Survival Analysis of Occipital Nerve Stimulator
Leads Placed under Fluoroscopic Guidance with
and without Ultrasonography
Authors: Jones James Harvey 
Published: February 2021

Background: Electrical stimulation of the greater occipital nerves is performed to treat pain secondary to
chronic daily headaches and occipital neuralgia. The use of fluoroscopy alone to guide the surgical placement
of electrodes near the greater occipital nerves disregards the impact of tissue planes on lead stability and
stimulation efficacy.
Objective: We hypothesized that occipital neurostimulator (ONS) leads placed with ultrasonography combined
with fluoroscopy would demonstrate increased survival rates and times when compared to ONS leads placed
with fluoroscopy alone.
Study Design: A 2-arm retrospective chart review.
Setting: A single academic medical center.
Methods: This retrospective chart review analyzed the procedure notes and demographic data of patients who
underwent the permanent implant of an ONS lead between July 2012 and August 2015. Patient data included
the diagnosis (reason for implant), smoking tobacco use, disability, and age. ONS lead data included the date
of permanent implant, the imaging modality used during permanent implant (fluoroscopy with or without
ultrasonography), and, if applicable, the date and reason for lead removal. A total of 21 patients (53 leads) were
included for the review. Chi-squared tests, Fishers exact tests, 2-sample t-tests, and Wilcoxon rank-sum tests
were used to compare fluoroscopy against combined fluoroscopy and ultrasonography as implant methods with
respect to patient demographics. These tests were also used to evaluate the primary aim of this study, which was
to compare the survival rates and times of ONS leads placed with combined ultrasonography and fluoroscopy
versus those placed with fluoroscopy alone. Survival analysis was used to assess the effect of implant method,
adjusted for patient demographics (age, smoking tobacco use, and disability), on the risk of lead explant.
Results: Data from 21 patients were collected, including a total of 53 ONS leads. There was no statistically
significant difference in the lead survival rate or time, disability, or patient age with respect to the implant
method with or without ultrasonography. There was a statistically significant negative effect on the risk of
explant with regards to lead removal in smoking patients compared to non-smoking patients (hazard ratio
0.36). There was also a statistically significant difference in smoking tobacco use with respect to the implant
method, such that a greater number of patients whose leads were placed with combined fluoroscopy and
ultrasonography had a history of smoking (P = 0.048).
Limitations: This study is a retrospective chart review that had statistically significant differences in the patient
groups and a small sample size.
Conclusion: This study assessed the survival rates and times of ONS leads placed with ultrasonography and
fluoroscopy versus fluoroscopy alone. We did not observe an effect to suggest that the incremental addition of
ultrasound guidance to fluoroscopy as the intraoperative imaging modality used during the permanent implant
of ONS leads yields statistically significant differences in lead survival rate or time. Medical comorbidities,
including age and smoking status, may play a role in determining the risk of surgical revision and should be
considered in future studies.
Key words: Neuromodulation, peripheral nerve stimulation, occipital nerve stimulation, occipital neuralgia,
chronic daily headaches, ultrasonograph