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Yuan B, Liu D, Liu X. Spinal cord stimulation exerts analgesia effects in chronic constriction injury rats via suppression of the TLR4/NF-κB pathway. Neurosci Lett 2014; 581:63-8. [DOI: 10.1016/j.neulet.2014.08.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 08/10/2014] [Accepted: 08/12/2014] [Indexed: 12/27/2022]
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Abstract
STUDY DESIGN Retrospective analysis of a population-based insurance claims data set. OBJECTIVE To evaluate the use of spinal cord stimulation (SCS) and lumbar reoperation for the treatment of failed back surgery syndrome (FBSS), and examine their associated complications and health care costs. SUMMARY OF BACKGROUND DATA FBSS is a major source of chronic neuropathic pain and affects up to 40% of patients who undergo lumbosacral spine surgery for back pain. Thus far, few economic analyses have been performed comparing the various treatments for FBSS, with these studies involving small sample sizes. In addition, the nationwide practices in the use of SCS for FBSS are unknown. METHODS The MarketScan data set was used to analyze patients with FBSS who underwent SCS or spinal reoperation between 2000 and 2009. Propensity score methods were used to match patients who underwent SCS with those who underwent lumbar reoperation to examine health care resource utilization. Postoperative complications were analyzed with multivariate logistic regression. Health care use was analyzed using negative binomial and general linear models. RESULTS The study cohort included 16,455 patients with FBSS, with 395 undergoing SCS implantation (2.4%). Complication rates at 90 days were significantly lower for SCS than spinal reoperation (P < 0.0001). Also in the matched cohort, hospital stay (P < 0.0001) and associated charges (P = 0.016) were lower for patients with SCS. However outpatient, emergency room, and medication charges were similar between the 2 groups. Overall cost totaling $82,586 at 2 years was slightly higher in the lumbar reoperation group than in the SCS group with total cost of $80,669 (P = 0.88). CONCLUSION Although previous studies have demonstrated superior efficacy for the treatment of FBSS, SCS remains underused. Despite no significant decreases in overall health care cost with SCS implantation, because it is associated with decreased complications and improved outcomes, this technology warrants closer consideration for the management of chronic pain in patients with FBSS.
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Kelly ML, Malone D, Okun MS, Booth J, Machado AG. Barriers to investigator-initiated deep brain stimulation and device research. Neurology 2014; 82:1465-73. [PMID: 24670888 PMCID: PMC4001198 DOI: 10.1212/wnl.0000000000000345] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 01/15/2014] [Indexed: 11/15/2022] Open
Abstract
The success of device-based research in the clinical neurosciences has overshadowed a critical and emerging problem in the biomedical research environment in the United States. Neuroprosthetic devices, such as deep brain stimulation (DBS), have been shown in humans to be promising technologies for scientific exploration of neural pathways and as powerful treatments. Large device companies have, over the past several decades, funded and developed major research programs. However, both the structure of clinical trial funding and the current regulation of device research threaten investigator-initiated efforts in neurologic disorders. The current atmosphere dissuades clinical investigators from pursuing formal and prospective research with novel devices or novel indications. We review our experience in conducting a federally funded, investigator-initiated, device-based clinical trial that utilized DBS for thalamic pain syndrome. We also explore barriers that clinical investigators face in conducting device-based clinical trials, particularly in early-stage studies or small disease populations. We discuss 5 specific areas for potential reform and integration: (1) alternative pathways for device approval; (2) eliminating right of reference requirements; (3) combining federal grant awards with regulatory approval; (4) consolidation of oversight for human subjects research; and (5) private insurance coverage for clinical trials. Careful reformulation of regulatory policy and funding mechanisms is critical for expanding investigator-initiated device research, which has great potential to benefit science, industry, and, most importantly, patients.
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Affiliation(s)
- Michael L Kelly
- From the Departments of Neurosurgery (M.L.K., A.G.M.) and Psychiatry (D.M.) and the Center for Neurological Restoration (A.G.M.), Neurological Institute, and the Center for Clinical Research (J.B.), Cleveland Clinic, OH; MacLean Center for Clinical Medical Ethics (M.L.K.), Department of Medicine, The University of Chicago, IL; and the Departments of Neurology and Neurosurgery (M.S.O.), University of Florida Center for Movement Disorders and Neurorestoration, Gainesville
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Huang KT, Hazzard MA, Babu R, Ugiliweneza B, Grossi PM, Huh BK, Roy LA, Patil C, Boakye M, Lad SP. Insurance Disparities in the Outcomes of Spinal Cord Stimulation Surgery. Neuromodulation 2013; 16:428-34; discussion 434-5. [DOI: 10.1111/ner.12059] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/14/2013] [Accepted: 03/05/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Kevin T. Huang
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Matthew A. Hazzard
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Ranjith Babu
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery; Center for Neurosurgical Outcomes Research; Maxine Dunitz Neurosurgical Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | - Peter M. Grossi
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Billy K. Huh
- Department of Anesthesia; Divison of Pain; Duke University Medical Center; Durham NC USA
| | - Lance A. Roy
- Department of Anesthesia; Divison of Pain; Duke University Medical Center; Durham NC USA
| | - Chirag Patil
- Department of Neurosurgery; Center for Neurosurgical Outcomes Research; Maxine Dunitz Neurosurgical Institute; Cedars-Sinai Medical Center; Los Angeles CA USA
| | - Maxwell Boakye
- Department of Neurosurgery; University of Louisville; Louisville KY USA
- Department of Neurosurgery; Robley Rex VA Medical Center; Louisville KY USA
| | - Shivanand P. Lad
- Division of Neurosurgery; Department of Surgery; Duke University Medical Center; Durham NC USA
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Flouty OE, Oya H, Kawasaki H, Reddy CG, Fredericks DC, Gibson-Corley KN, Jeffery ND, Gillies GT, Howard MA. Intracranial somatosensory responses with direct spinal cord stimulation in anesthetized sheep. PLoS One 2013; 8:e56266. [PMID: 23457542 PMCID: PMC3574132 DOI: 10.1371/journal.pone.0056266] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/07/2013] [Indexed: 11/20/2022] Open
Abstract
The efficacy of spinal cord stimulators is dependent on the ability of the device to functionally activate targeted structures within the spinal cord, while avoiding activation of near-by non-targeted structures. In theory, these objectives can best be achieved by delivering electrical stimuli directly to the surface of the spinal cord. The current experiments were performed to study the influence of different stimulating electrode positions on patterns of spinal cord electrophysiological activation. A custom-designed spinal cord neurostimulator was used to investigate the effects of lead position and stimulus amplitude on cortical electrophysiological responses to spinal cord stimulation. Brain recordings were obtained from subdural grids placed in four adult sheep. We systematically varied the position of the stimulating lead relative to the spinal cord and the voltage delivered by the device at each position, and then examined how these variables influenced cortical responses. A clear relationship was observed between voltage and electrode position, and the magnitude of high gamma-band oscillations. Direct stimulation of the dorsal column contralateral to the grid required the lowest voltage to evoke brain responses to spinal cord stimulation. Given the lower voltage thresholds associated with direct stimulation of the dorsal column, and its possible impact on the therapeutic window, this intradural modality may have particular clinical advantages over standard epidural techniques now in routine use.
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Affiliation(s)
- Oliver E. Flouty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States of America
| | - Hiroyuki Oya
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States of America
| | - Hiroto Kawasaki
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States of America
| | - Chandan G. Reddy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States of America
| | - Douglas C. Fredericks
- Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States of America
| | - Katherine N. Gibson-Corley
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States of America
| | - Nicholas D. Jeffery
- Department of Veterinary Clinical Sciences, Iowa State University, Ames, Iowa, United States of America
| | - George T. Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, Virginia, United States of America
| | - Matthew A. Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States of America
- * E-mail:
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Treatment of Chronic, Intractable Pain With a Conventional Implantable Pulse Generator. Clin J Pain 2013; 29:78-85. [DOI: 10.1097/ajp.0b013e318247309a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Levy RM. The extinction of comprehensive pain management: a casualty of the medical-industrial complex or an outdated concept? Neuromodulation 2012; 15:89-91. [PMID: 22487596 DOI: 10.1111/j.1525-1403.2012.00444.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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58
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Response to Letter From Ms Jane Shipley. Med Care 2012; 50:107. [DOI: 10.1097/mlr.0b013e3182009857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Costs and cost-effectiveness of spinal cord stimulation (SCS) for failed back surgery syndrome: an observational study in a workers' compensation population. Spine (Phila Pa 1976) 2011; 36:2076-83. [PMID: 21738098 DOI: 10.1097/brs.0b013e31822a867c] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE We estimated the cost-effectiveness of spinal cord stimulation (SCS) among workers' compensation recipients with failed back surgery syndrome (FBSS). SUMMARY OF BACKGROUND DATA Randomized controlled trial (RCT) evidence suggests that SCS is more effective at 6 months than medical management for patients with FBSS. However, procedure costs are high and workers' compensation claimants often have worse outcomes than other patients. METHODS We enrolled 158 FBSS patients receiving workers' compensation into three treatment groups: trial SCS with or without permanent device implant (n = 51), pain clinic (PC) evaluation with or without treatment (n = 39), and usual care (UC; n = 68). The primary outcome was a composite measure of pain, disability and opioid medication use. As reported previously, 5% of SCS patients, 3% of PC patients and 10% of UC patients achieved the primary outcome at 24 months. Using cost data from administrative databases, we calculated the cost-effectiveness of SCS, adjusting for baseline covariates. RESULTS Mean medical cost per SCS patient over 24 months was $52,091. This was $17,291 (95% confidence intervals [CI], $4100-30,490) higher than in the PC group and $28,128 ($17,620-38,630) higher than in the UC group. Adjusting for baseline covariates, the mean total medical and productivity loss costs per patient of the SCS group were $20,074 ($3840-35,990) higher than those of the PC group and $29,358 ($16,070-43,790) higher than those of the UC group. SCS was very unlikely (<5% probability) to be the most cost-effective intervention. CONCLUSION In this sample of workers' compensation recipients, the high procedure cost of SCS was not counterbalanced by lower costs of subsequent care, and SCS was not cost-effective. The benefits and potential cost savings reported in RCTs may not be replicated in workers' compensation patients treated in community settings.
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de Leon-Casasola O. New developments in the treatment algorithm for peripheral neuropathic pain. PAIN MEDICINE 2011; 12 Suppl 3:S100-8. [PMID: 21752181 DOI: 10.1111/j.1526-4637.2011.01160.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Neuropathic pain often imposes a substantial and unrelenting burden on those individuals who have it; single-agent analgesics typically only reduce pain at best. Worldwide, five sets of treatment recommendations offer insight into managing neuropathic pain, including two European guidelines, one Canadian, one Latin American, and another constructed under the auspices of the International Association for the Study of Pain (IASP). The analgesics common to these guidelines are topical lidocaine, secondary amine tricyclic antidepressants, serotonin and norepinephrine dual reuptake inhibitors, calcium channel α(2)-δ ligands, tramadol, and opioid antagonists. Still, significant knowledge gaps in the treatment of neuropathic pain conditions have hampered the development of algorithms and multimodal approaches. As the evidence base expands, the addition of new comparative trial data will further refine the development of new guidance for clinical management of neuropathic pain. New alternatives for managing neuropathic pain, such as the high-concentration capsaicin patch, will enlarge the treatment armamentarium and potentially impact therapeutic guidelines.
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Affiliation(s)
- Oscar de Leon-Casasola
- School of Medicine and Biomedical Sciences, University at Buffalo, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
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61
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Response to letter from Dr North. Med Care 2011; 50:107-8. [PMID: 22052296 DOI: 10.1097/mlr.0b013e31820097a9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rigoard P, Delmotte A, D'Houtaud S, Misbert L, Diallo B, Roy-Moreau A, Durand S, Royoux S, Giot JP, Bataille B. Back Pain: A Real Target for Spinal Cord Stimulation? Neurosurgery 2011; 70:574-84; discussion 584-5. [DOI: 10.1227/neu.0b013e318236a57c] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background:
Failed back surgery syndrome represents one of the most frequent etiologies of chronic back pain and is a major public health issue. Neurostimulation has currently not been validated in the treatment of back pain because of technological limitations in implantable spinal cord stimulation (SCS) systems. New-generation leads using several columns of stimulation can generate longitudinal and/or transverse stimulation fields into the spinal cord.
Objective:
To investigate, through extensive stimulation testing, the capacity of multicolumn tripolar leads to achieve back territory paresthesia coverage in refractory failed back surgery syndrome patients.
Methods:
Eleven patients implanted with a 16-contact spinal cord stimulation lead (Specify 5-6-5, Medtronic Inc) were assessed with a systematic exploration of 43 selected stimulation configurations to generate bilateral back paresthesia in addition to leg territory coverage.
Results:
The tripolar lead successfully generated paresthesia in both bilateral back and leg territories in 9 patients (81.8%). Success rates of multicolumn stimulation patterns were significantly higher than for longitudinal configurations for lombodorsal paresthesia coverage. Six months after implantation, significant pain relief was obtained compared with preoperative evaluation for global pain (Visual Analog Scale, 2.25 vs 8.2 preoperatively; P < .05), leg pain (Visual Analog Scale, 0.5 vs 7.6 preoperatively; P < .05), and back pain (Visual Analog Scale, 1.5 vs 7.8 preoperatively; P < .05).
Conclusion:
These results suggest that multicolumn leads can reliably generate back pain coverage and favor pain relief outcomes. This may lead physicians to reconsider new indications for spinal cord stimulation. Expanding neurostimulation perspectives to intractable back pain syndromes could become realistic in the near future.
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Affiliation(s)
- Philippe Rigoard
- Department of Neurosurgery, Poitiers University School of Medicine, Poitiers, France
| | - Alexandre Delmotte
- Department of Neurosurgery, Poitiers University School of Medicine, Poitiers, France
| | - Samuel D'Houtaud
- Department of Neurosurgery, Poitiers University School of Medicine, Poitiers, France
| | - Lorraine Misbert
- Pain Management and Research Centre, Poitiers University School of Medicine, Poitiers, France
| | - Bakari Diallo
- Pain Management and Research Centre, Poitiers University School of Medicine, Poitiers, France
| | | | | | - Solène Royoux
- Neurophysiological and Technological Institute, Faculty of Science, Poitiers, France
| | | | - Benoit Bataille
- Department of Neurosurgery, Poitiers University School of Medicine, Poitiers, France
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North RB, Kumar K, Wallace MS, Henderson JM, Shipley J, Hernandez J, Mekel-Bobrov N, Jaax KN. Spinal Cord Stimulation Versus Re-operation in Patients With Failed Back Surgery Syndrome: An International Multicenter Randomized Controlled Trial (EVIDENCE Study). Neuromodulation 2011; 14:330-5; discussion 335-6. [DOI: 10.1111/j.1525-1403.2011.00371.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Krames ES, Monis S, Poree L, Deer T, Levy R. Using the SAFE Principles When Evaluating Electrical Stimulation Therapies for the Pain of Failed Back Surgery Syndrome. Neuromodulation 2011; 14:299-311; discussion 311. [DOI: 10.1111/j.1525-1403.2011.00373.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Truin M, Janssen SPM, van Kleef M, Joosten EAJ. Successful pain relief in non-responders to spinal cord stimulation: the combined use of ketamine and spinal cord stimulation. Eur J Pain 2011; 15:1049.e1-9. [PMID: 21565537 DOI: 10.1016/j.ejpain.2011.04.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 03/27/2011] [Accepted: 04/05/2011] [Indexed: 11/25/2022]
Abstract
Although spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain, still 30% of patients do not respond adequately to trial stimulation. These so called "non-responders" do not receive a permanent implantation for pain relief. The induction and maintenance of central sensitization plays a pivotal role in (chronic) neuropathic pain and is thought to be the resultant of the activation of the N-methyl-d-aspartate (NMDA) receptor in the dorsal horn. Blocking the NMDA receptor through the use of the non-competitive blocker ketamine has shown to attenuate neuropathic pain, although the undesirable side effects limit its use. The present study was performed to examine whether the combination of SCS with an individually determined sub-effective dose of intrathecal (i.t.) ketamine could convert non-responders into responders in rats with chronic neuropathic pain. Rats received a partial ligation of the sciatic nerve for the induction of neuropathic pain. Animals with tactile hypersensitivity to von Frey monofilaments (n=15) received 30 min of SCS. Non-responders to SCS (n=8) received their individually determined sub-effective i.t. dose of ketamine followed by 30 min of SCS. No side effects of the sub-effective dose of ketamine could be noted. The combined treatment of SCS and sub-effective dose of i.t. ketamine in non-responders resulted in a significant reduction of the withdrawal threshold in all previous non-responders to SCS, thereby converting them into responders to SCS.
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Affiliation(s)
- M Truin
- Pain Management and Research Center, Department of Anesthesiology, Maastricht University Hospital, P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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Jezukaitis P, Kapur D. Management of occupation-related musculoskeletal disorders. Best Pract Res Clin Rheumatol 2011; 25:117-29. [DOI: 10.1016/j.berh.2011.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 12/16/2010] [Indexed: 12/13/2022]
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Aldrete JA. Arachnoiditis and Related Conditions. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00093-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Rudiger J, Thomson S. Infection Rate of Spinal Cord Stimulators After a Screening Trial Period. A 53-Month Third Party Follow-up. Neuromodulation 2010; 14:136-41; discussion 141. [DOI: 10.1111/j.1525-1403.2010.00317.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Levy RM. The Politics of Neuromodulation in the USA: Spinal Cord Stimulation and the Washington State Department of Labor and Industry. Neuromodulation 2010; 13:249-52. [DOI: 10.1111/j.1525-1403.2010.00300.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Turner JA, Hollingworth W, Comstock BA, Deyo RA. A response to Wasan editorial “Spinal cord stimulation in a workers’ compensation population: How difficult it can be to interpret a clinical trial”: Stimulating discussion. Pain 2010; 149:406-407. [DOI: 10.1016/j.pain.2010.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 02/09/2010] [Indexed: 10/19/2022]
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Wasan AD. Spinal cord stimulation in a workers’ compensation population: How difficult it can be to interpret a clinical trial. Pain 2010; 148:3-4. [DOI: 10.1016/j.pain.2009.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 10/22/2009] [Indexed: 11/24/2022]
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