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Gazzeri R, Castrucci T, Leoni MLG, Mercieri M, Occhigrossi F. Spinal Cord Stimulation for Intractable Chronic Limb Ischemia: A Narrative Review. J Cardiovasc Dev Dis 2024; 11:260. [PMID: 39330318 PMCID: PMC11431887 DOI: 10.3390/jcdd11090260] [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: 06/30/2024] [Revised: 08/21/2024] [Accepted: 08/23/2024] [Indexed: 09/28/2024] Open
Abstract
Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease, significantly impacting quality of life, morbidity and mortality. Common complications include severe limb pain, walking difficulties, ulcerations and limb amputations. For cases of CLI where surgical or endovascular reconstruction is not possible or fails, spinal cord stimulation (SCS) may be a treatment option. Currently, SCS is primarily prescribed as a symptomatic treatment for painful symptoms. It is used to treat intractable pain arising from various disorders, such as neuropathic pain secondary to persistent spinal pain syndrome (PSPS) and painful diabetic neuropathy. Data regarding the effect of SCS in treating CLI are varied, with the mechanism of action of vasodilatation in the peripheral microcirculatory system not yet fully understood. This review focuses on the surgical technique, new modalities of SCS, the mechanisms of action of SCS in vascular diseases and the parameters for selecting CLI patients, along with the clinical outcomes and complications. SCS is a safe and effective surgical option in selected patients with CLI, where surgical or endovascular revascularization is not feasible.
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Affiliation(s)
- Roberto Gazzeri
- Interventional and Surgical Pain Management Unit, San Giovanni-Addolorata Hospital, Via Amba Aradam 9, 00184 Rome, Italy
| | | | - Matteo Luigi Giuseppe Leoni
- Department of Medical and Surgical Sciences and Translational Medicine, Sapienza University of Rome, 29121 Rome, Italy
| | - Marco Mercieri
- Department of Medical and Surgical Sciences and Translational Medicine, Sapienza University of Rome, 29121 Rome, Italy
| | - Felice Occhigrossi
- Interventional and Surgical Pain Management Unit, San Giovanni-Addolorata Hospital, Via Amba Aradam 9, 00184 Rome, Italy
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Koetsier E, Vacchi E, Maino P, Dukanac J, Melli G, van Kuijk SMJ. Dorsal Root Ganglion Stimulation in Chronic Painful Polyneuropathy: A Potential Modulator for Small Nerve Fiber Regeneration. Neuromodulation 2023; 26:1772-1780. [PMID: 36192280 DOI: 10.1016/j.neurom.2022.08.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/02/2022] [Accepted: 08/23/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Neuromodulatory treatments like spinal cord stimulation and dorsal root ganglion stimulation (DRGS) have emerged as effective treatments to relieve pain in painful polyneuropathy. Animal studies have demonstrated that neurostimulation can enhance nerve regeneration. This study aimed to investigate if DRGS may impact intraepidermal nerve fiber regeneration and sensory nerve function. MATERIALS AND METHODS Nine patients with chronic, intractable painful polyneuropathy were recruited. Intraepidermal nerve fiber density (IENFD) quantification in 3 mm punch skin biopsy was performed 1 month before DRGS (placed at the level of the L5 and S1 dorsal root ganglion) and after 12- and 24-month follow-up. Quantitative sensory testing, nerve conduction studies, and a clinical scale score were also performed at the same time points. RESULTS In 7 of 9 patients, DRGS was successful (defined as a reduction of ≥ 50% in daytime and/or night-time pain intensity), allowing a definitive implantable pulse generator implantation. The median baseline IENFD among these 7 patients was 1.6 fibers/mm (first and third quartile: 1.2; 4.3) and increased to 2.6 fibers/mm (2.5; 2.9) and 1.9 fibers/mm (1.6; 2.4) at 1- and 2-years follow-up, respectively. These changes were not statistically significant (p = 1.000 and 0.375). Sensory nerve tests did not show substantial changes. CONCLUSIONS Although not significant, the results of this study showed that in most of the patients with implants, there was a slight increase of the IENFD at the 1- and 2-year follow-up. Larger-scale clinical trials are warranted to explore the possible role of DRGS in reversing the progressive neurodegeneration over time. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02435004; Swiss National Clinical Trials Portal: SNCTP000001376.
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Affiliation(s)
- Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| | - Elena Vacchi
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Laboratories for Translational Research, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Jasmina Dukanac
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giorgia Melli
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Laboratories for Translational Research, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Sander M J van Kuijk
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
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Shanthanna H, Eldabe S, Provenzano DA, Chang Y, Adams D, Kashir I, Goel A, Tian C, Couban RJ, Levit T, Hagedorn JM, Narouze S. Role of patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain: a comprehensive narrative review. Reg Anesth Pain Med 2023; 48:251-272. [PMID: 37001887 DOI: 10.1136/rapm-2022-103820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/22/2022] [Indexed: 04/03/2023]
Abstract
Background/importancePatient selection for spinal cord stimulation (SCS) therapy is crucial and is traditionally performed with clinical selection followed by a screening trial. The factors influencing patient selection and the importance of trialing have not been systematically evaluated.ObjectiveWe report a narrative review conducted to synthesize evidence regarding patient selection and the role of SCS trials.Evidence reviewMedline, EMBASE and Cochrane databases were searched for reports (any design) of SCS in adult patients, from their inception until March 30, 2022. Study selection and data extraction were carried out using DistillerSR. Data were organized into tables and narrative summaries, categorized by study design. Importance of patient variables and trialing was considered by looking at their influence on the long-term therapy success.FindingsAmong 7321 citations, 201 reports consisting of 60 systematic reviews, 36 randomized controlled trials (RCTs), 41 observational studies (OSs), 51 registry-based reports, and 13 case reports on complications during trialing were included. Based on RCTs and OSs, the median trial success rate was 72% and 82%, and therapy success was 65% and 61% at 12 months, respectively. Although several psychological and non-psychological determinants have been investigated, studies do not report a consistent approach to patient selection. Among psychological factors, untreated depression was associated with poor long-term outcomes, but the effect of others was inconsistent. Most RCTs except for chronic angina involved trialing and only one RCT compared patient selection with or without trial. The median (range) trial duration was 10 (0–30) and 7 (0–56) days among RCTs and OSs, respectively.ConclusionsDue to lack of a consistent approach to identify responders for SCS therapy, trialing complements patient selection to exclude patients who do not find the therapy helpful and/or intolerant of the SCS system. However, more rigorous and large studies are necessary to better evaluate its role.
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Affiliation(s)
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | | | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Adams
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Imad Kashir
- University of Waterloo, Waterloo, Ontario, Canada
| | - Akash Goel
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chenchen Tian
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Tal Levit
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan M Hagedorn
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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Gupta M, Chitneni A, Ghorayeb J, Schnetzer B, Klusek M. Cervical Spinal Cord Stimulation for Trigeminal Neuralgia: a Narrative Review. Curr Pain Headache Rep 2022; 26:639-645. [PMID: 35716273 DOI: 10.1007/s11916-022-01066-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Trigeminal neuralgia (TN) is a chronic neuropathic pain condition affecting one or more divisions of the fifth cranial (trigeminal) nerve. TN is defined by recurrent unilateral electric shock-like pain that is abrupt in both onset and termination. The pain is triggered by innocuous sensory stimuli and is classified as either classic TN, related to vascular compression; secondary TN, due to a tumor along the trigeminal nerve or an underlying disease like multiple sclerosis; or idiopathic TN. Among the various therapies available for TN, carbamazepine remains the first-line treatment. Newer medications have demonstrated efficacy in patients who do not respond to or cannot tolerate carbamazepine. When medical management and neuroablative procedures fail, spinal cord stimulation (SCS) serves as a promising and popular option, with an estimated 34,000 SCS procedures performed annually worldwide. SCS employs the implantation of electrical leads in the epidural space to manage pain. PURPOSE OF REVIEW A review of literature was conducted to explore the use of cervical spinal cord stimulation (SCS) for the treatment of trigeminal neuralgia. METHODS A MEDLINE/PubMed search using the search terms "spinal cord stimulation" and "trigeminal neuralgia" was employed to find any case reports and research studies (retrospective studies, double-blinded studies, observational studies) on the topic. No date limiters were used for the search. The initial search resulted in 76 non-duplicate entries from the database. After application of the search criteria, 58 studies were excluded because they were not relevant to the study. A further detailed review of the included articles was conducted by all the reviewers. During this phase of the review, additional 6 studies were excluded. A total of 11 studies were included: 7 case reports and 4 retrospective review studies. RECENT FINDINGS In the review, we discuss 7 different case reports on the use of cervical SCS for trigeminal neuralgia and an additional 4 retrospective studies reviewing outcomes and pain relief in patients who underwent treatment. The case reports and retrospective studies reviewed demonstrated that TN patients realized > 50% pain relief following permanent electrode implantation. In all the cases discussed, complications from SCS were rare and/or not reported. Additionally, most of the cases report that patients who had adequate pain relief from SCS were able to wean off, or significantly reduce, oral medications given the vast improvement in pain reduction. CONCLUSIONS Cervical spinal cord stimulation (SCS) is a safe and effective procedure for patients with trigeminal neuralgia (TN) who have refractory pain despite the use of medications. In many cases, the procedure provides an adequate level of pain relief with very few complications or side effects. The vast majority of current research on the use of cervical SCS for TN currently consists of case reports and retrospective analysis. In order to further evaluate the efficacy of SCS for treatment, large-scale randomized controlled studies or observational studies need to be conducted to properly evaluate SCS as a treatment modality for trigeminal neuralgia.
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Affiliation(s)
- Mayank Gupta
- Kansas Pain Management and Neuroscience Research Center, Overland Park, KS, USA
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital-Columbia and Cornell, New York, NY, USA.
| | - Joe Ghorayeb
- Physical Medicine & Rehabilitation, University of Medicine and Health Sciences, New York, NY, USA
| | | | - Malvina Klusek
- Peconic Bay Medical Center/Northwell Health, Riverhead, NY, USA
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Lu Y, Mao P, Wang G, Tao W, Xiong D, Ma K, Li R, Feng D, Duan W, Li S, Fu Z, Feng Z, Jin Y, Wan L, Lu Y, Zhang D, Fan B, Wang JJ, Li L. Spinal cord stimulation for chronic intractable trunk or limb pain: study protocol for a Chinese multicenter randomized withdrawal trial (CITRIP study). Trials 2020; 21:834. [PMID: 33028415 PMCID: PMC7542759 DOI: 10.1186/s13063-020-04768-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 09/24/2020] [Indexed: 01/20/2023] Open
Abstract
Background Although effective results of many studies support the use of spinal cord stimulation in chronic pain patients, no randomized controlled trial has been undertaken in China to date. CITRIP is a multicenter, prospective, randomized, withdrawal study designed to evaluate the clinical effectiveness and safety of spinal cord stimulation plus remote programming management in patients with intractable trunk or limb pain. Method Participants will be recruited in approximately 10 centers across China. Eligible participants with intractable trunk or limb and an average visual analog scale (VAS) score ≥ 5 will undergo a spinal cord stimulation test. Participants with VAS score reduction ≥ 50% could move forward to receive implantation of an implanted pulse generator. In the withdrawal period at 3-month follow-up visit, participants randomized to the experimental group (EG) will undergo continuous stimulation while ceasing the stimulation in the control group (CG). The outcome assessment will occur at baseline and at 1, 3 (pre- and post-randomization), and 6 months. The primary outcome is the difference of maximal VAS score between EG and CG in the withdrawal period compared with baseline before the withdrawal period. Additional outcomes include VAS score change at 1-, 3-, and 6-month follow-ups; responder rate (VAS score improving by 50%); achievement rate of a desirable pain state (VAS score ≤ 4); awake times during sleep; Beck Depression Inventory for depression evaluation; short-form 36 for quality of life evaluation; drug usage; and satisfaction rating of the device. Adverse events will be collected. The primary analysis will follow the intention-to-treat principle. Discussion The CITRIP study seeks to evaluate the effectiveness and safety of a randomized withdrawal trial of spinal cord stimulation for patients with intractable trunk or limb pain. Trial registration ClinicalTrials.gov NCT03858790. Registered on March 1, 2019, retrospectively registered
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Affiliation(s)
- Yang Lu
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.,National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Peng Mao
- Department of Pain Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Wei Tao
- Department of Neurosurgery, Shenzhen University General Hospital, Shenzhen, China
| | - Donglin Xiong
- Department of Pain Medicine, Huazhong University of Science and Technology of Union Shenzhen Hospital, Shenzhen, China
| | - Ke Ma
- Department of Algology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rongchun Li
- Department of Pain Management, Wuhan Pu'ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dan Feng
- Department of Pain Management, Wuhan No. 1 Hospital, Wuhan, China
| | - Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shun Li
- Department of Pain, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhijian Fu
- Department of Pain Management, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Zhiying Feng
- Department of Pain Medicine, The First Affiliated Hospital of Medical School of Zhejiang University, Hangzhou, China
| | - Yi Jin
- Department of Anesthesiology, Nanjing Jinling Hospital, Nanjing, China
| | - Li Wan
- Department of Pain Management, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yan Lu
- Department of Pain Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Daying Zhang
- Department of Pain Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bifa Fan
- Department of Pain Medicine, China-Japan Friendship Hospital, Beijing, China.
| | - James Jin Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China.
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6
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Stabingas K, Bergman J, Patterson M, Tomycz ND. Peripheral subcutaneous field stimulation for the treatment of spinal cord injury at-level pain: case report, literature review, and 5-year follow-up. Heliyon 2020; 6:e04515. [PMID: 32743101 PMCID: PMC7385456 DOI: 10.1016/j.heliyon.2020.e04515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 05/28/2020] [Accepted: 07/16/2020] [Indexed: 11/30/2022] Open
Abstract
Spinal cord injury (SCI) frequently engenders chronic pain which may be classified as occurring above, at, or below the level of injury. Since patients with SCI may have a complex combination of nociceptive and neuropathic pain, pharmacological interventions often fail. Peripheral subcutaneous field stimulation (PSFS) is a novel neuromodulation surgery for pain in which subcutaneous electrodes designed for spinal cord stimulation are placed subcutaneously in a region of pain. We report the case of a 26-year-old man who was an unrestrained driver in a motor vehicle accident and suffered a complete ASIA A spinal cord injury with paraplegia due to a T4 three-column burst fracture. He underwent successful surgical fixation of the fracture (7/27/12) and developed severe at-level SCI-associated pain which failed all conservative measures. After a successful trial, two octrode leads (Abbott Medical, Plano, TX, USA) were placed for PSFS under general anesthesia and were connected to a right flank rechargeable pulse generator (11/6/13). At 60 months postoperative, the patient continues to use the peripheral field stimulation system on a daily basis and reports near complete relief of his at-level spinal cord injury pain. He noted instantaneous relief of his pain once ideal stimulation programming was achieved and has tolerated complete cessation of all narcotic use. His current programming settings are: Frequency of 50 Hz (Hz), Pulse Width of 350 μs (μsec), Amplitude of 0.00 miliamps (mA), Comf of 7.70 mA, and Perc of 4.50 mA. Chronic pain is a challenging and expensive sequela to manage in SCI patients and newer therapies are needed. Our case suggests that SCI at-level pain may respond durably to PSFS and provides the longest published follow-up on a case of PSFS. Peripheral subcutaneous field stimulation remains an investigational treatment for chronic pain syndrome and larger, long-term follow up studies are needed for the FDA and payers to approve this modality.
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Affiliation(s)
- Kristen Stabingas
- Department of Neurosurgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Jeffrey Bergman
- Department of Neurosurgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
| | - Michael Patterson
- Center for Pain Relief, Allegheny Health Network, 161 Waterdam Road, McMurray, PA 15317, USA
| | - Nestor D Tomycz
- Department of Neurosurgery, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA
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7
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Ultrasound-guided popliteal sciatic nerve block: an effective alternative technique to control ischaemic severe rest pain during endovascular treatment of critical limb ischaemia. Pol J Radiol 2020; 84:e537-e541. [PMID: 32082452 PMCID: PMC7016492 DOI: 10.5114/pjr.2019.91271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/07/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose There are challenges with pain management related to a severely ischaemic limb. Although opioid-based treatment has been the cornerstone of pain relief, the use of these drugs should be limited because of their side effects in such vulnerable patients. We evaluated the utility and efficiency of sciatic nerve block as an alternative method to relieve severe rest pain during endovascular treatment of critical limb ischaemia. Material and methods We retrospectively investigated 10 patients who received ultrasound-guided popliteal sciatic nerve block for the relief of severe rest pain during endovascular treatment of critical limb ischaemia. The degree of pain relief was evaluated by using subjective criteria, from no relief of pain (= 1) to complete relief of pain (= 4). Details of endovascular treatment, time to perform the block, amount of local anaesthetics, duration of the block, need for supplemental analgesia, patient and operator satisfaction, and complications were recorded. Results All blocks were technically successful, and all of the patients had complete resolution of the pain within five minutes. The degree of pain relief was 3 in two patients and 4 in eight patients. All patients were satisfied with the block anaesthesia, and no patient required additional analgesia during this period. Operator satisfaction was very good in all cases. Complications secondary to block did not occur in any patient. Conclusions Ultrasound-guided popliteal sciatic nerve block provides effective pain control, which results in excellent patient and operator satisfaction during endovascular treatment of critical limb ischaemia with severe rest pain.
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van Beek M, Hermes D, Honig WM, Linderoth B, van Kuijk SMJ, van Kleef M, Joosten EA. Long-Term Spinal Cord Stimulation Alleviates Mechanical Hypersensitivity and Increases Peripheral Cutaneous Blood Perfusion in Experimental Painful Diabetic Polyneuropathy. Neuromodulation 2018. [PMID: 29522270 PMCID: PMC6099481 DOI: 10.1111/ner.12757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives This study utilizes a model of long‐term spinal cord stimulation (SCS) in experimental painful diabetic polyneuropathy (PDPN) to investigate the behavioral response during and after four weeks of SCS (12 hours/day). Second, we investigated the effect of long‐term SCS on peripheral cutaneous blood perfusion in experimental PDPN. Methods Mechanical sensitivity was assessed in streptozotocin induced diabetic rats (n = 50) with von Frey analysis. Hypersensitive rats (n = 24) were implanted with an internal SCS battery, coupled to an SCS electrode covering spinal levels L2–L5. The effects of four weeks of daily conventional SCS for 12 hours (n = 12) or Sham SCS (n = 12) were evaluated with von Frey assessment, and laser Doppler imaging (LDI). Results Average paw withdrawal thresholds (PWT) increased during long‐term SCS in the SCS group, in contrast to a decrease in the Sham group (Sham vs. SCS; p = 0.029). Twenty‐four hours after long‐term SCS average PWT remained higher in the SCS group. Furthermore, the SCS group showed a higher cutaneous blood perfusion during long‐term SCS compared to the Sham group (Sham vs. SCS; p = 0.048). Forty‐eight hours after long‐term SCS, no differences in skin perfusion were observed. Discussion We demonstrated that long‐term SCS results in decreased baseline mechanical hypersensitivity and results in increased peripheral blood perfusion during stimulation in a rat model of PDPN. Together, these findings indicate that long‐term SCS results in modulation of the physiological circuitry related to the nociceptive system in addition to symptomatic treatment of painful symptoms.
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Affiliation(s)
- Maarten van Beek
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Denise Hermes
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Wiel M Honig
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Bengt Linderoth
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, the Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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9
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Affiliation(s)
- Adam J Singer
- From Departments of Emergency Medicine and Vascular Surgery, Stony Brook University, Stony Brook, NY (A.J.S., A.T.); and the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami (R.S.K.)
| | - Apostolos Tassiopoulos
- From Departments of Emergency Medicine and Vascular Surgery, Stony Brook University, Stony Brook, NY (A.J.S., A.T.); and the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami (R.S.K.)
| | - Robert S Kirsner
- From Departments of Emergency Medicine and Vascular Surgery, Stony Brook University, Stony Brook, NY (A.J.S., A.T.); and the Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami (R.S.K.)
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Chang Chien GC, Mekhail N. Alternate Intraspinal Targets for Spinal Cord Stimulation: A Systematic Review. Neuromodulation 2017; 20:629-641. [PMID: 28160397 DOI: 10.1111/ner.12568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Conventional dorsal column spinal cord stimulation (SCS) provides less than optimal pain relief for certain pain syndromes and anatomic pain distributions. Practitioners have sought to treat these challenging therapeutic areas with stimulation of alternate intraspinal targets. OBJECTIVE To identify and systematically review the evidence for the value neuromodulating specific neuronal targets within the spinal canal to achieve relief of chronic pain. METHODS A systematic literature search was conducted using PubMed for clinical trials published from 1966 to March 1, 2015 to identify neurostimulation studies that employed non-dorsal column intraspinal stimulation to achieve pain relief. Identified studies on such targeted intraspinal stimulation were reviewed and graded using Evidence Based Interventional Pain Medicine criteria. RESULTS We found a total of 13 articles that satisfied our search criteria on targeted, non-dorsal column intraspinal stimulation for pain. We identified five studies on neurostimulation of the cervicomedullary junction, six studies on neurostimulation of the dorsal root ganglion, two studies on the neurostimulation of the conus medullaris, unfortunately none was found on intraspinal nerve root stimulation. LIMITATIONS The limitations of this review include the relative paucity of well-designed prospective studies on targeted SCS. CONCLUSIONS Clinical use of intraspinal neurostimulation is expanding at a very fast pace. Intraspinal stimulation of non-dorsal column targets may well be the future of neurostimulation as it provides new clinically significant neuromodulation of specific therapeutic targets that are not well or not easily addressed with conventional dorsal column SCS. In addition, they may avoid undesired stimulation induced paraesthesia, particularly in non-painful areas of the body.
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Affiliation(s)
- George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA.,Center for Regenerative Medicine, Southern California University of Health Sciences, Whittier, CA, USA
| | - Nagy Mekhail
- Evidence Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
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Eldabe S, Buchser E, Duarte RV. Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature. PAIN MEDICINE 2017; 17:325-36. [PMID: 26814260 DOI: 10.1093/pm/pnv025] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Spinal cord and peripheral neurostimulation techniques have been practiced since 1967 for the relief of pain, and some techniques are also used for improvement in organ function. Neuromodulation has recognized complications, although very rarely do these cause long-term morbidity. The aim of this article is to present a review of complications observed in patients treated with neurostimulation techniques. METHODS A review of the major recent publications in the literature on the subjects of spinal cord, occipital, sacral, and peripheral nerve field stimulation was conducted. RESULTS The incidence of complications reported varies from 30% to 40% of patients affected by one or more complications. Adverse events can be subdivided into hardware-related complications and biological complications. The commonest hardware-related complication is lead migration. Other lead related complications such as failure or fracture have also been reported. Common biological complications include infection and pain over the implant. Serious biological complications such as dural puncture headache and neurological damage are rarely observed. CONCLUSIONS Spinal cord and peripheral neurostimulation techniques are safe and reversible therapies. Hardware-related complications are more commonly observed than biological complications. Serious adverse events such as neurological damage are rare.
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De Caridi G, Massara M, Serra R, Risitano C, Giardina M, Acri IE, Volpe P, David A. Spinal Cord Stimulation Therapy for the Treatment of Concomitant Phantom Limb Pain and Critical Limb Ischemia. Ann Vasc Surg 2016; 32:131.e11-4. [DOI: 10.1016/j.avsg.2015.10.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 10/29/2015] [Accepted: 10/29/2015] [Indexed: 11/26/2022]
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Kumar K, Caraway DL, Rizvi S, Bishop S. Current challenges in spinal cord stimulation. Neuromodulation 2015; 17 Suppl 1:22-35. [PMID: 24974773 DOI: 10.1111/ner.12172] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 11/25/2013] [Accepted: 12/14/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aims to review the current state of spinal cord stimulation for the treatment of chronic pain associated with failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) and to describe intraspinal targets and stimulation parameters, patient selection, therapy cost-effectiveness, and strategies to improve outcomes. MATERIALS AND METHODS We drew on professional literature spanning four decades, our work with national and international professional societies, and our own extensive clinical experience to summarize contemporary knowledge of the safety, efficacy, cost-efficiency, and challenges associated with spinal cord stimulation in treating chronic pain. RESULTS The safety, efficacy, and cost-efficiency of spinal cord stimulation in treating chronic pain associated with FBSS and CRPS are well established through randomized controlled trials and long-term observational studies. Challenges include reducing wait-times before implant, which are associated with lower success rates; increasing awareness of this therapy among referring physicians, patients, and payers; decreasing device-related complications by incorporating advanced technology, improved operative and trialing techniques, and appropriate patient selection; and capturing functional and quality-of-life outcomes. Spinal cord stimulation must be part of an overall treatment plan to manage chronic pain, and must engage physicians, patients, their families, pharmacists, nursing staff, and mental health experts in supporting a return to employment, if possible, and to a full domestic and social life. CONCLUSIONS Innovation in spinal cord stimulation therapy has intensified with numerous new technical capabilities, safety advances, and novel stimulation targets. This progress holds hope for the many sufferers of chronic pain.
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Affiliation(s)
- Krishna Kumar
- Section of Neurosurgery, Department of Surgery, Regina General Hospital, University of Saskatchewan, Regina, SK, Canada
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Suematsu N, Iida O, Takahara M, Yamauchi Y, Soga Y, Nakano M, Hirano K, Kawasaki D, Yamaoka T, Suzuki K, Shintani Y, Miyashita Y, Tazaki J, Meno H, Inou T. Prognostic Factors in Hemodialysis Patients Undergoing Endovascular Treatment for Critical Limb Ischemia due to Isolated Below-the-Knee Disease. J Atheroscler Thromb 2014; 22:404-14. [PMID: 25346201 DOI: 10.5551/jat.25056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM To investigate the prognosis and to clarify the predictors of both patient and limb survival among hemodialysis (HD) patients with critical limb ischemia (CLI) due to isolated below-the-knee (BK) disease. METHODS An observational cohort study, analyzing a total of 546 HD patients with 681 limbs who underwent endovascular treatment (EVT) for CLI with isolated BK disease at 11 hospitals in Japan between March 2004 and June 2011, was performed. RESULTS The mean patient age was 69.0±9.5 years, and 420 (76.9%) of the subjects were men. The number of patients classified with Rutherford stage 4, 5 and 6 disease was 103 (18.9%), 332 (60.8%) and 111 (20.3%), respectively. The mean HbA1c level was 6.48±1.20%, and 195 (35.7%) of the subjects were active smokers. During the follow-up period (mean: 557.5 days), 191 (35.0%) patients died and 82 (12.0%) limbs underwent major amputation. The freedom from all-cause death was 75.5%, 53.4% and 36.9% and freedom from major amputation was 86.7%, 83.9% and 83.9% at one, three and five years after EVT, respectively. Cox proportional hazard regression analyses revealed that a non-ambulatory status, low serum albumin level and <2 runoff vessels after EVT were significant predictors for both all-cause death and major amputation. CONCLUSIONS Although patient survival remains poor, the limb salvage rate after EVT is favorable among those on HD with CLI due to isolated BK disease. The present results allow for the risk stratification of HD patients with CLI undergoing EVT for isolated BK disease.
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De Agostino R, Federspiel B, Cesnulis E, Sandor PS. High-Cervical Spinal Cord Stimulation for Medically Intractable Chronic Migraine. Neuromodulation 2014; 18:289-96; discussion 296. [DOI: 10.1111/ner.12236] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/07/2014] [Accepted: 07/22/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Rinaldo De Agostino
- Department of Internal Medicine and Pain Clinic; SeeSpital; Horgen Switzerland
| | - Barbara Federspiel
- Department of Internal Medicine and Pain Clinic; SeeSpital; Horgen Switzerland
| | - Evaldas Cesnulis
- Department of Neurosurgery; Hirslanden Hospital; Zurich Switzerland
| | - Peter S. Sandor
- ANNR RehaClinic; Kantonsspital Baden; CH-5404 Baden Switzerland
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De Caridi G, Massara M, David A, Giardina M, La Spada M, Stilo F, Spinelli F, Grande R, Butrico L, de Franciscis S, Serra R. Spinal cord stimulation to achieve wound healing in a primary lower limb critical ischaemia referral centre. Int Wound J 2014; 13:220-5. [PMID: 24712687 DOI: 10.1111/iwj.12272] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 03/10/2014] [Indexed: 12/12/2022] Open
Abstract
Critical lower limb ischaemia is a diffuse pathology that could cause claudication, severe ischaemic pain and tissue loss. The common treatment includes modification of risk factors, pharmacological therapy and endovascular or surgical revascularisation of the lower limb to restore a pulsatile flow distally. Spinal cord stimulator is seen as a valid alternative in patients unsuitable for revascularisation after endovascular or surgical revascularisation failure and as adjuvant therapy in the presence of a functioning bypass in patients with extensive tissue loss and gangrene presenting a slow and difficult wound healing. We report our experience on spinal cord stimulation (SCS) indication and implantation in patients with critical lower limb ischaemia, at a high-volume centre for the treatment of peripheral arterial disease.
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Affiliation(s)
- Giovanni De Caridi
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Mafalda Massara
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Antonio David
- Anesthesiological Sciences Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Massimiliano Giardina
- Anesthesiological Sciences Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Michele La Spada
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Francesco Stilo
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Francesco Spinelli
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Raffaele Grande
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Lucia Butrico
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Kumar K, Abbas M, Rizvi S. The use of spinal cord stimulation in pain management. Pain Manag 2014; 2:125-34. [PMID: 24645813 DOI: 10.2217/pmt.11.83] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
SUMMARY Pain is a complex behavior process, the anatomy and physiology of which is not completely understood, and is subject to continuous exploration and research. Following on the heels of Melzack and Wall's gate control theory of pain (1965), Shealey et al., in 1967, were the first to implant stimulation electrodes over the dorsal columns in an attempt to provide relief for patients with chronic, intractable pain. Since then, significant strides in both the technological and therapeutic sides have facilitated the evolution of spinal cord stimulation (SCS) in the management of a variety of pain pathologies. High-quality evidence attests to the efficacy and cost-effectiveness of this modality. In contrast to conventional medical management, SCS offers long-lasting symptom relief, improved quality of life and functional capability, often achieving these goals at a reduced cost. This article illustrates the present status, challenges and future of SCS.
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Affiliation(s)
- Krishna Kumar
- Section of Neurosurgery, Department of Surgery, Regina General Hospital, University of Saskatchewan, Regina SK, S4P 0W5, Canada
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Naoum JJ, Arbid EJ. Spinal cord stimulation for chronic limb ischemia. Methodist Debakey Cardiovasc J 2014; 9:99-102. [PMID: 23805343 DOI: 10.14797/mdcj-9-2-99] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The treatment of chronic limb ischemia involves the restoration of pulsatile blood flow to the distal extremity. Some patients cannot be treated with endovascular means or with open surgery; some may have medical comorbidities that render them unfit for surgery, while others may have persistent ischemia or pain even in the face of previous attempts at reperfusion. In spinal cord stimulation (SCS), a device with electrodes is implanted in the epidural space to stimulate sensory fibers. This activates cell-signaling molecules that in turn cause the release of vasodilatory molecules, a decrease in vascular resistance, and relaxation of smooth muscle cells. SCS also suppresses sympathetic vasoconstriction and pain transmission. When patient selection is based on microcirculatory parameters, SCS therapy can significantly improve pain relief, halt the progression of ulcers, and potentially achieve limb salvage.
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Dworkin RH, O’Connor AB, Kent J, Mackey SC, Raja SN, Stacey BR, Levy RM, Backonja M, Baron R, Harke H, Loeser JD, Treede RD, Turk DC, Wells CD. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain 2013; 154:2249-2261. [PMID: 23748119 PMCID: PMC4484720 DOI: 10.1016/j.pain.2013.06.004] [Citation(s) in RCA: 287] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/24/2013] [Accepted: 06/03/2013] [Indexed: 11/30/2022]
Abstract
Neuropathic pain (NP) is often refractory to pharmacologic and noninterventional treatment. On behalf of the International Association for the Study of Pain Neuropathic Pain Special Interest Group, the authors evaluated systematic reviews, clinical trials, and existing guidelines for the interventional management of NP. Evidence is summarized and presented for neural blockade, spinal cord stimulation (SCS), intrathecal medication, and neurosurgical interventions in patients with the following peripheral and central NP conditions: herpes zoster and postherpetic neuralgia (PHN); painful diabetic and other peripheral neuropathies; spinal cord injury NP; central poststroke pain; radiculopathy and failed back surgery syndrome (FBSS); complex regional pain syndrome (CRPS); and trigeminal neuralgia and neuropathy. Due to the paucity of high-quality clinical trials, no strong recommendations can be made. Four weak recommendations based on the amount and consistency of evidence, including degree of efficacy and safety, are: 1) epidural injections for herpes zoster; 2) steroid injections for radiculopathy; 3) SCS for FBSS; and 4) SCS for CRPS type 1. Based on the available data, we recommend not to use sympathetic blocks for PHN nor radiofrequency lesions for radiculopathy. No other conclusive recommendations can be made due to the poor quality of available data. Whenever possible, these interventions should either be part of randomized clinical trials or documented in pain registries. Priorities for future research include randomized clinical trials, long-term studies, and head-to-head comparisons among different interventional and noninterventional treatments.
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Affiliation(s)
- Robert H. Dworkin
- Departments of Anesthesiology and Neurology and Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
| | | | - Joel Kent
- University of Rochester, Rochester, NY, USA
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Eldabe S, Raphael J, Thomson S, Manca A, de Belder M, Aggarwal R, Banks M, Brookes M, Merotra S, Adeniba R, Davies E, Taylor RS. The effectiveness and cost-effectiveness of spinal cord stimulation for refractory angina (RASCAL study): study protocol for a pilot randomized controlled trial. Trials 2013; 14:57. [PMID: 23433492 PMCID: PMC3598727 DOI: 10.1186/1745-6215-14-57] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 02/11/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The RASCAL (Refractory Angina Spinal Cord stimulation and usuAL care) pilot study seeks to assess the feasibility of a definitive trial to assess if addition of spinal cord stimulation (SCS) to usual care is clinically superior and more cost-effective than usual care alone in patients with refractory angina. METHODS/DESIGN This is an external pilot, patient-randomized controlled trial.The study will take place at three centers in the United Kingdom - South Tees Hospitals NHS Foundation Trust (The James Cook University Hospital), Dudley Group of Hospitals NHS Foundation Trust, and Basildon and Thurrock University Hospitals NHS Foundation Trust.The subjects will be 45 adults with refractory angina, that is, limiting angina despite optimal anti-angina therapy, Canadian Cardiovascular Society Functional Classification Class III and IV, angiographically documented coronary artery disease not suitable for revascularization, satisfactory multidisciplinary assessment and demonstrable ischemia on functional testing.The study will be stratified by center, age and Canadian Cardiovascular Society Functional Classification.Interventions will involve spinal cord stimulation plus usual care ('SCS group') or usual care alone ('UC group'). Usual care received by both groups will include consideration of an education session with a pain consultant, trial of a transcutaneous electrical neurostimulation, serial thoracic sympathectomy and oral/systemic analgesics.Expected outcomes will be recruitment and retention rates; reasons for agreeing/declining participation; variability in primary and secondary outcomes (to inform power calculations for a definitive trial); and completion rates of outcome measures. Trial patient-related outcomes include disease-specific and generic health-related quality of life, angina exercise capacity, intake of angina medications, frequency of angina attacks, complications and adverse events, and satisfaction. DISCUSSION The RASCAL pilot trial seeks to determine the feasibility and design of a definitive randomized controlled trial comparing the addition of spinal cord stimulation to usual care versus usual care alone for patients with refractory angina.Fifteen patients have been recruited since recruitment opened in October 2011. The trial was originally scheduled to end in April 2013 but due to slow recruitment may have to be extended to late 2013. TRIAL REGISTRATION ISRCTN65254102.
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Affiliation(s)
- Sam Eldabe
- Department of Pain and Anesthesia, The James Cook University Hospital, Marton Road, Middlesbrough, UK
| | - John Raphael
- Department of Pain Medicine, Dudley Group of Hospitals NHS Foundation Trust, Russells Hall Hospital, Pensnett Road, Dudley, West Midlands, UK
| | - Simon Thomson
- Basildon and Thurrock University Hospitals, Nethermayne, Basildon, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Mark de Belder
- Department of Pain and Anesthesia, The James Cook University Hospital, Marton Road, Middlesbrough, UK
| | - Rajesh Aggarwal
- Basildon and Thurrock University Hospitals, Nethermayne, Basildon, UK
| | - Matthew Banks
- Department of Pain Medicine, Dudley Group of Hospitals NHS Foundation Trust, Russells Hall Hospital, Pensnett Road, Dudley, West Midlands, UK
| | - Morag Brookes
- Department of Pain and Anesthesia, The James Cook University Hospital, Marton Road, Middlesbrough, UK
| | - Susan Merotra
- Department of Pain Medicine, Dudley Group of Hospitals NHS Foundation Trust, Russells Hall Hospital, Pensnett Road, Dudley, West Midlands, UK
| | - Rashidat Adeniba
- Basildon and Thurrock University Hospitals, Nethermayne, Basildon, UK
| | - Ed Davies
- Cardiothoracic Department, Plymouth Hospitals NHS Trust, Derriford Road, Plymouth, UK
| | - Rod S Taylor
- University of Exeter Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter, EX2 4SG, UK
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Abstract
Some patients with peripheral arterial disease may present with critical limb ischemia, a condition associated with high rates of morbidity and mortality. Early diagnosis and effective medical therapy and revascularization are indicated to avoid amputation and reduce mortality. Ideally, a multidisciplinary approach with collaboration between endovascular interventionist, vascular surgeons, podiatrist, infectious disease, and wound care specialist is recommended for these patients.
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Lepäntalo MJ, Houbballah R, Raux M, LaMuraglia G. Lower extremity bypass vs endovascular therapy for young patients with symptomatic peripheral arterial disease. J Vasc Surg 2012; 56:545-54. [DOI: 10.1016/j.jvs.2012.06.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Part One: For the Motion. Lower Extremity Bypass versus Endovascular Therapy for Young Patients with Symptomatic Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2012; 44:112-5. [DOI: 10.1016/j.ejvs.2012.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lepäntalo M. The path from art to evidence in treating critical limb ischaemia--reflections on 35 years' experience. Scand J Surg 2012; 101:78-85. [PMID: 22623439 DOI: 10.1177/145749691210100202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite numerous attempts, chronic critical limb ischaemia (CLI) has not been unequivocally defined as yet. Its epidemiology is poorly investigated and its prevalence probably higher than anticipated. It is accompanied by high mortality and morbidity irrespective of the way it is treated. Its management is very expensive. Additionally, the prevailing diabetes epidemic is increasing the need for revascularizations although there is a clear lack of evidence as to when to revascularize an ulcerated diabetic foot. The fast development of endovascular techniques blurs the vision as the window of opportunity for gathering proper evidence keeps narrowing. The notion of endovascular artistry prevails, but attempts to conduct proper studies with clear definitions, strict criteria and appropriate outcome measures in a standardised manner should continue--preferably using propensity scoring if randomised controlled trials are not possible. This review highlights some of the steps leading from art to evidence and illustrates the difficulties encountered along the path. In parallel with this overview, the progress of the treatment for CLI in Finland is described from the perspective of the work concluded at Helsinki University Central Hospital.
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Affiliation(s)
- M Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Lee SH, Jeong HJ, Jeong SH, Lee HG, Choi JI, Yoon MH, Kim WM. Spinal cord stimulation for refractory angina pectoris -a case report-. Korean J Pain 2012; 25:121-5. [PMID: 22514782 PMCID: PMC3324738 DOI: 10.3344/kjp.2012.25.2.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 12/05/2011] [Accepted: 12/06/2011] [Indexed: 11/19/2022] Open
Abstract
Refractory angina pectoris is defined as angina refractory to optimal medical treatment and standard coronary revascularization procedures. Despite recent therapeutic advances, patients with refractory angina pectoris are not adequately treated. Spinal cord stimulation is a minimally invasive and reversible technique which utilizes electrical neuromodulation by means of an electrode implanted in the epidural space. It has been reported to be an effective and safe treatment for refractory angina pectoris. We report a case of spinal cord stimulation which has effectively relieved chest pain due to coronary artery disease in a 40-year-old man. This is the first report of spinal cord stimulation for treatment of refractory angina pectoris in South Korea.
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Affiliation(s)
- Seong Heon Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
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Gasper WJ, Runge SJ, Owens CD. Management of Infrapopliteal Peripheral Arterial Occlusive Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:136-48. [DOI: 10.1007/s11936-012-0164-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schlaier JR, Eichhammer P, Langguth B, Doenitz C, Binder H, Hajak G, Brawanski A. Effects of spinal cord stimulation on cortical excitability in patients with chronic neuropathic pain: A pilot study. Eur J Pain 2012; 11:863-8. [PMID: 17331763 DOI: 10.1016/j.ejpain.2007.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Revised: 10/22/2006] [Accepted: 01/21/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite a broad clinical use, the mechanism of action of SCS is poorly understood. Current information suggests that the effects of SCS are mediated by a complex set of interactions at several levels of the nervous system including spinal and supraspinal mechanisms. AIMS The study was undertaken to investigate the influence of SCS on distinct parameters of cortical excitability using single- and paired-pulse transcranial magnetic stimulation (TMS). METHODS Five patients with chronic neuropathic pain were examined with the SCS stimulator on and off by means of TMS. Pain was assessed using a visual-analogue scale. Electrophysiological and pain parameters of patients during this procedure were compared by means of a linear mixed effect model. RESULTS SCS induced a significant modulation of cortical excitability, especially by influencing the parameter "intracortical facilitation" (t=-2.657; df=8; p=0.029). A significant relationship between this parameter and "perceived pain" could be obtained (t=-4.798; df=8; p=0.002). CONCLUSIONS These results suggest that SCS is able to influence neurobiological processes at the supraspinal level and that clinical effects of SCS may be at least in part of cortical origin.
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Affiliation(s)
- Jürgen R Schlaier
- Department of Neurosurgery, University of Regensburg, 93053 Regensburg, Franz-Josef-Strauss-Allee 11, Germany.
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Recommendations for patient selection in spinal cord stimulation. J Clin Neurosci 2011; 18:1295-302. [DOI: 10.1016/j.jocn.2011.02.025] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 02/21/2011] [Accepted: 02/22/2011] [Indexed: 11/18/2022]
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Hsu CH, Tseng SB, Hsieh YJ, Wang CC. One-time-implantable spinal cord stimulation system prototype. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2011; 5:490-498. [PMID: 23852180 DOI: 10.1109/tbcas.2011.2157152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A prototype of a one-time-implantable spinal cord stimulation (SCS) system using wireless power and data-transmission techniques is presented in this paper. The power of the implant is induced by wireless coil coupling, and duplex amplitude-shift keying-load-shift keying wireless communication is used so that digital packets can be transmitted by the same inductive link. The proposed novel ASK demodulator attains high demodulation performance and small area without using any resistors and capacitors. The proposed SCS system utilizes many power saving schemes to reduce power dissipation (e.g., dual supply voltages on-chip, high-voltage impulse generation using small current, etc.). Meanwhile, the excess energy induced by the coils is stored in a rechargeable battery to extend the implant's operation time so that the number of battery replacement surgeries will be reduced significantly. The system-on-chip (SOC) is physically implemented on silicon and integrated in the implant as the system controller. The fabricated SOC area is 1410 × 1710 μm(2). Compared with existing commercial products, the proposed SCS system attains better flexibility and longer operation time.
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Tronnier V, Baron R, Birklein F, Eckert S, Harke H, Horstkotte D, Hügler P, Hüppe M, Kniesel B, Maier C, Schütze G, Thoma R, Treede R, Vadokas V. Epidurale Rückenmarkstimulation zur Therapie chronischer Schmerzen. Schmerz 2011; 25:484-92. [DOI: 10.1007/s00482-011-1094-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Wolter T, Kieselbach K. Spinal cord stimulation for Raynaud's syndrome: long-term alleviation of bilateral pain with a single cervical lead. Neuromodulation 2011; 14:229-33; discussion 233-4. [PMID: 21992245 DOI: 10.1111/j.1525-1403.2011.00332.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) has been described in a variety of neuropathic and vasospastic pain conditions including Raynaud's syndrome. METHODS We report here the outcome of single lead SCS in the case of a 49-year-old woman with severe Raynaud's syndrome, which had failed to respond to medical therapy. RESULTS With a single quadripolar cervical lead in midline position at the C2/C3 level sustained pain relief of the bilateral pain was accomplished. Pain scores sank from 7/10 to 2-3/10 on the nominal analog scale and remained stable more than nearly four years by now. CONCLUSIONS Treatment of bilateral pain in Raynaud's syndrome with SCS in a single technique is feasible. Advantages and disadvantages as compared with stimulation with bilateral leads are discussed.
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Affiliation(s)
- Tilman Wolter
- Interdisciplinary Pain Centre, University Hospital Freiburg, Breisacherstrasse 64, Freiburg, Germany.
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Chen XP, Fu WM, Gu W. Spinal cord stimulation for patients with inoperable chronic critical leg ischemia. World J Emerg Med 2011; 2:262-6. [PMID: 25215020 PMCID: PMC4129719 DOI: 10.5847/wjem.j.1920-8642.2011.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 10/11/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Because of the prevalence of diabetes, the treatment of diabetic foot is still challenging. Even an exactly proved effective and practical method can't be listed except vascular surgery which is not a long-term way for it. Spinal cord stimulation (SCS) is a very promising option in the treatment algorithm of inoperable chronic critical leg ischemia (CLI). DATA SOURCES We searched Pubmed database with key words or terms such as "spinal cord stimulation", "ischemic pain" and "limb ischemia" appeared in the last five years. RESULTS The mechanism of SCS is unclear. Two theories have emerged to interpret the benefits of SCS. Pain relief from SCS can be confirmed by a majority of the studies, while limb salvage and other more ambitious improvements have not come to an agreement. The complications of SCS are not fatal, but most of them are lead migration, lead connection failure, and local infection. CONCLUSIONS SCS is a safe, promising treatment for patients with inoperable CLI. It is effective in pain reduction compared with traditional medical treatment.
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Affiliation(s)
- Xiao-pei Chen
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China (Chen XP, Gu W) Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China (Fu WM)
| | - Wei-min Fu
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China (Chen XP, Gu W) Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China (Fu WM)
| | - Wei Gu
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China (Chen XP, Gu W) Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China (Fu WM)
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Varu VN, Hogg ME, Kibbe MR. Critical limb ischemia. J Vasc Surg 2010; 51:230-41. [PMID: 20117502 DOI: 10.1016/j.jvs.2009.08.073] [Citation(s) in RCA: 235] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 08/16/2009] [Indexed: 11/30/2022]
Abstract
Critical limb ischemia (CLI) continues to be a significantly morbid disease process for the aging population. Rigid guidelines for the management of patients with CLI are inappropriate due to the complexities that are involved in optimally treating these patients. A thin line exists in the decision process between medical management vs surgical management by revascularization or amputation, and the perception of "success" in this patient population is evolving. This review explores these issues and examines the challenges the treating physician will face when managing the care of patients with CLI. The epidemiology and natural history of CLI is discussed, along with the pathophysiology of the disease process. A review of the literature in regards to the different treatment modalities is presented to help the physician optimize therapy for patients with CLI. New scoring systems to help predict outcomes in patients with CLI undergoing revascularization or amputation are discussed, and an overview of the current status of patient-oriented outcomes is provided. Finally, we briefly examine emerging therapies for the treatment of CLI and provide an algorithm to help guide the practicing physician on how to approach the critically ischemic limb with regard to the complicated issues surrounding these patients.
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Affiliation(s)
- Vinit N Varu
- Division of Vascular Surgery, Northwestern University, Chicago, Ill 60611, USA
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Klomp HM, Steyerberg EW, Wittens CHA, van Urk H, Habbema JDF. A prognostic model for amputation in critical lower limb ischemia. Vasc Med 2009; 14:109-15. [PMID: 19366816 DOI: 10.1177/1358863x08098227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In a (negative) multicenter randomized trial on management for inoperable critical lower limb ischemia, comparing spinal cord stimulation and best medical treatment, a number of pre-defined factors were analyzed for prognostic value. We included a radiological arterial disease score, modified from the SVS/ISCVS runoff score. The purpose of this analysis was to evaluate clinical factors and commonly used circulatory measurements for prognostic modeling in patients with critical lower limb ischemia. We determined the incidence of amputation and its relation to various pre-defined risk factors. A total of 120 patients with critical limb ischemia were included in the study. The integrity of circulation in the affected limb was evaluated on five levels: suprainguinal, infrainguinal, popliteal, infrapopliteal and pedal. A total radiological arterial disease score was calculated from 1 (full integrity of circulation) to 20 (maximally compromised state). We used Cox regression analysis to quantify prognostic effects and differential treatment (predictive) effects. Major amputation occurred in 33% of the patients at 6 months and in 51% at 2 years. The presence of ischemic skin lesions and the radiological arterial disease score were independent prognostic factors for amputation. Patients with ulcerations or gangrene had a higher amputation risk (hazard ratio 2.38, p = 0.018 and 2.30, p = 0.036 respectively) as well as patients with a higher radiological arterial disease score (hazard ratio 1.17 per increment, p = 0.003). We did not observe significant interactions between prognostic factors and the effect of spinal cord stimulation. In conclusion, in patients with critical lower limb ischemia, the presence of ischemic skin lesions and the described radiological arterial disease score can be used to estimate amputation risk.
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Affiliation(s)
- H M Klomp
- Department of Public Health, Center for Clinical Decision Sciences, Erasmus MC.
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Taylor RS, De Vries J, Buchser E, Dejongste MJL. Spinal cord stimulation in the treatment of refractory angina: systematic review and meta-analysis of randomised controlled trials. BMC Cardiovasc Disord 2009; 9:13. [PMID: 19320999 PMCID: PMC2667170 DOI: 10.1186/1471-2261-9-13] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 03/25/2009] [Indexed: 11/22/2022] Open
Abstract
Background The aim of this paper was undertake a systematic review and meta-analysis of the use of spinal cord stimulation (SCS) in the management of refractory angina. Methods We searched a number of electronic databases including Medline, Embase and Cochrane Library up to February 2008 to identify randomised controlled trials (RCTs) reporting exercise capacity, ischemic burden, functional class, quality of life, usage of anti-anginal medication, costs and adverse events including mortality. Results were reported both descriptively for each study and using random effects meta-analysis. Given the variety in outcomes reported, some outcome results were pooled as standardised mean differences (SMD) and reported in standard deviation units. Results Seven RCTs were identified in a total of 270 refractory angina patients. The outcomes of SCS were found to be similar when directly compared to coronary artery bypass grafting (CABG) and percutaneous myocardial laser revascularisation (PMR). Compared to a 'no stimulation' control, there was some evidence of improvement in all outcomes following SCS implantation with significant gains observed in pooled exercise capacity (SMD: 0.76, 0.07 to 1.46, p = 0.03) and health-related quality of life (SMD: 0.83, 95% CI: 0.32 to 1.34, p = 0.001). Trials were small and were judged to range considerably in their quality. The healthcare costs of SCS appeared to be lower than CABG at 2-years follow up. Conclusion SCS appears to be an effective and safe treatment option in the management of refractory angina patients and of similar efficacy and safety to PMR, a potential alternative treatment. Further high quality RCT and cost effectiveness evidence is needed before SCS can be accepted as a routine treatment for refractory angina.
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Affiliation(s)
- Rod S Taylor
- Health Services Research, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK.
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Abejón D, Krames ES. Peripheral Nerve Stimulation or Is It Peripheral Subcutaneous Field Stimulation; What Is in a Moniker? Neuromodulation 2009; 12:1-4. [DOI: 10.1111/j.1525-1403.2009.00192.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rüger LJ, Irnich D, Grasmueller S, Lang PM. [Therapy of chronic ischemic pain in peripheral arterial disease. A survey among physicians]. Schmerz 2008; 22:164-70. [PMID: 17598132 DOI: 10.1007/s00482-007-0556-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The intention of this study was to determine the status quo of commonly used pain therapies amongst treating physicians of different specialties and to examine their view on the problem of chronic ischemic pain. METHODS A total of 281 physicians treating patients with chronic ischemic pain were surveyed. The surveyed physicians were mainly specialists in the fields of surgery, pain therapy, and internal medicine. RESULTS Mainly a pharmacological therapy (metamizol/paracetamol, weak and strong opioids) was used in the treatment of chronic ischemic pain. We found differences between the specialties, for instance pain specialists used antidepressants and anticonvulsants more often than others. Therapeutic options were also evaluated differently by surgeons, pain therapists, and internal specialists: 57% of the surgeons considered the available symptomatic treatment options as sufficient whereas only 21% of the pain specialists agreed with that opinion. CONCLUSION The differences among the specialties and the fact that the majority of physicians characterized the available symptomatic treatment options as insufficient point towards a need to review the treatment of ischemic pain in an interdisciplinary approach.
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Affiliation(s)
- L J Rüger
- Interdisziplinäre Schmerzambulanz, Klinik für Anästhesiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Pettenkoferstrasse 8a, 80336, München, Germany
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