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De Ridder D, Vanneste S, Smith M, Adhia D. Pain and the Triple Network Model. Front Neurol 2022; 13:757241. [PMID: 35321511 PMCID: PMC8934778 DOI: 10.3389/fneur.2022.757241] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
Acute pain is a physiological response that causes an unpleasant sensory and emotional experience in the presence of actual or potential tissue injury. Anatomically and symptomatically, chronic pathological pain can be divided into three distinct but interconnected pathways, a lateral “painfulness” pathway, a medial “suffering” pathway and a descending pain inhibitory circuit. Pain (fullness) can exist without suffering and suffering can exist without pain (fullness). The triple network model is offering a generic unifying framework that may be used to understand a variety of neuropsychiatric illnesses. It claims that brain disorders are caused by aberrant interactions within and between three cardinal brain networks: the self-representational default mode network, the behavioral relevance encoding salience network and the goal oriented central executive network. A painful stimulus usually leads to a negative cognitive, emotional, and autonomic response, phenomenologically expressed as pain related suffering, processed by the medial pathway. This anatomically overlaps with the salience network, which encodes behavioral relevance of the painful stimuli and the central sympathetic control network. When pain lasts longer than the healing time and becomes chronic, the pain- associated somatosensory cortex activity may become functionally connected to the self-representational default mode network, i.e., it becomes an intrinsic part of the self-percept. This is most likely an evolutionary adaptation to save energy, by separating pain from sympathetic energy-consuming action. By interacting with the frontoparietal central executive network, this can eventually lead to functional impairment. In conclusion, the three well-known pain pathways can be combined into the triple network model explaining the whole range of pain related co-morbidities. This paves the path for the creation of new customized and personalized treatment methods.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- *Correspondence: Dirk De Ridder
| | - Sven Vanneste
- School of Psychology, Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Mark Smith
- Neurofeedbackservices of New York, New York, NY, United States
| | - Divya Adhia
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Hagedorn JM, Falowski SM, Blomme B, Capobianco RA, Yue JJ. Burst spinal cord stimulation can attenuate pain and its affective components in chronic pain patients with high psychological distress: results from the prospective, international TRIUMPH study. Spine J 2022; 22:379-388. [PMID: 34419628 DOI: 10.1016/j.spinee.2021.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Psychological characteristics such as catastrophizing and depression have been shown to negatively impact outcome prognosis after spinal interventions. PURPOSE To evaluate whether high psychological distress, defined as clinically elevated levels of catastrophizing and depression, is associated with poorer outcomes after spinal cord stimulation utilizing a passive recharge burst stimulation design. This proprietary waveform may uniquely attenuate the emotional aspects of chronic pain given its affects on the medial pain pathway projecting to the dorsal anterior cingulate cortex and anterior insula. STUDY DESIGN/SETTINGS Data were extracted from the prospective, multi-center, single-arm, international TRIUMPH study. The purpose of TRIUMPH was to assess long-term (2 years) safety and effectiveness of spinal cord stimulation for chronic pain in the trunk and/or limbs using a passive recharge enabled burst spinal cord stimulation (B-SCS) system. PATIENT SAMPLE Two subsets of study patients were identified; those with (n=31) and those without (n=54) high psychological distress. OUTCOME MEASURES Psychological and functional outcomes as well as pain intensity and impact of pain on life were administered at baseline and all follow intervals. Additionally, patient satisfaction and patient global impression of change were assessed at all follow-up intervals. METHODS Psychological distress (PD) was defined as a baseline score of ≥ 30 on the Pain Catastrophizing Scale (PCS) and ≥ 10 on the Patient Health Questionnaire Depression scale (PHQ-9). Nondistressed (ND) patients had scores below these thresholds on both scales. All patients were implanted with a B-SCS system and completed data collection for the 24-month follow-up visit. This study was funded by Abbott. JMH is a consultant for Abbott and has received <$20,000 in lifetime consulting fees from Abbott. SMF is a consultant for Abbott and has received >$50,000 in lifetime consulting fees from Abbott. BB is an Abbott employee. RAC is a former Abbott employee. JJY is a consultant for Abbott and has received <$2,500 in lifetime consulting fees from Abbott. RESULTS Of the 128 participants with 24-month data, 31 (24%) and 54 (35%) met the criteria for PD and ND, respectively. Baseline measures indicated a more severe chronic pain profile and worse quality of life in the PD group. Two years after implant, 71% were no longer clinically catastrophizing and 58% were no longer clinically depressed. Notably, more than half of the PD patients on antidepressants discontinued or decreased their medication. Health-related quality of life was 82% higher in the PD group at 24 months, reaching levels similar to the ND group. Psychological distress did not impact outcomes after SCS therapy; composite multi-responder rates were similar in the 2 groups throughout the follow-up period. Patient reported pain relief (58% PD vs. 61% ND) was equivalent in each group. In both groups, 81% were satisfied or very satisfied with the pain relief provided. CONCLUSIONS Our results showed that B-SCS appears to be as effective in a chronic pain population with high psychological distress as in those without distress. This may be due to the unique mechanism of action with the stimulation design involving the emotional-affective medial pain pathway in the brain.
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Affiliation(s)
- Jonathan M Hagedorn
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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Endoscopic Lateral Approach for Dorsal Root Ganglion Burst Stimulation: Technical Note and Illustrative Case Series. Neuromodulation 2022; 25:1033-1039. [DOI: 10.1016/j.neurom.2021.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 09/19/2021] [Accepted: 10/11/2021] [Indexed: 11/22/2022]
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Graham RD, Sankarasubramanian V, Lempka SF. Dorsal Root Ganglion Stimulation for Chronic Pain: Hypothesized Mechanisms of Action. THE JOURNAL OF PAIN 2022; 23:196-211. [PMID: 34425252 PMCID: PMC8943693 DOI: 10.1016/j.jpain.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 07/20/2021] [Indexed: 02/03/2023]
Abstract
Dorsal root ganglion stimulation (DRGS) is a neuromodulation therapy for chronic pain that is refractory to conventional medical management. Currently, the mechanisms of action of DRGS-induced pain relief are unknown, precluding both our understanding of why DRGS fails to provide pain relief to some patients and the design of neurostimulation technologies that directly target these mechanisms to maximize pain relief in all patients. Due to the heterogeneity of sensory neurons in the dorsal root ganglion (DRG), the analgesic mechanisms could be attributed to the modulation of one or many cell types within the DRG and the numerous brain regions that process sensory information. Here, we summarize the leading hypotheses of the mechanisms of DRGS-induced analgesia, and propose areas of future study that will be vital to improving the clinical implementation of DRGS. PERSPECTIVE: This article synthesizes the evidence supporting the current hypotheses of the mechanisms of action of DRGS for chronic pain and suggests avenues for future interdisciplinary research which will be critical to fully elucidate the analgesic mechanisms of the therapy.
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Affiliation(s)
- Robert D. Graham
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Vishwanath Sankarasubramanian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Scott F. Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States,Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109, United States,Corresponding author: Scott F. Lempka, PhD, Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, NCRC 14-184, Ann Arbor, MI 48109-2800,
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Saber M, Schwabe D, Park HJ, Tessmer J, Khan Z, Ding Y, Robinson M, Hogan QH, Pawela CP. Tonic, Burst, and Burst-Cycle Spinal Cord Stimulation Lead to Differential Brain Activation Patterns as Detected by Functional Magnetic Resonance Imaging. Neuromodulation 2022; 25:53-63. [PMID: 35041588 DOI: 10.1111/ner.13460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The objective of this preclinical study was to examine the responses of the brain to noxious stimulation in the presence and absence of different modes of spinal cord stimulation (SCS) using blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD-fMRI). MATERIALS AND METHODS Sprague-Dawley rats were randomized to groups based on the mode of SCS delivered which included tonic stimulation (n = 27), burst stimulation (n = 30), and burst-cycle stimulation (n = 29). The control (sham) group (n = 28) received no SCS. The SCS electrode was inserted between T10 and T12 spinal levels prior to fMRI session. The experimental protocol for fMRI acquisition consisted of an initial noxious stimulation phase, a treatment phase wherein the SCS was turned on concurrently with noxious stimulation, and a residual effect phase wherein the noxious stimulation alone was turned on. The responses were statistically analyzed through paired t-test and the results were presented as z-scores for the quantitative analysis of the fMRI data. RESULTS The treatment with different SCS modes attenuated the BOLD brain responses to noxious hindlimb stimulation. The tonic, burst, and burst-cycle SCS treatment attenuated BOLD responses in the caudate putamen (CPu), insula (In), and secondary somatosensory cortex (S2). There was little to no corresponding change in sham control in these three regions. The burst and burst-cycle SCS demonstrated greater attenuation of BOLD signals in CPu, In, and S2 compared to tonic stimulation. CONCLUSION The high-resolution fMRI study using a rat model demonstrated the potential of different SCS modes to act on several pain-matrix-related regions of the brain in response to noxious stimulation. The burst and burst-cycle SCS exhibited greater brain activity reduction in response to noxious hindlimb stimulation in the caudate putamen, insula, and secondary somatosensory cortex compared to tonic stimulation.
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Affiliation(s)
- Mohammad Saber
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Schwabe
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - John Tessmer
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zan Khan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yujie Ding
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Maraika Robinson
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Quinn H Hogan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Intermittent Dorsal Root Ganglion Stimulation Is as Efficacious as Standard Continuous Dosing in Treating Chronic Pain: Results From a Randomized Controlled Feasibility Trial. Neuromodulation 2022; 25:989-997. [DOI: 10.1016/j.neurom.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022]
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Rigoard P, Roulaud M, Goudman L, Adjali N, Ounajim A, Voirin J, Perruchoud C, Bouche B, Page P, Guillevin R, Naudin M, Simoneau M, Lorgeoux B, Baron S, Nivole K, Many M, Maitre I, Rigoard R, David R, Moens M, Billot M. Comparison of Spinal Cord Stimulation vs. Dorsal Root Ganglion Stimulation vs. Association of Both in Patients with Refractory Chronic Back and/or Lower Limb Neuropathic Pain: An International, Prospective, Randomized, Double-Blinded, Crossover Trial (BOOST-DRG Study). MEDICINA (KAUNAS, LITHUANIA) 2021; 58:7. [PMID: 35056316 PMCID: PMC8780129 DOI: 10.3390/medicina58010007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 12/25/2022]
Abstract
While spinal cord stimulation (SCS) is a well-established therapy to address refractory persistent spinal pain syndrome after spinal surgery (PSPS-T2), its lack of spatial selectivity and reported discomfort due to positional effects can be considered as significant limitations. As alternatives, new waveforms, such as burst stimulation and different spatial neural targets, such as dorsal root ganglion stimulation (DRGS), have shown promising results. Comparisons between DRGS and standard SCS, or their combination, have never been studied on the same patients. "BOOST DRG" is the first prospective, randomized, double-blinded, crossover study to compare SCS vs. DRGS vs. SCS+DRGS. Sixty-six PSPS-T2 patients will be recruited internationally in three centers. Before crossing over, patients will receive each stimulation modality for 1 month, using tonic conventional stimulation. After 3 months, stimulation will consist in switching to burst for 1 month, and patients will choose which modality/waveform they receive and will then be reassessed at 6 and 12 months. In addition to our primary outcome based on pain rating, this study is designed to assess quality of life, functional disability, psychological distress, pain surface coverage, global impression of change, medication quantification, adverse events, brain functional imaging and electroencephalography, with the objective being to provide a multidimensional insight based on composite pain assessment.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
- Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France;
- Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360 Chasseneuil-du-Poitou, France
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium; (L.G.); (M.M.)
- STUMULUS Research Group, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Nihel Adjali
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Jimmy Voirin
- Department of Neurosurgery, Hopitaux Civils de Colmar, 68000 Colmar, France;
| | - Christophe Perruchoud
- Service of Anesthesiology and Pain Centre, University Hospital of Lausanne (CHUV), 1011 Lausanne, Switzerland;
| | - Bénédicte Bouche
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
- Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France;
| | - Philippe Page
- Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France;
| | - Rémy Guillevin
- Department of Radiology, Poitiers University Hospital, 86021 Poitiers, France; (R.G.); (M.N.)
- UMR CNRS 7348, DACTIM-MIS/LMA Laboratory, University of Poitiers, 86000 Poitiers, France
| | - Mathieu Naudin
- Department of Radiology, Poitiers University Hospital, 86021 Poitiers, France; (R.G.); (M.N.)
- UMR CNRS 7348, DACTIM-MIS/LMA Laboratory, University of Poitiers, 86000 Poitiers, France
| | - Martin Simoneau
- Department of Kinesiology, Faculty of Medicine, Laval University, Quebec, QC G1V 0A6, Canada;
- Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale (CIRRIS), Quebec, QC G1M 2S8, Canada
| | - Bertille Lorgeoux
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Sandrine Baron
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Kevin Nivole
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Mathilde Many
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Iona Maitre
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
| | - Raphaël Rigoard
- CEA Cadarache, Département de Support Technique et Gestion, Service des Technologies de l’Information et de la Communication, 13108 Saint-Paul-Lez-Durance, France;
| | - Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
- Department of Physical and Rehabilitation Medicine, Poitiers University Hospital, University of Poitiers, 86021 Poitiers, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium; (L.G.); (M.M.)
- STUMULUS Research Group, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (M.R.); (N.A.); (A.O.); (B.B.); (B.L.); (S.B.); (K.N.); (M.M.); (I.M.); (R.D.); (M.B.)
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Malinowski MN, Chopra PR, Tieppo Francio V, Budwany R, Deer TR. A narrative review and future considerations of spinal cord stimulation, dorsal root ganglion stimulation and peripheral nerve stimulation. Curr Opin Anaesthesiol 2021; 34:774-780. [PMID: 34608057 DOI: 10.1097/aco.0000000000001072] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW In recent years, neuromodulation has experienced a renaissance. Novel waveforms and anatomic targets show potential improvements in therapy that may signify substantial benefits. New innovations in peripheral nerve stimulation and dorsal root ganglion stimulation have shown prospective evidence and sustainability of results. Sub-perception physiologic bursting, high-frequency stimulation and feedback loop mechanisms provide significant benefits over traditional tonic spinal cords stimulation (SCS) in peer reviewed investigations. We reviewed the themes associated with novel technology in the context of historical stalwart publications. RECENT FINDINGS New innovations have led to better nerve targeting, improvements in disease-based treatment, and opioid alternatives for those in chronic pain. In addition, new neural targets from both structural and cellular perspectives have changed the field of Neurostimulation. SUMMARY For many years, tonic SCS was representative of neuromodulation, but as this review examines, the progression of the field in the past decade has reshaped patient options.
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Affiliation(s)
- Mark N Malinowski
- OhioHealth Grant Medical Center, Ohio University Heritage COM, Columbus, Ohio
| | | | - Vinicius Tieppo Francio
- The University of Kansas Medical Center, Department of Rehabilitative Medicine, Kansas City, Kansas
| | - Ryan Budwany
- Center for Integrative Pain Management, West Virginia University School of Medicine, Morgantown
| | - Timothy Ray Deer
- The Spine and Nerve Center of The Virginias
- Anesthesiology and Pain Medicine, WVU School of Medicine
- American Society of Pain and Neuroscience, Charleston, West Virginia, USA
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Tinnirello A, Mazzoleni S, Santi C. Chronic Pain in the Elderly: Mechanisms and Distinctive Features. Biomolecules 2021; 11:biom11081256. [PMID: 34439922 PMCID: PMC8391112 DOI: 10.3390/biom11081256] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Chronic pain is a major issue affecting more than 50% of the older population and up to 80% of nursing homes residents. Research on pain in the elderly focuses mainly on the development of clinical tools to assess pain in patients with dementia and cognitive impairment or on the efficacy and tolerability of medications. In this review, we searched for evidence of specific pain mechanisms or modifications in pain signals processing either at the cellular level or in the central nervous system. Methods: Narrative review. Results: Investigation on pain sensitivity led to conflicting results, with some studies indicating a modest decrease in age-related pain sensitivity, while other researchers found a reduced pain threshold for pressure stimuli. Areas of the brain involved in pain perception and analgesia are susceptible to pathological changes such as gliosis and neuronal death and the effectiveness of descending pain inhibitory mechanisms, particularly their endogenous opioid component, also appears to deteriorate with advancing age. Hyperalgesia is more common at older age and recovery from peripheral nerve injury appears to be delayed. In addition, peripheral nociceptors may contribute minimally to pain sensation at either acute or chronic time points in aged populations. Conclusions: Elderly subjects appear to be more susceptible to prolonged pain development, and medications acting on peripheral sensitization are less efficient. Pathologic changes in the central nervous system are responsible for different pain processing and response to treatment. Specific guidelines focusing on specific pathophysiological changes in the elderly are needed to ensure adequate treatment of chronic pain conditions.
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Affiliation(s)
- Andrea Tinnirello
- Anesthesiology and Pain Medicine Department, ASST Franciacorta, Ospedale di Iseo, 25049 Iseo, Italy
- Correspondence: ; Tel.: +39-030-7103-395
| | - Silvia Mazzoleni
- Second Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Piazzale Spedali Civili 1, 25100 Brescia, Italy; (S.M.); (C.S.)
| | - Carola Santi
- Second Division of Anesthesiology, Intensive Care & Emergency Medicine, University of Brescia at Spedali Civili Hospital, Piazzale Spedali Civili 1, 25100 Brescia, Italy; (S.M.); (C.S.)
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Niso G, Tjepkema-Cloostermans MC, Lenders MWPM, de Vos CC. Modulation of the Somatosensory Evoked Potential by Attention and Spinal Cord Stimulation. Front Neurol 2021; 12:694310. [PMID: 34413825 PMCID: PMC8369157 DOI: 10.3389/fneur.2021.694310] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/07/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction: Spinal Cord Stimulation (SCS) is a last-resort treatment for patients with intractable chronic pain in whom pharmacological and other treatments have failed. Conventional tonic SCS is accompanied by tingling sensations. More recent stimulation protocols like burst SCS are not sensed by the patient while providing similar levels of pain relief. It has been previously reported that conventional tonic SCS can attenuate sensory-discriminative processing in several brain areas, but that burst SCS might have additional effects on the medial, motivational-affective pain system. In this explorative study we assessed the influence of attention on the somatosensory evoked brain responses under conventional tonic SCS as well as burst SCS regime. Methods: Twelve chronic pain patients with an implanted SCS device had 2-weeks evaluation periods with three different SCS settings (conventional tonic SCS, burst SCS, and sham SCS). At the end of each period, an electro-encephalography (EEG) measurement was done, at which patients received transcutaneous electrical pulses at the tibial nerve to induce somatosensory evoked potentials (SEP). SEP data was acquired while patients were attending the applied pulses and while they were mind wandering. The effects of attention as well as SCS regimes on the SEP were analyzed by comparing amplitudes of early and late latencies at the vertex as well as brain activity at full cortical maps. Results: Pain relief obtained by the various SCS settings varied largely among patients. Early SEP responses were not significantly affected by attention nor SCS settings (i.e., burst, tonic, and sham). However, late SEP responses (P300) were reduced with tonic and burst SCS: conventional tonic SCS reduced P300 brain activity in the unattended condition, while burst SCS reduced P300 brain activity in both attended and unattended conditions. Conclusion: Burst spinal cord stimulation for the treatment of chronic pain seems to reduce cortical attention that is or can be directed to somatosensory stimuli to a larger extent than conventional spinal cord stimulation treatment. This is a first step in understanding why in selected chronic pain patients burst SCS is more effective than tonic SCS and how neuroimaging could assist in personalizing SCS treatment.
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Affiliation(s)
- Guiomar Niso
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Psychological & Brain Sciences, Indiana University, Bloomington, IN, United States.,ETSI Telecomunicación, Universidad Politécnica de Madrid and Center for Biomedical Research Network CIBER-BBN, Madrid, Spain
| | - Marleen C Tjepkema-Cloostermans
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Clinical Neurophysiology, Institute for Technical Medicine, University of Twente, Enschede, Netherlands
| | - Mathieu W P M Lenders
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Cecile C de Vos
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands.,Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
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61
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De Ridder D, Adhia D, Vanneste S. The anatomy of pain and suffering in the brain and its clinical implications. Neurosci Biobehav Rev 2021; 130:125-146. [PMID: 34411559 DOI: 10.1016/j.neubiorev.2021.08.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 02/08/2023]
Abstract
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Chronic pain, with a prevalence of 20-30 % is the major cause of human suffering worldwide, because effective, specific and safe therapies have yet to be developed. It is unevenly distributed among sexes, with women experiencing more pain and suffering. Chronic pain can be anatomically and phenomenologically dissected into three separable but interacting pathways, a lateral 'painfulness' pathway, a medial 'suffering' pathway and a descending pain inhibitory pathway. One may have pain(fullness) without suffering and suffering without pain(fullness). Pain sensation leads to suffering via a cognitive, emotional and autonomic processing, and is expressed as anger, fear, frustration, anxiety and depression. The medial pathway overlaps with the salience and stress networks, explaining that behavioural relevance or meaning determines the suffering associated with painfulness. Genetic and epigenetic influences trigger chronic neuroinflammatory changes which are involved in transitioning from acute to chronic pain. Based on the concept of the Bayesian brain, pain (and suffering) can be regarded as the consequence of an imbalance between the two ascending and the descending pain inhibitory pathways under control of the reward system. The therapeutic clinical implications of this simple pain model are obvious. After categorizing the working mechanisms of each of the available treatments (pain killers, psychopharmacology, psychotherapy, neuromodulation, psychosurgery, spinal cord stimulation) to 1 or more of the 3 pathways, a rational combination can be proposed of activating the descending pain inhibitory pathway in combination with inhibition of the medial and lateral pathway, so as to rebalance the pain (and suffering) pathways.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Divya Adhia
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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62
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Electrochemical Skin Conductance Alterations during Spinal Cord Stimulation: An Experimental Study. J Clin Med 2021; 10:jcm10163565. [PMID: 34441864 PMCID: PMC8397194 DOI: 10.3390/jcm10163565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
Despite the well-known clinical effects of spinal cord stimulation (SCS), the mechanisms of action have not yet been fully unraveled. The primary aim of this study was to measure whether electrochemical skin conductance, as a measure of peripheral sympathetic autonomic function, is altered by SCS. A second aim was to compare skin conductance levels of patients with failed back surgery syndrome (FBSS) with age- and sex-matched healthy controls. Twenty-three patients with FBSS treated with SCS participated in this study. Sudomotor function was measured with the SudoscanTM instrument on the hands and feet during SCS on and off states. Difference scores in skin conductance between patients and age- and sex-matched healthy controls were calculated. Normal sudomotor function at the painful lower limb was revealed for 61% of the patients when SCS was activated. Skin conductance levels were not altered between on and off states of SCS. Differences in scores between patients and healthy controls were significantly different from zero. This study showed that SCS does not influencing the sympathetic nervous system in patients with FBSS, as measured by skin conductance levels. Moreover, it suggested that there is no normalization of the functioning of the sympathetic nervous system, despite the effectiveness of SCS to reduce pain intensity.
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63
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Deer T, Wilson D, Schultz D, Falowski S, Tavel E, Moore G, Heros R, Patterson D, Fahey M, Capobianco R, Anitescu M. Ultra-Low Energy Cycled Burst Spinal Cord Stimulation Yields Robust Outcomes in Pain, Function, and Affective Domains: A Subanalysis From Two Prospective, Multicenter, International Clinical Trials. Neuromodulation 2021; 25:137-144. [PMID: 34315191 DOI: 10.1111/ner.13507] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION DeRidder's burst stimulation design has become a key spinal cord stimulation (SCS) waveform because it reduces the intensity of pain as well as its associated emotional distress. The brain pathways underlying these outcomes may also allow for the effects of stimulation to carry over after stimulation is turned off, making it amenable to intermittent application. Here, the utility of intermittently cycled burst was evaluated using data from two large real-world prospective studies (TRIUMPH, REALITY). MATERIALS AND METHODS Subjects used intermittent dosing in a 1:3 ratio (30 sec on, 90 sec off; N = 100) in TRIUMPH and 1:12 ratio in REALITY (30-sec on, 360-sec off; N = 95) for six months. Pain intensity (0-10 numeric rating scale), pain-related emotions on the pain catastrophizing scale (PCS), and physical function on PROMIS questionnaires were compared with preimplant baseline ratings and by group. RESULTS In both groups, mean pain intensity decreased by nearly 50% relative to baseline, PCS scores significantly decreased, and physical function improved. Importantly, no differences between the 1:3 and 1:12 groups were identified. A high proportion, 80% and 77% of the 1:3 and 1:12 groups, respectively, were considered responders on a multiple measures. No adverse events were associated with intermittent stimulation. DISCUSSION Intermittent cycling of burst SCS lowers the overall electric charge delivered to the spinal cord and preserves battery consumption, without compromising pain relief and associated symptoms.
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Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Derron Wilson
- Goodman Campbell Brain and Spine, St. Vincent Health, Indianapolis, IN, USA
| | | | | | - Ed Tavel
- Pain Specialists of Charleston, Charleston, SC, USA
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64
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Nissen M, Ikäheimo TM, Huttunen J, Leinonen V, Jyrkkänen HK, von Und Zu Fraunberg M. Gabapentinoids Associated With Lower Explantation Rate in 203 Patients With Spinal Cord Stimulation for Failed Back Surgery Syndrome. Neurosurgery 2021; 89:626-634. [PMID: 34270731 PMCID: PMC8632751 DOI: 10.1093/neuros/nyab242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/08/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Spinal cord stimulation (SCS) is an effective treatment in failed back surgery syndrome (FBSS). The effect of neuropathic pain medication use on SCS outcome is poorly understood. OBJECTIVE To study the effect of gabapentinoid use on SCS outcome measured by trial success, explantation rate and opioid dose reduction during a 2-yr follow-up. METHODS The study cohort included 203 consecutive FBSS patients who underwent SCS in a single tertiary center during January 1997 to March 2014. Purchase data of gabapentinoids, opioids, tricyclic antidepressants, serotonin and noradrenaline reuptake inhibitors, and benzodiazepines during January 1995 to March 2016 were retrieved from national registries. RESULTS In multivariate Cox regression analysis, patients using gabapentinoids had significantly fewer explantations during the 2-yr follow-up (hazard ratio [HR] 0.2, 95% CI 0.04-0.81, P = .03). In contrast, patients with opioid use of >40 morphine milligram equivalent before implantation had significantly more explantations (HR 6.7, 95% CI 2.5-18, P < .01). In bivariate logistic regression analysis adjusted for patient specific factors, year of SCS implantation, use of neuropathic pain medication, opioids, and benzodiazepines, patients using gabapentinoids significantly more often discontinued opioids or reduced their dose by more than 50% during the 2-yr follow-up (odds ratio 5.7, 95% CI 1.4-23, P = .015). CONCLUSION The use of gabapentinoids was associated with a significantly lower spinal cord stimulator explantation rate and a higher chance of opioid discontinuation or >50% dose reduction. This indicates that patients with SCS could benefit from concomitant use of gabapentinoids. Prospective randomized trials are warranted to verify this hypothesis.
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Affiliation(s)
- Mette Nissen
- Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Faculty of Health Sciences, School of Medicine Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | - Tiina-Mari Ikäheimo
- Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Jukka Huttunen
- Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Ville Leinonen
- Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Faculty of Health Sciences, School of Medicine Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland
| | | | - Mikael von Und Zu Fraunberg
- Neurosurgery of KUH NeuroCenter, Kuopio University Hospital, Kuopio, Finland.,Faculty of Health Sciences, School of Medicine Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland
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65
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Exploration of the Supraspinal Hypotheses about Spinal Cord Stimulation and Dorsal Root Ganglion Stimulation: A Systematic Review. J Clin Med 2021; 10:jcm10132766. [PMID: 34201877 PMCID: PMC8268298 DOI: 10.3390/jcm10132766] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/19/2021] [Accepted: 06/20/2021] [Indexed: 12/27/2022] Open
Abstract
Despite the established efficacy and effectiveness of Spinal Cord Stimulation (SCS), there is still no consensus on the supraspinal mechanisms of action of this therapy. The purpose of this study was to systematically review previously raised hypotheses concerning supraspinal mechanisms of action of SCS based on human, animal and computational studies. Searches were conducted using four electronic databases (PubMed, EMBASE, SCOPUS and Web of Science), backward reference searching and consultation with experts. The study protocol was registered prior to initiation of the review process (PROSPERO CRD42020161531). A total of 54 publications were included, 21 of which were animal studies, and 33 were human studies. The supraspinal hypotheses (n = 69) identified from the included studies could be categorized into six groups concerning the proposed supraspinal hypothesis, namely descending pathways (n = 24); ascending medial pathway (n = 13); ascending lateral pathway (n = 10); affective/motivational influences (n = 8); spinal–cerebral (thalamic)-loop (n = 3) and miscellaneous (n = 11). Scientific support is provided for the hypotheses identified. Modulation of the descending nociceptive inhibitory pathways, medial and lateral pathways were the most frequently reported hypotheses about the supraspinal mechanisms of action of SCS. These hypotheses were mainly supported by studies with a high or moderate confidence in the body of evidence.
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66
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Yu G, Segel I, Tran H, Park HJ, Ross E, Hogan QH, Pan B. Analgesic Effects of Tonic and Burst Dorsal Root Ganglion Stimulation in Rats With Painful Tibial Nerve Injury. Neuromodulation 2021; 25:970-979. [PMID: 34096146 DOI: 10.1111/ner.13472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/06/2021] [Accepted: 05/17/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Dorsal root ganglion (DRG) stimulation is effective in treating chronic pain. While burst stimulation has been proven to enhance the therapeutic efficacy in spinal cord stimulation, currently only a tonic stimulation waveform is clinically used in DRG stimulation. We hypothesized that burst DRG stimulation might also produce analgesic effect in a preclinical neuropathic pain model. We evaluated both the therapeutic effects of burst DRG stimulation and the possible effects of DRG stimulation upon inflammation within the DRG in a preclinical neuropathic pain model. MATERIALS AND METHODS Rats received either a painful tibial nerve injury or sham surgery. Analgesic effects of DRG stimulation were evaluated by testing a battery of evoked pain-related behaviors as well as measuring the positive affective state associated with relief of spontaneous pain using conditioned place preference. Histological evidence for neuronal trauma or neuroinflammation was evaluated. RESULTS All of the waveforms tested (20 Hz-tonic, 20 Hz-burst, and 40 Hz-burst) have similar analgesic effects in sensory tests and conditioned place preference. Long-term DRG stimulation for two weeks does not change DRG expression of markers for nerve injury and neuroinflammation. CONCLUSIONS DRG stimulation using burst waveform might be also suitable for treating neuropathic pain.
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Affiliation(s)
- Guoliang Yu
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Ian Segel
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Hai Tran
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | | | - Erika Ross
- Abbott Neuromodulation, Plano, TX, 75024, USA
| | - Quinn H Hogan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Bin Pan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
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67
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Lee KS, Jang YK, Park GH, Jun IJ, Koh JC. Successful application of burst spinal cord stimulation for refractory upper limb pain: a case series. J Int Med Res 2021; 49:3000605211004035. [PMID: 33788644 PMCID: PMC8020113 DOI: 10.1177/03000605211004035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Spinal cord stimulation (SCS) has been used to treat sustained pain that is
intractable despite various types of treatment. However, conventional tonic
waveform SCS has not shown promising outcomes for spinal cord injury (SCI) or
postamputation pain. The pain signal mechanisms of burst waveforms are different
to those of conventional tonic waveforms, but few reports have presented the
therapeutic potential of burst waveforms for the abovementioned indications.
This current case report describes two patients with refractory upper limb pain
after SCI and upper limb amputation that were treated with burst waveform SCS.
While the patients could not obtain sufficient therapeutic effect with
conventional tonic waveforms, the burst waveforms provided better pain reduction
with less discomfort. However, further studies are necessary to better clarify
the mechanisms and efficacy of burst waveform SCS in patients with intractable
pain.
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Affiliation(s)
- Kuen Su Lee
- Department of Anaesthesiology and Pain Medicine, Eulji University Uijeongbu Eulji Medical Centre, Uijeongbu, Republic of Korea
| | - Yoo Kyung Jang
- Department of Anaesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Gene Hyun Park
- Department of Anaesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - In Jae Jun
- Department of Anaesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jae Chul Koh
- Department of Anaesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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68
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Spinal cord stimulation in chronic neuropathic pain: mechanisms of action, new locations, new paradigms. Pain 2021; 161 Suppl 1:S104-S113. [PMID: 33090743 PMCID: PMC7434213 DOI: 10.1097/j.pain.0000000000001854] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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69
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Deer TR, Eldabe S, Falowski SM, Huntoon MA, Staats PS, Cassar IR, Crosby ND, Boggs JW. Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. J Pain Res 2021; 14:721-736. [PMID: 33737830 PMCID: PMC7966353 DOI: 10.2147/jpr.s297091] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is an effective tool for the treatment of chronic pain, although its efficacy and utilization have previously been significantly limited by technology. In recent years, purpose-built percutaneous PNS devices have been developed to overcome the limitations of conventional permanently implanted neurostimulation devices. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period, outcomes that have not previously been observed with conventional permanently implanted neurostimulation devices. This narrative review summarizes mechanistic processes that contribute to chronic pain, and the potential mechanisms by which selective large diameter afferent fiber activation may reverse these changes to induce a prolonged reduction in pain. The interplay of these mechanisms, supported by data in chronic pain states that have been effectively treated with percutaneous PNS, will also be discussed in support of a new theory of pain management in neuromodulation: Peripherally Induced Reconditioning of the Central Nervous System (CNS).
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Steven M Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Marc A Huntoon
- Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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70
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Petrou PA, Leong MS, Mackey SC, Salmasi V. Stanford Pragmatiec Effectiveness Comparison (SPEC) protocol: Comparing long-term effectiveness of high-frequency and burst spinal cord stimulation in real-world application. Contemp Clin Trials 2021; 103:106324. [PMID: 33621631 DOI: 10.1016/j.cct.2021.106324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/17/2021] [Accepted: 02/14/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES High-frequency and burst stimulation are newer waveforms that have demonstrated promise compared to traditional tonic spinal cord stimulation (SCS), but more studies are needed to compare their effectiveness. We report the study methods for an ongoing, single center, pragmatic randomized clinical trial to compare the effectiveness of high-frequency and burst SCS in patients with chronic back and/or leg pain. MATERIALS AND METHODS Participants who are candidates for spinal cord stimulation are enrolled and screened. Participants will be randomly assigned using point-of-care randomization to receive either high-frequency or burst SCS. Data collection will be through Stanford Pain Management Center's learning healthcare system: CHOIR. CHOIR surveys include National Institutes of Health Patient Reported Outcomes Measurement Information System item banks, a body map, questions about pain intensity, pain catastrophizing scale, and questions about patients' pain experience and healthcare utilization. Participants will complete online surveys at baseline and then 1, 3, 6, 12, 18, 24 and 36 months after their device implant. All participants will use our routine process of trial and implant. Reported adverse events are monitored throughout the study. Our primary outcome is change from baseline in pain intensity at 12 months. RESULTS We hypothesize that high-frequency SCS is more effective than burst SCS in improving pain, physical function and pain interference in participants with chronic low back and/or leg pain. CONCLUSIONS The pragmatic nature of our proposed trial enables us to recruit a larger participant cohort faster and to follow up these participants longer than currently published clinical trials.
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Affiliation(s)
- Philip Anthony Petrou
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA
| | - Michael S Leong
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA
| | - Sean C Mackey
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA
| | - Vafi Salmasi
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, USA.
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71
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Vanneste S, De Ridder D. Chronic pain as a brain imbalance between pain input and pain suppression. Brain Commun 2021; 3:fcab014. [PMID: 33758824 PMCID: PMC7966784 DOI: 10.1093/braincomms/fcab014] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 12/20/2022] Open
Abstract
Chronic pain is pain that persists beyond the expected period of healing. The subjective experience of chronic pain results from pathological brain network interactions, rather than from persisting physiological sensory input of nociceptors. We hypothesize that pain is an imbalance between pain evoking dorsal anterior cingulate cortex and somatosensory cortex and pain suppression (i.e. pregenual anterior cingulate cortex). This imbalance can be measured objectively by current density ratios between pain input and pain inhibition. A balance between areas involved in pain input and pain suppression requires communication, which can be objectively identified by connectivity measures, both functional and effective connectivity. In patients with chronic neuropathic pain, electroencephalography is performed with source localization demonstrating that pain is reflected by an abnormal ratio between the dorsal anterior cingulate cortex, somatosensory cortex and pregenual anterior cingulate cortex. Functional connectivity demonstrates decreased communication between these areas, and effective connectivity puts the culprit at the dorsal anterior cingulate cortex, suggesting that the problem is related to abnormal behavioral relevance attached to the pain. In conclusion, chronic pain can be considered as an imbalance between pain input and pain suppression.
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Affiliation(s)
- Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, 9016 Dunedin, New Zealand
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72
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Karri J, Palmer JS, Charnay A, Garcia C, Orhurhu V, Shah S, Abd-Elsayed A. Utility of Electrical Neuromodulation for Treating Chronic Pain Syndromes in the Pediatric Setting: A Systematic Review. Neuromodulation 2021; 25:671-679. [PMID: 33556220 DOI: 10.1111/ner.13365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Chronic pain syndromes in children can carry significant threats to psychological well-being, opioid overuse, functional impairments, and severe disability. While several high-level studies, almost exclusively in adults, have demonstrated the utility of implantable electrical neuromodulation systems for treating various chronic pain syndromes, there exists a paucity of pediatric-specific evidence. Unfortunately, evidence and practice patterns established from adults may not be fully translatable to children given differences in disease manifestations and anatomical variances. MATERIALS AND METHODS We performed a systematic review using conventional PRISMA methodology to identify studies reporting use of implantable electrical neuromodulation systems in children. The primary outcome parameters collected were analgesic relief and functional benefits. Additionally, previous interventions attempted, neuromodulation parameters, and limitations were collected as reported. RESULTS A total of 11 studies was identified, which described 19 patients who were refractory to multidisciplinary pain management strategies. The cohort was mostly adolescent (18/19), suffered from CRPS (14/19), and received SCS (17/19). Nearly all patients, both those with CRPS (13/14) and non-CRPS conditions (4/4), reported significant pain relief and functional recovery following neuromodulation. There were no severe complications reported; limitations included suboptimal benefit or loss of analgesia (3/19), lead or device revision (3/19), and subcutaneous infection (1/19), all of which were congruent with adult outcomes. CONCLUSION There exist children with chronic pain refractory to standard of care approaches who could be considered for neuromodulation interventions. The existing data, which was limited and from a low tier of evidence, suggest that these interventions are relatively safe and provide meaningful pain reduction and functional improvements. While not previously reported, we recommend careful consideration of the pubertal growth spurt prior to device lead placement-if reasonable and appropriate-given the possibility of inferior lead migration with physiologic growth in patients with SCS devices or foraminal extrusion in patients with dorsal root ganglion stimulation devices.
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Affiliation(s)
- Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Jeremé Sharíf Palmer
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Aaron Charnay
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Carol Garcia
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Vwaire Orhurhu
- Department of Anesthesia, Division of Pain Medicine, University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA
| | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, Division of Pain Medicine, University of California Irvine, Orange, CA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Multicentre, clinical trial of burst spinal cord stimulation for neck and upper limb pain NU-BURST: a trial protocol. Neurol Sci 2021; 42:3285-3296. [PMID: 33387056 DOI: 10.1007/s10072-020-04907-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain and most frequently utilised for Failed Back Surgery Syndrome (FBSS). BurstDR™ also known as DeRidder Burst-SCS, a novel waveform, has demonstrated superiority to conventional tonic stimulation of the thoracic spine in FBSS. There are case reports of an improvement in multidimensional pain outcomes using DeRidder Burst-SCS in the cervical spine for chronic neck and cervical radicular pain. The safety and efficacy of cervical DeRidder Burst-SCS stimulation still however remain undetermined. METHODS/DESIGN This is a prospective, multicentre feasibility trial evaluating the safety and therapeutic efficacy of DeRidder Burst-SCS stimulation for the treatment of chronic intractable neck pain with or without radiation to the arm, shoulder, and upper back. After baseline evaluation, subjects will undergo an SCS trial using the Abbott Invisible Trial system according to standard clinical procedures. During the trial phase, SCS leads will be implanted in the cervical epidural space. At the end of the SCS trial, subjects experiencing at least 50% pain relief will be considered for permanent implant. Pain intensity, medication usage, and other multidimensional pain outcomes will be collected. The timing of these will be at baseline, end of the SCS trial and at 3-, 6-, and 12-month visits. Incidence of adverse events will be collected throughout the study duration. DISCUSSION The results of this feasibility study will validate the efficacy and safety of DeRidder Burst-SCS stimulation in the cervical spine. The results obtained in this study will potentially be used to generate a level 1 evidence-based study with formal statistical hypotheses testing. TRIAL REGISTRATION www.clinicaltrials.gov Identifier: NCT03159169.
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74
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Vallejo R, Gupta A, Cedeno DL, Vallejo A, Smith WJ, Thomas SM, Benyamin R, Kaye AD, Manchikanti L. Clinical Effectiveness and Mechanism of Action of Spinal Cord Stimulation for Treating Chronic Low Back and Lower Extremity Pain: a Systematic Review. Curr Pain Headache Rep 2020; 24:70. [PMID: 32997170 DOI: 10.1007/s11916-020-00907-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW The purpose of the present systematic review is to provide a current understanding of the mechanism of action and the evidence available to support clinical decision-making. The focus is to summarize randomized controlled trials (RCTs) and nonrandomized or observational studies of spinal cord stimulation in chronic pain to understand clinical effectiveness and the mechanism of action. RECENT FINDINGS Several recent studies have demonstrated the benefit of spinal cord stimulation in managing chronic pain. Until recently, the mechanism of action was founded on a central paradigm derived from gate control theory, which is the need to stimulate the dorsal column of the spinal cord to generate paresthesia. The recent development of new therapies that do not rely on paresthesia has left the field without a clear mechanism of action that could serve as a strong foundation to further improve clinical outcomes. Consequently, multiple theories have emerged to explain how electrical pulse applied to the spinal cord could alleviate pain, including activation of specific supraspinal pathways, and segmental modulation of the neurological interaction. Recent systematic reviews also have shown the clinical effectiveness of spinal cord stimulation in managing chronic spinal pain, phantom limb pain, complex regional pain syndrome, and other chronic painful conditions. Spinal cord stimulation for the treatment of chronic pain is rapidly evolving with technology at its forefront. This comprehensive focused review evaluated 11 RCTs and 7 nonrandomized/observational studies which provided levels of evidence ranging from I to II.
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Affiliation(s)
- Ricardo Vallejo
- Millennium Pain Center - National Spine and Pain Centers, 2406 E Empire, Bloomington, IL, 61704, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,SGX Medical LLC, Bloomington, IL, USA
| | - Ashim Gupta
- South Texas Orthopaedic Research Institute, Laredo, TX, USA.,BioIntegrate, 2505 Newpoint Pkwy Suite 100-A, Lawrenceville, GA, USA.,Future Biologics, Lawrenceville, GA, USA
| | - David L Cedeno
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA. .,SGX Medical LLC, Bloomington, IL, USA. .,Lumbrera LLC, 2406 E Empire, Bloomington, IL, 61704, USA.
| | - Alejandro Vallejo
- Lumbrera LLC, 2406 E Empire, Bloomington, IL, 61704, USA.,Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - William J Smith
- Lumbrera LLC, 2406 E Empire, Bloomington, IL, 61704, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Samuel M Thomas
- College of Osteopathic Medicine, Des Moines University, Des Moines, IA, USA
| | - Ramsin Benyamin
- Millennium Pain Center - National Spine and Pain Centers, 2406 E Empire, Bloomington, IL, 61704, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,College of Medicine, University of Illinois, Urbana-Champaign, IL, USA
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Science Center, 1542 Tulane Ave Room 659, New Orleans, LA, 70112, USA.,Department of Pharmacology, LSU Health Science Center, 1542 Tulane Ave Room 659, New Orleans, LA, 70112, USA
| | - Laxmaiah Manchikanti
- Pain Management Centers of America, Management Center of Paducah, 67 Lakeview Dr., Paducah, KY, 42001, USA.,Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA.,Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, New Orleans, LA, USA
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75
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Buentjen L, Vicheva P, Chander BS, Beccard SA, Coutts C, Azañón E, Stenner MP, Deliano M. Spatial Filtering of Electroencephalography Reduces Artifacts and Enhances Signals Related to Spinal Cord Stimulation (SCS). Neuromodulation 2020; 24:1317-1326. [PMID: 32969569 DOI: 10.1111/ner.13266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/05/2020] [Accepted: 07/25/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES How spinal cord stimulation (SCS) in its different modes suppresses pain is poorly understood. Mechanisms of action may reside locally in the spinal cord, but also involve a larger network including subcortical and cortical brain structures. Tonic, burst, and high-frequency modes of SCS can, in principle, entrain distinct temporal activity patterns in this network, but finally have to yield specific effects on pain suppression. Here, we employ high-density electroencephalography (EEG) and recently developed spatial filtering techniques to reduce SCS artifacts and to enhance EEG signals specifically related to neuromodulation by SCS. MATERIALS AND METHODS We recorded high-density resting-state EEGs in patients suffering from pain of various etiologies under different modes of SCS. We established a pipeline for the robust spectral analysis of oscillatory brain activity during SCS, which includes spatial filtering for attenuation of pulse artifacts and enhancement of brain activity potentially modulated by SCS. RESULTS In sensor regions responsive to SCS, neuromodulation strongly reduced activity in the theta and low alpha range (6-10 Hz) in all SCS modes. Results were consistent in all patients, and in accordance with thalamocortical dysrhythmia hypothesis of pain. Only in the tonic mode showing paresthesia as side effect, SCS also consistently and strongly reduced high-gamma activity (>84 Hz). CONCLUSIONS EEG spectral analysis combined with spatial filtering allows for a spatially and temporally specific assessment of SCS-related, neuromodulatory EEG activity, and may help to disentangle therapeutic and side effects of SCS.
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Affiliation(s)
- Lars Buentjen
- Department of Stereotactic Neurosurgery, University Hospital, Magdeburg, Germany
| | - Petya Vicheva
- Translational Behavioral Physiology Group, Combinatorial Neuroimaging Core Facility (CNI), Leibniz Institute for Neurobiology (LIN), Magdeburg, Germany
| | - B S Chander
- AG Physiology of Motor Control, Department of Behavioral Neurology, LIN, Magdeburg, Germany
| | | | - Christopher Coutts
- Department of Stereotactic Neurosurgery, University Hospital, Magdeburg, Germany
| | - Elena Azañón
- Somatosensory & Body Lab, Department of Psychology, Otto-von-Guericke-University, Magdeburg, Germany
| | - Max-Philipp Stenner
- AG Physiology of Motor Control, Department of Behavioral Neurology, LIN, Magdeburg, Germany
| | - Matthias Deliano
- Translational Behavioral Physiology Group, Combinatorial Neuroimaging Core Facility (CNI), Leibniz Institute for Neurobiology (LIN), Magdeburg, Germany
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76
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De Groote S, Goudman L, Van Schuerbeek P, Peeters R, Sunaert S, Linderoth B, De Andrés J, Rigoard P, De Jaeger M, Moens M. Effects of spinal cord stimulation on voxel-based brain morphometry in patients with failed back surgery syndrome. Clin Neurophysiol 2020; 131:2578-2587. [PMID: 32927213 DOI: 10.1016/j.clinph.2020.07.024] [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: 05/22/2020] [Revised: 06/30/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Despite the clinical effectiveness of Spinal Cord Stimulation (SCS), potential structural brain modifications have not been explored. Our aim was to identify structural volumetric changes during subsensory SCS, in patients with Failed Back Surgery Syndrome (FBSS). METHODS In this cohort study, twenty-two FBSS patients underwent a magnetic resonance imaging protocol before SCS and 3 months after SCS. Clinical parameters were correlated with volumetric changes, calculated with voxel-based morphometry. RESULTS After 3 months, a significant volume decrease was found in the inferior frontal gyrus, precuneus, cerebellar posterior lobe and middle temporal gyrus. Significant increases were found in the inferior temporal gyrus, precentral gyrus and the middle frontal gyrus after SCS. Additionally, significant increases in volume of superior frontal and parietal white matter and a significant decrease in volume of white matter underlying the premotor/middle frontal gyrus were revealed after SCS. A significant correlation was highlighted between white matter volume underlying premotor/middle frontal gyrus and leg pain relief. CONCLUSIONS This study revealed for the first time that SCS is able to induce volumetric changes in gray and white matter, suggesting the reversibility of brain alterations after chronic pain treatment. SIGNIFICANCE Volumetric brain alterations are observable after 3 months of subsensory SCS in FBSS patients.
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Affiliation(s)
- Sander De Groote
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.; Pain in Motion International Research Group, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Peter Van Schuerbeek
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Ronald Peeters
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ Herestraat 49-bus 7003 54, 3000 Leuven, Belgium
| | - Stefan Sunaert
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ Herestraat 49-bus 7003 54, 3000 Leuven, Belgium
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jose De Andrés
- Surgical Specialties Department Valencia University Medical School, and Department of Anesthesiology Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | - Philippe Rigoard
- Department of Neurosurgery, Poitiers University Hospital, Poitiers, France; Institut Pprime UPR 3346, CNRS, University of Poitiers, Poitiers, ISAE-ENSMA, France; PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.; Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium.
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77
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Sclafani J, Leong M, Desai MJ, Mehta N, Sayed D, Singh JR. Conventional versus High-Frequency Neuromodulation in the Treatment of Low Back Pain Following Spine Surgery. PM R 2020; 11:1346-1353. [PMID: 31648418 DOI: 10.1002/pmrj.12270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022]
Affiliation(s)
| | - Michael Leong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Mehul J Desai
- International Spine, Pain & Performance Center, George Washington University, Washington, DC
| | - Neel Mehta
- Departmet of Anesthestiology, Division of Pain Medicine, Weill Cornell Medicine, New York, NY
| | - Dawood Sayed
- Department of Anesthesiology, Medical Director of Spine Center, University of Kansas, Kansas City, KS
| | - Jaspal R Singh
- Department of Rehabilitation Medicine, Weill Cornell Center for Comprehensive Spine Care, Weill Cornell Medicine, New York, NY
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78
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De Ridder D, Vanneste S. The Bayesian brain in imbalance: Medial, lateral and descending pathways in tinnitus and pain: A perspective. PROGRESS IN BRAIN RESEARCH 2020; 262:309-334. [PMID: 33931186 DOI: 10.1016/bs.pbr.2020.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Tinnitus and pain share similarities in their anatomy, pathophysiology, clinical picture and treatments. Based on what is known in the pain field, a heuristic model can be proposed for the pathophysiolgy of tinnitus. This heuristic pathophysiological model suggests that pain and tinnitus are the consequence of an imbalance between two pain/tinnitus evoking pathways, i.e., a lateral sensory pathway and a medial affective pathway, both of which are not balanced anymore by a pain/noise inhibitory pathway. Mechanistically, based on the Bayesian brain concept, it can be explained by a switch occuring under influence of the rostral to dorsal anterior cingulate cortex of its prior predictions, i.e., a reference resetting, in which the pain/tinnitus state is considered as the new reference state. This reference resetting is confirmed by the nucleus accumbens as part of the reward system and maintained by connectivity changes between the nucleus accumbens and the pregenual anterior cingulate cortex. As a consequence it can be suggested to treat pain/tinnitus via reconditioning, either surgically or non-surgically. The model can also be used to develop objective measures for tinnitus and pain via supervised machine learning.
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Affiliation(s)
- Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Sven Vanneste
- Global Brain Health Institute & Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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79
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Billot M, Naiditch N, Brandet C, Lorgeoux B, Baron S, Ounajim A, Roulaud M, Roy-Moreau A, de Montgazon G, Charrier E, Misbert L, Maillard B, Vendeuvre T, Rigoard P. Comparison of conventional, burst and high-frequency spinal cord stimulation on pain relief in refractory failed back surgery syndrome patients: study protocol for a prospective randomized double-blinded cross-over trial (MULTIWAVE study). Trials 2020; 21:696. [PMID: 32746899 PMCID: PMC7397663 DOI: 10.1186/s13063-020-04587-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 07/06/2020] [Indexed: 12/15/2022] Open
Abstract
Background While the evolution of technology provides new opportunities to manage chronic refractory pain using different waveform modalities of spinal cord stimulation in failed back surgery syndrome (FBSS), there is no randomized controlled trial available to compare the efficacy of these different stimulations waveforms to date. MULTIWAVE is a prospective, randomized, double-blinded, crossover trial study designed to compare the clinical efficacy of tonic conventional stimulation (TCS), burst stimulation (BURST) and high-frequency stimulation (HF) in FBSS patients over a 15-month period in SCS implanted patients. Methods/design Twenty-eight patients will be recruited in the Poitiers University Hospital, in Niort and La Rochelle Hospitals in France. Eligible patients with post-operative low back and leg pain with an average visual analog scale (VAS) score ≥ 5 for low back pain are implanted and randomly assigned to one of the six arms (in a 1:1:1:1:1:1 ratio), where they receive a 3-month combination of TCS, BURST and HF including one treatment modality per month and varying the order of the modality received within the six possible combinations. Patients receiving intrathecal drug delivery, peripheral nerve stimulation and back resurgery related to the original back pain complaint and experimental therapies are excluded from this study. Patients included in the spinal cord stimulation group undergo trial stimulation, and they all receive a TCS treatment for 2 months, as the gold standard modality. Thereafter, patients are randomly assigned to one of the six arms for the total duration of 3-month crossover period. Then, patients choose their preferred stimulation modality (TCS, BURST, or HF) for the follow-up period of 12 months. Outcome assessments are performed at baseline (first implant), before randomization (2 months after baseline) and at 1, 2, 3, 6, 9 and 15 months post-randomization. Our primary outcome is the average global VAS of pain over 5-day pain diary period between baseline and after each period of stimulation. Additional outcomes include changes in leg and back pain intensity, functional disability, quality of life, psychological state, paraesthesia intensity perception, patient satisfaction and the number of adverse events. Discussion Recruitment began in February 2017 and will continue through 2019. Trial registration Clinicaltrials.gov NCT03014583. Registered on 9 January 2017.
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Affiliation(s)
- Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Nicolas Naiditch
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Claire Brandet
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Bertille Lorgeoux
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Sandrine Baron
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | | | | | - Elodie Charrier
- Pain Management and Research Centre, Poitiers University School of Medicine, Poitiers, France
| | - Lorraine Misbert
- Pain Management and Research Centre, Poitiers University School of Medicine, Poitiers, France
| | - Benjamin Maillard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Tanguy Vendeuvre
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France.,Spine and Neuromodulation Functional Unit, Poitiers University Hospital, Poitiers, France.,Institut Pprime UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Poitiers, France.,Department of Orthopaedic Surgery and Traumatology, Poitiers University Hospital, Poitiers, France.,ABS Lab, University of Poitiers, Poitiers, France
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France. .,Spine and Neuromodulation Functional Unit, Poitiers University Hospital, Poitiers, France. .,Institut Pprime UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Poitiers, France.
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80
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Falowski SM, Moore GA, Cornidez EG, Hutcheson JK, Candido K, Peña I, Blomme B, Capobianco RA. Improved Psychosocial and Functional Outcomes and Reduced Opioid Usage Following Burst Spinal Cord Stimulation. Neuromodulation 2020; 24:581-590. [PMID: 32583937 PMCID: PMC8247278 DOI: 10.1111/ner.13226] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022]
Abstract
Objective Burst spinal cord stimulation (B‐SCS) has been shown to reduce neuronal firing in the anterior cingulate cortex through selective modulation of the medial pain pathway tract. This pain pathway communicates the affective component of pain processing. The purpose of this study was to assess the effect of B‐SCS on psychosocial functioning and its influence on pain and quality of life. Materials and Methods Eligible patients with chronic, intractable pain of the trunk, and/or lower limbs were enrolled. After a successful trial period, subjects received a permanent implant and returned for follow‐up at 6‐ and 12‐months. Results In total, 269 patients were enrolled at 22 centers. Trial success rate was 90%. Significant improvements in pain, physical, mental, and emotional functioning were observed from baseline to the 6‐ and 12‐month follow‐up (p < 0.001). Overall, patients had improved quality of life, became more active, and the negative impact of pain on daily life was decreasing. At one year, 81% of subjects were satisfied or very satisfied with their therapy. Subjects showing significant improvements on mental health outcomes reported enhanced pain relief and quality of life scores compared with subjects with continued impaired mental health at follow‐up. At one year, 89% of subjects who were taking opioids at baseline decreased or stayed at the same level of opioid use; 19% stopped taking any opioids. No unanticipated adverse events have been reported. Conclusions One‐year outcomes after B‐SCS show improvements across all evaluated psychological measures with the largest impact observed on catastrophizing and depression (the affective component of pain processing). These pain‐related beliefs and behaviors, and not pain intensity, have been shown to put patients at greatest risk of a poor prognosis and quality of life.
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Affiliation(s)
| | | | | | | | | | - Isaac Peña
- Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Bram Blomme
- Abbott (formerly St Jude Medical), Austin, TX, USA
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81
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Hagedorn JM, Engle AM, Ghosh P, R. Deer T. Device profile of the Proclaim XR neurostimulation system for the treatment of chronic pain: an overview of its safety and efficacy. Expert Rev Med Devices 2020; 17:499-505. [DOI: 10.1080/17434440.2020.1773258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Jonathan M. Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic , Rochester, MN, USA
| | - Alyson M. Engle
- Pain Medicine Fellow, Department of Anesthesiology, University of Pittsburgh School of Medicine , Pittsburgh, PA, USA
| | - Priyanka Ghosh
- Pain Medicine Fellow, Department of Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medicine , New York, NY, USA
| | - Timothy R. Deer
- Department of Anesthesiology and Pain Medicine, The Spine and Nerve Center of the Virginias , Charleston, WV, USA
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82
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Heijmans L, Joosten EA. Mechanisms and mode of action of spinal cord stimulation in chronic neuropathic pain. Postgrad Med 2020; 132:17-21. [PMID: 32403963 DOI: 10.1080/00325481.2020.1769393] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Tonic spinal cord stimulation (SCS) has been used as a treatment for chronic neuropathic pain ever since its discovery in late 1960s. Despite its clinical successes in a subset of chronic neuropathic pain syndromes, several limitations such as insufficient pain relief and uncomfortable paresthesias have led to the development of new targets, the dorsal root ganglion, and new stimulation waveforms, such as burst and high frequency. The aim of this review is to provide a brief overview of the main mechanisms behind the mode of action of the different SCS paradigms. Tonic SCS mainly acts via a segmental spinal mechanism where it induces GABA-release from inhibitory interneurons in the spinal dorsal horn. Tonic SCS concurrently initiates neuropathic pain modulation through a supraspinal-spinal feedback loop and serotonergic descending fibers. Mechanisms of stimulation of the DRG as well as those related to new SCS paradigms are now under investigation, where it seems that burst SCS not only stimulates sensory, discriminative aspects of pain (like Tonic SCS) but also emotional, affective, and motivational aspects of pain. Initial long-term study results on closed-loop SCS systems hold promise for improvement of future SCS treatment.
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Affiliation(s)
- Lonne Heijmans
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre , Maastricht, the Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University , Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre , Maastricht, the Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University , Maastricht, the Netherlands
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83
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Sheldon BL, Khazen O, Feustel PJ, Gechtman G, Rosoklija G, Patel S, DiMarzio M, Bridger C, Dentinger R, Slyer J, Pilitsis JG. Correlations Between Family History of Psychiatric Illnesses and Outcomes of Spinal Cord Stimulation. Neuromodulation 2020; 23:667-672. [DOI: 10.1111/ner.13162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Breanna L. Sheldon
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Paul J. Feustel
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Guy Gechtman
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Gavril Rosoklija
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Shrey Patel
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | | | - Rachel Dentinger
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Julia Slyer
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
| | - Julie G. Pilitsis
- Department of Neuroscience and Experimental Therapeutics Albany Medical Center Albany NY USA
- Department of Neurosurgery Albany Medical Center Albany NY USA
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84
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Royds J, Conroy MJ, Dunne MR, Cassidy H, Matallanas D, Lysaght J, McCrory C. Examination and characterisation of burst spinal cord stimulation on cerebrospinal fluid cellular and protein constituents in patient responders with chronic neuropathic pain - A Pilot Study. J Neuroimmunol 2020; 344:577249. [PMID: 32361148 DOI: 10.1016/j.jneuroim.2020.577249] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/11/2020] [Accepted: 04/21/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Patients with neuropathic pain have altered proteomic and neuropeptide constituents in cerebrospinal fluid (CSF) compared to controls. Tonic spinal cord stimulation (SCS) has demonstrated differential expression of neuropeptides in CSF before and after treatment suggesting potential mechanisms of action. Burst-SCS is an evidence-based paraesthesia free waveform utilised for neuropathic pain with a potentially different mechanistic action to tonic SCS. This study examines the dynamic biological changes of CSF at a cellular and proteome level after Burst-SCS. METHODS Patients with neuropathic pain selected for SCS had CSF sampled prior to implant of SCS and following 8 weeks of continuous Burst-SCS. Baseline and 8-week pain scores with demographics were recorded. T cell frequencies were analysed by flow cytometry, proteome analysis was performed using mass spectrometry and secreted cytokines, chemokines and neurotrophins were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS 4 patients (2 females, 2 males) with a mean age of 51 years (+/-SEM 2.74, SD 5.48) achieved a reduction in pain of >50% following 8 weeks of Burst-SCS. Analysis of the CSF proteome indicated a significant alteration in protein expression most related to synapse assembly and immune regulators. There was significantly lower expression of the proteins: growth hormone A1 (PRL), somatostatin (SST), nucleobindin-2 (NUCB2), Calbindin (CALB1), acyl-CoA binding protein (DBI), proSAAS (PCSK1N), endothelin-3 (END3) and cholecystokinin (CCK) after Burst-SCS. The concentrations of secreted chemokines and cytokines and the frequencies of T cells were not significantly changed following Burst-SCS. CONCLUSION This study characterised the alteration in the CSF proteome in response to burst SCS in vivo. Functional analysis indicated that the alterations in the CSF proteome is predominately linked to synapse assembly and immune effectors. Individual protein analysis also suggests potential supraspinal mechanisms.
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Affiliation(s)
- Jonathan Royds
- Department of Pain Medicine, St. James Hospital, Dublin and School of Medicine, Trinity College Dublin, Ireland.
| | - Melissa J Conroy
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital and Trinity College Dublin, Dublin 8, Ireland
| | - Margaret R Dunne
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital and Trinity College Dublin, Dublin 8, Ireland
| | - Hilary Cassidy
- Systems Biology Ireland, School of Medicine, University College Dublin, Dublin 4, Ireland
| | - David Matallanas
- Systems Biology Ireland, School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Joanne Lysaght
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital and Trinity College Dublin, Dublin 8, Ireland
| | - Connail McCrory
- Department of Pain Medicine, St. James Hospital, Dublin and School of Medicine, Trinity College Dublin, Ireland
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85
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Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. Burst Spinal Cord Stimulation: A Clinical Review. PAIN MEDICINE 2020; 20:S31-S40. [PMID: 31152175 PMCID: PMC6544556 DOI: 10.1093/pm/pnz003] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective Clinical review on outcomes using burst spinal cord stimulation (SCS) in the treatment of chronic, intractable pain. Design Narrative clinical literature review conducted utilizing a priori search terms including key words for burst spinal cord stimulation. Synthesis and reporting of data from publications including an overview of comparative SCS outcomes. Results Burst SCS demonstrated greater pain relief over tonic stimulation in multiple studies, which included blinded, sham-controlled, randomized trials. Additionally, burst stimulation impacts multiple dimensions of pain, including somatic pain as well as emotional and psychological elements. Patient preference is weighted toward burst over tonic due to increased pain relief, a lack of paresthesias, and impression of change in condition. Conclusion Burst SCS has been shown to be both statistically and clinically superior to tonic stimulation and may provide additional benefits through different mechanisms of action. Further high-quality controlled studies are warranted to not only elucidate the basic mechanisms of burst SCS but also address how this unique stimulation signature/pattern may more adequately handle the multiple affective dimensions of pain in varying patient populations.
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Affiliation(s)
- Terje Kirketeig
- Multidisciplinary Pain Clinic, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Carsten Schultheis
- Departement für Interventionelle Schmerzmedizin, Krankenhaus Neuwerk "Maria von den Aposteln" Muskulo-Skeletales Zentrum Mönchengladbach, Germany
| | - Xander Zuidema
- Department of Anesthesiology and Pain Management, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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86
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Fishman MA, Antony A, Esposito M, Deer T, Levy R. The Evolution of Neuromodulation in the Treatment of Chronic Pain: Forward-Looking Perspectives. PAIN MEDICINE 2020; 20:S58-S68. [PMID: 31152176 PMCID: PMC6600066 DOI: 10.1093/pm/pnz074] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The field of neuromodulation is continually evolving, with the past decade showing significant advancement in the therapeutic efficacy of neuromodulation procedures. The continued evolution of neuromodulation technology brings with it the promise of addressing the needs of both patients and physicians, as current technology improves and clinical applications expand. Design This review highlights the current state of the art of neuromodulation for treating chronic pain, describes key areas of development including stimulation patterns and neural targets, expanding indications and applications, feedback-controlled systems, noninvasive approaches, and biomarkers for neuromodulation and technology miniaturization. Results and Conclusions The field of neuromodulation is undergoing a renaissance of technology development with potential for profoundly improving the care of chronic pain patients. New and emerging targets like the dorsal root ganglion, as well as high-frequency and patterned stimulation methodologies such as burst stimulation, are paving the way for better clinical outcomes. As we look forward to the future, neural sensing, novel target-specific stimulation patterns, and approaches combining neuromodulation therapies are likely to significantly impact how neuromodulation is used. Moreover, select biomarkers may influence and guide the use of neuromodulation and help objectively demonstrate efficacy and outcomes.
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Affiliation(s)
| | | | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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87
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Chakravarthy K, Malayil R, Kirketeig T, Deer T. Burst Spinal Cord Stimulation: A Systematic Review and Pooled Analysis of Real-World Evidence and Outcomes Data. PAIN MEDICINE 2020; 20:S47-S57. [PMID: 31152177 PMCID: PMC6544549 DOI: 10.1093/pm/pnz046] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective This review provides a comprehensive assessment of the effectiveness of burst spinal cord stimulation (SCS). Ratings of pain intensity (visual analog scale or numeric rating scale) and patient-reported outcomes (PROs) on functional/psychometric domains such as depression (Beck Depression Index), catastrophizing (Pain Catastrophizing Scale), surveillance (Pain Vigilance and Attention Questionnaire), and others are addressed. Design Articles were identified and selected from the literature according to prospective, replicable methods. Effectiveness data—pain scores and PRO ratings—were weighted by study sample sizes and pooled. The effects of burst SCS were compared against values at baseline and with tonic SCS. For PROs, published population norms were used for comparison. Results Fifteen articles, with a combined sample size of 427, were included. Follow-up ranged from a few hours to two years. A variety of prospective designs were employed, including crossover studies, single-arm cohorts, and a randomized controlled trial, as well as retrospective case reports. The weighted pooled mean pain rating across articles at baseline was 76.7 (±27.4). With tonic SCS, this was reduced to 49.2 (±12.9), and with burst SCS it was further reduced to 36.7 (±11.6), a 12.5-point difference between tonic and burst values. Psychometric analyses of PROs noted preferential improvement with burst SCS. In addition, 65% of subjects stated a preference for burst SCS. Conclusions In pooled analyses that incorporated all available published evidence, the improvement over baseline for burst SCS was shown to have a clinically important incremental benefit over tonic SCS. In addition, burst SCS may support resolution of the emotional or cognitive aspects of pain that are mediated by medial thalamo-cortical pathways. This study highlights the value in considering the entire knowledge base in therapeutic assessments as well as adopting a consistent set of outcome variables within neuromodulation. Burst SCS is a valuable intervention, providing both analgesia and psychometric benefits that warrant further thoughtful applications.
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Affiliation(s)
| | - Rudy Malayil
- St. Mary's Pain Relief Specialists, Huntington, West Virginia
| | - Terje Kirketeig
- Multidisciplinary Pain Clinic, Uppsala University Hospital, Uppsala, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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88
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De Ridder D, Vancamp T, Falowski SM, Vanneste S. All bursts are equal, but some are more equal (to burst firing): burstDR stimulation versus Boston burst stimulation. Expert Rev Med Devices 2020; 17:289-295. [PMID: 32129099 DOI: 10.1080/17434440.2020.1736560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Since the introduction of burst spinal cord stimulation for neuropathic pain, several companies have developed their own version of burst stimulation, which is confusing the marketplace and clinicians of what burst stimulation truly is, the value and utilization of the therapy.Areas covered: We review those two burst stimulation designs and notice important differences. The original burstDRTM stimulation tries to mimic physiologic burst firing, which involves closely spaced high frequency sodium spikes nested on a calcium mediated plateau. This is realized by generating a train of 5 monophasic spikes of increasing amplitude with passive charge balance after the last spike, in contrast to the other burst designs which involve a version of cycling 4-5 spikes each being individually actively charge balanced spikes.Expert opinion: Based on the neurobiology of burst firing as well as abductive reasoning we like to clarify that burstDRTM is a true physiologic burst stimulation, and that other versions being called burst stimulation are essentially clustered tonic stimulation. This differentiating terminology will prevent confusion for healthcare providers, regulators, and the marketplace of what burst stimulation is.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | | | | | - Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.,Lab for Clinical and Integrative Neuroscience, School for Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
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89
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Meuwissen KPV, van der Toorn A, Gu JW, Zhang TC, Dijkhuizen RM, Joosten EAJ. Active Recharge Burst and Tonic Spinal Cord Stimulation Engage Different Supraspinal Mechanisms: A Functional Magnetic Resonance Imaging Study in Peripherally Injured Chronic Neuropathic Rats. Pain Pract 2020; 20:510-521. [PMID: 32124540 DOI: 10.1111/papr.12879] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To assess the supraspinal working mechanisms of the burst spinal cord stimulation (SCS) mode, we used functional magnetic resonance imaging (fMRI) in chronic neuropathic rats. We hypothesized that active recharge burst SCS would induce a more profound blood oxygenation level-dependent (BOLD) signal increase in areas associated with cognitive-emotional aspects of pain, as compared to tonic SCS. METHODS Sprague Dawley rats (n = 17) underwent a unilateral partial sciatic nerve ligation, which resulted in chronic neuropathic pain. Quadripolar SCS electrodes were epidurally positioned on top of the dorsal columns at Th13. Isoflurane-anesthetized (1.5%) rats received either tonic SCS (n = 8) or burst SCS (n = 9) at 66% of motor threshold. BOLD fMRI was conducted before, during, and after SCS using a 9.4-T horizontal bore scanner. RESULTS Overall, both tonic and burst SCS induced a significant increase of BOLD signal levels in areas associated with the location and intensity of pain, and areas associated with cognitive-emotional aspects of pain. Additionally, burst SCS significantly increased BOLD signal levels in the raphe nuclei, nucleus accumbens, and caudate putamen. Tonic SCS did not induce a significant increase in BOLD signal levels in these areas. CONCLUSIONS In conclusion, active recharge burst and tonic SCS have different effects on the intensity and localization of SCS-induced activation responses in the brain. This work demonstrates that active recharge burst is another waveform that can engage brain areas associated with cognitive-emotional aspects of pain as well as areas associated with location and intensity of pain. Previous studies showing similar engagement used only passive recharge burst.
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Affiliation(s)
- Koen P V Meuwissen
- Department of Anesthesiology and Pain Management, Pain Management and Research Centre, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Annette van der Toorn
- Biomedical MR Imaging and Spectroscopy group, Center for Image Sciences, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jianwen Wendy Gu
- Boston Scientific, Neuromodulation Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Tianhe C Zhang
- Boston Scientific, Neuromodulation Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy group, Center for Image Sciences, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Pain Management and Research Centre, 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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90
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Richter B, Novik Y, Bergman JJ, Tomycz ND. The Efficacy of BurstDR Spinal Cord Stimulation for Chronic Abdominal Pain: A Clinical Series. World Neurosurg 2020; 138:77-82. [PMID: 32105875 DOI: 10.1016/j.wneu.2020.02.075] [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: 12/02/2019] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic abdominal pain is a debilitating condition known for its multifactorial nature. Outcomes with spinal cord stimulation (SCS) for abdominal pain syndromes are noticeably absent in the literature. To date, there have been no published reports of novel waveforms of SCS for management of chronic abdominal pain. We assessed the efficacy and durability of BurstDR SCS in reducing abdominal pain and analgesic consumption. CASE DESCRIPTION We performed a retrospective review of medical records from 3 patients with different etiologies of abdominal pain (postherniorrhaphy pain syndrome, Crohn disease, abdominal neuropathy). All patients underwent thoracic laminectomy for BurstDR SCS paddle lead and pulse generator placement after a successful trial stimulation period. Data were collected with a telephone survey after a minimum duration of >24 months following implantation. Pain scores were measured using a numeric rating scale. Two of 3 patients were entirely pain-free and reported Patient Global Impression of Change scores of 7 after a minimum follow-up of >24 months. While the third patient continued to have chronic as well as episodic abdominal pain, he was able to discontinue all narcotic pain medications and experienced a 33% decrease in frequency and 60% decrease in severity of monthly pain exacerbations. He reported satisfaction and a Patient Global Impression of Change of 6. CONCLUSIONS BurstDR SCS is a new programming modality, and long-term follow-up is necessary to determine its durability. Despite varying etiologies of abdominal pain, this series suggests BurstDR SCS sustained for >2 years might be effective as a treatment for abdominal pain syndromes. Future studies of SCS would benefit from standardized abdominal pain scores and high-powered studies using global patient registries.
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Affiliation(s)
- Bertram Richter
- Department of Neurosurgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Yuri Novik
- Department of Neurosurgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.
| | - Jeffry J Bergman
- Department of Neurosurgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Nestor D Tomycz
- Department of Neurosurgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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91
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Pahapill PA, Chen G, Arocho-Quinones EV, Nencka AS, Li SJ. Functional connectivity and structural analysis of trial spinal cord stimulation responders in failed back surgery syndrome. PLoS One 2020; 15:e0228306. [PMID: 32074111 PMCID: PMC7029839 DOI: 10.1371/journal.pone.0228306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 01/13/2020] [Indexed: 01/02/2023] Open
Abstract
Background Chronic pain has been associated with alterations in brain structure and function that appear dependent on pain phenotype. Functional connectivity (FC) data on chronic back pain (CBP) is limited and based on heterogeneous pain populations. We hypothesize that failed back surgery syndrome (FBSS) patients being considered for spinal cord stimulation (SCS) therapy have altered resting state (RS) FC cross-network patterns that 1) specifically involve emotion and reward/aversion functions and 2) are related to pain scores. Methods RS functional MRI (fMRI) scans were obtained for 10 FBSS patients who are being considered for but who have not yet undergone implantation of a permanent SCS device and 12 healthy age-matched controls. Seven RS networks were analyzed including the striatum (STM). The Wilcoxon signed-rank test evaluated differences in cross-network FC strength (FCS). Differences in periaqueductal grey (PAG) FC were assessed with seed-based analysis. Results Cross-network FCS was decreased (p<0.05) between the STM and all other networks in these FBSS patients. There was a negative linear relationship (R2 = 0.76, p<0.0022) between STMFCS index and pain scores. The PAG showed decreased FC with network elements and amygdala but increased FC with the sensorimotor cortex and cingulate gyrus. Conclusions Decreased FC between STM and other RS networks in FBSS has not been previously reported. This STMFCS index may represent a more objective measure of chronic pain specific to FBSS which may help guide patient selection for SCS and subsequent management.
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Affiliation(s)
- Peter A. Pahapill
- Department of Neurosurgery, U.S. Department of Veterans Affairs Medical Center, Milwaukee, Wisconsin, United States of America
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Guangyu Chen
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Elsa V. Arocho-Quinones
- Department of Neurosurgery, U.S. Department of Veterans Affairs Medical Center, Milwaukee, Wisconsin, United States of America
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Andrew S. Nencka
- Center for Imaging Research, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Shi-Jiang Li
- Department of Biophysics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
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92
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Quindlen-Hotek JC, Kent AR, De Anda P, Kartha S, Benison AM, Winkelstein BA. Changes in Neuronal Activity in the Anterior Cingulate Cortex and Primary Somatosensory Cortex With Nonlinear Burst and Tonic Spinal Cord Stimulation. Neuromodulation 2020; 23:594-604. [PMID: 32027444 DOI: 10.1111/ner.13116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/20/2019] [Accepted: 01/02/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although nonlinear burst and tonic SCS are believed to treat neuropathic pain via distinct pain pathways, the effectiveness of these modalities on brain activity in vivo has not been investigated. This study compared neuronal firing patterns in the brain after nonlinear burst and tonic SCS in a rat model of painful radiculopathy. METHODS Neuronal activity was recorded in the ACC or S1 before and after nonlinear burst or tonic SCS on day 7 following painful cervical nerve root compression (NRC) or sham surgery. The amplitude of nonlinear burst SCS was set at 60% and 90% motor threshold to investigate the effect of lower amplitude SCS on brain activity. Neuronal activity was recorded during and immediately following light brush and noxious pinch of the paw. Change in neuron firing was measured as the percent change in spikes post-SCS relative to pre-SCS baseline. RESULTS ACC activity decreases during brush after 60% nonlinear burst compared to tonic (p < 0.05) after NRC and compared to 90% nonlinear burst (p < 0.04) and pre-SCS baseline (p < 0.03) after sham. ACC neuron activity decreases (p < 0.01) during pinch after 60% and 90% nonlinear burst compared to tonic for NRC. The 60% of nonlinear burst decreases (p < 0.02) ACC firing during pinch in both groups compared to baseline. In NRC S1 neurons, tonic SCS decreases (p < 0.01) firing from baseline during light brush; 60% nonlinear burst decreases (p < 0.01) firing from baseline during brush and pinch. CONCLUSIONS Nonlinear burst SCS reduces firing in the ACC from a painful stimulus; a lower amplitude nonlinear burst appears to have the greatest effect. Tonic and nonlinear burst SCS may have comparable effects in S1.
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Affiliation(s)
| | | | - Patrisia De Anda
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Sonia Kartha
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Beth A Winkelstein
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.,Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
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93
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Spinal Stimulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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94
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Leong SL, De Ridder D, Deer T, Vanneste S. Potential Therapeutic Effect of Low Amplitude Burst Spinal Cord Stimulation on Pain. Neuromodulation 2019; 24:574-580. [PMID: 31854070 DOI: 10.1111/ner.13090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/02/2019] [Accepted: 11/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The SUNBURST Study, a USA-based controlled cross-over trial demonstrated that burst spinal cord stimulation was superior compared to tonic stimulation in suppressing chronic intractable pain. However, when on burst stimulation, participants preferred lower to higher amplitudes. This led to the hypothesis that lower burst amplitudes will correlate with lower pain scores while higher amplitudes will be associated with higher pain scores. OBJECTIVE To investigate correlations between burst amplitude and self-reported pain and different psychosocial measures. MATERIALS AND METHODS One hundred participants in the SUNBURST study were randomized to receive burst or tonic stimulation, each for 12 weeks in a cross-over manner. Complete data of 99 participants were used in this secondary analysis. Pearson correlations were conducted at 6-, 12-, 18-, and 24-weeks postactivation to determine the strength of linear relationships between burst amplitude and (1) the average seven-day daily pain Visual Analogue Scale (VAS), (2) the different domains of the Pain Catastrophizing Scale (PCS), (3) the different domains of the SF-36v2 (Quality Metric Incorporated, Lincoln, RI) Health Survey. In addition, correlations between tonic stimulation amplitude and the above-mentioned outcome measures were examined. RESULTS Significant positive correlations were identified between burst amplitude and total, "worst," and "trunk" pain for VAS; all domains for PCS; and "Role-Physical," "Bodily Pain," and "General Health" for SF-36v2™ after 12-weeks of burst stimulation. CONCLUSIONS In burst spinal cord stimulation, in contrast to tonic stimulation, lower amplitudes are more effective in suppressing pain than high amplitudes.
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Affiliation(s)
- Sook Ling Leong
- Trinity Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sven Vanneste
- Trinity Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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De Groote S, Goudman L, Peeters R, Linderoth B, Van Schuerbeek P, Sunaert S, De Jaeger M, De Smedt A, De Andrés J, Moens M. The influence of High Dose Spinal Cord Stimulation on the descending pain modulatory system in patients with failed back surgery syndrome. NEUROIMAGE-CLINICAL 2019; 24:102087. [PMID: 31795057 PMCID: PMC6978217 DOI: 10.1016/j.nicl.2019.102087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 11/04/2019] [Accepted: 11/09/2019] [Indexed: 12/22/2022]
Abstract
For the first time, the influence of HD-SCS on the descending pathways was tested. rsfMRI and functional connectivity were used to evaluate this a priori hypothesis. HD-SCS does influence the descending pain modulatory system.
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Affiliation(s)
- Sander De Groote
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium; Pain in Motion International Research Group, www.paininmotion.be and Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ronald Peeters
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ Herestraat 49-bus 7003, Leuven 3000, Belgium
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Peter Van Schuerbeek
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium
| | - Stefan Sunaert
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ Herestraat 49-bus 7003, Leuven 3000, Belgium
| | - Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium
| | - Ann De Smedt
- Department of Neurology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium
| | - José De Andrés
- Surgical Specialties Department Valencia University Medical School, Department of Anesthesiology Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels 1090, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, Brussels 1090, Belgium.
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96
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Meuwissen KPV, de Vries LE, Gu JW, Zhang TC, Joosten EAJ. Burst and Tonic Spinal Cord Stimulation Both Activate Spinal GABAergic Mechanisms to Attenuate Pain in a Rat Model of Chronic Neuropathic Pain. Pain Pract 2019; 20:75-87. [PMID: 31424152 PMCID: PMC7004135 DOI: 10.1111/papr.12831] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/28/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Experimental and clinical studies have shown that tonic spinal cord stimulation (SCS) releases gamma-aminobutyric acid (GABA) in the spinal dorsal horn. Recently, it was suggested that burst SCS does not act via spinal GABAergic mechanisms. Therefore, we studied spinal GABA release during burst and tonic SCS, both anatomically and pharmacologically, in a well-established chronic neuropathic pain model. METHODS Animals underwent partial sciatic nerve ligation (PSNL). Quantitative immunohistochemical (IHC) analysis of intracellular GABA levels in the lumbar L4 to L6 dorsal spinal cord was performed after 60 minutes of burst, tonic, or sham SCS in rats that had undergone PSNL (n = 16). In a second pharmacological experiment, the effects of intrathecal administration of the GABAA antagonist bicuculline (5 μg) and the GABAB antagonist phaclofen (5 μg) were assessed. Paw withdrawal thresholds to von Frey filaments of rats that had undergone PSNL (n = 20) were tested during 60 minutes of burst and tonic SCS 30 minutes after intrathecal administration of the drugs. RESULTS Quantitative IHC analysis of GABA immunoreactivity in spinal dorsal horn sections of animals that had received burst SCS (n = 5) showed significantly lower intracellular GABA levels when compared to sham SCS sections (n = 4; P = 0.0201) and tonic SCS sections (n = 7; P = 0.0077). Intrathecal application of the GABAA antagonist bicuculline (5 μg; n = 10) or the GABAB antagonist phaclofen (5 μg; n = 10) resulted in ablation of the analgesic effect for both burst SCS and tonic SCS. CONCLUSIONS In conclusion, our anatomical and pharmacological data demonstrate that, in this well-established chronic neuropathic animal model, the analgesic effects of both burst SCS and tonic SCS are mediated via spinal GABAergic mechanisms.
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Affiliation(s)
- Koen P V Meuwissen
- Department of Anesthesiology and Pain Management, Pain Management and Research Centre, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Luuk E de Vries
- School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jianwen Wendy Gu
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Tianhe C Zhang
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Pain Management and Research Centre, 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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Goudman L, Brouns R, De Groote S, De Jaeger M, Huysmans E, Forget P, Moens M. Association Between Spinal Cord Stimulation and Top-Down Nociceptive Inhibition in People With Failed Back Surgery Syndrome: A Cohort Study. Phys Ther 2019; 99:915-923. [PMID: 30916768 DOI: 10.1093/ptj/pzz051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 09/16/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Descending nociceptive inhibitory pathways often malfunction in people with chronic pain. Conditioned pain modulation (CPM) is an experimental evaluation tool for assessing the functioning of these pathways. Spinal cord stimulation (SCS), a well-known treatment option for people with failed back surgery syndrome (FBSS), probably exerts its pain-relieving effect through a complex interplay of segmental and higher-order structures. OBJECTIVE To the best of our knowledge, no clinical studies have thoroughly investigated the associations between SCS and CPM. DESIGN This was a prospective cohort study in people with FBSS. METHODS Seventeen people who had FBSS and were scheduled for SCS were enrolled in this study. The CPM model was evaluated at both sural nerves and was induced by electrical stimulation as the test stimulus and the cold pressor test as the conditioning stimulus. RESULTS Before SCS, less than 30% of the participants with FBSS showed a CPM effect. Significant increases in the electrical detection threshold on the symptomatic side and the nonsymptomatic side were found. On the symptomatic side, no differences in the numbers of CPM responders before and after SCS could be found. On the nonsymptomatic side, more participants showed a CPM effect during SCS. Additionally, there were significant differences for CPM activation and SCS treatment. LIMITATIONS Limitations were the small sample size and the subjective outcome parameters in the CPM model. CONCLUSIONS This study revealed a bilateral effect of SCS that suggests the involvement of higher-order structures, such as the periaqueductal gray matter and rostroventromedial medulla (key regions in the descending pathways), as previously suggested by animal research.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Pain in Motion International Research Group; and Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Raf Brouns
- Department of Neurology, ZorgSaam Hospital, Terneuzen, the Netherlands, and Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel
| | | | - Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel
| | - Eva Huysmans
- Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel; and Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel
| | - Patrice Forget
- Department of Anesthesiology, Universitair Ziekenhuis Brussel
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel; and Department of Radiology, Universitair Ziekenhuis Brussel
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98
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Goudman L, Brouns R, Linderoth B, Moens M. Effects of spinal cord stimulation on heart rate variability in patients with Failed Back Surgery Syndrome. PLoS One 2019; 14:e0219076. [PMID: 31260496 PMCID: PMC6602188 DOI: 10.1371/journal.pone.0219076] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 06/12/2019] [Indexed: 02/07/2023] Open
Abstract
Background Building on the recent finding that chronic pain patients with impaired functioning of the descending nociceptive inhibitory system (DNIS) present lower resting heart rate variability (HRV), this study aims to investigate the impact of Spinal Cord Stimulation (SCS) on HRV in patients with Failed Back Surgery Syndrome (FBSS). More precisely, we hypothesize that SCS influences the DNIS, with increased parasympathetic tone as a consequence, as measurable by HRV analysis. Methods Twenty-two patients diagnosed with FBSS and treated with SCS participated in this study. HRV was measured with a 2-lead ECG registration tool during on and off states of SCS. HRV analysis for time, frequency, time-frequency and nonlinear domain parameters was based on a 5-minute recording segment. Results The mean heart rate and low frequency power were significantly lower when SCS was activated. HRV, absolute and normalized high frequency power significantly increased during SCS compared to without SCS. The ratio of low frequency/high frequency ratios, as parameter for global sympathetic-parasympathetic equilibrium, significantly decreased when SCS was activated. Conclusions When SCS is switched off, patients with FBSS present relatively stronger sympathetic tone and weaker parasympathetic activity. Activation of the SCS, possibly via stimulation of the DNIS, restores this disbalance of autonomic activity.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Raf Brouns
- Department of Neurology, ZorgSaam Hospital, Terneuzen, Netherlands
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium
- * E-mail:
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99
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Miller SM. Occupational Pain Medicine: From Paradigm Shift in Pain Neuroscience to Contextual Model of Care. Front Hum Neurosci 2019; 13:188. [PMID: 31249517 PMCID: PMC6582749 DOI: 10.3389/fnhum.2019.00188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/22/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Steven M Miller
- Perceptual and Clinical Neuroscience Laboratory, Department of Physiology, Monash Biomedicine Discovery Institute, School of Biomedical Sciences, Monash University, Melbourne, VIC, Australia.,Monash Alfred Psychiatry Research Centre, Central Clinical School, Monash University and Alfred Health, Melbourne, VIC, Australia
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Sokal P, Harat M, Malukiewicz A, Kiec M, Świtońska M, Jabłońska R. Effectiveness of tonic and burst motor cortex stimulation in chronic neuropathic pain. J Pain Res 2019; 12:1863-1869. [PMID: 31354335 PMCID: PMC6580141 DOI: 10.2147/jpr.s195867] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 04/08/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Motor cortex stimulation (MCS) is an intracranial, invasive method for treatment of chronic pain. Main indications for MCS are central post stroke pain, neuropathic facial pain, phantom limb pain and brachial plexus or spinal cord injury pain. Spinal cord stimulation (SCS) with burst waveform has been proved to be more effective than tonic mode in chronic pain. Necessity to replace depleted batteries of motor cortex tonic stimulators gave us an opportunity of applying burst stimulation. The objective of the pilot study was to evaluate the effects of burst stimulation applied on motor cortex in patients with chronic pain syndromes as well as comparison to tonic mode. Materials and methods: We have evaluated 6 patients (females N=3, males N=3) belonging to the group of 14 cases (females N=5, males N=9) who had undergone surgical procedure of MCS in years 2005-2017. Selected for the study were 6 patients with thalamic pain N=3, with facial pain N=3 (anaesthesia dolorosa and neuropathic trigeminal neuralgia). The patients were subjected to both modes of stimulation then they chose which one was better in relieving pain: tonic or burst. Pain intensity was assessed with the visual analogue scale (VAS) before the replacement of implanted pulse generator (IPG) and after the stimulation with tonic and burst modes. Results: In the study, 5 out of 6 patients with MCS found burst mode more effective than tonic mode. Baseline VAS score in patients that had at least 3 months depleted battery of tonic IPG was 95 mm. After implantation of a new IPG mean VAS score on tonic stimulation was 72 mm, on burst 53 mm. Conclusions: The most preferred option of MCS in selected group of patients was burst stimulation. This study has shown, that the burst stimulation of cerebral cortex is a promising modality when tonic stimulation is not sufficient in refractory, neuropathic pain.
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Affiliation(s)
- Paweł Sokal
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Marek Harat
- Division of Preventive Medicine and Healthy Policy, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Agnieszka Malukiewicz
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michał Kiec
- Department of Neurosurgery, The 10th Military Clinical Hospital, Bydgoszcz, Poland
| | - Milena Świtońska
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Renata Jabłońska
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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