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Sun Y, Xiao Z, Chen B, Zhao Y, Dai J. Advances in Material-Assisted Electromagnetic Neural Stimulation. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2400346. [PMID: 38594598 DOI: 10.1002/adma.202400346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/26/2024] [Indexed: 04/11/2024]
Abstract
Bioelectricity plays a crucial role in organisms, being closely connected to neural activity and physiological processes. Disruptions in the nervous system can lead to chaotic ionic currents at the injured site, causing disturbances in the local cellular microenvironment, impairing biological pathways, and resulting in a loss of neural functions. Electromagnetic stimulation has the ability to generate internal currents, which can be utilized to counter tissue damage and aid in the restoration of movement in paralyzed limbs. By incorporating implanted materials, electromagnetic stimulation can be targeted more accurately, thereby significantly improving the effectiveness and safety of such interventions. Currently, there have been significant advancements in the development of numerous promising electromagnetic stimulation strategies with diverse materials. This review provides a comprehensive summary of the fundamental theories, neural stimulation modulating materials, material application strategies, and pre-clinical therapeutic effects associated with electromagnetic stimulation for neural repair. It offers a thorough analysis of current techniques that employ materials to enhance electromagnetic stimulation, as well as potential therapeutic strategies for future applications.
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Affiliation(s)
- Yuting Sun
- State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and developmental Biology, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Zhifeng Xiao
- State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and developmental Biology, Chinese Academy of Sciences, Beijing, 100101, China
| | - Bing Chen
- State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and developmental Biology, Chinese Academy of Sciences, Beijing, 100101, China
| | - Yannan Zhao
- State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and developmental Biology, Chinese Academy of Sciences, Beijing, 100101, China
| | - Jianwu Dai
- State Key Laboratory of Molecular Developmental Biology, Institute of Genetics and developmental Biology, Chinese Academy of Sciences, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
- Tianjin Key Laboratory of Biomedical Materials, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300192, China
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Abd-Elsayed A, Keith MK, Cao NN, Fiala KJ, Martens JM. Temporary Peripheral Nerve Stimulation as Treatment for Chronic Pain. Pain Ther 2023; 12:1415-1426. [PMID: 37737951 PMCID: PMC10616055 DOI: 10.1007/s40122-023-00557-3] [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: 07/09/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION Chronic pain is a growing problem across the world, and in the midst of an opioid epidemic, it is imperative that alternative treatment measures are identified to help alleviate the pain experienced by these patients. Chronic pain greatly affects ones quality of life and many patients do not experience adequate relief with conventional treatment measures. The purpose of this retrospective analysis is to assess the efficacy of peripheral nerve stimulation (PNS) therapy in adult patients suffering from chronic pain refractory to conventional treatment measures who underwent therapy on various anatomical locations. METHODS This retrospective analysis consisted of data collected from electronic health records for n = 89 patients who underwent PNS therapy. Data collected relates to patient age, sex, weight, height, body mass index (BMI), diagnosis, targeted nerves, follow-up encounters, pain scores from before and after PNS therapy, and duration of improvement. Statistical analysis used SPSS software, version 26 (IBM), using a paired t test to assess significance between pre and post PNS therapy pain scores. P values were significant if found to be ≤ 0.05. Further analysis assessed the correlation between age and BMI with visual analog scale (VAS) pain improvement and subjective percentage pain relief. RESULTS The mean pre-operative (pre-op) pain score before PNS therapy was 6.36 (standard deviation (SD) = 2.18, SEM = 0.23) and the mean post-operative (post-op) pain score after PNS therapy was 4.19 (SD = 2.70, SEM = 0.29). The mean patient-reported percent improvement in pain following PNS therapy was 49.04% (SD = 34.79). The improvement in pain scores between pre-op and post-op was statistically significant (M = 2.17, SD = 2.82, SEM = 0.30, t(88) = 7.26, p < .001), 95% confidence interval (CI) [1.57, 2.76]. The mean duration of improvement for patients was 123 days after therapy initiation (min = 6, max = 683, SD = 126). CONCLUSIONS This study demonstrated the potential role for PNS therapy in improving patient-reported pain levels for various neuropathies, targeting various nerves. With PNS therapy's use as a chronic pain treatment and available research being limited, further study needs to be done on the efficacy of PNS therapy for pain management and complications associated with PNS device placements at various locations.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA.
| | - Mitchell K Keith
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - Nancy N Cao
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - Kenneth J Fiala
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - Joshua M Martens
- Department of Anesthesiology, Division of Chronic Pain Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
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Cho AM, Xiong JS, Burns SL. The Emerging Role of Peripheral Nerve Stimulation in Postoperative Analgesia. Curr Pain Headache Rep 2023; 27:601-605. [PMID: 37556045 DOI: 10.1007/s11916-023-01159-6] [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] [Accepted: 06/28/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE OF REVIEW Though peripheral nerve stimulation has long been utilized in the field of chronic pain management, its use in acute pain management in the postoperative period is relatively novel and warrants further consideration. RECENT FINDINGS In the postsurgical period, peripheral nerve stimulation may offer an additional low-risk, opioid-sparing analgesic option, which is particularly pertinent in the setting of the ongoing opioid epidemic, as inadequate postsurgical analgesia has been shown to increase the risk of developing persistent or chronic postsurgical pain. In this review, we discuss the current literature that illustrate the emerging role of peripheral nerve stimulation as an effective treatment modality in the postoperative period for the management of acute pain, as various studies have recently been conducted evaluating the feasibility of utilizing percutaneous peripheral nerve stimulation as an adjunct in postsurgical analgesia. Nonetheless, future studies are necessary to continue to elucidate the short- and long-term impacts of peripheral nerve stimulation use in acute postsurgical analgesia.
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Affiliation(s)
- Annie M Cho
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jennifer S Xiong
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Stacey L Burns
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Ong Sio LC, Hom B, Garg S, Abd-Elsayed A. Mechanism of Action of Peripheral Nerve Stimulation for Chronic Pain: A Narrative Review. Int J Mol Sci 2023; 24:ijms24054540. [PMID: 36901970 PMCID: PMC10003676 DOI: 10.3390/ijms24054540] [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: 01/12/2023] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
The use of stimulation of peripheral nerves to test or treat various medical disorders has been prevalent for a long time. Over the last few years, there has been growing evidence for the use of peripheral nerve stimulation (PNS) for treating a myriad of chronic pain conditions such as limb mononeuropathies, nerve entrapments, peripheral nerve injuries, phantom limb pain, complex regional pain syndrome, back pain, and even fibromyalgia. The ease of placement of a minimally invasive electrode via percutaneous approach in the close vicinity of the nerve and the ability to target various nerves have led to its widespread use and compliance. While most of the mechanism behind its role in neuromodulation is largely unknown, the gate control theory proposed by Melzack and Wall in the 1960s has been the mainstay for understanding its mechanism of action. In this review article, the authors performed a literature review to discuss the mechanism of action of PNS and discuss its safety and usefulness in treating chronic pain. The authors also discuss current PNS devices available in the market today.
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Affiliation(s)
- Lady Christine Ong Sio
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Brian Hom
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Shuchita Garg
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA
- Correspondence: ; Tel.: +1-608-263-8100; Fax: +1-608-263-0575
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Abd-Elsayed A, Moghim R. Efficacy of Peripheral Nerve Stimulation with a High Frequency Electromagnetic Coupled (HF-EMC) Powered Implanted Receiver in Treating Different Pain Targets/Neuralgias. J Pain Res 2023; 16:589-596. [PMID: 36861112 PMCID: PMC9969801 DOI: 10.2147/jpr.s399532] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Chronic pain is a significant global public health problem. Peripheral nerve stimulation (PNS) has been gaining popularity in recent years as it is effective, safe and less invasive than surgery for the treatment of chronic pain. The authors aimed to document and share a collection of patient-reported pain scores before and after implanting a percutaneous PNS lead/s with an external wireless generator at various target nerves. Methods The authors designed a retrospective study, reviewing electronic medical records. Statistical analysis was performed using SPSS 26; p-value ≤ 0.05 was considered significant. Results The mean baseline pain scores of 57 patients have reduced significantly after the procedure at different follow-up durations. Target nerves included genicular nerves, superior cluneal nerves, posterior tibial nerve ± sural nerve, middle cluneal nerves, radial and ulnar nerves and right common peroneal nerve. In the one-month follow-up group, mean pain score was reduced from 7.44 ± 1.48 pre-procedure to 1.6 ± 1.49, from 7.42 ± 1.5 pre-procedure to 1.6 ± 1.5 7.42 at 3 months, from 7.52 ± 1.5 to 1.72 ± 1.57 at 6 months, from 7.41 ± 1.53 to 1.7 ± 1.55 at 9 months, from 7.41 ± 1.58 to 1.76 ± 1.63 at 12 months, from 7.38 ± 1.59 to 1.69 ± 1.56 at 15 months and from 7.5 ± 1.7 to 1.45 ± 1.57 at 24 months (p ≤ 0.001). Patients also reported significant reduction in morphine milliequivalent, pre-procedure MME 47.75 ± 452.5 to 37.92 ± 43.51 at 6 months (p = 0.002, N = 57), pre-procedure MME 42.72 ± 43.19 to 30.38 ± 41.62 at 12 months (p = 0.003, N = 42), and pre-procedure MME 41.2 ± 46.12 to 21.19 ± 40.88 at 24 months (p ≤ 0.001, N = 27). The only complications occurred post procedure with 2 patients receiving an explant and 1 patient receiving a lead migration. Conclusion PNS has been shown to be safe and effective in treating chronic pain at different sites with sustained pain relief for up to 24 months. This study is unique in providing long-term follow-up data.
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Affiliation(s)
- Alaa Abd-Elsayed
- Anesthesiology Department, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA,Correspondence: Alaa Abd-Elsayed, Department of Anesthesiology and Pain Management, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI, 53792-3272, USA, Email
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Managing Chronic Neuropathic Pain: Recent Advances and New Challenges. Neurol Res Int 2022; 2022:8336561. [PMID: 36277331 PMCID: PMC9581623 DOI: 10.1155/2022/8336561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/03/2022] [Accepted: 08/07/2022] [Indexed: 11/17/2022] Open
Abstract
Aim. Neuropathic pain affects 7–10% of the population, with most of the patients receiving inadequate and incomplete treatment. Owing to the high financial burden and the poor quality of life of the patients and their caretakers, there is a dire need to address the challenges in diagnosing and treating chronic neuropathic pain. Methods. This literature review was conducted to review novel treatments and related challenges through a systematic search from sources such as PubMed, Google Scholar with the combination of MESH words such as neuropathic pain, management of neuropathic pain. Articles from non-English literature, reports without human subjects, animal studies, and abstracts/posters were excluded. However, human studies and studies published in English were included. Result. This review article discusses novel treatment modalities while acknowledging the challenges medical workers face while encountering neuropathic pain. Despite the recent advances in diagnosis and treatment modalities, several challenges still exist. Hence, there is still a need to explore the various treatment modalities, emphasizing the cause and underlying pathophysiology of neuropathic pain. Conclusion. We recommend integrated multimodal treatment with the current treatment facility, including various medical disciplines. However, a personalized approach would work the best depending on the ’patient’s medical history. Therefore, this article recommends an integrated, cause-specific, cost-effective approach to address this problem of chronic neuropathic pain.
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Pingree MJ, Hurdle MF, Spinner DA, Valimahomed A, Crosby ND, Boggs JW. Real-world evidence of sustained improvement following 60-day peripheral nerve stimulation treatment for pain: a cross-sectional follow-up survey. Pain Manag 2022; 12:611-621. [PMID: 35510333 DOI: 10.2217/pmt-2022-0005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: This study presents real-world data from a cross-sectional follow-up survey of patients who previously received 60-day peripheral nerve stimulation (PNS) treatment for pain. Materials & methods: A survey including validated pain and other related outcome measures was distributed to patients who previously underwent implantation of temporary PNS leads for 60-day PNS treatment. Results: Among survey respondents who were at least 3 months from the start of treatment, most reported sustained clinically significant improvements in pain and/or quality of life, with the length of follow-up at the time of survey completion ranging from 3 to 30 months. Conclusion: These real-world data support recent prospective studies indicating that 60-day percutaneous PNS provides significant and sustained relief across a wide range of pain conditions.
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Affiliation(s)
- Matthew J Pingree
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55901, USA
| | - Mark Fb Hurdle
- Pain Medicine & Spine Care, Mayo Clinic, Jacksonville, FL 32224, USA
| | - David A Spinner
- Rehabilitation Medicine, Mount Sinai Health System, New York, NY 10029, USA
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8
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Naidu R, Li S, Desai MJ, Sheth S, Crosby ND, Boggs JW. 60-Day PNS Treatment May Improve Identification of Delayed Responders and Delayed Non-Responders to Neurostimulation for Pain Relief. J Pain Res 2022; 15:733-743. [PMID: 35310895 PMCID: PMC8932923 DOI: 10.2147/jpr.s349101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Conventional neurostimulation typically involves a brief (eg, ≤10-day) trial to assess presumed effectiveness prior to permanent implantation. Low trial conversion rates and high explant rates due to inadequate pain relief highlight the need for improved patient identification strategies. The development of a 60-day percutaneous peripheral nerve stimulation (PNS) system enables evaluation of outcomes following an extended temporary treatment period of up to 60 days, that may obviate or validate the need for permanent implant. The present study provides the first real-world evidence regarding patient response throughout a 60-day PNS treatment period. Methods Anonymized data listings were compiled from patients who underwent implantation of temporary percutaneous leads and opted-in to provide real-world data to the device manufacturer during routine interactions with device representatives throughout the 60-day treatment. Results Overall, 30% (222/747) of patients were early responders (≥50% pain relief throughout treatment). Another 31% (231/747) of patients initially presented as non-responders but surpassed 50% pain relief by the end of treatment. Conversely, 32% (239/747) of patients were non-responders throughout treatment. An additional 7% (55/747) of patients initially presented as responders but fell below 50% relief by the end of the treatment period. Conclusion An extended, 60-day PNS treatment may help identify delayed responders, providing the opportunity for sustained relief and improving access to effective PNS treatment. Compared to a conventionally short trial of ≤10 days, a longer 60-day PNS treatment may also help reduce explant rates by identifying delayed non-responders unlikely to benefit long-term. These scenarios support the importance of an extended 60-day temporary PNS stimulation period to help inform stepwise treatment strategies that may optimize outcomes and cost-effectiveness.
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Affiliation(s)
- Ramana Naidu
- California Orthopedics & Spine, Larkspur, CA, USA
- Correspondence: Ramana Naidu, California Orthopedics & Spine, 2 Bon Air Road #120, Larkspur, CA, 94939, USA, Tel +1 608-695-7266, Email
| | - Sean Li
- Premier Pain Centers, Shrewsbury, NJ, USA
| | - Mehul J Desai
- International Spine Pain & Performance Center, Washington, DC, USA
- George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Samir Sheth
- Sutter Roseville Pain Management, Roseville, CA, USA
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Helm S, Shirsat N, Calodney A, Abd-Elsayed A, Kloth D, Soin A, Shah S, Trescot A. Peripheral Nerve Stimulation for Chronic Pain: A Systematic Review of Effectiveness and Safety. Pain Ther 2021; 10:985-1002. [PMID: 34478120 PMCID: PMC8586061 DOI: 10.1007/s40122-021-00306-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 12/01/2022] Open
Abstract
Peripheral nerve stimulation (PNS) was the first application of neuromodulation. Widespread application of PNS was limited by technical concerns. Recent advances now allow the percutaneous placement of leads with ultrasound or fluoroscopic guidance, while the transcutaneous powering of these leads removes the need for leads to cross major joints. This systematic review was written to assess the current status of high-quality evidence supporting the use of PNS for pain conditions treated by interventional pain physicians. The available literature on PNS, limited to conditions treated by interventional pain physicians, was reviewed and the quality assessed. Literature from 1966 to June 2021 was reviewed. The outcome measures were pain relief and functional improvement. One hundred and two studies were identified. Five randomized controlled trials (RCT) and four observational studies, all case series, met the inclusion criteria. One RCT was of high quality and four were of moderate quality; all four case series were of moderate quality. Three of the RCTs and all four case series evaluated peripheral nerve neuropathic pain. Based upon these studies, there is level II evidence supporting the use of PNS to treat refractory peripheral nerve injury. One moderate-quality RCT evaluated tibial nerve stimulation for pelvic pain, providing level III evidence for this indication. One moderate-quality RCT evaluated surgically placed cylindrical leads for cluster headaches, providing level III evidence for this indication. The evidence suggests that approximately two-thirds of patients with peripheral neuropathic pain will have at least 50% sustained pain relief. Adverse events from PNS are generally minor. A major advantage of PNS over spinal cord stimulation is the absence of any risk of central cord injury. The study was limited by the paucity of literature for some indications. No studies dealt with joint-related osteoarthritic pain.
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Affiliation(s)
- Standiford Helm
- Department of Anesthesiology and Pain Management, University of California, Irvine, Orange, CA, USA.
| | - Nikita Shirsat
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | | | - Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Management, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | - Shalini Shah
- Department of Anesthesiology and Pain Management, University of California, Irvine, Orange, CA, USA
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Vanzant DR, Mukhdomi JJ, Bolash R. Peripheral Nerve Stimulation Yields an Unexpected Motor Response in a Patient with Chronic Shoulder Pain: A Case Report. PAIN MEDICINE 2021; 23:1338-1341. [PMID: 34791443 DOI: 10.1093/pm/pnab328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/31/2021] [Accepted: 11/08/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel R Vanzant
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Junaid J Mukhdomi
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Robert Bolash
- Department of Pain Management, Cleveland Clinic, Cleveland, OH
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Peripheral Nerve Stimulation for Treatment of Headaches: An Evidence-Based Review. Biomedicines 2021; 9:biomedicines9111588. [PMID: 34829819 PMCID: PMC8615534 DOI: 10.3390/biomedicines9111588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 01/06/2023] Open
Abstract
Headaches are one of the most common medical complaints worldwide, and treatment is often made difficult because of misclassification. Peripheral nerve stimulation has emerged as a novel treatment for the treatment of intractable headaches in recent years. While high-quality evidence does exist regarding its use, efficacy is generally limited to specific nerves and headache types. While much research remains to bring this technology to the mainstream, clinicians are increasingly able to provide safe yet efficacious pain control.
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Ye Y, Gabriel RA, Mariano ER. The expanding role of chronic pain interventions in multimodal perioperative pain management: a narrative review. Postgrad Med 2021; 134:449-457. [PMID: 34033737 DOI: 10.1080/00325481.2021.1935281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Surgery is a risk factor for chronic pain and long-term opioid use. As perioperative pain management continues to evolve, treatment modalities traditionally used for chronic pain therapy may provide additional benefit to patients undergoing surgery. Interventions such as radiofrequency ablation, cryoneurolysis, and neuromodulation may potentially be used in conjunction with acute pain procedures such as nerve blocks and multimodal analgesia. Pharmacological agents associated with chronic pain medicine, including gabapentinoids, ketamine, and selective serotonin reuptake inhibitors, may be useful adjuncts in perioperative pain management when indicated. There may also be a role for acupuncture, music therapy, and other integrative medicine therapies. A transitional pain service can help coordinate outpatient care with inpatient perioperative pain management and promote a more personalized and comprehensive approach that can improve postoperative outcomes.
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Affiliation(s)
- Ying Ye
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine; Stanford, California, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia, University of California, San Diego; California, USA.,Department of Medicine, Division of Biomedical Informatics, University of California, San Diego; California, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine; Stanford, California, USA
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Gazzeri R, Cesaroni A, Amorizzo E, Piraccini E, Micheli F, Raggi M, Occhigrossi F. Cadaveric Model Simulations for Training in Ultrasound-Guided Percutaneous Placement of a Novel Peripheral Nerve Stimulation Electrode. Surg Technol Int 2021; 38:491-495. [PMID: 33999402 DOI: 10.52198/21.sti.38.ns1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Peripheral nerve stimulation (PNS) electrodes are used to treat intractable painful conditions involving peripheral nerves. Methods for performing PNS continue to evolve, from open surgical to minimally invasive placement of electrodes. A PNS system consisting of subcutaneously implanted leads with an integrated anchor and electrodes, and an external pulse generator to produce peripheral neuromodulation, is now available for use in the clinical setting. This novel system allows either surgical or percutaneous lead positioning, and avoids the use of long leads or extensions crossing the joints, which are exposed to mechanical stress and damage. To identify methods for successfully inserting these electrodes, we investigated if a cadaver model could be an effective educational tool for teaching PNS electrode placement using ultrasound guidance. Six cadavers were studied in an attempt to find an ideal approach for ultrasound-guided electrode placement into the upper and lower extremities and cervical spine, and to describe the unique anatomy of the peripheral nerves relative to percutaneous stimulation-electrode placement. The use of cadaveric model simulations offers opportunities to practice percutaneous placement of PNS electrodes under stress-free conditions without patient discomfort, to acquire skill and confidence in performing these surgical approaches. Ultrasound-guided percutaneous placement of PNS electrodes should be learned in a simulation laboratory before such placement is performed in actual patients.
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Affiliation(s)
- Roberto Gazzeri
- Pain Therapy Department, San Giovanni Addolorata Hospital, Rome, Italy
| | | | | | | | - Fabrizio Micheli
- Pain Therapy Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
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Singh H, Gargya A, Lin T, Gulati A. Sciatic, Femoral, and Lateral Femoral Cutaneous Nerve Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation. PAIN MEDICINE 2021; 21:S47-S50. [PMID: 32804221 DOI: 10.1093/pm/pnaa040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE With advances in peripheral nerve stimulation technology, there has been an emergence of new minimally invasive techniques to provide neurostimulation therapies for chronic pain. This technical note describes the utilization of ultrasonography for percutaneous placement of peripheral nerve stimulation leads at the sciatic, femoral, and lateral femoral cutaneous nerves. METHODS Ultrasound can be utilized to localize a specific nerve, view neighboring soft tissue anatomy, and plan a needle trajectory. Various ultrasound techniques and transducer orientations allow for multiple options for lead placement relative to the targeted nerve. CONCLUSIONS The option of ultrasound-guided percutaneous technique for neurostimulation lead placement allows this treatment modality to be made available to more patients with chronic pain in specific nerve distributions.
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Affiliation(s)
- Harmandeep Singh
- Department of Anesthesiology, New York Presbyterian Hospital, New York, New York.,Weill Cornell Medical College, New York, New York.,Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Akshat Gargya
- Department of Anesthesiology, New York Presbyterian Hospital, New York, New York.,Weill Cornell Medical College, New York, New York.,Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Tiffany Lin
- Department of Anesthesiology, New York Presbyterian Hospital, New York, New York.,Weill Cornell Medical College, New York, New York.,Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Beeve AT, Shen I, Zhang X, Magee K, Yan Y, MacEwan MR, Scheller EL. Neuroskeletal Effects of Chronic Bioelectric Nerve Stimulation in Health and Diabetes. Front Neurosci 2021; 15:632768. [PMID: 33935630 PMCID: PMC8080454 DOI: 10.3389/fnins.2021.632768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/16/2021] [Indexed: 12/02/2022] Open
Abstract
Background/Aims Bioelectric nerve stimulation (eStim) is an emerging clinical paradigm that can promote nerve regeneration after trauma, including within the context of diabetes. However, its ability to prevent the onset of diabetic peripheral neuropathy (DPN) has not yet been evaluated. Beyond the nerve itself, DPN has emerged as a potential contributor to sarcopenia and bone disease; thus, we hypothesized that eStim could serve as a strategy to simultaneously promote neural and musculoskeletal health in diabetes. Methods To address this question, an eStim paradigm pre-optimized to promote nerve regeneration was applied to the sciatic nerve, which directly innervates the tibia and lower limb, for 8 weeks in control and streptozotocin-induced type 1 diabetic (T1D) rats. Metabolic, gait, nerve and bone assessments were used to evaluate the progression of diabetes and the effect of sciatic nerve eStim on neuropathy and musculoskeletal disease, while also considering the effects of cuff placement and chronic eStim in otherwise healthy animals. Results Rats with T1D exhibited increased mechanical allodynia in the hindpaw, reduced muscle mass, decreased cortical and cancellous bone volume fraction (BVF), reduced cortical bone tissue mineral density (TMD), and decreased bone marrow adiposity. Type 1 diabetes also had an independent effect on gait. Placement of the cuff electrode alone resulted in altered gait patterns and unilateral reductions in tibia length, cortical BVF, and bone marrow adiposity. Alterations in gait patterns were restored by eStim and tibial lengthening was favored unilaterally; however, eStim did not prevent T1D-induced changes in muscle, bone, marrow adiposity or mechanical sensitivity. Beyond this, chronic eStim resulted in an independent, bilateral reduction in cortical TMD. Conclusion Overall, these results provide new insight into the pathogenesis of diabetic neuroskeletal disease and its regulation by eStim. Though eStim did not prevent neural or musculoskeletal complications in T1D, our results demonstrate that clinical applications of peripheral neuromodulation ought to consider the impact of device placement and eStim on long-term skeletal health in both healthy individuals and those with metabolic disease. This includes monitoring for compounded bone loss to prevent unintended consequences including decreased bone mineral density and increased fracture risk.
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Affiliation(s)
- Alec T Beeve
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States.,Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Ivana Shen
- Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Xiao Zhang
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States.,Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Kristann Magee
- Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Ying Yan
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Matthew R MacEwan
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Erica L Scheller
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States.,Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
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Deer TR, Eldabe S, Falowski SM, Huntoon MA, Staats PS, Cassar IR, Crosby ND, Boggs JW. Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. J Pain Res 2021; 14:721-736. [PMID: 33737830 PMCID: PMC7966353 DOI: 10.2147/jpr.s297091] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is an effective tool for the treatment of chronic pain, although its efficacy and utilization have previously been significantly limited by technology. In recent years, purpose-built percutaneous PNS devices have been developed to overcome the limitations of conventional permanently implanted neurostimulation devices. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period, outcomes that have not previously been observed with conventional permanently implanted neurostimulation devices. This narrative review summarizes mechanistic processes that contribute to chronic pain, and the potential mechanisms by which selective large diameter afferent fiber activation may reverse these changes to induce a prolonged reduction in pain. The interplay of these mechanisms, supported by data in chronic pain states that have been effectively treated with percutaneous PNS, will also be discussed in support of a new theory of pain management in neuromodulation: Peripherally Induced Reconditioning of the Central Nervous System (CNS).
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Steven M Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Marc A Huntoon
- Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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17
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Buwembo J, Munson R, Rizvi SA, Ijaz A, Gupta S. Direct Sciatic Nerve Electrical Stimulation for Complex Regional Pain Syndrome Type 1. Neuromodulation 2020; 24:1075-1082. [PMID: 33171547 DOI: 10.1111/ner.13294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Foot and leg pain in complex regional pain syndrome (CRPS) presents a challenge even with neuromodulation techniques such as spinal cord stimulation (SCS). We report our experience with a novo technique of direct sciatic nerve electrical stimulation (DISNES) for intractable foot and leg pain in CRPS I. MATERIALS AND METHODS Following Research Ethics Board (REB) approval, data were gathered for 16 patients (10 women and 6 men, age 26-61 years) who had been subjected to ipsilateral DISNES. All 16 patients had failed conventional medical management. As well, seven subjects were previously treated with SCS for CRPS I pain. These subjects reported pain relief in the thigh and leg, however the SCS was unable to alleviate the disabling foot pain despite varied and multiple programming techniques. The remaining nine subjects were treated primarily with DISNES. Evaluation was done using visual analog scale (VAS), Oswestry Disability Index version 2 (ODI), and quality of life (EQ-5D and SF-36) scores done both pre-DISNES and at two follow-ups. RESULTS VAS scores decreased by 59% at follow-up (F/U) 1 (P = 0.00001) and 46% F/U 2. ODI improving by 40% F/U 1 (P = 0.0038) and 37% F/U 2. SF-36 scores improved by 69% F/U 1 (P = 0.015) and 80% F/U 2. EQ-5D scores improved significantly by F/U 1 (P = 0.00030) but insignificantly at F/U 2 (P = 0.81). There was also a rapid resolution of autonomic features such as edema, hyperemia, and allodynia (within 7-10 days). Three subjects returned to work post-DISNES. CONCLUSION Our study shows that DISNES helps to control the disabling foot pain in CRPS I, thus improving the quality of life, improving ambulation and decreasing disability. DISNES also alleviates autonomic features and dystonia in CRPS I. Further studies are needed to determine long-term efficacy as this study pool is limited in size and follow-up period.
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Affiliation(s)
| | | | | | - Aadam Ijaz
- Saskatchewan Health Authority, Regina, SK, Canada
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18
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Chmiela MA, Hendrickson M, Hale J, Liang C, Telefus P, Sagir A, Stanton-Hicks M. Direct Peripheral Nerve Stimulation for the Treatment of Complex Regional Pain Syndrome: A 30-Year Review. Neuromodulation 2020; 24:971-982. [PMID: 33098229 DOI: 10.1111/ner.13295] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is a difficult to treat condition characterized by debilitating pain and limitations in functional ability. Neuromodulation, in the form of spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS), have been traditionally used as a treatment for CRPS with variable success. OBJECTIVE This chart review describes the use of implantable PNS systems in the treatment of CRPS of the upper and lower extremities spanning nearly three decades. MATERIALS AND METHODS A retrospective chart review was performed on 240 patients with PNS implanted between 1990 and 2017 at our institution. Of these, 165 patients were identified who had PNS systems implanted for a diagnosis of CRPS. Patient profile, including baseline characteristics, comorbidities, past/current interventions/medications and targeted nerves, was descriptively summarized through standard summary statistics. Patients' pain scores and opioid consumptions at baseline (preimplant), 1 month, 6 months, and 12 months were collected and compared. Device revisions and explants were summarized, and patient functional outcomes were described. RESULTS Pain scores at baseline and at 12-month follow-up were decreased from a mean of 7.4 ± 1.6 to 5.5 ± 2.4 and estimated to be 1.87 (95% CI: [1.29, 2.46], paired t-test p-value <0.001) lower at 12 months. At baseline, 62% of patients were on chronic opioid therapy, compared with 41% at 12 months. Of 126 patients who reported changes in functional status, 64 (51%) reported improvement, 27 (21%) reported worsening, and 35 (28%) did not report any meaningful change. Excluding end-of-life battery replacements, surgical revision occurred in 56 (34%) of patients. Thirteen patients (8%) underwent implantation of a second PNS because of symptomatic expansion outside of the original painful region. Device explant was performed in 32 (19%) of patients. Median length of follow-up was 74 [14, 147] months. Of the 36 patients who continue to follow-up at our institution, 29 (81%) continue to use their PNS. CONCLUSIONS We can conclude that PNS is a useful modality to improve function and reduce long-term pain in selected patients suffering from CRPS type I and type II.
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Affiliation(s)
- Mark A Chmiela
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark Hendrickson
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jason Hale
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chen Liang
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Phillip Telefus
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Afrin Sagir
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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19
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Lee MT, Chen YH, Mackie K, Chiou LC. Median Nerve Stimulation as a Nonpharmacological Approach to Bypass Analgesic Tolerance to Morphine: A Proof-of-Concept Study in Mice. THE JOURNAL OF PAIN 2020; 22:300-312. [PMID: 33069869 DOI: 10.1016/j.jpain.2020.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023]
Abstract
Analgesic tolerance to opioids contributes to the opioid crisis by increasing the quantity of opioids prescribed and consumed. Thus, there is a need to develop non-opioid-based pain-relieving regimens as well as strategies to circumvent opioid tolerance. Previously, we revealed a non-opioid analgesic mechanism induced by median nerve electrostimulation at the overlaying PC6 (Neiguan) acupoint (MNS-PC6). Here, we further examined the efficacy of MNS-PC6 in morphine-tolerant mice with neuropathic pain induced by chronic constriction injury (CCI) of the sciatic nerve. Daily treatments of MNS-PC6 (2 Hz, 2 mA), but not electrostimulation at a nonmedian nerve-innervated location, for a week post-CCI induction significantly suppressed established mechanical allodynia in CCI-mice in an orexin-1 (OX1) and cannabinoid-1 (CB1) receptor-dependent fashion. This antiallodynic effect induced by repeated MNS-PC6 was comparable to that induced by repeated gabapentin (50 mg/kg, i.p.) or single morphine (10 mg/kg, i.p.) treatments, but without tolerance, unlike repeated morphine-induced analgesia. Furthermore, single and repeated MNS-PC6 treatments remained fully effective in morphine-tolerant CCI-mice, also in an OX1 and CB1 receptor-dependent fashion. In CCI-mice receiving escalating doses of morphine for 21 days (10, 20 and 50 mg/kg), single and repeated MNS-PC6 treatments remained fully effective. Therefore, repeated MNS-PC6 treatments induce analgesia without tolerance, and retain efficacy in opioid-tolerant mice via a mechanism that involves OX1 and CB1 receptors. This study suggests that MNS-PC6 is an alternative pain management strategy that maybe useful for combatting the opioid epidemic, and opioid-tolerant patients receiving palliative care. PERSPECTIVE: Median nerve stimulation relieves neuropathic pain in mice without tolerance and retains efficacy even in mice with analgesic tolerance to escalating doses of morphine, via an opioid-independent, orexin-endocannabinoid-mediated mechanism. This study provides a proof of concept for utilizing peripheral nerve stimulating devices for pain management in opioid-tolerant patients.
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Affiliation(s)
- Ming Tatt Lee
- Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan; Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Yi-Hung Chen
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan; Chinese Medicine Research Center, China Medical University, Taichung, Taiwan
| | - Ken Mackie
- Gill Center for Biomolecular Research, Indiana University, Bloomington, Indiana; Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Lih-Chu Chiou
- Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan.
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20
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Frederico TN, da Silva Freitas T. Peripheral Nerve Stimulation of the Brachial Plexus for Chronic Refractory CRPS Pain of the Upper Limb: Description of a New Technique and Case Series. PAIN MEDICINE 2020; 21:S18-S26. [PMID: 32804227 DOI: 10.1093/pm/pnaa201] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Upper limb complex regional pain syndrome is an important cause of chronic pain, and its treatment is challenging. In this pilot case series, we preliminarily evaluated the feasibility, effectiveness, and safety of a new technique for brachial plexus neuromodulation in the treatment of this disease in patients refractory to conservative treatment. METHODS Between 2017 and 2018, 14 patients considered to be refractory to optimized conservative treatment were recruited to this study. In the first stage, patients were trialed for seven days with a new technique of implant of the brachial plexus. Patients with ≥50% pain relief in visual analog scale (VAS) score received a definitive implantation in the second stage. Follow-ups were conducted at pre-implant and 12 months using the Neuropathic Pain Scale, SF-32, and the visual analogic scale for pain. RESULTS After the initial trial, 10 patients had a pain reduction of ≥50% and received a permanent implant. At 12-month follow-up, VAS, Neuropathic Pain Scale, SF-12 physical and mental scores improved by 57.4% +/- 10% (P = 0.005), 60.2% +/- 12.9% (P = 0.006), and 21.9% +/- 5.9% (P = 0.015), respectively. CONCLUSIONS Our data suggest that this new technique of brachial plexus stimulation may have long-term utility in the treatment of painful upper limb complex regional pain syndrome. New more detailed comprehensive studies should be carried out to confirm our findings in a larger population and to further refine the clinical implementation of this technique.
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21
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Kretzschmar M, Reining M, Schwarz MA. Three-Year Outcomes After Dorsal Root Ganglion Stimulation in the Treatment of Neuropathic Pain After Peripheral Nerve Injury of Upper and Lower Extremities. Neuromodulation 2020; 24:700-707. [PMID: 32573868 DOI: 10.1111/ner.13222] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Traumatic peripheral nerve injuries (PNI) often result in severe neuropathic pain which typically becomes chronic, is recalcitrant to common analgesics, and is associated with sleep disturbances, anxiety, and depression. Pharmacological treatments proven to be effective against neuropathic pain are not well tolerated due to side effects. Neuromodulative interventions such as peripheral nerve or spinal cord stimulation have generated mixed results and may be limited by reduced somatotopic specificity. Dorsal root ganglion (DRG) stimulation may be more effective in this etiology. MATERIALS AND METHODS Twenty-seven patients were trialed with a DRG neurostimulation system for PNI; trial success (defined as ≥50% pain relief) was 85%, and 23 patients received a permanent stimulator. However, 36-month outcome data was only available for 21 patients. Pain, quality of life, mental and physical function, and opioid usage were assessed at baseline and at 3-, 6-, 12-, 18-, 24-, and 36 months post-permanent implant. Implant-related complications were also documented. RESULTS Compared to baseline, we observed a significant pain relief (p < 0.001) at 3 (58%), 12 (66%), 18 (69%), 24 (71%), and 36 months (73%) in 21 patients (52.5 ± 14.2 years; 12 female), respectively. Mental and physical function showed immediate and sustained improvements. Participants reported improvements in quality of life. Opioid dosage reduced significantly (p < 0.001) at 3 (30%), 12 (93%), 18 (98%), 24 (99%), and 36 months (99%), and 20 of 21 patients were completely opioid-free after 36 months. There were five lead migrations and two electrode fractures (corrected by surgical intervention) and one wound infection (conservatively managed). CONCLUSIONS DRG neuromodulation appears to be a safe, effective, and durable option for treating neuropathic pain caused by PNI. The treatment allows cessation of often ineffective pharmacotherapy (including opioid misuse) and significantly improves quality of life.
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Affiliation(s)
- Michael Kretzschmar
- SRH Wald-Klinikum Gera, Department of Pain Medicine and Palliative Care, Gera, Strasse des Friedens 122, D-07548, Germany.,SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Neue Strasse 30-32, D-07548, Germany
| | - Marco Reining
- SRH Wald-Klinikum Gera, Department of Pain Medicine and Palliative Care, Gera, Strasse des Friedens 122, D-07548, Germany
| | - Marcus A Schwarz
- SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Neue Strasse 30-32, D-07548, Germany
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22
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Percutaneous and Implanted Peripheral Nerve Stimulation for the Management of Pain: Current Evidence and Future Directions. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-019-00256-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Gilmore CA, Ilfeld BM, Rosenow JM, Li S, Desai MJ, Hunter CW, Rauck RL, Nader A, Mak J, Cohen SP, Crosby ND, Boggs JW. Percutaneous 60-day peripheral nerve stimulation implant provides sustained relief of chronic pain following amputation: 12-month follow-up of a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2019; 45:rapm-2019-100937. [PMID: 31740443 DOI: 10.1136/rapm-2019-100937] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/03/2019] [Accepted: 10/27/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Peripheral nerve stimulation (PNS) has historically been used to treat chronic pain, but generally requires implantation of a permanent system for sustained relief. A recent study found that a 60-day PNS treatment decreases post-amputation pain, and the current work investigates longer-term outcomes out to 12 months in the same cohort. METHODS As previously reported, 28 traumatic lower extremity amputees with residual and/or phantom limb pain were randomized to receive 8 weeks of PNS (group 1) or 4 weeks of placebo followed by a crossover 4 weeks of PNS (group 2). Percutaneous leads were implanted under ultrasound guidance targeting the femoral and sciatic nerves. During follow-up, changes in average pain and pain interference were assessed using the Brief Pain Inventory-Short Form and comparing with baseline. RESULTS Significantly more participants in group 1 reported ≥50% reductions in average weekly pain at 12 months (67%, 6/9) compared with group 2 at the end of the placebo period (0%, 0/14, p=0.001). Similarly, 56% (5/9) of participants in group 1 reported ≥50% reductions in pain interference at 12 months, compared with 2/13 (15%, p=0.074) in group 2 at crossover. Reductions in depression were also statistically significantly greater at 12 months in group 1 compared with group 2 at crossover. CONCLUSIONS This work suggests that percutaneous PNS delivered over a 60-day period may provide significant carry-over effects including pain relief, potentially avoiding the need for a permanently implanted system while enabling improved function in patients with chronic pain. TRIAL REGISTRATION NUMBER NCT01996254.
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Affiliation(s)
| | - Brian M Ilfeld
- Anesthesiology, University of California, San Diego, La Jolla, California, USA
| | - Joshua M Rosenow
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Mehul J Desai
- International Spine, Pain, and Performance Center, Washington, District of Columbia, USA
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York City, New York, USA
| | - Richard L Rauck
- Center for Clinical Research, Winston-Salem, North Carolina, USA
| | - Antoun Nader
- Department of Anesthesiology, Northwestern University, Chicago, Illinois, USA
| | - John Mak
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Steven P Cohen
- Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Oswald J, Shahi V, Chakravarthy KV. Prospective case series on the use of peripheral nerve stimulation for focal mononeuropathy treatment. Pain Manag 2019; 9:551-558. [PMID: 31686589 DOI: 10.2217/pmt-2019-0028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This case series looks at outcomes in 39 patients implanted using the Bioness Stimrouter system on various isolated mononeuropathies. Patients & methods: A case series of 39 patients with a total of 42 implants were enrolled starting August 2017 at various pain management centers. Results: Of 39 patients studied, 78% of the participants noticed an improvement in their pain. There was a 71% reduction in pain scores with the average preprocedure score of 8 improving to 2 post-implant. Participants noted on average a 72% improvement in activity with the greatest observed in the brachial plexus (80%) and suprascapular nerve (80%) and smallest in the intercostal nerve (40%). Approximately 89% of those implanted with a peripheral nerve stimulator experienced a greater than 50% reduction in opioid consumption. Conclusion: Peripheral nerve stimulators are a new, minimally invasive neuromodulation modality that shows promising early results in our 39-patient case series.
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Affiliation(s)
- Jessica Oswald
- Department of Anesthesiology & Pain Medicine, University of California San Diego Health Sciences, San Diego, CA 92037, USA
| | - Varun Shahi
- Department of Emergency Medicine, University of California, Oakland, CA 90095, USA
| | - Krishnan V Chakravarthy
- Department of Anesthesiology & Pain Medicine, University of California San Diego Health Sciences, San Diego, CA 92037, USA.,VA San Diego Healthcare System, San Diego, CA 92161, USA
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25
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Abstract
Phantom limb pain is a chronic neuropathic pain that develops in 45-85% of patients who undergo major amputations of the upper and lower extremities and appears predominantly during two time frames following an amputation: the first month and later about 1 year. Although in most patients the frequency and intensity of pain diminish over time, severe pain persists in about 5-10%. It has been proposed that factors in both the peripheral and central nervous systems play major roles in triggering the development and maintenance of pain associated with extremity amputations. Chronic pain is physically and mentally debilitating, affecting an individual's capacity for self-care, but also diminishing an individual's daily capacity for personal and economic independence. In addition, the pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering from this condition. Although the pain can be reduced by antiepileptic drugs and analgesics, they are frequently ineffective or their side effects preclude their use. The optimal approach for eliminating neuropathic pain and improving individuals' quality of life is the development of novel techniques that permanently prevent the development and maintenance of neuropathic pain, or that eliminate the pain once it has developed. What is still required is understanding when and where an effective novel technique must be applied, such as onto the nerve stump of the transected peripheral axons, dorsal root ganglion neurons, spinal cord, or cortex to induce the desired influences. This review, the second of two in this journal volume, examines the techniques that may be capable of reducing or eliminating chronic neuropathic pain once it has developed. Such an understanding will improve amputees' quality of life by blocking the mechanisms that trigger and/or maintain PLP and chronic neuropathic pain.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, University of Puerto Rico, Medical Science Campus, 201 Blvd. del Valle, San Juan, PR, 00901, Puerto Rico.
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26
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Abstract
Nerve stimulation is a reversible technique that is used successfully for the treatment of traumatic neuropathic pain, complex regional pain syndrome, and craniofacial neuropathic pain. Nerve field stimulation targets painful regions rather than a single nerve and has expanded indications, including axial low back pain. Appropriate patient education and motivation are crucial prior to surgery. Ongoing research is necessary to provide high-level evidence for the use of nerve stimulation. Most electrodes are primarily designed for spinal cord stimulation, hence the need to develop nerve electrodes dedicated for nerve stimulation.
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Affiliation(s)
- Mark Corriveau
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Wendell Lake
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA
| | - Amgad Hanna
- Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, USA.
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27
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Harsh V, Mishra P, Gond PK, Kumar A. Peripheral nerve stimulation: black, white and shades of grey. Br J Neurosurg 2019; 33:332-336. [DOI: 10.1080/02688697.2018.1538479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Viraat Harsh
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Parijat Mishra
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Preeti K Gond
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Anil Kumar
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
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28
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Gilmore C, Ilfeld B, Rosenow J, Li S, Desai M, Hunter C, Rauck R, Kapural L, Nader A, Mak J, Cohen S, Crosby N, Boggs J. Percutaneous peripheral nerve stimulation for the treatment of chronic neuropathic postamputation pain: a multicenter, randomized, placebo-controlled trial. Reg Anesth Pain Med 2019; 44:637-645. [PMID: 30954936 DOI: 10.1136/rapm-2018-100109] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/30/2019] [Accepted: 02/16/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Chronic neuropathic pain is a common challenging condition following amputation. Recent research demonstrated the feasibility of percutaneously implanting fine-wire coiled peripheral nerve stimulation (PNS) leads in proximity to the sciatic and femoral nerves for postamputation pain. A multicenter, double-blinded, randomized, placebo-controlled study collected data on the safety and effectiveness of percutaneous PNS for chronic neuropathic pain following amputation. METHODS Twenty-eight lower extremity amputees with postamputation pain were enrolled. Subjects underwent ultrasound-guided implantation of percutaneous PNS leads and were randomized to receive PNS or placebo for 4 weeks. The placebo group then crossed over and all subjects received PNS for four additional weeks. The primary efficacy endpoint evaluated the proportion of subjects reporting ≥50% pain reduction during weeks 1-4. RESULTS A significantly greater proportion of subjects receiving PNS (n=7/12, 58%, p=0.037) demonstrated ≥50% reductions in average postamputation pain during weeks 1-4 compared with subjects receiving placebo (n=2/14, 14%). Two subjects were excluded from efficacy analysis due to eligibility changes. Significantly greater proportions of PNS subjects also reported ≥50% reductions in pain (n=8/12, 67%, p=0.014) and pain interference (n=8/10, 80%, p=0.003) after 8 weeks of therapy compared with subjects receiving placebo (pain: n=2/14, 14%; pain interference: n=2/13, 15%). Prospective follow-up is ongoing; four of five PNS subjects who have completed 12-month follow-up to date reported ≥50% pain relief. CONCLUSIONS This work demonstrates that percutaneous PNS therapy may provide enduring clinically significant pain relief and improve disability in patients with chronic neuropathic postamputation pain. TRIAL REGISTRATION NUMBER NCT01996254.
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Affiliation(s)
| | - Brian Ilfeld
- Anesthesiology, University of California, San Diego, La Jolla, California, USA
| | - Joshua Rosenow
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Mehul Desai
- International Spine, Pain & Performance Center, Washington, District of Columbia, USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York City, New York, USA
| | - Richard Rauck
- Center for Clinical Research, Winston-Salem, North Carolina, USA
| | - Leonardo Kapural
- Center for Clinical Research, Winston-Salem, North Carolina, USA
| | - Antoun Nader
- Department of Anesthesiology, Northwestern University, Chicago, Illinois, USA
| | - John Mak
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Steven Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Effects of Spinal Cord and Peripheral Nerve Stimulation Reflected in Sensory Profiles and Endogenous Pain Modulation. Clin J Pain 2019; 35:111-120. [DOI: 10.1097/ajp.0000000000000661] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Median nerve stimulation induces analgesia via orexin-initiated endocannabinoid disinhibition in the periaqueductal gray. Proc Natl Acad Sci U S A 2018; 115:E10720-E10729. [PMID: 30348772 DOI: 10.1073/pnas.1807991115] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Adequate pain management remains an unmet medical need. We previously revealed an opioid-independent analgesic mechanism mediated by orexin 1 receptor (OX1R)-initiated 2-arachidonoylglycerol (2-AG) signaling in the ventrolateral periaqueductal gray (vlPAG). Here, we found that low-frequency median nerve stimulation (MNS) through acupuncture needles at the PC6 (Neiguan) acupoint (MNS-PC6) induced an antinociceptive effect that engaged this mechanism. In mice, MNS-PC6 reduced acute thermal nociceptive responses and neuropathy-induced mechanical allodynia, increased the number of c-Fos-immunoreactive hypothalamic orexin neurons, and led to higher orexin A and lower GABA levels in the vlPAG. Such responses were not seen in mice with PC6 needle insertion only or electrical stimulation of the lateral deltoid, a nonmedian nerve-innervated location. Directly stimulating the surgically exposed median nerve also increased vlPAG orexin A levels. MNS-PC6-induced antinociception (MNS-PC6-IA) was prevented by proximal block of the median nerve with lidocaine as well as by systemic or intravlPAG injection of an antagonist of OX1Rs or cannabinoid 1 receptors (CB1Rs) but not by opioid receptor antagonists. Systemic blockade of OX1Rs or CB1Rs also restored vlPAG GABA levels after MNS-PC6. A cannabinoid (2-AG)-dependent mechanism was also implicated by the observations that MNS-PC6-IA was prevented by intravlPAG inhibition of 2-AG synthesis and was attenuated in Cnr1 -/- mice. These findings suggest that PC6-targeting low-frequency MNS activates hypothalamic orexin neurons, releasing orexins to induce analgesia through a CB1R-dependent cascade mediated by OX1R-initiated 2-AG retrograde disinhibition in the vlPAG. The opioid-independent characteristic of MNS-PC6-induced analgesia may provide a strategy for pain management in opioid-tolerant patients.
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Current Innovations in Peripheral Nerve Stimulation. PAIN RESEARCH AND TREATMENT 2018; 2018:9091216. [PMID: 30302288 PMCID: PMC6158945 DOI: 10.1155/2018/9091216] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/08/2018] [Accepted: 08/19/2018] [Indexed: 12/17/2022]
Abstract
Peripheral nerve stimulation has been used in the treatment of several chronic pain conditions including pain due to peripheral nerve dysfunctions, complex regional pain syndrome, and cranial neuralgias. It has been shown to be effective for chronic, intractable pain that is refractory to conventional therapies such as physical therapy, medications, transcutaneous electrical stimulations, and nerve blocks. Recently, a new generation of peripheral nerve stimulation devices has been developed; these allow external pulse generators to transmit impulses wirelessly to the implanted electrode, and their implantation is significantly less invasive. In this review, we discuss the history, pathophysiology, indications, implantation process, and outcomes of employing peripheral nerve stimulation to treat chronic pain conditions.
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Ilfeld BM, Ball ST, Gabriel RA, Sztain JF, Monahan AM, Abramson WB, Khatibi B, Said ET, Parekh J, Grant SA, Wongsarnpigoon A, Boggs JW. A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty. Neuromodulation 2018; 22:653-660. [PMID: 30024078 PMCID: PMC6339601 DOI: 10.1111/ner.12790] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Scott T Ball
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Amanda M Monahan
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jesal Parekh
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Stuart A Grant
- Duke University Medical Center, Duke University, Durham, NC, USA
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Boggs JW, Chae J, Bennett ME. Peripheral Nerve Stimulation for Pain Suppression. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00057-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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34
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Barolat G. Peripheral Nerve Field Stimulation for Intractable Pain. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00061-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
A major challenge in the growing field of bioelectronic medicine is the development of tissue interface technologies promoting device integration with biological tissues. Materials based on organic bioelectronics show great promise due to a unique combination of electronic and ionic conductivity properties. In this review, we outline exciting developments in the field of organic bioelectronics and demonstrate the medical importance of these active, electronically controllable materials. Importantly, organic bioelectronics offer a means to control cell-surface attachment as required for many device-tissue applications. Experiments have shown that cells readily attach and proliferate on reduced but not oxidized organic bioelectronic materials. In another application, the active properties of organic bioelectronics were used to develop electronically triggered systems for drug release. After incorporating drugs by advanced loading strategies, small compound drugs were released upon electrochemical trigger, independent of charge. Another type of delivery device was used to achieve well-controlled, spatiotemporal delivery of cationic drugs. Via electrophoretic transport within a polymer, cations were delivered with single-cell precision. Finally, organic bioelectronic materials are commonly used as electrode coatings improving the electrical properties of recording and stimulation electrodes. Because such coatings drastically reduce the electrode impedance, smaller electrodes with improved signal-to-noise ratio can be fabricated. Thus, rapid technological advancement combined with the creation of tiny electronic devices reacting to changes in the tissue environment helps to promote the transition from standard pharmaceutical therapy to treatment based on 'electroceuticals'. Moreover, the widening repertoire of organic bioelectronics will expand the options for true biological interfaces, providing the basis for personalized bioelectronic medicine.
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Affiliation(s)
- S Löffler
- Swedish Medical Nanoscience Center, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - K Melican
- Swedish Medical Nanoscience Center, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - K P R Nilsson
- Division of Chemistry, Department of Physics, Chemistry and Biology, Linköping University, Linköping, Sweden
| | - A Richter-Dahlfors
- Swedish Medical Nanoscience Center, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Reddy CG, Flouty OE, Holland MT, Rettenmaier LA, Zanaty M, Elahi F. Novel technique for trialing peripheral nerve stimulation: ultrasonography-guided StimuCath trial. Neurosurg Focus 2017; 42:E5. [DOI: 10.3171/2016.12.focus16475] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Peripheral nerve stimulation (PNS) has been used for the treatment of neuropathic pain for many decades. Despite the specific indications for PNS, clinicians often have difficulty screening for candidates likely to have a good or fair outcome. Given the expense of a permanent implant, most insurance companies will not pay for the implant without a successful PNS trial. And since PNS has only recently been approved by the US Food and Drug Administration, many insurance companies will not pay for a conventional trial of PNS. The objective of this study is to describe a short low-cost method for trialing and screening patients for peripheral nerve stimulator implantation. Additionally, this study demonstrates the long-term efficacy of PNS in the treatment of chronic neuropathic pain and the relative effectiveness of this novel screening method.
METHODS
The records of all patients who had undergone trialing and implantation of a PNS system for chronic refractory pain at the authors' institution over a 1-year period (August 1, 2012–July 31, 2013) were examined in this retrospective case series. The search revealed 17 patients, 13 who had undergone a novel in-office ultrasonography-guided StimuCath screening technique and 4 who had undergone a traditional week-long screening procedure. All 17 patients experienced a successful PNS trial and proceeded to permanent PNS system implantation. Patients were followed up for a mean duration of 3.0 years. Visual analog scale (VAS) pain scores were used to assess pain relief in the short-term (< 6 weeks), at 1 year, and at the last follow-up. Final outcome was also characterized as good, fair, poor, or bad.
RESULTS
Of these 17 patients, 10 were still using their stimulator at the last follow-up, with 8 of them obtaining good relief (classified as ≥ 50% pain relief, with an average 81% reduction in the VAS score) and 2 patients attaining fair relief (< 50% relief but still using stimulation therapy). Among the remaining 7 patients, the stimulator had been explanted in 4 and there had been no relief in 3. Excluding explanted cases, follow-up ranged from 14 to 46 months, with an average of 36 months. Patients with good or fair relief had experienced pain prior to implantation for an average of 5.1 years (range 1.8–15.2 years). A longer duration of pain trended toward a poorer outcome (bad outcome 7.6 years vs good outcome 4.1 years, p = 0.03). Seven (54%) of the 13 patients with the shorter trial experienced a good or fair outcome with an average 79% reduction in the VAS score; however, all 4 of the bad outcome cases came from this group. Three (75%) of the 4 patients with the longer trial experienced a good or fair outcome at the last follow-up, with an average 54% reduction in the VAS score. There was no difference between the trialing methods and the proportion of favorable (good or fair) outcomes (p = 0.71).
CONCLUSIONS
Short, ultrasonography-guided StimuCath trials were feasible in screening patients for permanent implantation of PNS, with efficacy similar to the traditional week-long screening noted at the 3-year follow-up.
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Bouche B, Manfiotto M, Rigoard P, Lemarie J, Dix-Neuf V, Lanteri-Minet M, Fontaine D. Peripheral Nerve Stimulation of Brachial Plexus Nerve Roots and Supra-Scapular Nerve for Chronic Refractory Neuropathic Pain of the Upper Limb. Neuromodulation 2017; 20:684-689. [PMID: 28160364 DOI: 10.1111/ner.12573] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 11/14/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We report the outcome of a consecutive series of 26 patients suffering from chronic medically-refractory neuropathic pain of the upper limb (including 16 patients with complex regional pain syndrome), topographically limited, treated by brachial plexus (BP) nerve roots or supra-scapular nerve (SSN) peripheral nerve stimulation (PNS). MATERIALS AND METHODS The technique consisted in ultrasound-guided percutaneous implantation of a cylindrical lead (Pisces-Quad, Medtronic) close to the SSN or the cervical nerve roots within the BP, depending on the pain topography. All the patients underwent a positive trial stimulation before lead connection to a subcutaneous stimulator. Chronic bipolar stimulation mean parameters were: frequency 55.5 Hertz, voltage 1.17 Volts. The voltage was set below the threshold inducing muscle contractions or paresthesias. RESULTS Two patients were lost immediately after surgery. At last follow-up (mean 27.5 months), the 20 patients still using the stimulation experienced a mean pain relief of 67.1%. Seventeen patients were improved ≥50%, including 12 improved ≥70%. In 11 patients with a follow-up >2 years, the mean pain relief was 68%. At last follow-up, respectively, six out of the nine (67%) patients treated by SSN stimulation and 10 out of 17 patients (59%) treated by BP stimulation were improved ≥50%. At last follow-up, 12 out of 20 patients still using the stimulation were very satisfied, six were satisfied, and two were poorly satisfied. Complications were: stimulation intolerance due to shock-like sensations (three cases), superficial infection (1), lead fractures (2), and migration (1). CONCLUSION In this pilot study, SSN or BP roots PNS provided a relatively safe, durable and effective option to control upper limb neuropathic pain.
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Affiliation(s)
- Bénédicte Bouche
- Pain Clinic, Clinique Saint Léonard Village Santé, Trélazé, France
| | | | - Philippe Rigoard
- Spine & Neuromodulation Unit, Department of Neurosurgery, Poitiers University Hospital, Poitiers, France.,PRISMATICS Lab, Predictive Research In Spine Management/Neuromodulation & Thoracic Innovations/Cardiac Surgery Lab, Poitiers University Hospital, Poitiers, France
| | | | | | - Michel Lanteri-Minet
- Pain Department, CHU de Nice, Nice, France.,Fédération Hospitalo-Universitaire INOVPAIN, Université Nice Côte-d'Azur, Nice, France.,INSERM/UdA, U1107, Neuro-Dol, Université d'Auvergne, Clermont-Ferrand, France
| | - Denys Fontaine
- Department of Neurosurgery, CHU de Nice, Nice, France.,Fédération Hospitalo-Universitaire INOVPAIN, Université Nice Côte-d'Azur, Nice, France
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Ilfeld BM, Gilmore CA, Grant SA, Bolognesi MP, Del Gaizo DJ, Wongsarnpigoon A, Boggs JW. Ultrasound-guided percutaneous peripheral nerve stimulation for analgesia following total knee arthroplasty: a prospective feasibility study. J Orthop Surg Res 2017; 12:4. [PMID: 28086940 PMCID: PMC5234248 DOI: 10.1186/s13018-016-0506-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 12/19/2016] [Indexed: 11/10/2022] Open
Abstract
Background Peripheral nerve stimulation has been used for decades to treat chronic pain but has not been used for postoperative analgesia due to multiple limitations, beginning with invasive electrode placement. With the development of small-diameter/gauge leads enabling percutaneous insertion, ultrasound guidance for accurate introduction, and stimulators small enough to be adhered to the skin, neurostimulation may now be provided in a similar manner to continuous peripheral nerve blocks. Here, we report on the use of ultrasound-guided percutaneous peripheral nerve stimulation to treat postoperative pain. Materials and methods Subjects within 60 days of a total knee arthroplasty with pain insufficiently treated with oral analgesics had a 0.2-mm-diameter electrical lead (pre-loaded into a 20 gauge needle) introduced percutaneously using ultrasound guidance with the tip located approximately 0.5–1.0 cm from the femoral nerve (a second lead was inserted approximately 1.0–3.0 cm from the sciatic nerve for posterior knee pain). An external stimulator delivered current. Endpoints were assessed before and after lead insertion and the leads subsequently removed. Due to the small sample size for this pilot/feasibility study, no statistics were applied to the data. Results Leads were inserted in subjects (n = 5) 8–58 days postoperatively. Percutaneous peripheral nerve stimulation decreased pain an average of 93% at rest (from a mean of 5.0 to 0.2 on a 0–10 numeric rating scale), with 4 of 5 subjects experiencing complete resolution of pain. During passive and active knee motion pain decreased an average of 27 and 30%, respectively. Neither maximum passive nor active knee range-of-motion was consistently affected. Conclusions Ultrasound-guided percutaneous peripheral nerve stimulation may be a practical modality for the treatment of postoperative pain following orthopedic surgical procedures, and further investigation appears warranted.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA, 92103-8770, USA.
| | - Christopher A Gilmore
- Department of Anesthesiology, Wake Forest University Baptist Medical Center, 145 Kimel Park Drive, Ste 330, Winston-Salem, NC, 27103, USA.,The Center for Clinical Research, Winston-Salem, NC, USA.,Carolinas Pain Institute, Winston-Salem, NC, USA
| | - Stuart A Grant
- Department of Anesthesiology, Duke University Medical Center, DUMC 3094, Durham, NC, 27710, USA
| | - Michael P Bolognesi
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Dr. #5216, Durham, NC, 27710, USA
| | - Daniel J Del Gaizo
- Department of Orthopedic Surgery, University of North Carolina, 3147 Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599-7055, USA
| | - Amorn Wongsarnpigoon
- SPR Therapeutics, LLC, 22901 Millcreek Blvd, Suite 110, Cleveland, OH, 44122, USA
| | - Joseph W Boggs
- SPR Therapeutics, LLC, 22901 Millcreek Blvd, Suite 110, Cleveland, OH, 44122, USA
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40
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Peripheral Nerve Stimulation. PAIN MEDICINE 2017. [DOI: 10.1007/978-3-319-43133-8_104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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41
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Chung W, Kim Y, Lee J, Lee S, Kim Y, Shin Y, Lee W, Ko Y. Ultrasound-guided placement of a permanent peripheral nerve stimulator in a patient with complex regional pain syndrome -A case report-. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.3.295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yohan Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jiyong Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sunyul Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yoonhee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yongsup Shin
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Wonhyung Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Youngkwon Ko
- Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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Mitchell B, Verrills P, Vivian D, DuToit N, Barnard A, Sinclair C. Peripheral Nerve Field Stimulation Therapy for Patients With Thoracic Pain: A Prospective Study. Neuromodulation 2016; 19:752-759. [PMID: 27376969 DOI: 10.1111/ner.12458] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/13/2016] [Accepted: 04/29/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Relative to the number of patients suffering chronic lumbar and cervical pain, fewer patients suffer persistent thoracic pain. Consequently there is less literature, with smaller sample sizes, reporting treatment of this cohort. Here, we assess peripheral nerve field stimulation (PNfS) as a potential treatment for chronic thoracic pain. MATERIALS AND METHODS This study included 20 consecutive chronic thoracic pain sufferers that responded successfully to PNfS trial. The patients were subsequently implanted with permanent eight-contact electrode linear percutaneous leads within their major area of pain. Patients were followed up at 12 months for outcome reporting. All 20 patients were considered in the statistical analysis, despite removal of three devices prior to follow up. RESULTS The average baseline pre-treatment Numerical Pain Rating Scale (NPRS) score was 7.75 ± 1.4. Following PNfS, the mean NPRS score was 2.25 ±2.14, reflecting a significant average improvement of 5.5 ± 3.31. Three patients were explanted prior to follow up: the first gained excellent thoracic pain relief but pain at the Implantable Pulse Generator (IPG) site could not be overcome, the second achieved excellent pain relief but the PNfS was removed due to recurrent infection and in the final instance, the intervention offered only poor relief and the device removed. CONCLUSION PNfS is an effective intervention for intractable disabling thoracic pain, offering sustained and worthwhile pain relief, for the overwhelming majority of the cohort. This may be especially true when considering a combined treatment approach of PNfS and analgesic use to manage remnant pain.
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Hanna SA, Catapano J, Borschel GH. Painful pediatric traumatic neuroma: surgical management and clinical outcomes. Childs Nerv Syst 2016; 32:1191-4. [PMID: 27179535 DOI: 10.1007/s00381-016-3109-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Painful neuromas can limit function and decrease quality of life. Although management of traumatic neuromas in adults is well represented in the literature, traumatic neuromas are seen less frequently in children and adolescents, and their management is underrepresented in the literature. We present a sample of our clinical experience with painful pediatric neuromas and describe the surgical management and clinical outcomes of these cases. METHODS A retrospective case review was conducted on patients treated at our pediatric tertiary care center. The same surgeon was responsible for management and follow-up of all patients. RESULTS The sample of five patients was 60 % female and had a mean age of 12.2 (3-16) years. Each case was managed using a different surgical technique. All the patients had acceptable outcomes with a mean post-operative pain score of 0.4 (0-2) out of 10 and no residual functional outcomes. CONCLUSIONS It is important for clinicians to recognize that pediatric patients develop painful neuromas following nerve trauma and to understand the neurophysiologic basis for their management. Our report demonstrates that many of the techniques that we use for neuroma repair in adults are applicable in the pediatric population.
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Affiliation(s)
- Steven A Hanna
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Joseph Catapano
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Gregory H Borschel
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Peripheral nerve field stimulation for chronic neuropathic pain: a single institution experience. Acta Neurochir (Wien) 2016; 158:767-772. [PMID: 26858209 DOI: 10.1007/s00701-016-2713-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Peripheral nerve field stimulation (PNFS) is a novel neurosurgical procedure consisting of implantation of subcutaneous leads in specific painful areas in different types of painful, drug-resistant syndromes. The objective of this study was to evaluate the efficacy of PNFS in several patients affected by different chronic neuropathic pain syndromes, along with its risks, limits and possible correlation between the results achieved and the patients' main symptoms. METHODS Twenty-two patients affected by different types of chronic neuropathic pain were submitted to PNFS at the Department of Neurosurgery of the Istituto Neurologico "C. Besta" in Milan between July 2009 and July 2013. The visual analog scale (VAS) and variations in the use of analgesic drugs, along with complications, were considered to assess results. RESULTS In 59 % of our patients, an average pain reduction of 5.50 points on the visual analog scale was observed (average pre-implant score 8.86 and average post-implant score 3.36). These patients reduced their analgesic drug use after PNFS. We observed no early or long-term complications after our last follow-up evaluation. CONCLUSIONS PNFS can be considered an effective and safe option to treat carefully selected, drug-resistant and chronic neuropathic pain patients; the reversibility of the procedure and its lack, at least in our hands, of long-term complications may contribute to wider use of this procedure.
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Sierakowski A, Jing S, Poel J, Elliot D. Transcutaneous Peripheral Nerve Stimulation for the Treatment of Neuropathic Pain in the Upper Limb. J Hand Surg Asian Pac Vol 2016; 21:37-43. [DOI: 10.1142/s2424835516500041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: A small number of patients develop intractable peripheral nerve pain following injury or surgery to the upper limb that is refractory to pharmacological treatment. This study reports our results of using transcutaneous peripheral nerve stimulation (TPNS), a non-invasive form of neuromodulation, to treat this difficult problem. Methods: Seventy-two patients were treated for intractable pain in the upper limb using this technique. Electrical current was delivered transcutaneously through a handheld probe, placed on the skin overlying the affected peripheral nerve proximal to the site of pain. Pain severity was determined before and immediately after treatment by subjective patient self-assessment using a visual analogue pain scale. Pre-post treatment changes in pain severity were analysed by Student's test for paired data. Outcome in respect of overall effectiveness of this treatment, was graded according to the maximum duration of pain relief achieved. Results: Overall, TPNS reduced pain intensity from 8.4 (SD 1.6) before treatment to 4.2 (SD 3.5) immediately after treatment, a highly significant effect ([Formula: see text]). The treatment achieved cure in 8/72 (11%) of our patients and a useful therapeutic outcome (pain relief ≥ 1 day) in 27/72 (38%). The treatment failed in 37/72 (51%). Conclusions: TPNS warrants consideration as a therapy for neuropathic pain in the upper limb after drug treatment has failed and before offering surgery or spinal root stimulation.
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Affiliation(s)
- A. Sierakowski
- Department of Hand Surgery, St Andrew's Centre For Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - S.S. Jing
- Department of Hand Surgery, St Andrew's Centre For Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - J. Poel
- Department of Hand Surgery, St Andrew's Centre For Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - D. Elliot
- Department of Hand Surgery, St Andrew's Centre For Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
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Tibioperoneal Short Circuiting for Stump Neuroma Pain in Amputees: Revival of an Old Technique. World Neurosurg 2015; 84:681-7. [PMID: 25937355 DOI: 10.1016/j.wneu.2015.04.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/12/2015] [Accepted: 04/16/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Stump neuroma pain in amputees can be quite challenging. Surgical treatment may be largely subdivided into neuromodulative and non-neuromodulative methods. The latter includes neurocapsis, insertion of nerve stump into the bone marrow, centro-central short circuit (CCSC), and coverage with vascularized soft tissue flaps. CCSC was shown to be extremely effective in alleviation of pain. Reports on CCSC for the treatment of stump neuroma pain have disappeared from the literature, with a shift toward neuromodulation for the treatment of pain irrespective of etiology. METHODS We observed 8 lower limb amputees undergoing CCSC of the sciatic nerve during a follow-up of 12 years. All had the same stump neuroma pain rendering them unable to wear their prostheses. The sciatic nerve was explored at the midthigh area, much proximal to the amputation site, and a short circuit was established between the tibial and peroneal parts of the nerve. Assessment was by means of pain quantification as per the quadruple visual analogue scale, medication intake, and ability to use prostheses. RESULTS The median worst quadruple visual analogue scale before surgery was 8.0. After surgery it decreased to 2.5 (P = 0.00094). Medication intake was reduced from regular intake of a combination of opioids, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, and pregabalin in all patients to irregular intake of nonsteroidal anti-inflammatory drug alone in 3 of 8 patients. All patients were able to wear their limb prosthesis since surgery. CONCLUSIONS CCSC is a simple, effective, and long-lasting method to treat painful stump neuromas in amputees. It should be strongly considered in deserving cases before resorting to neuromodulative methods.
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Cornish P, Wall C. Successful Peripheral Neuromodulation for Phantom Limb Pain. PAIN MEDICINE 2015; 16:761-4. [DOI: 10.1111/pme.12532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sharma M, Shaikhouni A, Saleh E, Shaw A, Deogaonkar M. Peripheral nerve field stimulation for otalgia: A novel therapy for refractory deep ear pain. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2014. [DOI: 10.1016/j.inat.2014.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Johnson S, Ayling H, Sharma M, Goebel A. External Noninvasive Peripheral Nerve Stimulation Treatment of Neuropathic Pain: A Prospective Audit. Neuromodulation 2014; 18:384-91. [PMID: 25308421 DOI: 10.1111/ner.12244] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/17/2014] [Accepted: 08/12/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peripheral nerve stimulation (PNS) is a neuromodulation technique in which electrical current is applied to the peripheral nerves to ameliorate chronic pain through preferential activation of myelinated fibres, inducing long-term depression of synaptic efficacy. External noninvasive peripheral nerve stimulation (EN-PNS) is a novel and simple form of PNS that involves stimulation via an external nerve-mapping probe that is placed on the skin and connected to a power source. OBJECTIVES We aimed to assess the clinical utility of EN-PNS in patients with refractory neuropathic pains referred to a tertiary pain treatment center. METHODS We undertook a prospective audit of EN-PNS. Patients with a diagnosis of either complex regional pain syndrome or neuropathic pain after peripheral nerve injury who met inclusion criteria were included. Participants completed three stages of the audit: stage 1, six weekly outpatient treatment sessions; stage 2, six-week equipment home loan; stage 3, six weeks of no EN-PNS treatment. The primary outcome was the average post-treatment instantaneous pain intensity during the last week in stage 2 compared with baseline (11-point numerical rating scale). RESULTS EN-PNS provided significant short-term pain relief (n = 20 patients, average reduction of 2.8 numerical rating scale points, 95% CI 1.6-4.0, p < 0.001, intention-to-treat analysis). Eight patients (40%) improved in several outcome parameters ("responders"), including quality of life and function. CONCLUSION In this first prospective report on the use of EN-PNS in neuropathic pain, this technology provided significant clinical benefit for some patients. Controlled studies are required to confirm our results and the place of EN-PNS in future neuromodulation treatment algorithms. Given the refractory nature of these conditions, these results are encouraging.
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Affiliation(s)
- Selina Johnson
- Pain Management Department, Walton Centre NHS Trust, Liverpool, UK
| | - Helen Ayling
- Pain Management Department, Walton Centre NHS Trust, Liverpool, UK
| | - Manohar Sharma
- Pain Management Department, Walton Centre NHS Trust, Liverpool, UK
| | - Andreas Goebel
- Pain Management Department, Walton Centre NHS Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
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Sharma M, Shaw A, Deogaonkar M. Surgical Options for Complex Craniofacial Pain. Neurosurg Clin N Am 2014; 25:763-75. [DOI: 10.1016/j.nec.2014.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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