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Mol F, Scheltinga M, Roumen R, Wille F, Gültuna I, Kallewaard JW, Elzinga L, van de Minkelis J, Nijhuis H, Stronks DL, Huygen FJPM. Comparing the Efficacy of Dorsal Root Ganglion Stimulation With Conventional Medical Management in Patients With Chronic Postsurgical Inguinal Pain: Post Hoc Analyzed Results of the SMASHING Study. Neuromodulation 2023; 26:1788-1794. [PMID: 36456417 DOI: 10.1016/j.neurom.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Approximately 10% of patients who undergo inguinal hernia repair or Pfannenstiel incision develop chronic (> three months) postsurgical inguinal pain (PSIP). If medication or peripheral nerve blocks fail, a neurectomy is the treatment of choice. However, some patients do not respond to this treatment. In such cases, stimulation of the dorsal root ganglion (DRG) appears to significantly reduce chronic PSIP in selected patients. MATERIALS AND METHODS In this multicenter, randomized controlled study, DRG stimulation was compared with conventional medical management (CMM) (noninvasive treatments, such as medication, transcutaneous electric neurostimulation, and rehabilitation therapy) in patients with PSIP that was resistant to a neurectomy. Patients were recruited at a tertiary referral center for groin pain (SolviMáx, Eindhoven, The Netherlands) between March 2015 and November 2016. Suitability for implantation was assessed according to the Dutch Neuromodulation Association guidelines. The sponsor discontinued the study early owing to slow enrollment. Of 78 planned patients, 18 were randomized (DRG and CMM groups each had nine patients). Six patients with CMM (67%) crossed over to DRG stimulation at the six-month mark. RESULTS Fifteen of the 18 patients met the six-month primary end point with a complete data set for a per-protocol analysis. Three patients with DRG stimulation had a negative trial and were lost to follow-up. The average pain reduction was 50% in the DRG stimulation and crossover group (from 6.60 ± 1.24 to 3.28 ± 2.30, p = 0.0029). Conversely, a 13% increase in pain was observed in patients with CMM (from 6.13 ± 2.24 to 6.89 ± 1.24, p = 0.42). Nine patients with DRG stimulation experienced a total of 19 adverse events, such as lead dislocation and pain at the implantation site. CONCLUSIONS DRG stimulation is a promising effective therapy for pain relief in patients with PSIP resistant to conventional treatment modalities; larger studies should confirm this. The frequency of side effects should be a concern in a new study. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02349659.
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Affiliation(s)
| | | | - Rudi Roumen
- Maxima Medical Center, Eindhoven, The Netherlands
| | - Frank Wille
- Maxima Medical Center, Eindhoven, The Netherlands
| | | | | | - Lars Elzinga
- Maxima Medical Center, Eindhoven, The Netherlands
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Liu AR, Lin ZJ, Wei M, Tang Y, Zhang H, Peng XG, Li Y, Zheng YF, Tan Z, Zhou LJ, Feng X. The potent analgesia of intrathecal 2R, 6R-HNK via TRPA1 inhibition in LF-PENS-induced chronic primary pain model. J Headache Pain 2023; 24:141. [PMID: 37858040 PMCID: PMC10585932 DOI: 10.1186/s10194-023-01667-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Chronic primary pain (CPP) is an intractable pain of unknown cause with significant emotional distress and/or dysfunction that is a leading factor of disability globally. The lack of a suitable animal model that mimic CPP in humans has frustrated efforts to curb disease progression. 2R, 6R-hydroxynorketamine (2R, 6R-HNK) is the major antidepressant metabolite of ketamine and also exerts antinociceptive action. However, the analgesic mechanism and whether it is effective for CPP are still unknown. METHODS Based on nociplastic pain is evoked by long-term potentiation (LTP)-inducible high- or low-frequency electrical stimulation (HFS/LFS), we wanted to develop a novel CPP mouse model with mood and cognitive comorbidities by noninvasive low-frequency percutaneous electrical nerve stimulation (LF-PENS). Single/repeated 2R, 6R-HNK or other drug was intraperitoneally (i.p.) or intrathecally (i.t.) injected into naïve or CPP mice to investigate their analgesic effect in CPP model. A variety of behavioral tests were used to detect the changes in pain, mood and memory. Immunofluorescent staining, western blot, reverse transcription-quantitative real-time polymerase chain reaction (RT-qPCR) and calcium imaging of in cultured dorsal root ganglia (DRG) neurons by Fluo-8-AM were used to elucidate the role and mechanisms of 2R, 6R-HNK in vivo or in vitro. RESULTS Intrathecal 2R, 6R-HNK, rather than intraperitoneal 2R, 6R-HNK or intrathecal S-Ketamine, successfully mitigated HFS-induced pain. Importantly, intrathecal 2R, 6R-HNK displayed effective relief of bilateral pain hypersensitivity and depressive and cognitive comorbidities in a dose-dependent manner in LF-PENS-induced CPP model. Mechanically, 2R, 6R-HNK markedly attenuated neuronal hyperexcitability and the upregulation of calcitonin gene-related peptide (CGRP), transient receptor potential ankyrin 1 (TRPA1) or vanilloid-1 (TRPV1), and vesicular glutamate transporter-2 (VGLUT2) in peripheral nociceptive pathway. In addition, 2R, 6R-HNK suppressed calcium responses and CGRP overexpression in cultured DRG neurons elicited by the agonists of TRPA1 or/and TRPV1. Strikingly, the inhibitory effects of 2R, 6R-HNK on these pain-related molecules and mechanical allodynia were substantially occluded by TRPA1 antagonist menthol. CONCLUSIONS In the newly designed CPP model, our findings highlighted the potential utility of intrathecal 2R, 6R-HNK for preventing and therapeutic modality of CPP. TRPA1-mediated uprgulation of CGRP and neuronal hyperexcitability in nociceptive pathways may undertake both unique characteristics and solving process of CPP.
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Affiliation(s)
- An-Ran Liu
- Department of Anesthesiology and Pain Clinic, First Affiliated Hospital of Sun Yat-Sen University, No.58, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Zhen-Jia Lin
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Ming Wei
- Department of Anesthesiology and Pain Clinic, First Affiliated Hospital of Sun Yat-Sen University, No.58, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Yuan Tang
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Hui Zhang
- Department of Anesthesiology, Guangdong Second Provincial General Hospital, No.466, Mid Xingang Road, Haizhu District, Guangzhou, 510317, China
| | - Xiang-Ge Peng
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Ying Li
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Yu-Fan Zheng
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Zhi Tan
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China.
| | - Li-Jun Zhou
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China.
| | - Xia Feng
- Department of Anesthesiology and Pain Clinic, First Affiliated Hospital of Sun Yat-Sen University, No.58, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China.
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Fabregat-Cid G, Cedeño DL, Harutyunyan A, Rodríguez-López R, Monsalve-Dolz V, Mínguez-Martí A, Hernández-Cádiz MJ, Escrivá-Matoses N, Villanueva-Pérez V, Asensio Samper JM, De Andrés J, Vallejo R. Effect of Conventional Spinal Cord Stimulation on Serum Protein Profile in Patients With Persistent Spinal Pain Syndrome: A Case-Control Study. Neuromodulation 2023; 26:1441-1449. [PMID: 37516956 DOI: 10.1016/j.neurom.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/30/2023] [Accepted: 05/30/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS) provides pain relief for most patients with persistent spinal pain syndrome type 2 (PSPS 2). Evidence is mounting on molecular changes induced by SCS as one of the mechanisms to explain pain improvement. We report the SCS effect on serum protein expression in vivo in patients with PSPS 2. MATERIALS AND METHODS Serum proteins were identified and quantified using mass spectrometry. Proteins with significantly different expression among patients with PSPS 2 relative to controls, responders, and nonresponders to SCS, or significantly modulated by SCS relative to baseline, were identified. Those most correlated with the presence and time course of pain were selected using multivariate discriminant analysis. Bioinformatic tools were used to identify related biological processes. RESULTS Thirty patients with PSPS 2, of whom 23 responded to SCS, were evaluated, together with 14 controls with no pain who also had undergone lumbar spinal surgery. A significant improvement in pain intensity, disability, and quality of life was recorded among responders. Five proteins differed significantly at baseline between patients with PSPS 2 and controls, with three proteins, mostly involved in immune processes and inflammation, being downregulated and two, mostly involved in vitamin metabolism, synaptic transmission, and restorative processes, being upregulated. In addition, four proteins, mostly related to immune processes and inflammation, decreased significantly, and three, mostly related to iron metabolism and containment of synaptic sprouting, increased significantly during SCS. CONCLUSION This study identifies various biological processes that may underlie PSPS 2 pain and SCS therapeutic effects, including the modulation of neuroimmune response and inflammation, synaptic sprouting, vitamin and iron metabolism, and restorative processes.
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Affiliation(s)
- Gustavo Fabregat-Cid
- Multidisciplinary Pain Management Department, University General Hospital, Valencia, Spain; Surgery Department, Medical School, University of Valencia, Valencia, Spain.
| | | | - Anushik Harutyunyan
- Multidisciplinary Pain Management Department, University General Hospital, Valencia, Spain
| | | | - Vicente Monsalve-Dolz
- Multidisciplinary Pain Management Department, University General Hospital, Valencia, Spain
| | - Ana Mínguez-Martí
- Multidisciplinary Pain Management Department, University General Hospital, Valencia, Spain
| | | | | | | | - Juan Marcos Asensio Samper
- Multidisciplinary Pain Management Department, University General Hospital, Valencia, Spain; Surgery Department, Medical School, University of Valencia, Valencia, Spain
| | - José De Andrés
- Multidisciplinary Pain Management Department, University General Hospital, Valencia, Spain; Surgery Department, Medical School, University of Valencia, Valencia, Spain
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Van Zundert J, Liem L, Joosten B. Maarten van Kleef, MD, PhD, FIPP - 1953-2022. Neuromodulation 2022; 25:S1094-7159(22)00596-7. [PMID: 35562263 DOI: 10.1016/j.neurom.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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van Velzen M, Dahan JD, van Dorp EL, Mogil JS, Hooijmans CR, Dahan A. Efficacy of ketamine in relieving neuropathic pain: a systematic review and meta-analysis of animal studies. Pain 2021; 162:2320-2330. [PMID: 33790195 PMCID: PMC8374709 DOI: 10.1097/j.pain.0000000000002231] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 12/09/2022]
Abstract
ABSTRACT In humans, proof of long-term efficacy of ketamine treatment in neuropathic pain is lacking. To improve our understanding of ketamine behavior under various administration conditions, we performed a systematic review and meta-analyses of controlled studies on the efficacy of ketamine in mice and rats with a disease model of nerve injury on relief of allodynia. Searches in PubMed and EMBASE identified 31 unique studies. Four meta-analyses were conducted. The first analysis included 19 comparisons on a single ketamine dose and measurement of effect within 3 hours of dosing and showed an appreciable effect (standardized mean difference 1.6, 95% confidence interval 1.1-2.1). Subgroup analyses showed no effect of species, administration route, or dose. A single administration was insufficient to sustain relief of allodynia at 24 or 72 hours after dosing, as observed in our second analysis (7 comparisons) with similar effects in ketamine-treated and control animals. Chronic ketamine administration (9 comparisons) caused profound relief of allodynia when tested during ketamine exposure (effect size 5.1, 3.7-6.5). The final analysis (6 comparisons) showed that chronic administration caused a slow loss of relief of allodynia with 70% loss of effect 24 days after end of treatment. No subgroups analyses were possible in the last 3 meta-analyses due to small group sizes. These results indicate long-term ketamine anti-allodynic effects after chronic exposure (>3 days) but not after a single administration. Given several limitations, extrapolation of the animal data to the human condition is tenuous.
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Affiliation(s)
- Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jack D.C. Dahan
- Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Eveline L.A van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeffrey S. Mogil
- Department of Psychology and Anesthesia, McGill University, Montreal, Canada
| | - Carlijn R. Hooijmans
- Department of Health Evidence unit SYRCLE and Department of Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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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: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Heijmans L, Mons MR, Joosten EA. A systematic review on descending serotonergic projections and modulation of spinal nociception in chronic neuropathic pain and after spinal cord stimulation. Mol Pain 2021; 17:17448069211043965. [PMID: 34662215 PMCID: PMC8527581 DOI: 10.1177/17448069211043965] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/01/2021] [Accepted: 08/16/2021] [Indexed: 12/11/2022] Open
Abstract
Chronic neuropathic pain is a debilitating ordeal for patients worldwide and pharmacological treatment efficacy is still limited. As many pharmacological interventions for neuropathic pain often fail, insights into the underlying mechanism and role of identified receptors is of utmost importance. An important target for improving treatment of neuropathic pain is the descending serotonergic system as these projections modulate nociceptive signaling in the dorsal horn. Also with use of last resort treatments like spinal cord stimulation (SCS), the descending serotonergic projections are known to be involved in the pain relieving effect. This systematic review summarizes the involvement of the serotonergic system on nociceptive modulation in the healthy adult rodent and the chronic neuropathic rodent and summarizes all available literature on the serotonergic system in the SCS-treated neuropathic rodent. Medline, Embase and Pubmed databases were used in the search for articles. Descending serotonergic modulation of nociceptive signaling in spinal dorsal horn in normal adult rat is mainly inhibitory and mediated by 5-HT1a, 5-HT1b, 5-HT2c, 5-HT3 and 5-HT4 receptors. Upon injury and in the neuropathic rat, this descending serotonergic modulation becomes facilitatory via activation of the 5-HT2a, 5-HT2b and 5-HT3 receptors. Analgesia due to neuromodulatory intervention like SCS restores the inhibitory function of the descending serotonergic system and involves 5-HT2, 5-HT3 and 5-HT4 receptors. The results of this systematic review provide insights and suggestions for further pharmacological and or neuromodulatory treatment of neuropathic pain based on targeting selected serotonergic receptors related to descending modulation of nociceptive signaling in spinal dorsal horn. With the novel developed SCS paradigms, the descending serotonergic system will be an important target for mechanism-based stimulation induced analgesia.
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Affiliation(s)
- Lonne Heijmans
- Department of Anesthesiology and Pain Management, Maastricht
University Medical Centre, the Netherlands
- Department of Translational Neuroscience, School of Mental
Health and Neuroscience, Maastricht University, the Netherlands
| | - Martijn R Mons
- Department of Anesthesiology and Pain Management, Maastricht
University Medical Centre, the Netherlands
- Department of Translational Neuroscience, School of Mental
Health and Neuroscience, Maastricht University, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht
University Medical Centre, the Netherlands
- Department of Translational Neuroscience, School of Mental
Health and Neuroscience, Maastricht University, the Netherlands
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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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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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Meuwissen KPV, van Beek M, Joosten EAJ. Burst and Tonic Spinal Cord Stimulation in the Mechanical Conflict-Avoidance System: Cognitive-Motivational Aspects. Neuromodulation 2019; 23:605-612. [PMID: 30974021 PMCID: PMC7496869 DOI: 10.1111/ner.12955] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/12/2019] [Accepted: 03/06/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Clinical research suggests that a novel spinal cord stimulation (SCS) waveform, known as Burst-SCS, specifically targets cognitive-motivational aspects of pain. The objective of the present study was to assess the cognitive-motivational aspects of Tonic- and Burst SCS-induced pain relief, by means of exit latency in the mechanical conflict-avoidance system (MCAS), in a rat model of chronic neuropathic pain. METHODS Exit latency on the MCAS operant testing setup was evaluated at various probe heights for rats (n = 26) with chronic neuropathic pain induced by a partial sciatic nerve ligation (PSNL). Von Frey paw withdrawal analysis was performed to assess mechanical hypersensitivity. In a second experiment (n = 12), the behavioral effect of Tonic SCS or biphasic Burst SCS on both Von Frey analysis and MCAS exit latency was assessed. RESULTS Burst SCS exit latencies differed significantly from Tonic SCS exit latencies at 4 mm probe height (3.8 vs. 5.8 sec, respectively; p < 0.01) and 5 mm probe height (3.2 vs. 5.4 sec respectively; p < 0.05). This difference was not detected with reflex-based Von Frey testing (Tonic-SCS vs. Burst-SCS at 30 min stimulation: p = 0.73, and at 60 min stimulation; p = 0.42). CONCLUSIONS Testing of MCAS exit latency allows for detection of cognitive-motivational pain relieving aspects induced by either Tonic- or Burst-SCS in treatment of chronic neuropathic rats. Our behavioral findings strongly suggest that Burst-SCS specifically affects, much more than Tonic-SCS, the processing of cognitive-motivational aspects of pain.
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Affiliation(s)
- Koen P V Meuwissen
- Department of Anesthesiology and Pain Management, MUMC, Pain Management and Research Centre, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Maarten van Beek
- Department of Anesthesiology and Pain Management, MUMC, Pain Management and Research Centre, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, MUMC, Pain Management and Research Centre, 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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Meuwissen KPV, Gu JW, Zhang TC, Joosten EAJ. Burst Spinal Cord Stimulation in Peripherally Injured Chronic Neuropathic Rats: A Delayed Effect. Pain Pract 2018; 18:988-996. [PMID: 29679457 DOI: 10.1111/papr.12701] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/03/2017] [Accepted: 04/11/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Two well-known spinal cord stimulation (SCS) paradigms, conventional (Con) and burst SCS, are hypothesized to exert their antinociceptive effects through different stimulation-induced mechanisms. We studied the course of the behavioral antinociceptive effect during 60 minutes of SCS and 30 minutes post-SCS in a rat model of chronic neuropathic pain. METHODS Animals underwent a unilateral partial sciatic nerve ligation, after which quadripolar electrodes were implanted into the epidural space at vertebral level T13 (n = 43 rats). While receiving either Con SCS or biphasic burst SCS, the pain behavior of the rats was assessed by means of paw withdrawal thresholds (WTs) in response to the application of von Frey monofilaments. RESULTS After 15 minutes of Con SCS (n = 21), WTs significantly differed from baseline (P = 0.04), whereas WTs of the burst SCS group (n = 22) did not. After 30 minutes of SCS, WTs of the Con SCS and burst SCS groups reached similar levels, both significantly different from baseline, indicating a comparable antinociceptive effect for these SCS paradigms. Yet, the WTs of the burst SCS group were still significantly increased compared with baseline at 30 minutes post-stimulation, whereas the WTs of the Con SCS group were not. CONCLUSIONS To conclude, biphasic burst SCS results in a delayed antinociceptive effect after onset of the stimulation, as compared with Con SCS, in a chronic neuropathic pain model. Furthermore, biphasic burst SCS seems to exhibit a delayed wash-out of analgesia after stimulation is turned off.
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Affiliation(s)
- Koen P V Meuwissen
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, the Netherlands.,Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Jianwen Wendy Gu
- Neuromodulation, Research and Advanced Concepts Team, Boston Scientific, Natick, Massachusetts, U.S.A
| | - Tianhe C Zhang
- Neuromodulation, Research and Advanced Concepts Team, Boston Scientific, Natick, Massachusetts, U.S.A
| | - Elbert A J Joosten
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, the Netherlands.,Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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12
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van Beek M, Hermes D, Honig WM, Linderoth B, van Kuijk SMJ, van Kleef M, Joosten EA. Long-Term Spinal Cord Stimulation Alleviates Mechanical Hypersensitivity and Increases Peripheral Cutaneous Blood Perfusion in Experimental Painful Diabetic Polyneuropathy. Neuromodulation 2018. [PMID: 29522270 PMCID: PMC6099481 DOI: 10.1111/ner.12757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives This study utilizes a model of long‐term spinal cord stimulation (SCS) in experimental painful diabetic polyneuropathy (PDPN) to investigate the behavioral response during and after four weeks of SCS (12 hours/day). Second, we investigated the effect of long‐term SCS on peripheral cutaneous blood perfusion in experimental PDPN. Methods Mechanical sensitivity was assessed in streptozotocin induced diabetic rats (n = 50) with von Frey analysis. Hypersensitive rats (n = 24) were implanted with an internal SCS battery, coupled to an SCS electrode covering spinal levels L2–L5. The effects of four weeks of daily conventional SCS for 12 hours (n = 12) or Sham SCS (n = 12) were evaluated with von Frey assessment, and laser Doppler imaging (LDI). Results Average paw withdrawal thresholds (PWT) increased during long‐term SCS in the SCS group, in contrast to a decrease in the Sham group (Sham vs. SCS; p = 0.029). Twenty‐four hours after long‐term SCS average PWT remained higher in the SCS group. Furthermore, the SCS group showed a higher cutaneous blood perfusion during long‐term SCS compared to the Sham group (Sham vs. SCS; p = 0.048). Forty‐eight hours after long‐term SCS, no differences in skin perfusion were observed. Discussion We demonstrated that long‐term SCS results in decreased baseline mechanical hypersensitivity and results in increased peripheral blood perfusion during stimulation in a rat model of PDPN. Together, these findings indicate that long‐term SCS results in modulation of the physiological circuitry related to the nociceptive system in addition to symptomatic treatment of painful symptoms.
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Affiliation(s)
- Maarten van Beek
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Denise Hermes
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Wiel M Honig
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Bengt Linderoth
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, the Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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13
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Spinal Cord Stimulation for Peripheral Neuropathic Pain. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00049-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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14
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15
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Meuwissen KPV, Gu JW, Zhang TC, Joosten EAJ. Conventional-SCS vs. Burst-SCS and the Behavioral Effect on Mechanical Hypersensitivity in a Rat Model of Chronic Neuropathic Pain: Effect of Amplitude. Neuromodulation 2017; 21:19-30. [PMID: 29178358 DOI: 10.1111/ner.12731] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 09/13/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Various spinal cord stimulation (SCS) modes are used in the treatment of chronic neuropathic pain disorders. Conventional (Con) and Burst-SCS are hypothesized to exert analgesic effects through different stimulation-induced mechanisms. Preclinical electrophysiological findings suggest that stimulation intensity is correlated with the effectiveness of Burst-SCS. Therefore, we aimed to investigate the relation between amplitude (charge per second) and behavioral effects in a rat model of chronic neuropathic pain, for both Conventional Spinal Cord Stimulation (Con-SCS) and biphasic Burst-SCS. MATERIALS AND METHODS Animals (n = 12 rats) received a unilateral partial sciatic nerve ligation, after which they were implanted with quadripolar electrodes in the epidural space at thoracic level 13. Mechanical hypersensitivity was assessed using paw withdrawal thresholds (WTs) to von Frey monofilaments, at various SCS intensities (amplitudes) and multiple time points during 60 minutes of stimulation and 30 minutes post stimulation. RESULTS Increasing amplitude was shown to improve the efficacy of Con-SCS, whereas the efficacy of Burst-SCS showed a non-monotonic relation with amplitude. Con-SCS at 66% MT (n = 5) and Burst-SCS at 50% MT (n = 6) were found to be equally effective in normalizing mechanical hypersensitivity. However, in the assessed time period Burst-SCS required significantly more mean charge per second to do so (p < 0.01). When applied at comparable mean charge per second, Con-SCS resulted in a superior behavioral outcome (p < 0.01), compared with Burst-SCS. CONCLUSION Biphasic Burst-SCS requires significantly more mean charge per second in order to achieve similar pain relief, as compared with Con-SCS, in an experimental model of chronic neuropathic pain.
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Affiliation(s)
- Koen P V Meuwissen
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Jianwen Wendy Gu
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, CA, USA
| | - Tianhe C Zhang
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, CA, USA
| | - Elbert A J Joosten
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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16
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Lind AL, Emami Khoonsari P, Sjödin M, Katila L, Wetterhall M, Gordh T, Kultima K. Spinal Cord Stimulation Alters Protein Levels in the Cerebrospinal Fluid of Neuropathic Pain Patients: A Proteomic Mass Spectrometric Analysis. Neuromodulation 2017; 19:549-62. [PMID: 27513633 DOI: 10.1111/ner.12473] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 06/07/2016] [Accepted: 06/09/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Electrical neuromodulation by spinal cord stimulation (SCS) is a well-established method for treatment of neuropathic pain. However, the mechanism behind the pain relieving effect in patients remains largely unknown. In this study, we target the human cerebrospinal fluid (CSF) proteome, a little investigated aspect of SCS mechanism of action. METHODS Two different proteomic mass spectrometry protocols were used to analyze the CSF of 14 SCS responsive neuropathic pain patients. Each patient acted as his or her own control and protein content was compared when the stimulator was turned off for 48 hours, and after the stimulator had been used as normal for three weeks. RESULTS Eighty-six proteins were statistically significantly altered in the CSF of neuropathic pain patients using SCS, when comparing the stimulator off condition to the stimulator on condition. The top 12 of the altered proteins are involved in neuroprotection (clusterin, gelsolin, mimecan, angiotensinogen, secretogranin-1, amyloid beta A4 protein), synaptic plasticity/learning/memory (gelsolin, apolipoprotein C1, apolipoprotein E, contactin-1, neural cell adhesion molecule L1-like protein), nociceptive signaling (neurosecretory protein VGF), and immune regulation (dickkopf-related protein 3). CONCLUSION Previously unknown effects of SCS on levels of proteins involved in neuroprotection, nociceptive signaling, immune regulation, and synaptic plasticity are demonstrated. These findings, in the CSF of neuropathic pain patients, expand the picture of SCS effects on the neurochemical environment of the human spinal cord. An improved understanding of SCS mechanism may lead to new tracks of investigation and improved treatment strategies for neuropathic pain.
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Affiliation(s)
- Anne-Li Lind
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Payam Emami Khoonsari
- Department of Medical Sciences, Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
| | - Marcus Sjödin
- Department of Chemistry-BMC, Analytical Chemistry, Uppsala University, Uppsala//GE Healthcare, Sweden
| | - Lenka Katila
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Magnus Wetterhall
- Department of Chemistry-BMC, Analytical Chemistry, Uppsala University, Uppsala//GE Healthcare, Sweden
| | - Torsten Gordh
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Kim Kultima
- Department of Medical Sciences, Cancer Pharmacology and Computational Medicine, Uppsala University, Uppsala, Sweden
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Sun L, Tai L, Qiu Q, Mitchell R, Fleetwood-Walker S, Joosten EA, Cheung CW. Endocannabinoid activation of CB 1 receptors contributes to long-lasting reversal of neuropathic pain by repetitive spinal cord stimulation. Eur J Pain 2017; 21:804-814. [PMID: 28107590 DOI: 10.1002/ejp.983] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) has been shown to be effective in the management of certain neuropathic pain conditions, however, the underlying mechanisms are incompletely understood. In this study, we investigated repetitive SCS in a rodent neuropathic pain model, revealing long-lasting and incremental attenuation of hyperalgesia and a mechanism of action involving endocannabinoids. METHOD Animals were implanted with monopolar electrodes at the time of partial sciatic nerve injury. Dorsal columns at spinal segments T12/13 were stimulated 3 days later (early SCS), and again at day 7 (late SCS) using low-frequency parameters. Hypersensitivity to cutaneous mechanical stimuli was assessed using von Frey filaments. Pharmacological agents, selected to identify endocannabinoid and opioid involvement, were administered intraperitoneally, 10 min before SCS. RESULTS Early SCS caused partial reversal of mechanical hypersensitivity with corresponding changes in the biomarker of central sensitization, [phospho-Tyr1472 ]-GluN2B. The partial reversal of hyperalgesia by early SCS was amplified by co-administration of LY 2183240, an inhibitor of endocannabinoid reuptake/breakdown. This amplification was inhibited by a CB1 R antagonist, AM251, but not by a CB2 R antagonist, AM630. Early SCS-induced reversal of hyperalgesia was attenuated by naloxone, indicating a role for opioids. Late SCS resulted in an incremental level of reversal of hyperalgesia, which was inhibited by AM251, but not by CB2 or opioid receptor antagonists. CONCLUSION The endocannabinoid system, and in particular the CB1 R, plays a pivotal role in the long-lasting and incremental reversal of hyperalgesia induced by repetitive SCS in a neuropathic pain model. SIGNIFICANCE Alternative parameters for repetitive spinal cord stimulation (SCS) at 25/10 Hz elicit particularly long-lasting and incremental reversal of hyperalgesia in a neuropathic pain model through a mechanism involving endocannabinoids.
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Affiliation(s)
- L Sun
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, HKSAR, China
| | - L Tai
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, HKSAR, China
| | - Q Qiu
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, HKSAR, China
| | - R Mitchell
- Centre for Integrative Physiology, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, UK
| | - S Fleetwood-Walker
- Centre for Integrative Physiology, Edinburgh Medical School: Biomedical Sciences, The University of Edinburgh, UK
| | - E A Joosten
- Department of Anesthesiology/Pain Management, The University Pain Center Maastricht, Maastricht University Medical Center, The Netherlands
| | - C W Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, HKSAR, China
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18
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Yamamoto T, Watanabe M, Obuchi T, Kano T, Kobayashi K, Oshima H, Fukaya C, Yoshino A. Importance of Pharmacological Evaluation in the Treatment of Poststroke Pain by Spinal Cord Stimulation. Neuromodulation 2016; 19:744-751. [DOI: 10.1111/ner.12408] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 01/04/2016] [Accepted: 01/12/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Takamitsu Yamamoto
- Division of Applied System Neuroscience, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
| | - Mitsuru Watanabe
- Division of Applied System Neurosurgery, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
| | - Toshiki Obuchi
- Division of Applied System Neurosurgery, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
| | - Toshikazu Kano
- Division of Applied System Neurosurgery, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
| | - Kazutaka Kobayashi
- Division of Applied System Neurosurgery, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
| | - Hideki Oshima
- Division of Applied System Neurosurgery, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
| | - Chikashi Fukaya
- Division of Applied System Neuroscience, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
| | - Atsuo Yoshino
- Division of Applied System Neurosurgery, Department of Neurological Surgery; Nihon University School of Medicine; Tokyo Japan
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A Multiplex Protein Panel Applied to Cerebrospinal Fluid Reveals Three New Biomarker Candidates in ALS but None in Neuropathic Pain Patients. PLoS One 2016; 11:e0149821. [PMID: 26914813 PMCID: PMC4767403 DOI: 10.1371/journal.pone.0149821] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/04/2016] [Indexed: 12/13/2022] Open
Abstract
The objective of this study was to develop and apply a novel multiplex panel of solid-phase proximity ligation assays (SP-PLA) requiring only 20 μL of samples, as a tool for discovering protein biomarkers for neurological disease and treatment thereof in cerebrospinal fluid (CSF). We applied the SP-PLA to samples from two sets of patients with poorly understood nervous system pathologies amyotrophic lateral sclerosis (ALS) and neuropathic pain, where patients were treated with spinal cord stimulation (SCS). Forty-seven inflammatory and neurotrophic proteins were measured in samples from 20 ALS patients and 15 neuropathic pain patients, and compared to normal concentrations in CSF from control individuals. Nineteen of the 47 proteins were detectable in more than 95% of the 72 controls. None of the 21 proteins detectable in CSF from neuropathic pain patients were significantly altered by SCS. The levels of the three proteins, follistatin, interleukin-1 alpha, and kallikrein-5 were all significantly reduced in the ALS group compared to age-matched controls. These results demonstrate the utility of purpose designed multiplex SP-PLA panels in CSF biomarker research for understanding neuropathological and neurotherapeutic mechanisms. The protein changes found in the CSF of ALS patients may be of diagnostic interest.
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20
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Tilley DM, Vallejo R, Kelley CA, Benyamin R, Cedeño DL. A continuous spinal cord stimulation model attenuates pain-related behavior in vivo following induction of a peripheral nerve injury. Neuromodulation 2015; 18:171-6; discussion 176. [PMID: 25683886 DOI: 10.1111/ner.12280] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 11/17/2014] [Accepted: 12/31/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Models that simulate clinical conditions are needed to gain an understanding of the mechanism involved during spinal cord stimulation (SCS) treatment of chronic neuropathic pain. An animal model has been developed for continuous SCS in which animals that have been injured to develop neuropathic pain behavior were allowed to carry on with regular daily activities while being stimulated for 72 hours. MATERIAL AND METHODS Sprague-Dawley rats were randomized into each of six different groups (N = 10-13). Three groups included animals in which the spared nerve injury (SNI) was induced. Animals in two of these groups were implanted with a four-contact electrode in the epidural space. Animals in one of these groups received stimulation for 72 hours continuously. Three corresponding sham groups (no SNI) were included. Mechanical and cold-thermal allodynia were evaluated using von Frey filaments and acetone drops, respectively. Mean withdrawal thresholds were compared. Statistical significance was established using one-way ANOVAs followed by Holm-Sidak post hoc analysis. RESULTS Continuous SCS attenuates mechanical allodynia in animals with neuropathic pain behavior. Mechanical withdrawal threshold increases significantly in SNI animals after 24 and 72 hours stimulation vs. SNI no stimulation (p = 0.007 and p < 0.001, respectively). SCS for 24 and 72 hours provides significant increase in mechanical withdrawal thresholds relative to values before stimulation (p = 0.001 and p < 0.001, respectively). Stimulation did not provide recovery to baseline values. SCS did not seem to attenuate cold-thermal allodynia. CONCLUSION A continuous SCS model has been developed. Animals with neuropathic pain behavior that were continuously stimulated showed significant increase in withdrawal thresholds proportional to stimulation time.
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Affiliation(s)
- Dana M Tilley
- Basic Science, Millennium Pain Center, Bloomington, IL, USA; School of Biological Sciences, Illinois State University, Normal, IL, USA
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Kumar K, Caraway DL, Rizvi S, Bishop S. Current challenges in spinal cord stimulation. Neuromodulation 2015; 17 Suppl 1:22-35. [PMID: 24974773 DOI: 10.1111/ner.12172] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 11/25/2013] [Accepted: 12/14/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aims to review the current state of spinal cord stimulation for the treatment of chronic pain associated with failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) and to describe intraspinal targets and stimulation parameters, patient selection, therapy cost-effectiveness, and strategies to improve outcomes. MATERIALS AND METHODS We drew on professional literature spanning four decades, our work with national and international professional societies, and our own extensive clinical experience to summarize contemporary knowledge of the safety, efficacy, cost-efficiency, and challenges associated with spinal cord stimulation in treating chronic pain. RESULTS The safety, efficacy, and cost-efficiency of spinal cord stimulation in treating chronic pain associated with FBSS and CRPS are well established through randomized controlled trials and long-term observational studies. Challenges include reducing wait-times before implant, which are associated with lower success rates; increasing awareness of this therapy among referring physicians, patients, and payers; decreasing device-related complications by incorporating advanced technology, improved operative and trialing techniques, and appropriate patient selection; and capturing functional and quality-of-life outcomes. Spinal cord stimulation must be part of an overall treatment plan to manage chronic pain, and must engage physicians, patients, their families, pharmacists, nursing staff, and mental health experts in supporting a return to employment, if possible, and to a full domestic and social life. CONCLUSIONS Innovation in spinal cord stimulation therapy has intensified with numerous new technical capabilities, safety advances, and novel stimulation targets. This progress holds hope for the many sufferers of chronic pain.
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Affiliation(s)
- Krishna Kumar
- Section of Neurosurgery, Department of Surgery, Regina General Hospital, University of Saskatchewan, Regina, SK, Canada
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23
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Voet C, le Polain de Waroux B, Forget P, Deumens R, Masquelier E. Spinal cord stimulation for complex regional pain syndrome type 1 with dystonia: a case report and discussion of the literature. F1000Res 2014; 3:97. [PMID: 25254100 PMCID: PMC4168752 DOI: 10.12688/f1000research.3771.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2014] [Indexed: 11/20/2022] Open
Abstract
Background: Complex Regional Pain Syndrome type 1 (CRPS-1) is a debilitating chronic pain disorder, the physiopathology of which can lead to dystonia associated with changes in the autonomic, central and peripheral nervous system. An interdisciplinary approach (pharmacological, interventional and psychological therapies in conjunction with a rehabilitation pathway) is central to progress towards pain reduction and restoration of function.Aim: This case report aims to stimulate reflection and development of mechanism-based therapeutic strategies concerning CRPS associated with dystonia.Case description: A 31 year old female CRPS-1 patient presented with dystonia of the right foot following ligamentoplasty for chronic ankle instability. She did not have a satisfactory response to the usual therapies. Multiple anesthetic blocks (popliteal, epidural and intrathecal) were not associated with significant anesthesia and analgesia. Mobilization of the foot by a physiotherapist was not possible. A multidisciplinary approach with psychological support, physiotherapy and spinal cord stimulation (SCS) brought pain relief, rehabilitation and improvement in the quality of life.Conclusion: The present case report demonstrates the occurrence of multilevel (peripheral and central) pathological modifications in the nervous system of a CRPS-1 patient with dystonia. This conclusion is based on the patient’s pain being resistant to anesthetic blocks at different levels and the favourable, at least initially, response to SCS. The importance of the bio-psycho-social model is also suggested, permitting behavioural change.
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Affiliation(s)
- Caroline Voet
- Rehabilitation Medicine, Université Catholique de Louvain, Brussels, Belgium
- Multidisciplinary Reference Unit for Chronic Pain, Université Catholique de Louvain, Brussels, Belgium
| | - Bernard le Polain de Waroux
- Multidisciplinary Reference Unit for Chronic Pain, Université Catholique de Louvain, Brussels, Belgium
- Anaesthesiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
- Neuropharmacology Unit, pole CEMO, Université Catholique de Louvain, Brussels, Belgium
| | - Patrice Forget
- Multidisciplinary Reference Unit for Chronic Pain, Université Catholique de Louvain, Brussels, Belgium
- Anaesthesiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
- Neuropharmacology Unit, pole CEMO, Université Catholique de Louvain, Brussels, Belgium
| | - Ronald Deumens
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
- Neuropharmacology Unit, pole CEMO, Université Catholique de Louvain, Brussels, Belgium
| | - Etienne Masquelier
- Rehabilitation Medicine, Université Catholique de Louvain, Brussels, Belgium
- Multidisciplinary Reference Unit for Chronic Pain, Université Catholique de Louvain, Brussels, Belgium
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
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Sato K, King E, Johanek L, Sluka K. Spinal cord stimulation reduces hypersensitivity through activation of opioid receptors in a frequency-dependent manner. Eur J Pain 2012; 17:551-61. [DOI: 10.1002/j.1532-2149.2012.00220.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2012] [Indexed: 11/10/2022]
Affiliation(s)
- K.L. Sato
- Physical Therapy and Rehabilitation Science, Carver College of Medicine; The University of Iowa; USA
| | - E.W. King
- Department of Anesthesia; Carver College of Medicine; The University of Iowa; USA
| | | | - K.A. Sluka
- Physical Therapy and Rehabilitation Science, Carver College of Medicine; The University of Iowa; USA
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Spinal cord stimulation: neurophysiological and neurochemical mechanisms of action. Curr Pain Headache Rep 2012; 16:217-25. [PMID: 22399391 DOI: 10.1007/s11916-012-0260-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic neuropathic pain can significantly reduce quality of life and place an economic burden on individuals and society. Spinal cord stimulation (SCS) is an alternative approach to the treatment of neuropathic pain when standard pharmacological agents have failed. However, an improved understanding of the mechanisms by which SCS inhibits pain is needed to enhance its clinical utility. This review summarizes important findings from recent studies of SCS in animal models of neuropathic pain, highlights current understanding of the spinal neurophysiological and neurochemical mechanisms by which SCS produces an analgesic effect, and discusses the potential clinical applicability of these findings and future directions for research.
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Smits H, van Kleef M, Holsheimer J, Joosten EAJ. Experimental spinal cord stimulation and neuropathic pain: mechanism of action, technical aspects, and effectiveness. Pain Pract 2012; 13:154-68. [PMID: 22780956 DOI: 10.1111/j.1533-2500.2012.00579.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Spinal cord stimulation (SCS) is a valuable treatment for chronic intractable neuropathic pain. Although SCS has gone through a technological revolution over the last four decades, the neurophysiologic and biochemical mechanisms of action have only been partly elucidated. Animal experimental work has provided some evidence for spinal as well as supraspinal mechanisms of neuropathic pain relief of SCS. A SCS computer model of the electrical properties of the human spinal cord revealed many basic neurophysiologic principles that were clinically validated later on. The main question in clinical SCS is how to further improve the effectiveness of SCS as there is still a significant failure rate of 30%. In this context, experimental studies are needed to elucidate which target pain neuron(s) are involved, as well as with what exact electrical stimulation this target neuron can be influenced to produce an optimal supapression of neuropathic pain. This article reviews the basic clinical and experimental technical aspects in relation to the effectiveness of SCS in view of recent understanding of the dorsal horn pain circuit involved. These data may then result in experiments needed for an improved understanding of the mechanisms underlying SCS and consequently lead to improvement and increased effectiveness of SCS in neuropathic pain as a clinical therapy.
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Affiliation(s)
- Helwin Smits
- Department of Anaesthesiology and Pain Management, Pain Management and Research Centre, Maastricht University Hospital, Maastricht, The Netherlands
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Lee N, Vasudevan S. Spinal cord stimulation use in patients with failed back surgery syndrome. Pain Manag 2012; 2:135-40. [DOI: 10.2217/pmt.12.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The increase in failed back surgery syndrome (FBSS) cases in the USA has been paralleled by an increase in the number of spinal cord stimulation (SCS) treatments performed. Over the last 40 years, SCS technique has improved drastically and has been shown to be efficacious in FBSS patients with radiculopathy and neuropathic pain. This article will focus on the current patient selection process of SCS in the setting of FBSS, with a review of pertinent clinical trials and current evidence-based guidelines. The current working mechanism of SCS, complications surrounding SCS and the definition of FBSS will also be briefly discussed.
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Affiliation(s)
- Nancy Lee
- Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226-3548, USA
| | - Sridhar Vasudevan
- Wisconsin Rehabilitation Medicine Professionals, SC PO Box 240860, Milwaukee, WI 53224, USA
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