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da Cunha PHM, de Andrade DC. The deep and the deeper: Spinal cord and deep brain stimulation for neuropathic pain. Presse Med 2024; 53:104231. [PMID: 38636785 DOI: 10.1016/j.lpm.2024.104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Neuropathic pain occurs in people experiencing lesion or disease affecting the somatosensorial system. It is present in 7 % of the general population and may not fully respond to first- and second-line treatments in up to 40 % of cases. Neuromodulation approaches are often proposed for those not tolerating or not responding to usual pharmacological management. These approaches can be delivered surgically (invasively) or non-invasively. Invasive neuromodulation techniques were the first to be employed in neuropathic pain. Among them is spinal cord stimulation (SCS), which consists of the implantation of epidural electrodes over the spinal cord. It is recommended in some guidelines for peripheral neuropathic pain. While recent studies have called into question its efficacy, others have provided promising data, driven by advances in techniques, battery capabilities, programming algorithms and software developments. Deep brain stimulation (DBS) is another well-stablished neuromodulation therapy routinely used for movement disorders; however, its role in pain management remains limited to specific research centers. This is not only due to variable results in the literature contesting its efficacy, but also because several different brain targets have been explored in small trials, compromising comparisons between these studies. Structures such as the periaqueductal grey, posterior thalamus, anterior cingulate cortex, ventral striatum/anterior limb of the internal capsule and the insula are the main targets described to date in literature. SCS and DBS present diverse rationales for use, mechanistic backgrounds, and varying levels of support from experimental studies. The present review aims to present their methodological details, main mechanisms of action for analgesia and their place in the current body of evidence in the management of patients with neuropathic pain, as well their particularities, effectiveness, safety and limitations.
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Affiliation(s)
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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Sagalajev B, Zhang T, Abdollahi N, Yousefpour N, Medlock L, Al-Basha D, Ribeiro-da-Silva A, Esteller R, Ratté S, Prescott SA. Absence of paresthesia during high-rate spinal cord stimulation reveals importance of synchrony for sensations evoked by electrical stimulation. Neuron 2024; 112:404-420.e6. [PMID: 37972595 DOI: 10.1016/j.neuron.2023.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/24/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023]
Abstract
Electrically activating mechanoreceptive afferents inhibits pain. However, paresthesia evoked by spinal cord stimulation (SCS) at 40-60 Hz becomes uncomfortable at high pulse amplitudes, limiting SCS "dosage." Kilohertz-frequency SCS produces analgesia without paresthesia and is thought, therefore, not to activate afferent axons. We show that paresthesia is absent not because axons do not spike but because they spike asynchronously. In a pain patient, selectively increasing SCS frequency abolished paresthesia and epidurally recorded evoked compound action potentials (ECAPs). Dependence of ECAP amplitude on SCS frequency was reproduced in pigs, rats, and computer simulations and is explained by overdrive desynchronization: spikes desychronize when axons are stimulated faster than their refractory period. Unlike synchronous spikes, asynchronous spikes fail to produce paresthesia because their transmission to somatosensory cortex is blocked by feedforward inhibition. Our results demonstrate how stimulation frequency impacts synchrony based on axon properties and how synchrony impacts sensation based on circuit properties.
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Affiliation(s)
- Boriss Sagalajev
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Tianhe Zhang
- Boston Scientific Neuromodulation, Valencia, CA 25155, USA
| | - Nooshin Abdollahi
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Noosha Yousefpour
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC H3G 1Y6, Canada
| | - Laura Medlock
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Dhekra Al-Basha
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Alfredo Ribeiro-da-Silva
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC H3G 1Y6, Canada; Department of Anatomy and Cell Biology, McGill University, Montreal, QC H3A 0C7, Canada
| | | | - Stéphanie Ratté
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Steven A Prescott
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada; Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada.
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Fang K, Lu P, Cheng W, Yu B. Kilohertz high-frequency electrical stimulation ameliorate hyperalgesia by modulating transient receptor potential vanilloid-1 and N-methyl-D-aspartate receptor-2B signaling pathways in chronic constriction injury of sciatic nerve mice. Mol Pain 2024; 20:17448069231225810. [PMID: 38148592 PMCID: PMC10851768 DOI: 10.1177/17448069231225810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/30/2023] [Accepted: 12/12/2023] [Indexed: 12/28/2023] Open
Abstract
The number of patients with neuropathic pain is increasing in recent years, but drug treatments for neuropathic pain have a low success rate and often come with significant side effects. Consequently, the development of innovative therapeutic strategies has become an urgent necessity. Kilohertz High Frequency Electrical Stimulation (KHES) offers pain relief without inducing paresthesia. However, the specific therapeutic effects of KHES on neuropathic pain and its underlying mechanisms remain ambiguous, warranting further investigation. In our previous study, we utilized the Gene Expression Omnibus (GEO) database to identify datasets related to neuropathic pain mice. The majority of the identified pathways were found to be associated with inflammatory responses. From these pathways, we selected the transient receptor potential vanilloid-1 (TRPV1) and N-methyl-D-aspartate receptor-2B (NMDAR2B) pathway for further exploration. Mice were randomly divided into four groups: a Sham group, a Sham/KHES group, a chronic constriction injury of the sciatic nerve (CCI) group, and a CCI/KHES stimulation group. KHES administered 30 min every day for 1 week. We evaluated the paw withdrawal threshold (PWT) and thermal withdrawal latency (TWL). The expression of TRPV1 and NMDAR2B in the spinal cord were analyzed using quantitative reverse-transcriptase polymerase chain reaction, Western blot, and immunofluorescence assay. KHES significantly alleviated the mechanical and thermal allodynia in neuropathic pain mice. KHES effectively suppressed the expression of TRPV1 and NMDAR2B, consequently inhibiting the activation of glial fibrillary acidic protein (GFAP) and ionized calcium binding adapter molecule 1 (IBA1) in the spinal cord. The administration of the TRPV1 pathway activator partially reversed the antinociceptive effects of KHES, while the TRPV1 pathway inhibitor achieved analgesic effects similar to KHES. KHES inhibited the activation of spinal dorsal horn glial cells, especially astrocytes and microglia, by inhibiting the activation of the TRPV1/NMDAR2B signaling pathway, ultimately alleviating neuropathic pain.
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Affiliation(s)
- Kexin Fang
- Department of Anesthesia and Pain Rehabilitation, Yangzhi Affiliated Rehabilitation Hospital of Tongji University, Shanghai, China
- Tongji University School of Medicine, Shanghai, China
| | - Peixin Lu
- Department of Anesthesia and Pain Rehabilitation, Yangzhi Affiliated Rehabilitation Hospital of Tongji University, Shanghai, China
- Tongji University School of Medicine, Shanghai, China
| | - Wen Cheng
- Department of Anesthesia and Pain Rehabilitation, Yangzhi Affiliated Rehabilitation Hospital of Tongji University, Shanghai, China
- Tongji University School of Medicine, Shanghai, China
| | - Bin Yu
- Department of Anesthesia and Pain Rehabilitation, Yangzhi Affiliated Rehabilitation Hospital of Tongji University, Shanghai, China
- Tongji University School of Medicine, Shanghai, China
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Zheng Y, Liu CW, Hui Chan DX, Kai Ong DW, Xin Ker JR, Ng WH, Wan KR. Neurostimulation for Chronic Pain: A Systematic Review of High-Quality Randomized Controlled Trials With Long-Term Follow-Up. Neuromodulation 2023; 26:1276-1294. [PMID: 37436342 DOI: 10.1016/j.neurom.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE This study aimed to review the best evidence on the long-term efficacy of neurostimulation for chronic pain. MATERIALS AND METHODS We systematically reviewed PubMed, CENTRAL, and WikiStim for studies published between the inception of the data bases and July 21, 2022. Randomized controlled trials (RCTs) with a minimum of one-year follow-up that were of high methodologic quality as ascertained using the Delphi list criteria were included in the evidence synthesis. The primary outcome was long-term reduction in pain intensity, and the secondary outcomes were all other reported outcomes. Level of recommendation was graded from I to III, with level I being the highest level of recommendation. RESULTS Of the 7119 records screened, 24 RCTs were included in the evidence synthesis. Therapies with recommendations for their usage include pulsed radiofrequency (PRF) for postherpetic neuralgia, transcutaneous electrical nerve stimulation for trigeminal neuralgia, motor cortex stimulation for neuropathic pain and poststroke pain, deep brain stimulation for cluster headache, sphenopalatine ganglion stimulation for cluster headache, occipital nerve stimulation for migraine, peripheral nerve field stimulation for back pain, and spinal cord stimulation (SCS) for back and leg pain, nonsurgical back pain, persistent spinal pain syndrome, and painful diabetic neuropathy. Closed-loop SCS is recommended over open-loop SCS for back and leg pain. SCS is recommended over PRF for postherpetic neuralgia. Dorsal root ganglion stimulation is recommended over SCS for complex regional pain syndrome. CONCLUSIONS Neurostimulation is generally effective in the long term as an adjunctive treatment for chronic pain. Future studies should evaluate whether the multidisciplinary management of the physical perception of pain, affect, and social stressors is superior to their management alone.
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Affiliation(s)
- Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Diana Xin Hui Chan
- Anaesthesiology and Pain Management, Singapore General Hospital, Singapore
| | - Damian Wen Kai Ong
- Anaesthesia & Chronic and Interventional Pain Management, Tan Tock Seng Hospital, Singapore
| | | | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Kai Rui Wan
- Department of Neurosurgery, National Neuroscience Institute, Singapore.
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Papadopoulos DV, Suk MS, Andreychik D, Nikolaou V, Haak M. Rates and Causes of Reoperations Following Spinal Cord Stimulation Within a 2-12 year Period. Global Spine J 2023:21925682231194466. [PMID: 37542526 DOI: 10.1177/21925682231194466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2023] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Spinal cord stimulation has been mainly used for the management of postsurgical persistent neuropathic. The purpose of the study was to evaluate the rate and causes for reoperation following spinal cord stimulation, and to identify risk factors for reoperation. METHODS A retrospective study was conducted including patients who underwent surgical implantation of spinal cord stimulators within a 10-year period. The medical records of the included patients were reviewed for reoperations, demographics and certain clinical parameters. Demographics and clinical parameters were compared between patients with and without reoperations, and between patients with and without surgical site infections. RESULTS Overall, 1014 index procedures and 175 reoperations were performed within the study period. At least 1 reoperation was performed in 97 (9.5%) cases. The most common cause for revision was lead migration or lead misplacement (n = 31, 3.0%). In 31 (3.1%) cases the stimulator was removed due to no pain relief. Surgical site infection that required reoperation developed in 30 cases (2.9%). Younger age was associated with a need for reoperation (Odds Ratio [OR]: .97,95% Confidence Interval [CI]:0.95-.99, P = .005), while higher Body Mass index and diabetes were associated with development of infection (OR: 1.05, 95% CI: 1.00-1.11, P = .036 and OR: 2.42, 95% CI: 1.05-5.47, P = .033 respectively). CONCLUSIONS The results of this study indicate that certain measures could improve the overall reoperation rate after spinal cord stimulation, such as accurate positioning of the spinal cord stimulators and design of smaller generators. Moreover, preoperative optimization of patients could result in lower complication rate, lower reoperations rate, and subsequently better clinical outcomes.
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Affiliation(s)
- Dimitrios V Papadopoulos
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Madeline S Suk
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - David Andreychik
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Vasileios Nikolaou
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Michael Haak
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
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Bandres MF, Gomes JL, McPherson JG. Spinal stimulation for motor rehabilitation immediately modulates nociceptive transmission. J Neural Eng 2022; 19:10.1088/1741-2552/ac9a00. [PMID: 36228593 PMCID: PMC9797038 DOI: 10.1088/1741-2552/ac9a00] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/13/2022] [Indexed: 12/31/2022]
Abstract
Objective. Spinal cord injury (SCI) often results in debilitating movement impairments and neuropathic pain. Electrical stimulation of spinal neurons holds considerable promise both for enhancing neural transmission in weakened motor pathways and for reducing neural transmission in overactive nociceptive pathways. However, spinal stimulation paradigms currently under development for individuals living with SCI continue overwhelmingly to be developed in the context of motor rehabilitation alone. The objective of this study is to test the hypothesis that motor-targeted spinal stimulation simultaneously modulates spinal nociceptive transmission.Approach. We characterized the neuromodulatory actions of motor-targeted intraspinal microstimulation (ISMS) on the firing dynamics of large populations of discrete nociceptive specific and wide dynamic range (WDR) neurons. Neurons were accessed via dense microelectrode arrays implantedin vivointo lumbar enlargement of rats. Nociceptive and non-nociceptive cutaneous transmission was induced before, during, and after ISMS by mechanically probing the L5 dermatome.Main results. Our primary findings are that (a) sub-motor threshold ISMS delivered to spinal motor pools immediately modulates concurrent nociceptive transmission; (b) the magnitude of anti-nociceptive effects increases with longer durations of ISMS, including robust carryover effects; (c) the majority of all identified nociceptive-specific and WDR neurons exhibit firing rate reductions after only 10 min of ISMS; and (d) ISMS does not increase spinal responsiveness to non-nociceptive cutaneous transmission. These results lead to the conclusion that ISMS parameterized to enhance motor output results in an overall net decrease n spinal nociceptive transmission.Significance. These results suggest that ISMS may hold translational potential for neuropathic pain-related applications and that it may be uniquely suited to delivering multi-modal therapeutic benefits for individuals living with SCI.
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Affiliation(s)
- Maria F. Bandres
- Program in Physical Therapy, Washington University School of Medicine in St. Louis
- Department of Biomedical Engineering; Washington University in St. Louis
| | - Jefferson L. Gomes
- Program in Physical Therapy, Washington University School of Medicine in St. Louis
| | - Jacob G. McPherson
- Program in Physical Therapy, Washington University School of Medicine in St. Louis
- Department of Anesthesiology, Washington University School of Medicine in St. Louis
- Washington University Pain Center, Washington University School of Medicine in St. Louis
- Program in Neuroscience; Washington University School of Medicine in St. Louis
- Department of Biomedical Engineering; Washington University in St. Louis
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Fan X, Ren H, Bu C, Lu Z, Wei Y, Xu F, Fu L, Ma L, Kong C, Wang T, Zhang Y, Liu Q, Huang W, Bu H, Yuan J. Alterations in local activity and functional connectivity in patients with postherpetic neuralgia after short-term spinal cord stimulation. Front Mol Neurosci 2022; 15:938280. [PMID: 36034501 PMCID: PMC9405669 DOI: 10.3389/fnmol.2022.938280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThe efficacy of short-term spinal cord stimulation (stSCS) as a treatment for neuropathic pain in patients with postherpetic neuralgia (PHN) has already been validated. However, the potential alterations in brain functionality that are induced by such treatment have yet to be completely elucidated.MethodsThis study use resting-state functional magnetic resonance imaging (rs-fMRI) to detect the changes in regional homogeneity (ReHo) and degree centrality (DC) related to stimulator-induced pain relief in patients with PHN. A total of 10 patients with PHN underwent an MRI protocol at baseline and after stSCS. Alterations in ReHo and DC were then compared between baseline and after stSCS. We investigated the relationship between clinical parameters and functional changes in the brain.ResultsClinical parameters on pain, emotion, and sleep quality were correlated with ReHo and DC. ReHo and DC were significantly altered in the middle temporal gyrus, precuneus, superior frontal gyrus, supramarginal gyrus, inferior parietal lobule, rolandic operculum, middle occipital gyrus, superior parietal gyrus, and the precentral gyrus after stSCS. A significant correlation was detected between ReHo changes in the middle occipital gyrus, precuneus, inferior parietal gyrus, and changes in pain, emotion, and sleep quality. A significant negative correlation was detected between DC changes in the middle temporal gyrus, rolandic operculum, supramarginal gyrus, precuneus, inferior parietal gyrus, and changes in pain, emotion, and sleep quality.ConclusionThis study found that stSCS is able to induce ReHo and DC changes in patients with PHN, thus suggesting that stSCS can change brain function to alleviate pain, sleep, and emotional disorder.
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Affiliation(s)
- Xiaochong Fan
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Xiaochong Fan
| | - Huan Ren
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chunxiao Bu
- Department of Magnetic Resonance Imaging, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhongyuan Lu
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yarui Wei
- Department of Magnetic Resonance Imaging, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fuxing Xu
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijun Fu
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Letian Ma
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cunlong Kong
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tao Wang
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yong Zhang
- Department of Magnetic Resonance Imaging, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qingying Liu
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital Sun Yat-sen University, Guangzhou, China
| | - Huilian Bu
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingjing Yuan
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Jingjing Yuan
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Kiang L, Woodington B, Carnicer-Lombarte A, Malliaras G, Barone DG. Spinal cord bioelectronic interfaces: opportunities in neural recording and clinical challenges. J Neural Eng 2022; 19. [PMID: 35320780 DOI: 10.1088/1741-2552/ac605f] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/23/2022] [Indexed: 11/11/2022]
Abstract
Bioelectronic stimulation of the spinal cord has demonstrated significant progress in restoration of motor function in spinal cord injury (SCI). The proximal, uninjured spinal cord presents a viable target for the recording and generation of control signals to drive targeted stimulation. Signals have been directly recorded from the spinal cord in behaving animals and correlated with limb kinematics. Advances in flexible materials, electrode impedance and signal analysis will allow SCR to be used in next-generation neuroprosthetics. In this review, we summarize the technological advances enabling progress in SCR and describe systematically the clinical challenges facing spinal cord bioelectronic interfaces and potential solutions, from device manufacture, surgical implantation to chronic effects of foreign body reaction and stress-strain mismatches between electrodes and neural tissue. Finally, we establish our vision of bi-directional closed-loop spinal cord bioelectronic bypass interfaces that enable the communication of disrupted sensory signals and restoration of motor function in SCI.
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Affiliation(s)
- Lei Kiang
- Orthopaedic Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore, 169608, SINGAPORE
| | - Ben Woodington
- Department of Engineering, University of Cambridge, Electrical Engineering Division, 9 JJ Thomson Ave, Cambridge, Cambridge, CB2 1TN, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Alejandro Carnicer-Lombarte
- Clinical Neurosciences, University of Cambridge, Bioelectronics Laboratory, Cambridge, CB2 0PY, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - George Malliaras
- University of Cambridge, University of Cambridge, Cambridge, CB2 1TN, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Damiano G Barone
- Department of Engineering, University of Cambridge, Electrical Engineering Division, 9 JJ Thomson Ave, Cambridge, Cambridge, Cambridgeshire, CB2 1TN, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
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Fan W, Sullivan SJ, Sdrulla AD. Dorsal Column and Root Stimulation at Aβ-fiber Intensity Activate Superficial Dorsal Horn Glutamatergic and GABAergic Populations. Mol Pain 2022; 18:17448069221079559. [PMID: 35088625 PMCID: PMC8891844 DOI: 10.1177/17448069221079559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurostimulation therapies are frequently used in patients with chronic pain conditions. They emerged from Gate Control Theory (GCT), which posits that Aβ-fiber activation recruits superficial dorsal horn (SDH) inhibitory networks to “close the gate” on nociceptive transmission, resulting in pain relief. However, the efficacy of current therapies is limited, and the underlying circuits remain poorly understood. For example, it remains unknown whether ongoing stimulation of Aβ-fibers is sufficient to drive activity in SDH neurons. We used multiphoton microscopy in spinal cords extracted from mice expressing the genetically encoded calcium indicator GCaMP6s in glutamatergic and GABAergic populations; activity levels were inferred from deconvolved calcium signals using CaImAn software. Sustained Aβ-fiber stimulation at the dorsal columns or dorsal roots drove robust yet transient activation of both SDH populations. Following the initial increase, activity levels decreased below baseline in glutamatergic neurons and were depressed after stimulation ceased in both populations. Surprisingly, only about half of GABAergic neurons responded to Aβ-fiber stimulation. This subset showed elevated activity for the entire duration of stimulation, while non-responders decreased with time. Our findings suggest that Aβ-fiber stimulation initially recruits both excitatory and inhibitory populations but has divergent effects on their activity, providing a foundation for understanding the analgesic effects of neurostimulation devices. Perspective: This article used microscopy to characterize the responses of mouse spinal cord cells to stimulation of non-painful nerve fibers. These findings deepen our understanding of how the spinal cord processes information and provide a foundation for improving pain-relieving therapies.
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Affiliation(s)
- Wei Fan
- Anesthesiology and Pain Management6684Oregon Health & Science University
| | - Steve J Sullivan
- Anesthesiology and Pain Management6684Oregon Health & Science University
| | - Andrei D Sdrulla
- Anesthesiology and Pain Management6684Oregon Health & Science University
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10
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Chao D, Mecca CM, Yu G, Segel I, Gold MS, Hogan QH, Pan B. Dorsal root ganglion stimulation of injured sensory neurons in rats rapidly eliminates their spontaneous activity and relieves spontaneous pain. Pain 2021; 162:2917-2932. [PMID: 33990112 PMCID: PMC8486885 DOI: 10.1097/j.pain.0000000000002284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Dorsal root ganglion field stimulation (GFS) relieves evoked and spontaneous neuropathic pain by use-dependent blockade of impulse trains through the sensory neuron T-junction, which becomes complete within less than 1 minute for C-type units, also with partial blockade of Aδ units. We used this tool in the spinal nerve ligation (SNL) rat model to selectively block sensory neuron spontaneous activity (SA) of axotomized neurons at the fifth lumbar (L5) level vs blockade of units at the L4 level that remain uninjured but exposed to inflammation. In vivo dorsal root single-unit recordings after SNL showed increased SA in L5 units but not L4 units. Ganglion field stimulation blocked this SA. Ganglion field stimulation delivered at the L5 dorsal root ganglion blocked mechanical hyperalgesia behavior, mechanical allodynia, and ongoing spontaneous pain indicated by conditioned place preference, whereas GFS at L4 blocked evoked pain behavior but not spontaneous pain. In vivo single-unit recordings of spinal cord dorsal horn (DH) wide-dynamic-range neurons showed elevated SA after SNL, which was reduced by GFS at the L5 level but not by GFS at the L4 level. In addition, L5 GFS, but not L4 GFS, increased mechanical threshold of DH units during cutaneous mechanical stimulation, while L5 GFS exceeded L4 GFS in reducing evoked firing rates. Our results indicate that SA in injured neurons supports increased firing of DH wide-dynamic-range neurons, contributing to hyperalgesia, allodynia, and ongoing pain. Ganglion field stimulation analgesic effects after nerve injury are at least partly attributable to blocking propagation of this SA.
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Affiliation(s)
- Dongman Chao
- Department of Anesthesiology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - Christina M. Mecca
- Department of Anesthesiology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - Guoliang Yu
- Department of Anesthesiology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - Ian Segel
- Department of Anesthesiology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - Michael S. Gold
- Department of Neurobiology, University of Pittsburgh, 3500 Terrace Street Rm E1440 BST, Pittsburgh, PA 15213
| | - Quinn H. Hogan
- Department of Anesthesiology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - Bin Pan
- Department of Anesthesiology, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
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11
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Spinal cord stimulation for neuropathic pain. Rev Neurol (Paris) 2021; 177:838-842. [PMID: 34384626 DOI: 10.1016/j.neurol.2021.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 07/28/2021] [Indexed: 01/20/2023]
Abstract
Spinal cord stimulation (SCS) is used for more than 40years to treat localized chronic medically refractory neuropathic pain involving limb(s) and trunk. The most frequent indications remain complex regional pain syndrome (CRPS) failed back surgery syndrome (FBSS), and peripheral neuropathy. Stimulation-induced paresthesias, perceived by the patient, prevent blinded evaluation and increase the placebo effect, decreasing the credibility of the tonic SCS efficacy. Retrospective studies reported that about 50% of the patients are improved more than 50% at short-term, but long-term improvement is less. Several comparative randomized trials (RCT) are now available. In CRPS, a RCT demonstrated the superiority of SCS plus physiotherapy compared to physiotherapy alone. In FBSS, two RCTs have shown that SCS was superior to reoperation and conventional medical treatment, (CMM) respectively. New stimulation waveforms, namely burst, high frequency (10KHz) stimulation and close-loop SCS, have been proposed recently to avoid the perception of paresthesias and/or increase the pain relief. RCTs in FBSS have suggested that these new SCS modalities were as least as efficient than conventional tonic SCS and perhaps slightly superior. Two RCTs confirmed SCS efficacy in painful diabetic neuropathy in comparison with CMM. Complications are frequent (hardware dysfunction or migration, superficial infection) but exceptionally serious. Consequently, the risk/benefit ratio is favorable to SCS, considering that chronic pain patients undergoing this procedure are usually resistant to all the other therapies.
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12
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Malone IG, Nosacka RL, Nash MA, Otto KJ, Dale EA. Electrical epidural stimulation of the cervical spinal cord: implications for spinal respiratory neuroplasticity after spinal cord injury. J Neurophysiol 2021; 126:607-626. [PMID: 34232771 DOI: 10.1152/jn.00625.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Traumatic cervical spinal cord injury (cSCI) can lead to damage of bulbospinal pathways to the respiratory motor nuclei and consequent life-threatening respiratory insufficiency due to respiratory muscle paralysis/paresis. Reports of electrical epidural stimulation (EES) of the lumbosacral spinal cord to enable locomotor function after SCI are encouraging, with some evidence of facilitating neural plasticity. Here, we detail the development and success of EES in recovering locomotor function, with consideration of stimulation parameters and safety measures to develop effective EES protocols. EES is just beginning to be applied in other motor, sensory, and autonomic systems; however, there has only been moderate success in preclinical studies aimed at improving breathing function after cSCI. Thus, we explore the rationale for applying EES to the cervical spinal cord, targeting the phrenic motor nucleus for the restoration of breathing. We also suggest cellular/molecular mechanisms by which EES may induce respiratory plasticity, including a brief examination of sex-related differences in these mechanisms. Finally, we suggest that more attention be paid to the effects of specific electrical parameters that have been used in the development of EES protocols and how that can impact the safety and efficacy for those receiving this therapy. Ultimately, we aim to inform readers about the potential benefits of EES in the phrenic motor system and encourage future studies in this area.
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Affiliation(s)
- Ian G Malone
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, Florida.,Breathing Research and Therapeutics Center (BREATHE), University of Florida, Gainesville, Florida
| | - Rachel L Nosacka
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida
| | - Marissa A Nash
- Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida
| | - Kevin J Otto
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, Florida.,Breathing Research and Therapeutics Center (BREATHE), University of Florida, Gainesville, Florida.,J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida.,Department of Neuroscience, University of Florida, Gainesville, Florida.,Department of Neurology, University of Florida, Gainesville, Florida.,Department of Materials Science and Engineering, University of Florida, Gainesville, Florida.,McKnight Brain Institute, University of Florida, Gainesville, Florida
| | - Erica A Dale
- Breathing Research and Therapeutics Center (BREATHE), University of Florida, Gainesville, Florida.,Department of Physiology and Functional Genomics, University of Florida, Gainesville, Florida.,Department of Neuroscience, University of Florida, Gainesville, Florida.,McKnight Brain Institute, University of Florida, Gainesville, Florida
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13
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Dietz BE, Mugan D, Vuong QC, Obara I. Electrically Evoked Compound Action Potentials in Spinal Cord Stimulation: Implications for Preclinical Research Models. Neuromodulation 2021; 25:64-74. [PMID: 34224656 DOI: 10.1111/ner.13480] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/05/2021] [Accepted: 05/17/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The study aimed to assess the feasibility of recording electrically evoked compound action potentials (ECAPs) from the rat spinal cord. To achieve this, we characterized electrophysiological responses of dorsal column (DC) axons from electrical stimulation and quantified the relationship between ECAP and motor thresholds (ECAPTs and MTs). MATERIAL AND METHODS Naïve, anesthetized and freely behaving rats were implanted with a custom-made epidural spinal cord stimulation (SCS) lead. Epidural stimulation and recordings were performed on the same lead using specifically designed equipment. RESULTS The ECAPs recorded from the rat spinal cord demonstrated the expected triphasic morphology. Using 20 μsec pulse duration and 2 Hz frequency rate, the current required in anesthetized rats to generate ECAPs was 0.13 ± 0.02 mA, while the average current required to observe MT was 1.49 ± 0.14 mA. In unanesthetized rats, the average current required to generate ECAPs was 0.09 ± 0.02 mA, while the average current required to observe MT was 0.27 ± 0.04 mA. Thus, there was a significant difference between the ECAPT and MT in both anesthetized and unanesthetized rats (MT was 13.39 ± 2.40 and 2.84 ± 0.33 times higher than ECAPT, respectively). Signal analysis revealed average conduction velocities (CVs) suggesting that predominantly large, myelinated fibers were activated. In addition, a morphometric evaluation of spinal cord slices indicated that the custom-made lead may preferentially activate DC axons. CONCLUSIONS This is the first evidence demonstrating the feasibility of recording ECAPs from the rat spinal cord, which may be more useful in determining parameters of SCS in preclinical SCS models than MTs. Thus, this approach may allow for the development of a novel model of SCS in rats with chronic pain that will translate better between animals and humans.
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Affiliation(s)
| | - Dave Mugan
- Saluda Medical Europe Ltd, Harrogate, UK
| | - Quoc Chi Vuong
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Ilona Obara
- School of Pharmacy, Newcastle University, Newcastle-upon-Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
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14
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Spinal cord stimulation in chronic neuropathic pain: mechanisms of action, new locations, new paradigms. Pain 2021; 161 Suppl 1:S104-S113. [PMID: 33090743 PMCID: PMC7434213 DOI: 10.1097/j.pain.0000000000001854] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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15
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Hagedorn JM, Layno-Moses A, Sanders DT, Pak DJ, Bailey-Classen A, Sowder T. Overview of HF10 spinal cord stimulation for the treatment of chronic pain and an introduction to the Senza Omnia™ system. Pain Manag 2020; 10:367-376. [DOI: 10.2217/pmt-2020-0047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Chronic intractable pain affects a significant percentage of the worldwide population, and it is one of the most disabling and expensive health conditions across the globe. Spinal cord stimulation (SCS) has been used to treat chronic pain for a number of years, but high-frequency SCS was not the US FDA approved until 2015. In this review, we describe the history and development of high-frequency SCS and discuss the benefits of the Omnia™ implantable pulse generator. We also provide a thorough literature review of the published work, highlighting the efficacy and safety profiles of high-frequency SCS for the treatment of multiple chronic pain conditions. Lastly, we offer our outlook on future developments with the Omnia SCS system.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology & Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Annie Layno-Moses
- Source Healthcare, 2801 Wilshire Blvd, Suite A, Santa Monica, CA 90403, USA
| | - Daniel T Sanders
- Spine Team Texas, 1120 Raintree Circle, Suite 110, Allen, TX 75013, USA
| | - Daniel J Pak
- Pain Medicine Division, New York-Presbyterian Hospital, Weill Cornell Medicine, 1300 York Ave, New York, NY 10065, USA
| | | | - Timothy Sowder
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
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16
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Garcia BB, Junior ER, Araújo MFPD, Simplício H. History of and Insights Into Spinal Cord Stimulation in Parkinson Disease. Neurorehabil Neural Repair 2020; 34:967-978. [PMID: 33048030 DOI: 10.1177/1545968320956984] [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: 12/28/2022]
Abstract
BACKGROUND Current available therapies for Parkinson disease (PD) have strong limitations, and patients usually present with refractory symptoms despite all efforts. Deep brain stimulation (DBS), which has been used in PD patients for decades (since 1987), has best indications for symptoms like tremor, motor fluctuations, or dyskinesia. However, postural instability and gait disturbances (PIGD) have restricted benefits with DBS. In 2009, spinal cord stimulation (SCS), a well-established therapy for chronic pain, has emerged as a potential alternative therapy that may help control unresponsive symptoms such as bradykinesia, PIGD, and freezing of gait. METHODS The main studies regarding SCS in PD are reviewed here from the first studies in animal models to the latest clinical trials. CONCLUSIONS Despite promising findings, the heterogeneity of methodologies used and small samples in human studies pose a challenging problem to be addressed in order to have robust clinical evidence to support SCS as a viable PD treatment.
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Affiliation(s)
- Bruno Braz Garcia
- Edmond and Lily Safra International Institute of Neuroscience, Macaiba, Brazil
| | | | - Mariana Ferreira Pereira de Araújo
- Edmond and Lily Safra International Institute of Neuroscience, Macaiba, Brazil.,Federal University of Espirito Santo, Vitoria, ES, Brazil
| | - Hougelle Simplício
- Edmond and Lily Safra International Institute of Neuroscience, Macaiba, Brazil.,Santos Dumont Institute, Macaíba, Brazil.,State University of Rio Grande do Norte, Mossoró, Brazil.,Brain Research and Development Co, Natal, Brazil
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17
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Shu B, He SQ, Guan Y. Spinal Cord Stimulation Enhances Microglial Activation in the Spinal Cord of Nerve-Injured Rats. Neurosci Bull 2020; 36:1441-1453. [PMID: 32889636 DOI: 10.1007/s12264-020-00568-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Microglia can modulate spinal nociceptive transmission. Yet, their role in spinal cord stimulation (SCS)-induced pain inhibition is unclear. Here, we examined how SCS affects microglial activation in the lumbar cord of rats with chronic constriction injury (CCI) of the sciatic nerve. Male rats received conventional SCS (50 Hz, 80% motor threshold, 180 min, 2 sessions/day) or sham stimulation on days 18-20 post-CCI. SCS transiently attenuated the mechanical hypersensitivity in the ipsilateral hind paw and increased OX-42 immunoreactivity in the bilateral dorsal horns. SCS also upregulated the mRNAs of M1-like markers, but not M2-like markers. Inducible NOS protein expression was increased, but brain-derived neurotrophic factor was decreased after SCS. Intrathecal minocycline (1 μg-100 μg), which inhibits microglial activation, dose-dependently attenuated the mechanical hypersensitivity. Pretreatment with low-dose minocycline (1 μg, 30 min) prolonged the SCS-induced pain inhibition. These findings suggest that conventional SCS may paradoxically increase spinal M1-like microglial activity and thereby compromise its own ability to inhibit pain.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shao-Qiu He
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA. .,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
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18
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Esposito MF, Malayil R, Hanes M, Deer T. Unique Characteristics of the Dorsal Root Ganglion as a Target for Neuromodulation. PAIN MEDICINE 2020; 20:S23-S30. [PMID: 31152179 PMCID: PMC6544557 DOI: 10.1093/pm/pnz012] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective The dorsal root ganglion (DRG) is a novel target for neuromodulation, and DRG stimulation is proving to be a viable option in the treatment of chronic intractable neuropathic pain. Although the overall principle of conventional spinal cord stimulation (SCS) and DRG stimulation—in which an electric field is applied to a neural target with the intent of affecting neural pathways to decrease pain perception—is similar, there are significant differences in the anatomy and physiology of the DRG that make it an ideal target for neuromodulation and may account for the superior outcomes observed in the treatment of certain chronic neuropathic pain states. This review highlights the anatomy of the DRG, its function in maintaining homeostasis and its role in neuropathic pain, and the unique value of DRG as a target in neuromodulation for pain. Methods A narrative literature review was performed. Results Overall, the DRG is a critical structure in sensory transduction and modulation, including pain transmission and the maintenance of persistent neuropathic pain states. Unique characteristics including selective somatic organization, specialized membrane characteristics, and accessible and consistent location make the DRG an ideal target for neuromodulation. Because DRG stimulation directly recruits the somata of primary sensory neurons and harnesses the filtering capacity of the pseudounipolar neural architecture, it is differentiated from SCS, peripheral nerve stimulation, and other neuromodulation options. Conclusions There are several advantages to targeting the DRG, including lower energy usage, more focused and posture-independent stimulation, reduced paresthesia, and improved clinical outcomes.
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Affiliation(s)
| | - Rudy Malayil
- St. Mary's Pain Relief Specialists, Huntington, West Virginia
| | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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19
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Moisset X, Lanteri-Minet M, Fontaine D. Neurostimulation methods in the treatment of chronic pain. J Neural Transm (Vienna) 2019; 127:673-686. [PMID: 31637517 DOI: 10.1007/s00702-019-02092-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/06/2019] [Indexed: 02/07/2023]
Abstract
The goal of this narrative review was to give an up-to-date overview of the peripheral and central neurostimulation methods that can be used to treat chronic pain. Special focus has been given to three pain conditions: neuropathic pain, nociplastic pain and primary headaches. Both non-invasive and invasive techniques are briefly presented together with their pain relief potentials. For non-invasive stimulation techniques, data concerning transcutaneous electrical nerve stimulation (TENS), transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), remote electrical neuromodulation (REN) and vagus nerve stimulation (VNS) are provided. Concerning invasive stimulation techniques, occipital nerve stimulation (ONS), vagus nerve stimulation (VNS), epidural motor cortex stimulation (EMCS), spinal cord stimulation (SCS) and deep brain stimulation (DBS) are presented. The action mode of all these techniques is only partly understood but can be very different from one technique to the other. Patients' selection is still a challenge. Recent consensus-based guidelines for clinical practice are presented when available. The development of closed-loop devices could be of interest in the future, although the clinical benefit over open loop is not proven yet.
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Affiliation(s)
- X Moisset
- Service de Neurologie, Université Clermont-Auvergne, INSERM, Neuro-Dol, CHU Clermont-Ferrand, Clermont-Ferrand, France.
| | - M Lanteri-Minet
- Pain Department, CHU Nice, FHU InovPain Côte Azur University, Nice, France
- Université Clermont-Auvergne, INSERM, Neuro-Dol, Clermont-Ferrand, France
| | - D Fontaine
- Department of Neurosurgery, Université Côte Azur University, CHU de Nice, FHU InovPain, Nice, France
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20
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Sadashivaiah V, Sacre P, Guan Y, Anderson WS, Sarma SV. Selective relay of afferent sensory-induced action potentials from peripheral nerve to brain and the effects of electrical stimulation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2018:3606-3609. [PMID: 30441157 DOI: 10.1109/embc.2018.8513029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Electrical stimulation of peripheral nerve fibers and dorsal column fibers is used to treat acute and chronic pain. Recent studies have shown that sensitized A-fibers maybe involved in the relay of pain information. These nerve fibers also carry sensory-induced action potentials (APs), such as proprioception, mechanoreception, etc. Electrical stimulation of these nerve fibers can result in interactions between sensory-induced APs and stimulation-induced APs. For example, the sensory-induced APs can collide with stimulus APs, and thus may never be relayed to the brain. In this study, we aimed to quantify the effects of stimulation frequency on these interactions. Specifically, we focused on the goal of stimulation to simultaneously (i) block noxious sensory signals while (ii) relaying innocuous sensory signals from the periphery to the brain via a myelinated nerve fiber. We defined a performance metric called the "selective relay $(SR)$ " measure. Specifically, we constructed a tractable model of a nerve fiber that receives two inputs: the underlying sensory activity at the bottom of the fiber (noxious or innocuous), and the external stimulus applied to the middle of the fiber. We then defined relay reliability, $R$, as the percentage of sensory APs that make it to the top of the fiber. $SR$ is then a product of relaying innocuous sensory information while blocking noxious pain stimuli, i.e., $SR=R_{\mathrm {s}\mathrm {e}\mathrm {n}}(1-R_{\mathrm {p}\mathrm {a}\mathrm {i}\mathrm {n}})$. We applied the two inputs to the fiber at various frequencies and analyzed relay reliability and then we studied selective relay assuming noxious and innocuous stimuli produce APs with distinct frequencies. We found that frequency stimulation between 50-100Hz effectively blocks relay of low-frequency pain signals, allowing mid-to-high frequency sensory signals to transmit to the brain.
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21
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Idlett S, Halder M, Zhang T, Quevedo J, Brill N, Gu W, Moffitt M, Hochman S. Assessment of axonal recruitment using model-guided preclinical spinal cord stimulation in the ex vivo adult mouse spinal cord. J Neurophysiol 2019; 122:1406-1420. [PMID: 31339796 DOI: 10.1152/jn.00538.2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Spinal cord stimulation (SCS) is used clinically to limit chronic pain, but fundamental questions remain on the identity of axonal populations recruited. We developed an ex vivo adult mouse spinal cord preparation to assess recruitment following delivery of clinically analogous stimuli determined by downscaling a finite element model of clinical SCS. Analogous electric field distributions were generated with 300-µm × 300-µm electrodes positioned 200 µm above the dorsal column (DC) with stimulation between 50 and 200 µA. We compared axonal recruitment using electrodes of comparable size and stimulus amplitudes when contacting the caudal thoracic DC and at 200 or 600 μm above. Antidromic responses recorded distally from the DC, the adjacent Lissauer tract (LT), and in dorsal roots (DRs) were found to be amplitude and site dependent. Responses in the DC included a unique component not seen in DRs, having the lowest SCS recruitment amplitude and fastest conduction velocity. At 200 μm above, mean cathodic SCS recruitment threshold for axons in DRs and LT were 2.6 and 4.4 times higher, respectively, than DC threshold. SCS recruited primary afferents in all (up to 8) caudal segments sampled. Whereas A and C fibers could be recruited at nearby segments, only A fiber recruitment and synaptically mediated dorsal root reflexes were observed in more distant (lumbar) segments. In sum, clinically analogous SCS led to multisegmental recruitment of several somatosensory-encoding axonal populations. Most striking is the possibility that the lowest threshold recruitment of a nonprimary afferent population in the DC are postsynaptic dorsal column tract cells (PSDCs) projecting to gracile nuclei.NEW & NOTEWORTHY Spinal cord stimulation (SCS) is used clinically to control pain. To identify axonal populations recruited, finite element modeling identified scaling parameters to deliver clinically analogous SCS in an ex vivo adult mouse spinal cord preparation. Results showed that SCS first recruited an axonal population in the dorsal column at a threshold severalfold lower than primary afferents. These putative postsynaptic dorsal column tract cells may represent a previously unconsidered population responsible for SCS-induced paresthesias necessary for analgesia.
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Affiliation(s)
- Shaquia Idlett
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia.,Department of Physiology, Emory University School of Medicine, Atlanta, Georgia
| | - Mallika Halder
- Department of Physiology, Emory University School of Medicine, Atlanta, Georgia
| | - Tianhe Zhang
- Boston Scientific Neuromodulation, Valencia, California
| | - Jorge Quevedo
- Departamento de Fisiología, Biofísica y Neurociencias, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City, Mexico
| | - Natalie Brill
- Boston Scientific Neuromodulation, Valencia, California
| | - Wendy Gu
- Boston Scientific Neuromodulation, Valencia, California
| | | | - Shawn Hochman
- Department of Physiology, Emory University School of Medicine, Atlanta, Georgia
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Yang F, Duan W, Huang Q, Chen Z, Ford N, Gao X, Sivanesan E, Sarma SV, Vera-Portocarrero LP, Linderoth B, Raja SN, Guan Y. Modulation of Spinal Nociceptive Transmission by Sub-Sensory Threshold Spinal Cord Stimulation in Rats After Nerve Injury. Neuromodulation 2019; 23:36-45. [PMID: 31162783 DOI: 10.1111/ner.12975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/10/2019] [Accepted: 05/01/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVES High-frequency spinal cord stimulation (SCS) administered below the sensory threshold (subparesthetic) can inhibit pain, but the mechanisms remain obscure. We examined how different SCS paradigms applied at intensities below the threshold of Aβ-fiber activation (sub-sensory threshold) affect spinal nociceptive transmission in rats after an L5 spinal nerve ligation (SNL). MATERIALS AND METHODS Electrophysiology was used to record local field potential (LFP) at L4 spinal cord before, during, and 0-60 min after SCS in SNL rats. LFP was evoked by high-intensity paired-pulse test stimulation (5 mA, 0.2 msec, 400 msec interval) at the sciatic nerve. Epidural SCS was delivered through a miniature electrode placed at T13-L1 and L2-L3 spinal levels. Four patterns of SCS (200 Hz, 1 msec; 500 Hz, 0.5 msec; 1200 Hz; 0.2 msec; 10,000 Hz, 0.024 msec, 30 min, bipolar) were tested at 90% Aβ-threshold as a subthreshold intensity. As a positive control, traditional SCS (50 Hz, 0.2 msec) was tested at 100% Aβ-plateau as a suprathreshold intensity. RESULTS Traditional suprathreshold SCS at T13-L1 level significantly reduced LFP to C-fiber inputs (C-LFP). Subthreshold SCS of 200 and 500 Hz, but not 1200 or 10,000 Hz, also reduced C-LFP, albeit to a lesser extent than did traditional SCS (n = 7-10/group). When SCS was applied at the L2-L3 level, only traditional SCS and subthreshold SCS of 200 Hz inhibited C-LFP (n = 8-10/group). CONCLUSIONS Traditional suprathreshold SCS acutely inhibits spinal nociceptive transmission. Low-frequency subthreshold SCS with a long pulse width (200 Hz, 1 msec), but not higher-frequency SCS, also attenuates C-LFP.
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Affiliation(s)
- Fei Yang
- Department of Neurobiology, School of Basic Medical Sciences, Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Wanru Duan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qian Huang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Zhiyong Chen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Neil Ford
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Xinyan Gao
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Eellan Sivanesan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Sridevi V Sarma
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Neurological Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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23
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Pak DJ, Gruber J, Deer T, Provenzano D, Gulati A, Xu Y, Tangel V, Mehta N. Spinal cord stimulator education during pain fellowship: unmet training needs and factors that impact future practice. Reg Anesth Pain Med 2019; 44:407-414. [DOI: 10.1136/rapm-2018-100065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 09/07/2018] [Indexed: 11/04/2022]
Abstract
Background and objectivesWith a growing need for non-opioid chronic pain treatments, pain physicians should understand the proper utilization of neuromodulation therapies to provide the most comprehensive care. We aimed to identify the unmet training needs that deter physicians from using spinal cord stimulation (SCS) devices.MethodsInternet-based surveys were fielded to fellows enrolled in pain fellowships during the 2016–2017 academic year accredited by the Accreditation Council for Graduate Medical Education and past pain fellows identified through pain medicine societies and SCS manufacturers.ResultsCurrent fellows were more likely to have received SCS training during fellowship compared with past fellows (100.0% vs 84.0%), yet there was variability in fellows’ SCS experiences with a wide range of trials and implants performed. Forty-six percent of current fellows felt there was an unmet training need regarding SCS. Deficiency in SCS case volume was the most common barrier that was noted (38.5%), followed by lack of SCS curriculum (30.8%) and lack of faculty with SCS expertise (23.1%). Lack of training was a predominant reason for past fellows choosing not to use SCS devices postfellowship. The majority of current and past fellows (79.5% and 55.4%, respectively) strongly supported direct training of fellows by SCS manufacturers.ConclusionsWhile SCS training during pain fellowship has become more universal, the experiences that fellows receive are highly variable, and most rely on industry-sponsored programs to supplement training deficiencies. Standardization of SCS procedures may also enable less experienced providers to navigate the SCS treatment algorithm.
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24
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Maheshwari A, Pope JE, Deer TR, Falowski S. Advanced methods of spinal stimulation in the treatment of chronic pain: pulse trains, waveforms, frequencies, targets, and feedback loops. Expert Rev Med Devices 2019; 16:95-106. [PMID: 30625000 DOI: 10.1080/17434440.2019.1567325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Spinal cord stimulation has emerged as a state-of-the-art evidence-based treatment for chronic neuropathic pain and mixed nociceptive-neuropathic pain. In recent years, several newer devices and treatment algorithms have provided unique and effective ways of treating chronic pain by spinal cord stimulation. In a previous review, the authors commented on the 5-year forecast for high frequency and Burst waveforms, as the only two paresthesia independent SCS strategies. Over the last 5 years, there has been considerable addition to the outcome data related to these modalities. Additionally, new treatment algorithms and modalities for spinal cord stimulation have emerged. In this review, the authors provide an up to date summary of these modalities of treatment, indications, and evidence on all different modalities and programming paradigms that are available today. AREAS COVERED A literature review was performed using key bibliographic databases to find outcomes related studies pertaining to spinal cord stimulation, limited to the English language and human data, between 2010 and 2018. The literature search yielded the following based on our inclusion criteria; six articles on burst stimulation, three articled on high density/high dose stimulation, six articles on Dorsal Root Ganglion stimulation, nine articles on high-frequency stimulation, and one article on closed-loop stimulation. We have also included in the discussion some smaller and anecdotal studies. EXPERT COMMENTARY The evidence to support outcomes of spinal cord stimulation has evolved considerably since our last review in 2014. New targets, frequencies and pulse trains, and feedback appear to have advanced the efficacy of spinal cord stimulation. Future developments aim to continue to refine patient selection and maintenance of patients in therapy.
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Affiliation(s)
- Ankit Maheshwari
- a Case Western Reserve University, University Hospitals , Cleveland , OH , USA
| | - Jason E Pope
- b Evolve Restorative Center , Santa Rosa , CA , USA
| | - Timothy R Deer
- c The Spine and Nerve Centers of Virginia , Charleston , WV , USA
| | - Steven Falowski
- d Functional Neurosurgery , St. Lukes University Health Network , Bethlehem , PA , USA
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Spinal Cord Stimulation for Pain Treatment After Spinal Cord Injury. Neurosci Bull 2018; 35:527-539. [PMID: 30560438 DOI: 10.1007/s12264-018-0320-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/11/2018] [Indexed: 12/30/2022] Open
Abstract
In addition to restoration of bladder, bowel, and motor functions, alleviating the accompanying debilitating pain is equally important for improving the quality of life of patients with spinal cord injury (SCI). Currently, however, the treatment of chronic pain after SCI remains a largely unmet need. Electrical spinal cord stimulation (SCS) has been used to manage a variety of chronic pain conditions that are refractory to pharmacotherapy. Yet, its efficacy, benefit profiles, and mechanisms of action in SCI pain remain elusive, due to limited research, methodological weaknesses in previous clinical studies, and a lack of mechanistic exploration of SCS for SCI pain control. We aim to review recent studies and outline the therapeutic potential of different SCS paradigms for traumatic SCI pain. We begin with an overview of its manifestations, classification, potential underlying etiology, and current challenges for its treatment. The clinical evidence for using SCS in SCI pain is then reviewed. Finally, future perspectives of pre-clinical research and clinical study of SCS for SCI pain treatment are discussed.
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Jensen MP, Brownstone RM. Mechanisms of spinal cord stimulation for the treatment of pain: Still in the dark after 50 years. Eur J Pain 2018; 23:652-659. [PMID: 30407696 PMCID: PMC6491991 DOI: 10.1002/ejp.1336] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 09/26/2018] [Accepted: 10/28/2018] [Indexed: 11/10/2022]
Abstract
Background and Objective Despite the value of spinal cord stimulation (SCS) in treating some patients with focal neuropathic pain, technological advances in stimulator design and treatment protocols have not correlated with significant improvements in clinical outcomes. This may be because incomplete understanding of the mechanisms underlying SCS precludes improvement in clinical efficacy. In this brief review, we (a) review phenomenological effects of SCS, (b) review the literature on proposed spinal sites of action of SCS and (c) propose a novel hypothesis of mechanism of action. Results Dorsal columns, dorsal roots and dorsal horns have each been proposed as spinal sites of action of SCS. We suggest that evidence in favour of the dorsal columns or dorsal roots as the primary mediators of SCS is weak and propose that the dorsal horn is the crucial site of action. Furthermore, we hypothesize that, based on their location, and neurochemical and morphological properties, dorsal horn islet cells may mediate the effects of SCS. Conclusions The precise spinal mechanisms of action of SCS are still unknown. Dorsal horn islet cells have properties that position them to play a key role in analgesic effects of electrical stimulation. Understanding the mechanisms responsible for positive SCS effects are needed for successful translation into clinical dividends. Significance We review possible spinal mechanisms of action of spinal cord stimulation for neuropathic pain, proposing that direct modulation of dorsal horn neurons is crucial. We suggest that mechanistic insights are needed for translation into more favourable clinical outcomes.
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Affiliation(s)
- Melanie P Jensen
- Sobell Department of Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
| | - Robert M Brownstone
- Sobell Department of Neuromuscular Diseases, Institute of Neurology, University College London, London, UK
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Meuwissen KPV, Gu JW, Zhang TC, Joosten EAJ. Burst Spinal Cord Stimulation in Peripherally Injured Chronic Neuropathic Rats: A Delayed Effect. Pain Pract 2018; 18:988-996. [PMID: 29679457 DOI: 10.1111/papr.12701] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/03/2017] [Accepted: 04/11/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Two well-known spinal cord stimulation (SCS) paradigms, conventional (Con) and burst SCS, are hypothesized to exert their antinociceptive effects through different stimulation-induced mechanisms. We studied the course of the behavioral antinociceptive effect during 60 minutes of SCS and 30 minutes post-SCS in a rat model of chronic neuropathic pain. METHODS Animals underwent a unilateral partial sciatic nerve ligation, after which quadripolar electrodes were implanted into the epidural space at vertebral level T13 (n = 43 rats). While receiving either Con SCS or biphasic burst SCS, the pain behavior of the rats was assessed by means of paw withdrawal thresholds (WTs) in response to the application of von Frey monofilaments. RESULTS After 15 minutes of Con SCS (n = 21), WTs significantly differed from baseline (P = 0.04), whereas WTs of the burst SCS group (n = 22) did not. After 30 minutes of SCS, WTs of the Con SCS and burst SCS groups reached similar levels, both significantly different from baseline, indicating a comparable antinociceptive effect for these SCS paradigms. Yet, the WTs of the burst SCS group were still significantly increased compared with baseline at 30 minutes post-stimulation, whereas the WTs of the Con SCS group were not. CONCLUSIONS To conclude, biphasic burst SCS results in a delayed antinociceptive effect after onset of the stimulation, as compared with Con SCS, in a chronic neuropathic pain model. Furthermore, biphasic burst SCS seems to exhibit a delayed wash-out of analgesia after stimulation is turned off.
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Affiliation(s)
- Koen P V Meuwissen
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, the Netherlands.,Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Jianwen Wendy Gu
- Neuromodulation, Research and Advanced Concepts Team, Boston Scientific, Natick, Massachusetts, U.S.A
| | - Tianhe C Zhang
- Neuromodulation, Research and Advanced Concepts Team, Boston Scientific, Natick, Massachusetts, U.S.A
| | - Elbert A J Joosten
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, Maastricht University Medical Center, Maastricht, the Netherlands.,Faculty of Health, Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome. Asian Spine J 2018; 12:574-585. [PMID: 29879788 PMCID: PMC6002183 DOI: 10.4184/asj.2018.12.3.574] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 08/20/2017] [Accepted: 09/12/2017] [Indexed: 12/28/2022] Open
Abstract
The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients’ clinical history (observing “red flags”), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.
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Sdrulla AD, Guan Y, Raja SN. Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms. Pain Pract 2018. [PMID: 29526043 DOI: 10.1111/papr.12692] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Spinal cord stimulation (SCS) is a minimally invasive therapy used for the treatment of chronic neuropathic pain. SCS is a safe and effective alternative to medications such as opioids, and multiple randomized controlled studies have demonstrated efficacy for difficult-to-treat neuropathic conditions such as failed back surgery syndrome. Conventional SCS is believed mediate pain relief via activation of dorsal column Aβ fibers, resulting in variable effects on sensory and pain thresholds, and measurable alterations in higher order cortical processing. Although potentiation of inhibition, as suggested by Wall and Melzack's gate control theory, continues to be the leading explanatory model, other segmental and supraspinal mechanisms have been described. Novel, non-standard, stimulation waveforms such as high-frequency and burst have been shown in some studies to be clinically superior to conventional SCS, however their mechanisms of action remain to be determined. Additional studies are needed, both mechanistic and clinical, to better understand optimal stimulation strategies for different neuropathic conditions, improve patient selection and optimize efficacy.
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Affiliation(s)
- Andrei D Sdrulla
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A.,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
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Spinal Cord Stimulation Modulates Gene Expression in the Spinal Cord of an Animal Model of Peripheral Nerve Injury. Reg Anesth Pain Med 2018; 41:750-756. [PMID: 27512935 DOI: 10.1097/aap.0000000000000452] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Previously, we found that application of pulsed radiofrequency to a peripheral nerve injury induces changes in key genes regulating nociception concurrent with alleviation of paw sensitivity in an animal model. In the current study, we evaluated such genes after applying spinal cord stimulation (SCS) therapy. METHODS Male Sprague-Dawley rats (n = 6 per group) were randomized into test and control groups. The spared nerve injury model was used to simulate a neuropathic pain state. A 4-contact microelectrode was implanted at the L1 vertebral level and SCS was applied continuously for 72 hours. Mechanical hyperalgesia was tested. Spinal cord tissues were collected and analyzed using real-time polymerase chain reaction to quantify levels of IL1β, GABAbr1, subP, Na/K ATPase, cFos, 5HT3ra, TNFα, Gal, VIP, NpY, IL6, GFAP, ITGAM, and BDNF. RESULTS Paw withdrawal thresholds significantly decreased in spared nerve injury animals and stimulation attenuated sensitivity within 24 hours (P = 0.049), remaining significant through 72 hours (P = 0.003). Nerve injury caused up-regulation of TNFα, GFAP, ITGAM, and cFOS as well as down-regulation of Na/K ATPase. Spinal cord stimulation therapy modulated the expression of 5HT3ra, cFOS, and GABAbr1. Strong inverse relationships in gene expression relative to the amount of applied current were observed for GABAbr1 (R = -0.65) and Na/K ATPase (R = -0.58), and a positive linear correlations between 5HT3r (R = 0.80) and VIP (R = 0.50) were observed. CONCLUSIONS Continuously applied SCS modulates expression of key genes involved in the regulation of neuronal membrane potential.
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Yang F, Anderson M, He S, Stephens K, Zheng Y, Chen Z, Raja SN, Aplin F, Guan Y, Fridman G. Differential expression of voltage-gated sodium channels in afferent neurons renders selective neural block by ionic direct current. SCIENCE ADVANCES 2018; 4:eaaq1438. [PMID: 29651458 PMCID: PMC5895440 DOI: 10.1126/sciadv.aaq1438] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/21/2018] [Indexed: 06/01/2023]
Abstract
The assertion that large-diameter nerve fibers have low thresholds and small-diameter fibers have high thresholds in response to electrical stimulation has been held in a nearly axiomatic regard in the field of neuromodulation and neuroprosthetics. In contrast to the short pulses used to evoke action potentials, long-duration ionic direct current has been shown to block neural activity. We propose that the main determinant of the neural sensitivity to direct current block is not the size of the axon but the types of voltage-gated sodium channels prevalent in its neural membrane. On the basis of the variants of voltage-gated sodium channels expressed in different types of neurons in the peripheral nerves, we hypothesized that the small-diameter nociceptive fibers could be preferentially blocked. We show the results of a computational model and in vivo neurophysiology experiments that offer experimental validation of this novel phenomenon.
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Affiliation(s)
- Fei Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Neurobiology, Capital Medical University, Beijing 100069, PR China
| | - Michael Anderson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Shaoqiu He
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Kimberly Stephens
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Yu Zheng
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Zhiyong Chen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Srinivasa N. Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Felix Aplin
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Gene Fridman
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD 21205, USA
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Ou P, Fridman G. Electronics for a Safe Direct Current Stimulator. IEEE BIOMEDICAL CIRCUITS AND SYSTEMS CONFERENCE : HEALTHCARE TECHNOLOGY : [PROCEEDINGS]. IEEE BIOMEDICAL CIRCUITS AND SYSTEMS CONFERENCE 2018; 2017. [PMID: 30406219 DOI: 10.1109/biocas.2017.8325191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Commercially available neuroprostheses, while successful and effective, are limited in their functionality by their reliance on pulsatile stimulation. Direct current (DC) has been shown to have great potential for the purposes of neuromodulation; however, direct current cannot be applied directly to neurons due to the charge injection thresholds of electrodes. We are developing a Safe Direct Current Stimulator (SDCS) that applies ionic direct current (iDC) without inducing toxic electrochemical reactions. The current design of the SDCS uses a series of eight valves in conjunction with four electrodes to rectify ionic current in microfluidic channels. This paper outlines the design, implementation, and testing of the electronics of the SDCS. These electronics will ultimately be interfaced with a separate microfluidic circuit in the device prototype. Testing the outputs of the electronics confirmed adherence to its design requirements. The completion of the SDCS electronics enables the further development of iDC as a mechanism for neuromodulation.
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Affiliation(s)
- Patrick Ou
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Gene Fridman
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
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Ahmed S, Yearwood T, De Ridder D, Vanneste S. Burst and high frequency stimulation: underlying mechanism of action. Expert Rev Med Devices 2017; 15:61-70. [PMID: 29249191 DOI: 10.1080/17434440.2018.1418662] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Paresthesia-free spinal cord stimulation (SCS) techniques, such as burst and high-frequency (HF) SCS, have been developed and demonstrated to be successful for treating chronic pain, albeit via different mechanisms of action. The goal of this review is to discuss the mechanisms of action for pain suppression at both the cellular and systems levels for burst and HF SCS. In addition, we also discuss the neuromodulation devices that mimic these paradigms. AREAS COVERED The authors performed a literature review to unravel the mechanisms of action for burst and HF SCS coupled with booklets and user manuals from neuromodulation companies to understand the programmable parameters and operating ranges. Burst SCS modulates the medial pathway to suppress pain. On cellular level, burst SCS is independent on activation of γ-aminobutyric acid (GABA) receptors to inhibit neuronal firing. HF SCS blocks large-diameter fibers from producing action potentials with little influence on smaller fibers, increasing pain suppression as frequency increases. EXPERT COMMENTARY The neuromodulation industry is in a phase of intense innovation characterized by adaptive stimulation to improve patients' experience and experiment with alternative frequencies and novel stimulation targets.
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Affiliation(s)
- Shaheen Ahmed
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
| | | | - Dirk De Ridder
- c Department of Surgical Sciences, Dunedin School of Medicine , University of Otago , Dunedin , New Zealand
| | - Sven Vanneste
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
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Meuwissen KPV, Gu JW, Zhang TC, Joosten EAJ. Conventional-SCS vs. Burst-SCS and the Behavioral Effect on Mechanical Hypersensitivity in a Rat Model of Chronic Neuropathic Pain: Effect of Amplitude. Neuromodulation 2017; 21:19-30. [PMID: 29178358 DOI: 10.1111/ner.12731] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 09/13/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Various spinal cord stimulation (SCS) modes are used in the treatment of chronic neuropathic pain disorders. Conventional (Con) and Burst-SCS are hypothesized to exert analgesic effects through different stimulation-induced mechanisms. Preclinical electrophysiological findings suggest that stimulation intensity is correlated with the effectiveness of Burst-SCS. Therefore, we aimed to investigate the relation between amplitude (charge per second) and behavioral effects in a rat model of chronic neuropathic pain, for both Conventional Spinal Cord Stimulation (Con-SCS) and biphasic Burst-SCS. MATERIALS AND METHODS Animals (n = 12 rats) received a unilateral partial sciatic nerve ligation, after which they were implanted with quadripolar electrodes in the epidural space at thoracic level 13. Mechanical hypersensitivity was assessed using paw withdrawal thresholds (WTs) to von Frey monofilaments, at various SCS intensities (amplitudes) and multiple time points during 60 minutes of stimulation and 30 minutes post stimulation. RESULTS Increasing amplitude was shown to improve the efficacy of Con-SCS, whereas the efficacy of Burst-SCS showed a non-monotonic relation with amplitude. Con-SCS at 66% MT (n = 5) and Burst-SCS at 50% MT (n = 6) were found to be equally effective in normalizing mechanical hypersensitivity. However, in the assessed time period Burst-SCS required significantly more mean charge per second to do so (p < 0.01). When applied at comparable mean charge per second, Con-SCS resulted in a superior behavioral outcome (p < 0.01), compared with Burst-SCS. CONCLUSION Biphasic Burst-SCS requires significantly more mean charge per second in order to achieve similar pain relief, as compared with Con-SCS, in an experimental model of chronic neuropathic pain.
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Affiliation(s)
- Koen P V Meuwissen
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Jianwen Wendy Gu
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, CA, USA
| | - Tianhe C Zhang
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, CA, USA
| | - Elbert A J Joosten
- Pain Management and Research Centre, Department of Anesthesiology and Pain Management, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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Activation of cannabinoid CB1 receptor contributes to suppression of spinal nociceptive transmission and inhibition of mechanical hypersensitivity by Aβ-fiber stimulation. Pain 2017; 157:2582-2593. [PMID: 27589093 DOI: 10.1097/j.pain.0000000000000680] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Activation of Aβ-fibers is an intrinsic feature of spinal cord stimulation (SCS) pain therapy. Cannabinoid receptor type 1 (CB1) is important to neuronal plasticity and pain modulation, but its role in SCS-induced pain inhibition remains unclear. In this study, we showed that CB1 receptors are expressed in both excitatory and inhibitory interneurons in substantia gelatinosa (SG). Patch-clamp recording of the evoked excitatory postsynaptic currents (eEPSCs) in mice after spinal nerve ligation (SNL) showed that electrical stimulation of Aβ-fibers (Aβ-ES) using clinical SCS-like parameters (50 Hz, 0.2 millisecond, 10 μA) induced prolonged depression of eEPSCs to C-fiber inputs in SG neurons. Pretreatment with CB1 receptor antagonist AM251 (2 μM) reduced the inhibition of C-eEPSCs by Aβ-ES in both excitatory and inhibitory SG neurons. We further determined the net effect of Aβ-ES on spinal nociceptive transmission in vivo by recording spinal local field potential in SNL rats. Epidural SCS (50 Hz, Aβ-plateau, 5 minutes) attenuated C-fiber-evoked local field potential. This effect of SCS was partially reduced by spinal topical application of AM251 (25 μg, 50 μL), but not CB2 receptor antagonist AM630 (100 μg). Finally, intrathecal pretreatment with AM251 (50 μg, 15 μL) in SNL rats blocked the inhibition of behavioral mechanical hypersensitivity by SCS (50 Hz, 0.2 millisecond; 80% of motor threshold, 60 minutes). Our findings suggest that activation of spinal CB1 receptors may contribute to synaptic depression to high-threshold afferent inputs in SG neurons after Aβ-ES and may be involved in SCS-induced inhibition of spinal nociceptive transmission after nerve injury.
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Shamji MF, De Vos C, Sharan A. The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain. Neurosurgery 2017; 80:S108-S113. [PMID: 28350939 DOI: 10.1093/neuros/nyw047] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 09/30/2016] [Indexed: 01/09/2023] Open
Abstract
Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. These procedures can be done with acceptably low morbidity and provide a cost-effective solution for those patients in whom medical therapies have failed. Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.
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Affiliation(s)
- Mohammed F Shamji
- Division of Neurosurgery, Toronto West-ern Hospital, Toronto, Canada.,Depart-ment of Surgery, University of Toronto, Toronto, Canada.,Institute of Biomate-rials and Biomedical Engineering, Uni-versity of Toronto, Toronto, Canada.,Krembil Research Institute, Toronto, Canada.,Techna Research Institute, Toronto, Canada
| | - Cecile De Vos
- Medisch Spectrum Twente hospital, Enschede, Netherlands
| | - Ashwini Sharan
- Division of Neurosurgery, Thomas Jefferson University, Philadephia, PA
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Yadav AP, Nicolelis MAL. Electrical stimulation of the dorsal columns of the spinal cord for Parkinson's disease. Mov Disord 2017; 32:820-832. [PMID: 28497877 DOI: 10.1002/mds.27033] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/07/2017] [Accepted: 04/10/2017] [Indexed: 11/10/2022] Open
Abstract
Spinal cord stimulation has been used for the treatment of chronic pain for decades. In 2009, our laboratory proposed, based on studies in rodents, that electrical stimulation of the dorsal columns of the spinal cord could become an effective treatment for motor symptoms associated with Parkinson's disease (PD). Since our initial report in rodents and a more recent study in primates, several clinical studies have now described beneficial effects of dorsal column stimulation in parkinsonian patients. In primates, we have shown that dorsal column stimulation activates multiple structures along the somatosensory pathway and desynchronizes the pathological cortico-striatal oscillations responsible for the manifestation of PD symptoms. Based on recent evidence, we argue that neurological disorders such as PD can be broadly classified as diseases emerging from abnormal neuronal timing, leading to pathological brain states, and that the spinal cord could be used as a "channel" to transmit therapeutic electrical signals to disrupt these abnormalities. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Amol P Yadav
- Department of Neurobiology, Duke University, Durham, North Carolina, USA.,Duke Center for Neuroengineering, Duke University, Durham, North Carolina, USA
| | - Miguel A L Nicolelis
- Department of Neurobiology, Duke University, Durham, North Carolina, USA.,Duke Center for Neuroengineering, Duke University, Durham, North Carolina, USA.,Department of Psychology and Neuroscience, Duke University, Durham, North Carolina, USA.,Department of Biomedical Engineering, Duke University, Durham, North Carolina, USA.,Department of Neurology, Duke University, Durham, North Carolina, USA.,Edmond and Lily Safra International Institute of Neuroscience of Natal, Natal, Brazil
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Salimzade A, Hosseini-Sharifabad A, Rabbani M. Comparative effects of chronic administrations of gabapentin, pregabalin and baclofen on rat memory using object recognition test. Res Pharm Sci 2017. [PMID: 28626478 PMCID: PMC5465829 DOI: 10.4103/1735-5362.207201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Memory impairment is one of the greatest concerns when it comes to long-term CNS-affecting drug administration. Drugs like gabapentin, pregabalin and baclofen are administered in a long-term period in conditions such as epilepsy, neuropathic pain, spasticity associated with spinal cord injury or multiple sclerosis. Despite their wide spread use, few data are available on the effects of these drugs on cognitive functions, such as learning memory. In the present study, the effects of long-term administration of gabapentin, pregabalin and baclofen on memory were investigated in a comparative manner. Male Wistar rats received intraperitoneal (i.p.) injection of gabapentin (30 mg/kg), pregabalin (30 mg/kg), baclofen (3 mg/kg), combination of gabapentin/baclofen (30/3 mg/kg) and combination of pregabalin/baclofen (30/3 mg/kg) once a day for 3 weeks respective to their groups. After the end of treatments, rat memories were assessed using the object-recognition task. The discrimination and recognition indices (RI and DI) in the T2 trials were used as the memory indicating factors. The results showed that daily i.p. administrations of pregabalin but not gabapentin or baclofen significantly decreased DI and RI compared to saline group. In combination groups, either gabapentin or pregabalin impaired discrimination between new and familiar objects. Our findings suggested that pregabalin alone or in combination with baclofen significantly caused cognitive deficits.
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Affiliation(s)
- Asma Salimzade
- Department of Pharmacology and Toxicology and Isfahan Pharmaceutical Sciences Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Ali Hosseini-Sharifabad
- Department of Pharmacology and Toxicology and Isfahan Pharmaceutical Sciences Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Mohammad Rabbani
- Department of Pharmacology and Toxicology and Isfahan Pharmaceutical Sciences Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
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Pan B, Yu H, Fischer GJ, Kramer JM, Hogan QH. Dorsal Root Ganglionic Field Stimulation Relieves Spontaneous and Induced Neuropathic Pain in Rats. THE JOURNAL OF PAIN 2016; 17:1349-1358. [DOI: 10.1016/j.jpain.2016.09.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/23/2016] [Accepted: 09/13/2016] [Indexed: 11/16/2022]
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Wille F, Breel JS, Bakker EW, Hollmann MW. Altering Conventional to High Density Spinal Cord Stimulation: An Energy Dose-Response Relationship in Neuropathic Pain Therapy. Neuromodulation 2016; 20:71-80. [DOI: 10.1111/ner.12529] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/01/2016] [Accepted: 08/23/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Frank Wille
- Department of Anesthesiology-Pain Medicine; Diakonessenhuis Zeist; Zeist The Netherlands
- Department of Anesthesiology-Pain Medicine; Academic Medical Center (AMC) Amsterdam; Amsterdam The Netherlands
| | - Jennifer S. Breel
- Department of Anesthesiology-Pain Medicine; Diakonessenhuis Zeist; Zeist The Netherlands
- Department of Anesthesiology-Pain Medicine; Academic Medical Center (AMC) Amsterdam; Amsterdam The Netherlands
| | - Eric W.P. Bakker
- Division Clinical Methods and Public Health, Department of Clinical Epidemiology, Biostatistics and Bioinformatics; University of Amsterdam, Faculty of Medicine, Academic Medical Center (AMC); Amsterdam The Netherlands
| | - Markus W. Hollmann
- Department of Anesthesiology-Pain Medicine; Academic Medical Center (AMC) Amsterdam; Amsterdam The Netherlands
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Sacré P, Sarma SV, Guan Y, Anderson WS. Electrical neurostimulation for chronic pain: On selective relay of sensory neural activities in myelinated nerve fibers. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:4705-8. [PMID: 26737344 DOI: 10.1109/embc.2015.7319444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chronic pain affects about 100 million adults in the US. Despite their great need, neuropharmacology and neurostimulation therapies for chronic pain have been associated with suboptimal efficacy and limited long-term success, as their mechanisms of action are unclear. Yet current computational models of pain transmission suffer from several limitations. In particular, dorsal column models do not include the fundamental underlying sensory activity traveling in these nerve fibers. We developed a (simple) simulation test bed of electrical neurostimulation of myelinated nerve fibers with underlying sensory activity. This paper reports our findings so far. Interactions between stimulation-evoked and underlying activities are mainly due to collisions of action potentials and losses of excitability due to the refractory period following an action potential. In addition, intuitively, the reliability of sensory activity decreases as the stimulation frequency increases. This first step opens the door to a better understanding of pain transmission and its modulation by neurostimulation therapies.
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Abstract
PURPOSE OF REVIEW Neurostimulation is a well tolerated, cost-efficient, and effective method to treat chronic pain. Although spinal cord stimulation (SCS) has been shown to help patients, newer modalities such as burst, kilohertz-frequency, and dorsal root ganglion stimulation may provide greater pain relief, fewer paresthesias, and better outcomes. RECENT FINDINGS Burst stimulation, programed as five-impulse burst at a frequency of 500 Hz, delivers more charge per second than conventional stimulation. Trials of burst stimulation have shown superior pain relief, decreased paresthesias, and patient preference compared with conventional SCS. Kilohertz-frequency SCS uses low-amplitude, high-frequency (10 kHz), and short-duration pulses. The SENZA trial showed superiority in both back and leg pain with greater pain relief as well as decreased opioid use. Dorsal root ganglion stimulation stimulates the ganglion cells allowing for precise targeting of pain regions. Multiple studies, including the ACCURATE trial, have shown superior pain relief in multiple conditions. SUMMARY Improvements in pain control and patient satisfaction suggest that these new stimulation patterns will greatly increase the utility of neurostimulation; however, clinical trials with broader patient populations have to be done to support more extensive use of these therapies.
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Arle JE, Mei L, Carlson KW, Shils JL. High-Frequency Stimulation of Dorsal Column Axons: Potential Underlying Mechanism of Paresthesia-Free Neuropathic Pain Relief. Neuromodulation 2016; 19:385-97. [DOI: 10.1111/ner.12436] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 02/22/2016] [Accepted: 03/02/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Jeffrey E. Arle
- Department of Neurosurgery; Beth Israel Deaconess Medical Center; Boston MA USA
- Department of Neurosurgery; Harvard Medical School; Boston MA USA
| | - Longzhi Mei
- Department of Neurosurgery; Beth Israel Deaconess Medical Center; Boston MA USA
| | - Kristen W. Carlson
- Department of Neurosurgery; Beth Israel Deaconess Medical Center; Boston MA USA
| | - Jay L. Shils
- Department of Anesthesiology; Rush University Medical Center; Chicago IL USA
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Gong WY, Johanek LM, Sluka KA. A Comparison of the Effects of Burst and Tonic Spinal Cord Stimulation on Hyperalgesia and Physical Activity in an Animal Model of Neuropathic Pain. Anesth Analg 2016; 122:1178-1185. [PMID: 26859873 DOI: 10.1213/ane.0000000000001161] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Parameters of spinal cord stimulation (SCS) play a role in its effectiveness and may impact SCS mechanisms and outcomes. For example, SCS applied in a bursting pattern may result in better pain relief than that for tonic SCS for neuropathic pain. We tested the effectiveness of different SCS pulse frequencies given at 2 different burst frequencies in an animal model of neuropathic pain. METHODS After Sprague-Dawley rats were anesthetized, neuropathic pain was induced using the spared nerve injury model, and an epidural SCS lead was implanted in the upper lumber spinal cord. One of the 8 different SCS parameters was delivered daily for 4 days at 90% motor threshold 2 weeks after nerve injury. Four burst patterns were administered at 4- or 40-Hz frequency with a train of 4 pulses at frequencies of 60, 500, and 1000 Hz. Sham and tonic patterns at 16, 60, and 160 Hz were chosen as controls. Paw withdrawal threshold was assessed before the surgery and 15 minutes before, during, and after SCS daily for 4 days. Physical activity (distance, crossing, rearing, and grooming) was assessed before surgery, before SCS on day 1, and after SCS on day 4. RESULTS Animals showed a decrease in paw withdrawal threshold and physical activity levels 2 weeks after nerve injury. During stimulation, burst SCS with pulse frequencies of 60, 500, or 1000 Hz were more effective for improving paw withdrawal threshold than sham and tonic SCS at 16 Hz. Burst SCS with higher pulse frequencies (500 and 1000 Hz) than 60-Hz SCS and burst SCS with higher pulse frequencies (1000 Hz) than 160-Hz SCS were more effective. In addition, tonic SCS at 160 Hz and burst SCS with higher pulse frequencies (500 and 1000 Hz) significantly increased the distance traveled. Burst SCS at 4 Hz with pulse frequency of 1000 Hz also increased the number of crossings when compared with sham control and tonic SCS at 16 Hz. CONCLUSIONS The current study shows that a variety of SCS pulse frequencies applied with a burst frequency result in greater improvement in hyperalgesia and activity levels than tonic SCS in a neuropathic pain model during stimulation.
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Affiliation(s)
- Wei-Yi Gong
- From the *Department of Pain Management, Xuanwu Hospital, Capital Medical University, Beijing, China; †Department of Physical Therapy and Rehabilitation Science, University of Iowa, Carver College of Medicine, Iowa City, Iowa; and ‡Medtronic Neuromodulation, Medtronic, Inc., Minneapolis, Minnesota
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Lamer TJ, Deer TR, Hayek SM. Advanced Innovations for Pain. Mayo Clin Proc 2016; 91:246-58. [PMID: 26848005 DOI: 10.1016/j.mayocp.2015.12.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 01/13/2023]
Abstract
Chronic pain represents one of the most important public health problems in terms of both the number of patients afflicted and health care costs. Most patients with chronic pain are treated with medications as the mainstay of therapy, and yet most medically treated patients continue to report ongoing pain. Additionally, adverse effects from pain medications represent a major challenge for clinicians and patients. Spinal cord stimulation and intrathecal drug delivery systems are well-established techniques that have been utilized for over 25 years. Intrathecal drug delivery systems have proven efficacy for a wide variety of intractable pain conditions and fewer adverse effects than systemic medical therapy in patients with refractory cancer-related pain. Spinal cord stimulation is cost-effective and provides improved pain control compared with medical therapy in patients with a variety of refractory pain conditions including complex regional pain syndrome, painful diabetic neuropathy, and chronic radiculopathy. Patients who have intractable pain that has not responded to reasonable attempts at conservative pain care measures should be referred to a qualified interventional pain specialist to determine candidacy for the procedures discussed in this article.
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Affiliation(s)
- Tim J Lamer
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN.
| | | | - Salim M Hayek
- Department of Anesthesiology, University Hospitals Case Medical Center, Cleveland, OH
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Shamji MF, Westwick HJ, Heary RF. Complications related to the use of spinal cord stimulation for managing persistent postoperative neuropathic pain after lumbar spinal surgery. Neurosurg Focus 2015; 39:E15. [DOI: 10.3171/2015.7.focus15260] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Structural spinal surgery yields improvement in pain and disability for selected patients with spinal stenosis, spondylolisthesis, or a herniated intervertebral disc. A significant fraction of patients exhibit persistent postoperative neuropathic pain (PPNP) despite technically appropriate intervention, and such patients can benefit from spinal cord stimulation (SCS) to alleviate suffering. The complication profile of this therapy has not been systematically assessed and, thus, was the goal of this review.
METHODS
A comprehensive literature search was performed to identify prospective cohorts of patients who had PPNP following structurally corrective lumbar spinal surgery and who underwent SCS device implantation. Data about study design, technique of SCS lead introduction, and complications encountered were collected and analyzed. Comparisons of complication incidence were performed between percutaneously and surgically implanted systems, with the level of significance set at 0.05.
RESULTS
Review of 11 studies involving 542 patients formed the basis of this work: 2 randomized controlled trials and 9 prospective cohorts. Percutaneous implants were used in 4 studies and surgical implants were used in 4 studies; in the remainder, the types were undefined. Lead migration occurred in 12% of cases, pain at the site of the implantable pulse generator occurred in 9% of cases, and wound-related complications occurred in 5% of cases; the latter 2 occurred more frequently among surgically implanted devices.
CONCLUSIONS
Spinal cord stimulation can provide for improved pain and suffering and for decreased narcotic medication use among patients with PPNP after lumbar spinal surgery. This study reviewed the prospective studies forming the evidence base for this therapy, to summarize the complications encountered and, thus, best inform patients and clinicians considering its use. There is a significant rate of minor complications, many of which require further surgical intervention to manage, including lead migration or implant infection, although such complications do not directly threaten patient life or function.
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Affiliation(s)
- Mohammed F. Shamji
- 1Department of Surgery, University of Toronto
- 2Division of Neurosurgery, Toronto Western Hospital., Toronto, Ontario
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Bentley LD, Duarte RV, Furlong PL, Ashford RL, Raphael JH. Brain activity modifications following spinal cord stimulation for chronic neuropathic pain: A systematic review. Eur J Pain 2015; 20:499-511. [PMID: 26424514 DOI: 10.1002/ejp.782] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Spinal cord stimulation (SCS) is believed to exert supraspinal effects; however, these mechanisms are still far from fully elucidated. This systematic review aims to assess existing neurophysiological and functional neuroimaging literature to reveal current knowledge regarding the effects of SCS for chronic neuropathic pain on brain activity, to identify gaps in knowledge, and to suggest directions for future research. DATABASES AND DATA TREATMENT Electronic databases and hand-search of reference lists were employed to identify publications investigating brain activity associated with SCS in patients with chronic neuropathic pain, using neurophysiological and functional neuroimaging techniques (fMRI, PET, MEG, EEG). Studies investigating patients with SCS for chronic neuropathic pain and studying brain activity related to SCS were included. Demographic data (age, gender), study factors (imaging modality, patient diagnoses, pain area, duration of SCS at recording, stimulus used) and brain areas activated were extracted from the included studies. RESULTS Twenty-four studies were included. Thirteen studies used neuroelectrical imaging techniques, eight studies used haemodynamic imaging techniques, two studies employed both neuroelectrical and haemodynamic techniques separately, and one study investigated cerebral neurobiology. CONCLUSIONS The limited available evidence regarding supraspinal mechanisms of SCS does not allow us to develop any conclusive theories. However, the studies included appear to show an inhibitory effect of SCS on somatosensory evoked potentials, as well as identifying the thalamus and anterior cingulate cortex as potential mediators of the pain experience. The lack of substantial evidence in this area highlights the need for large-scale controlled studies of this kind.
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Affiliation(s)
- L D Bentley
- Faculty of Health, Education & Life Sciences, Birmingham City University, UK
| | - R V Duarte
- Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, UK
| | - P L Furlong
- Aston Brain Centre, Aston University, Birmingham, UK
| | - R L Ashford
- Faculty of Health, Education & Life Sciences, Birmingham City University, UK
| | - J H Raphael
- Faculty of Health, Education & Life Sciences, Birmingham City University, UK.,Department of Pain Management, Russells Hall Hospital, Dudley Group of Hospitals NHS Trust, UK
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Deogaonkar M, Sharma M, Oluigbo C, Nielson DM, Yang X, Vera-Portocarrero L, Molnar GF, Abduljalil A, Sederberg PB, Knopp M, Rezai AR. Spinal Cord Stimulation (SCS) and Functional Magnetic Resonance Imaging (fMRI): Modulation of Cortical Connectivity With Therapeutic SCS. Neuromodulation 2015; 19:142-53. [PMID: 26373920 DOI: 10.1111/ner.12346] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/03/2015] [Accepted: 08/05/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The neurophysiological basis of pain relief due to spinal cord stimulation (SCS) and the related cortical processing of sensory information are not completely understood. The aim of this study was to use resting state functional magnetic resonance imaging (rs-fMRI) to detect changes in cortical networks and cortical processing related to the stimulator-induced pain relief. METHODS Ten patients with complex regional pain syndrome (CRPS) or neuropathic leg pain underwent thoracic epidural spinal cord stimulator implantation. Stimulation parameters associated with "optimal" pain reduction were evaluated prior to imaging studies. Rs-fMRI was obtained on a 3 Tesla, Philips Achieva MRI. Rs-fMRI was performed with stimulator off (300TRs) and stimulator at optimum (Opt, 300 TRs) pain relief settings. Seed-based analysis of the resting state functional connectivity was conducted using seeds in regions established as participating in pain networks or in the default mode network (DMN) in addition to the network analysis. NCUT (normalized cut) parcellation was used to generate 98 cortical and subcortical regions of interest in order to expand our analysis of changes in functional connections to the entire brain. We corrected for multiple comparisons by limiting the false discovery rate to 5%. RESULTS Significant differences in resting state connectivity between SCS off and optimal state were seen between several regions related to pain perception, including the left frontal insula, right primary and secondary somatosensory cortices, as well as in regions involved in the DMN, such as the precuneus. In examining changes in connectivity across the entire brain, we found decreased connection strength between somatosensory and limbic areas and increased connection strength between somatosensory and DMN with optimal SCS resulting in pain relief. This suggests that pain relief from SCS may be reducing negative emotional processing associated with pain, allowing somatosensory areas to become more integrated into default mode activity. CONCLUSION SCS reduces the affective component of pain resulting in optimal pain relief. Study shows a decreased connectivity between somatosensory and limbic areas associated with optimal pain relief due to SCS.
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Affiliation(s)
- Milind Deogaonkar
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Mayur Sharma
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - Dylan M Nielson
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Xiangyu Yang
- Department of Radiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | | | | | - Amir Abduljalil
- Department of Radiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Per B Sederberg
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Michael Knopp
- Department of Radiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ali R Rezai
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
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Kriek N, Groeneweg JG, Stronks DL, Huygen FJPM. Comparison of tonic spinal cord stimulation, high-frequency and burst stimulation in patients with complex regional pain syndrome: a double-blind, randomised placebo controlled trial. BMC Musculoskelet Disord 2015; 16:222. [PMID: 26303326 PMCID: PMC4547415 DOI: 10.1186/s12891-015-0650-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 07/27/2015] [Indexed: 01/14/2023] Open
Abstract
Background Complex Regional Pain Syndrome (CRPS) is a disabling disease that is sometimes difficult to treat. Although spinal cord stimulation (SCS) can reduce pain in most patients with CRPS, some do not achieve the desired reduction in pain. Moreover, the pain reduction can diminish over time even after an initially successful period of SCS. Pain reduction can be regained by increasing the SCS frequency, but this has not been investigated in a prospective trial. This study compares pain reduction using five SCS frequencies (standard 40 Hz, 500 Hz, 1200 Hz, burst and placebo stimulation) in patients with CRPS to determine which of the modalities is most effective. Design All patients with a confirmed CRPS diagnosis that have unsuccessfully tried all other therapies and are eligible for SCS, can enroll in this trial (primary implantation group). CRPS patients that already receive SCS therapy, or those previously treated with SCS but with loss of therapeutic effect over time, can also participate (re-implantation group). Once all inclusion criteria are met and written informed consent obtained, patients will undergo a baseline assessment (T0). A 2-week trial with SCS is performed and, if successful, a rechargeable internal pulse generator (IPG) is implanted. For the following 3 months the patient will have standard 40 Hz stimulation therapy before a follow-up assessment (T1) is performed. Those who have completed the T1 assessment will enroll in a 10-week crossover period in which the five SCS frequencies are tested in five periods, each frequency lasting for 2 weeks. At the end of the crossover period, the patient will choose which frequency is to be used for stimulation for an additional 3 months, until the T2 assessment. Discussion Currently no trials are available that systematically investigate the importance of variation in frequency during SCS in patients with CRPS. Data from this trial will provide better insight as to whether SCS with a higher frequency, or with burst stimulation, results in more effective pain relief. Trial registration Current Controlled Trials ISRCTN36655259
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Affiliation(s)
- N Kriek
- Center for Pain Medicine, Erasmus University Medical Center, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
| | - J G Groeneweg
- Center for Pain Medicine, Erasmus University Medical Center, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
| | - D L Stronks
- Center for Pain Medicine, Erasmus University Medical Center, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
| | - F J P M Huygen
- Center for Pain Medicine, Erasmus University Medical Center, Postbox 2040, 3000 CA, Rotterdam, The Netherlands.
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