Supraorbital Nerve Stimulation for Facial Pain

Abstract

Purpose of review: Chronic facial pain is considered one of the conditions that affect quality of daily life of patients significantly and makes them seek medical help. Intractable facial pain with failed trials of medical treatment and other pain management therapies presents a challenge for neurologists, pain specialists, and neurosurgeons. We describe the possibility of proposing peripheral nerve stimulation of the supraorbital nerves to treat patients with medically intractable facial pain. Stimulation of the supraorbital nerves is performed using percutaneously inserted electrodes that are positioned in the epi-fascial plane, traversing the course of the supraorbital nerves. The procedure has two phases starting with a trial by temporary electrodes that are inserted under fluoroscopic guidance and are anchored to the skin. This trial usually lasts for a few days to 2 weeks. If successful, we proceed to the insertion of a permanent electrode that is tunneled under the skin behind the ear toward the infraclavicular region in which we make a pocket for the implantable pulse generator.

Recent findings: This procedure has been used in multiple patients with promising results which was published in literature. Literature shows that it provides relief of medically intractable pain, without the need for destructive procedures or more central modulation approaches with a preferable safety profile compared to other invasive procedures. Supraorbital nerve stimulation is now considered a valid modality of treatment for patients with medically intractable facial pain and can be offered as a reliable alternative for the patients while discussing the proper plan of management.

Keywords: Chronic facial pain; Intractable facia pain; Neuromodulation of facial pain; Supraorbital nerve stimulation; Trigeminal branch stimulation.

Fig. 1

Surgical steps for percutaneous placement of peripheral nerve stimulator of the supraorbital nerve. A Skin infiltration with local anesthetic at entry point. B Stab incision is done at entry point in the lateral forehead superolateral to the tip of eyebrow. C Insertion of Touhy needle guided by fluoroscopy. D Advancement of the guide wire, then the plastic cannula is inserted. E The lead is introduced toward its position through the cannula guided by fluoroscopy. F Fluoroscopic imaging showing the lead in its targeted position [10]

Fig. 2

X-ray skull lateral view showing the supraorbital nerve stimulator in the supraorbital region with its anchor and strain-relief loop in the parieto-occipital region [•]

Fig. 3

X-ray chest anteroposterior view showing the course of the lead down to the IPG in the generator pocket which is located in the infraclavicular region [10]