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Horan M, Jacobsen AH, Scherer C, Rosenlund C, Gulisano HA, Søe M, Sørensen JCH, Meier K, Blichfeldt-Eckhardt MR. Complications and Effects of Dorsal Root Ganglion Stimulation in the Treatment of Chronic Neuropathic Pain: A Nationwide Cohort Study in Denmark. Neuromodulation 2020; 24:729-737. [PMID: 32539189 DOI: 10.1111/ner.13171] [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: 11/17/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Dorsal root ganglion (DRG) stimulation is a novel treatment of chronic neuropathic pain and has been shown to be efficacious across several case reports and randomized trials. However, long-term follow-up is limited, as are reports of complication rates. This study presents efficacy and complications for patients treated with DRG stimulation. MATERIALS AND METHODS We performed an observational, multicenter cohort study of all patients in Denmark implanted with FDA-approved DRG stimulation systems to treat chronic, neuropathic pain between 2014 and 2018. Follow-up period was one to three years. RESULTS Forty-three patients underwent trial DRG stimulation; 33 were subsequently fully implanted. Pain location: 58% lower extremity; 21% upper extremity; 21% thoracic/abdominal. At the end of the observation period, 58% of fully implanted patients were still implanted; 42% had fully functional systems. In these patients, average Numerical Rating Scale (NRS)-score of pain was reduced from 6.8 to 3.5 (p = 0.00049) and worst NRS-score was reduced from 8.6 to 6.0 (p = 0.0039) at 12 months follow-up. Pain Catastrophizing Score was reduced from 32 to 15 (p = 0.0039). Thirteen patients experienced complications related to defect leads (39% of implanted systems). In four patients (12%), lead removal left fragments in the root canal due to lead fracture, and three patients suffered permanent nerve damage during attempts to replace broken leads. CONCLUSIONS This study suggests a significant, clinically relevant effect of DRG stimulation on neuropathic pain, but also demonstrates substantial problems with maintenance and revision of currently available systems. Consequently, treatment with equipment marketed specifically for DRG stimulation is currently paused in Denmark.
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Affiliation(s)
- Mattias Horan
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | | | - Christian Scherer
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Morten Søe
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | - Kaare Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Rune Blichfeldt-Eckhardt
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
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Chronic intractable lumbosacral radicular pain, is there a remedy? Pulsed radiofrequency treatment and volumetric modifications of the lumbar dorsal root ganglia. Radiol Med 2020; 126:124-132. [DOI: 10.1007/s11547-020-01212-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 04/21/2020] [Indexed: 12/12/2022]
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Esposito MF, Malayil R, Hanes M, Deer T. Unique Characteristics of the Dorsal Root Ganglion as a Target for Neuromodulation. PAIN MEDICINE 2020; 20:S23-S30. [PMID: 31152179 PMCID: PMC6544557 DOI: 10.1093/pm/pnz012] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective The dorsal root ganglion (DRG) is a novel target for neuromodulation, and DRG stimulation is proving to be a viable option in the treatment of chronic intractable neuropathic pain. Although the overall principle of conventional spinal cord stimulation (SCS) and DRG stimulation—in which an electric field is applied to a neural target with the intent of affecting neural pathways to decrease pain perception—is similar, there are significant differences in the anatomy and physiology of the DRG that make it an ideal target for neuromodulation and may account for the superior outcomes observed in the treatment of certain chronic neuropathic pain states. This review highlights the anatomy of the DRG, its function in maintaining homeostasis and its role in neuropathic pain, and the unique value of DRG as a target in neuromodulation for pain. Methods A narrative literature review was performed. Results Overall, the DRG is a critical structure in sensory transduction and modulation, including pain transmission and the maintenance of persistent neuropathic pain states. Unique characteristics including selective somatic organization, specialized membrane characteristics, and accessible and consistent location make the DRG an ideal target for neuromodulation. Because DRG stimulation directly recruits the somata of primary sensory neurons and harnesses the filtering capacity of the pseudounipolar neural architecture, it is differentiated from SCS, peripheral nerve stimulation, and other neuromodulation options. Conclusions There are several advantages to targeting the DRG, including lower energy usage, more focused and posture-independent stimulation, reduced paresthesia, and improved clinical outcomes.
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Affiliation(s)
| | - Rudy Malayil
- St. Mary's Pain Relief Specialists, Huntington, West Virginia
| | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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Falowski SM. A Prospective Analysis of the Use of Intraoperative Neuromonitoring for Mapping the S1 Dorsal Root Ganglion Location to Determine Ideal Lead Positioning and Predict Postoperative Programming. Neuromodulation 2020; 24:758-762. [PMID: 32282103 DOI: 10.1111/ner.13156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/29/2020] [Accepted: 03/10/2020] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The location of the sacral dorsal root ganglion (DRG) is variable and can range from a location in the canal to the foramen. It is therefore imperative to not only ensure a dorsal placement but also map the location of the DRG. MATERIALS AND METHODS This is a prospective analysis of the use of intraoperative neuromonitoring (IONM) being utilized in asleep patients to map the location of the S1 DRG with somatosensory evoked potential (SSEP) and electromyogram (EMG) thresholds, as well as comparing this with postoperative programming. These observations were then correlated with the position of the electrode contacts relative to the sacral border. It was performed in a single center with 12 lead placements in eight patients. RESULTS The IONM demonstrated that EMG thresholds decrease or stay the same as you stimulate more distal on the lead. Sensory signals are generated the majority of the time either proximal or on the sacral border. Postoperative programming correlated with the mapped location of the DRG on IONM, which was either posterior or on the sacral border. There was a single lead in which the IONM confirmed DRG location on the distal contact, which was anterior to the sacral border, and also correlated with postoperative programming. CONCLUSIONS This prospective analysis further demonstrates the utility and accuracy of IONM. The use of DRG IONM is reliable for confirming dorsal placement along the S1 DRG, mapping its position, and guiding postoperative programming. The S1 DRG is located at the border of the foramen and canal in most, but not all cases.
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55
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Chapman KB, Ramsook RR, Groenen PS, Vissers KC, Helmond N. Lumbar Transgrade Dorsal Root Ganglion Stimulation Lead Placement in Patients with Post‐Surgical Anatomical Changes: A Technical Note. Pain Pract 2020; 20:399-404. [DOI: 10.1111/papr.12859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/08/2019] [Accepted: 11/10/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Kenneth B. Chapman
- The Spine & Pain Institute of New York New York New York U.S.A
- Department of Anesthesiology New York University Langone Medical Center New York New York U.S.A
- Northwell Health New York New York U.S.A
| | - Ryan R. Ramsook
- The Spine & Pain Institute of New York New York New York U.S.A
| | - Pauline S. Groenen
- The Spine & Pain Institute of New York New York New York U.S.A
- College of Medicine Radboud University Nijmegen The Netherlands
| | - Kris C. Vissers
- Department of Anesthesiology, Pain and Palliative Medicine Radboud University Medical Center Nijmegen The Netherlands
| | - Noud Helmond
- The Spine & Pain Institute of New York New York New York U.S.A
- Department of Anesthesiology, Pain and Palliative Medicine Radboud University Medical Center Nijmegen The Netherlands
- Department of Anesthesiology Cooper Medical School of Rowan University Cooper University Hospital Camden New Jersey U.S.A
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56
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Soloukey S, Drenthen J, Osterthun R, de Rooij JD, De Zeeuw CI, Huygen FJPM, Harhangi BS. Bilateral L2 dorsal root ganglion-stimulation suppresses lower limb spasticity following chronic motor complete Spinal Cord Injury: A case report. Brain Stimul 2020; 13:637-639. [PMID: 32289689 DOI: 10.1016/j.brs.2020.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 01/18/2023] Open
Affiliation(s)
- Sadaf Soloukey
- Department of Neurosurgery, Erasmus MC, Rotterdam, the Netherlands; Department of Neuroscience, Erasmus MC, Rotterdam, the Netherlands
| | - Judith Drenthen
- Department of Clinical Neurophysiology, Erasmus MC, Rotterdam, the Netherlands
| | - Rutger Osterthun
- Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, the Netherlands; Spinal Cord Injury Department, Rijndam Rehabilitation Center, Rotterdam, the Netherlands
| | - Judith D de Rooij
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands; Unit of Physiotherapy, Department of Orthopedics, Erasmus MC, Rotterdam, the Netherlands
| | - Chris I De Zeeuw
- Department of Neuroscience, Erasmus MC, Rotterdam, the Netherlands; Netherlands Institute for Neuroscience, Royal Dutch Academy for Arts and Sciences, Amsterdam, the Netherlands
| | - Frank J P M Huygen
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands
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Sivanesan E, Bicket MC, Cohen SP. Retrospective analysis of complications associated with dorsal root ganglion stimulation for pain relief in the FDA MAUDE database. Reg Anesth Pain Med 2019; 44:100-106. [PMID: 30640660 DOI: 10.1136/rapm-2018-000007] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 03/30/2018] [Accepted: 05/09/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Dorsal root ganglion stimulation is an emerging therapy in the treatment of chronic pain. Compared with traditional spinal cord stimulation, it allows a discretely targeted stimulation profile and may act via differing mechanisms of action. Despite these advantages, little is known about the complications associated with this new modality. METHODS We queried the MAUDE (Manufacturer and User Facility Device Experience) database for all entries named 'Dorsal root ganglion stimulator for pain relief' reported between May 1, 2016 and December 31, 2017. We verified these data through the Office of the Freedom of Information Act at the US Food and Drug Administration. We then eliminated duplicate entries and categorized each complication based on the event description. A secondary analysis was performed to characterize the serious adverse events and the severity of new neurologic symptoms and infections. RESULTS We identified 979 unique episodes following our process of deduplication. Almost half (47%) of entries were categorized as device-related complications, a quarter (28%) as procedural complications, with the remainder as patient complaints (12%), serious adverse events (2.4%), and 'other' complications (4.6%). The majority of complications were managed surgically with revision (n = 488; 49.8%) rather than explant (n = 161; 16.4%) events, respectively. CONCLUSIONS The 'Dorsal root ganglion stimulator for pain relief' device has been publicized as a breakthrough in neuromodulation technologies. As with any new technology, we must proceed with caution and re-evaluate effectiveness as information becomes available. The MAUDE database has provided safety data unique for this device that will aid in informed consent and further refinement of this innovative therapy.
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Affiliation(s)
- Eellan Sivanesan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Mark C Bicket
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA.,Departments of Neurology and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Bethesda, Maryland, USA.,Departments of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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58
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Nanivadekar AC, Ayers CA, Gaunt RA, Weber DJ, Fisher LE. Selectivity of afferent microstimulation at the DRG using epineural and penetrating electrode arrays. J Neural Eng 2019; 17:016011. [PMID: 31577993 PMCID: PMC9131467 DOI: 10.1088/1741-2552/ab4a24] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We have shown previously that microstimulation of the lumbar dorsal root ganglia (L5-L7 DRG) using penetrating microelectrodes, selectively recruits distal branches of the sciatic and femoral nerves in an acute preparation. However, a variety of challenges limit the clinical translatability of DRG microstimulation via penetrating electrodes. For clinical translation of a DRG somatosensory neural interface, electrodes placed on the epineural surface of the DRG may be a viable path forward. The goal of this study was to evaluate the recruitment properties of epineural electrodes and compare their performance with that of penetrating electrodes. Here, we compare the number of selectively recruited distal nerve branches and the threshold stimulus intensities between penetrating and epineural electrode arrays. APPROACH Antidromically propagating action potentials were recorded from multiple distal branches of the femoral and sciatic nerves in response to epineural stimulation on 11 ganglia in four cats to quantify the selectivity of DRG stimulation. Compound action potentials (CAPs) were recorded using nerve cuff electrodes implanted around up to nine distal branches of the femoral and sciatic nerve trunks. We also tested stimulation selectivity with penetrating microelectrode arrays implanted into ten ganglia in four cats. A binary search was carried out to identify the minimum stimulus intensity that evoked a response at any of the distal cuffs, as well as whether the threshold response selectively occurred in only a single distal nerve branch. MAIN RESULTS Stimulation evoked activity in just a single peripheral nerve through 67% of epineural electrodes (35/52) and through 79% of the penetrating microelectrodes (240/308). The recruitment threshold (median = 9.67 nC/phase) and dynamic range of epineural stimulation (median = 1.01 nC/phase) were significantly higher than penetrating stimulation (0.90 nC/phase and 0.36 nC/phase, respectively). However, the pattern of peripheral nerves recruited for each DRG were similar for stimulation through epineural and penetrating electrodes. SIGNIFICANCE Despite higher recruitment thresholds, epineural stimulation provides comparable selectivity and superior dynamic range to penetrating electrodes. These results suggest that it may be possible to achieve a highly selective neural interface with the DRG without penetrating the epineurium.
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Affiliation(s)
- Ameya C Nanivadekar
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, United States of America. Rehabilitation Neural Engineering Laboratories, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA 15213, United States of America. Center for Neural Basis of Cognition, Pittsburgh, PA 15213, United States of America
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Franken G, Debets J, Joosten EAJ. Nonlinear Relation Between Burst Dorsal Root Ganglion Stimulation Amplitude and Behavioral Outcome in an Experimental Model of Painful Diabetic Peripheral Neuropathy. Neuromodulation 2019; 23:158-166. [PMID: 31738474 PMCID: PMC7065114 DOI: 10.1111/ner.13070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/25/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022]
Abstract
Background and objective Dorsal root ganglion stimulation (DRGS) has recently emerged as a neuromodulation modality in the treatment of chronic neuropathic pain. The objective of this study was to compare the efficacy of different Burst‐DRGS amplitudes in an experimental model of painful diabetic peripheral neuropathy (PDPN). Methods Diabetes mellitus was induced in female Sprague–Dawley rats by intraperitoneal injection of streptozotocin (STZ, n = 28). Animals were tested for mechanical hypersensitivity (von Frey paw withdrawal test) before, and four weeks after STZ injection. PDPN rats (n = 13) were implanted with a unilateral bipolar electrode at the L5 DRG. Animals received Burst‐DRGS at 0%, 10%, 33%, 50%, 66%, and 80% of motor threshold (MT) in a randomized crossover design on post‐implantation days 2–7 (n = 9). Mechanical hypersensitivity was assessed before stimulation onset, 15 and 30 min during stimulation, and 15 and 30 min after stimulation. Results Burst‐DRGS at amplitudes of 33%, 50%, 66%, and 80% MT resulted in significant attenuation of STZ‐induced mechanical hypersensitivity at 15 and 30 min during stimulation, as well as 15 min after cessation of stimulation. No effect on mechanical hypersensitivity was observed for Burst‐DRGS at 0% MT and 10% MT. Optimal pain relief and highest responder rates were achieved with Burst‐DRGS at 50–66% MT, with an estimated optimum at 52% MT. Conclusion Our findings indicate a nonlinear relationship between Burst‐DRGS amplitude and behavioral outcome, with an estimated optimal amplitude of 52% MT. Further optimization and analysis of DRGS driven by insights into the underlying mechanisms related to the various stimulation paradigms is warranted.
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Affiliation(s)
- Glenn Franken
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, MUMC, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jacques Debets
- Muroidean Facility, School of Cardiovascular Diseases, CARIM, Maastricht, The Netherlands
| | - Elbert A J Joosten
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, MUMC, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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60
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Moisset X, Lanteri-Minet M, Fontaine D. Neurostimulation methods in the treatment of chronic pain. J Neural Transm (Vienna) 2019; 127:673-686. [PMID: 31637517 DOI: 10.1007/s00702-019-02092-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/06/2019] [Indexed: 02/07/2023]
Abstract
The goal of this narrative review was to give an up-to-date overview of the peripheral and central neurostimulation methods that can be used to treat chronic pain. Special focus has been given to three pain conditions: neuropathic pain, nociplastic pain and primary headaches. Both non-invasive and invasive techniques are briefly presented together with their pain relief potentials. For non-invasive stimulation techniques, data concerning transcutaneous electrical nerve stimulation (TENS), transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), remote electrical neuromodulation (REN) and vagus nerve stimulation (VNS) are provided. Concerning invasive stimulation techniques, occipital nerve stimulation (ONS), vagus nerve stimulation (VNS), epidural motor cortex stimulation (EMCS), spinal cord stimulation (SCS) and deep brain stimulation (DBS) are presented. The action mode of all these techniques is only partly understood but can be very different from one technique to the other. Patients' selection is still a challenge. Recent consensus-based guidelines for clinical practice are presented when available. The development of closed-loop devices could be of interest in the future, although the clinical benefit over open loop is not proven yet.
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Affiliation(s)
- X Moisset
- Service de Neurologie, Université Clermont-Auvergne, INSERM, Neuro-Dol, CHU Clermont-Ferrand, Clermont-Ferrand, France.
| | - M Lanteri-Minet
- Pain Department, CHU Nice, FHU InovPain Côte Azur University, Nice, France
- Université Clermont-Auvergne, INSERM, Neuro-Dol, Clermont-Ferrand, France
| | - D Fontaine
- Department of Neurosurgery, Université Côte Azur University, CHU de Nice, FHU InovPain, Nice, France
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Bockbrader MA, Francisco G, Lee R, Olson J, Solinsky R, Boninger ML. Brain Computer Interfaces in Rehabilitation Medicine. PM R 2019; 10:S233-S243. [PMID: 30269808 DOI: 10.1016/j.pmrj.2018.05.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/22/2018] [Accepted: 05/31/2018] [Indexed: 12/24/2022]
Abstract
One innovation currently influencing physical medicine and rehabilitation is brain-computer interface (BCI) technology. BCI systems used for motor control record neural activity associated with thoughts, perceptions, and motor intent; decode brain signals into commands for output devices; and perform the user's intended action through an output device. BCI systems used for sensory augmentation transduce environmental stimuli into neural signals interpretable by the central nervous system. Both types of systems have potential for reducing disability by facilitating a user's interaction with the environment. Investigational BCI systems are being used in the rehabilitation setting both as neuroprostheses to replace lost function and as potential plasticity-enhancing therapy tools aimed at accelerating neurorecovery. Populations benefitting from motor and somatosensory BCI systems include those with spinal cord injury, motor neuron disease, limb amputation, and stroke. This article discusses the basic components of BCI for rehabilitation, including recording systems and locations, signal processing and translation algorithms, and external devices controlled through BCI commands. An overview of applications in motor and sensory restoration is provided, along with ethical questions and user perspectives regarding BCI technology.
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Affiliation(s)
- Marcia A Bockbrader
- Department of Physical Medicine & Rehabilitation, The Ohio State University, 480 Medical Center Dr, Columbus, OH 43210; and Neurological Institute, Ohio State University Wexner Medical Center, Columbus, OH(∗).
| | - Gerard Francisco
- Department of Physical Medicine & Rehabilitation, The University of Texas, Houston, TX(†)
| | - Ray Lee
- Department of Orthopaedic and Rehabilitation, Schwab Rehabilitation Hospital, University of Chicago, Chicago, IL(‡)
| | - Jared Olson
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO(§)
| | - Ryan Solinsky
- Spaulding Rehabilitation Hospital, Boston; and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA(¶)
| | - Michael L Boninger
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh; and VA Pittsburgh Health Care System, Pittsburgh, PA(#)
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Chapman KB, Groenen PS, Patel KV, Vissers KC, van Helmond N. T12 Dorsal Root Ganglion Stimulation to Treat Chronic Low Back Pain: A Case Series. Neuromodulation 2019; 23:203-212. [PMID: 31588662 DOI: 10.1111/ner.13047] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/13/2019] [Accepted: 08/19/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) is a neuromodulation technique for treating neuropathic pain syndromes. Research has demonstrated DRG-S to be more effective than conventional SCS in treating RSD/CRPS, particularly of the lower extremities. Results from recent case series and prospective studies suggest that DRG-S may be effective in treatment of pain syndromes considered to have non-neuropathic components and characteristics (e.g. nociceptive). There have been multiple, small studies demonstrating efficacy of DRG-S for axial low back pain. There has, however, been no consensus regarding the best location for DRG lead placement in the treatment of low back pain. METHODS Patients presenting with refractory low back pain in a private pain management practice were considered for DRG-S. Patients were provided a trial stimulator prior to potential implantation. Per standard practice, pain intensity, disability, general health status, and quality of life were followed using the visual analog scale (VAS), Oswestry Disability Index, EQ-5D index, and the SF-36 survey, respectively. Data were collected prior to implantation and at variable follow-ups after DRG-S initiation. RESULTS Seventeen consecutive patients presented with predominantly axial low back pain with/without a secondary component of lower extremity pain. All were trialed and subsequently implanted for DRG-S. Leads were placed at T12 to target the low back. Stimulation levels were set very low, below that of which patients experienced paresthesias. Last follow-up times averaged 8.3 months. More than half of the patients experienced pain relief ≥80%, with an average low back pain relief of 78% at last follow-up. Additionally, substantial improvements in physical and mental functioning, disability, and quality of life were reported. CONCLUSIONS T12 DRG-S can be an effective treatment for chronic axial low back pain. Stimulation results in reduced pain and disability, while improving quality of life. These outcomes can be achieved without paresthesias.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Pauline S Groenen
- The Spine & Pain Institute of New York, New York City, NY, USA.,College of Medicine, Radboud University, Nijmegen, The Netherlands
| | - Kiran V Patel
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Kris C Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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Koetsier E, Franken G, Debets J, van Kuijk SMJ, Linderoth B, Joosten EA, Maino P. Dorsal Root Ganglion Stimulation in Experimental Painful Diabetic Polyneuropathy: Delayed Wash-Out of Pain Relief After Low-Frequency (1Hz) Stimulation. Neuromodulation 2019; 23:177-184. [PMID: 31524325 DOI: 10.1111/ner.13048] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/24/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Up until now there is little data about the pain relieving effect of different frequency settings in DRGS. The aim of this study was to compare the pain relieving effect of DRGS at low-, mid-, and high-frequencies and Sham-DRGS in an animal model of painful diabetic neuropathy (PDPN). MATERIAL AND METHODS Diabetes mellitus was induced by an intraperitoneal injection of streptozotocin in 8-week-old female Sprague-Dawley rats (n = 24; glucose ≥15 mmol/L: n = 20; mechanical hypersensitivity: n = 15). Five weeks later, a DRGS device was implanted at the L5 DRG. Ten animals were included for stimulation, alternating 30 minutes of low (1 Hz)-, mid (20 Hz)-, and high (1000 Hz)-frequencies and Sham-DRGS during four days, with a pulse width of 0.2 msec (average amplitude: 0.19 ± 0.01 mA), using a randomized cross-over design. The effect on mechanical hypersensitivity of the hind paw to von Frey filaments was evaluated. RESULTS All DRGS frequencies resulted in a complete reversal of mechanical hypersensitivity and "a clinically relevant reduction" was achieved in 70-80% of animals. No significant differences in maximal pain relieving effect were found between the different frequency treatments (p = 0.24). Animals stimulated at 1000 and 20 Hz returned to baseline mechanical hypersensitivity values 15 and 30 min after stimulation cessation, respectively, while animals stimulated at 1 Hz did not. CONCLUSIONS These results show that DRGS is equally effective when applied at low-, mid-, and high-frequency in an animal model of PDPN. However, low-frequency-(1 Hz)-DRGS resulted in a delayed wash-out effect, which suggests that this is the most optimal frequency for pain therapy in PDPN as compared to mid- and high-frequency.
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Affiliation(s)
- Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Division of Anaesthesiology, Department of Acute Medicine, Regional Hospital of Lugano, Lugano, Switzerland
| | - Glenn Franken
- Department of Anesthesiology and Pain Management, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, The Netherlands
| | - Jacques Debets
- Muroidean Facility, School of Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, The Netherlands
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Division of Anaesthesiology, Department of Acute Medicine, Regional Hospital of Lugano, Lugano, Switzerland
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Falowski SM, Conti KR, Mogilner AY. Analysis of S1 DRG Programming to Determine Location of the DRG and Ideal Anatomic Positioning of the Electrode. Neuromodulation 2019; 23:252-257. [DOI: 10.1111/ner.13039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/14/2019] [Accepted: 07/18/2019] [Indexed: 01/04/2023]
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Abstract
In addition to basic image-guided injections, there are many advanced procedures to address the challenges of spine pain. Patients with debilitating symptoms are offered relief, a shorter recovery period, and fewer potential complications. Pain arises from numerous sites along the spine, presenting as spine pain or radiculopathy. This article is an overview of advanced techniques in this rapidly progressing field, including neuromodulation, radiofrequency thermocoagulation, discography, intradiscal thermocoagulation, and percutaneous image-guided lumbar decompression; and it highlights etiologic factors and their relationship to therapeutic technique and clinical evidence.
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66
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Caylor J, Reddy R, Yin S, Cui C, Huang M, Huang C, Rao R, Baker DG, Simmons A, Souza D, Narouze S, Vallejo R, Lerman I. Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectron Med 2019; 5:12. [PMID: 31435499 PMCID: PMC6703564 DOI: 10.1186/s42234-019-0023-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/30/2019] [Indexed: 12/30/2022] Open
Abstract
Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.
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Affiliation(s)
- Jacob Caylor
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Rajiv Reddy
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Sopyda Yin
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Christina Cui
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Mingxiong Huang
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
| | - Charles Huang
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Bioengineering, Stanford University, Palo Alto, CA USA
| | - Ramesh Rao
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
| | - Dewleen G. Baker
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Alan Simmons
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Ricardo Vallejo
- Basic Science Research, Millennium Pain Center, Bloomington, IL USA
- School of Biological Sciences, Illinois State University, Normal, IL USA
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL USA
| | - Imanuel Lerman
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
- Present Address: VA San Diego, 3350 La Jolla Village Dr, (MC116A), San Diego, CA 92161 USA
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Feng B, Chen L, Ilham SJ. A review on ultrasonic neuromodulation of the peripheral nervous system: enhanced or suppressed activities? APPLIED SCIENCES-BASEL 2019; 9. [PMID: 34113463 PMCID: PMC8188893 DOI: 10.3390/app9081637] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ultrasonic (US) neuromodulation has emerged as a promising therapeutic means by delivering focused energy deep into the tissue. Low-intensity ultrasound (US) directly activates and/or inhibits neurons in the central nervous system (CNS). US neuromodulation of the peripheral nervous system (PNS) is less developed and rarely used clinically. Literature on the neuromodulatory effects of US on the PNS is controversy with some documenting enhanced neural activities, some showing suppressed activities, and others reporting mixed effects. US, with different range of intensity and strength, is likely to generate distinct physical effects in the stimulated neuronal tissues, which underlies different experimental outcomes in the literature. In this review, we summarize all the major reports that documented the effects of US on peripheral nerve endings, axons, and/or somata in the dorsal root ganglion. In particular, we thoroughly discuss the potential impacts by the following key parameters to the study outcomes of PNS neuromodulation by the US: frequency, pulse repetition frequency, duty cycle, intensity, metrics for peripheral neural activities, and type of biological preparations used in the studies. Potential mechanisms of peripheral US neuromodulation are summarized to provide a plausible interpretation to the seemly contradictory effects of enhanced and suppressed neural activities from US neuromodulation.
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Affiliation(s)
- Bin Feng
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
- Correspondence: ; Tel.: (001-860-486-6435)
| | - Longtu Chen
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
| | - Sheikh J. Ilham
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
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Deer T, Pope J, Hunter C, Falowski S, Kapural L, Kramer J, Levy R. Safety Analysis of Dorsal Root Ganglion Stimulation in the Treatment of Chronic Pain. Neuromodulation 2019; 23:239-244. [PMID: 30861617 PMCID: PMC7065079 DOI: 10.1111/ner.12941] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/08/2019] [Indexed: 12/23/2022]
Abstract
Background Stimulation of the dorsal root ganglion (DRG) in the treatment of chronic, intractable pain has shown excellent clinical results in multiple published studies, including a large prospective, randomized, controlled trial. Both safety and efficacy have been demonstrated utilizing this therapeutic approach for many chronic complaints. Continued assessment of neuromodulation therapies, such as DRG stimulation, are not only an important aspect of vigilant care, but are also necessary for the evaluation for safety. Materials and Methods Safety and complaint records for DRG and spinal cord stimulation (SCS) stimulation were obtained from the manufacturer, analyzed and compiled to further assess ongoing device safety. Complaint event data were stratified according to complain type as well as overall rates. Data from similar time periods were compared between epidural neurostimulation devices by the same manufacturer as well as rates reported in the literature. Results Overall, DRG stimulation device event rates were lower or comparable to similar epidurally placed neurostimulation devices. Rates of events varied from 0 to 1.0% for DRG stimulation (n >500+ implants) which was similar to the event rate for SCS by the same manufacturer (n >2000+ implants). In comparison, complaints and adverse events ranged from 0 to 14% for SCS in the literature. Discussions The current results from a large consecutive cohort obtained from manufacturer records indicates that DRG stimulation demonstrates an excellent safety profile. Reported event rates are similar to previously reported adverse event and complaint rates in the literature for this therapy. Similarly, safety events rates were lower or similar to previously reported rates for SCS, further demonstrating the comparative safety of this neuromodulation technique for chronic pain treatment.
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Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of The Virginias, Charleston, WV, USA
| | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | | | | | - Robert Levy
- University of Illinois, Chicago, IL, USA.,Institute for Neuromodulation, Boca Raton, FL, USA
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Koetsier E, Franken G, Debets J, van Kuijk SMJ, Perez RSGM, Linderoth B, Joosten EAJ, Maino P. Effectiveness of dorsal root ganglion stimulation and dorsal column spinal cord stimulation in a model of experimental painful diabetic polyneuropathy. CNS Neurosci Ther 2019; 25:367-374. [PMID: 30246327 PMCID: PMC6488890 DOI: 10.1111/cns.13065] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/31/2018] [Accepted: 08/21/2018] [Indexed: 12/11/2022] Open
Abstract
AIMS Conventional dorsal root ganglion stimulation (DRGS) is known to achieve better pain-paresthesia overlap of difficult-to-reach areas like the feet compared to dorsal column spinal cord stimulation (SCS). As in painful diabetic polyneuropathy (PDPN) pain is mostly present in the feet, we hypothesized that DRGS is more effective in relieving pain in PDPN when compared to SCS. METHODS Diabetes was induced in female Sprague-Dawley rats with an intraperitoneal injection of 65 mg/kg of streptozotocin (STZ; n = 48). Rats with a significant decrease in mechanical paw withdrawal response to von Frey filaments 4 weeks after injection were implanted with DRGS electrodes (n = 18). Rats were assigned to DRGS (n = 11) or sham-DRGS (n = 7). Mechanical paw withdrawal thresholds (WT, measured in grams) in response to DRGS (50 Hz, 0.18 ± 0.05 mA) were assessed with von Frey testing. The results of the experiments on these animals were compared to the results of a previous study using exactly the same model on PDPN animals selected for SCS (n = 8) (40-50 Hz, 0.19 ± 0.01 mA) and sham-SCS (n = 3). RESULTS In the SCS group, the log10 (10 000 × 50% WT) increased from 4910 to 5211 at t = 15 minutes (P < 0.05) and 5264 at t = 30 minutes (P = 0.11). In the DRGS group, the log10 (10,000 × 50% WT) increased from 4376 to 4809 at t = 15 minutes (P < 0.01) and 5042 at t = 30 minutes (P < 0.01). Both DRGS and SCS induced a similar and complete reversal of mechanical hypersensitivity. After cessation of stimulation (t = 60), the return of the log10 (10 000 × 50% WT) response was significantly faster with DRGS than that of SCS (P < 0.05). CONCLUSIONS We conclude that conventional DRGS is as effective as SCS in reduction of PDPN-associated mechanical hypersensitivity in STZ-induced diabetic rats. The wash-in effect of DRGS and SCS was similar, but DRGS showed a faster washout course. Long-term efficacy should be studied in future animal research.
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Affiliation(s)
- Eva Koetsier
- Pain Management Center, Neurocenter of Southern SwitzerlandRegional Hospital of LuganoLuganoSwitzerland
| | - Glenn Franken
- Department of Anesthesiology and Pain ManagementMaastricht University Medical CenterMaastrichtThe Netherlands
- Department of Translational Neuroscience, School of Mental Health and Neuroscience (MHeNS)University of MaastrichtMaastrichtThe Netherlands
| | - Jacques Debets
- Muroidean Facility, School of Cardiovascular Diseases (CARIM)MaastrichtThe Netherlands
| | - Sander M. J. van Kuijk
- Department of Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Roberto S. G. M. Perez
- Department of Anesthesiology and Pain ManagementVU University Medical CenterAmsterdamThe Netherlands
| | - Bengt Linderoth
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
| | - Elbert A. J. Joosten
- Department of Anesthesiology and Pain ManagementMaastricht University Medical CenterMaastrichtThe Netherlands
- Department of Translational Neuroscience, School of Mental Health and Neuroscience (MHeNS)University of MaastrichtMaastrichtThe Netherlands
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern SwitzerlandRegional Hospital of LuganoLuganoSwitzerland
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Vuka I, Marciuš T, Došenović S, Ferhatović Hamzić L, Vučić K, Sapunar D, Puljak L. Neuromodulation with electrical field stimulation of dorsal root ganglion in various pain syndromes: a systematic review with focus on participant selection. J Pain Res 2019; 12:803-830. [PMID: 30881093 PMCID: PMC6398970 DOI: 10.2147/jpr.s168814] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective We conducted a systematic review about patient selection, efficacy, and safety of neuromodulation with electrical field stimulation (EFS) of dorsal root ganglion (DRG) in various painful conditions. We also analyzed conclusion statements as well as conflict of interest and financing of the included studies. Methods All study designs were eligible for inclusion. We searched MEDLINE, CINAHL, Embase, PsycINFO, and clinical trial registries until September 7, 2018. We assessed risk of bias by using Cochrane tool for randomized controlled trials (RCTs). Results Among the 29 included studies, only one was RCT, majority being case series and case reports. The evidence is based on studies with small number of participants (median: 6, range 1–152) with various painful conditions. Neuromodulation with EFS of DRG was mostly performed in participants who have failed other treatment modalities. Most of the authors of the included studies reported positive, but inconclusive, evidence regarding efficacy of neuro-modulation with EFS of DRG. Meta-analysis was not possible since only one RCT was included. Conclusion Available evidence suggest that neuromodulation with EFS of DRG may help highly selected participants with various pain syndromes, who have failed to achieve adequate pain relief with other pharmacological and nonpharmacological interventions. However, these findings should be confirmed in high-quality RCTs with sufficient numbers of participants.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, 21000 Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, 21000 Split, Croatia
| | - Svjetlana Došenović
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, 21000 Split, Croatia
| | - Lejla Ferhatović Hamzić
- Department for Proteomics, Center for Translational and Clinical Research, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
| | - Katarina Vučić
- Department for Safety and Efficacy Assessment of Medicinal Products, Agency for Medicinal Products and Medical Devices, 10000 Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, 21000 Split, Croatia.,Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, 10000 Zagreb, Croatia,
| | - Livia Puljak
- Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, 10000 Zagreb, Croatia,
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Verrills P, Mitchell B, Vivian D, Cusack W, Kramer J. Dorsal Root Ganglion Stimulation Is Paresthesia-Independent: A Retrospective Study. Neuromodulation 2019; 22:937-942. [PMID: 30701632 DOI: 10.1111/ner.12921] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/20/2018] [Accepted: 12/04/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Neuromodulation is an important tool for achieving pain relief in otherwise-intractable neuropathic pain conditions. Dorsal root ganglion (DRG) stimulation, in which primary sensory neurons are stimulated prior to their entry into the spinal canal, provides treatment with high levels of dermatomal specificity and can provide advantages compared to conventional spinal cord stimulation. Although DRG stimulation can produce perceptible paresthesias, many patients operate their systems at subthreshold amplitudes that do not elicit this sensation. Pain relief both with and without paresthesia was investigated in this retrospective analysis. MATERIALS AND METHODS A retrospective review of all qualifying permanent DRG stimulation systems at a single center over more than a three-year period was completed. Pain (0-10 numeric rating scale) was assessed at baseline, at the end of the trial, and after three, six, and twelve months of treatment. Patients were categorized based on their usage of the stimulator at amplitudes that either did or did not produce paresthesias. RESULTS Of the 39 patients, 34 (87%) reported having no-paresthesias at any of the follow-up visits. Average pain relief was 73.9% after the trial period and 63.1% after 12 months of treatment. The responder rate (50% or better pain relief) after three months of treatment was more than 80%. Exploratory subgroup analyses showed that similar degrees of pain relief were achieved in numerous body regions and with various pain etiologies. The five patients who reported paresthesias during treatment had pain relief similar to those of the group that did not experience paresthesias. DISCUSSION Clinically significant and sustained pain relief over more than a period of 12 months was achieved with DRG stimulation programmed at amplitudes below the perceptual level. Thus, the reported analgesia was paresthesia-independent. That good clinical outcomes were observed independent of the generation of paresthesia in DRG stimulation suggests several mechanisms of action, including the inhibition of supraspinal regions involved in somatic paresthesia sensation. The retrospective results presented here posit that future prospective study of DRG stimulation delivered at below the threshold of perceptible paresthesias is warranted.
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Deer TR, Jain S, Hunter C, Chakravarthy K. Neurostimulation for Intractable Chronic Pain. Brain Sci 2019; 9:E23. [PMID: 30682776 PMCID: PMC6406470 DOI: 10.3390/brainsci9020023] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/15/2019] [Accepted: 01/21/2019] [Indexed: 12/20/2022] Open
Abstract
The field of neuromodulation has seen unprecedented growth over the course of the last decade with novel waveforms, hardware advancements, and novel chronic pain indications. We present here an updated review on spinal cord stimulation, dorsal root ganglion stimulation, and peripheral nerve stimulation. We focus on mechanisms of action, clinical indications, and future areas of research. We also present current drawbacks with current stimulation technology and suggest areas of future advancements. Given the current shortage of viable treatment options using a pharmacological based approach and conservative interventional therapies, neuromodulation presents an interesting area of growth and development for the interventional pain field and provides current and future practitioners a fresh outlook with regards to its place in the chronic pain treatment paradigm.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, VA 25301, USA.
| | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, AR 72205, USA.
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY 10022, USA.
| | - Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA 92037, USA.
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Maheshwari A, Pope JE, Deer TR, Falowski S. Advanced methods of spinal stimulation in the treatment of chronic pain: pulse trains, waveforms, frequencies, targets, and feedback loops. Expert Rev Med Devices 2019; 16:95-106. [PMID: 30625000 DOI: 10.1080/17434440.2019.1567325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Spinal cord stimulation has emerged as a state-of-the-art evidence-based treatment for chronic neuropathic pain and mixed nociceptive-neuropathic pain. In recent years, several newer devices and treatment algorithms have provided unique and effective ways of treating chronic pain by spinal cord stimulation. In a previous review, the authors commented on the 5-year forecast for high frequency and Burst waveforms, as the only two paresthesia independent SCS strategies. Over the last 5 years, there has been considerable addition to the outcome data related to these modalities. Additionally, new treatment algorithms and modalities for spinal cord stimulation have emerged. In this review, the authors provide an up to date summary of these modalities of treatment, indications, and evidence on all different modalities and programming paradigms that are available today. AREAS COVERED A literature review was performed using key bibliographic databases to find outcomes related studies pertaining to spinal cord stimulation, limited to the English language and human data, between 2010 and 2018. The literature search yielded the following based on our inclusion criteria; six articles on burst stimulation, three articled on high density/high dose stimulation, six articles on Dorsal Root Ganglion stimulation, nine articles on high-frequency stimulation, and one article on closed-loop stimulation. We have also included in the discussion some smaller and anecdotal studies. EXPERT COMMENTARY The evidence to support outcomes of spinal cord stimulation has evolved considerably since our last review in 2014. New targets, frequencies and pulse trains, and feedback appear to have advanced the efficacy of spinal cord stimulation. Future developments aim to continue to refine patient selection and maintenance of patients in therapy.
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Affiliation(s)
- Ankit Maheshwari
- a Case Western Reserve University, University Hospitals , Cleveland , OH , USA
| | - Jason E Pope
- b Evolve Restorative Center , Santa Rosa , CA , USA
| | - Timothy R Deer
- c The Spine and Nerve Centers of Virginia , Charleston , WV , USA
| | - Steven Falowski
- d Functional Neurosurgery , St. Lukes University Health Network , Bethlehem , PA , USA
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Spinal Cord Stimulation 50 Years Later: Clinical Outcomes of Spinal Cord Stimulation Based on Randomized Clinical Trials-A Systematic Review. Reg Anesth Pain Med 2019; 43:391-406. [PMID: 29481371 DOI: 10.1097/aap.0000000000000744] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To assess the efficacy of spinal cord stimulation (SCS) for each indication, one must critically assess each specific clinical outcome to identify outcomes that benefit from SCS therapy. To date, a comprehensive review of clinically relevant outcome-specific evidence regarding SCS has not been published. We aimed to assess all randomized controlled trials from the world literature for the purpose of evaluating the clinical outcome-specific efficacy of SCS for the following outcomes: perceived pain relief or change pain score, quality of life, functional status, psychological impact, analgesic medication utilization, patient satisfaction, and health care cost and utilization. Interventions were SCS, without limitation to the type of controls or the type of SCS in the active arms. For each study analyzed, a quality assessment was performed using a validated scale that assesses reporting, external validity, bias, confounding, and power. Each outcome was assessed specific to its indication, and the primary measure of each abovementioned outcome was a summary of the level of evidence. Twenty-one randomized controlled trials were analyzed (7 for trunk and limb pain, inclusive of failed back surgery syndrome; 8 for refractory angina pectoris; 1 for cardiac X syndrome; 3 for critical limb ischemia; 2 for complex regional pain syndrome; and 2 for painful diabetic neuropathy). Evidence assessments for each outcome for each indication were depicted in tabular format. Outcome-specific evidence scores were established for each of the abovementioned indications, providing both physicians and patients with a summary of evidence to assist in choosing the optimal evidence-based intervention. The evidence presented herein has broad applicability as it encompasses a breadth of patient populations, variations of SCS therapy, and comparable controls that, together, reflect comprehensive clinical decision making.
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Piedade GS, Vesper J, Chatzikalfas A, Slotty PJ. Cervical and High-Thoracic Dorsal Root Ganglion Stimulation in Chronic Neuropathic Pain. Neuromodulation 2019; 22:951-955. [PMID: 30620789 DOI: 10.1111/ner.12916] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/07/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Dorsal root ganglion stimulation is a meanwhile established but rather new technique of neuromodulation to treat chronic pain states of different origin. While being primarily used in the lumbar region, dorsal root ganglion (DRG) stimulation also can be used in the upper thoracic and cervical region with slight alterations of the surgical approach. This offers new therapeutic options especially in the treatment of neuropathic pain states of the upper extremities. Data on surgical technique, outcome and complications rates of DRG in this region are limited. MATERIALS AND METHODS We report a consecutive series of 20 patients treated with DRG stimulation in the upper thoracic and cervical region. All patients suffered from chronic neuropathic pain unresponsive to best medical treatment. Main pain etiologies were trauma, spine surgery, postherpetic neuralgia, and peripheral nerve surgery. All patients were trialed with externalized electrodes prior to permanent pulse generator implantation. Routine clinical follow-up was performed during reprogramming sessions. RESULTS Out of all 20 patients trialed, 18 were successfully trialed and implanted with a permanent stimulation system. The average pain relief after three months compared to the baseline was of 60.9% (mean VAS 8.5 to VAS 3.2). 77.8% of the patients reported a pain relief of at least 50% after three months. One patient developed a transient paresis of the arm caused by the procedure. She completely recovered within three months. CONCLUSION Cervical and upper thoracic DRG stimulation resulted in good overall response rates to trialing and similar pain relief when compared to DRG stimulation for groin and lower limb pain. A modified surgical approach has to be used when compared with lumbar DRG electrode placement. Surgery itself in this region is more complication prone and challenging.
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Affiliation(s)
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Apostolos Chatzikalfas
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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Morgalla MH, de Barros Filho MF, Chander BS, Soekadar SR, Tatagiba M, Lepski G. Neurophysiological Effects of Dorsal Root Ganglion Stimulation (DRGS) in Pain Processing at the Cortical Level. Neuromodulation 2018; 22:36-43. [PMID: 30561852 DOI: 10.1111/ner.12900] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/25/2018] [Accepted: 10/25/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Dorsal root ganglion stimulation (DRGS) has been used successfully against localized neuropathic pain. Nevertheless, the effects of DRGS on pain processing, particularly at the cortical level, remain largely unknown. In this study, we investigated whether positive responses to DRGS treatment would alter patients' laser-evoked potentials (LEP). METHODS We prospectively enrolled 12 adult patients with unilateral localized neuropathic pain in the lower limbs or inguinal region and followed them up for six months. LEPs were assessed at baseline, after one month of DRGS, and after six months of DRGS. Clinical assessment included the Numerical Rating Scale (NRS), Brief Pain Inventory (BPI), SF-36, and Beck Depression Inventory (BDI). For each patient, LEP amplitudes and latencies of the N2 and P2 components on the deafferented side were measured and compared to those of the healthy side and correlated with pain intensity, as measured with the NRS. RESULTS At the one- and six-month follow-ups, N2-P2 amplitudes were significantly greater and NRS scores were significantly lower compared with baseline (all p's < 0.01). There was a negative correlation between LEP amplitudes and NRS scores (rs = -0.31, p < 0.10). CONCLUSIONS DRGS is able to restore LEPs to normal values in patients with localized neuropathic pain, and LEP alterations are correlated with clinical response in terms of pain intensity.
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Affiliation(s)
| | - Marcos Fortunato de Barros Filho
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany.,Applied Neurotechnology Laboratory, Department of Psychiatry and Psychotherapy, University of Tuebingen, Tuebingen, Germany.,Division of Functional Neurosurgery, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Bankim Subhash Chander
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany.,Applied Neurotechnology Laboratory, Department of Psychiatry and Psychotherapy, University of Tuebingen, Tuebingen, Germany
| | - Surjo Raphael Soekadar
- Applied Neurotechnology Laboratory, Department of Psychiatry and Psychotherapy, University of Tuebingen, Tuebingen, Germany.,Clinical Neurotechnology Laboratory, Neuroscience Research Center (NWFZ) & Department of Psychiatry and Psychotherapy, Charité - University Medicine Berlin, Berlin, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Guilherme Lepski
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany.,Division of Functional Neurosurgery, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
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77
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Kallewaard JW, Nijhuis H, Huygen F, Wille F, Zuidema X, van de Minkelis J, Raza A. Prospective Cohort Analysis of DRG Stimulation for Failed Back Surgery Syndrome Pain Following Lumbar Discectomy. Pain Pract 2018; 19:204-210. [PMID: 30269439 DOI: 10.1111/papr.12734] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/30/2018] [Accepted: 08/05/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Surgical lumbar discectomy is a commonly performed routine spinal procedure that is usually undertaken to alleviate lumbar radicular symptoms caused by a herniated intervertebral disc. Surgical lumbar discectomy can also lead to chronic postsurgical leg and/or back pain (failed back surgery syndrome [FBSS]), a condition that can be refractory to conventional medical management. Early clinical results on the use of dorsal root ganglion (DRG) stimulation for FBSS have supported the use of this treatment alternative. METHODS A multicenter, single-arm, observational cohort study enrolled patients who had chronic pain following surgical lumbar discectomy, had failed conservative treatments, and reported pain intensity of at least 6 out of 10 in the primary region of pain. Data were collected on pain, quality of life, disability, and mood at baseline and through 12 months. RESULTS Thirteen patients underwent a trial of DRG stimulation; 11 (84.6%; 95% confidence interval = 57.8% to 95.7%) had good outcomes and underwent permanent device placement. Pain was reduced from a score of 8.64 (±0.92) at baseline to 2.40 (±2.38; n = 9) after 12 months of treatment, a 72.05% average reduction (P < 0.001). Similar improvements were observed across the secondary clinical measures, and safety data were in line with published rates. DISCUSSION These results suggest that DRG stimulation induces pain relief in subjects diagnosed with FBSS. These reductions in pain were also associated with improvements in quality of life and disability. Additional prospective studies are warranted to further investigate this potential application of DRG stimulation, as well as to optimize patient selection, lead placement, and programming strategies.
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Affiliation(s)
| | | | | | - Frank Wille
- Diakonessenhuis Utrecht, Zeist, The Netherlands.,Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Xander Zuidema
- Diakonessenhuis Utrecht, Zeist, The Netherlands.,Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Adil Raza
- Abbott Laboratories, Plano, Texas, U.S.A
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78
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Jain S, Deer TR. New Advances in Neuromodulation. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0298-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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79
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Gravius N, Chaudhry SR, Muhammad S, Boström A, Gravius S, Randau T, Scheele D, Westhofen P, Kruppenbacher J, Stoffel-Wagner B, Maier C, Weidlich A, Yearwood TL, Chakravarthy KV, Kramer JM, Hurlemann R, Kinfe TM. Selective L4 Dorsal Root Ganglion Stimulation Evokes Pain Relief and Changes of Inflammatory Markers: Part I Profiling of Saliva and Serum Molecular Patterns. Neuromodulation 2018; 22:44-52. [DOI: 10.1111/ner.12866] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/01/2018] [Accepted: 08/15/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Nadine Gravius
- Department of Orthopedics and Trauma Surgery; University Hospital Bonn; Bonn Germany
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
| | - Shafqat R. Chaudhry
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
- Department of Neurosurgery; University Hospital Bonn; Bonn Germany
| | - Sajjad Muhammad
- Department of Neurosurgery; Helsinki University Hospital; Helsinki Finland
| | - Azize Boström
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
- Department of Neurosurgery; University Hospital Bonn; Bonn Germany
| | - Sascha Gravius
- Department of Orthopedics and Trauma Surgery; University Hospital Bonn; Bonn Germany
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
| | - Thomas Randau
- Department of Orthopedics and Trauma Surgery; University Hospital Bonn; Bonn Germany
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
| | - Dirk Scheele
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
- Department of Psychiatry; University Hospital Bonn; Bonn Germany
- Division of Medical Psychology; University Hospital Bonn; Bonn Germany
| | | | | | - Birgit Stoffel-Wagner
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
- Department of Clinical Chemistry and Clinical Pharmacology; University Hospital Bonn; Bonn Germany
| | - Christian Maier
- Department of Radiology and Neuroradiology; Hochsauerland Clinics, Hospital Arnsberg; Arnsberg Germany
| | - Anna Weidlich
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
- Department of Psychiatry; University Hospital Bonn; Bonn Germany
- Division of Medical Psychology; University Hospital Bonn; Bonn Germany
| | | | - Krishnan V. Chakravarthy
- Department of Anesthesiology and Pain Medicine; University of California, San Diego Health Sciences; San Diego CA USA
- VA San Diego Healthcare System; San Diego CA USA
| | | | - Rene Hurlemann
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
- Department of Psychiatry; University Hospital Bonn; Bonn Germany
- Division of Medical Psychology; University Hospital Bonn; Bonn Germany
| | - Thomas M. Kinfe
- University Hospital Bonn, Rheinische Friedrich-Wilhelms-University Bonn; Bonn Germany
- Department of Psychiatry; University Hospital Bonn; Bonn Germany
- Division of Medical Psychology; University Hospital Bonn; Bonn Germany
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80
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Petersen BA, Nanivadekar AC, Chandrasekaran S, Fisher LE. Phantom limb pain: peripheral neuromodulatory and neuroprosthetic approaches to treatment. Muscle Nerve 2018; 59:154-167. [DOI: 10.1002/mus.26294] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Bailey A. Petersen
- Department of Bioengineering; University of Pittsburgh; 3520 Fifth Avenue, Pittsburgh Pennsylvania 15213 USA
| | - Ameya C. Nanivadekar
- Department of Bioengineering; University of Pittsburgh; 3520 Fifth Avenue, Pittsburgh Pennsylvania 15213 USA
| | - Santosh Chandrasekaran
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh Pennsylvania USA
| | - Lee E. Fisher
- Department of Bioengineering; University of Pittsburgh; 3520 Fifth Avenue, Pittsburgh Pennsylvania 15213 USA
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh; Pittsburgh Pennsylvania USA
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81
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Victor S, Burnett C, Lange R, Pohler K. Dorsal root ganglion stimulator for avascular necrosis of the hip. Proc (Bayl Univ Med Cent) 2018; 31:532-533. [DOI: 10.1080/08998280.2018.1483149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/23/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Sandra Victor
- Division of Pain Management, Department of Anesthesiology, Scott & White Medical CenterTempleTexas
| | - Christopher Burnett
- Division of Pain Management, Department of Anesthesiology, Scott & White Medical CenterTempleTexas
| | - Rodney Lange
- Division of Pain Management, Department of Anesthesiology, Scott & White Medical CenterTempleTexas
| | - Kelsey Pohler
- Division of Pain Management, Department of Anesthesiology, Scott & White Medical CenterTempleTexas
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82
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Roy H, Offiah I, Dua A. Neuromodulation for Pelvic and Urogenital Pain. Brain Sci 2018; 8:brainsci8100180. [PMID: 30274287 PMCID: PMC6209873 DOI: 10.3390/brainsci8100180] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/21/2022] Open
Abstract
Chronic pain affecting the pelvic and urogenital area is a major clinical problem with heterogeneous etiology, affecting both male and female patients and severely compromising quality of life. In cases where pharmacotherapy is ineffective, neuromodulation is proving to be a potential avenue to enhance analgesic outcomes. However, clinicians who frequently see patients with pelvic pain are not traditionally trained in a range of neuromodulation techniques. The aim of this overview is to describe major types of pelvic and urogenital pain syndromes and the neuromodulation approaches that have been trialed, including peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and brain stimulation techniques. Our conclusion is that neuromodulation, particularly of the peripheral nerves, may provide benefits for patients with pelvic pain. However, larger prospective randomized studies with carefully selected patient groups are required to establish efficacy and determine which patients are likely to achieve the best outcomes.
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Affiliation(s)
- Holly Roy
- Neurosurgery Department, University Hospitals Plymouth, Plymouth PL6 8DH, UK.
| | - Ifeoma Offiah
- Department of Obstetrics and Gynaecology, University Hospitals Plymouth, Plymouth PL6 8DH, UK.
| | - Anu Dua
- Department of Obstetrics and Gynaecology, University Hospitals Plymouth, Plymouth PL6 8DH, UK.
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83
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Falowski S, Pope JE, Raza A. Early US Experience With Stimulation of the Dorsal Root Ganglia for the Treatment of Peripheral Neuropathy in the Lower Extremities: A Multicenter Retrospective Case Series. Neuromodulation 2018; 22:96-100. [DOI: 10.1111/ner.12860] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/10/2018] [Accepted: 08/15/2018] [Indexed: 11/28/2022]
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84
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Deer TR, Pope JE, Lamer TJ, Grider JS, Provenzano D, Lubenow TR, FitzGerald JJ, Hunter C, Falowski S, Sayed D, Baranidharan G, Patel NK, Davis T, Green A, Pajuelo A, Epstein LJ, Harned M, Liem L, Christo PJ, Chakravarthy K, Gilmore C, Huygen F, Lee E, Metha P, Nijhuis H, Patterson DG, Petersen E, Pilitsis JG, Rowe JJ, Rupert MP, Skaribas I, Sweet J, Verrills P, Wilson D, Levy RM, Mekhail N. The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation. Neuromodulation 2018; 22:1-35. [PMID: 30246899 DOI: 10.1111/ner.12845] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/03/2018] [Accepted: 05/29/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. METHODS The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. RESULTS The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation. CONCLUSION The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.
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Affiliation(s)
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - James J FitzGerald
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, PA, USA
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nikunj K Patel
- Institute of Clinical Neurosciences, Department of Neurosurgery, Southmead Hospital, University of Bristol, Bristol, UK
| | | | - Alex Green
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | | | - Michael Harned
- Department of Anesthesiology, University of Kentucky, Lexington, KY, USA
| | - Liong Liem
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | | | - Frank Huygen
- Erasmus University Hospital, Rotterdam, The Netherlands
| | - Eric Lee
- Summit Pain Alliance, Santa Rosa, CA, USA
| | | | | | | | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie G Pilitsis
- Neurosurgery and Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | | | | | | | - Jennifer Sweet
- Case Western Reserve University, Stereotactic & Functional Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Derron Wilson
- Goodman Campbell Brain and Spine, Indiana University School of Medicine Department of Neurological Surgery, Indianapolis, IN, USA
| | | | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, OH, USA
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Barry AM, Sondermann JR, Sondermann JH, Gomez-Varela D, Schmidt M. Region-Resolved Quantitative Proteome Profiling Reveals Molecular Dynamics Associated With Chronic Pain in the PNS and Spinal Cord. Front Mol Neurosci 2018; 11:259. [PMID: 30154697 PMCID: PMC6103001 DOI: 10.3389/fnmol.2018.00259] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 07/10/2018] [Indexed: 12/27/2022] Open
Abstract
To obtain a thorough understanding of chronic pain, large-scale molecular mapping of the pain axis at the protein level is necessary, but has not yet been achieved. We applied quantitative proteome profiling to build a comprehensive protein compendium of three regions of the pain neuraxis in mice: the sciatic nerve (SN), the dorsal root ganglia (DRG), and the spinal cord (SC). Furthermore, extensive bioinformatics analysis enabled us to reveal unique protein subsets which are specifically enriched in the peripheral nervous system (PNS) and SC. The immense value of these datasets for the scientific community is highlighted by validation experiments, where we monitored protein network dynamics during neuropathic pain. Here, we resolved profound region-specific differences and distinct changes of PNS-enriched proteins under pathological conditions. Overall, we provide a unique and validated systems biology proteome resource (summarized in our online database painproteome.em.mpg.de), which facilitates mechanistic insights into somatosensory biology and chronic pain—a prerequisite for the identification of novel therapeutic targets.
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Affiliation(s)
- Allison M Barry
- Max-Planck Institute of Experimental Medicine, Somatosensory Signaling and Systems Biology Group, Goettingen, Germany
| | - Julia R Sondermann
- Max-Planck Institute of Experimental Medicine, Somatosensory Signaling and Systems Biology Group, Goettingen, Germany
| | - Jan-Hendrik Sondermann
- Max-Planck Institute of Experimental Medicine, Somatosensory Signaling and Systems Biology Group, Goettingen, Germany
| | - David Gomez-Varela
- Max-Planck Institute of Experimental Medicine, Somatosensory Signaling and Systems Biology Group, Goettingen, Germany
| | - Manuela Schmidt
- Max-Planck Institute of Experimental Medicine, Somatosensory Signaling and Systems Biology Group, Goettingen, Germany
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86
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Huygen FJPM, Liem L, Nijhuis H, Cusack W, Kramer J. Evaluating Dorsal Root Ganglion Stimulation in a Prospective Dutch Cohort. Neuromodulation 2018; 22:80-86. [PMID: 30079622 DOI: 10.1111/ner.12798] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/09/2018] [Accepted: 04/29/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Dorsal root ganglion (DRG) stimulation is a recent neuromodulation option that has delivered safe, effective pain relief for a number of etiologies. This prospective observational study was intended to establish the effectiveness of this treatment in a typical real-world clinical context. MATERIALS AND METHODS Participants with chronic, intractable pain of the trunk or lower limbs were recruited from multiple pain clinics in the Netherlands. Subjects were trialed and implanted with DRG stimulation systems. Pain, function, mood, and quality of life, ratings were collected through 12 months postimplant. RESULTS Of the 66 subjects enrolled, failed back surgery syndrome, peripheral nerve injury, and complex regional pain syndrome formed the largest etiologies. Permanent implants were placed in 86.2% subjects (56/65). After 12 months of treatment, average pain ratings in subjects' primary area of pain decreased from 8.0 cm at baseline to 4.1 cm, and 49% of subjects had ≥50% reduction in pain (visual analog scale). In addition, functional capacity was increased, and mood and quality of life improved. No confirmed lead migrations were observed, and there was a low rate of infection. CONCLUSIONS DRG stimulation significantly reduced the severity of subjects' pain and enabled participatory changes that improved quality of life through 12-months postimplant.
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Affiliation(s)
| | - Liong Liem
- Maastricht University Medical Centre, Maastricht, The Netherlands
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87
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Sdrulla AD, Guan Y, Raja SN. Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms. Pain Pract 2018. [PMID: 29526043 DOI: 10.1111/papr.12692] [Citation(s) in RCA: 197] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Spinal cord stimulation (SCS) is a minimally invasive therapy used for the treatment of chronic neuropathic pain. SCS is a safe and effective alternative to medications such as opioids, and multiple randomized controlled studies have demonstrated efficacy for difficult-to-treat neuropathic conditions such as failed back surgery syndrome. Conventional SCS is believed mediate pain relief via activation of dorsal column Aβ fibers, resulting in variable effects on sensory and pain thresholds, and measurable alterations in higher order cortical processing. Although potentiation of inhibition, as suggested by Wall and Melzack's gate control theory, continues to be the leading explanatory model, other segmental and supraspinal mechanisms have been described. Novel, non-standard, stimulation waveforms such as high-frequency and burst have been shown in some studies to be clinically superior to conventional SCS, however their mechanisms of action remain to be determined. Additional studies are needed, both mechanistic and clinical, to better understand optimal stimulation strategies for different neuropathic conditions, improve patient selection and optimize efficacy.
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Affiliation(s)
- Andrei D Sdrulla
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A.,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
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88
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Billet B, Hanssens K, De Coster O, Nagels W, Weiner RL, Wynendaele R, Vanquathem N. Wireless high-frequency dorsal root ganglion stimulation for chronic low back pain: A pilot study. Acta Anaesthesiol Scand 2018; 62:1133-1138. [PMID: 29671870 DOI: 10.1111/aas.13138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/28/2018] [Accepted: 03/31/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Evaluation of the efficacy of a wireless high-frequency stimulator placed over selected DRG of exiting nerve roots for the treatment of chronic low back pain. DESIGN Feasibility. SUBJECTS Six subjects with chronic, intractable back pain refractory to standard medical treatment. METHODS Four stimulators (Freedom-4A) provided by Stimwave Technologies, were implanted over the DRG exiting nerve roots, bilaterally at both the T9 and L2 vertebral levels. Subjects were asked to evaluate stimulation independently with the devices turned on at T9 and subsequently L2 for each of 2 weeks. Subjects were then monitored for 8 weeks with the preferred stimulator. Pain reduction with the Visual Analog Scale (VAS), functionality with the Oswestry Disability Index (ODI), Patient Global Impression of Change (PGIC) and medication usage were evaluated. RESULTS Four subjects preferred T9 stimulation with only one subject preferring stimulation at L2. One subject dropped out of the study before conclusion of the 4-week evaluation and is not included in this report. Average pain levels (n = 5) at 12-week post-implantation decreased with 61% for back pain and 56% for leg pain with a significant reduction in pain medication, including a 100% reduction in opioid pain medications. The average reduction in disability was 12%. Subjects reported an average impression of change of 6 (1 = no change, 7 = great deal better). CONCLUSIONS Wireless high-frequency stimulation of the DRG is a viable option to treat chronic low back pain. Preliminary results show a subject preference for stimulation at the T9 vertebral level.
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Affiliation(s)
| | | | | | | | - R L Weiner
- Presbyterian Hospital, Dallas, University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - N Vanquathem
- Stimwave Technologies, Inc., Pompano Beach, FL, USA
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89
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Eldabe S, Espinet A, Wahlstedt A, Kang P, Liem L, Patel NK, Vesper J, Kimber A, Cusack W, Kramer J. Retrospective Case Series on the Treatment of Painful Diabetic Peripheral Neuropathy With Dorsal Root Ganglion Stimulation. Neuromodulation 2018; 21:787-792. [DOI: 10.1111/ner.12767] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 11/27/2017] [Accepted: 01/04/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Sam Eldabe
- Department of Pain; The James Cook University Hospital; Middlesbrough UK
| | | | | | - Porhan Kang
- Flinders Medical Centre; Bedford Park SA Australia
| | - Liong Liem
- Sint Antonius Hospital; Nieuwegein The Netherlands
| | | | - Jan Vesper
- Medical Faculty; Heinrich-Heine-University; Duesseldorf Germany
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90
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Fundamentals and Mechanisms of Dorsal Root Ganglion Stimulation. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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91
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92
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Dorsal Root Ganglion Stimulation for Pain Control. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00053-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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93
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Ahmed S, Yearwood T, De Ridder D, Vanneste S. Burst and high frequency stimulation: underlying mechanism of action. Expert Rev Med Devices 2017; 15:61-70. [PMID: 29249191 DOI: 10.1080/17434440.2018.1418662] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Paresthesia-free spinal cord stimulation (SCS) techniques, such as burst and high-frequency (HF) SCS, have been developed and demonstrated to be successful for treating chronic pain, albeit via different mechanisms of action. The goal of this review is to discuss the mechanisms of action for pain suppression at both the cellular and systems levels for burst and HF SCS. In addition, we also discuss the neuromodulation devices that mimic these paradigms. AREAS COVERED The authors performed a literature review to unravel the mechanisms of action for burst and HF SCS coupled with booklets and user manuals from neuromodulation companies to understand the programmable parameters and operating ranges. Burst SCS modulates the medial pathway to suppress pain. On cellular level, burst SCS is independent on activation of γ-aminobutyric acid (GABA) receptors to inhibit neuronal firing. HF SCS blocks large-diameter fibers from producing action potentials with little influence on smaller fibers, increasing pain suppression as frequency increases. EXPERT COMMENTARY The neuromodulation industry is in a phase of intense innovation characterized by adaptive stimulation to improve patients' experience and experiment with alternative frequencies and novel stimulation targets.
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Affiliation(s)
- Shaheen Ahmed
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
| | | | - Dirk De Ridder
- c Department of Surgical Sciences, Dunedin School of Medicine , University of Otago , Dunedin , New Zealand
| | - Sven Vanneste
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
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94
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Huygen F, Liem L, Cusack W, Kramer J. Stimulation of the L2-L3 Dorsal Root Ganglia Induces Effective Pain Relief in the Low Back. Pain Pract 2017; 18:205-213. [PMID: 28486758 DOI: 10.1111/papr.12591] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/22/2017] [Accepted: 03/28/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Chronic low back pain affects millions of people worldwide and can arise through a variety of clinical origins. In the case of failed back surgery syndrome (FBSS), previous surgical procedures can contribute to low back pain that is often unresponsive to intervention. Although spinal cord stimulation (SCS) can be an effective treatment modality, it does not provide sufficient pain relief for some intractable cases. Recently, alternative neuromodulation options have been developed, including dorsal root ganglion (DRG) stimulation. The objective of this report is to further investigate these clinical observations. METHODS Twelve patients with significant chronic discogenic low back pain due to FBSS were included. All subjects underwent implantation of DRG stimulation systems that had at least 1 lead placed at L2 or L3. Subjects' pain ratings, mood, and quality of life were tracked prospectively for up to 12 months. RESULTS More than half of subjects reported 50% or better pain relief in the low back, and the average low back pain relief was 45.5% at 12 months. Concomitant reductions in overall pain, leg pain, pain interference, mood, and quality of life were also found. DISCUSSION For the studied population, DRG stimulation at the L2-L3 levels was effective at relieving low back pain. These reductions in pain were associated with improvements in quality of life. Thus, DRG stimulation at these levels may be effective for low back pain by recruiting both segmental and nonsegmental neural pathways that are not otherwise accessible via traditional SCS.
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Affiliation(s)
- Frank Huygen
- Erasmus University, Rotterdam, Maastricht, The Netherlands
| | - Liong Liem
- Maastricht University Medical Centre, Maastricht, The Netherlands
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95
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Spinal Cord Stimulation for Failed Back Surgery Syndrome. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0163-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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96
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Vuka I, Vučić K, Repić T, Ferhatović Hamzić L, Sapunar D, Puljak L. Electrical Stimulation of Dorsal Root Ganglion in the Context of Pain: A Systematic Review of In Vitro and In Vivo Animal Model Studies. Neuromodulation 2017; 21:213-224. [PMID: 29152818 DOI: 10.1111/ner.12722] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/26/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Dorsal root ganglion (DRG) has recently emerged as an attractive target for neuromodulation therapy since primary sensory neurons and their soma in DRGs are important sites for pathophysiologic changes that lead to neuropathic pain. Our aim was to create evidence synthesis about the effects of electrical stimulation of DRG in the context of pain from in vitro and in vivo animal models, analyze methodology and quality of studies in the field. METHODS For conducting systematic review we searched three data bases: MEDLINE, Embase and Web of Science. The quality of included studies was assessed with the Systematic Review Centre for Laboratory Animal Experimentation risk of bias tool for animal studies. The study was registered in the Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies data base. RESULTS We included six in vitro and eight in vivo animal studies. All included in vitro studies combined neurostimulation with substances or drugs and reported an improvement in pain-related parameters due to neurostimulation. Among in vivo studies, six used pulsed radiofrequency, while two used electrical field stimulation. All in vivo studies reported improvement in pain-related behavior following stimulation. Meta-analysis was not possible because of heterogeneity and missing data. The quality of included studies was suboptimal since all had an unclear risk of bias in multiple domains. CONCLUSIONS Limited data from in vitro and in vivo animal studies indicate that electrical stimulation of DRG has a positive therapeutic effect in the context of pain-related outcomes. Further studies with a standardized methodological approach and outcomes will provide useful information about electrical stimulation of DRG in animal models.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Katarina Vučić
- Department for Quality, Safety and Efficacy Assessment of Medicinal Products, Agency for Medicinal Products and Medical Devices, Zagreb, Croatia
| | - Tihana Repić
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | | | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Livia Puljak
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia.,Department for Development, Research and Health Technology Assessment, Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, Croatia
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97
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Morgalla MH, Bolat A, Fortunato M, Lepski G, Chander BS. Dorsal Root Ganglion Stimulation Used for the Treatment of Chronic Neuropathic Pain in the Groin: A Single-Center Study With Long-Term Prospective Results in 34 Cases. Neuromodulation 2017; 20:753-760. [DOI: 10.1111/ner.12713] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 08/15/2017] [Accepted: 09/11/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Anil Bolat
- Department of Neurosurgery; University of Tuebingen; Tuebingen Germany
| | - Marcos Fortunato
- Department of Neurosurgery; University of Tuebingen; Tuebingen Germany
| | - Guilherme Lepski
- Department of Neurosurgery; University of Tuebingen; Tuebingen Germany
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98
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Wireless Neuromodulation for Chronic Back Pain: Delivery of High-Frequency Dorsal Root Ganglion Stimulation by a Minimally Invasive Technique. Case Rep Med 2017; 2017:4203271. [PMID: 29230247 PMCID: PMC5688258 DOI: 10.1155/2017/4203271] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/04/2017] [Accepted: 10/11/2017] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the analgesic effect of a dorsal root ganglion (DRG) stimulation technology utilizing high-frequency pulse rates to treat intractable chronic back and leg pain. Methods This case study presents the outcomes, with a novel, wireless, minimally invasive miniature neurostimulator system in a case of chronic back pain. The subject was implanted bilaterally with a Freedom 4A quadripolar electrode array at the L2 dorsal root ganglion. Stimulation was applied using 10 kHz pulse rate and 30 μs pulse width. A VAS pain-rating scale, Oswestry Disability Index (ODI), EQ-5D-5L Quality of Life Questionnaire 5 dimensions, and Patients' Global Impression of Change (PGIC) scale were evaluated at 12 weeks and 6 months post implantation. Results VAS pain scores for back pain reduced from 91 to 31 mms and 80 to 35 mms for leg pain. Additionally, while stimulation remained paresthesia-free, there were a marked decrease in pain medications and an increase in quality of life. Also, an increase in functionality from crippled to moderate was reported. There were no adverse reactions related to the procedure or device. Conclusion The minimally invasive, wireless approach to deliver high-frequency, paresthesia-free DRG stimulation for treatment of chronic back and leg pain associated with FBSS was effective and encouraging.
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99
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Shamji MF, De Vos C, Sharan A. The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain. Neurosurgery 2017; 80:S108-S113. [PMID: 28350939 DOI: 10.1093/neuros/nyw047] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 09/30/2016] [Indexed: 01/09/2023] Open
Abstract
Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. These procedures can be done with acceptably low morbidity and provide a cost-effective solution for those patients in whom medical therapies have failed. Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.
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Affiliation(s)
- Mohammed F Shamji
- Division of Neurosurgery, Toronto West-ern Hospital, Toronto, Canada.,Depart-ment of Surgery, University of Toronto, Toronto, Canada.,Institute of Biomate-rials and Biomedical Engineering, Uni-versity of Toronto, Toronto, Canada.,Krembil Research Institute, Toronto, Canada.,Techna Research Institute, Toronto, Canada
| | - Cecile De Vos
- Medisch Spectrum Twente hospital, Enschede, Netherlands
| | - Ashwini Sharan
- Division of Neurosurgery, Thomas Jefferson University, Philadephia, PA
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100
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Harrison C, Epton S, Bojanic S, Green AL, FitzGerald JJ. The Efficacy and Safety of Dorsal Root Ganglion Stimulation as a Treatment for Neuropathic Pain: A Literature Review. Neuromodulation 2017; 21:225-233. [PMID: 28960653 DOI: 10.1111/ner.12685] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/26/2017] [Accepted: 07/28/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Dorsal root ganglion stimulation (DRGS) received its first regulatory approval (CE marking in Europe) in late 2011, and so its use is now almost six years old. Several thousand patients have already been treated, and a landmark trial in lower limb complex regional pain syndrome (CRPS) and causalgia has recently been published. METHODS In this review we have summarized the literature to date on the use of DRGS in the treatment of neuropathic pain. RESULTS The results so far are encouraging, with reports of successful use in treating a wide range of indications including postsurgical pain, CRPS, and phantom pain. Treatment of failed back surgery syndrome (FBSS) appears less successful. The therapy is still young, and long term results are not yet available. There is now good randomized clinical trial (RCT) evidence that DRGS provides superior pain relief to spinal cord stimulation for CRPS and causalgia of the lower limb, and produces stimulation that is more posturally stable, with more precise paraesthesia coverage. However evidence of this quality for other indications and pain locations is lacking. CONCLUSION There is now Class A RCT evidence that DRGS provides superior pain relief to SCS for CRPS and causalgia of the lower limb. In the coming years we hope that randomized controlled trials will be performed on an indication-by-indication basis, which, together with the publication of longer term follow-up data, will provide a more complete understanding of the role of DRGS in the treatment of neuropathic pain syndromes.
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Affiliation(s)
- Conrad Harrison
- John Radcliffe Hospital, University of Oxford Medical Sciences Office, Oxford, UK
| | - Sarah Epton
- Vascular Research Department, St George's Hospital, London, UK
| | - Stana Bojanic
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Alexander L Green
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - James J FitzGerald
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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