Occipital Nerve Stimulation Technique

Updated: Oct 11, 2018
  • Author: Antonios Mammis, MD; Chief Editor: Jonathan P Miller, MD  more...
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Technique

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

Next:

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.

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