Approach Considerations

Complications of occipital nerve stimulation (ONS) placement are avoidable by taking certain necessary steps, as follows:

Anchoring leads to fascia at retromastoid incision
Swabbing all candidates to rule out methicillin-resistant Staphylococcus aureus (MRSA) colonization
Preoperative (prior to implantation) antibiotic treatment to eliminate MRSA colonization
Trimming patient's occipital region hair with clippers
Sterile surgical technique to help reduce the incidence of infection

Occipital Nerve Stimulator Implantation

Upon a successful trial of neurostimulation, permanent implantation may be considered. Permanent implantation is performed under general anesthesia. The patient is positioned supine with the head turned towards the left.

A vertical 2-cm incision is made under fluoroscopic control at the level of the C1 lamina, either medial and inferior to the mastoid process or in the midline posteriorly, extending to but not into the cervicodorsal fascia.

The subcutaneous tissues immediately lateral to the incision are undermined sharply to accept a loop of electrode created after placement and tunneling to prevent electrode migration. A Tuohy needle is gently curved to conform to the transverse posterior cervical curvature (bevel concave) and, without further dissection, is passed transversely in the subcutaneous space across the base of the affected greater and/or lesser occipital nerves, which, at the level of C1, are located within the cervical musculature and overlying fascia.

After lead placement, stimulation is applied using a temporary neurostimulator to various select electrode combinations, enabling the patient to report on the table the stimulation location, intensity, and overall sensation. Most patients have reported an immediate stimulation in the selected occipital nerve distribution with voltage settings from 1 to 4 volts with midrange pulse widths and frequencies.

Three options are available for the system power source: an external radiofrequency transmitter/receiver system, a primary cell implantable pulse generator, and a rechargeable implantable pulse generator.

Typical implant locations include the following:

Upper buttock: Facilitates single-stage electrode and generator placement in the prone position
Abdomen: Usually performed the patient in the lateral position
Upper chest: Lateral or supine positions favor this location

The 3 primary manufacturers of neurostimulation devices include Medtronic, Advanced Neuromodulation Systems/St. Jude, and Advanced Bionics/Boston Scientific.

The device is programmed by a clinical specialist appointed by the manufacturer.

Questions

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Media Gallery

A fluoroscopic images of occipital leads in the supraorbital (A), infraorbital (B), and occipital (C) region in a patient with intractable cluster headache
A fluoroscopic images of occipital leads showing stacked left-sided occipital leads in a woman with hemicrania continua.
A schematic diagram of the gate control theory of pain.

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Author

Antonios Mammis, MD Assistant Professor of Neurological Surgery, Director, Functional and Restorative Neurosurgery, Director, Center for Neuromodulation, Director, Rutgers Center for Headache, Orofacial, and Neuropathic Pain, Rutgers New Jersey Medical School

Antonios Mammis, MD is a member of the following medical societies: American Academy of Pain Medicine, American Association of Neurological Surgeons, American Medical Association, Medical Society of the State of New York, World Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery

Disclosure: Nothing to disclose.

Coauthor(s)

Mickey E Abraham, MSc Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Yehuda Herschman, MD Resident Physician, Department of Neurosurgery, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Max Ward Rutgers New Jersey Medical School

Max Ward is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Gaurav Gupta, MD, FAANS, FACS Associate Professor of Neurosurgery, System Co-Director, Cerebrovascular and Endovascular Neurosurgery, Fellowship Director, Endovascular Neurosurgery Fellowship (Site), Department of Surgery, Division of Neurosurgery, Rutgers RWJ Barnabas Healthcare, Rutgers Robert Wood Johnson Medical School

Gaurav Gupta, MD, FAANS, FACS is a member of the following medical societies: American Academy of Neurology, American Association for the Advancement of Science, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, Congress of Neurological Surgeons, Facial Pain Association, Society for Neuroscience, Society of NeuroInterventional Surgery

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery, Director of Epilepsy Surgery, Attending Neurosurgeon, University Hospitals Cleveland Medical Center; Director, Functional and Restorative Neurosurgery Center, UH Cleveland Medical Center Neurological Institute; Associate Professor of Neurosurgery, Fellowship Director, Functional and Stereotactic Neurosurgery, Associate Residency Program Director, Department of Neurosurgery, Surgical Director, Neuromodulation Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Epilepsy Society, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Neuromodulation Society, North American Neuromodulation Society, Ohio State Neurosurgical Society, Society of Neurological Surgeons

Disclosure: Nothing to disclose.