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Peripheral Nerve Stimulation for Acute Postoperative Pain 483
Fig. 1 Schematic representing the “Gate Control Theory” applied to electric neuromodulation of
pain
3 Equipment and Insertion Technique
for Ultrasound-Guided Percutaneous Peripheral Nerve
Stimulation
There is currently one PNS system approved for treatment of acute pain by the
USFDA [7]. This system comprises a steel and fluoropolymer percutaneous lead
connected to a pulse generator/battery pack. The lead itself consists of a 19-strand
stainless-steel wire core (160 µm in diameter) insulted with a fluoropolymer. This
steel and fluoropolymer wire is wound into an open helical coil (300 µm in diameter)
with the distal end bent back at a 75° (approximate) angle to anchor the lead in the
tissue adjacent to the target nerve (Fig. 2). As the wire is extremely flexible and thus
cannot be threaded through an introducer, the lead is pre-mounted in a 20-Gauge
needle to be inserted percutaneously. The needle with its mounted lead is inserted
through the skin and guided adjacent to the target nerve using ultrasound or other
imaging device. When in the desired position, the needle is withdrawn and the anchor
at the end holds the lead in place.
The stimulator lead connects to a pulse generator/battery pack, adherent to the
patient via an adhesive mounting pad (Fig. 3). The pulse generator is small (6.2
× 3.7 × 1.4 cm) and light enough (approximately 30 g) to be worn by the patient
without interference in activities of daily living. The generator should be secured to
the patient’s skin in a location that is easily reached by the patient.
The needle with mounted lead may be inserted using in- or out-of-plane ultra-
sound guidance based on the operator’s preference (Fig. 4). A small volume of local
anesthetic (usually 1% lidocaine) is infiltrated in the skin prior to insertion of the
needle/lead. If necessary for patient comfort, the needle tract may be anesthetized as
well, however, care should be taken to avoid injecting any local anesthetic adjacent
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484 J. J. Finneran IV and B. M. Ilfeld
Fig. 2 Percutaneous peripheral nerve stimulation lead and insertion needle. Used with permission
from Brian M. Ilfeld, M.D., M.S
Fig. 3 Pulse generator snaps into place with a rechargeable battery and is attached to a patient’s
skin by its adhesive mounting pad
to the target nerve/plexus as this will interfere with stimulation. Initial guidance of
the needle toward the target nerve or plexus is by ultrasound, with a goal of placing
the lead 0.5–1.5 cm from the target.
Following initial advancement of the needle under ultrasound guidance,the
final location of the lead should be determined by the patient’s perceived sensation
during testing. Most patients describe a tingling or massage sensation in the region
of the expected pain following surgery (i.e., brachial plexus stimulation should elicit
a massage sensation in the shoulder for a planned rotator cuff repair). If the patient
fails to experience any sensation in the therapeutic window of the device, the lead
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Peripheral Nerve Stimulation for Acute Postoperative Pain 485
Fig. 4 Set-up for initial test of sciatic nerve stimulation. Used with permission from John J. Finneran
IV, M.D.
should be moved closer to the target. If, prior to the patient describing a tingling
or massage sensation, pain and/or muscle contraction are experienced, a location
further from the nerve or plexus should be trialed as stimulating the nerve from too
short a distance may increase activation of small diameter afferent fibers resulting in
pain (Fig. 5).
Early PNS lead insertion systems consisted of only a wire lead pre-mounted in
a needle. These systems had the significant drawback that the needle could only be
advanced when trialing a stimulation location since withdrawing the needle resulted
in lead deployment. If suboptimal positioning was found in that initial trajectory and
needle repositioning was necessary, an entirely new lead-needle was required. This
frequently lead to the need for multiple leads in each patient (the suboptimal leads
ultimately removed once the optimal site was determined). Later generation insertion
systems employ a testing needle combined with a sleeve that can be advanced and
withdrawn to optimize the location prior to placement of the lead. Once the desired
location is determined, the testing needle is withdrawn, leaving the sleeve in place.
The sleeve then serves as a conduit for insertion of the needle-lead complex (Fig. 6).
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486 J. J. Finneran IV and B. M. Ilfeld
Fig. 5 Remote stimulation of the nerve may allow for more uniform activation of large diameter
(touch) afferent fibers, while close stimulation may result in activation of small diameter (pain)
afferent fibers. Used with permission from Brian M. Ilfeld, M.D., M.S.
Fig. 6 Ultrasound-guided insertion of the testing needle and percutaneous sleeve to a distance of
approximately 1 cm from the sciatic nerve; with and without the needle, sleeve, and nerve labeled
4 Applications for Acute Pain
The United States is currently experiencing an opioid epidemic. Pain following
surgery is a common cause of new opioid prescriptions with approximately 80% of
patients prescribed either oxycodone or hydrocodone following low risk surgery [9].
Peripheral nerve blocks offer a method of potent and targeted analgesia following
painful orthopedic surgery; however, both single injection and continuous local anes-
thetic-based techniques have limitations. Single injection peripheral nerve blocks are
limited in duration to hours, while continuous nerve blocks are limited in duration to
days due to the size and weight of the external reservoir of local anesthetic as well as
infection risk associated with extended duration indwelling catheters [10]. However,
pain after orthopedic surgery often lasts for weeks. Further, local anesthetic-based
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Peripheral Nerve Stimulation for Acute Postoperative Pain 487
nerve blocks produce weakness of the operative extremity as well as predisposition
to falls for lower extremity nerve blocks [12].
In contrast to local anesthetic-based nerve blocks (Table1), PNS offers analgesia
without producing weakness or sensory/proprioceptive deficits. Additionally, the
device that has been used for most investigations involving PNS for acute postoper-
ative analgesia is cleared by the USFDA for 60 days of continuous use. Thus, PNS
may be an analgesic modality better paired with the expected duration of intense
pain following major orthopedic surgery. In comparison to local anesthetic nerve
blocks, PNS does suffer from substantially increased cost, which may be an order
of magnitude more than conventional nerve blocks. In addition, lead placement may
be associated with a significant increase in total procedural time. As these leads
remain in situ and functioning for a much longer duration than what is expected
from a continuous peripheral nerve block, follow-up time requirements are similarly
prolonged. In the authors’ experience, the intensity of patient interactions and time
required for analgesic/complication management is greatly reduced with stimulation
techniques.
Percutaneous stimulation of the brachial plexus, femoral nerve, and sciatic nerve
has been described [11] for postoperative analgesia (Table 2). Early investigations
were aimed at determining if PNS would provide sufficient analgesia in the imme-
diate postoperative period to obviate the need of a local anesthetic-based peripheral
nerve block. However, the majority of participants in these studies required a single
injection peripheral nerve block prior to discharge. As such, more recent studies on
PNS for postoperative analgesia have incorporated a single injection nerve block for
all participants, followed by immediate activation of the stimulator in the recovery
area.
Table 1 Comparison of single injection and continuous nerve blocks with peripheral nerve
stimulation for postoperative analgesia
Single injection
peripheral nerve block
Continuous peripheral
nerve block
Peripheral nerve
stimulation
Analgesia Duration Hours Days Weeks to Months
Titratability – + ++
Administration Time + ++ +++ to ++++
Sensory deficit +++ + –
Motor deficit ++ + –
Cost + ++ ++++
Follow-up
requirements
+ ++ ++++
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488 J. J. Finneran IV and B. M. Ilfeld
Table 2 Sites for peripheral
nerve stimulation and
corresponding surgical
procedures
Stimulation site Surgical procedure
Upper extremity
Brachial plexus Rotator cuff repair
Lower extremity
Femoral nerve Anterior cruciate ligament repair
Sciatic nerve Ankle arthroplasty
Hallux valgus surgery
Femoral and sciatic nerves Total knee arthroplasty
5 Contraindications and Complications
Clinicians will be familiar with most contraindications to PNS as they are similar
to other regional anesthetics. The only contraindication specific to PNS is the pres-
ence of another electric stimulation device whose current would overlap with that
of the nerve stimulator. These include but are not limited to: (1) deep brain stim-
ulator, (2) implanted active cardiac implant (e.g., pacemaker or defibrillator), (3)
other implanted neurostimulation device (e.g., spinal cord stimulator). Each of
these represents an absolute contraindication to the use of PNS. Other contraindi-
cations common to all regional anesthetics include bleeding disorders, infection,
pharmacologic anticoagulation, and severe adhesive allergies.
As with its contraindications, complications of PNS are comparable to other
regional anesthetic procedures. These include infection, nerve injury, skin irritation,
lead dislodgement, and lead fracture. The infection rate for PNS leads is extremely
low, with approximately one infection for every 32,000 indwelling days for helically
coiled leads [13]. This low rate is likely the result of both the extremely small size of
the lead (160 µm) and its helically coiled shape. The small size of the lead correlates
to a very small opening in the skin; while the helical coil helps to induce fibrosis
around the lead. This fibrosis combined with the helical coil likely prevents pistoning
of the lead (microscopic motions in and out of the skin) that can draw potentially
pathogenic microbial organisms from the skin subcutaneously while also breaking
any bacteriostatic seal at the entry site. When percutaneous brachial plexus stimula-
tion is utilized for shoulder surgery, it is important to keep the lead insertion site high
on the neck where it will not be under the strap of the patient’s arm sling (Fig. 7).
Lead insertion sites under a sling may not fibrose due to the continued motion at the
site and therefore not create the same bacteriostatic seal that is normally found at the
lead insertion site [14].
Any procedure involving the intentional insertion of a needle or other device
adjacent to a peripheral nerve has the potential to produce a nerve injury. However,
there has never been a published report of a nerve injury resulting from percutaneous
PNS. Compared to conventional nerve blocks with local anesthetic, both single injec-
tion and continuous, the theoretical risk of nerve injury should be lower for PNS.
Local anesthetic-based nerve blocks require the block needle to be placed within the
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Peripheral Nerve Stimulation for Acute Postoperative Pain 489
Fig. 7 Infected peripheral nerve stimulation lead insertion site. This infection likely resulted from
the lead being inserted under the strap of the patient’s sling following rotator cuff repair
connective tissue sheath just surrounding the epineurium; in contrast, PNS leads are
placed 0.5–1.5 cm from the epineurium. Thus, there is theoretically less trauma to
the nerve associated with placement of a PNS lead than during a conventional nerve
block. Additionally, local anesthetic nerve blocks involve the injection of fluid in
this perineural space with the potential for unrecognized intraneural injection. As
PNS leads may be left in situ far longer than most transcutaneous catheters (USFDA
cleared for up to 60 days of use), there is increased risk of skin irritation and break-
down. This risk may be lessened by rotating the site of the adhesive mounting pad and
replacing the occlusive dressing covering the lead site regularly. Due to the fibrosis
that occurs at the lead insertion site and along its tract as well as the barb shaped distal
end, unintentional lead dislodgement is rare and may be further reduced by the use
of 2-octyl cyanoacrylate surgical glue at the lead insertion site. When dislodgement
does occur, the clinician and patient must weigh the cost and risk of replacement
with the patient’s pain level following discontinuation of the stimulation therapy.
Reported incidence of lead fracture (breakage at or deep to the insertion site
leaving a segment of the wire inside the patient) has varied from 3 to 25% in PNS for
acute pain studies. This data is based on the initial lead design, and the manufacturer
claims that a newly designed lead is far more durable and associated with a greatly
decreased risk of lead fractures. All fractured leads reported in the literature were
left in situ with no subsequent negative sequelae reported. This includes infected
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490 J. J. Finneran IV and B. M. Ilfeld
fractured leads, which have been successfully treated with oral antibiotics and did
not require surgical retrieval. Importantly, even if fracture occurs at the insertion
site and the entire length of lead is left in situ, patients may still undergo magnetic
resonance imaging in machines up to 3.0 Tesla. The risk of fracture may increase
when a lead is placed in a highly mobile regional (e.g., sciatic leads placed in the
popliteal fossa fracture at a higher rate than those placed in a more proximal thigh
position) or when resistance is encountered during removal of the lead. When the
latter occurs, slow constant pressure and injection of subcutaneous short acting local
anesthetic at the lead insertion site may help to prevent fracture during removal.
6 Summary
Electric stimulation of peripheral nerves is an emerging technology for management
of acute postoperative pain. When combined with a single injection peripheral nerve
block, PNS offers analgesia for weeks following painful orthopedic surgery of the
extremities with no deficits in sensation, strength, or proprioception, and thus may
facilitate participation in rehabilitation and return to normal functioning. Ongoing
randomized trials will continue to elucidate the role of this novel technology in
perioperative care.
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Ultrasound-Guided Percutaneous
Cryoneurolysis for Acute Pain
Management in Surgical and Trauma
Patients
Michael Gyorfi, Ian Pillai, and Rodney A. Gabriel
Abstract Ultrasound-guided percutaneous cryoneurolysis is a minimally-invasive
procedure that involves the use of extreme cold temperatures to destroy target tissues.
Cryoneurolysis has been increasingly used for the treatment of acute pain, particu-
larly in surgical and trauma patients. By applying cold temperatures to target nerves,
transmission of pain signals to the brain may be disrupted. This therapeutic modality
can provide long-lasting pain relief that persists for weeks to months and dimin-
ishes the need for additional opioids. This chapter will cover acute pain indications
for cryoneurolysis for surgical (e.g. mastectomy, joint arthroplasty, thoracotomy,
limb amputation) and trauma (e.g. acute burns and rib fractures) indications. Several
reports have shown that cryoneurolysis can be an effective treatment option with
a low risk of complications when provided to the appropriate patient and nerve.
As the use of ultrasound-guided percutaneous cryoneurolysis continues to expand,
further research is needed to determine the optimal application of this procedure
for different pain conditions, as well as to further refine the technique and improve
patient outcomes.
Keywords Cryoneurolysis
· Cryoangelsia · Cryoablation · Acute pain · Regional
anesthesia
M. Gyorfi
Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI,
USA
e-mail: mgyorfi@uwhealth.org
I. Pillai
Midwestern University, Downers Grove, IL, USA
e-mail: ipillai@wisc.edu
R. A. Gabriel (
B
)
Anesthesiology, University of California, San Diego, CA, USA
e-mail: ragabriel@health.ucsd.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_32
493
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