Occipital Nerve Stimulator

Occipital Nerve Stimulation

Hello, I’m Dr. Ganesan Baranidharan, and I’m one of the consultants at Leeds Teaching Hospitals Trust. You’re here because you have been selected to have a therapy called occipital nerve stimulation. In the next few minutes, I will explain what occipital nerve stimulation is, when we choose to perform it, how it is done, what can go wrong, and the aftercare.

Occipital nerve stimulation involves stimulating specific nerves with small electrical wires to treat various kinds of headaches. Common reasons for this treatment include migraine, cluster headaches, and occipital neuralgia (nerve pain in the occipital region).

This procedure is done as a day case. You will have a pre-assessment to check your medical conditions and plan for anaesthesia and sedation. An anaesthetist will manage your sedation, and you will be given an antiseptic wash as per the hospital policy to reduce the risk of infection. The procedure is done under mild sedation and local anaesthesia, meaning you will be awake but comfortable due to painkillers and sleepy medications administered by the anaesthetist. You can discuss the details of sedation during the pre-assessment and again with the anaesthetist on the day of the procedure. Your pain consultant will call you 10 to 15 days before the operation to address any concerns or questions you may have. Once you arrive on the day of the operation, you’ll also have the opportunity to talk to your consultant if needed.

After you have given your consent, you’ll enter the operating room, which will have a team of professionals with specific roles. You will be positioned face down on the operating table. A needle will be placed in the back of your hand for antibiotics and sedation. The surgeon will shave the back of your head (please do not trim your hair prior to the procedure as it will help with the shaving). After the shave, a small incision will be made in the middle of your head, and wires will be placed over the nerves. These wires can be positioned in the middle or lower part of your head. Once the wires are in place, they are tunnelled under the skin toward the shoulder blades or sometimes underneath the head. The wires have four electrical contacts and tines (hooks) that help hold them in place. There is also an antenna at the back of the wire that receives the electrical signals. The wires communicate with a pad and a battery, which can be external, and occasionally we use implantable batteries, though this is very rare. If implantable batteries are used, the wire will be tunnelled to the chest wall or the buttock area, where the battery is placed inside the body.

After surgery, you might use the therapy for anywhere from one hour a day to as long as needed, depending on your response to electrical stimulation. However, this therapy is not guaranteed to work for everyone. If we start with 10 people, around six might experience significant benefit. The therapy can reduce the intensity and frequency of headaches, and it may improve your quality of life, allowing you to do things like go to the cinema, which might not have been possible before. If it doesn’t work, the wires can be safely removed. We typically allow 6 months to a year to assess whether the therapy has worked.

As with any surgery, there are potential risks. Infection is a common concern, with a risk ranging from 0.2% to 2%, meaning about two out of 100 people might experience an infection. Pain after the procedure is also common due to the placement of wires in the back of your head, which can cause tenderness and muscle spasms temporarily. The wires may also erode over time, especially if they move with neck movement. In some cases, wires may need to be trimmed or completely removed to prevent infections. Other complications can include bleeding, allergic reactions, and problems with the implanted hardware, such as battery failure or issues with rechargeability. Swelling, due to fluid or blood collection around the surgical site, can also occur.

Post-operative care is crucial. After surgery, you can begin mobilizing once you’re back on the ward. While some discomfort is normal, pain relief will be provided as needed. We advise against prolonged sitting or standing, but gentle movement and normal daily activities will support healing. You will need to book an appointment with your GP or practice nurse for a wound check 2 weeks after surgery. If this isn’t possible, you may need to contact the pain nurses at Leeds and send pictures of the wound for review. You will not be able to shower until the dressing is removed, which will happen 3 days after the procedure. Once the dressing is removed, you can shower, but be gentle and do not scrub or pick at the wound. Avoid swimming, hot tubs, saunas, or steam rooms for at least 6 weeks to reduce the risk of infection.

Be vigilant for signs of infection, including redness, excessive swelling, increased pain, or leakage of fluid or pus. If you develop a fever or feel unwell, contact the pain nurses immediately or seek advice from your GP or A&E if it’s after hours. If you have stopped taking any medications prior to surgery, such as blood thinners, ask when they can be safely restarted. Continue your regular pain medications until you have fully recovered from the procedure.

Regarding driving, you can be a passenger in a car immediately, but avoid driving for at least 4 weeks. This will allow the wires to settle and reduce the risk of them moving or eroding. If you have questions, feel free to discuss them with your consultant, especially regarding driving restrictions based on where the wires are placed.

It’s useful to watch this video with your partner or a caregiver so that both of you can write down any questions to ask during your next appointment. Thank you.

Introduction to the Leeds Pain Team

Hello my name is Dr Ganesan Baranidharan i’m one of the pain consultants at Leeds Teaching Hospitals. You’re here today because the pain team has felt that you’re suitable for a spinal implant to manage your chronic pain.

Leeds teaching hospitals is a tertiary care centre we cater to patients within Leeds for pain management and we also look after patients outside Yorkshire and outside leads for tertiary. Cat spinal cord stimulation is one of the tertiary care services that we provide at Leeds Teaching Hospitals.

Leeds teaching hospital is a cluster of hospitals which is located at different parts of Leeds such as leech general infirmary in the city centre. St James’s Hospital Wharfedale, Leeds Dental Institute, the Cancer Centre within this and St James’s hospital and Chapel Allerton Hospital.

Pain services are currently located at four sites which includes Leeds General Infirmary, St James’s hospital and the cancer institute cancer services within the saint James Hospital, Wharfedale general hospital and Seacroft hospital.

You might be expected to visit these centres for your specific pathway and we can’t move to different hospitals depending upon your accessibility. If you are asked to come to a certain hospital that means there are services located in that particular hospital and you have to make your way for that appointment.

Leeds pain service consists of pain doctors and there are five of us at present we have specialist nurses who look after both the clinical side and the research side.

We have administrative team who actually manages the whole pathway by offering you the appointment at the appropriate time. We have our pharmacists our psychologists and our physiotherapists who work within our team the aim of this presentation is for you to understand what spinal cord stimulation is.

Is this the right treatment for you and to understand the various things that goes with the spinal cord stimulation. This also helps you because you can watch it with your family so it could be made as a decision together for the suitability of this procedure.

The video is divided into five sections and this flows in the way of how your pathway is going to be initial introduction followed by pre-operation details and what happens in the operation period and what happens immediately after the operation and the long term changes so we’ve split them into five groups you should be able to dip in and dip out of each individual sections.

As you need at any time you want but the first time we would prefer you to watch the whole video as much as possible so you can get a clear understanding of what commitment we expect from yourself to go through this treatment pathway.

Types of Pain

My name is Dr Andy Whelan and I’m a pain consultant working for Leeds Teaching Hospitals I’d like to discuss the different types of pain we can experience and the reasons why spinal cord stimulators are implanted.

Pain usually exists to warn us of harm that is occurring to our bodies and is there to protect us. We call this type of pain acute pain and it can be felt when we stub our toe twist our ankle or break a bone this is the type of pain that usually disappears as the injury heals.

In some people this pain can continue for a prolonged period of time after the initial injury and this type of pain is called chronic pain and it can be more challenging to treat. Chronic pain can be of two different types the first is called nociceptive pain or non-nerve pain and it does not respond to spinal cord stimulation this pain describes the pain from physical damage or potential damage to the body and good examples of what no septic pain can feel like are pain from a sports injury a dental procedure or pain from arthritis.

The second type of pain is called neuropathic pain or nerve pain this is the type of pain that does respond well to spinal cord stimulation and this type of pain often occurs during sciatica shingles or in diabetes related pain neuropathic pain is more complex and is associated with an injury or a disease of the nerves that provide sensation it is therefore very different from noceptive pain in how it feels and how it develops.

People with neuropathic pain often describe it using words such as burning shooting stabbing and prickling light touch and gentle movement can feel very painful sometimes. Even things like clothes touching the skin can cause severe pain nice are the national institute for health and care excellence and provide guidance on which treatments have evidence to support their use in the NHS.

NICE have recommended spinal cord stimulation as a treatment option for adults with chronic pain of neuropathic origin who continue to experience chronic pain measuring at least five out of ten and have done so for at least six months despite conventional medical management.

In summary we have discussed that pain can be acute or chronic and it can fill no susceptible or non-nerve pain or neuropathic nerve pain we have explained that neuropathic nerve pain responds well to spinal cord stimulation and we have also covered the national guidance that spinal cord stimulators should be considered to treat moderate to severe chronic neuropathic pain.

Medication

My name’s Lis and I’m the pharmacist that works as part of the chronic pain team. Here in Leeds I’m going to talk for a few minutes about medication and how it fits into managing long-term pain. I’m going to look at what to expect from a medicine the challenge of balancing benefits and side effects and a bit about how you can go about reducing your medication. Firstly what can you expect from a painkiller sounds like an obvious question really you’d like it to take away all your pain but real life experience shows that, that’s not actually what happens.

Most people with chronic pain are unlikely to find one or a combination of medicines that take the pain away totally. I’m guessing that that may be your experience too when researchers look at how well a painkiller works. Reducing pain by 30 percent is counted as a successful result this is the same as saying that your pain has reduced from 10 out of 10 to 7 out of 10. So if we look at this diagram it shows that even if the medicine is working well. There’s a strong chance that you will still be left with some pain.

So this helps to show that relying on a painkiller is the only way to manage your pain is probably not a helpful strategy. If you’re expecting your painkiller to take away all of your pain you’re very likely to be disappointed. Now that probably sounds really very negative and you might well be thinking well why bother.

With them painkillers can play a useful part in managing pain although they’re unlikely to make the pain stop totally they may ease the pain so that you’re able to do more. For example it may mean that you can do an activity that wouldn’t have seemed possible before you might be able to do something for longer without having to stop because of the pain or you may also be more comfortable at night time and sleep better and therefore you feel better the next day to manage whatever comes your way.

I think sometimes it will be more helpful to think of the medicines as pain reducers rather than painkillers the reason for taking a painkiller is to improve your quality of life so it’s also important to think about any negative effects the medicines cause what are the costs of taking it all medicines have side effects.

Some are obvious and others can be more subtle a good example of this is the memory loss that can happen with opioid medicines when you take them long term things like morphine oxycodone and fentanyl it happens gradually over time and people don’t often realize what’s happening but the effect on everyday life is significant forgetting appointments plans conversations things that you’ve promised you’ll do.

Which will impact on you how you do life and your relationships with the people around you. So it can actually end up reducing your quality of life there needs to be a balance between the benefits and the side effects of the medicine that works positively for you.

You may feel that you want to take less medication but aren’t sure where to start depending on how many medicines you’re taking or how long you’ve been taking them for it may be useful to discuss this with your doctor or pharmacist.

First my general advice would be only make one change at a time that way you’ve got a good idea if something changes why it might be and take a slow and steady approach.

Remember it’s probably taken you a long time to get to this point so it’s also reasonable to expect it would take time to change and expect a time of things. Being more unsettled depending on which drug you’re taking you may experience withdrawal symptoms these can take time to settle and can make pain feel worse.

You need to work with your body and give yourself time to adjust it’s helpful to remember that for most people pain can vary from day to day anyway so you need to let things settle before you can properly assess what pain is like at the new dose.

Opioid Reduction

Why reduce your opioid medicines you may have been asked to look at reducing the amount of opioid that you take you may feel yourself that you want to stop taking them or you may actually be quite happy with what you’re taking and aren’t totally sure what all the fuss is about.

I wanted just to give you a summary of the situation that might help you understand things better opioids are strong painkillers that have been in use for a long time.

They’re used a lot to help with short-term pain for example following on from an accident or an operation then as the body heals itself and the pain reduces the painkillers are stopped.

The other place they’re used a lot is in end-of-life care helping to make people as comfortable as possible in both these situations we’re not looking at long-term use and haven’t been studying the side effects about 20 years ago. Doctors began to question why we weren’t using these effective medicines for people who have long term pain and so for the last 15 to 20 years they’ve been more widely used as we’ve used them more we’ve learnt more about them and what happens if you take them day in day out year after year.

Unfortunately the picture that we’re seeing and we’re building up of them is not particularly good the first thing is that they tend not to stay effective for most people their experiences the the start the medicine works really well it reduces their pain and they’re able to do a lot more but over time this wears off so you go back to the doctor and the dose is increased and for a while it’s good again but then it wears off so you go back the dose gets increased and so on and so on and eventually you end up taking high doses of opioids but find you’re still experiencing high levels of pain so opioids don’t really live up to their promise.

The second thing is knowing more now about what side effects might happen when these medicines are taken longer term there’s a few things that we now know opioids can affect hormones within your body there are many different hormone systems that work to keep everything in check one set of hormones that we know are affected because there’s something we can measure easily are the sex hormones so for women you find that periods can stop and for men testosterone levels can drop leading to problems with sexual function.

We suspect that other hormone systems can be affected too for example your thyroid which keeps your metabolism in balance and also those involved in keeping bones healthy the next one is a weird idea but opioids can actually start to make pain worse.

I know that sounds wrong but they can make the more painful areas sensitive and make you experience pain in new areas we don’t really know why this happens or how but there have been enough cases to know that it does the bizarre thing is that the pain actually gets better by taking less painkillers this seems to happen more often in cases where people have been taking high doses.

For a long period of time opioids can lower mood too it’s not that they cause depression on their own but they can definitely drag me down lower than it might otherwise be they tend to cause a general lack of energy.

Opioids can have a big effect on what we call your cognitive function so that’s how your brain takes in information how it processes information and then how it stores it so taking in information often your concentration is affected.

People find that they can’t concentrate or focus on anything for long so doing activities like crosswords or knitting stop being enjoyable and the same thing for reading.

People find that they can’t actually remember what happened on the previous page and so by the time they finish the book it it’s not enjoyable anymore and the same thing for watching tv programs and films also the idea of being properly involved in what’s going on around you.

You’re in the room but you’re not actually really there and somebody described it as possibly like being on standby processing information people often describe their thinking as being slowed they’re not as sharp as they used to be someone has described it as like trying to walk through treacle another thing that can happen is difficulty finding the right word in a conversation.

You know what you want to say but it’s kind of it’s on the tip of your tongue and you can’t do it and the third one is storing information short-term memory tends to be affected and remembering conversations that you had five minutes ago and that you’re supposed to be at an appointment that you said that you’re going to do something for somebody all of these things on their own might sound quite small but are yet another thing that you have to manage on a daily basis and they all affect your quality of life the aim of any type of pain intervention should be to improve your overall quality of life.

We’re looking to help you not just have a lower level of pain but to be able to do more of the things that make life worthwhile so that means for medicines we need to look at not just the benefits that they have but also at the side effects that they have too.

What are the costs of that benefit and how does that stack up for you opioids often offer the promise of doing great things for you but actually end up rubbing you of your quality of life we’ve worked with lots of people who started off taking really high doses of opioids and eventually are taking less but they feel that they’re in a much better place they still have pain.

But as the amount of medicine that they’re taking drops their quality of life has actually increased so how would you go about reducing an opioid medicine there isn’t really one correct way to do this it’s important to think about doing it in a way that feels manageable for you now.

It will depend a little bit on what medicine you’re taking the size of tablet and patch that it comes in you want to aim for a slow and steady reduction maybe a small drop every two to four weeks remember it’s probably taken a long time to get to the point where you are so it would seem reasonable to expect it to take time to change.

It it can be helpful to have the support of a healthcare professional a your GP or a pharmacist or a specialist nurse while you’re doing this process the other thing would be to expect the possibly getting some withdrawal withdrawal is something that happens when you stop taking an opioid it’s a physiological reaction from your body that you cannot control it’s not a sign that you’re addicted or that your body can’t manage without the drug.

I sometimes think of it as a little bit like your body having a tantrum your body has been used to having the opioid and it likes it if you stop or take some of it away it tends to let you know I don’t know if you’ve ever had the experience of taking a toy away from a toddler when they’re in the middle of playing with it usually all hell breaks loose for a few minutes and then after a bit they give up and move on to something else.

Your body tends to be a bit the same the withdrawal process can be intense and usually peaks around three to five days in and can take up to about 14 days to settle fully a really unhelpful thing is that often pain can feel worse as part of the withdrawal so the obvious thing is to think oh my goodness my pain is so much worse at this dose I must need that five milligrams but actually that’s not true.

You need to get through the withdrawal phase and let things settle and then you can properly see what your pain will be like at the lower dose this is the reason why we tend to suggest making changes every two to four weeks so that your body has time to adjust and then you can genuinely see what your pain is like at each dose level.

It can be helpful to think ahead about how you might manage some of the withdrawal symptoms and possibly talking to the friends and family around you really the question that you’re trying to answer is do I still need this medicine if so how much do I really need where’s the tipping point for me you.

Introduction Psychology and Activity

Hello my name is Alex Puchala and I’m a clinical psychologist today I’m going to tell you how we think about long-term pain and psychology and what is it that we offer as a part of the leads pain service pain is a powerful biological mechanism designed to protect us there are many different types of pain.

Like nerve pain mechanical pain pain comes with a lot of tension in our body when muscles want to protect the sight that is hurting pain is also by design grabbing our attention making it very difficult to focus on anything else and when pain is severe we cannot even engage in a simple conversation.

Pain is by design extremely unpleasant we share the experience of pain with animals but as human beings we developed extra things on top of that experience most people that we work with comment about sadness and suffering that comes with pain a very common experience is constant worrying worrying even about things that we typically look forward to like family holidays or wedding people might worry months or years in advance on how they’ll be able to get there whether they’ll be able to sit through it or enjoy it long term pain also comes with a lot of frustration the diagnostic processes and waiting lists can make people feel very frustrated.

Also the ignorance or lack of knowledge of friends family or healthcare professionals can be extremely frustrating it is normal for people living with long-term pain to experience a lot of anger it’s often anger at other people and they lack of support but sometimes that anger is internalized and people start to hate themselves and hate the life that they’re living and hate what their life became it’s normal to experience a lot of fear when it comes to long-term pain fear of certain conversations or meeting people being asked how are you busy places or activities that can trigger pain.

It’s also normal to experience avoidance of things and activities that might trigger pain what also people tell us about is a grief they experience over their life that they feel have lost or the part of self that they feel they have lost and also long term pain can lead to isolation and a lot of grief and guilt and shame over the things that the person is no longer able to do.

What people tell us often is about the experience of burden managing long-term pain is a burden for the person because there’s so many different things that the person have to look after or do or plan or problem solve managing long term pain is a burden for the family but what we often hear is after a while of living with long term pain the person themselves is starting to feel like a burden long-term pain can lead to isolation and loneliness and withdrawal from activities previously enjoyed and there is many other experiences that people share with us who live with long-term pain.

 So you see what has been developed as this really protective and helpful biological mechanism when it comes to long-term pain sometimes called chronic pain there is no protective function and there is no helpful function anymore it just becomes extremely difficult to manage and becomes a massive and complex difficulty for the person and people around them so what we know from scientific research and also from my experiences working with people of long term pain is that our mood how we think about pain.

How we understand it and knowledge about pain and the environment that we are in if these factors are negative they can put up the volume on pain the opposite is also true if we feel supported cared for and safe that can help us to manage the pain better in the leads pain service we use the model of holistic pain approach. 

What we mean by that is that we look at not only the person’s medical history but also on their social support on their beliefs on their value system what’s important to them and we take all of that into consideration when thinking about the best way to help and support the person one way of explaining what a holistic pain management is might be a use of a metaphor that we came up with in Leeds called the Leeds chair model so the lead chair model is a metaphor to explain what a good long-term pain management should look like imagine a really well-constructed chair a very well-designed chair that is very comfortable for you to sit in so let’s start with the back of the chair the back of the chair is all of the different treatments and investigations that you might have tried out to help you manage your pain better.

For majority of people that we work with it starts with trying different types of medication or injections another thing that people often use might be smaller but not less important it’s use of a hot water bottle massage or warm baths when you’re listening to this video one of the options that you and your pain team are considering is the use of spinal cord stimulator so it’s good to have that really well designed back of the chair but no matter how much padding goes into the back of the chair the most important thing about a comfortable and stable chair is the base of the chair so what do we understand by a good base of the chair in the pain management mode.

The first leg is diet what we eat how we eat how often we eat the frequency of our meals and how we hydrate our body is extremely important not just for our physical health and pain but also for our mental health another very important part of the chair model is sleep hygiene on purpose we didn’t just title it sleep because sleep for majority of people living with long term pain will be of low quality because pain can make it not only difficult to fall asleep but pain can wake people up and make it extremely difficult to fall back into sleep so what is the sleep hygiene sleep hygiene are all of the different strategies and things we can do throughout the day on the evening and during the night that can help us to get a better quality of sleep.

There is plenty resources about sleep hygiene and other strategies on our website the third leg of the chair is activity finding the right level of activity finding an exercise form a gentle form of exercise it’s essential to prevent pain from getting worse and to also give people a good quality of life the fourth lack of the chair is a little bit of a mix it includes and recognizes the importance of social interaction and social support but also the importance of things like having a hobby or being able to relax so imagine that one of those legs or maybe more of those legs of the chair are unstable of crumbly no matter how much we invest in the back of the chair you’re not going to be able to sit comfortably so remember one of the legs of the chair was the activity so we have an excellent team of physiotherapists who specialize in chronic pain and it’s very important that you think about optimizing your level of activity before.

Considering a spinal cord stimulator for best results so if you have concerns that maybe your level of activity is not what you would like it to be please ask your team for a referral to our pain physiotherapists to find out whether there is anything we can do to help you get a better level of activity.

I’m going to briefly now tell you about what is it that we do and offer in Leeds pain service from psychology we offer a living with pain group as name suggests it’s a group for people living with long term pain we also offer individual sessions with psychologists we also have an excellent opioid reduction clinic run jointly with our pharmacology and psychology and we also offer a psychological assessment of suitability for spinal cord stimulators.

If this short talk made you curious about psychology and how can it can help you to live the best life you can with your pain please go into our website the link will be in the description and see we’ve got breadth of resources about the sleep hygiene and other strategies that can help you live a better life with pain also if you’re interested in how psychology can help you better prepare for the spinal cord stimulator you can read about what we offer there thank you for your attention.

Research

Hello my name is Tracy Crowther and I’m a clinical research nurse I work in the pain and interventional neuromodulation research group or the pain research group as we often call ourselves. We’re a team of consultants research nurses research fellows and clinical trials assistants we’re all working together to try and find the best treatments to treat your chronic pain.

We are interested in improving your experience of chronic pain treatments one way that we can do this is by inviting you to take part in our clinical trials. Most of the clinical trials that we study in our pain research group are investigating medical devices similar to the spinal cord stimulator you have been invited to find out more about the aim of these studies is to improve our understanding of chronic pain conditions and to see if we can help find better treatments to treat your pain.

If you’re referred to the pain management service in Leeds you may be offered the opportunity to take part in one of our clinical trials this is totally voluntary you don’t need to do this if you don’t feel comfortable doing so.

But if you do decide you’d like to take part it may involve you needing to complete a few extra questionnaires and maybe attend a few extra visits in addition to the standard care pathway visits you’ll be asked to come and see us for you may not want to take part in one of our clinical trials but may still be interested in research.

If that’s the case please let us know because we have a patient and public involvement group that you could be a member of the group that we have review new studies that we’re designing and read all the paperwork and give us feedback on whether or not we are designing the studies in a way in which patients will be happy to take part.

If you’d like to get involved in this please let us know we’re always looking for volunteers.

NNR Pre Op

Hello my name is Dr Ganesan Baranidharan I’m a paint consultant at Leeds Teaching Hospitals registry is an important part of collecting data you might have heard about breast implant, hernia repair related, mesh problems.

The government is now focused on keeping a central registry of all implantable devices so if there is any problems in the future these could be brought back and the patients could be contacted appropriately so what is national neuromodulation registry.

This is a registry specifically designed for collecting data on patients and the devices that had been implanted in each of these patients you will be asked to take part in this data collection and this is purely for safety reasons as if there is any problems with these devices in the future it will be easy for us to contact you and do the appropriate management from our end.

We would be able to collect outcome data and also help other people in the future on the appropriate selection of devices and to improve the patient outcomes.

So once you sign this we would collect your demographic data such as your patient details, your email address your mobile number. We will then add details about the implantation into this you will be asked to give certain selected questions to be done before and you would get an automated email at about six months time where you would fill these in and this could be emails or text messages we will also hopefully have a patient application which meant you could possibly do all this using your smartphone or your iPad.

This way we improve the improve the safety of the device in summary we hope you would consent for having your data input into the national registry which is a key information that we collect and we would kindly ask you to fill the outcome data before and after to help us offer this therapy appropriately and effectively for patients in the future also.