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A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study

  • Richard L. Weiner , Carlos Montes Garcia und Niek Vanquathem EMAIL logo
Veröffentlicht/Copyright: 1. Oktober 2017
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Scandinavian Journal of Pain
Aus der Zeitschrift Scandinavian Journal of Pain Band 17 Heft 1

Abstract

Objective

To report a novel wireless neuromodulation system for treatment of refractory craniofacial pain.

Background

Previous studies utilizing peripheral nerve stimulation (PNS) of the occipital and trigeminal nerves reported positive outcomes for alleviating neuropathic pain localized to the craniofacial and occipital areas. However several technological limitations and cosmetic concerns inhibited a more widespread acceptance and use of neuromodulation. Also, a relatively high incidence of adverse events like electrode erosions, dislocation, wire fracture and/or infection at the surgical site mandates a change in our approach to neuromodulation technology and implant techniques in the craniofacial region.

Methods

We report a novel approach for the management of craniofacial pain with a wirelessly powered, minimally invasive PNS system. The system is percutaneously implanted and placed subcutaneously adjacent to affected facial nerves via visual guidance by the clinician. In this feasibility study, pilot evidence was gathered in a cohort of ten subjects suffering from a combination of chronic headaches, facial pain for at least 15 days per month and for at least 4 h/day.

Results

At four weeks post-implant follow up, all patients reported sustained pain relief of the primary pain area. Electrode location and total number of electrodes used per subject varied across the cohort. The average pain reduction using the visual analog scale was >82%. The procedure had no adverse events or side effects.

Conclusions

Percutaneous placement of a wireless neurostimulation device directly adjacent to affected craniofacial nerve (s) is a minimally invasive and reversible method of pain control in patients with craniofacial pain refractory to conventional medical managements. Preliminary results are encouraging and further larger scale studies are required for improved applications.

Keywords: Peripheral nerve stimulation; Neurostimulator; Wireless implant; Cranial nerve; Trigeminal neuralgia; Chronic facial pain

1 Introduction

Chronic craniofacial pain (CCFP) or atypical facial pain or persistent idiopathic facial pain or atypical trigeminal neuralgia are a few of the names applied for the debilitating/refractory painful conditions with a varied lifetime prevalence [1,2]. Facial pain affects nearly 26% of people during their lifetime [3] while typical trigeminal neuralgia in population occurs in 0.3% [1].

CCFP arises from abnormal peripheral activation of cranial nerves that convey pain information to the brain and can result from events including but not limited to, infection, trauma, surgery, or invasive dental procedures. It is characteristically similar to pain due to trigeminal neuralgia and these disorders possibly are located on the same spectrum in a temporal sequence [2,4,5]. Intractable headache and/or migraine affect nearly 40 million Americans and in spite of various treatment protocols 3-5% of these patients does not improve but suffer from overwhelming despair in dark quiet rooms consuming high doses of narcotics [6,7,8].

Opioids are the most commonly prescribed for treatment of CCP along with anticonvulsants and anti depressants. Longstanding usage of opioids is associated with tolerance and dependence while opioid dose escalation over time to maintain analgesic effects become regular events. Additionally, chronic opioid use has the potential for increased risks of diversion, abuse, addiction, and can cause opioid induced side effects including nausea, sedation, constipation and hyperalgesia. A recent FDA recommendation for opioid use calling for reductions in chronic opioid prescription is another reason to consider neurostimulation treatment for pain control [9].

Lack of effective medical management resulting in persistent pain and significant decrease in quality of life has led to the development of destructive procedures including hot or cold radiofrequency nerve ablation. Surgical/chemical neurectomy or decompressive neurotomies were common treatments [10].These, however, may result in irreversible side effects including sensory or motor loss and subsequent differentiation pain along the ablated nerve [11]. Neither radiosurgery nor sphenopalatine ganglion ablation or neurectomy yielded successful results in CCFP conditions [12,13].

Peripheral nerve stimulation (PNS) for craniofacial pain has proven to be a viable therapeutic option in the treatment of chronic disabling pain because of its non-destructive and reversible nature [14,15].

The Neuromodulation Appropriateness Consensus Committee (NACC) after evaluation of peer reviewed literature, current research and clinical experience found evidence to support extracranial stimulation for treatment of facial pain and migraine [16]. Advancements in wireless energy transmission and microprocessor technology have recently enabled development of miniature, percutaneous neurostimulation hardware and software to help control these pain syndromes involving craniofacial peripheral nerves [19]. Several studies have shown encouraging results [17,18].

However, widespread use of PNS neuromodulation has been limited by multiple technological issues/concerns and remains underutilized [18,19,20]. Available neurostimulation systems have not been designed for use in the peripheral nerve space, especially in and about the craniofacial region and are associated with complications including electrode migrations and procedural complications due to cumbersome equipment as well as stimulation systems. Not only cosmetic concerns, but relatively high adverse event rates including such events as device erosion, fracture, and infection have also played a discouraging role [11,18,19,20,21]. Our experience with a novel wireless, minimally invasive design in the treatment of occipital neuralgia yielded good results [22]. We report this alternative approach for the management of CCFP. A minimally invasive, wireless stimulation system is percutaneously implanted and placed subcutaneously adjacent to affected facial and/or occipital nerves involved in intractable craniofacial pain. Initial data were gathered in a cohort of ten subjects suffering from chronic headaches, facial pain for at least 15 days per month and at least 4 h/day. The primary objective of this study was to determine the analgesic effect of wireless neuromodulation in controlling chronic pain as applied to various nerve distributions within the CCFP.

2 Methods

Inclusion criteria: Patients of at least 22 years of age at the time of signing the informed consent and without anatomical defects that would compromise or complicate the study were included. The Subjects were on stable doses of pain medications for at least 4 weeks prior to screening. Subjects were willing to undergo the surgical implant procedure, attend visits as scheduled and comply with the study requirements. Patients were willing and able to operate the programmer, recharge the equipment and properly fill out the electronic diary. Subjects were good surgical candidates for the implant procedure and had a life expectancy greater than 12 months beyond the study period. Subjects had a decreased pain intensity of at least 50% from baseline after local anesthetic block of the targeted craniofacial nerves in the past.

Exclusion criteria: Patients with migraine, cluster headache, trigeminal autonomic cephalgia, other types of craniofacial pain considered to be of central origin and those who failed psychological evaluation were excluded. Subjects on anticoagulation therapy and/or unfit for surgical procedures were also excluded.

Demographics: Ten patients (7 female, 3 male) were enrolled (mean age of 60 years). All patients were selected based on a history of CCFP (Table 1) manifesting as chronic headache, facial or occipital pain for at least 15 days per month and at least 4 h/day. Pain was of neuropathic origin from direct or indirect neural injury to the trigeminal, supraorbital, infraorbital nerves. Root causes of CCFP included trauma, surgery, infection, congenital defects, and trigeminal neuropathy.

Table 1

Demographics and target nerves.

Sub Sex Age Location of pain Target nerve (s)
1 F 67 Right V3 Mental nerve
2 M 55 Left V3 Mental nerve
3 F 58 Left V3 Mental nerve
4 F 64 Right V2 Infraorbital nerve
5 F 76 Left V1, V3 Supraorbital, mental nerves
6 F 62 Right V2, V3 Infraorbital, mental nerves
7 F 42 Right V1, V3 Supraorbital, mental nerves
8 M 74 Left V2, V3 Infraorbital, mental nerves
9 M 75 Left V2, V3 Infraorbital, mental nerves
10 F 63 Right V2 Infraorbital nerve

Device description: Subjects were implanted with one or more wireless stimulator systems (StimRelieve LLC, Miami Beach, FL, USA) each containing four or eight contacts (3 mm in diameter with 4 mm spacing). The stimulator system utilizes an implantable electrode contact array, microprocessor receiver and antenna embedded within the electrode wire that couples to an external transmitting antenna and pulse generator (Figs. 1 and 2) The implanted stimulator is 100% passive (i.e., no implanted power source). The external transmitting antenna was worn in a baseball cap (Fig. 3) and is wirelessly coupled to provide energy to the implanted stimulator. Subjects would have to wear the baseball cap on a daily base for at least 8 h/day. The antenna component would cover the location of the inbedded receiver, externally powering the electrode array and thus providing therapeutic stimulation to the enervated nerves. The external pulse generator is programmed by the clinician to send desired stimulation parameters through a direct electric coupling RF transmitting antenna to the electrode receiver, thereby wirelessly transferring stimulation commands and power to the implanted stimulator. The system uses radiofrequency energy at 915 MHz to transfer power and selected parameters to the implanted stimulator. The implanted stimulator and power source are coupled at such a short distance that the energy emitted from the antenna is relatively low. Wavelengths and product specifications have been designed to decrease risk related to the wireless transmission of energy12 and reliably transfer the clinician’s desired stimulation parameters [23].

Fig. 1 Neuro-stimulator electrode, MRI compatible, for both 1.5 and 3 T.
Fig. 1

Neuro-stimulator electrode, MRI compatible, for both 1.5 and 3 T.

Fig. 2 Neurostimulator receiver.
Fig. 2

Neurostimulator receiver.

Fig. 3 External pulse generator in a baseball cap.
Fig. 3

External pulse generator in a baseball cap.

The stimulation parameter spectrum available for clinical use and evaluation include: amplitude:1-24mA, pulse width: 10-1000 ms, frequency: 5-20,000 Hz.

Surgical procedure: Under strict aseptic precautions, the skin and subcutaneous tissues were infiltrated with local 1% lidocaine. A small skin incision was made for needle insertion, which was shaped by hand to match the skull contour to achieve appropriate device placement. A 14-gauge Tuohy needle at supraorbital, infraorbital, and/or auriculotemporal nerve targets was used for stimulator insertion. Doppler ultrasound was used to map out arterial vasculature around the target stimulator path and the stimulating electrodes were placed adjacent to nerves previously identified as pain generators by successful diagnostic nerve blocks using local anesthetic injections.

AP and lateral fluoroscopic images were used to document final electrode positioning (Figs. 4 and 5). The stimulator system was subsequently activated wirelessly to confirm electrode positioning while the patient reported comfortable paresthesia along the distribution of the targeted nerve, after retraction of the needle tip exposing electrode contacts. The device was anchored via a sub- dermal suture located at the skin entry point. Distal tubing was cut at the insertion site and buried subcutaneously. The skin entry site was closed with suture/steristrip.

Fig. 4 Skull X-ray anterior-posterior view showing the supraorbital and infraorbital location of the electrode.
Fig. 4

Skull X-ray anterior-posterior view showing the supraorbital and infraorbital location of the electrode.

Fig. 5 Skull X-ray lateral view showing the supraorbital and infraorbital placement of the electrodes.
Fig. 5

Skull X-ray lateral view showing the supraorbital and infraorbital placement of the electrodes.

Stimulation protocol: Stimulation parameters were set at pulse widths of 100-200 ms and frequency of 60 Hz. (This is not to be confused with the device communication frequency between the external generator and electrode microprocessor of 915 MHz.) Amplitudes were set at patient preference, which was typically between 1 and 3 mA. A therapeutic stimulation regimen was applied for up to 30 days followed by removal of the devices utilizing fluoroscopy and a small incision at the electrode insertion site. During stimulation sessions, when therapy was needed to alleviate pain, patients wore a special baseball cap that housed the external pulse generator within the fabric lining (Fig. 3).

Metrics for evaluating pain: Patients were monitored for ongoing pain relief and adverse events at 2 weeks and 4 weeks post-implant. Subjects were asked to describe their pain relief using the visual analog scale (VAS). Subjects were asked to report on medication usage at each assessment.

3 Results

All patients reported sustained pain relief over primary pain areas with various electrode placements and number of electrode contacts (Table 2). Patients were uniformly pleased with results in terms of pain relief and post-implant cosmetics. Average pain reduction across all subjects using the Visual Analog Scale (VAS) was ≥82%. The average baseline VAS pain score for the patient population was 8.44 with a median of 9.17 ±1.77 STD. The post stimulation average VAS pain score was 1.61 ± 0.35 STD (Fig. 6).

Table 2

Patient responses and type of stimulator.

Sub VAS baseline VAS week 4 Mandibular Infraorbital Supraorbital
1 10.0 0.0 8 contact 8 contact
2 10.0 0.7 8 contact
3 10.0 0.0 8 contact
4 6.0 0.5 8 contact
5 9.6 0.6 4 contact
6 6.5 3.4 4 contact
7 9.7 0.8 8 contact 8 contact
8 9.3 0.9 4 contact
9 8.6 0.1 4 contact
10 9.1 0.0 8 contact

There were no reported or observed adverse events. All patients reported reduced pain medication dosage by at least 50%. Over 40% of the patients were able to stop taking pain medication completely during the four-week period. After the end of the trial period, subjects had to restart medication.

Fig. 6 Average pain reduction as measured by VAS STD (n = 10).Consort flow chart.
Fig. 6

Average pain reduction as measured by VAS STD (n = 10).Consort flow chart.

4 Discussion

PNS has been a valuable therapeutic option in the management of chronic disabling facial pain since it is non-destructive and reversible [6,11,15]. Extracranial stimulation of nerves supplying craniofacial region has been recommended by the NACC for the treatment of chronic facial pain (and migraine) backed up by evaluation of published literature on current research and clinical experience. The committee did not find support for intracranial nerve stimulation [16].

Nevertheless the delivery systems utilized for PNS have not been designed for the peripheral nerve space, anatomically, especially in the craniofacial region. Thus these neurostimulation devices suffer from complications resulting from the bulk of the equipment, implantable nature of the batteries and lengthy surgical procedure [11,18,19,20,21].

The adverse events and side effects also make an effective treatment method such a PNS, an unacceptable one. FDA approval and insurance coverage are also lacking/limited at this time [21,24,25].

Wireless neuromodulation, on the other hand, mitigates the complications related to the conventional PNS devices and shows promise while expanding the number of indications for the treatment of chronic pain conditions [26]. There is a significant reduction in hardware components. A simple percutaneous placement of the electrode without the need to tunnel and attach an implanted pulse generator can be advantageous to the patient and the surgeon in reducing costs, procedure time, postoperative pain, and adverse events while achieving the desired pain control. It also adds to the cosmetic results and the positive emotional appeal.

The application and advantages with this minimally invasive wireless modality has been reported earlier for occipital neuralgia. Both patients tolerated the procedure very well and no complications related to the device or the stimulation procedure was reported [22].

In the present series also, we did not encounter any complications related to the surgery or the stimulation protocol. During the trial period the pain relief was sustainable in all the patients.

However, at the present time, the experience has been limited to fewer patients. Future studies will focus on larger patient populations with expanding metrics beyond the VAS and medication log usage, to include the Short-Form McGill Pain Questionnaire (MPQ-SF), Quality of Life (SF-36), European Quality of Life - Five Dimensions (EQ-5D), Patient Global Impression of Change (PGIC) and long term adverse events.

5 Conclusion

Percutaneous placement of a novel, wirelessly powered, neurostimulation system adjacent to affected craniofacial nerves for the treatment of craniofacial pain appears to be a safe and effective option while avoiding significant adverse events associated with conventional devices of PNS. Further studies are necessary to better understand long-term results, expanded indications and placement techniques for a variety of pain conditions referable to the peripheral nervous system (Fig. 7).

Fig. 7 Targeted subcutaneous percutaneous placement of four electrode array neurostimulators through an introducer cathether is placed in various targeted craniofacial nerve locations (trigeminal and supraorbital shown in this illustration).
Fig. 7

Targeted subcutaneous percutaneous placement of four electrode array neurostimulators through an introducer cathether is placed in various targeted craniofacial nerve locations (trigeminal and supraorbital shown in this illustration).

Highlights

  • Technological and cosmetic limitations inhibit use of PNS for craniofacial pain.

  • Management of craniofacial pain with a wirelessly powered PNS system.

  • 10 patients implanted with wireless stimulators, powered by an external transmitter.

  • Patients monitored for pain relief and AE’s for 4 weeks.

  • All patients reported pain relief over primary pain areas with no reported AE’s.

✰The study was carried out at: Medica Paseo de la Victoria, 4370 Partido Iglesias 32618, Ciudad Juarez CHIH, México.

  1. Ethical issues: Ethics committee approval was secured and 10 patients were consented and subsequently recruited for this pilot study.

  2. Authorship statement: Dr. Weiner designed the study. All physicians treated patients at the study site. Dr. Weiner and Dr. Montes recruited patients, collected and analyzed the data. Niek Vanquathem prepared the manuscript. All authors reviewed the manuscript critically and approved the final version.

  3. Sponsor and financial support: StimRelieve LLC, 1310 Park Central Boulevard South, Pompano Beach, FL33064, USA.

  4. Conflict of interest

    Conflict of interest statement: Dr. Richard L. Weiner: Consultant for StimRelieve LLC.

    Dr. Carlos Montes Garcia: Nothing to disclose.

    Mr. Vanquathem: Employee of the sponsor.

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Received: 2017-07-19
Revised: 2017-09-11
Accepted: 2017-09-12
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
https://doi.org/10.1016/j.sjpain.2017.09.010
Schlagwörter für diesen Artikel
Peripheral nerve stimulation; Neurostimulator; Wireless implant; Cranial nerve; Trigeminal neuralgia; Chronic facial pain

Artikel in diesem Heft

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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Heruntergeladen am 20.1.2026 von https://www.degruyterbrill.com/document/doi/10.1016/j.sjpain.2017.09.010/html?lang=de
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