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Gazzeri R, Galarza M, Occhigrossi F. Motor improvement and spasms recovery with high-frequency 10 kHz spinal cord stimulation in a patient with spastic tetraparesis: beyond pain relief. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08505-1. [PMID: 39322776 DOI: 10.1007/s00586-024-08505-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 09/02/2024] [Accepted: 09/20/2024] [Indexed: 09/27/2024]
Abstract
PURPOSE To describe the clinical outcomes beyond pain relief of high-frequency spinal cord stimulation at 10 kHz (10 kHz SCS) in a patient with cervical myelopathy and drug-resistant chronic neuropathic pain with spastic tetraparesis. METHODS A patient with C3-C6 myelomalacia and spastic tetraparesis previously treated with decompressive laminectomy underwent implantation of 10 kHz SCS for pain management through a trial procedure followed by permanent implantation. Due to the presence of epidural fibrotic scar tissue in the area of the previous C3-C6 laminectomy, the leads could not be implanted at the cervical level; therefore, the leads were positioned at the thoracic level. Data were collected during routine follow-up visits up to 15 months after implantation. RESULTS Since the trialing phase and during all follow-up visits, along with complete pain relief in the lower limbs, a recovery from spasms was observed with an improvement in motor function. The patient recovered from a sensation of stiffness and difficulty in movement, with a significant decrease in muscle tone, regaining confidence in walking, and no longer needing assistance even for long walking distances. Although all disabling and painful symptomatology in the upper limbs instead did not ameliorate, the Oswestry Disability Index (ODI) score decreased from 50% at baseline to 6%. CONCLUSION To our knowledge, recovery from spasms and motor improvement in a spastic tetraparesis patient has never been reported before with 10 kHz SCS and possibly this new stimulation paradigm may overcome some performance limitations of traditional low-frequency SCS (LF-SCS). Treatment eliminated spasms at the lower limbs but not at the upper ones, thus suggesting that the location of the epidural leads could affect outcomes.
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Affiliation(s)
- Roberto Gazzeri
- Interventional and Surgical Pain Management Unit, San Giovanni Addolorata Hospital, Via Amba Aradam 9, Rome, 00136, Italy.
| | - Marcelo Galarza
- Regional Service of Neurosurgery, "Virgen de la Arrixaca" University Hospital, Murcia, Spain
| | - Felice Occhigrossi
- Interventional and Surgical Pain Management Unit, San Giovanni Addolorata Hospital, Via Amba Aradam 9, Rome, 00136, Italy
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Deer TR, Russo M, Grider JS, Sayed D, Lamer TJ, Dickerson DM, Hagedorn JM, Petersen EA, Fishman MA, FitzGerald J, Baranidharan G, De Ridder D, Chakravarthy KV, Al-Kaisy A, Hunter CW, Buchser E, Chapman K, Gilligan C, Hayek SM, Thomson S, Strand N, Jameson J, Simopoulos TT, Yang A, De Coster O, Cremaschi F, Christo PJ, Varshney V, Bojanic S, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for Spinal Cord Stimulation Long-Term Outcome Optimization and Salvage Therapy. Neuromodulation 2024; 27:951-976. [PMID: 38904643 DOI: 10.1016/j.neurom.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has recognized a need to establish best practices for optimizing implantable devices and salvage when ideal outcomes are not realized. This group has established the Neurostimulation Appropriateness Consensus Committee (NACC)® to offer guidance on matters needed for both our members and the broader community of those affected by neuromodulation devices. MATERIALS AND METHODS The executive committee of the INS nominated faculty for this NACC® publication on the basis of expertise, publications, and career work on the issue. In addition, the faculty was chosen in consideration of diversity and inclusion of different career paths and demographic categories. Once chosen, the faculty was asked to grade current evidence and along with expert opinion create consensus recommendations to address the lapses in information on this topic. RESULTS The NACC® group established informative and authoritative recommendations on the salvage and optimization of care for those with indwelling devices. The recommendations are based on evidence and expert opinion and will be expected to evolve as new data are generated for each topic. CONCLUSIONS NACC® guidance should be considered for any patient with less-than-optimal outcomes with a stimulation device implanted for treating chronic pain. Consideration should be given to these consensus points to salvage a potentially failed device before explant.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dawood Sayed
- The University of Kansas Health System, Kansas City, KS, USA
| | | | | | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erika A Petersen
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Ganesan Baranidharan
- Leeds Teaching Hospital National Health Service (NHS) Trust, University of Leeds, Leeds, UK
| | - Dirk De Ridder
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Adnan Al-Kaisy
- Guy's and St Thomas NHS Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Corey W Hunter
- Ainsworth Institute, Ichan School of Medicine, Mt Sinai Hospital, New York, NY, USA
| | | | | | - Chris Gilligan
- Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Simon Thomson
- Pain & Neuromodulation Consulting Ltd, Nuffield Health Brentwood and The London Clinic, Brentwood, UK; Pain & Neuromodulation Centre, Mid & South Essex University NHS Hospitals, Basildon, UK
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Thomas T Simopoulos
- Arnold Warfield Pain Management Center, Harvard Medical School, Boston, MA, USA
| | - Ajax Yang
- Spine and Pain Consultant, PLLC, Staten Island, NY, USA
| | | | - Fabián Cremaschi
- Department of Neurosciences, National University of Cuyo, Mendoza, Argentina
| | - Paul J Christo
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishal Varshney
- Providence Healthcare, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Provenzano DA, Leech JE, Bendersky M, Azalde R. Defining Short- and Long-Term Programming Requirements in Patients Treated With 10-kHz Spinal Cord Stimulation. Neuromodulation 2024; 27:1045-1054. [PMID: 38829295 DOI: 10.1016/j.neurom.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVES High-frequency spinal cord stimulation (10-kHz SCS) has been shown to be an effective treatment for refractory low back pain and neck pain with and without limb pain in clinical trial and real-world studies. However, limited information is available in the literature on the type and frequency of programming parameters required to optimize pain relief. MATERIALS AND METHODS Retrospective trial and postimplant clinical and system device data were analyzed from consecutive patients with neck pain and low back pain, with and without limb pain, from a single clinical site, including both thoracic and cervical lead placement. Best bipole, stimulation parameters, and outcomes, including pain relief, change in opioid medication use, sleep, and daily function, were analyzed. RESULTS Of the 92 patients in the trial, 70 received a permanent implant. Of these, the mean duration of follow-up was 1.8 ± 1.3 years. Pain relief of ≥50% at the last follow-up was achieved by 64% of patients implanted; in addition, 65% reduced their opioid medication use; 65% reported improved sleep, and 71% reported improved function. There was some consistency between the "best" bipole at trial and permanent implant, with 82% of patients within one bipole location, including 54% of permanent implants who were using the same best bipole as at trial. After permanent implant, device reprogramming was minimal, with ≤one reprogramming change per patient per quarter required to maintain pain outcomes. CONCLUSIONS In the study, 10-kHz SCS was an effective therapy for treating chronic pain, whereby a high responder rate (≥50% pain relief) was achieved with short time to pain relief in trial and maintained with limited device programming after permanent implant. The data presented here provide insight into the programming required during the trial and implant stages to obtain and maintain therapeutic efficacy.
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Affiliation(s)
| | - Jozef E Leech
- Pain Diagnostics and Interventional Care, Sewickley, PA, USA
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Covington S, Strand N, Pew S, Dawodu A, Dunn T, Johnson B, Hand B, Abd-Elsayed A. Cervical Spinal Cord Stimulation for Failed Neck Surgery Syndrome. Curr Pain Headache Rep 2024; 28:607-612. [PMID: 38308745 DOI: 10.1007/s11916-024-01214-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE OF REVIEW Cervical spine pain with or without radicular symptoms is a common condition leading to high utilization of the healthcare system with over 10 million medical visits per year. Many patients undergo surgical interventions and unfortunately are still left with neck and upper extremity pain, sometimes referred to as "Failed Neck Surgery Syndrome." When these options fail, cervical spinal cord stimulation can be a useful tool to decrease pain and suffering as well as reduce prescription medication use. RECENT FINDINGS Spinal cord stimulation is a well-established therapy for chronic back and leg pain and is becoming more popular for neck and upper extremity pain. Recent studies have explored cervical spinal cord stimulation with successful outcomes regarding improved pain scores, functional outcomes, and reduction of prescription medication use. Continued research into cervical spinal cord stimulation is essential for maximizing its therapeutic potential for patients with chronic neck and upper extremity pain. This review highlights the importance of cervical spinal cord stimulation as an option for patients with failed neck surgery syndrome.
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Affiliation(s)
- S Covington
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA.
| | - N Strand
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - S Pew
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - A Dawodu
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - T Dunn
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - B Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - B Hand
- Mayo Alix School of Medicine, Scottsdale, AZ, USA
| | - A Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
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Sun S, Yin J, Wei H, Zeng Y, Jia H, Jin Y. Long-Term Efficacy and Safety of High-Frequency Spinal Stimulation for Chronic Pain: A Meta-Analysis of Randomized Controlled Trials. Clin J Pain 2024; 40:415-427. [PMID: 38595082 DOI: 10.1097/ajp.0000000000001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/26/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE The aim of our meta-analysis was to systematically assess the enduring effectiveness and safety of high-frequency spinal stimulation (HF-SCS) in the management of chronic pain. METHODS We developed a comprehensive literature search strategy to identify clinical trials investigating the efficacy of high-frequency spinal stimulation for chronic pain. The search was conducted in multiple databases, including Web of Science, Cochrane, PubMed, and Embase, covering the period from 2004 to 2023. The inclusion and exclusion criteria established for this study were applied to screen the eligible literature by carefully reviewing abstracts and, when necessary, examining the full text of selected articles. To assess the quality of the included studies, we utilized the Risk of Bias assessment tool provided by the Cochrane Collaboration. The PRISMA method was followed for the selection of articles, and the quality of the articles was evaluated using the risk assessment table for bias provided by the Cochrane Collaboration. Meta-analysis of the selected studies was performed using Review Manager 5.4 and STATA 16.0. Effect sizes for continuous data were reported as mean differences (MD) or standardized mean differences (SMD), while categorical data were analyzed using relative risks (RR). RESULTS According to our predefined literature screening criteria, a total of seven English-language randomized controlled trials (RCTs) were included in the meta-analysis. The findings from the meta-analysis demonstrated that HF-SCS exhibited superior efficacy in the long-term treatment of chronic pain when compared with the control group (RR=2.44, 95% CI: 1.20-4.96, P =0.01). Furthermore, HF-SCS demonstrated a statistically significant improvement in the Oswestry Disability Index score (mean difference MD=3.77, 95% CI: 1.17-6.38, P =0.005). However, for pain assessment (standardized mean difference SMD=-0.59, 95% CI: -1.28 to 0.10, P =0.09), Patient Global Impression of Improvement (PGI-I) score (MD=0.11, 95% CI: -0.66 to 0.88, P =0.78 for 6 months; MD=0.02, 95% CI: -0.42 to 0.43, P =0.97 for 12 mo), Clinical Global Impression of Improvement (CGI-I) score (MD=-0.58, 95% CI: -1.62 to 0.43, P =0.27 for 6 mo; MD=-0.23, 95% CI: -0.94 to 0.48, P =0.52 for 12 mo), and occurrence of adverse effects (odds ratio [OR]=0.77, 95% CI: 0.23-2.59, P =0.67), HF-SCS did not show statistically sufficient effects compared with the control group. CONCLUSIONS The findings from our comprehensive review and meta-analysis offer encouraging data about the prolonged efficacy and safety of HF-SCS in chronic pain management on some but not all outcomes. Recognizing the constraints of the existing evidence is crucial. Additional clinical trials, meticulously planned and stringent, are essential to bolster the current body of evidence and reach more conclusive findings.
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Affiliation(s)
- Sisi Sun
- Department of Pain Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Ali R, Schwalb JM. History and Future of Spinal Cord Stimulation. Neurosurgery 2024; 94:20-28. [PMID: 37681953 DOI: 10.1227/neu.0000000000002654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/27/2023] [Indexed: 09/09/2023] Open
Abstract
Spinal cord stimulation (SCS) is a surgical treatment for chronic neuropathic pain refractory to medical management. An SCS system comprised one or more leads implanted in the epidural space, typically connected to an implantable pulse generator. This review discusses the history, indications, surgical technique, technological advances, and future directions of SCS.
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Affiliation(s)
- Rushna Ali
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Medical Group, West Bloomfield , Michigan , USA
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Petersen EA. Spinal cord stimulation in painful diabetic neuropathy: An overview. Diabetes Res Clin Pract 2023; 206 Suppl 1:110760. [PMID: 38245324 DOI: 10.1016/j.diabres.2023.110760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/30/2023] [Indexed: 01/22/2024]
Abstract
Up to 25% of people with diabetes develop painful diabetic neuropathy (PDN). The standard of care pharmacotherapies for PDN have limited efficacy with a considerable side effect profile. Spinal cord stimulation (SCS) is a form of electrical neurostimulation that modulates neural function via electrodes implanted into the spinal epidural space. While low frequency SCS has been shown to be potentially effective for treating pain associated with neuropathies, it masks pain perception by inducing paresthesia. Compared to low frequency SCS, high frequency (10 kHz) SCS delivers paresthesia-free therapy. As was shown in a randomized controlled trial, SENZA-PDN (NCT03228420), 10 kHz SCS is safe and effective for the treatment of painful diabetic neuropathy. 10 kHz SCS offered a comprehensive treatment that improved pain levels, sleep, quality of life, and neurological function. These improvements correlated with a high degree of patient satisfaction. 10 kHz SCS provides a safe, durable and effective treatment for PDN with the unique potential to improve neurological function. In patients for whom durable, effective treatments have been limited thus far, the findings of the SENZA-PDN study are encouraging.
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Affiliation(s)
- Erika A Petersen
- University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Saleki M, Khabbass M, Bretherton B, Baranidharan G. Exploring Patient Satisfaction and Other Outcome Measures With Pain Relief in Spinal Cord Stimulation: A Single-Site, Cohort Audit. Cureus 2023; 15:e51339. [PMID: 38288220 PMCID: PMC10824466 DOI: 10.7759/cureus.51339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 01/31/2024] Open
Abstract
Context Spinal cord stimulation (SCS) is an approved treatment for chronic pain of neuropathic origin. Initial research suggests a close relationship between pain relief and patient satisfaction with SCS. Objectives To see whether similar patterns were observed in our center and to identify areas of improvement, this single-site, cohort audit explored the association between pain relief and satisfaction as well as specific factors that influence satisfaction at follow-up in patients with fully implanted SCS. Methods Age, gender, pain condition, SCS system, average pain (numerical rating scale, NRS), and worst pain (NRS) scores at baseline and the most recent follow-up visit were collected. Percentage change in average pain was calculated, and the patients were allocated to one of three pain improvement groups: <30%, 30%-50%, or >50%. A telephone survey explored patient outcomes including patient satisfaction, sleep, fatigue, quality of life (QoL), walking ability, and medication use. Chi-square tests of independence were performed. Results The final sample comprised 87 patients (<30%: n = 26; 30%-50%: n = 29; >50%: n = 32). The pain improvement group was significantly associated with satisfaction (p = 0.010): all patients in the >50% improvement group reported being either very satisfied or somewhat satisfied with SCS. The pain improvement group was also significantly associated with change in sleep (p < 0.001), fatigue (p = 0.001), QoL (p = 0.003), and opioid consumption (p = 0.010). Improvements were most frequently reported in the >50% improvement group. Conclusion Findings point to an association between pain relief and patient satisfaction with SCS. Other factors, including sleep, fatigue, QoL, and opioid consumption, may influence this association and deserve further exploration.
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Shlobin NA, Wu C. Current Neurostimulation Therapies for Chronic Pain Conditions. Curr Pain Headache Rep 2023; 27:719-728. [PMID: 37728863 DOI: 10.1007/s11916-023-01168-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation treatment options have become more commonly used for chronic pain conditions refractory to these options. In this review, we characterize current neurostimulation therapies for chronic pain conditions and provide an analysis of their effectiveness and clinical adoption. This manuscript will inform clinicians of treatment options for chronic pain. RECENT FINDINGS Non-invasive neurostimulation includes transcranial direct current stimulation and repetitive transcranial magnetic stimulation, while more invasive options include spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), dorsal root ganglion stimulation, motor cortex stimulation, and deep brain stimulation. Developments in transcranial direct current stimulation, repetitive transcranial magnetic stimulation, spinal cord stimulation, and peripheral nerve stimulation render these modalities most promising for the alleviating chronic pain. Neurostimulation for chronic pain involves non-invasive and invasive modalities with varying efficacy. Well-designed randomized controlled trials are required to delineate the outcomes of neurostimulatory modalities more precisely.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Floor 2, Philadelphia, PA, 19107, USA.
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Yang CT, Guan Y, Chen CC, Lin WT, Lu KH, Lin CR, Shyu BC, Wen YR. Novel Pulsed Ultrahigh-frequency Spinal Cord Stimulation Inhibits Mechanical Hypersensitivity and Brain Neuronal Activity in Rats after Nerve Injury. Anesthesiology 2023; 139:646-663. [PMID: 37428715 DOI: 10.1097/aln.0000000000004680] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is an important pain treatment modality. This study hypothesized that a novel pulsed ultrahigh-frequency spinal cord stimulation (pUHF-SCS) could safely and effectively inhibit spared nerve injury-induced neuropathic pain in rats. METHODS Epidural pUHF-SCS (± 3V, 2-Hz pulses comprising 500-kHz biphasic sinewaves) was implanted at the thoracic vertebrae (T9 to T11). Local field brain potentials after hind paw stimulation were recorded. Analgesia was evaluated by von Frey-evoked allodynia and acetone-induced cold allodynia. RESULTS The mechanical withdrawal threshold of the injured paw was 0.91 ± 0.28 g lower than that of the sham surgery (24.9 ± 1.2 g). Applying 5-, 10-, or 20-min pUHF-SCS five times every 2 days significantly increased the paw withdrawal threshold to 13.3 ± 6.5, 18.5 ± 3.6, and 21.0 ± 2.8 g at 5 h post-SCS, respectively (P = 0.0002, < 0.0001, and < 0.0001; n = 6 per group) and to 6.1 ± 2.5, 8.2 ± 2.7, and 14.3 ± 5.9 g on the second day, respectively (P = 0.123, 0.013, and < 0.0001). Acetone-induced paw response numbers decreased from pre-SCS (41 ± 12) to 24 ± 12 and 28 ± 10 (P = 0.006 and 0.027; n = 9) at 1 and 5 h after three rounds of 20-min pUHF-SCS, respectively. The areas under the curve from the C component of the evoked potentials at the left primary somatosensory and anterior cingulate cortices were significantly decreased from pre-SCS (101.3 ± 58.3 and 86.9 ± 25.5, respectively) to 39.7 ± 40.3 and 36.3 ± 20.7 (P = 0.021, and 0.003; n = 5) at 60 min post-SCS, respectively. The intensity thresholds for pUHF-SCS to induce brain and sciatic nerve activations were much higher than the therapeutic intensities and thresholds of conventional low-frequency SCS. CONCLUSIONS Pulsed ultrahigh-frequency spinal cord stimulation inhibited neuropathic pain-related behavior and paw stimulation evoked brain activation through mechanisms distinct from low-frequency SCS. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Chin-Tsang Yang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan; and Department of Leisure Industry and Health Promotion, National Ilan University, Yilan, Taiwan
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Department of Neurological Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chih-Cheng Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan; Neuroscience Program of Academia Sinica, Academia Sinica, Taipei, Taiwan; and Taiwan Mouse Clinic, Biomedical Translational Research Center, Academia Sinica, Taipei, Taiwan
| | | | - Kuo-Hsiang Lu
- Kuo-Hsiang Lu, M.S.; Gimer Medical Co., New Taipei City, Taiwan
| | - Chung-Ren Lin
- Department of Anesthesiology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Bai-Chuang Shyu
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Yeong-Ray Wen
- Pain Management and Research Center, Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
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West T, Driver CN, D'Souza RS. Incidence of Neuraxial and Non-Neuraxial Hematoma Complications From Spinal Cord Stimulator Surgery: Systematic Review and Proportional Meta-Analysis. Neuromodulation 2023; 26:1328-1338. [PMID: 35985940 DOI: 10.1016/j.neurom.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/17/2022] [Accepted: 07/05/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of this meta-analysis was to estimate the incidence of total hematomas, neuraxial hematomas, and non-neuraxial hematomas in patients who underwent temporary spinal cord stimulator (SCS) lead trial placement and permanent implantation of SCS leads and internal pulse generator (IPG). MATERIALS AND METHODS A comprehensive search was conducted of databases of any publications before October 21, 2021. Eligible study designs included randomized control trials and prospective or retrospective observational studies with more than ten patients. The primary outcome variables were the incidences of total hematomas, neuraxial hematomas, and non-neuraxial hematomas in patients with SCS. These dichotomous categorical outcomes were abstracted from studies after Freeman-Tukey arcsine square root transformation using random-effects meta-analysis (DerSimonian and Laird method). Pooled incidence rates and 95% CIs were calculated for each outcome variable. RESULTS A total of 40 studies met the inclusion criteria. Included in the neuraxial and non-neuraxial hematoma analyses were 4751 patients and 3862 patients, respectively. The pooled incidence of any hematoma in patients with SCS was 0.81% (95% CI, 0.45%-1.27%). The pooled incidence of neuraxial hematoma in patients with SCS was 0.32% (95% CI, 0.18%-0.50%). This included primarily epidural hematomas (11/4751) but also comprised an intracranial hemorrhage in a patient on enoxaparin bridge therapy from warfarin and one patient not on anticoagulation with an intracranial subdural hematoma that resulted in death. The pooled incidence of non-neuraxial hematomas in patients with SCS was 0.59% (95% CI, 0.29%-1.00%). CONCLUSION The overall incidence of hematomas in patients with temporary SCS trial lead placement and permanent SCS/IPG implantations is less than 1%. Furthermore, the incidence of neuraxial hematomas is less than 0.5%, which is of particular interest given the potential devastating consequences of this complication. The results of this study can be used to inform patients and implanting physicians on hematoma complications from SCS and highlight that the benefits of SCS outweigh the hematoma risks if anticoagulation is appropriately managed perioperatively.
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Affiliation(s)
- Tyler West
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - C Noelle Driver
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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Armstrong DG, Grunberger G. Stimulating Results Signal a New Treatment Option for People Living With Painful Diabetic Neuropathy. J Diabetes Sci Technol 2023; 17:1387-1391. [PMID: 35770993 PMCID: PMC10563543 DOI: 10.1177/19322968221099542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Painful diabetic neuropathy (PDN) is a progressive condition that deprives many patients of quality of life. With limited treatment options available, successful pain management can be difficult to achieve. METHODS We reviewed results of recent data evaluating high frequency spinal cord stimulation (SCS). RESULTS from the SENZA-PDN randomized clinical trial (NCT03228420), the largest such trial to date, demonstrated 10-kHz spinal cord stimulation substantially reduced PDN refractory to conventional medical management along with improvements in health-related quality-of-life measures that were sustained over 12 months. These data supported the recent U.S. Food & Drug Administration (FDA) approval for 10-kHz SCS in PDN patients and contributed to the body of evidence on SCS available to health care professionals managing the effects of PDN. CONCLUSION High frequency spinal cord simulation appears to hold promise in treatment of painful diabetic neuropathy. We look forward to future works in the literature that will further elucidate these promising findings.
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Affiliation(s)
- David G. Armstrong
- Department of Surgery, Southwestern Academic Limb Salvage Alliance, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - George Grunberger
- Grunberger Diabetes Institute, Bloomfield Hills, MI, USA
- Internal Medicine, Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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13
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West T, ElSaban M, Hussain N, Schappell J, Rogers K, Orhurhu V, Prokop LJ, D'Souza RS. Incidence of Lead Migration With Loss of Efficacy or Paresthesia Coverage After Spinal Cord Stimulator Implantation: Systematic Review and Proportional Meta-Analysis of Prospective Studies and Randomized Clinical Trials. Neuromodulation 2023:S1094-7159(23)00150-2. [PMID: 37204361 DOI: 10.1016/j.neurom.2023.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/15/2023] [Accepted: 03/24/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The objective of this meta-analysis was to approximate the incidence of overall lead migration, clinically significant lead migration, and asymptomatic lead migration in patients who have undergone spinal cord stimulator implantation. MATERIALS AND METHODS A comprehensive literature search was performed for studies published before May 31, 2022. Only randomized controlled trials and prospective observational studies with more than ten patients were included. Two reviewers analyzed the articles from the literature search for final inclusion, after which, study characteristics and outcome data were extracted. The primary dichotomous categorical outcome variables were the incidence of overall lead migration, clinically significant lead migration (defined as lead migration resulting in loss of efficacy), and asymptomatic lead migration (defined as lead migration discovered incidentally on follow-up imaging) in patients with spinal cord stimulator implant. Freeman-Tukey arcsine square root transformation for meta-analysis of proportions using random effects (DerSimonian and Laird method) was used to calculate incidence rates for the outcome variables. Pooled incidence rates and 95% CIs were calculated for the outcome variables. RESULTS Fifty-three studies met the inclusion criteria, with a total of 2932 patients having received spinal cord stimulator implants. The pooled incidence of overall lead migration was 9.97% (95% CI of 7.62%-12.59%). Only 24 of the included studies commented on the clinical significance of reported lead migrations, of which every lead migration was clinically significant. In these 24 studies, 96% of the reported lead migrations required a revision procedure or explant. Unfortunately, no studies that reported lead migration commented on asymptomatic lead migrations; therefore, the incidence of asymptomatic lead migrations could not be defined. CONCLUSIONS This meta-analysis found that the rate of lead migration in patients who have received spinal cord stimulator implants is approximately one in ten patients. This likely closely approximates the incidence of clinically significant lead migration owing to the included studies not routinely performing follow-up imaging. Therefore, lead migrations were primarily discovered owing to loss of efficacy, and no included studies clearly reported asymptomatic lead migration. The results of this meta-analysis can be used to inform patients more accurately on the risks and benefits of spinal cord stimulator implantation.
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Affiliation(s)
- Tyler West
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mariam ElSaban
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Justin Schappell
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Kristopher Rogers
- Department of Anesthesiology, University of Illinois Chicago, Chicago, IL, USA
| | - Vwaire Orhurhu
- Department of Anesthesiology, University of Pittsburgh Medical Center, Williamsport, PA, USA
| | | | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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14
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Black S, Bretherton B, Baranidharan G, Murray A, Crowther T, Deuchars S, Deuchars J. A Feasibility Study Exploring Measures of Autonomic Function in Patients With Failed Back Surgery Syndrome Undergoing Spinal Cord Stimulation. Neuromodulation 2023; 26:192-205. [PMID: 35088730 DOI: 10.1016/j.neurom.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/20/2021] [Accepted: 09/07/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Failed back surgery syndrome (FBSS) is associated with impaired autonomic tone, characterized by sympathetic prevalence and vagal withdrawal. Although spinal cord stimulation (SCS) alleviates pain in FBSS, there is limited research investigating how SCS affects measures of autonomic function. This was a prospective, open-label, feasibility study exploring measures of autonomic function in patients with FBSS receiving SCS therapy. MATERIALS AND METHODS A total of 14 patients with FBSS were recruited for baseline measurements and underwent a trial of 10-kHz SCS. There were three failed trials, resulting in the remaining 11 participants receiving a fully implanted 10-kHz SCS system. One participant requested an explant, resulting in ten participants completing both baseline and follow-up (three to six months after SCS implant) measurements. Autonomic function was assessed using time- and frequency-domain heart rate variability (HRV), baroreceptor reflex sensitivity (BRS), and muscle sympathetic nerve activity (MSNA) using microneurography. Because this was a feasibility study, most of the analysis was descriptive. However, paired t-tests and Wilcoxon signed-rank tests tested for differences between baseline and follow-up. RESULTS In the whole (N = 14) and final (N = 10) samples, there was between-participant variation in baseline and follow-up measures. This, combined with a small sample, likely contributed to finding no statistically significant differences in any of the measures between baseline and follow-up. However, plotting baseline and follow-up scores for individual participants revealed that those who showed increases in MSNA frequency, square root of the mean of the squared differences between adjacent RR intervals (RMSSD), percentage of the number of RR intervals >50 ms (pRR50), total power, and up BRS between baseline and follow-up had distinct clustering of baseline values compared with those who showed decreases in these measures. CONCLUSIONS Findings from this feasibility study will aid with informing hypotheses for future research. A key aspect that should be considered in future research concerns exploring the role of baseline measures of autonomic function in influencing change in autonomic function with SCS therapy.
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Affiliation(s)
- Sheila Black
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK.
| | - Beatrice Bretherton
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Ganesan Baranidharan
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Aaron Murray
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Tracey Crowther
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Deuchars
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Jim Deuchars
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
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15
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Salmon J, Bates D, Du Toit N, Verrills P, Yu J, Taverner MG, Mohabbati V, Green M, Heit G, Levy R, Staats P, Ruais J, Kottalgi S, Makous J, Mitchell B. Early Experience With a Novel Miniaturized Spinal Cord Stimulation System for the Management of Chronic Intractable Pain of the Back and Legs. Neuromodulation 2023; 26:172-181. [PMID: 36608962 DOI: 10.1016/j.neurom.2022.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION A novel, spinal cord stimulation (SCS) system with a battery-free miniaturized implantable pulse generator (IPG) was used in this feasibility study. The system uses an external power source that communicates bidirectionally with the IPG (< 1.5 cm3). Human factors, subject comfort, and effects on low back and leg pain were evaluated in this first-in-human study. MATERIALS AND METHODS A prospective, multicenter, open-label clinical trial was initiated to evaluate the safety and performance of a novel miniaturized stimulator in the treatment of chronic, intractable leg and low-back pain. Eligible subjects were recruited for the study and gave consent. Subjects who passed the screening/trial phase (defined as ≥ 50% decrease in pain) continued to the long-term implant phase and were followed up at predefined time points after device activation. Interim clinical and usability outcomes were captured and reported at 90 days. RESULTS Results of 22 subjects who chose a novel pulsed stimulation pattern therapy using the battery-free IPG (< 1.5 cm3) are described here. At 90-days follow-up, the average pain reduction was 79% in the leg (n = 22; p < 0.0001) and 76% in the low back (n = 21; p < 0.0001) compared with baseline. Responder rates (≥ 50% pain relief) at 90 days were 86% in leg pain (19/22) and 81% in low-back pain (17/21). Subjects rated the level of comfort of the external wearable power source to be 0.41 ± 0.73 at 90 days on an 11-point rating scale (0 = very comfortable, 10 = very uncomfortable). DISCUSSION These interim results from the ongoing study indicate the favorable efficacy and usability of a novel, externally powered, battery-free SCS IPG (< 1.5 cm3) for leg and low-back pain. Study subjects wore the external power source continuously and found it comfortable, and the system provided significant pain relief. These preliminary findings warrant further investigation. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is ACTRN12618001862235.
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Affiliation(s)
- John Salmon
- Pain Care Perth and Western Australia, Pain Management, Perth, Western Australia, Australia
| | - Dan Bates
- Metro Pain Group, Pain Management, Melbourne, Victoria, Australia
| | - Neels Du Toit
- Metro Pain Group, Pain Management, Melbourne, Victoria, Australia
| | - Paul Verrills
- Metro Pain Group, Pain Management, Melbourne, Victoria, Australia
| | - James Yu
- Sydney Spine and Pain, Pain Management, Sydney, New South Wales, Australia
| | | | - Vahid Mohabbati
- Sydney Pain Management Centre, Sydney, New South Wales, Australia
| | - Matthew Green
- Pain Medicine of South Australia, Pain Management, Adelaide, South Australia, Australia
| | - Gary Heit
- Department of Neurosurgery, Hue University of Medicine and Pharmacy, Hue, Vietnam
| | - Robert Levy
- Institute for Neuromodulation, Neurosurgery, Boca Raton, FL, USA
| | | | | | | | | | - Bruce Mitchell
- Metro Pain Group, Pain Management, Melbourne, Victoria, Australia
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16
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Hoelzer BC, Edgar D, Lu SP, Taylor RS. Indirect Comparison of 10 kHz Spinal Cord Stimulation (SCS) versus Traditional Low-Frequency SCS for the Treatment of Painful Diabetic Neuropathy: A Systematic Review of Randomized Controlled Trials. Biomedicines 2022; 10:2630. [PMID: 36289892 PMCID: PMC9599433 DOI: 10.3390/biomedicines10102630] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/30/2022] Open
Abstract
Spinal cord stimulation (SCS) is increasingly used to treat painful diabetic neuropathy (PDN). At the time of a recent meta-analysis in this field, data were only available from randomized controlled trials (RCTs) of traditional low-frequency SCS (LF-SCS). However, outcomes from high-frequency 10 kHz SCS treatment are now available. Our study aimed to systematically review the contemporary evidence for SCS in patients with lower limb pain due to PDN and include an indirect comparison of the high- and low-frequency modalities. We searched the PubMed/CENTRAL databases up to 18 August 2022, for peer-reviewed RCTs of SCS that enrolled PDN patients with lower limb pain symptoms. The quality of the evidence was assessed with the Cochrane Risk of Bias tool. Using SCS treatment arm data from the RCTs, we indirectly compared the absolute treatment effect of 10 kHz SCS and LF-SCS. Results are presented in tables and forest plots. This systematic review was reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. Three RCTs met our eligibility criteria, including the recent 10 kHz SCS RCT (N = 216, 90 implanted) and 2 others that examined LF-SCS (N = 36, 17 implanted; N = 60, 37 implanted). Our analysis of 6-month data found clinically meaningful pain relief with each SCS modality. However, significantly greater pain reduction was identified for 10 kHz SCS over LF-SCS: average pain reduction in the 10 kHz SCS cohort was 73.7% compared with 47.5% in the pooled LF-SCS group (p < 0.0001). In the permanent implant subset, the 50% pain reduction responder rate was 83.3% in the 10 kHz SCS cohort versus 63.0% in the pooled LF-SCS group (p = 0.0072). The overall risk of bias of each included RCT was deemed high, mainly due to the absence of patient blinding. Our analysis indicates that paresthesia-free 10 kHz SCS can provide superior pain relief and responder rate over LF-SCS for managing PDN patients refractory to conventional medical management.
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Affiliation(s)
- Bryan C. Hoelzer
- Medical Director, Southwest Spine and Pain Center, Provo, UT 84059, USA
| | | | | | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, School of Health and Well Being, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK
- Health Service Research, College of Medicine and Health, University of Exeter, Exeter EX1 2LU, UK
- National Institute of Public Health, University of South Denmark, 1455 Copenhagen, Denmark
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17
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Hagedorn JM, Pittelkow TP, Bendel MA, Moeschler SM, Orhurhu V, Sanchez-Sotelo J. The painful shoulder arthroplasty: appropriate work-up and review of interventional pain treatments. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:269-276. [PMID: 37588877 PMCID: PMC10426573 DOI: 10.1016/j.xrrt.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Shoulder arthroplasty is a successful surgical procedure for several conditions when patients become refractory to conservative management modalities. Unfortunately, some patients experience persistent chronic pain after shoulder arthroplasty. These individuals should undergo a comprehensive evaluation by an orthopedic surgeon to determine whether structural pathology is responsible for the pain and to decide whether reoperation is indicated. At times, a surgical solution does not exist. In these circumstances, a thorough and specific plan for the management of persistent chronic pain should be developed and instituted. In this article, we review common reasons for persistent pain after shoulder arthroplasty and outline the evaluation of the painful shoulder arthroplasty. We then provide a thorough review of interventional pain management strategies. Finally, we hypothesize developments in our field that might provide better outcomes in the future for patients suffering with chronic intractable pain after shoulder arthroplasty.
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Affiliation(s)
- Jonathan M. Hagedorn
- Corresponding author: Jonathan M. Hagedorn, MD, Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Thomas P. Pittelkow
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Markus A. Bendel
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Susan M. Moeschler
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Vwaire Orhurhu
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joaquin Sanchez-Sotelo
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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18
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Pirvulescu I, Biskis A, Candido KD, Knezevic NN. Overcoming clinical challenges of refractory neuropathic pain. Expert Rev Neurother 2022; 22:595-622. [PMID: 35866187 DOI: 10.1080/14737175.2022.2105206] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Refractory neuropathic pain (ReNP), and its definition, is widely disputed amongst clinicians due in part to unclear categorical diagnosing guidelines, overall time duration of neuropathic pain, and the exhaustiveness of treatment options. Usually ReNP is defined as chronic, intractable, and unresponsive neuropathic pain that have otherwise been untreatable. AREAS COVERED : In this narrative review, we discuss and summarize the effectiveness of prospective ReNP research conducted over the past 10 years. This research looks at pharmacological and interventional therapies in clinical trial settings. The pharmacological therapies discussed include the use of adjuvant treatments to improve the safety and efficacy of conventional approaches. Different modalities of administration, such as injection therapy and intrathecal drug delivery systems, provide targeted drug delivery. Interventional therapies such as neuromodulation, pulse radiofrequency, and nerve lesioning are more invasive, however, they are increasingly utilized in the field, as reflected in ongoing clinical trials. EXPERT OPINION : Based on the current data from RCTs and systematic reviews, it is clear that single drug therapy cannot be effective and has significant limitations. Transitioning to interventional modalities that showed more promising results sooner rather than later may be even more cost-efficient than attempting different conservative treatments with a high failure rate.
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Affiliation(s)
- Iulia Pirvulescu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Alexandras Biskis
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Advocate Aurora Research Institute, Chicago, IL, USA.,College of Aviation, Science and Technology, Lewis University, Romeoville, IL, USA
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.,Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Department of Surgery, University of Illinois, Chicago, IL, USA
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19
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Hagedorn JM, Parmele JB, Wolff JS, Bendel MA, D'Souza RS. The Prevalence of Elevated Impedances and Magnetic Resonance Imaging Ineligibility Following Implantation of 10 kHz Spinal Cord Stimulation Devices: A Retrospective Review. Neuromodulation 2022; 25:719-723. [PMID: 35803678 DOI: 10.1111/ner.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/26/2021] [Accepted: 05/18/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) is increasingly utilized in the treatment of multiple chronic pain conditions. However, patients will continue to experience other medical issues and the potential for future magnetic resonance imaging (MRI) needs must not be overlooked. SCS devices have device-specific MRI conditional labeling and if impedances are elevated the patient may not be able to obtain an MRI. With 10 kHz SCS devices specifically, an impedance value above 10,000 ohms (Ω) is MRI ineligible. The primary objective of this article was to report the incidence of elevated impedances with a multilumen lead design per electrode, per lead, and to describe the total number of MRI ineligible patients due to elevated impedances using 10 kHz SCS cutoff values. The secondary objective was to determine whether certain patient demographics or surgery characteristics put patients at increased risk of elevated impedances. MATERIALS AND METHODS We performed a retrospective review of 327 patients who were implanted with a 10 kHz SCS device between January 2015 and November 2020. Regression models were fitted to determine associations between MRI ineligibility status with clinical characteristics including age, sex, BMI, lead location, implantable pulse generator (IPG) location, and time since implant. RESULTS We found elevated impedances with subsequent MRI ineligibility in 13 patients (4.0%). Regression analysis did not identify any associations with MRI ineligibility and patient risk factors including age, sex, body mass index, lead location, IPG location, and follow-up time since implant. CONCLUSION We found the prevalence of elevated impedances above 10,000 Ω to be 4% of implanted patients. This information is important for patients and physicians alike and should be considered when device selection is occurring in the pre-operative visits.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA.
| | | | | | - Markus A Bendel
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
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20
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Petersen EA, Stauss TG, Scowcroft JA, Brooks ES, White JL, Sills SM, Amirdelfan K, Guirguis MN, Xu J, Yu C, Nairizi A, Patterson DG, Tsoulfas KC, Creamer MJ, Galan V, Bundschu RH, Mehta ND, Sayed D, Lad SP, DiBenedetto DJ, Sethi KA, Goree JH, Bennett MT, Harrison NJ, Israel AF, Chang P, Wu PW, Argoff CE, Nasr CE, Taylor RS, Caraway DL, Mekhail NA. High-Frequency 10-kHz Spinal Cord Stimulation Improves Health-Related Quality of Life in Patients With Refractory Painful Diabetic Neuropathy: 12-Month Results From a Randomized Controlled Trial. Mayo Clin Proc Innov Qual Outcomes 2022; 6:347-360. [PMID: 35814185 PMCID: PMC9256824 DOI: 10.1016/j.mayocpiqo.2022.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objective To evaluate high-frequency (10-kHz) spinal cord stimulation (SCS) treatment in refractory painful diabetic neuropathy. Patients and Methods A prospective, multicenter randomized controlled trial was conducted between Aug 28, 2017 and March 16, 2021, comparing conventional medical management (CMM) with 10-kHz SCS+CMM. The participants had hemoglobin A1c level of less than or equal to 10% and pain greater than or equal to 5 of 10 cm on visual analog scale, with painful diabetic neuropathy symptoms 12 months or more refractory to gabapentinoids and at least 1 other analgesic class. Assessments included measures of pain, neurologic function, and health-related quality of life (HRQoL) over 12 months with optional crossover at 6 months. Results The participants were randomized 1:1 to CMM (n=103) or 10-kHz SCS+CMM (n=113). At 6 months, 77 of 95 (81%) CMM group participants opted for crossover, whereas none of the 10-kHz SCS group participants did so. At 12 months, the mean pain relief from baseline among participants implanted with 10-kHz SCS was 74.3% (95% CI, 70.1-78.5), and 121 of 142 (85%) participants were treatment responders (≥50% pain relief). Treatment with 10-kHz SCS improved HRQoL, including a mean improvement in the EuroQol 5-dimensional questionnaire index score of 0.136 (95% CI, 0.104-0.169). The participants also reported significantly less pain interference with sleep, mood, and daily activities. At 12 months, 131 of 142 (92%) participants were "satisfied" or "very satisfied" with the 10-kHz SCS treatment. Conclusion The 10-kHz SCS treatment resulted in substantial pain relief and improvement in overall HRQoL 2.5- to 4.5-fold higher than the minimal clinically important difference. The outcomes were durable over 12 months and support 10-kHz SCS treatment in patients with refractory painful diabetic neuropathy. Trial registration clincaltrials.gov Identifier: NCT03228420.
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Key Words
- CMM, conventional medical management
- DN4, Douleur Neuropathique
- DSPN, diabetic sensorimotor peripheral neuropathy
- EQ-5D-5L, EuroQol 5-Dimension 5-Level questionnaire
- HRQoL, health-related quality of life
- HbA1c, hemoglobin A1c
- IPG, implantable pulse generator
- NNT, number needed to treat
- PDN, painful diabetic neuropathy
- RCT, randomized controlled trial
- SCS, spinal cord stimulation
- VAS, visual analog scale
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Affiliation(s)
- Erika A. Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock,Correspondence: Address to Erika A. Petersen, MD, Department of Neurosurgery, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205.
| | | | | | | | | | | | | | | | - Jijun Xu
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH
| | - Cong Yu
- Swedish Medical Center, Seattle, WA
| | | | | | | | | | | | | | - Neel D. Mehta
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS
| | | | | | - Khalid A. Sethi
- Department of Neurosurgery, United Health Services, Johnson City, NY
| | - Johnathan H. Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | | | | | | | | | - Paul W. Wu
- Holy Cross Hospital, Fort Lauderdale, FL
| | | | - Christian E. Nasr
- Department of Endocrinology, Cleveland Clinic Foundation, Cleveland, OH
| | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, United Kingdom
| | | | - Nagy A. Mekhail
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH
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21
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Poulsen DM, Nikolajsen L, Blichfeldt-Eckhardt MR, Gulisano HA, Hedemann Sørensen JC, Meier K. Comparison of Spinal Cord Stimulation Outcomes Between Preoperative Opioid Users and Nonusers: A Cohort Study of 467 Patients. Neuromodulation 2022; 25:700-709. [DOI: 10.1016/j.neurom.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/25/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
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22
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Hagedorn JM, Romero J, Ha CT, D’Souza RS. Patient Satisfaction With Spinal Cord Stimulation and Dorsal Root Ganglion Stimulation for Chronic Intractable Pain: A Systematic Review and Meta-Analysis. Neuromodulation 2022; 25:947-955. [DOI: 10.1016/j.neurom.2022.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/03/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
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23
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Sevcencu C. Single-interface bioelectronic medicines - concept, clinical applications and preclinical data. J Neural Eng 2022; 19. [PMID: 35533654 DOI: 10.1088/1741-2552/ac6e08] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 05/08/2022] [Indexed: 11/12/2022]
Abstract
Presently, large groups of patients with various diseases are either intolerant, or irresponsive to drug therapies and also intractable by surgery. For several diseases, one option which is available for such patients is the implantable neurostimulation therapy. However, lacking closed-loop control and selective stimulation capabilities, the present neurostimulation therapies are not optimal and are therefore used as only "third" therapeutic options when a disease cannot be treated by drugs or surgery. Addressing those limitations, a next generation class of closed-loop controlled and selective neurostimulators generically named bioelectronic medicines seems within reach. A sub-class of such devices is meant to monitor and treat impaired functions by intercepting, analyzing and modulating neural signals involved in the regulation of such functions using just one neural interface for those purposes. The primary objective of this review is to provide a first broad perspective on this type of single-interface devices for bioelectronic therapies. For this purpose, the concept, clinical applications and preclinical studies for further developments with such devices are here analyzed in a narrative manner.
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Affiliation(s)
- Cristian Sevcencu
- National Institute for Research and Development of Isotopic and Molecular Technologies, 67-103 Donat Street, Cluj-Napoca, 400293, ROMANIA
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Strand NH, Burkey AR. Neuromodulation in the Treatment of Painful Diabetic Neuropathy: A Review of Evidence for Spinal Cord Stimulation. J Diabetes Sci Technol 2022; 16:332-340. [PMID: 34842478 PMCID: PMC8861784 DOI: 10.1177/19322968211060075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neuropathies, the most common complication of diabetes, manifest in various forms, including entrapments, mononeuropathies or, most frequently, a distal symmetric polyneuropathy. Painful diabetic neuropathy (PDN) in the classic "stocking" distribution is a disease of increasing prevalence worldwide and a condition for which standard medical treatment only provides modest relief. Neuromodulation offers a potential alternative to pharmacotherapies given its demonstrated efficacy in other refractory chronic neuropathic pain syndromes. High-quality evidence from randomized controlled trials (RCTs) is available in these other settings for two approaches to spinal cord stimulation (SCS): (1) conventional low-frequency SCS (LF-SCS), which modulates axonal activity in the dorsal column and is paresthesia-dependent, and (2) high-frequency SCS delivered at 10 kilohertz (10 kHz SCS), which targets neurons in the superficial dorsal horn and is paresthesia-independent. METHOD This review examines the evidence for SCS from published RCTs as well as prospective studies exploring the safety and effectiveness of treating PDN with neuromodulation. RESULTS Two RCTs enrolling 60 and 36 participants with PDN showed treatment with LF-SCS reduced daytime pain by 45% to 55% for up to two years. An RCT testing 10 kHz SCS versus conventional medical management (CMM) in 216 participants with PDN revealed 76% mean pain relief after six months of stimulation. None of the studies revealed unexpected safety issues in the use of neuromodulation in this patient population. CONCLUSION These well-designed RCTs address the unmet need for improved PDN therapies and provide data on the safety, effectiveness, and durability of SCS therapy.
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Affiliation(s)
- Natalie H. Strand
- Division of Pain Medicine, Department
of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA
- Natalie H. Strand, MD, Division of Pain
Medicine, Department of Anesthesiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd,
Phoenix, AZ 85054, USA.
| | - Adam R. Burkey
- Chair of Pain Section, American Academy
of Neurology, Minneapolis, MI, USA
- Anesis Spine & Pain Care, Renton,
WA, USA
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Chen JL, Hesseltine AW, Nashi SE, Sills SM, McJunkin TL, Patil S, Bharara M, Caraway DL, Brooks ES. A Real-World Analysis of High-Frequency 10 kHz Spinal Cord Stimulation for the Treatment of Painful Diabetic Peripheral Neuropathy. J Diabetes Sci Technol 2022; 16:282-288. [PMID: 34842489 PMCID: PMC8861794 DOI: 10.1177/19322968211060316] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetes is one of the most prevalent chronic health conditions and diabetic neuropathy one of its most prevalent and debilitating complications. While there are treatments available for painful diabetic peripheral neuropathy (pDPN), their effectiveness is limited. METHOD This retrospective, multi-center, real-world review assessed pain relief and functional improvements for consecutive patients with diabetic neuropathy aged ≥18 years of age who were permanently implanted with a high-frequency (10 kHz) spinal cord stimulation (SCS) device. Available data were extracted from a commercial database. RESULTS In total 89 patients consented to being included in the analysis. Sixty-one percent (54/89) of participants were male and the average age was 64.4 years (SD = 9.1). Most patients (78.7%, 70/89) identified pain primarily in their feet or legs bilaterally. At the last assessment, 79.5% (58/73) of patients were treatment responders, defined as having at least 50% patient-reported pain relief from baseline. The average time of follow-up was 21.8 months (range: 4.3 to 46.3 months). A majority of patients reported improvements in sleep and overall function relative to their baseline. CONCLUSIONS This real-world study in typical clinical practices found 10 kHz SCS provided meaningful pain relief for a substantial proportion of patients refractory to current pDPN management, similar to published literature. This patient population has tremendous unmet needs and this study helps demonstrate the potential for 10 kHz SCS to provide an alternative pain management approach.
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Affiliation(s)
- Jeffrey L. Chen
- Center for Pain, University of
California San Diego, San Diego, CA, USA
- Jeffrey Chen, MD, MHS, Associate Professor
of Anesthesiology, Center for Pain, University of California San Diego, 9300
Campus Point Dr., MC 7651, La Jolla, CA 92037, USA.
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Smith CA, Roman J, Mammis A. The Role of Spinal Cord Stimulation in Reducing Opioid Use in the Setting of Chronic Neuropathic Pain: A Systematic Review. Clin J Pain 2022; 38:285-291. [PMID: 35132028 DOI: 10.1097/ajp.0000000000001021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/24/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim was to examine research on the impact of spinal cord stimulation (SCS) on the reduction of preimplantation opioid dose and what preimplantation opioid dose is associated with a reduction or discontinuation of opioid use postimplantation. METHODS Systematic review of literature from PubMed, Web of Science, and Ovid Medline search of "opioid" and "pain" and "spinal cord stimulator." Inclusion criteria included original research providing data on SCS preimplantation opioid dosing and 12 months postimplantation opioid dosing or that correlated specific preimplantation opioid dose or opioid dose cutoff with significantly increased likelihood of opioid use discontinuation at 12 months postimplantation. RESULTS Systematic review of the literature yielded 17 studies providing data on pre-SCS and post-SCS implantation dose and 4 providing data on the preimplantation opioid dose that significantly increased likelihood of opioid use discontinuation at 12 months postimplantation. Data from included studies indicated that SCS is an effective tool in reducing opioid dose from preimplantation levels at 12 months postimplantation. Data preliminarily supports the assertion that initiation of SCS at a preimplantation opioid dose of ≤20 to ≤42.5 morphine milligram equivalents increases the likelihood of postimplantation elimination of opioid use. DISCUSSION SCS is an effective treatment for many types of chronic pain and can reduce or eliminate chronic opioid use. Preimplantation opioid dose may impact discontinuation of opioid use postimplantation and the effectiveness of SCS in the relief of chronic pain. More research is needed to support and strengthen clinical recommendations for initiation of SCS use at lower daily opioid dose.
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Affiliation(s)
- Cynthia A Smith
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Jessica Roman
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Antonios Mammis
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY
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The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Best Practices for Cervical Neurostimulation. Neuromodulation 2022; 25:35-52. [DOI: 10.1016/j.neurom.2021.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
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Gupta M, Ray M, Ladesich N, Gupta A. Health-Care Utilization and Outcomes with 10 kHz Spinal Cord Stimulation for Chronic Refractory Pain. J Pain Res 2021; 14:3675-3683. [PMID: 34880672 PMCID: PMC8648088 DOI: 10.2147/jpr.s306126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/21/2021] [Indexed: 11/23/2022] Open
Abstract
Background Chronic pain is a common condition associated with decreased quality of life and increased health-care costs. Opioid analgesics are routinely used to treat chronic pain despite limited evidence of long-term efficacy. Spinal cord stimulation at a frequency of 10 kilohertz (10kHz-SCS) has been shown to be effective for treating chronic pain. Objective This study was conducted to evaluate the effects of 10kHz-SCS on patients’ pain intensity, volume of pain interventions, and opioid intake in a real-world setting. Study Design This study was a retrospective review of patient data. Setting The study was conducted at a single, community-based clinic. Methods Outcomes including pain relief, quality of life, opioid intake, and rate of health-care usage were evaluated using data from patients who were implanted with a 10kHz-SCS device to treat chronic pain. These outcomes were then compared for the pre- and post-implant periods. Results A total of 47 patients with a mean follow-up duration of 15.6 ± 6.2 months were included in this analysis. Mean pain relief was 73 ± 22% and 89% were responders at the final follow-up visit. The rate of medical interventions fell from 3.48±3.05 per year before starting 10kHz-SCS to 0.49±1.16 per year afterward (P < 0.001). Of 30 patients with available opioid consumption data, 89% maintained or decreased their intake after implant. Conclusion Retrospective data from a single center, with minimal exclusion criteria shows clinically significant pain relief with 10kHz-SCS, accompanied by significant indirect benefits including stable or reduced opioid use and reduced interventional procedures.
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Affiliation(s)
- Mayank Gupta
- Neuroscience Research Center, LLC, Overland Park, KS, USA
| | - Mahoua Ray
- Neuroscience Research Center, LLC, Overland Park, KS, USA
| | | | - Akshat Gupta
- Neuroscience Research Center, LLC, Overland Park, KS, USA
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Pain Relief and Safety Outcomes with Cervical 10 kHz Spinal Cord Stimulation: Systematic Literature Review and Meta-analysis. Pain Ther 2021; 10:849-874. [PMID: 34031856 PMCID: PMC8586436 DOI: 10.1007/s40122-021-00269-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic pain in head, neck, shoulders and upper limbs is debilitating, and patients usually rely on pain medications or surgery to manage their symptoms. However, given the current opioid epidemic, non-pharmacological interventions that reduce pain, such as spinal cord stimulation (SCS), are needed. The purpose of this study was to review the evidence on paresthesia-free 10 kHz SCS therapy for neck and upper extremity pain. METHODS Systematic literature search was performed for studies reporting outcomes for cervical 10 kHz SCS using date limits from May 2008 to November 2020. The study results were analyzed and described qualitatively. Additionally, when feasible, meta-analyses of the outcome data, with 95% confidence intervals (CIs), were conducted using both the fixed-effects (FE) and random-effects (RE) models. RESULTS A total of 15 studies were eligible for inclusion. The proportion of patients who achieved ≥ 50% pain reduction was 83% (95% CI 77-89%) in both the FE and RE models. The proportion of patients who reduced/eliminated their opioid consumption was 39% (95% CI 31-46%) in the FE model and 39% (95% CI 31-48%) in the RE model. Pain or discomfort with the implant, lead migration, and infections were potential risks following cervical SCS. Explant rate was 0.1 (95% CI 0.0-0.2) events per 100 person-months, and no patients in the included studies experienced a neurological complication or paresthesia. CONCLUSION Findings suggest 10 kHz SCS is a promising, safe, minimally invasive alternative for managing chronic upper limb and neck pain.
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Malinowski MN, Chopra PR, Tieppo Francio V, Budwany R, Deer TR. A narrative review and future considerations of spinal cord stimulation, dorsal root ganglion stimulation and peripheral nerve stimulation. Curr Opin Anaesthesiol 2021; 34:774-780. [PMID: 34608057 DOI: 10.1097/aco.0000000000001072] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW In recent years, neuromodulation has experienced a renaissance. Novel waveforms and anatomic targets show potential improvements in therapy that may signify substantial benefits. New innovations in peripheral nerve stimulation and dorsal root ganglion stimulation have shown prospective evidence and sustainability of results. Sub-perception physiologic bursting, high-frequency stimulation and feedback loop mechanisms provide significant benefits over traditional tonic spinal cords stimulation (SCS) in peer reviewed investigations. We reviewed the themes associated with novel technology in the context of historical stalwart publications. RECENT FINDINGS New innovations have led to better nerve targeting, improvements in disease-based treatment, and opioid alternatives for those in chronic pain. In addition, new neural targets from both structural and cellular perspectives have changed the field of Neurostimulation. SUMMARY For many years, tonic SCS was representative of neuromodulation, but as this review examines, the progression of the field in the past decade has reshaped patient options.
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Affiliation(s)
- Mark N Malinowski
- OhioHealth Grant Medical Center, Ohio University Heritage COM, Columbus, Ohio
| | | | - Vinicius Tieppo Francio
- The University of Kansas Medical Center, Department of Rehabilitative Medicine, Kansas City, Kansas
| | - Ryan Budwany
- Center for Integrative Pain Management, West Virginia University School of Medicine, Morgantown
| | - Timothy Ray Deer
- The Spine and Nerve Center of The Virginias
- Anesthesiology and Pain Medicine, WVU School of Medicine
- American Society of Pain and Neuroscience, Charleston, West Virginia, USA
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Surges G, Paulus J, Blaß T, Mendryscha K, Bettag M, Rotte A. Efficacy and Safety of 10 kHz Spinal Cord Stimulation Using Cervical and Thoracic Leads: A Single-Center Retrospective Experience. Pain Ther 2021; 10:1255-1268. [PMID: 34236671 PMCID: PMC8586300 DOI: 10.1007/s40122-021-00287-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Spinal cord stimulation (SCS) with lower thoracic leads has been studied extensively. However, the evidence base for cervical SCS is less well developed, and reports of multiarea SCS lead placement are uncommon. Therefore, this single-center retrospective study evaluated outcomes from 10-kHz SCS with cervical or combined cervical and thoracic lead placement. METHOD All patients that underwent a 10-kHz SCS trial with either cervical or combined cervical and thoracic lead placement between 2015 and 2020 were included in our study. We reviewed patient's charts for demographic information, lead placement, and pain scores up to 48 months after implantation. RESULTS Of the 105 patients that underwent a 10-kHz SCS trial during the review period, 92 (88%) had back/neck or extremity pain that responded to therapy (≥ 50% pain relief from baseline) and received a permanent system. Sixty-two of these patients (67%) were implanted with combined cervical and thoracic leads, while 30 (33%) received cervical-only leads. Pain relief in both regions exceeded 60% at most visits throughout the 48-month study period. Throughout follow-up, the responder rate in both pain areas was consistently ≥ 70%. No unexpected adverse events occurred. CONCLUSION The 10-kHz SCS provided effective and durable pain relief with either cervical or combined cervical and thoracic leads. The efficacy and safety profile of both applications appears to be comparable to lower thoracic SCS. Our results suggest that 10-kHz SCS is a useful paresthesia-free therapeutic option for chronic neuropathic pain originating in the cervical area, as well as more complex multiarea pain presentations.
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Duarte RV, Nevitt S, Maden M, Meier K, Taylor RS, Eldabe S, de Vos CC. Spinal cord stimulation for the management of painful diabetic neuropathy: a systematic review and meta-analysis of individual patient and aggregate data. Pain 2021; 162:2635-2643. [PMID: 33872236 DOI: 10.1097/j.pain.0000000000002262] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/05/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Spinal cord stimulation (SCS) has been suggested as a treatment option for patients with painful diabetic neuropathy (PDN). We conducted a systematic review and undertook a meta-analysis on individual patient data from randomised controlled trials (RCTs) to assess the effectiveness of SCS for the management of PDN. Electronic databases were searched from inception to May 2020 for RCTs of SCS for PDN. Searches identified 2 eligible RCTs (total of 93 patients with PDN) and 2 long-term follow-up studies of one of the RCTs. Individual patient data were obtained from the authors of one of these RCTs. Meta-analysis showed significant and clinically meaningful reductions in pain intensity for SCS compared with best medical therapy alone, pooled mean difference (MD) -3.13 (95% confidence interval [CI]: -4.19 to -2.08) on a 10-point scale at the 6-month follow-up. More patients receiving SCS achieved at least a 50% reduction in pain intensity compared with best medical therapy, pooled risk ratio 0.08 (95% CI: 0.02-0.38). Increases were observed for health-related quality of life assessed as EQ-5D utility score (pooled MD 0.16, 95% CI: 0.02-0.30) and visual analogue scale (pooled MD 11.21, 95% CI: 2.26-20.16). Our findings demonstrate that SCS is an effective therapeutic adjunct to best medical therapy in reducing pain intensity and improving health-related quality of life in patients with PDN. Large well-reported RCTs with long-term follow-up are required to confirm these results.
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Affiliation(s)
- Rui V Duarte
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Sarah Nevitt
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Kaare Meier
- Departments of Neurosurgery and
- Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, Glasgow, United Kingdom
- College of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, United Kingdom
| | - Cecile C de Vos
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Centre for Pain Medicine, Department of Anesthesiology, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
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High-frequency 10 kHz Spinal Cord Stimulation for Chronic Back and Leg Pain: Cost-consequence and Cost-effectiveness Analyses. Clin J Pain 2021; 36:852-861. [PMID: 32769414 PMCID: PMC7671822 DOI: 10.1097/ajp.0000000000000866] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES There is good evidence that spinal cord stimulation (SCS) is effective for reducing chronic back and leg pain (CBLP). SENZA randomized controlled trial showed high-frequency (10 kHz) stimulation (10 kHz-SCS) is clinically superior to traditional low-frequency SCS (LF-SCS).Undertake cost-consequence and cost-effectiveness analysis of 10 kHz-SCS compared with LF-SCS. METHODS A probabilistic decision tree and Markov decision analytic model was used to synthesize data on CBLP outcomes and costs over a 15-year time horizon from a UK National Health Service perspective using data from the SENZA randomized controlled trial and other publications. Results are expressed as incremental cost per quality-adjusted life year (QALY) in 2016 Pounds Sterling. RESULTS 10 kHz-SCS is cost-saving and cost-effective compared with LF-SCS, with mean cost-savings of £7170 (95% confidence interval: £6767-£7573) and £3552 (95% confidence interval: £3313-£3792) per patient compared with nonrechargeable and rechargeable LF-SCS devices, respectively. 10 kHz-SCS has a 95% likelihood of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY. Our findings were robust across a wide range of sensitivity analyses. CONCLUSIONS There is a strong economic case for choosing 10 kHz-SCS over LF-SCS for CBLP. Furthermore, 10 kHz-SCS has clinical advantages not captured in our analysis, including shorter, and more predictable procedure times.
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Spinal cord stimulation for neuropathic pain. Rev Neurol (Paris) 2021; 177:838-842. [PMID: 34384626 DOI: 10.1016/j.neurol.2021.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 07/28/2021] [Indexed: 01/20/2023]
Abstract
Spinal cord stimulation (SCS) is used for more than 40years to treat localized chronic medically refractory neuropathic pain involving limb(s) and trunk. The most frequent indications remain complex regional pain syndrome (CRPS) failed back surgery syndrome (FBSS), and peripheral neuropathy. Stimulation-induced paresthesias, perceived by the patient, prevent blinded evaluation and increase the placebo effect, decreasing the credibility of the tonic SCS efficacy. Retrospective studies reported that about 50% of the patients are improved more than 50% at short-term, but long-term improvement is less. Several comparative randomized trials (RCT) are now available. In CRPS, a RCT demonstrated the superiority of SCS plus physiotherapy compared to physiotherapy alone. In FBSS, two RCTs have shown that SCS was superior to reoperation and conventional medical treatment, (CMM) respectively. New stimulation waveforms, namely burst, high frequency (10KHz) stimulation and close-loop SCS, have been proposed recently to avoid the perception of paresthesias and/or increase the pain relief. RCTs in FBSS have suggested that these new SCS modalities were as least as efficient than conventional tonic SCS and perhaps slightly superior. Two RCTs confirmed SCS efficacy in painful diabetic neuropathy in comparison with CMM. Complications are frequent (hardware dysfunction or migration, superficial infection) but exceptionally serious. Consequently, the risk/benefit ratio is favorable to SCS, considering that chronic pain patients undergoing this procedure are usually resistant to all the other therapies.
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Hagedorn JM, Romero J, Thuc Ha C, Bendel MA, D'Souza RS. Paresthesia-Based Versus High-Frequency Spinal Cord Stimulation: A Retrospective, Real-World, Single-Center Comparison. Neuromodulation 2021; 25:710-718. [PMID: 34272921 DOI: 10.1111/ner.13497] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) has become a common treatment modality for chronic pain of various etiologies. Over the past two decades, significant technological evolution has occurred in the SCS space, and this includes high-frequency (10 kHz) stimulation. Level I evidence exists reporting superiority of 10 kHz SCS over traditional SCS, however, conflicting reports have been published. The primary objective was to report site-collected real-world patient reported percentage improvement in pain scale (PR-PIPS) with traditional SCS and 10 kHz SCS from a single, academic medical center. MATERIALS AND METHODS This study was a single-center retrospective review to determine PR-PIPS of traditional SCS and 10 kHz SCS in those patients implanted for at least 12 months. Data were collected by two independent physicians not involved with the implant surgery to minimize bias in the data collection process. PR-PIPS and other clinical variables were abstracted either via chart review or via phone call for patients who were at least 12 months post-implant at the last clinical follow-up. RESULTS A total of 163 implanted patients (traditional stimulation n = 85; high-frequency stimulation n = 78) were identified. Twenty-two explants (traditional stimulation n = 10; high-frequency stimulation n = 12) were performed (13.5%). Seventy-five total remaining SCS implants utilizing traditional stimulation and 66 total remaining SCS implants utilizing high-frequency stimulation were included. There was no difference in PR-PIPS between traditional stimulation (50.6% ± 30.1%) and high-frequency stimulation (47.6% ± 31.5%) in the adjusted linear regression model in a variety of implant indications (p = 0.399). There was no difference in frequency of patient categorization into various thresholds of percentage pain relief based on type of stimulation. The most common reasons for explant were loss of efficacy (50.0%) and infection (40.0%) in the traditional cohort, and loss of efficacy (58.3%) in the high-frequency cohort. CONCLUSIONS This study adds further evidence to the published literature that successful long-term results can be achieved with SCS. Our retrospective analysis did not find a statistically significant difference in PR-PIPS between traditional stimulation and high-frequency stimulation in a variety of indications over an average follow-up of nearly two years. Notably, there were statistically significant differences in treatment indications and primary sites of pain between the two patient cohorts, and this should be considered when interpreting the results.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joshua Romero
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chris Thuc Ha
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Markus A Bendel
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
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Galan V, Scowcroft J, Chang P, Li S, Staats P, Subbaroyan J, Caraway D. Ten kHz spinal cord stimulation for the treatment of chronic peripheral polyneuropathy: 12-Month results from prospective open-label pilot study. Pain Pract 2021; 21:898-906. [PMID: 34251751 DOI: 10.1111/papr.13059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/24/2021] [Accepted: 07/07/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The goal of this study was to demonstrate that the paresthesia-independent 10 kHz spinal cord stimulation (SCS) can provide long-term pain relief in patients with peripheral polyneuropathy (PPN). Clinically diagnosed subjects with PPN refractory to conventional medical management were enrolled in this prospective, multicenter study between November 2015 and August 2016, after institutional review board approval and patient informed consent were obtained. METHODS Subjects underwent trial stimulation utilizing 2 epidural leads, and if successful, were implanted with a permanent 10 kHz SCS system and followed up for 12 months post-implant. Outcome measures included adverse events, pain, neurological assessments, disability, function, quality of life, pain interference, sleep, satisfaction, and global impression of change. Data are presented as descriptive statistics. Permanent implant population results are reported as mean ± standard error. RESULTS Twenty-one of the 26 trialed subjects had a successful trial and 18 received a permanent implant. All subjects had the leads placed anatomically without the need for paresthesia. Subjects experienced significant and sustained pain relief (at least 65% at all timepoints) whereas physicians noted improvements in neurological function. Significant improvements in disability, function, sleep, sensory, and affective dimensions of pain were reported at all timepoints. All adverse events were resolved without sequelae. CONCLUSION Findings from this study suggest that 10 kHz SCS may provide sustained pain relief and disability improvements in patients suffering from PPN.
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Affiliation(s)
| | | | - Paul Chang
- Georgia Pain Care, Stockbridge, Georgia, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Peter Staats
- Premier Pain Centers, Shrewsbury, New Jersey, USA
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Al-Kaisy A, Palmisani S, Carganillo R, Wesley S, Pang D, Rotte A, Santos A, Lambru G. Safety and Efficacy of 10 kHz Spinal Cord Stimulation for the Treatment of Refractory Chronic Migraine: A Prospective Long-Term Open-Label Study. Neuromodulation 2021; 25:103-113. [PMID: 34110663 DOI: 10.1111/ner.13465] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/06/2021] [Accepted: 05/04/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Refractory chronic migraine (rCM) is a highly disabling condition for which novel safe and effective treatments are needed. Safety and long-term efficacy of paresthesia-free high cervical 10 kHz spinal cord stimulation (SCS) were here prospectively evaluated for the treatment of rCM. MATERIALS AND METHODS Twenty adults with rCM (mean numbers of preventive treatments failed: 12.2 ± 3.1) were enrolled in this single-center, open-label, prospective study and implanted with a 10 kHz SCS system (Senza™ system, Nevro Corp.), with the distal tip of the lead(s) positioned epidurally at the C2 vertebral level. Safety and effectiveness outcomes, such as adverse events, headache and migraine reductions, responder rates, Migraine Disability Assessment (MIDAS), Headache Impact Test-6 (HIT-6), and Migraine-Specific Quality-of-Life (MSQ), were captured up to 52 weeks after implantation. RESULTS Compared to baseline, at 52 weeks postimplantation, there was a significant reduction of mean monthly migraine days (MMD) by 9.3 days (p < 0.001). Sixty percent and 50% of patients obtained respectively at least 30% and at least 50% reduction in mean MMD. By week 52, 50% of patients' chronic pattern converted to an episodic pattern. The proportion of subjects classified with severe headache-related disability on the HIT-6, decreased from 100% to 60% at week 52. Meaningful improvements of headache-related quality of life measured by the MSQ scale were observed with mean gain of 24.9 ± 23.1 (p < 0.001) points at 52 weeks. No unanticipated adverse device effects occurred. No patients required any additional device surgical revision. CONCLUSION 10 kHz SCS may a be safe and effective neurostimulation option for rCM patients. The paresthesia-free waveform constitutes an unprecedented advantage for future methodologically sound sham-controlled studies in headache neuromodulation.
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Affiliation(s)
- Adnan Al-Kaisy
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Stefano Palmisani
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Roy Carganillo
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Samuel Wesley
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - David Pang
- Pain & Neuromodulation Academic Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Giorgio Lambru
- The Headache Service, Pain Management and Neuromodulation Centre Guy's & St Thomas' NHS Foundation Trust, London, UK
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Tieppo Francio V, Polston KF, Murphy MT, Hagedorn JM, Sayed D. Management of Chronic and Neuropathic Pain with 10 kHz Spinal Cord Stimulation Technology: Summary of Findings from Preclinical and Clinical Studies. Biomedicines 2021; 9:biomedicines9060644. [PMID: 34200097 PMCID: PMC8229652 DOI: 10.3390/biomedicines9060644] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/12/2021] [Accepted: 06/01/2021] [Indexed: 12/12/2022] Open
Abstract
Since the inception of spinal cord stimulation (SCS) in 1967, the technology has evolved dramatically with important advancements in waveforms and frequencies. One such advancement is Nevro’s Senza® SCS System for HF10, which received Food and Drug and Administration (FDA) approval in 2015. Low-frequency SCS works by activating large-diameter Aβ fibers in the lateral discriminatory pathway (pain location, intensity, quality) at the dorsal column (DC), creating paresthesia-based stimulation at lower-frequencies (30–120 Hz), high-amplitude (3.5–8.5 mA), and longer-duration/pulse-width (100–500 μs). In contrast, high-frequency 10 kHz SCS works with a proposed different mechanism of action that is paresthesia-free with programming at a frequency of 10,000 Hz, low amplitude (1–5 mA), and short-duration/pulse-width (30 μS). This stimulation pattern selectively activates inhibitory interneurons in the dorsal horn (DH) at low stimulation intensities, which do not activate the dorsal column fibers. This ostensibly leads to suppression of hyperexcitable wide dynamic range neurons (WDR), which are sensitized and hyperactive in chronic pain states. It has also been reported to act on the medial pathway (drives attention and pain perception), in addition to the lateral pathways. Other theories include a reversible depolarization blockade, desynchronization of neural signals, membrane integration, glial–neuronal interaction, and induced temporal summation. The body of clinical evidence regarding 10 kHz SCS treatment for chronic back pain and neuropathic pain continues to grow. There is high-quality evidence supporting its use in patients with persistent back and radicular pain, particularly after spinal surgery. High-frequency 10 kHz SCS studies have demonstrated robust statistically and clinically significant superiority in pain control, compared to paresthesia-based SCS, supported by level I clinical evidence. Yet, as the field continues to grow with the technological advancements of multiple waveforms and programming stimulation algorithms, we encourage further research to focus on the ability to modulate pain with precision and efficacy, as the field of neuromodulation continues to adapt to the modern healthcare era.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Keith F Polston
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Micheal T Murphy
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center, Kansas City, KS 66160, USA
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Petersen EA, Stauss TG, Scowcroft JA, Brooks ES, White JL, Sills SM, Amirdelfan K, Guirguis MN, Xu J, Yu C, Nairizi A, Patterson DG, Tsoulfas KC, Creamer MJ, Galan V, Bundschu RH, Paul CA, Mehta ND, Choi H, Sayed D, Lad SP, DiBenedetto DJ, Sethi KA, Goree JH, Bennett MT, Harrison NJ, Israel AF, Chang P, Wu PW, Gekht G, Argoff CE, Nasr CE, Taylor RS, Subbaroyan J, Gliner BE, Caraway DL, Mekhail NA. Effect of High-frequency (10-kHz) Spinal Cord Stimulation in Patients With Painful Diabetic Neuropathy: A Randomized Clinical Trial. JAMA Neurol 2021; 78:687-698. [PMID: 33818600 PMCID: PMC8022268 DOI: 10.1001/jamaneurol.2021.0538] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Question Will 10-kHz spinal cord stimulation improve pain relief for patients with painful diabetic neuropathy refractory to medical management? Findings In this randomized clinical trial including 216 patients, there was a significant benefit of 10-kHz spinal cord stimulation, with 79% of treatment responders whose underlying neurological deficits did not worsen compared with 5% of controls treated with conventional medical management. Meaning Patients with painful diabetic neuropathy with inadequate pain relief despite best available medical treatments should be considered for 10-kHz spinal cord stimulation. Importance Many patients with diabetic peripheral neuropathy experience chronic pain and inadequate relief despite best available medical treatments. Objective To determine whether 10-kHz spinal cord stimulation (SCS) improves outcomes for patients with refractory painful diabetic neuropathy (PDN). Design, Setting, and Participants The prospective, multicenter, open-label SENZA-PDN randomized clinical trial compared conventional medical management (CMM) with 10-kHz SCS plus CMM. Participants with PDN for 1 year or more refractory to gabapentinoids and at least 1 other analgesic class, lower limb pain intensity of 5 cm or more on a 10-cm visual analogue scale (VAS), body mass index (calculated as weight in kilograms divided by height in meters squared) of 45 or less, hemoglobin A1c (HbA1c) of 10% or less, daily morphine equivalents of 120 mg or less, and medically appropriate for the procedure were recruited from clinic patient populations and digital advertising. Participants were enrolled from multiple sites across the US, including academic centers and community pain clinics, between August 2017 and August 2019 with 6-month follow-up and optional crossover at 6 months. Screening 430 patients resulted in 214 who were excluded or declined participation and 216 who were randomized. At 6-month follow-up, 187 patients were evaluated. Interventions Implanted medical device delivering 10-kHz SCS. Main Outcomes and Measures The prespecified primary end point was percentage of participants with 50% pain relief or more on VAS without worsening of baseline neurological deficits at 3 months. Secondary end points were tested hierarchically, as prespecified in the analysis plan. Measures included pain VAS, neurological examination, health-related quality of life (EuroQol Five-Dimension questionnaire), and HbA1c over 6 months. Results Of 216 randomized patients, 136 (63.0%) were male, and the mean (SD) age was 60.8 (10.7) years. Additionally, the median (interquartile range) duration of diabetes and peripheral neuropathy were 10.9 (6.3-16.4) years and 5.6 (3.0-10.1) years, respectively. The primary end point assessed in the intention-to-treat population was met by 5 of 94 patients in the CMM group (5%) and 75 of 95 patients in the 10-kHz SCS plus CMM group (79%; difference, 73.6%; 95% CI, 64.2-83.0; P < .001). Infections requiring device explant occurred in 2 patients in the 10-kHz SCS plus CMM group (2%). For the CMM group, the mean pain VAS score was 7.0 cm (95% CI, 6.7-7.3) at baseline and 6.9 cm (95% CI, 6.5-7.3) at 6 months. For the 10-kHz SCS plus CMM group, the mean pain VAS score was 7.6 cm (95% CI, 7.3-7.9) at baseline and 1.7 cm (95% CI, 1.3-2.1) at 6 months. Investigators observed neurological examination improvements for 3 of 92 patients in the CMM group (3%) and 52 of 84 in the 10-kHz SCS plus CMM group (62%) at 6 months (difference, 58.6%; 95% CI, 47.6-69.6; P < .001). Conclusions and Relevance Substantial pain relief and improved health-related quality of life sustained over 6 months demonstrates 10-kHz SCS can safely and effectively treat patients with refractory PDN. Trial Registration ClincalTrials.gov Identifier: NCT03228420
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Affiliation(s)
- Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock
| | | | | | | | | | - Shawn M Sills
- Touchstone Interventional Pain Center, Medford, Oregon
| | | | | | - Jijun Xu
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cong Yu
- Swedish Medical Center, Seattle, Washington
| | - Ali Nairizi
- Nevada Advanced Pain Specialists, Reno, Nevada
| | | | | | | | | | | | - Christopher A Paul
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | - Neel D Mehta
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Heejung Choi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Khalid A Sethi
- Department of Neurosurgery, United Health Services, Johnson City, New York
| | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | - Matthew T Bennett
- Department of Neurosurgery, United Health Services, Johnson City, New York
| | | | | | | | - Paul W Wu
- Holy Cross Hospital, Fort Lauderdale, Florida
| | - Gennady Gekht
- Coastal Orthopedics and Sports Medicine, Bradenton, Florida
| | - Charles E Argoff
- Department of Neurology, Albany Medical Center, Albany, New York
| | - Christian E Nasr
- Department of Endocrinology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland, United Kingdom
| | | | | | | | - Nagy A Mekhail
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, Ohio
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Baranidharan G, Edgar D, Bretherton B, Crowther T, Lalkhen AG, Fritz AK, Vajramani G. Efficacy and Safety of 10 kHz Spinal Cord Stimulation for the Treatment of Chronic Pain: A Systematic Review and Narrative Synthesis of Real-World Retrospective Studies. Biomedicines 2021; 9:180. [PMID: 33670252 PMCID: PMC7918133 DOI: 10.3390/biomedicines9020180] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/27/2021] [Accepted: 02/05/2021] [Indexed: 12/14/2022] Open
Abstract
10 kHz spinal cord stimulation (SCS) is increasingly utilized globally to treat chronic pain syndromes. Real-world evidence complementing randomized controlled trials supporting its use, has accumulated over the last decade. This systematic review aims to summarize the retrospective literature with reference to the efficacy and safety of 10 kHz SCS. We performed a systematic literature search of PubMed between 1 January 2009 and 21 August 2020 for English-language retrospective studies of ≥3 human subjects implanted with a Senza® 10 kHz SCS system and followed-up for ≥3 months. Two independent reviewers screened titles/abstracts of 327 studies and 46 full-text manuscripts. In total, 16 articles were eligible for inclusion; 15 reported effectiveness outcomes and 11 presented safety outcomes. Follow-up duration ranged from 6-34 months. Mean pain relief was >50% in most studies, regardless of follow-up duration. Responder rates ranged from 67-100% at ≤12 months follow-up, and from 46-76% thereafter. 32-71% of patients decreased opioid or nonopioid analgesia intake. Complication incidence rates were consistent with other published SCS literature. Findings suggest 10 kHz SCS provides safe and durable pain relief in pragmatic populations of chronic pain patients. Furthermore, it may decrease opioid requirements, highlighting the key role 10 kHz SCS can play in the medium-term management of chronic pain.
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Affiliation(s)
- Ganesan Baranidharan
- Leeds Teaching Hospitals NHS Trust Leeds, Leeds LS1 3EX, UK; (B.B.); (T.C.)
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | | | - Beatrice Bretherton
- Leeds Teaching Hospitals NHS Trust Leeds, Leeds LS1 3EX, UK; (B.B.); (T.C.)
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Tracey Crowther
- Leeds Teaching Hospitals NHS Trust Leeds, Leeds LS1 3EX, UK; (B.B.); (T.C.)
| | | | - Ann-Katrin Fritz
- Pain Management Centre, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK;
| | - Girish Vajramani
- Centre for Functional Neurosurgery, University Hospital Southampton NHS Foundation Trust, Hampshire SO16 6YD, UK;
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A Retrospective Review of Lead Migration Rate in Patients Permanently Implanted with Percutaneous Leads and a 10 kHz SCS Device. Pain Res Manag 2021; 2021:6639801. [PMID: 33613793 PMCID: PMC7878096 DOI: 10.1155/2021/6639801] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/12/2020] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
Background Spinal cord stimulation (SCS) has been used over decades for pain management, but migration of percutaneous leads has been the most common complication. Better surgical techniques and newer SCS technologies likely reduced the incidence of lead migration requiring surgical revision, although data are sparse. This study aimed to retrospectively evaluate the incidence of clinically significant percutaneous lead migration in patients permanently implanted with a 10 kHz SCS system. Methods Consecutive patients with chronic trunk and/or limb pain, permanently implanted between January 2016 and June 2019, were included in the analysis. Data were collected from the hospital's electronic medical records and the manufacturer's database. Clinically significant lead migration, defined as diminished pain relief followed by surgery to correct lead location, was assessed at the 6-month follow-up. Results At the 6-month follow-up, there were no cases of clinically significant lead migration, average pain relief was 65.2%, 82% of patients had response (≥50% pain relief), improvement of function was noted in 72% of patients, and decrease of medication was observed in 42% of patients. Therapy efficacy was sustained in patients with >12 months follow-up; the average pain relief was 58.5%, and the response rate was 82%. Conclusions The surgical techniques in use today are designed to minimise the risk of percutaneous lead migration and may have reduced its incidence. In addition, new SCS systems may give greater opportunity to mitigate cases of minor lead movement using alternative stimulation programs.
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Canós-Verdecho A, Abejón D, Robledo R, Izquierdo R, Bermejo A, Gallach E, Argente P, Peraita-Costa I, Morales-Suárez-Varela M. Randomized Prospective Study in Patients With Complex Regional Pain Syndrome of the Upper Limb With High-Frequency Spinal Cord Stimulation (10-kHz) and Low-Frequency Spinal Cord Stimulation. Neuromodulation 2021; 24:448-458. [PMID: 33462918 DOI: 10.1111/ner.13358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this prospective randomized study of cases and controls was to evaluate the efficacy of treatment with low-frequency spinal cord stimulation (LF-SCS) and 10 kHz spinal cord stimulation (10-kHz SCS) in patients diagnosed with complex regional pain syndrome type I (CRPS) with upper limb involvement. MATERIALS AND METHODS Fifty patients were randomized to receive conventional treatment or SCS with a commercially available low-frequency or 10-kHz system. Patients were assessed at 1, 3, 6, and 12 months. The primary endpoint was at 12-months post permanent implantation of the SCS devices. Outcome measures assessed included: Numerical Rating Scale (NRS), 12-Item Short-Format Health Survey (SF-12), Oswestry Disability Index (ODI), Study Sleep Scale medical outcomes (MOS-SS), Douleur Neuropathique 4 questions pain questionnaire (DN4), Patient Global Impression Scale on the impact of treatment improvement (PGI-I), Clinician Global Impression Scale on the impact of improving the patient (CGI-I). RESULTS Forty-one patients were finally included in the analysis, 19 patients in the conventional treatment group, 12 in the LF-SCS group, and 10 in the 10-kHz SCS group. At the primary endpoint, patients treated with LF-SCS presented improvements in the NRS and DN4 outcomes around 2.4 and 1.5 times above the minimal clinically important difference (MCID) thresholds. At the primary endpoint, patients treated with 10-kHz SCS presented improvements in the NRS and DN4 outcomes around 2 and 1.4 times above the MCID thresholds. CONCLUSIONS Patients experienced considerable improvement after SCS. The results show that LF-SCS has very good results when compared with conventional treatment. The results obtained with 10-kHz SCS are encouraging, with the advantages of the absence of paresthesia making it an alternative in the treatment of CRPS.
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Affiliation(s)
- Angeles Canós-Verdecho
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - David Abejón
- Multidisciplinary Pain Management Unit, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Ruth Robledo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rosa Izquierdo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ara Bermejo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Elisa Gallach
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Psychiatry Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Argente
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Surgical Specialities Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Isabel Peraita-Costa
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine, Universitat de València, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP). The Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - María Morales-Suárez-Varela
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine, Universitat de València, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP). The Institute of Health Carlos III (ISCIII), Madrid, Spain
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Baranidharan G, Feltbower R, Bretherton B, Crowther T, Cooper L, Castino P, Radford H. One-Year Results of Prospective Research Study Using 10 kHz Spinal Cord Stimulation in Persistent Nonoperated Low Back Pain of Neuropathic Origin: Maiden Back Study. Neuromodulation 2020; 24:479-487. [PMID: 33351230 DOI: 10.1111/ner.13345] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Spinal cord stimulation (SCS) is a recommended treatment for chronic neuropathic pain. Persistent nonoperative low back pain of neuropathic origin has profound negative impacts on patient's lives. This prospective, open label, research study aimed to explore the use of SCS in patients with associated features of central sensitisation such as allodynia and hyperalgesia. MATERIALS AND METHODS Twenty-one patients with back pain and hyperalgesia or allodynia who had not had prior spinal surgery underwent a SCS trial followed by full implantation. SCS comprised administering electrical impulses epidurally at a frequency of 10 kHz and pulse width of 30 μsec. Patients attended follow-up visits after 6 and 12 months of SCS. Repeated measure ANOVAs/Friedman tests explored change after 6 and 12 months of 10 kHz SCS. Independent sample t-tests/Mann-Whitney U tests examined differences in response after 12 months of 10 kHz SCS. RESULTS Back and leg pain, quality of life (QoL), pain-related disability, and morphine equivalence significantly improved compared with baseline following 6 and 12 months of 10 kHz SCS. There were no increases in the consumption of opioids, amitriptyline, gabapentin or pregabalin in any patient. After 12 months of treatment, 52% encountered ≥50% improvement in back pain, 44% achieved remission (0-3 cm back pain VAS), 40% reported ODI scores between 0 and 40 and 60% experienced a reduction of at least 10 ODI points. Patients reporting ≥10-point improvement in ODI had significantly longer pain history durations and experienced significantly greater improvements in back pain, leg pain and QoL than those reporting <10-point improvement in ODI. CONCLUSION The 10 kHz SCS improved back and leg pain, QoL, pain-related disability and medication consumption in patients with nonoperative back pain of neuropathic origin. With further research incorporating a sham control arm, the efficacy of 10 kHz SCS in this patient cohort will become more established.
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Affiliation(s)
- Ganesan Baranidharan
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Richard Feltbower
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Beatrice Bretherton
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | | | | | | | - Helen Radford
- Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Medicine, Leeds Institute of Clinical Trials Research, Faculty of Medicine & Health, University of Leeds, Leeds, UK
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46
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Markosian C, Taruvai VS, Mammis A. Neuromodulatory hacking: a review of the technology and security risks of spinal cord stimulation. Acta Neurochir (Wien) 2020; 162:3213-3219. [PMID: 33009931 DOI: 10.1007/s00701-020-04592-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is a neuromodulatory technique used to relieve chronic pain. Previous instances of malicious remote control of implantable medical devices, including insulin delivery pumps and implantable cardiac defibrillators, have been documented. Though no cases of neuromodulatory hacking have been recorded outside of the academic setting, an understanding of SCS technology and the possible consequences of manipulation is important in promoting safety. METHODS We review the components and implantation protocol of a SCS system, the functionality and technological specifications for SCS systems in the global market based on their device manuals, and patient- and clinician-specific adjustable factors. Furthermore, we assess documented instances of implantable medical device hacking and speculate on the potential harms of targeting SCS systems. RESULTS SCS systems from Abbott Laboratories, Boston Scientific, Medtronic, and Nevro have unique functionality and technological specifications. Six parameters in device control can potentially be targeted and elicit various harms, including loss of therapeutic effect, accelerated battery drainage, paresthesia in unintended locations, muscle weakness or dysfunction, tissue burn, and electrical shock. CONCLUSIONS Based on the history of implantable medical device hacking, SCS systems may also be susceptible to manipulation. As the prevalence of SCS use increases and SCS systems continuously evolve in the direction of wireless control and compatibility with mobile devices, appropriate measures should be taken by manufacturers and governmental agencies to ensure safety.
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Affiliation(s)
- Christopher Markosian
- Department of Neurological Surgery, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ, 07103, USA.
| | - Varun S Taruvai
- Department of Neurological Surgery, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ, 07103, USA
| | - Antonios Mammis
- Department of Neurological Surgery, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ, 07103, USA
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Amirdelfan K, Vallejo R, Benyamin R, Rosen S, Kosek P, Caraway D, Rotte A, Burgher A. Pain relief and opioid usage in upper limb and neck pain patients after 10-kHz spinal cord stimulation treatment: subanalysis of USA studies. Pain Manag 2020; 11:133-143. [PMID: 33183130 DOI: 10.2217/pmt-2020-0074] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: It is argued that chronic pain patients who reduce/eliminate their opioids may have compromised pain relief. This study therefore aimed to analyze if reduced opioid consumption associated with 10-kHz spinal cord stimulation adversely affected pain relief. Methods: Post hoc analysis was performed on data from two prospective studies in subjects with upper limbs and neck pain conducted in USA. Results & conclusion: A 10-kHz spinal cord stimulation treatment was associated with reduction in mean visual analog scale scores for upper limbs and neck pain and mean daily opioid consumption. Pain scores decreased in subjects who decreased opioid use and in those who maintained/increased use. Opioid reduction and pain relief was also achieved in subjects taking >90 mg morphine equivalents of opioids at baseline.
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Affiliation(s)
| | | | | | - Steven Rosen
- Delaware Valley Spine & Pain, Trevose, PA 19053, USA
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48
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Burgher A, Kosek P, Surrett S, Rosen SM, Bromberg T, Gulve A, Kansal A, Wu P, McRoberts WP, Udeshi A, Esposito M, Gliner BE, Maneshi M, Rotte A, Subbaroyan J. Ten kilohertz SCS for Treatment of Chronic Upper Extremity Pain (UEP): Results from Prospective Observational Study. J Pain Res 2020; 13:2837-2851. [PMID: 33204145 PMCID: PMC7667505 DOI: 10.2147/jpr.s278661] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Chronic upper extremity pain (UEP) has complex etiologies and is often disabling. It has been shown that 10 kHz SCS can provide paresthesia-free and durable pain relief in multiple pain types and improve the quality of life of patients. Objective To gain additional evidence on the safety and effectiveness of 10 kHz SCS for the treatment of chronic UEP. Study Design It was a prospective, multicenter, and observational study. The study was registered on ClinicalTrials.gov prospectively (clinical trial identifier: NCT02703818). Setting Multicenter. Patients Intervention and Main Outcomes A total of 43 subjects with chronic UEP of ≥5 cm (on a 0-10 cm visual analog scale; VAS) underwent a trial of 10 kHz SCS, and subjects with ≥40% pain relief received a permanent implant. All subjects had upper limb pain at baseline, while some had concomitant shoulder or neck pain. Subject outcomes were assessed for 12 months, and the primary outcome was the responder rate (percentage of subjects experiencing ≥50% pain relief from baseline) at three months. Results Thirty-eight subjects successfully completed the trial (88.3% success rate), 33 received permanent implants (five withdrew consent), and 32 had device activation (per protocol population). There were no paresthesias or uncomfortable changes in stimulation related to changes in posture during the study and there were no neurological deficits. Responder rates at 12 months for upper limb, shoulder, and neck pain in per protocol population (N=32) were 78.1%, 85.2%, and 75.0%, respectively. At 12 months, 84.4% of subjects were satisfied or very satisfied with 10 kHz SCS, and 38.7% either reduced or eliminated opioid usage. Conclusion This study further supports the effectiveness of 10 kHz SCS for chronic UEP treatment and documents the safety profile of the therapy. Clinical Trial Identifier NCT02703818.
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Affiliation(s)
| | | | | | | | | | - Ashish Gulve
- The James Cook University Hospital, Middlesbrough, UK
| | - Anu Kansal
- The James Cook University Hospital, Middlesbrough, UK
| | - Paul Wu
- Holy Cross Hospital, Inc., Ft, Lauderdale, FL, USA
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49
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Hagedorn JM, Layno-Moses A, Sanders DT, Pak DJ, Bailey-Classen A, Sowder T. Overview of HF10 spinal cord stimulation for the treatment of chronic pain and an introduction to the Senza Omnia™ system. Pain Manag 2020; 10:367-376. [DOI: 10.2217/pmt-2020-0047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Chronic intractable pain affects a significant percentage of the worldwide population, and it is one of the most disabling and expensive health conditions across the globe. Spinal cord stimulation (SCS) has been used to treat chronic pain for a number of years, but high-frequency SCS was not the US FDA approved until 2015. In this review, we describe the history and development of high-frequency SCS and discuss the benefits of the Omnia™ implantable pulse generator. We also provide a thorough literature review of the published work, highlighting the efficacy and safety profiles of high-frequency SCS for the treatment of multiple chronic pain conditions. Lastly, we offer our outlook on future developments with the Omnia SCS system.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology & Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Annie Layno-Moses
- Source Healthcare, 2801 Wilshire Blvd, Suite A, Santa Monica, CA 90403, USA
| | - Daniel T Sanders
- Spine Team Texas, 1120 Raintree Circle, Suite 110, Allen, TX 75013, USA
| | - Daniel J Pak
- Pain Medicine Division, New York-Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, USA
| | | | - Timothy Sowder
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
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50
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Luecke T, Edgar D, Huse D. 10 kHz spinal cord stimulation for the treatment of chronic back and/or leg pain: Summary of clinical studies. SAGE Open Med 2020; 8:2050312120951369. [PMID: 32913650 PMCID: PMC7444111 DOI: 10.1177/2050312120951369] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/27/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic pain has a major impact on sufferers and their families. The associated health care costs are substantial. In the context of increasing prevalence, effective treatment options are ever more important. 10 kHz spinal cord stimulation has been shown to effectively provide pain relief, aid in opioid reduction, and improve quality of life in patients with chronic intractable pain. The present review aims to summarize the clinical evidence related to the use of 10 kHz SCS in chronic back and/or leg pain. We searched the PubMed database between 2009 and 2 June 2020 for articles reporting clinical studies that included at least 10 human subjects permanently treated with a 10 kHz SCS system (Senza® system) for chronic back and/or leg pain for a minimum of 3 months. A randomized controlled trial (SENZA-RCT), as well as several prospective and retrospective studies, reported clinical outcomes in subjects with chronic back and leg pain treated with 10 kHz SCS. A high proportion of subjects (60%–80%) reported long-term response to therapy. Pain relief was provided without paresthesia. Other studies showed promising pain relief outcomes in subjects with back pain ineligible for spinal surgery, neuropathic limb pain, and in those with previously failed traditional low-frequency SCS. Most studies reported improved quality of life metrics and/or reduced opioid intake. Level 1 evidence has already been established for the use of 10 kHz SCS in treating chronic back and leg pain, corroborated by real-world, clinical experience. Exploratory studies also show the potential of the therapy in other refractory pain syndromes, although larger studies are desired to validate their findings. Overall, the literature suggests that 10 kHz SCS provides long-term pain relief in a high proportion of patients, along with improved quality of life and reduced opioid consumption.
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Affiliation(s)
- Thorsten Luecke
- Department of Anesthesiology and Surgery, Franziskus Krankenhaus Linz, Linz am Rhein, Germany
| | | | - Daniel Huse
- Department of Anesthesiology and Surgery, Franziskus Krankenhaus Linz, Linz am Rhein, Germany
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