arm immobilization to allow the electrode(s) to better fibrose into place.

13

ULNAR NERVE location

The ulnar nerve is superficial to the medial head of the triceps muscle. the nerve was easily identified at a point 9 to 13 cm proximal
to the medial epicondyle in the medial/posterior
arm.

14

ULNAR NERVE PNS technique

Ultrasound scanning can commence at the elbow
and, with the probe in a transverse orientation to the arm, continue to scan more proximally until the nerve fascicular
arrangements can be well identified. The needle may be advanced from posterior to anterior on the medial aspect
of the arm to lie between nerve and humerus, staying superficial to the medial head of the triceps.

15

In ULNAR NERVE PNS Caution is important to avoid injury to the

medial cutaneous nerve of the arm, as well as
the recurrent ulnar collateral artery

16

MEDIAN NERVE location

The median nerve enters the antecubital fossa medial to the biceps muscle and its tendon, and next to the brachial artery. In the upper forearm at a point
approximately 4 to 6 cm distal to the antecubital crease, the nerve passes between the two heads of the pronator teres muscle, and then passes under the sublimis bridge of
the two heads of the flexor digitorum superficialis

17

in the forearm an important consideration in terms of expected stimulation patterns of the Median nerve

common neural fascicular communications between the median and ulnar nerves

18

Median nerve stimulation may be accomplished either

superior to the elbow, or inferior.

19

The common peroneal nerve may be identified at its branch point from

the sciatic nerve, a point 6 to 12 cm proximal to the popliteal crease

20

POPLITEAL AREA PNS Technique

Either transverse or longitudinal placement can be used, with transverse placement being more forgiving of movement, but a greater number of possible electrodes contacting
the nerves with longitudinal placement. The needle may be
advanced from posterolateral to anteromedial in a slightly
oblique plane, attempting to avoid passing through the biceps femoris.

21

POPLITEAL AREA PNS One must also scan thoroughly to see

the sural branches to
avoid injury

22

POSTERIOR TIBIAL location

Approximately 8 to 14 cm proximal to the
medial malleolus, the nerve is in close proximity to the tibialis
posterior muscle, the digitorum profundus, one or two large veins, and the flexor hallucis longus.

23

POPLITEAL AREA PNS technique

US scanning begins
at the ankle near the medial malleolus, with the probe in a transverse orientation to the leg, and then continued
proximally until the desired approach is identified. The needle may be advanced from anterior to posterior along the medial aspect of the ankle to lie just superficial (or deep)
to the nerve.

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