ICDs, Occipital stimulation for Migraine and Treatment of Vertebral Fractures

Subcutaneous ICDs
The first guideline advises that subcutaneous ICDs can be used. Traditional ICDs have leads placed transvenously, which is more complicated and requires a GA. Subcutaneous ICDs seem to be safe and effective, though so far data is on short term use. A nice to know detail only!

Occipital Stimulation for Migraine
This guideline advises that occipital nerve stimulation can be used for intractable chronic migraine. There isn't enough good data to be sure that it is effective, though some small studies suggest that it may be. A neurostimulator is placed subcutaneously and leads run to the level of the occipital nerve, so it doesn't sound the simplest of procedures. Worth being aware of as patients may ask about it...

Percutaneous Vertebroplasty and Balloon Kyphoplasty for Vertebral Fractures
This guideline isn't talking about new procedures, but they do seem to go in and out of fashion. These procedures do both work and also confer a mortality benefit. The main thing for us to be aware of is that the earlier these patients are treated, the better (ideally around the 6 week mark, when the pain should have settled if it's going to, but before the fractures have fully healed). However, patients must already be on 'optimal pain relief', which is tricky to achieve by 6 weeks and my experience of these patients is that they often present quite late. As these procedures are normally organised by the pain clinic they'll also have to wait about 3 months to get seen. So all in all, nice to know it works, but not very practical.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton locum chambers, and Pallant Medical Chambers Clinical Guidelines Lead Partner.

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