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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: Executive Summary. J Am Coll Cardiol 2012. [DOI: 10.1016/j.jacc.2012.07.012] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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52
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1231] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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53
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Yampolsky C, Hem S, Bendersky D. Dorsal column stimulator applications. Surg Neurol Int 2012; 3:S275-89. [PMID: 23230533 PMCID: PMC3514915 DOI: 10.4103/2152-7806.103019] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/04/2012] [Indexed: 11/25/2022] Open
Abstract
Background: Spinal cord stimulation (SCS) has been used to treat neuropathic pain since 1967. Following that, technological progress, among other advances, helped SCS become an effective tool to reduce pain. Methods: This article is a non-systematic review of the mechanism of action, indications, results, programming parameters, complications, and cost-effectiveness of SCS. Results: In spite of the existence of several studies that try to prove the mechanism of action of SCS, it still remains unknown. The mechanism of action of SCS would be based on the antidromic activation of the dorsal column fibers, which activate the inhibitory interneurons within the dorsal horn. At present, the indications of SCS are being revised constantly, while new applications are being proposed and researched worldwide. Failed back surgery syndrome (FBSS) is the most common indication for SCS, whereas, the complex regional pain syndrome (CRPS) is the second one. Also, this technique is useful in patients with refractory angina and critical limb ischemia, in whom surgical or endovascular treatment cannot be performed. Further indications may be phantom limb pain, chronic intractable pain located in the head, face, neck, or upper extremities, spinal lumbar stenosis in patients who are not surgical candidates, and others. Conclusion: Spinal cord stimulation is a useful tool for neuromodulation, if an accurate patient selection is carried out prior, which should include a trial period. Undoubtedly, this proper selection and a better knowledge of its underlying mechanisms of action, will allow this cutting edge technique to be more acceptable among pain physicians.
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Affiliation(s)
- Claudio Yampolsky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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54
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Dejongste MJ. Efficacy, safety and mechanisms of spinal cord stimulation used as an additional therapy for patients suffering from chronic refractory angina pectoris. Neuromodulation 2012; 2:188-92. [PMID: 22151207 DOI: 10.1046/j.1525-1403.1999.00188.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- M J Dejongste
- Dept of Cardiology, Thoraxcenter University Hospital of Groningen, Groningen, The Netherlands
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55
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Andersen C, Enggaard TP, Scherer C. Spinal cord stimulation has proven benefit on pain and quality of life in patients with angina pectoris when less invasive therapies have failed. Neuromodulation 2012; 9:314-9. [PMID: 22151765 DOI: 10.1111/j.1525-1403.2006.00073.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background. Since 1988, spinal cord stimulation (SCS) has been used at Odense University Hospital for patients with refractory angina pectoris. The aim of our prospective study was to evaluate the long-term effects of SCS on pain, activities of daily living (ADLs), quality of life (QOL), sleep hygiene, and physical functioning for patients with angina pectoris. Methods. Before and after placement of SCS for patients with intractable angina pectoris, we performed structured telephone interviews questioning for pain relief, ADLs (Nottingham Health Profile), physical functioning (Seattle Angina Questionnaire) and sleep hygiene. Results. Out of 150 patients with SCS over 15 years, 41 patients had died, 46 patients had their devices explanted, and four patients did not participate or could not be reached. Three patients had less than 6 months of follow-up and were therefore not included in our analysis. The beneficial effects of SCS treatment for intractable angina pectoris were reduction in pain and improvement in QOL. Sleep pattern and physical functioning were not improved to the same extent as reduction in pain or improvement in QOL. Almost all of our SCS-treated patients did recommend SCS for intractable angina pectoris. About 30% of patients discontinued treatment, the most common cause being electrode displacement and malfunction of the system. Other reasons for discontinued therapy were the evolvement of invasive treatment options such as coronary artery bypass graft and PTCA and use of such options in some patients during our prolonged observation period. Conclusion. This survey shows that SCS leads to a 70-80% improvement in pain, which, in turn, leads to improvement in QOL, whereas, physical condition and sleep pattern did not improve to the same extent.
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Affiliation(s)
- Claus Andersen
- ESES-unit, Department of Anesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
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56
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57
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Epstein LJ, Palmieri M. Managing chronic pain with spinal cord stimulation. ACTA ACUST UNITED AC 2012; 79:123-32. [PMID: 22238045 DOI: 10.1002/msj.21289] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Since its introduction as a procedure of last resort in a terminally ill patient with intractable cancer-related pain, spinal cord stimulation has been used to effectively treat chronic pain of varied origins. Spinal cord stimulation is commonly used for control of pain secondary to failed back surgery syndrome and complex regional pain syndrome, as well as pain from angina pectoris, peripheral vascular disease, and other causes. By stimulating one or more electrodes implanted in the posterior epidural space, the patient feels paresthesias in their areas of pain, which reduces the level of pain. Pain is reduced without the side effects associated with analgesic medications. Patients have improved quality of life and improved function, with many returning to work. Spinal cord stimulation has been shown to be cost effective as compared with conservative management alone. There is strong evidence for efficacy and cost effectiveness of spinal cord stimulation in the treatment of pain associated with intractable angina, failed back surgery syndrome, and complex regional pain syndrome. In this article, we review the history and pathophysiology of spinal cord stimulation, and the evidence (or lack thereof) for efficacy in common clinical practice.
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Affiliation(s)
- Lawrence J Epstein
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA.
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58
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Jeon YH. Spinal cord stimulation in pain management: a review. Korean J Pain 2012; 25:143-50. [PMID: 22787543 PMCID: PMC3389317 DOI: 10.3344/kjp.2012.25.3.143] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/08/2012] [Indexed: 11/30/2022] Open
Abstract
Spinal cord stimulation has become a widely used and efficient alternative for the management of refractory chronic pain that is unresponsive to conservative therapies. Technological improvements have been considerable and the current neuromodulation devices are both extremely sophisticated and reliable in obtaining good results for various clinical situations of chronic pain, such as failed back surgery syndrome, complex regional pain syndrome, ischemic and coronary artery disease. This technique is likely to possess a savings in costs compared with alternative therapy strategies despite its high initial cost. Spinal cord stimulation continues to be a valuable tool in the treatment of chronic disabling pain.
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Affiliation(s)
- Young Hoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu, Korea
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59
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Steagall RJ, Sipe AL, Williams CA, Joyner WL, Singh K. Substance P release in response to cardiac ischemia from rat thoracic spinal dorsal horn is mediated by TRPV1. Neuroscience 2012; 214:106-19. [PMID: 22525132 DOI: 10.1016/j.neuroscience.2012.04.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/11/2012] [Accepted: 04/12/2012] [Indexed: 11/24/2022]
Abstract
Spinal cord stimulation (SCS) inhibits substance P (SP) release and decreases the expression of the transient receptor potential vanilloid 1 (TRPV1) in the spinal cord at thoracic 4 (T4) during cardiac ischemia in rat models (Ding et al., 2007). We hypothesized that activation of TRPV1 in the T4 spinal cord segment by intermittent occlusion of the left anterior descending coronary artery (CoAO) mediates spinal cord SP release. Experiments were conducted in urethane-anesthetized Sprague-Dawley male rats using SP antibody-coated microprobes to measure SP release at the central terminal endings of cardiac ischemic-sensitive afferent neurons (CISAN) in the spinal T4 dorsal horns. Vehicle, capsaicin (CAP; TRPV1 agonist) and capsazepine (CZP; TRPV1 antagonist) were injected into the left T4 prior to stimulation of CISAN by intermittent CoAO (with or without upper cervical SCS). CAP induced endogenous SP release from laminae I and II in the T4 spinal cord above baseline. Conversely, CZP injections significantly inhibited SP release from laminae I-VII in the T4 spinal cord segment below baseline. CZP also attenuated CoAO-induced SP release, while T4 injections of CZP with SCS completely restored SP release to basal levels during CoAO activation. CAP increased the number of c-Fos (a marker for CISAN activation) positive T4 dorsal horn neurons compared to sham-operated animals, while CZP (alone or during CoAO and SCS+CoAO) significantly reduced the number of c-Fos positive neurons. These results suggest that spinal release of the putative nociceptive transmitter SP occurs, at least in part, via a TRPV1 mechanism.
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Affiliation(s)
- R J Steagall
- Department of Physiology, Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614-1708, United States.
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60
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Zipes DP, Svorkdal N, Berman D, Boortz-Marx R, Henry T, Lerman A, Ross E, Turner M, Irwin C. Spinal cord stimulation therapy for patients with refractory angina who are not candidates for revascularization. Neuromodulation 2012; 15:550-8; discussion 558-9. [PMID: 22494013 DOI: 10.1111/j.1525-1403.2012.00452.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the safety and efficacy of spinal cord stimulation (SCS) for refractory angina. MATERIALS AND METHODS This multicenter, randomized, single-blind, controlled trial evaluated SCS in two patient groups: high stimulation (HS) (treatment) and low stimulation (LS) (control). The HS group controlled SCS with a programmer for a minimum of two hours four times daily. The LS group received SCS therapy above the paresthesia threshold for one min once daily. The primary efficacy endpoint was number of angina attacks recorded by patients at six months. The primary safety endpoint was the major adverse cardiac event (MACE) rate at six months. RESULTS Due to slow enrollment, a futility analysis was performed, resulting in early termination of the study. Sixty-eight patients were randomized after implantation. Mean change in angina attacks per day from baseline to six months was -1.19 ± 2.13 (HS) and -1.29 ± 1.66 (LS). The difference from baseline was significant within each group (both p < 0.001) but not between groups (p = 0.45). Total exercise time and time to angina onset increased significantly from baseline to six months within each group (both p = 0.02 and 0.002) but not between groups (p = 0.52 and 0.51). MACE was similar between groups. CONCLUSION Although this study was terminated early, the results obtained at six months suggest that SCS (HS) is not more effective than the control (LS) in patients with refractory angina.
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Affiliation(s)
- Douglas P Zipes
- Indiana University School of Medicine, Indianapolis, IN 46202-4800, USA.
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61
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Management of Patients With Refractory Angina: Canadian Cardiovascular Society/Canadian Pain Society Joint Guidelines. Can J Cardiol 2012; 28:S20-41. [DOI: 10.1016/j.cjca.2011.07.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 11/24/2022] Open
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62
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Lanza GA, Barone L, Di Monaco A. Effect of Spinal Cord Stimulation in Patients With Refractory Angina: Evidence From Observational Studies. Neuromodulation 2012; 15:542-9; disdcussion 549. [DOI: 10.1111/j.1525-1403.2012.00430.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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63
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Invasive and Device Management of Refractory Angina. Coron Artery Dis 2012. [DOI: 10.1007/978-1-84628-712-1_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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64
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Cohen MG, Ohman EM. Therapeutic Goals in Patients with Refractory Angina. Coron Artery Dis 2012. [DOI: 10.1007/978-1-84628-712-1_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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65
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Börjesson M, Andréll P, Mannheimer C. Spinal cord stimulation for long-term treatment of severe angina pectoris: what does the evidence say? Future Cardiol 2011; 7:825-33. [DOI: 10.2217/fca.11.58] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Patients who continue to suffer from severe and disabling angina pectoris, despite optimum treatment in terms of conventional pharmacological therapy and/or revascularization procedures, have been termed as having refractory angina pectoris. The future group of patients with refractory angina pectoris will be different from today’s patients and represent a ‘moving target’ as risk factors, efficacy of treatment and indications continue to change. Spinal cord stimulation (SCS) is today considered as first-line treatment of refractory angina pectoris, by the European Society of Cardiology, with an anti-ischemic effect. There is strong evidence for SCS giving symptomatic benefits (decrease in anginal attacks), improved quality of life and improvement of functional status. In addition, SCS seems to be cost effective with a ‘break-even’ after approximately 15–16 months.
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Affiliation(s)
| | - Paulin Andréll
- Department of Acute & Cardiovascular Medicine, Multidisciplinary Pain Center, Pain Center, Sahlgrenska University Hospital/Ostra, Goteborg, 416 85, Sweden
| | - Clas Mannheimer
- Department of Acute & Cardiovascular Medicine, Multidisciplinary Pain Center, Pain Center, Sahlgrenska University Hospital/Ostra, Goteborg, 416 85, Sweden
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Tronnier V, Baron R, Birklein F, Eckert S, Harke H, Horstkotte D, Hügler P, Hüppe M, Kniesel B, Maier C, Schütze G, Thoma R, Treede R, Vadokas V. Epidurale Rückenmarkstimulation zur Therapie chronischer Schmerzen. Schmerz 2011; 25:484-92. [DOI: 10.1007/s00482-011-1094-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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67
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Ryabov VV, Oyunarov EO, Markov VA. Refractory post-infarction myocardial ischemia: treatment potential. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2011. [DOI: 10.15829/1728-8800-2011-4-121-127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The treatment of recurrent, refractory post-infarction myocardial ischemia remains an unresolved clinical problem. Aggressive pharmaceutical therapy has limited effectiveness, while percutaneous coronary intervention or coronary artery bypass graft surgery are not possible in these patients, due to various reasons. Currently, alternative methods for refractory angina treatment are being developed for patients with chronic stable angina. The potential of these methods in patients with acute coronary syndrome should be investigated in the future studies.
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Affiliation(s)
| | - E. O. Oyunarov
- Research Institute of Cardiology, Siberian Division of the Russian Academy of Medical Sciences
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68
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Odenstedt J, Linderoth B, Bergfeldt L, Ekre O, Grip L, Mannheimer C, Andréll P. Spinal cord stimulation effects on myocardial ischemia, infarct size, ventricular arrhythmia, and noninvasive electrophysiology in a porcine ischemia–reperfusion model. Heart Rhythm 2011; 8:892-8. [DOI: 10.1016/j.hrthm.2011.01.029] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 01/12/2011] [Indexed: 12/26/2022]
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69
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Nanthakumar K. Spinal cord stimulators for treatment of ventricular arrhythmias: antiarrhythmic in a can. Heart Rhythm 2011; 8:899-900. [PMID: 21316486 DOI: 10.1016/j.hrthm.2011.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Indexed: 11/29/2022]
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70
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Goroszeniuk T, Pang D, Al-Kaisy A, Sanderson K. Subcutaneous Target Stimulation-Peripheral Subcutaneous Field Stimulation in the Treatment of Refractory Angina: Preliminary Case Reports. Pain Pract 2011; 12:71-9. [DOI: 10.1111/j.1533-2500.2011.00455.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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71
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Abstract
Angina pectoris, cardiac pain associated with ischemia, is considered refractory when optimal anti-anginal therapy fails to resolve symptoms. It is associated with a decreased life expectancy and diminishes the quality of life. Spinal cord stimulation (SCS) may be considered for patients who have also undergone comprehensive interventions, such as coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) procedures. The mechanism of action of SCS is not entirely clear. Pain reduction is related to the increased release of inhibitory neuropeptides as well as normalization of the intrinsic nerve system of the heart muscle, and may have a protective myocardial effect. SCS in patients with refractory angina pectoris results in reduced anginal attacks as well as improved rate pressure product prior to the occurrence of ischemic events. This may be the result of reduced Myocardial Volume Oxygen (MVO(2) ) and possibly the redistribution of the coronary blood flow to ischemic areas. There are a number of studies that demonstrate that SCS does not mask acute myocardial infarction. The efficacy of the treatment has been investigated in two prospective, randomized studies. The long-term results showed an improvement of the symptoms and of the quality of life. SCS can be an alternative to surgical intervention in a selected patient population. In addition, SCS is a viable option in patients in whom surgery is not possible. SCS is recommended in patients with chronic refractory angina pectoris that does not respond to conventional treatment and in whom revascularization procedures have been attempted or not possible, and who are optimized from a medical perspective.
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Affiliation(s)
- Maarten van Kleef
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, the Netherlands.
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72
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Lanza GA, Grimaldi R, Greco S, Ghio S, Sarullo F, Zuin G, De Luca A, Allegri M, Di Pede F, Castagno D, Turco A, Sapio M, Pinato G, Cioni B, Trevi G, Crea F. Spinal cord stimulation for the treatment of refractory angina pectoris: A multicenter randomized single-blind study (the SCS-ITA trial). Pain 2011; 152:45-52. [DOI: 10.1016/j.pain.2010.08.044] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 08/17/2010] [Accepted: 08/27/2010] [Indexed: 11/16/2022]
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73
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Ramamurthy S, Eckmann MS. Thoracic Epidural Nerve Block. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00158-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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74
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Kones R. Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization. Vasc Health Risk Manag 2010; 6:749-74. [PMID: 20859545 PMCID: PMC2941787 DOI: 10.2147/vhrm.s11100] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Indexed: 12/19/2022] Open
Abstract
The objectives in treating angina are relief of pain and prevention of disease progression through risk reduction. Mechanisms, indications, clinical forms, doses, and side effects of the traditional antianginal agents - nitrates, β-blockers, and calcium channel blockers - are reviewed. A number of patients have contraindications or remain unrelieved from anginal discomfort with these drugs. Among newer alternatives, ranolazine, recently approved in the United States, indirectly prevents the intracellular calcium overload involved in cardiac ischemia and is a welcome addition to available treatments. None, however, are disease-modifying agents. Two options for refractory angina, enhanced external counterpulsation and spinal cord stimulation (SCS), are presented in detail. They are both well-studied and are effective means of treating at least some patients with this perplexing form of angina. Traditional modifiable risk factors for coronary artery disease (CAD) - smoking, hypertension, dyslipidemia, diabetes, and obesity - account for most of the population-attributable risk. Individual therapy of high-risk patients differs from population-wide efforts to prevent risk factors from appearing or reducing their severity, in order to lower the national burden of disease. Current American College of Cardiology/American Heart Association guidelines to lower risk in patients with chronic angina are reviewed. The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial showed that in patients with stable angina, optimal medical therapy alone and percutaneous coronary intervention (PCI) with medical therapy were equal in preventing myocardial infarction and death. The integration of COURAGE results into current practice is discussed. For patients who are unstable, with very high risk, with left main coronary artery lesions, in whom medical therapy fails, and in those with acute coronary syndromes, PCI is indicated. Asymptomatic patients with CAD and those with stable angina may defer intervention without additional risk to see if they will improve on optimum medical therapy. For many patients, coronary artery bypass surgery offers the best opportunity for relieving angina, reducing the need for additional revascularization procedures and improving survival. Optimal medical therapy, percutaneous coronary intervention, and surgery are not competing therapies, but are complementary and form a continuum, each filling an important evidence-based need in modern comprehensive management.
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Affiliation(s)
- Richard Kones
- Cardiometabolic Research Institute, Houston, Texas 77055, USA.
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75
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Cohen MG, Pascual M, Scirica BM, Magnus Ohman E. Therapeutic goals in patients with refractory chronic angina. Rev Esp Cardiol 2010; 63:571-82. [PMID: 20450851 DOI: 10.1016/s1885-5857(10)70119-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Refractory angina presents a major clinical challenge for everyday medical practice. Despite the widespread use of statins and improvements in revascularization techniques, a substantial proportion of patients with preserved left ventricular function and no life-threatening arrhythmias remain symptomatic, with severe debilitating angina. Because the rate of major cardiac events in this population is relatively low, the major aim of therapy should be not only to prolong survival but also to improve quality of life. The cornerstone of therapy for all these patients should be the aggressive modification of risk factors using evidence-based treatment, with the aim of stabilizing the disease process and improving overall survival. No opportunity for revascularization should be overlooked. Complementary approaches should be implemented to raise the angina threshold by either reducing oxygen demand or improving hemodynamics to increase myocardial oxygen supply. This review provides an update on therapeutic techniques and goals, and reinforces the need for a multidisciplinary approach to the management of patients with refractory angina.
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76
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Cohen MG, Pascual M, Scirica BM, Magnus Ohman E. Metas terapéuticas en pacientes con angina refractaria crónica. Rev Esp Cardiol (Engl Ed) 2010. [DOI: 10.1016/s0300-8932(10)70119-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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77
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Fernandez SF, Tandar A, Boden WE. Emerging medical treatment for angina pectoris. Expert Opin Emerg Drugs 2010; 15:283-98. [DOI: 10.1517/14728210903544482] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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78
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Jeon Y, Huh BK. Spinal Cord Stimulation for Chronic Pain. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n11p998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Spinal cord stimulation (SCS) is one of the most effective modalities for management of re- fractory neuropathic pain unresponsive to conservative therapies. The SCS has been successful in providing analgesia, improving function, and enhancing quality of life for patients suffering from chronic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, ischaemic and phantom limb pain, and coronary artery disease. This technique has proven to be cost effective in the long term despite its high initial cost. In this review article, we discuss the history of SCS development, mechanism of action, and indications for SCS.
Key words: Failed back surgery syndrome, Ischaemic pain, Neuropathic pain
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Affiliation(s)
- Younghoon Jeon
- Kyungpook National University Hospital, Republic of Korea
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79
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Raphael JH, Mutagi HS, Kapur S. Spinal cord stimulation and its anaesthetic implications. ACTA ACUST UNITED AC 2009. [DOI: 10.1093/bjaceaccp/mkp009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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80
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Taylor RS, De Vries J, Buchser E, Dejongste MJL. Spinal cord stimulation in the treatment of refractory angina: systematic review and meta-analysis of randomised controlled trials. BMC Cardiovasc Disord 2009; 9:13. [PMID: 19320999 PMCID: PMC2667170 DOI: 10.1186/1471-2261-9-13] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 03/25/2009] [Indexed: 11/22/2022] Open
Abstract
Background The aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina. Methods We searched a number of electronic databases including Medline, Embase and Cochrane Library up to February 2008 to identify randomised controlled trials (RCTs) reporting exercise capacity, ischemic burden, functional class, quality of life, usage of anti-anginal medication, costs and adverse events including mortality. Results were reported both descriptively for each study and using random effects meta-analysis. Given the variety in outcomes reported, some outcome results were pooled as standardised mean differences (SMD) and reported in standard deviation units. Results Seven RCTs were identified in a total of 270 refractory angina patients. The outcomes of SCS were found to be similar when directly compared to coronary artery bypass grafting (CABG) and percutaneous myocardial laser revascularisation (PMR). Compared to a 'no stimulation' control, there was some evidence of improvement in all outcomes following SCS implantation with significant gains observed in pooled exercise capacity (SMD: 0.76, 0.07 to 1.46, p = 0.03) and health-related quality of life (SMD: 0.83, 95% CI: 0.32 to 1.34, p = 0.001). Trials were small and were judged to range considerably in their quality. The healthcare costs of SCS appeared to be lower than CABG at 2-years follow up. Conclusion SCS appears to be an effective and safe treatment option in the management of refractory angina patients and of similar efficacy and safety to PMR, a potential alternative treatment. Further high quality RCT and cost effectiveness evidence is needed before SCS can be accepted as a routine treatment for refractory angina.
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Affiliation(s)
- Rod S Taylor
- Health Services Research, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK.
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81
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Spinal cord stimulation for the treatment of angina and peripheral vascular disease. Curr Pain Headache Rep 2009; 13:18-23. [DOI: 10.1007/s11916-009-0005-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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82
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Spinal Cord Stimulation for Refractory Angina. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00070-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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83
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North RB, Shipley J, Taylor RS. The Cost-effectiveness of Spinal Cord Stimulation. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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84
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85
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Comparison of patients undergoing enhanced external counterpulsation and spinal cord stimulation for refractory angina pectoris. Coron Artery Dis 2008; 19:627-34. [DOI: 10.1097/mca.0b013e3283162489] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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86
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DeJongste MJL, Taylor R. Can spinal cord stimulation bail out Sisyphus' burden of sufferings? Pain 2008; 140:397-398. [PMID: 19004547 DOI: 10.1016/j.pain.2008.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 10/16/2008] [Indexed: 11/19/2022]
Affiliation(s)
- Mike J L DeJongste
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, Groningen, The Netherlands Institute of Health Services Research, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK
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87
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Spinal cord stimulation in severe angina pectoris--a systematic review based on the Swedish Council on Technology assessment in health care report on long-standing pain. Pain 2008; 140:501-508. [PMID: 19004553 DOI: 10.1016/j.pain.2008.10.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 09/28/2008] [Accepted: 10/10/2008] [Indexed: 11/23/2022]
Abstract
Patients who continue to suffer from lasting and severely disabling angina pectoris despite optimum drug treatment and who are not suitable candidates for invasive procedures, suffer from a condition referred to as "chronic refractory angina pectoris". Based on the available data, spinal cord stimulation, SCS, is considered as the first-line additional treatment for these patients by the European Society of Cardiology. However, no systematic review of randomised controlled studies has yet been published. A systematic literature research, 1966-2003, as part of the Swedish Board of Health and Welfare (SBU) report on long-standing pain, and an additional research covering the years 2003-2007, were carried out. Acute studies, case reports and mechanistic reviews were excluded, and the remaining 43 studies were graded for study quality according to a modified Jadad score. The eight medium- to high-score studies formed the basis for conclusions regarding the scientific evidence (strong, moderately strong or limited) for the efficacy of SCS. There is strong evidence that SCS gives rise to symptomatic benefits (decrease in anginal attacks) and improved quality of life in patients with severe angina pectoris. There is also a strong evidence that SCS can improve the functional status of these patients, as illustrated by the improved exercise time on treadmill or longer walking distance without angina. In addition, SCS does not seem to have any negative effects on mortality in these patients (limited scientific evidence). The complication rate was found to be acceptable.
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88
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Myers GR, Weintraub WS. Medical therapies for chronic stable angina. CURRENT CARDIOVASCULAR RISK REPORTS 2008. [DOI: 10.1007/s12170-008-0063-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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89
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Fricke E, Eckert S, Dongas A, Fricke H, Preuss R, Lindner O, Horstkotte D, Burchert W. Myocardial sympathetic innervation in patients with symptomatic coronary artery disease: follow-up after 1 year with neurostimulation. J Nucl Med 2008; 49:1458-64. [PMID: 18703600 DOI: 10.2967/jnumed.108.052340] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED In both diabetic and nondiabetic patients, there is a loose correlation between coronary flow reserve (CFR) and sympathetic innervation in viable myocardial segments. The loose correlation implies that sympathetic innervation may be preserved even with major impairment of myocardial blood supply. In some patients, denervation is due to repetitive episodes of ischemia in areas with severely reduced CFR. We investigated the long-term effect of reduced CFR on myocardial sympathetic innervation in diabetic and nondiabetic patients with spinal cord stimulation. METHODS We analyzed 23 patients (10 diabetic and 13 nondiabetic) with coronary artery disease and without known cardiac autonomic neuropathy. At baseline, we determined quantitative myocardial blood flow using (13)N-ammonia PET, myocardial viability using (18)F-FDG PET, and cardiac innervation using (11)C-hydroxyephedrine (HED) PET. At the 1-y follow-up we measured CFR and (11)C-HED retention. During follow-up, no cardiac intervention was performed and no myocardial infarction occurred. In all patients, spinal cord stimulation was performed for relief of angina. RESULTS There was no significant difference in segmental (11)C-HED retention between baseline and follow-up in the whole patient group. In diabetic patients, as well as in segments with severely reduced CFR (<1.5), (11)C-HED retention showed a small but significant decrease (P<0.05). Linear regression of segmental (11)C-HED retention between baseline and follow-up was high (r(2)=0.81), confirming good reproducibility of the investigation on the one hand and little change in regional sympathetic innervation on the other hand. CONCLUSION In patients with stable chronic coronary artery disease, sympathetic innervation of the myocardium is almost unchanged in both diabetic and nondiabetic patients in a 1-y follow-up. In myocardial segments with severely altered blood supply, a small but significant decrease in (11)C-HED retention most probably reflects ischemic neuronal damage. The prognostic relevance of sympathetic denervation in viable myocardium still has to be determined.
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Affiliation(s)
- Eva Fricke
- Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Centre North Rhine-Westphalia, Bad Oeynhausen, Germany.
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90
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Latif OA, Raj PP. Spinal Cord Stimulation: A Comparison of Efficacy versus Other Novel Treatments for Refractory Angina Pectoris. Pain Pract 2008. [DOI: 10.1111/j.1533-2500.2001.01005.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Osman A. Latif
- Texas Tech University Health Science Center, International Pain Institute,
Department of Anesthesiology, Lubbock, Texas
| | - P. Prithvi Raj
- Texas Tech University Health Science Center, International Pain Institute,
Department of Anesthesiology, Lubbock, Texas
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91
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Dyer MT, Goldsmith KA, Khan SN, Sharples LD, Freeman C, Hardy I, Buxton MJ, Schofield PM. Clinical and cost-effectiveness analysis of an open label, single-centre, randomised trial of spinal cord stimulation (SCS) versus percutaneous myocardial laser revascularisation (PMR) in patients with refractory angina pectoris: The SPiRiT trial. Trials 2008; 9:40. [PMID: 18590536 PMCID: PMC2481243 DOI: 10.1186/1745-6215-9-40] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 06/30/2008] [Indexed: 11/16/2022] Open
Abstract
Background Patients with refractory angina have significant morbidity. This study aimed to compare two of the treatment options, Spinal Cord Stimulation (SCS) and Percutaneous Myocardial Laser Revascularisation (PMR) in terms of clinical outcomes and cost-effectiveness. Methods Eligible patients were randomised to PMR or SCS and followed up for exercise tolerance time (ETT), Canadian Cardiovascular Society (CCS) classification and the quality of life measures SF-36, Seattle Angina Questionnaire and the EuroQoL at 3, 12 and 24 months. Utilities were calculated using the EQ-5D and these and costs were compared between groups. The incremental cost-effectiveness ratio (ICER) per QALY for SCS compared to PMR was also calculated. Results At 24 months post-randomisation, patients that had SCS and PMR had similar ETT (mean difference 0.05, 95% CI -2.08, 2.18, p = 0.96) and there was no difference in CCS classification or quality of life outcomes. The difference in overall mean costs when comparing SCS to PMR was GBP5,520 (95% CI GBP1,966 to GBP8,613; p < 0.01) and the ICER of using SCS was GBP46,000 per QALY. Conclusion Outcomes after SCS did not differ appreciably from those after PMR, with the former procedure being less cost-effective as currently applied. Larger studies could clarify which patients would most benefit from SCS, potentially increasing cost-effectiveness. Trial registration Current Controlled Trials ISRCTN09648950
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Affiliation(s)
- M T Dyer
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK.
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92
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Klassen A, Di Iorio B, Guastaferro P, Bahner U, Heidland A, De Santo N. High-tone external muscle stimulation in end-stage renal disease: effects on symptomatic diabetic and uremic peripheral neuropathy. J Ren Nutr 2008; 18:46-51. [PMID: 18089443 DOI: 10.1053/j.jrn.2007.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE AND DESIGN Pain and peripheral neuropathy are frequent complications of end-stage renal disease (ESRD). Because drug treatment is associated with numerous side effects and is largely ineffective in many maintenance hemodialysis (MHD) patients, nonpharmacologic strategies such as electrotherapy are a potential recourse. Among various forms of electrostimulation, high-tone external muscle stimulation (HTEMS) is a promising alternative treatment for symptomatic diabetic peripheral polyneuropathy (PPN), as demonstrated in a short-term study. Based on these novel findings, we performed a prospective, nonrandomized, pilot trial in MHD patients to determine (1) whether HTEMS is also effective in treating diabetic PPN in the uremic state, and (2) whether uremic PPN is similarly modulated. PATIENTS AND INTERVENTIONS In total, 40 MHD patients diagnosed with symptomatic PPN (25 with diabetic and 15 with uremic PPN) were enrolled. Both lower extremities were treated intradialytically with HTEMS for 1 hour, three times a week. Initially, a subgroup of 12 patients was followed for 4 weeks, and a further 28 patients for 12 weeks. The patients' degree of neuropathy was graded at baseline before HTEMS and after 1 and 3 months, respectively. Five neuropathic symptoms (tingling, burning, pain, numbness, and numbness in painful areas) as well as sleep disturbances were measured, using the 10-point Neuropathic Pain Scale of Galer and Jensen (Neurology 48:332-338, 1997). A positive response was defined as the improvement of one symptom or more, by at least 3 points. Other parameters included blood pressure, heart rate, dry body weight, and a routine laboratory investigation. RESULTS The HTEMS led to a significant improvement in all five neuropathic symptoms, and to a significant reduction in sleep disturbances for both diabetic and uremic PPN. The response was independent of the patient's age, with a responder rate of 73%. The improvement of neuropathy was time-dependent, with the best results achieved after 3 months of treatment. The HTEMS was well-tolerated by nearly all patients. CONCLUSIONS This pilot study shows for the first time that HTEMS can ameliorate the discomfort and pain associated with both diabetic and uremic PPN in MHD patients, and could be a valuable supplement in the treatment of pain and neuropathic discomfort in patients who do not respond to, or are unable to participate in, exercise programs during hemodialysis treatment.
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Affiliation(s)
- A Klassen
- Department of Internal Medicine, University of Würzburg, Würzburg, Germany
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93
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Jang HD, Kim MS, Chang CH, Kim SW, Kim OL, Kim SH. Analysis of failed spinal cord stimulation trials in the treatment of intractable chronic pain. J Korean Neurosurg Soc 2008; 43:85-9. [PMID: 19096610 DOI: 10.3340/jkns.2008.43.2.85] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Accepted: 02/11/2008] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The purpose of this study is to identify the factors affecting the failure of trials (<50% pain reduction in pain for trial period) to improve success rate of spinal cord stimulation (SCS) trial. METHODS A retrospective review of the failed trials (44 patients, 36.1%) among the patients (n=122) who underwent SCS trial between January 1990 and December 1998 was conducted. We reviewed the causes of failed trial stimulation, age, sex, etiology of pain, type of electrode, and third party support. RESULTS Of the 44 patients, 65.9% showed unacceptable pain relief in spite of sufficient paresthesia on the pain area with trial stimulation. Four of six patients felt insufficient paresthesia with stimulation had the lesions of the spinal cord. Seventy five percent of the patients experienced unpleasant or painful sensation during stimulation had allodynia dominant pain. Third-party involvement, sex, age and electrode type had no influence on the outcome. CONCLUSION We conclude that SCS trial is less effective for patients with neuropathic pain of cord lesions, postherpetic neuropathy or post-amputation state. Further, patients with allodynia dominant pain can feel unpleasant or painful during trial stimulation.
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Affiliation(s)
- Hyun-Dong Jang
- Department of Neurosurgery, College of Medicine, Yeungnam University, Daegu, Korea
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94
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Survey of the practice of spinal cord stimulators and intrathecal analgesic delivery implants for management of pain in Canada. Pain Res Manag 2008; 12:281-5. [PMID: 18080047 DOI: 10.1155/2007/312582] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In 2006, the Canadian Neuromodulation Society was formed. The present survey characterizes the practice of spinal cord stimulator (SCS) and intrathecal analgesic delivery pump (IADP) implantation for pain management in different centres across Canada. METHOD A structured questionnaire was designed to examine the funding source, infrastructure and patient screening process in different centres implanting SCSs and IADPs. Centres that performed more than 10 implants per year were surveyed. The survey was centre-based, ie, each centre received one questionnaire regardless of the number of staff involved in neuromodulation practice. RESULTS Fourteen centres were identified and 13 responded. Implantation of SCS and IADP was performed in 12 and 10 centres, respectively. In most centres, failed back surgery syndrome was the most frequent indication for SCS and IADP implantation. For SCS, all centres always performed a trial; the majority used percutaneous electrode (83%) before the SCS implantation. Routine psychological screening was performed in 25% of centres before any SCS trial procedure. For IADP, all centres performed a trial injection or infusion before implantation. Five centres (50%) performed psychological screening in almost all patients. Continuous infusion techniques were the most popular (50%) used for the trial. CONCLUSION The present survey provides a 'snapshot' of the practice of SCS and IADP implantation in Canada. A review of SCS and IADP trials indicated that Canadian practices are mostly, but not always, consistent with those elsewhere.
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95
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Abstract
Spinal cord stimulation has been used in the treatment of many chronic pain disorders since 1967. In this update, the indications for spinal cord stimulation are reviewed with attention to recent publications. A focused review of the literature on abdominal and visceral pain syndromes is also provided. Furthermore, the technology has evolved from the use of monopolar electrodes to complex electrode arrays. Similarly, the power source has changed from a radio frequency-driven system to a rechargeable impulse generator. These topics are covered, along with a short discussion of implant technique. Finally, we include a review of complications of such therapy. SCS as a technology and therapy continues to evolve.
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Affiliation(s)
- Steven Falowski
- grid.265008.90000000121665843Department of Neurosurgery, Jefferson Medical College, 909 Walnut Street, 2nd Floor, 19107 Philadelphia, PA
| | - Amanda Celii
- grid.265008.90000000121665843Department of Neurosurgery, Jefferson Medical College, 909 Walnut Street, 2nd Floor, 19107 Philadelphia, PA
| | - Ashwini Sharan
- grid.265008.90000000121665843Department of Neurosurgery, Jefferson Medical College, 909 Walnut Street, 2nd Floor, 19107 Philadelphia, PA
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96
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Ding X, Ardell JL, Hua F, McAuley RJ, Sutherly K, Daniel JJ, Williams CA. Modulation of cardiac ischemia-sensitive afferent neuron signaling by preemptive C2 spinal cord stimulation: effect on substance P release from rat spinal cord. Am J Physiol Regul Integr Comp Physiol 2007; 294:R93-101. [PMID: 17989135 DOI: 10.1152/ajpregu.00544.2007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The upper cervical spinal region functions as an intraspinal controller of thoracic spinal reflexes and contributes to neuronal regulation of the ischemic myocardium. Our objective was to determine whether stimulation of the C2 cervical spinal cord (SCS) of rats modified the input signal at the thoracic spinal cord when cardiac ischemia-sensitive (sympathetic) afferents were activated by transient occlusion of the left anterior descending coronary artery (CoAO). Changes in c-Fos expression were used as an index of neuronal activation within the spinal cord and brain stem. The pattern of substance P (SP) release, a putative nociceptive transmitter, was measured using antibody-coated microprobes. Two SCS protocols were used: reactive SCS, applied concurrently with intermittent CoAO and preemptive, sustained SCS starting 15 min before and continuing during the repeated intermittent CoAO. CoAO increased SP release from laminae I and II in the T4 spinal cord above resting levels. Intermittent SCS with CoAO resulted in greater levels of SP release from deeper laminae IV-VII in T4 than CoAO alone. In contrast, SP release from laminae I and II was inhibited when CoAO was applied during preemptive, sustained SCS. Preemptive SCS likewise reduced c-Fos expression in the T4 spinal cord (laminae I-V) and nucleus tractus solitarius but increased expression in the intermediolateral cell column of T4 compared with CoAO alone. These results suggest that preemptive SCS from the high cervical region modulates sensory afferent signaling from the ischemic myocardium.
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Affiliation(s)
- Xiaohui Ding
- Department of Physiology, Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614-1708, USA
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97
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Abstract
Optimum heart failure medication and an increasing array of interventions have had an enormous effect on morbidity and mortality over the past 10 years. However, patients with end stage disease can still be highly symptomatic. Moreover, such patients are disadvantaged compared with patients with malignant disease. They are less likely to have an understanding of their illness or have access to supportive care. They are also less likely to have the opportunity to plan for care with regard to death and dying. There is increasing demand that the multi-professional clinical team gain good communication and supportive care skills, and that appropriate access to specialist palliative care services is available.
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98
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Sgueglia GA, Sestito A. Spinal cord stimulation: a new form of pain modulatory treatment in cardiac syndrome X. Am J Med 2007; 120:e17. [PMID: 17765031 DOI: 10.1016/j.amjmed.2006.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Accepted: 09/13/2006] [Indexed: 11/28/2022]
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99
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Fumero A, Rapati D, Diso S, Lapenna E, Alfieri O. Spinal cord stimulation for refractory chronic angina pectoris: influence on quality of life. Expert Rev Pharmacoecon Outcomes Res 2007; 7:343-9. [PMID: 20528416 DOI: 10.1586/14737167.7.4.343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Percutaneous coronary revascularization, coronary artery bypass graft surgery and medical management are nowadays very effective in treating coronary artery disease. Nevertheless, the number of patients affected by refractory chronic angina pectoris is increasing. Epidemiological estimates for refractory angina pectoris predict the diagnosis of more than 100,000 patients each year in the USA and approximately 50,000 in Europe. Spinal cord stimulation is a valuable therapeutic option for patients who have failed multiple percutaneous and surgical revascularizations and who are not eligible for further revascularization procedures. The aim of this study is to assess the benefits, in terms of quality of life, of spinal cord stimulation in no-option patients affected by refractory angina pectoris.
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Affiliation(s)
- Andrea Fumero
- IRCCS Ospedale Universitario San Raffaele, Div. Cardiochirurgia, Via Olgettina 60, 20132 Milano, Italy.
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100
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De Andrés J, Tatay J, Revert A, Valía JC, Villanueva V. The beneficial effect of spinal cord stimulation in a patient with severe cerebral ischemia and upper extremity ischemic pain. Pain Pract 2007; 7:135-42. [PMID: 17559483 DOI: 10.1111/j.1533-2500.2007.00121.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Spinal cord stimulation (SCS) is used in the treatment of chronic pain, ischemia because of obstructive arterial disease, and anginal pain. Recently, a number of studies have described the effects of the high cervical SCS, including increased cerebral blood flow, although the underlying mechanisms are unknown. This case report describes a patient with a severe complex ischemic condition affecting both cerebral and upper limb blood flow with an associated complex regional pain syndrome in upper limb. While all previous clinical treatments proved ineffective, cervical SCS afforded satisfactory results. Possible mechanisms underlying the cervical SCS effect are discussed.
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Affiliation(s)
- Jose De Andrés
- Valencia University Medical School, and Multidisciplinary Pain Management Department, General University Hospital, Valencia, Spain.
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