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Moens M, Crunelle CL, Putman K, Wuyts E, Bultinck F, Van Puyenbroeck H, Goudman L. Pain medication tapering for patients with Persistent Spinal Pain Syndrome Type II, treated with Spinal Cord Stimulation: A RCT-study protocol of the PIANISSIMO study. PLoS One 2024; 19:e0302842. [PMID: 39133680 PMCID: PMC11318931 DOI: 10.1371/journal.pone.0302842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Spinal Cord Stimulation (SCS) may provide pain relief in patients with therapy-refractory Persistent Spinal Pain Syndrome Type II (PSPS-T2). Despite the evidence that SCS can reduce disability and reduce pain medication usage, only 25% of the patients is able to completely omit pain medication usage after 12 months of SCS. To tackle the high burden of patients who consume a lot of pain medication, tapering programs could be initiated before starting a trajectory with SCS. The current objective is to examine whether a pain medication tapering program before SCS alters disability in PSPS-T2 patients compared to no tapering program. METHODS AND DESIGN A three-arm, parallel-group multicenter randomized controlled trial will be conducted including 195 patients who will be randomized (1:1:1) to either (a) a standardized pain medication tapering program, (b) a personalized pain medication tapering program, or (c) no tapering program before SCS implantation, all with a follow-up period until 12 months after implantation. The primary outcome is disability. The secondary outcomes are pain intensity, health-related quality of life, participation, domains affected by substance use, anxiety and depression, medication usage, psychological constructs, sleep, symptoms of central sensitization, and healthcare expenditure. DISCUSSION Within the PIANISSIMO project we propose a way to reduce the risks of adverse events, medication-induced hyperalgesia, tolerance, and dependence by providing pain medication tapering before SCS. Due to the lack of a commonly accepted in-hospital tapering approach, two different tapering programs will be evaluated in this study. If pain medication tapering programs are deemed to be more effective than no tapering on disability, this would add to the evidence towards an improved patient-centered care model in this patient group and set a clear path to advocate for pain medication tapering before SCS as the new standard treatment guideline for these patients. TRIAL REGISTRATION ClinicalTrials.gov NCT05861609. Registered on May 17, 2023.
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Affiliation(s)
- Maarten Moens
- STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Cleo Lina Crunelle
- Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium
- Department of Psychiatry, Vrije Universiteit Brussel, University Hospital Brussels (UZ Brussel), Brussel, Belgium
| | - Koen Putman
- Faculty of Medicine and Pharmacy, Department of Public Health (GEWE), Interuniversity Centre for Health Economics Research (I-CHER), Vrije Universiteit Brussel, Brussels, Belgium
| | - Elke Wuyts
- STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Frenn Bultinck
- Faculty of Medicine and Pharmacy, Department of Public Health (GEWE), Interuniversity Centre for Health Economics Research (I-CHER), Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | - Lisa Goudman
- STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Research Foundation Flanders (FWO), Brussel, Belgium
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Kapural L, Viradia I, Poddar N, Bekavac C. Ten-kHz Spinal Cord Stimulation vs Radiofrequency Ablation of Splanchnic Nerves: A Single-Site Retrospective Comparison of 12-Month Outcomes. Neuromodulation 2024:S1094-7159(24)00650-0. [PMID: 39101872 DOI: 10.1016/j.neurom.2024.07.001] [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: 04/28/2024] [Revised: 06/19/2024] [Accepted: 07/08/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVES A prospective study on 10-kHz spinal cord stimulation (SCS) for various causes of chronic abdominal pain (CAP) showed robust improvements in subjects' pain and function. Radiofrequency ablation of splanchnic nerves (snRFA) has been used in advanced pain management treatment algorithms for CAP. This analysis was designed to provide what we believe is the first comparison of the efficacy of these two therapies. Propensity-score matched analysis (PMA) was performed to compare pain relief and decrease in medication usage in snRFA and SCS for treating refractory CAP. MATERIALS AND METHODS Medical records were extracted for consecutive patients with CAP treated from June 2015 to June 2021 who underwent either snRFA or SCS at the Carolinas Pain Institute after positive diagnostic splanchnic block. The patients' diagnoses included gastroparesis, chronic pancreatitis, postsurgical CAP, and other dysmotility syndromes. PMA was performed to produce matched pairs in terms of baseline clinical status, reported pain, and opioid use over 12 months, after treatment was compared in the groups. RESULTS PMA produced two well-balanced groups (n = 31) for SCS and snRFA. Analysis showed significant improvement in pain scores in both groups through 12 months, but the mean reduction in reported numerical rating scale points was significantly greater for the SCS group, averaging 4.7 vs 3.0 points for the snRFA group (p < 0.01). Responder rates (≥50% pain relief) similarly diverged at 12 months, with 67.7% vs 30.0% responders in the SCS and snRFA groups, respectively (p = 0.017). Opioid usage did not change in the snRFA group but was reduced in the SCS group at 12 months (p = 0.004). CONCLUSIONS SCS provided longer pain relief than did snRFA in this propensity-matched study. Pain scores and opioid usage were significantly less at 12-month follow-up when SCS was used for control of CAP.
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Affiliation(s)
| | | | - Neil Poddar
- Carolinas Pain Institute, Winston-Salem, NC, USA
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Malinowski MN, Gish BE, Moreira AM, Karcz M, Bracero LA, Deer TR. Electrical neuromodulation for the treatment of chronic pain: derivation of the intrinsic barriers, outcomes and considerations of the sustainability of implantable spinal cord stimulation therapies. Expert Rev Med Devices 2024:1-13. [PMID: 39044340 DOI: 10.1080/17434440.2024.2382234] [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: 04/25/2024] [Accepted: 07/16/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION For over 60 years, spinal cord stimulation has endured as a therapy through innovation and novel developments. Current practice of neuromodulation requires proper patient selection, risk mitigation and use of innovation. However, there are tangible and intangible challenges in physiology, clinical science and within society. AREAS COVERED We provide a narrative discussion regarding novel topics in the field especially over the last decade. We highlight the challenges in the patient care setting including selection, as well as economic and socioeconomic challenges. Physician training challenges in neuromodulation is explored as well as other factors related to the use of neuromodulation such as novel indications and economics. We also discuss the concepts of technology and healthcare data. EXPERT OPINION Patient safety and durable outcomes are the mainstay goal for neuromodulation. Substantial work is needed to assimilate data for larger and more relevant studies reflecting a population. Big data and global interconnectivity efforts provide substantial opportunity to reinvent our scientific approach, data analysis and its management to maximize outcomes and minimize risk. As improvements in data analysis become the standard of innovation and physician training meets demand, we expect to see an expansion of novel indications and its use in broader cohorts.
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Affiliation(s)
| | - Brandon E Gish
- Lexington Clinic Interventional Pain, Lexington, KY, USA
| | - Alexandra M Moreira
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
| | - Marcin Karcz
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Lucas A Bracero
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
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Gulve A, Mehta V, Provenzano DA, Eggington S, Scheffler S, Gasquet NC, Ricker CN. Differential Target Multiplexed Spinal Cord Stimulation: A UK Cost-Effectiveness Analysis. Neuromodulation 2024; 27:908-915. [PMID: 38971582 DOI: 10.1016/j.neurom.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/19/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVES The aim of this economic analysis was to evaluate the cost-effectiveness of differential target multiplexed spinal cord stimulation (DTM-SCS) for treating chronic intractable low back pain, compared with conventional spinal cord stimulation (C-SCS) and conservative medical management (CMM), by updating and expanding the inputs for a previously published cross-industry model. MATERIALS AND METHODS This model comprised a 12-month decision-tree phase followed by a long-term Markov model. Costs and outcomes were calculated from a UK National Health Service perspective, over a base-case horizon of 15 years and up to a maximum of 40 years. All model inputs were derived from published literature or other deidentified sources and updated to reflect recent clinical trials and costs. Deterministic and one-way sensitivity analyses were performed to calculate costs and quality-adjusted life-years (QALYs) across the 15-year time horizon and to explore the impact of individual parameter variability on the cost-effectiveness results. Probabilistic sensitivity analysis was undertaken to explore the impact of joint parameter uncertainty on the results. RESULTS DTM-SCS was the most cost-effective option from a payer perspective. Compared with CMM alone, DTM-SCS was associated with an incremental cost-effectiveness ratio (ICER) of £6101 per QALY gained (incremental net benefit [INB] = £21,281). The INB for C-SCS compared with CMM was lower than for DTM-SCS, at £8551. For the comparison of DTM-SCS and C-SCS, an ICER of £897 per QALY gained was calculated, with a 99.5% probability of cost-effectiveness at a £20,000 per QALY threshold. CONCLUSIONS Among patients with low back pain treated over a 15-year follow-up period, DTM-SCS and C-SCS are cost-effective compared with CMM, from both payer and societal perspectives. DTM-SCS is associated with a lower ICER than that of C-SCS. Wider uptake of DTM-SCS in the UK health care system is warranted to manage chronic low back pain.
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Affiliation(s)
- Ashish Gulve
- James Cook University Hospital, Middlesbrough, UK.
| | | | - David A Provenzano
- Pain Diagnostics and Interventional Care, Edgeworth Medical Commons, Sewickley, PA, USA
| | - Simon Eggington
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
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Rajkumar S, Venkatraman V, Zidanyue Yang L, Parente B, Lee HJ, Lad SP. Healthcare Economics of High Frequency Spinal Cord Stimulation for Painful Diabetic Peripheral Neuropathy. J Diabetes Sci Technol 2024; 18:635-643. [PMID: 36314587 PMCID: PMC11089884 DOI: 10.1177/19322968221128321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Painful diabetic peripheral neuropathy (pDPN) is a debilitating complication of long-term diabetes. High-frequency spinal cord stimulation (HF-SCS) was recently shown to be an effective treatment option, but the associated healthcare resource utilization (HCRU) on real-world patient populations with pDPN is unknown. METHODS Using IBM MarketScan databases, we identified patients with HF-SCS implantation between January 2016 and December 2019 who had a diagnosis of diabetes or diabetic neuropathy within two years before implant. Cost data were collected for the six months before HF-SCS implantation (baseline) and for the periods of one, three, and six months post-implantation. The six-month explant rate was calculated. RESULTS A total of 132 patients met inclusion criteria. The median total cost at baseline was $19 220 and was $1356 at one month post-implant, $4858 at three months post-implant, and $13 305 at six months post-implant. The median baseline out-of-pocket cost was $1477 and was $710 at six months post-implant. The average total cost reduction from baseline to six months post-implant was $5118 (P < .001), or $853 per month. The median device acquisition cost was $35 755. The explant rate within six months was 2.1%. CONCLUSIONS High frequency spinal cord stimulation significantly reduces total HCRU in patients with pDPN, and based on the average monthly cost reduction of $853, we estimate that the therapy recoups acquisition costs within 3.5 years. As policy increasingly focuses on value-based care, it will be critical to consider the cost and outcomes of innovative therapies.
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Affiliation(s)
- Shashank Rajkumar
- Department of Neurosurgery, Duke University Hospital, Duke University Medical Center, Duke University School of Medicine, Durham, NC, USA
| | - Vishal Venkatraman
- Department of Neurosurgery, Duke University Hospital, Duke University Medical Center, Duke University School of Medicine, Durham, NC, USA
| | | | - Beth Parente
- Department of Neurosurgery, Duke University Hospital, Duke University Medical Center, Duke University School of Medicine, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics, Duke University, Durham, NC, USA
| | - Shivanand P. Lad
- Department of Neurosurgery, Duke University Hospital, Duke University Medical Center, Duke University School of Medicine, Durham, NC, USA
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Tieppo Francio V, Leavitt L, Alm J, Mok D, Yoon BJV, Nazir N, Lam CM, Latif U, Sowder T, Braun E, Sack A, Khan TW, Sayed D. Healthcare Utilization (HCU) Reduction with High-Frequency (10 kHz) Spinal Cord Stimulation (SCS) Therapy. Healthcare (Basel) 2024; 12:745. [PMID: 38610166 PMCID: PMC11012032 DOI: 10.3390/healthcare12070745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Spinal cord stimulation (SCS) is a well-established treatment for patients with chronic pain. With increasing healthcare costs, it is important to determine the benefits of SCS in healthcare utilization (HCU). This retrospective, single-center observational study involved 160 subjects who underwent implantation of a high-frequency (10 kHz) SCS device. We focused on assessing trends in HCU by measuring opioid consumption in morphine milligram equivalents (MME), as well as monitoring emergency department (ED) and office visits for interventional pain procedures during the 12-month period preceding and following the SCS implant. Our results revealed a statistically significant reduction in HCU in all domains assessed. The mean MME was 51.05 and 26.52 pre- and post-implant, respectively. There was a 24.53 MME overall decrease and a mean of 78.2% statistically significant dose reduction (p < 0.0001). Of these, 91.5% reached a minimally clinically important difference (MCID) in opioid reduction. Similarly, we found a statistically significant (p < 0.01) decrease in ED visits, with a mean of 0.12 pre- and 0.03 post-implant, and a decrease in office visits for interventional pain procedures from a 1.39 pre- to 0.28 post-10 kHz SCS implant, representing a 1.11 statistically significant (p < 0.0001) mean reduction. Our study reports the largest cohort of real-world data published to date analyzing HCU trends with 10 kHz SCS for multiple pain etiologies. Furthermore, this is the first and only study evaluating HCU trends with 10 kHz SCS by assessing opioid use, ED visits, and outpatient visits for interventional pain procedures collectively. Preceding studies have individually investigated these outcomes, consistently yielding positive results comparable to our findings.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Logan Leavitt
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - John Alm
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Daniel Mok
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Byung-jo Victor Yoon
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Niaman Nazir
- Department of Population Health, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Christopher M. Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Usman Latif
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Timothy Sowder
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Edward Braun
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Andrew Sack
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Talal W. Khan
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
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Zhou X, Zhou Y, Zhang X, Jiang F. Economic evaluation of management strategies for complex regional pain syndrome (CRPS). Front Pharmacol 2024; 15:1297927. [PMID: 38318140 PMCID: PMC10839065 DOI: 10.3389/fphar.2024.1297927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024] Open
Abstract
Background: The economic impact of Complex Regional Pain Syndrome (CRPS) on both patients and the global healthcare system continues to escalate. However, the economic implications associated with management interventions for CRPS have received limited attention. Therefore, our objective is to perform a thorough examination of published economic assessments of the various management strategies utilized for CRPS. Methods: A thorough search spanning four general medical databases and three health economic databases to identify full economic evaluations on CRPS management strategies from January 1994 to June 2023 were conducted. The quality of these studies were evaluated by employing the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. To enable cross-study comparisons conducted in different countries, we adjusted the costs reported in the selected studies for inflation and converted them into 2023 US dollars. Results: A total of nine economic evaluations, consisting of eight high-quality and one medium-quality, were identified across five nations during a span of 29 years. The findings suggest that the most economically efficient intervention for CRPS are interventional approaches of Spinal Cord Stimulation (SCS) in comparison to conventional management for long periods of time. Furthermore, in situations where there is a limited time period of less than 1 year, rehabilitation therapies, particularly physical therapy, have been demonstrated to be more effective in terms of both cost and clinical outcomes. Conclusion: The interventional management strategies, particularly for severe and persistent CRPS over long periods, may offer the greatest cost efficiency. In conditions with limited timelines, rehabilitation measures, such as rehabilitation therapies, can be cost-effective. However, insufficient data for other common interventions prevents the formation of a definitive conclusion. Similarly, it is crucial to recognize that the results of these interventions might be affected by the selection of comparator and the threshold for willingness to pay.
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Affiliation(s)
- Xiaofeng Zhou
- Department of Pain, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yi Zhou
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xiaofei Zhang
- Department of Neuro-Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Feng Jiang
- Department of Ophthalmology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Yeung AM, Huang J, Nguyen KT, Xu NY, Hughes LT, Agrawal BK, Ejskjaer N, Klonoff DC. Painful Diabetic Neuropathy: The Need for New Approaches. J Diabetes Sci Technol 2024; 18:159-167. [PMID: 36305521 PMCID: PMC10899841 DOI: 10.1177/19322968221132252] [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] [Indexed: 11/16/2022]
Abstract
Painful diabetic neuropathy is a common vexing problem for people with diabetes and a costly problem for society. The pathophysiology is not well understood, and no safe and effective mechanistically-based treatment has been identified. Poor glycemic control is a risk factor for painful diabetic neuropathy. Excessive intraneuronal glucose in people with diabetes can be shunted away from physiological glycolysis into multiple pathological pathways associated with neuropathy and pain. The first three treatments that are traditionally offered consist of risk factor reduction, lifestyle modifications, and pharmacological therapy, which includes only three drugs that are approved for this indication by the United States Food and Drug Administration. All of these traditional treatments are often inadequate for relieving neuropathic pain, and thus, new approaches are needed. Modern devices based on neuromodulation technology, which act directly on the nervous system, have been recently cleared by the United States Food and Drug Administration for painful diabetic neuropathy and offer promise as next-in-line therapy when traditional therapies fail.
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Affiliation(s)
| | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | - Lorenzo T. Hughes
- Balance Health, San Francisco, CA, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | | | - Niels Ejskjaer
- Steno Diabetes Center North Denmark and Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - David C. Klonoff
- Diabetes Technology Society, Burlingame, CA, USA
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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Doshi PP, Russo M, Doshi PK. Practice Trends of Neuromodulation Therapies for Pain and Spasticity in India. Neuromodulation 2023; 26:1876-1882. [PMID: 33900661 DOI: 10.1111/ner.13393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/21/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neuromodulation has been successfully used globally to address severe refractory chronic pain for over five decades. Compared to the wide acceptance that it enjoys in United States and Europe, it is fairly underutilized in Asia, including India. OBJECTIVES We conducted the first systematic nationwide survey to provide an overview of neuromodulation in the past 20 years to investigate the practice trends for severe refractory chronic pain and barriers for the uptake of neuromodulation therapies for pain in India. DESIGN A 20-point detailed questionnaire survey was sent out for online completion in August 2020 to practitioners in India involved in interventions for pain. The survey was completed by 112 practitioners (10% return rate). The response data collected were analyzed, tabulated, and presented as percentages. RESULTS The average duration of pain practice in India for the majority of respondents was less than a decade. About 70% of practitioners expressed that they manage severe refractory pain without neuromodulation. This survey confirms that neuromodulation is grossly underutilized for pain, comprising only 10% of total neuromodulation implants performed per annum in India. The most common indications were neuropathic pain (45%) and failed back surgery syndrome (42%). The respondents expressed the main barriers to be related to the cost (85%), lack of awareness (68%), and lack of good training (59%). More than 50% of respondents also expressed difficulty of access to neuromodulation therapies for pain and acceptance by patients. CONCLUSION The younger generation of pain practitioners in India is becoming more aware and convinced about the role of neuromodulation to alleviate severe pain and suffering. An all-round approach combining improved training, awareness at various levels, more flexible options of newer technology and reimbursement approval can positively influence its use. This can be achieved with the collective efforts of physicians, insurers, industry, and focused academic activities of clinical societies.
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Affiliation(s)
- Preeti P Doshi
- Department of Pain Medicine, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India.
| | - Marc Russo
- Department of Pain Medicine, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Paresh K Doshi
- Department of Pain Medicine, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
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Duarte RV, Bentley A, Soliday N, Leitner A, Gulve A, Staats PS, Sayed D, Falowski SM, Hunter CW, Taylor RS. Cost-utility Analysis of Evoke Closed-loop Spinal Cord Stimulation for Chronic Back and Leg Pain. Clin J Pain 2023; 39:551-559. [PMID: 37440335 PMCID: PMC10498882 DOI: 10.1097/ajp.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES The effectiveness of Evoke closed-loop spinal cord stimulation (CL-SCS), a novel modality of neurostimulation, has been demonstrated in a randomized controlled trial (RCT). The objective of this cost-utility analysis was to develop a de novo economic model to estimate the cost-effectiveness of Evoke CL-SCS when compared with open-loop SCS (OL-SCS) for the management of chronic back and leg pain. METHODS A decision tree followed by a Markov model was used to estimate the costs and outcomes of Evoke CL-SCS versus OL-SCS over a 15-year time horizon from the UK National Health Service perspective. A "high-responder" health state was included to reflect improved levels of SCS pain reduction recently reported. Results are expressed as incremental cost per quality-adjusted life year (QALY). Deterministic and probabilistic sensitivity analysis (PSA) was conducted to assess uncertainty in the model inputs. RESULTS Evoke CL-SCS was estimated to be the dominant treatment strategy at ~5 years postimplant (ie, it generates more QALYs while cost saving compared with OL-SCS). Probabilistic sensitivity analysis showed that Evoke CL-SCS has a 92% likelihood of being cost-effective at a willingness to pay threshold of £20,000/QALY. Results were robust across a wide range of scenario and sensitivity analyses. DISCUSSION The results indicate a strong economic case for the use of Evoke CL-SCS in the management of chronic back and leg pain with or without prior spinal surgery with dominance observed at ~5 years.
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Affiliation(s)
- Rui V. Duarte
- Department of Health Data Science, University of Liverpool, Liverpool, UK
- Saluda Medical Pty Ltd., Artarmon, NSW, Australia
| | | | | | | | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | | | - Dawood Sayed
- The University of Kansas Health System, Kansas City, KS
| | | | | | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
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11
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Armstrong DG, Grunberger G. Stimulating Results Signal a New Treatment Option for People Living With Painful Diabetic Neuropathy. J Diabetes Sci Technol 2023; 17:1387-1391. [PMID: 35770993 PMCID: PMC10563543 DOI: 10.1177/19322968221099542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Painful diabetic neuropathy (PDN) is a progressive condition that deprives many patients of quality of life. With limited treatment options available, successful pain management can be difficult to achieve. METHODS We reviewed results of recent data evaluating high frequency spinal cord stimulation (SCS). RESULTS from the SENZA-PDN randomized clinical trial (NCT03228420), the largest such trial to date, demonstrated 10-kHz spinal cord stimulation substantially reduced PDN refractory to conventional medical management along with improvements in health-related quality-of-life measures that were sustained over 12 months. These data supported the recent U.S. Food & Drug Administration (FDA) approval for 10-kHz SCS in PDN patients and contributed to the body of evidence on SCS available to health care professionals managing the effects of PDN. CONCLUSION High frequency spinal cord simulation appears to hold promise in treatment of painful diabetic neuropathy. We look forward to future works in the literature that will further elucidate these promising findings.
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Affiliation(s)
- David G. Armstrong
- Department of Surgery, Southwestern Academic Limb Salvage Alliance, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - George Grunberger
- Grunberger Diabetes Institute, Bloomfield Hills, MI, USA
- Internal Medicine, Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Witkam RL, Kragt EAM, Arnts IJJ, Bronkhorst EM, van Dongen R, Kurt E, Steegers MAH, van Haren FGAM, Maandag NJG, Gort C, Henssen DJHA, Wegener JT, Vissers KCP. Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial? THE JOURNAL OF PAIN 2023; 24:1298-1306. [PMID: 36878384 DOI: 10.1016/j.jpain.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practiced to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialed and nontrialed implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multicenter cohort analysis was performed in 2 comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least 3 months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within 1 session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients (N = 570), respectively. A statistically but not clinically significant difference in pain intensity (P = .003; effect = 0.506 (.172-.839)) was found in favor of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialed SCS patients were more likely to cease opioid usage (P = .003; OR = .509 (.326-.792)), patients in the No-Trial group endured fewer infections (P = .006; proportion difference = .43 (.007-.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. PERSPECTIVE: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted.
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Affiliation(s)
- Richard L Witkam
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Elisabeth A M Kragt
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge J J Arnts
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert van Dongen
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erkan Kurt
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique A H Steegers
- Department of Anaesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frank G A M van Haren
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Natasja J G Maandag
- Department of Anaesthesiology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Cees Gort
- Department of Anaesthesiology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Dylan J H A Henssen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jessica T Wegener
- Department of Anaesthesiology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Kris C P Vissers
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Poree L, Foster A, Staats PS. Device profile of the Evoke physiologic closed-loop spinal cord stimulation system for the treatment of chronic intractable pain: overview of its safety and efficacy. Expert Rev Med Devices 2023; 20:885-898. [PMID: 37691581 DOI: 10.1080/17434440.2023.2255520] [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: 04/26/2023] [Revised: 07/14/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The Evoke® spinal cord stimulation (SCS) device enables the closed-loop feedback of dynamically measured evoked compound action potentials (ECAPs) to adjust stimulation amplitude for every stimulation pulse to maintain the stimulation output level near a targeted ECAP amplitude. No other commercially available SCS device presently uses physiologic feedback from the spinal cord to adjust stimulation. Clinicians should be familiar with the differences in devices and with the latest technologies to provide optimized patient care. AREAS COVERED In this device profile, the Evoke system is described and the system capabilities are differentiated from other available SCS devices. A systematic review was conducted based on best practice guidance to identify all available evidence on the safety and efficacy of the Evoke SCS system. EXPERT OPINION The Evoke SCS system offers unique capabilities as a means to optimize therapy delivery tailored to each individual patient. Data through 24-months follow-up show statistically significant, clinically meaningful, ample, consistent, and strong evidence of the safety and efficacy of the Evoke system for the treatment of chronic intractable pain.
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Affiliation(s)
- Lawrence Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Allison Foster
- Foster Medical Communications Ltd, Auckland, New Zealand
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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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15
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Goudman L, Putman K, Van Doorslaer L, Billot M, Roulaud M, Rigoard P, Moens M. Proportion of clinical holistic responders in patients with persistent spinal pain syndrome type II treated by subthreshold spinal cord stimulation compared to best medical treatment: a study protocol for a multicentric randomised controlled trial (TRADITION). Trials 2023; 24:120. [PMID: 36803412 PMCID: PMC9940414 DOI: 10.1186/s13063-023-07140-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Integrating information on bodily functions, pain intensity and quality of life into one composite measure of a holistic responder has recently been proposed as a useful method to evaluate treatment efficacy of spinal cord stimulation (SCS) in patients with therapy-refractory persistent spinal pain syndrome type II (PSPS-T2). Previous studies already demonstrated the efficacy of standard SCS over best medical treatment (BMT) and the superiority of new subthreshold (i.e. paresthesia free) SCS paradigms compared to standard SCS. Nevertheless, the efficacy of subthreshold SCS compared to BMT has not yet been investigated in patients with PSPS-T2, neither with unidimensional outcomes nor with a composite measure. The current objective is to examine whether subthreshold SCS, compared to BMT, provided to patients with PSPS-T2 results in a different proportion of clinical holistic responders (as composite measure) at 6 months. METHODS A two-arm multicentre randomised controlled trial will be conducted whereby 114 patients will be randomised (1:1) to (a) BMT or (b) paresthesia-free SCS. After a follow-up period of 6 months (primary time endpoint), patients receive the opportunity to cross over towards the other treatment group. The primary outcome is the proportion of clinical holistic responders at 6 months (i.e. a composite measure of pain intensity, medication, disability, health-related quality of life and patient satisfaction). The secondary outcomes are work status, self-management, anxiety, depression and healthcare expenditure. DISCUSSION Within the TRADITION project, we propose to shift the focus from a unidimensional outcome measure towards a composite measure as primary outcome measure to evaluate the efficacy of currently used subthreshold SCS paradigms. The lack of methodologically rigorous trials exploring the clinical efficacy and socio-economic consequences of subthreshold SCS paradigms is pressing, especially in light of the growing burden of PSPS-T2 on the society. TRIAL REGISTRATION ClinicalTrials.gov NCT05169047. Registered on December 23, 2021.
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Affiliation(s)
- Lisa Goudman
- STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium. .,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Physiotherapy, Pain in Motion Research Group (PAIN), Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Research Foundation Flanders (FWO), Egmontstraat 5, 1000, Brussels, Belgium.
| | - Koen Putman
- grid.8767.e0000 0001 2290 8069Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Interuniversity Centre for Health Economics Research (I-CHER), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Leen Van Doorslaer
- grid.8767.e0000 0001 2290 8069STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Maxime Billot
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Manuel Roulaud
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Philippe Rigoard
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France ,grid.411162.10000 0000 9336 4276Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France ,grid.434217.70000 0001 2178 9782Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360 Chasseneuil-du-Poitou, France
| | | | - Maarten Moens
- grid.8767.e0000 0001 2290 8069STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.411326.30000 0004 0626 3362Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Department of Physiotherapy, Pain in Motion Research Group (PAIN), Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.411326.30000 0004 0626 3362Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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16
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Patel NP, Wu C, Lad SP, Jameson J, Kosek P, Sayed D, Waldorff EI, Shum LC, Province-Azalde R, Kapural L. Cost-effectiveness of 10-kHz spinal cord stimulation therapy compared with conventional medical management over the first 12 months of therapy for patients with nonsurgical back pain: randomized controlled trial. J Neurosurg Spine 2023; 38:249-257. [PMID: 36272125 DOI: 10.3171/2022.9.spine22416] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This analysis evaluated if spinal cord stimulation (SCS) at 10 kHz plus conventional medical management (CMM) is cost-effective compared with CMM alone for the treatment of nonsurgical refractory back pain (NSRBP). METHODS NSRBP subjects were randomized 1:1 into the 10-kHz SCS (n = 83) or CMM (n = 76) group. Outcomes assessed at 6 months included EQ-5D 5-level (EQ-5D-5L), medication usage, and healthcare utilization (HCU). There was an optional crossover at 6 months and follow-up to 12 months. The incremental cost-effectiveness ratio (ICER) was calculated with cost including all HCU and medications except for the initial device and implant procedure, and cost-effectiveness was analyzed based on a willingness-to-pay threshold of < $50,000 per quality-adjusted life-year. RESULTS Treatment with 10-kHz SCS resulted in a significant improvement in quality of life (QOL) over CMM (EQ-5D-5L index score change of 0.201 vs -0.042, p < 0.001) at a lower cost, based on reduced frequency of HCU resulting in an ICER of -$4964 at 12 months. The ICER was -$8620 comparing the 6 months on CMM with postcrossover on 10-kHz SCS. CONCLUSIONS Treatment with 10-kHz SCS provides higher QOL at a lower average cost per patient compared with CMM. Assuming an average reimbursement for device and procedure, 10-kHz SCS therapy is predicted to be cost-effective for the treatment of NSRBP compared with CMM within 2.1 years.
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Affiliation(s)
- Naresh P Patel
- 1Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona
| | - Chengyuan Wu
- Departments of2Neurosurgery and
- 10Radiology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Shivanand P Lad
- 3Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | | | - Peter Kosek
- 5Oregon Neurosurgery Specialists, Springfield, Oregon
| | - Dawood Sayed
- 6Department of Anesthesiology, University of Kansas Hospital, Kansas City, Kansas
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17
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Muacevic A, Adler JR, Plaza-Lloret M, Dua A, Sun Z. Spinal Cord Stimulation for the Treatment of Refractory Pain From Tarlov Cysts: A Case Report. Cureus 2023; 15:e33928. [PMID: 36819355 PMCID: PMC9937083 DOI: 10.7759/cureus.33928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 01/19/2023] Open
Abstract
Tarlov cysts are extradural meningeal cysts with a collection of cerebrospinal fluid that most often affects sacral nerve roots, causing chronic low back pain and radiculopathy. Still, there is no consensus regarding the best treatment for symptomatic cysts. We describe a patient who developed worsening lower back pain and radiculopathy after interventional drainage and surgical management. Medication and various procedures failed to relieve the pain. Subsequently, the patient received significant pain relief from spinal cord stimulation (SCS). This case provides evidence that SCS could be used to manage refractory pain from Tarlov cysts that have failed to respond to other treatment modalities.
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18
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Duarte RV, Nevitt S, Houten R, Brookes M, Bell J, Earle J, Taylor RS, Eldabe S. Spinal Cord Stimulation for Neuropathic Pain in England From 2010 to 2020: A Hospital Episode Statistics Analysis. Neuromodulation 2023; 26:109-114. [PMID: 35396189 DOI: 10.1016/j.neurom.2022.02.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/24/2022] [Accepted: 02/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) is a recognized intervention for the management of chronic neuropathic pain. The United Kingdom National Institute of Health and Care Excellence has recommended SCS as a management option for chronic neuropathic pain since 2008. The aim of this study is to undertake an assessment of SCS uptake across the National Health Service in England up to 2020. MATERIALS AND METHODS Hospital Episode Statistics were obtained for patients with neuropathic pain potentially eligible for SCS and patients receiving an SCS-related procedure. Data were retrieved nationally and per region from the years 2010-2011 to 2019-2020. RESULTS There were 50,288 adults in England attending secondary care with neuropathic pain in 2010-2011, increasing to 66,376 in 2019-2020. The number of patients with neuropathic pain with an SCS procedure increased on a year-to-year basis until 2018-2019. However, less than 1% of people with neuropathic pain received an SCS device with no evidence of an increase over time when considering the background increase in neuropathic pain prevalence. CONCLUSION Only a small proportion of patients in England with neuropathic pain potentially eligible for SCS receives this intervention. The recommendation for routine use of SCS for management of neuropathic pain has not resulted in an uptake of SCS over the last decade.
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Affiliation(s)
- Rui V Duarte
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK.
| | - Sarah Nevitt
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Rachel Houten
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Morag Brookes
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Jill Bell
- Patient and Public Involvement Representatives, Middlesbrough, UK
| | - Jenny Earle
- Patient and Public Involvement Representatives, Middlesbrough, UK
| | - Rod S Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK; MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
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Eldabe S, Nevitt S, Griffiths S, Gulve A, Thomson S, Baranidharan G, Houten R, Brookes M, Kansal A, Earle J, Bell J, Taylor RS, Duarte RV. Does a Screening Trial for Spinal Cord Stimulation in Patients With Chronic Pain of Neuropathic Origin Have Clinical Utility (TRIAL-STIM)? 36-Month Results From a Randomized Controlled Trial. Neurosurgery 2023; 92:75-82. [PMID: 36226961 PMCID: PMC10158909 DOI: 10.1227/neu.0000000000002165] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Screening trials before full implantation of a spinal cord stimulation device are recommended by clinical guidelines and regulators, although there is limited evidence for their use. The TRIAL-STIM study showed that a screening trial strategy does not provide superior patient pain outcome at 6-month follow-up compared with not doing a screening trial and that it was not cost-effective. OBJECTIVE To report the long-term follow-up results of the TRIAL-STIM study. METHODS The primary outcome of this pragmatic randomized controlled trial was pain intensity as measured on a numerical rating scale (NRS) and secondary outcomes were the proportion of patients achieving at least 50% and 30% pain relief at 6 months, health-related quality of life, and complication rates. RESULTS Thirty patients allocated to the "Trial Group" (TG) and 36 patients allocated to the "No Trial Group" (NTG) completed outcome assessment at 36-month follow-up. Although there was a reduction in NRS pain and improvements in utility scores from baseline to 36 months in both groups, there was no difference in the primary outcome of pain intensity NRS between TG and NTG (adjusted mean difference: -0.60, 95% CI: -1.83 to 0.63), EuroQol-5 Dimension utility values (adjusted mean difference: -0.02, 95% CI: -0.13 to 0.10), or proportion of pain responders (33% TG vs 31% NTG). No differences were observed between the groups for the likelihood of spinal cord stimulation device explant or reporting an adverse advent up to 36-month follow-up. CONCLUSION The long-term results show no patient outcome benefit in undertaking an SCS screening trial.
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Affiliation(s)
- Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Sarah Nevitt
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Sara Griffiths
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Simon Thomson
- Department of Pain Medicine and Neuromodulation, Mid and South Essex University Hospitals, Essex,UK
| | | | - Rachel Houten
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Morag Brookes
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Anu Kansal
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Jenny Earle
- Patient and Public Involvement Representatives, Middlesbrough, UK
| | - Jill Bell
- Patient and Public Involvement Representatives, Middlesbrough, UK
| | - Rod S. Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Rui V. Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
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20
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Goudman L, Duarte RV, De Smedt A, Copley S, Eldabe S, Moens M. Cross-Country Differences in Pain Medication Before and After Spinal Cord Stimulation: A Pooled Analysis of Individual Patient Data From Two Prospective Studies in the United Kingdom and Belgium. Neuromodulation 2023; 26:215-223. [PMID: 34427369 DOI: 10.1111/ner.13524] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/01/2021] [Accepted: 07/28/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) can reduce the need for opioids; however, the influence on the full spectrum of pain medication is less known. The aims of this study were to explore general prescription practices for patients scheduled for SCS, potential differences in prescriptions between Belgium and United Kingdom, and the influence of SCS on pain medication. MATERIALS AND METHODS Individual patient data from the TRIAL-STIM study in the United Kingdom and DISCOVER in Belgium were pooled. Medication use was collected before SCS and three months after SCS from 180 chronic pain patients. The Medication Quantification Scale III (MQS) was used to calculate a total score for medication use, as well as subscores for several classes. Differences in prescription practices between United Kingdom and Belgium were evaluated with two-sided Wilcoxon tests. To evaluate differences in medication use after three months of SCS between United Kingdom and Belgium, Tweedie-generalized linear models were calculated. RESULTS There was a statistically significant difference (-6.40 [95% CI from -3.40 to -9.10]) between the median total MQS score in United Kingdom and Belgium before SCS. Additionally, a significant difference was found for nonsteroidal anti-inflammatory drugs (NSAIDs) (-3.40 [95% CI -3.40 to -6.80]), neuropathic agents (-2.30 [95% CI -0.40 to -3.80]), and benzodiazepines (1.83e-05 [95% CI 2.64-05 to 7.45-05]) between United Kingdom and Belgium, before SCS. Tweedie-generalized models revealed a statistically significant interaction between country and time for MQS, neuropathic agents, and opioids. CONCLUSIONS Our combined analysis revealed differences in prescription practice in patients scheduled for SCS implantation between Belgium and United Kingdom. NSAIDs and neuropathic mood agents are more frequently used in the United Kingdom, presumably due to easier access to repeat prescriptions and over the counter medications. After three months of SCS, a decrease in medication use is observed in both countries, with higher reductions in Belgium, presumably due to strict regulations concerning reimbursement criteria.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium; Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rui V Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Ann De Smedt
- Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium; Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Sue Copley
- Pain Clinic, The James Cook University Hospital, Middlesbrough, UK
| | - Sam Eldabe
- Pain Clinic, The James Cook University Hospital, Middlesbrough, UK
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium; Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium.
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Moens M, Goudman L, Van de Velde D, Godderis L, Putman K, Callens J, Lavreysen O, Ceulemans D, Leysen L, De Smedt A. Personalised rehabilitation to improve return to work in patients with persistent spinal pain syndrome type II after spinal cord stimulation implantation: a study protocol for a 12-month randomised controlled trial-the OPERA study. Trials 2022; 23:974. [PMID: 36471349 PMCID: PMC9721015 DOI: 10.1186/s13063-022-06895-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND For patients with therapy-refractory persistent spinal pain syndrome type II (PSPS-T2), spinal cord stimulation (SCS) may serve as an effective minimally invasive treatment. Despite the evidence that SCS can improve return to work (RTW), only 9.5 to 14% of patients implanted with SCS are effectively capable of returning to work. Thus, it seems that current post-operative interventions are not effective for achieving RTW after SCS implantation in clinical practice. The current objective is to examine whether a personalised biopsychosocial rehabilitation programme specifically targeting RTW alters the work ability in PSPS-T2 patients after SCS implantation compared to usual care. METHODS A two-arm, parallel-group multicentre randomised controlled trial will be conducted including 112 patients who will be randomised (1:1) to either (a) a personalised biopsychosocial RTW rehabilitation programme of 14 weeks or (b) a usual care arm, both with a follow-up period until 12 months after the intervention. The primary outcome is work ability. The secondary outcomes are work status and participation, pain intensity, health-related quality of life, physical activity and functional disability, functional capacities, sleep quality, kinesiophobia, self-management, anxiety, depression and healthcare expenditure. DISCUSSION Within the OPERA project, we propose a multidisciplinary personalised biopsychosocial rehabilitation programme specifically targeting RTW for patients implanted with SCS, to tackle the high socio-economic burden of patients that are not re-entering the labour market. The awareness is growing that the burden of PSPS-T2 on our society is expected to increase over time due to the annual increase of spinal surgeries. However, innovative and methodologically rigorous trials exploring the potential to decrease the socio-economic burden when patients initiate a trajectory with SCS are essentially lacking. TRIAL REGISTRATION ClinicalTrials.gov NCT05269212. Registered on 7 March 2022.
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Affiliation(s)
- Maarten Moens
- grid.8767.e0000 0001 2290 8069STIMULUS research group, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.411326.30000 0004 0626 3362Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Jette, 1090 Belgium ,grid.411326.30000 0004 0626 3362Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Jette, 1090 Belgium ,grid.8767.e0000 0001 2290 8069Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.8767.e0000 0001 2290 8069Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium
| | - Lisa Goudman
- grid.8767.e0000 0001 2290 8069STIMULUS research group, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.411326.30000 0004 0626 3362Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Jette, 1090 Belgium ,grid.8767.e0000 0001 2290 8069Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.8767.e0000 0001 2290 8069Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.434261.60000 0000 8597 7208Research Foundation Flanders (FWO), Egmontstraat 5, Brussels, 1000 Belgium
| | - Dominique Van de Velde
- grid.5342.00000 0001 2069 7798Faculty of Medicine and Healthcare Sciences, Department of Rehabilitation Sciences, Occupational Therapy Program, Ghent University, Ghent, 9000 Belgium
| | - Lode Godderis
- grid.5596.f0000 0001 0668 7884Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, 3000 Belgium ,IDEWE, External Service for Prevention and Protection at Work, Heverlee, 3001 Belgium
| | - Koen Putman
- grid.8767.e0000 0001 2290 8069Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium
| | - Jonas Callens
- grid.8767.e0000 0001 2290 8069STIMULUS research group, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.8767.e0000 0001 2290 8069Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium
| | - Olivia Lavreysen
- grid.5596.f0000 0001 0668 7884Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, 3000 Belgium
| | - Dries Ceulemans
- grid.5342.00000 0001 2069 7798Faculty of Medicine and Healthcare Sciences, Department of Rehabilitation Sciences, Occupational Therapy Program, Ghent University, Ghent, 9000 Belgium
| | - Laurence Leysen
- grid.8767.e0000 0001 2290 8069STIMULUS research group, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.8767.e0000 0001 2290 8069Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium
| | | | - Ann De Smedt
- grid.8767.e0000 0001 2290 8069STIMULUS research group, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.8767.e0000 0001 2290 8069Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090 Belgium ,grid.411326.30000 0004 0626 3362Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Jette, 1090 Belgium
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Rowald A, Amft O. A computational roadmap to electronic drugs. Front Neurorobot 2022; 16:983072. [PMID: 36386388 PMCID: PMC9659757 DOI: 10.3389/fnbot.2022.983072] [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: 06/30/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022] Open
Abstract
A growing number of complex neurostimulation strategies promise symptom relief and functional recovery for several neurological, psychiatric, and even multi-organ disorders. Although pharmacological interventions are currently the mainstay of treatment, neurostimulation offers a potentially effective and safe alternative, capable of providing rapid adjustment to short-term variation and long-term decline of physiological functions. However, rapid advances made by clinical studies have often preceded the fundamental understanding of mechanisms underlying the interactions between stimulation and the nervous system. In turn, therapy design and verification are largely driven by clinical-empirical evidence. Even with titanic efforts and budgets, it is infeasible to comprehensively explore the multi-dimensional optimization space of neurostimulation through empirical research alone, especially since anatomical structures and thus outcomes vary dramatically between patients. Instead, we believe that the future of neurostimulation strongly depends on personalizable computational tools, i.e. Digital Neuro Twins (DNTs) to efficiently identify effective and safe stimulation parameters. DNTs have the potential to accelerate scientific discovery and hypothesis-driven engineering, and aid as a critical regulatory and clinical decision support tool. We outline here how DNTs will pave the way toward effective, cost-, time-, and risk-limited electronic drugs with a broad application bandwidth.
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Affiliation(s)
- Andreas Rowald
- ProModell Group, Chair of Digital Health, Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- *Correspondence: Andreas Rowald
| | - Oliver Amft
- ProModell Group, Chair of Digital Health, Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Intelligent Embedded Systems Lab, Institute of Computer Science, University of Freiburg, Freiburg im Breisgau, Germany
- Hahn-Schickard, Freiburg, Germany
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Duarte RV, Nevitt S, Copley S, Maden M, de Vos CC, Taylor RS, Eldabe S. Systematic Review and Network Meta-analysis of Neurostimulation for Painful Diabetic Neuropathy. Diabetes Care 2022; 45:2466-2475. [PMID: 36150057 DOI: 10.2337/dc22-0932] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/15/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Different waveforms of spinal cord stimulation (SCS) have now been evaluated for the management of painful diabetic neuropathy (PDN). However, no direct or indirect comparison between SCS waveforms has been performed to date. PURPOSE To conduct a systematic review and network meta-analysis to evaluate the effectiveness of SCS for PDN. DATA SOURCES MEDLINE, CENTRAL, Embase, and WikiStim were searched from inception until December 2021. STUDY SELECTION Randomized controlled trials (RCTs) of SCS for PDN were included. DATA EXTRACTION Pain intensity, proportion of patients achieving at least a 50% reduction in pain intensity, and health-related quality of life (HRQoL) data were extracted. DATA SYNTHESIS Significant reductions in pain intensity were observed for low-frequency SCS (LF-SCS) (mean difference [MD] -3.13 [95% CI -4.19 to -2.08], moderate certainty) and high-frequency SCS (HF-SCS) (MD -5.20 [95% CI -5.77 to -4.63], moderate certainty) compared with conventional medical management (CMM) alone. There was a significantly greater reduction in pain intensity on HF-SCS compared with LF-SCS (MD -2.07 [95% CI -3.26 to -0.87], moderate certainty). Significant differences were observed for LF-SCS and HF-SCS compared with CMM for the outcomes proportion of patients with at least 50% pain reduction and HRQoL (very low to moderate certainty). No significant differences were observed between LF-SCS and HF-SCS (very low to moderate certainty). LIMITATIONS Limited number of RCTs and no head-to-head RCTs conducted. CONCLUSIONS Our findings confirm the pain relief and HRQoL benefits of the addition of SCS to CMM for patients with PDN. However, in the absence of head-to-head RCT evidence, the relative benefits of HF-SCS compared with LF-SCS for patients with PDN remain uncertain.
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Affiliation(s)
- Rui V Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, U.K
| | - Sarah Nevitt
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, U.K
| | - Sue Copley
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, U.K
| | - Michelle Maden
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, U.K
| | - Cecile C de Vos
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Centre for Pain Medicine, Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit and Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, U.K
- College of Medicine and Health, University of Exeter, Exeter, U.K
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, U.K
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Igarashi A, Yuasa A, Yonemoto N, Kamei K, LoPresti M, Murofushi T, Ikeda S. A Systematic Literature Review of Economic Evaluations and Cost Studies of the Treatment of Psoriasis, Atopic Dermatitis, and Chronic Urticaria. Dermatol Ther (Heidelb) 2022; 12:1729-1751. [PMID: 35909186 PMCID: PMC9357586 DOI: 10.1007/s13555-022-00774-2] [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] [Received: 05/06/2022] [Accepted: 07/07/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Psoriasis (PSO), atopic dermatitis (AD), and chronic urticaria (CU) are common manifestations of immunological skin and subcutaneous conditions and have been shown to have a substantial impact on the quality of life of patients. The cost of treating those conditions can also be high, as the use of biologic treatments has become more common for moderate to severe patients. In this review, we examine characteristics of economic evaluations and cost studies conducted for the three conditions. Methods A literature search was conducted using PubMed, Embase, and the Cochrane Library from January 1, 2016 to October 26, 2020 to identify economic evaluations where the cost of one or more drug treatment was evaluated and cost studies covering any intervention type. Each database was searched using keyword and MeSH terms related to treatment costs (e.g., health care cost, drug cost, etc.) and each condition (e.g., PSO, AD, eczema, CU, etc.). Results A total of 123 studies were reviewed, including 104 studies (85%) of PSO (including psoriasis, plaque psoriasis, psoriatic arthritis, and psoriasis vulgaris), 14 studies (11%) of AD, and 5 studies (4%) of CU. Seventy-two studies (59%) reviewed reported the inclusion of biologic treatments, 10 studies (8%) did not include biologic treatments, and 41 studies (33%) did not report whether or not a biologic treatment was included. While nearly all studies (98%) included direct costs, only 22 studies (18%) included indirect costs. Conclusions Economic evaluations for AD and CU may be needed in order to better understand the value of new treatments. Moreover, a clearer delineation for biologic treatments and indirect costs (i.e., productivity losses and gains) may be required. Supplementary Information The online version contains supplementary material available at 10.1007/s13555-022-00774-2.
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Affiliation(s)
| | - Akira Yuasa
- Pfizer Japan Inc., Shinjuku Bunka Quint Building, 3-22-7, Yoyogi, Shibuya-ku, Tokyo, 151-8589, Japan.
| | - Naohiro Yonemoto
- Pfizer Japan Inc., Shinjuku Bunka Quint Building, 3-22-7, Yoyogi, Shibuya-ku, Tokyo, 151-8589, Japan
| | - Kazumasa Kamei
- Pfizer Japan Inc., Shinjuku Bunka Quint Building, 3-22-7, Yoyogi, Shibuya-ku, Tokyo, 151-8589, Japan
| | | | | | - Shunya Ikeda
- Department of Public Health, School of Medicine, International University of Health and Welfare, Narita, Japan
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Mullins GS, Burns JJ, Schneider AP, El Helou A. Spinal Cord Stimulation as an Alternative to Opioid for Axial Neck and Back Pain: A Case Series. FRONTIERS IN PAIN RESEARCH 2022; 3:847504. [PMID: 35295798 PMCID: PMC8915574 DOI: 10.3389/fpain.2022.847504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionSpinal cord stimulation is emerging as a minimally invasive technique for treatment of persistent spinal pain syndrome (PSPS).MethodsWe describe a case series of 25 individuals with PSPS who underwent implantation of a spinal cord stimulator device between 2017 and 2021.ResultsThere was a significant reduction in mean visual analog scale pain scores in the immediate postoperative phase, (8.61 vs. 2.3, p < 0.001). There were twelve patients who consumed pre-operative opioid, and 75% showed reduction of use with a significantly lower average daily dose (66.8 vs. 26.9 meq/D, p < 0.05). There was a significant reduction in the Oswestry Disability Index during postoperative follow-up visits (p < 0.001). There were no major perioperative or long-term complications from the procedure in follow-up.ConclusionThe analysis of this cohort suggests successful long-term treatment of a diverse set of patients with PSPS who underwent spinal cord stimulation (SCS) and had meaningful improvement in quality of life and reduction in opioid consumption.
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Affiliation(s)
- Graeme Sampson Mullins
- Faculty of Medicine, Dalhousie University, Halifax Regional Municipality, Halifax, NS, Canada
- Department of Family Medicine, The Moncton Hospital, Moncton, NB, Canada
| | | | - Andre Perillier Schneider
- Université de Sherbrooke, Sherbrooke, QC, Canada
- Department of Anesthesia and Pain Medicine, Vitalité Health Network, Bathurst Hospital, Bathurst, NB, Canada
| | - Antonios El Helou
- Faculty of Medicine, Dalhousie University, Halifax Regional Municipality, Halifax, NS, Canada
- Université de Sherbrooke, Sherbrooke, QC, Canada
- Department of Neurosurgery, The Moncton Hospital, Moncton, NB, Canada
- *Correspondence: Antonios El Helou
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O'Connell NE, Ferraro MC, Gibson W, Rice AS, Vase L, Coyle D, Eccleston C. Implanted spinal neuromodulation interventions for chronic pain in adults. Cochrane Database Syst Rev 2021; 12:CD013756. [PMID: 34854473 PMCID: PMC8638262 DOI: 10.1002/14651858.cd013756.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Implanted spinal neuromodulation (SNMD) techniques are used in the treatment of refractory chronic pain. They involve the implantation of electrodes around the spinal cord (spinal cord stimulation (SCS)) or dorsal root ganglion (dorsal root ganglion stimulation (DRGS)), and a pulse generator unit under the skin. Electrical stimulation is then used with the aim of reducing pain intensity. OBJECTIVES To evaluate the efficacy, effectiveness, adverse events, and cost-effectiveness of implanted spinal neuromodulation interventions for people with chronic pain. SEARCH METHODS We searched CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science (ISI), Health Technology Assessments, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry from inception to September 2021 without language restrictions, searched the reference lists of included studies and contacted experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing SNMD interventions with placebo (sham) stimulation, no treatment or usual care; or comparing SNMD interventions + another treatment versus that treatment alone. We included participants ≥ 18 years old with non-cancer and non-ischaemic pain of longer than three months duration. Primary outcomes were pain intensity and adverse events. Secondary outcomes were disability, analgesic medication use, health-related quality of life (HRQoL) and health economic outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently screened database searches to determine inclusion, extracted data and evaluated risk of bias for prespecified results using the Risk of Bias 2.0 tool. Outcomes were evaluated at short- (≤ one month), medium- four to eight months) and long-term (≥12 months). Where possible we conducted meta-analyses. We used the GRADE system to assess the certainty of evidence. MAIN RESULTS We included 15 unique published studies that randomised 908 participants, and 20 unique ongoing studies. All studies evaluated SCS. We found no eligible published studies of DRGS and no studies comparing SCS with no treatment or usual care. We rated all results evaluated as being at high risk of bias overall. For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as low or very low, downgraded due to limitations of studies, imprecision and in some cases, inconsistency. Active stimulation versus placebo SCS versus placebo (sham) Results were only available at short-term follow-up for this comparison. Pain intensity Six studies (N = 164) demonstrated a small effect in favour of SCS at short-term follow-up (0 to 100 scale, higher scores = worse pain, mean difference (MD) -8.73, 95% confidence interval (CI) -15.67 to -1.78, very low certainty). The point estimate falls below our predetermined threshold for a clinically important effect (≥10 points). No studies reported the proportion of participants experiencing 30% or 50% pain relief for this comparison. Adverse events (AEs) The quality and inconsistency of adverse event reporting in these studies precluded formal analysis. Active stimulation + other intervention versus other intervention alone SCS + other intervention versus other intervention alone (open-label studies) Pain intensity Mean difference Three studies (N = 303) demonstrated a potentially clinically important mean difference in favour of SCS of -37.41 at short term (95% CI -46.39 to -28.42, very low certainty), and medium-term follow-up (5 studies, 635 participants, MD -31.22 95% CI -47.34 to -15.10 low-certainty), and no clear evidence for an effect of SCS at long-term follow-up (1 study, 44 participants, MD -7 (95% CI -24.76 to 10.76, very low-certainty). Proportion of participants reporting ≥50% pain relief We found an effect in favour of SCS at short-term (2 studies, N = 249, RR 15.90, 95% CI 6.70 to 37.74, I2 0% ; risk difference (RD) 0.65 (95% CI 0.57 to 0.74, very low certainty), medium term (5 studies, N = 597, RR 7.08, 95 %CI 3.40 to 14.71, I2 = 43%; RD 0.43, 95% CI 0.14 to 0.73, low-certainty evidence), and long term (1 study, N = 87, RR 15.15, 95% CI 2.11 to 108.91 ; RD 0.35, 95% CI 0.2 to 0.49, very low certainty) follow-up. Adverse events (AEs) Device related No studies specifically reported device-related adverse events at short-term follow-up. At medium-term follow-up, the incidence of lead failure/displacement (3 studies N = 330) ranged from 0.9 to 14% (RD 0.04, 95% CI -0.04 to 0.11, I2 64%, very low certainty). The incidence of infection (4 studies, N = 548) ranged from 3 to 7% (RD 0.04, 95%CI 0.01, 0.07, I2 0%, very low certainty). The incidence of reoperation/reimplantation (4 studies, N =5 48) ranged from 2% to 31% (RD 0.11, 95% CI 0.02 to 0.21, I2 86%, very low certainty). One study (N = 44) reported a 55% incidence of lead failure/displacement (RD 0.55, 95% CI 0.35, 0 to 75, very low certainty), and a 94% incidence of reoperation/reimplantation (RD 0.94, 95% CI 0.80 to 1.07, very low certainty) at five-year follow-up. No studies provided data on infection rates at long-term follow-up. We found reports of some serious adverse events as a result of the intervention. These included autonomic neuropathy, prolonged hospitalisation, prolonged monoparesis, pulmonary oedema, wound infection, device extrusion and one death resulting from subdural haematoma. Other No studies reported the incidence of other adverse events at short-term follow-up. We found no clear evidence of a difference in otherAEs at medium-term (2 studies, N = 278, RD -0.05, 95% CI -0.16 to 0.06, I2 0%) or long term (1 study, N = 100, RD -0.17, 95% CI -0.37 to 0.02) follow-up. Very limited evidence suggested that SCS increases healthcare costs. It was not clear whether SCS was cost-effective. AUTHORS' CONCLUSIONS We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to conventional medical management or physical therapy. SCS is associated with complications including infection, electrode lead failure/migration and a need for reoperation/re-implantation. The level of certainty regarding the size of those risks is very low. SNMD may lead to serious adverse events, including death. We found no evidence to support or refute the use of DRGS for chronic pain.
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Affiliation(s)
- Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Andrew Sc Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Doug Coyle
- Epidemiology and Community Medicine, Ottawa Health Research Institute, Ottawa, Canada
- Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences, Brunel University London, Uxbridge, UK
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Rojo E, Pérez Hernández C, Sánchez Martínez N, Margarit AC, Blanco Arias T, Muñoz Martínez M, Crespo C, Ochoa Mazarro D. Real-World Cost-Effectiveness Analysis of Spinal Cord Stimulation vs Conventional Therapy in the Management of Failed Back Surgery Syndrome. J Pain Res 2021; 14:3025-3032. [PMID: 34611433 PMCID: PMC8485354 DOI: 10.2147/jpr.s326092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/05/2021] [Indexed: 01/02/2023] Open
Abstract
Purpose Failed back surgery syndrome (FBSS) causes disability and lowers health-related quality of life (HRQoL) for patients. Many patients become refractory to conventional medical management (CMM) and spinal cord stimulation (SCS) is advised. However, comparative cost-effectiveness research of both clinical approaches still lacks further evidence. This probabilistic cost-effectiveness analysis compares CMM versus SCS plus CMM in FBSS patients for a 5-year period in Spain. Patients and Methods Patient-level data was obtained from a 2-year real-world study (SEFUDOCE) of adults diagnosed with FBSS who were treated with CMM or SCS. Incremental cost-effectiveness ratios (ICER) were estimated in terms of direct clinical cost and quality-adjusted life years (QALYs). Costs (€ for 2019) were estimated from the Spanish National Health Service (NHS) perspective. We applied a yearly discount rate of 3% to both costs and outcomes and performed a probabilistic sensitivity analysis using bootstrapping. Results After 2 years, the health-related quality of life measured by the EQ-5D displayed greater improvements for SCS patients (00.39) than for improved CMM patients (0.01). The proportion of SCS patients using medication fell substantially, particularly for opioids (-49%). In the statistical model projection, compared with the CMM group at year 5, the SCS group showed an incremental cost of € 15,406 for an incremental gain of 0.56 0.56 QALYs, for an ICER of € 27,330, below the €30,000 willingness-to-pay threshold for Spain. SCS had a 79% of probability of being cost-effective. Conclusion SCS is a cost-effective treatment for FBSS compared to CMM alone based on real-world evidence.
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Affiliation(s)
- Elena Rojo
- Pain Unit, La Princesa University Hospital, Madrid, Spain
| | | | | | - A César Margarit
- Pain Unit, General University Hospital of Alicante, Alicante, Comunitat Valenciana, Spain
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Eriksen LE, Terkelsen AJ, Blichfeldt-Eckhardt MR, Sørensen JCH, Meier K. Spinal cord stimulation in severe cases of complex regional pain syndrome: A retrospective cohort study with long-term follow-up. Eur J Pain 2021; 25:2212-2225. [PMID: 34196075 DOI: 10.1002/ejp.1834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a debilitating pain condition often resistant to standard treatment modalities. In these cases, spinal cord stimulation (SCS) can be an option, but the effect on CRPS remains disputed. We aimed to assess the long-term effect of SCS on CRPS. METHODS We retrospectively analysed 51 CRPS patients implanted with an SCS system at the University Hospitals in Aarhus or Odense, Denmark, with a median follow-up time of 4.4 years. Primary outcomes were pain intensity on a numeric rating scale (NRS) and the Patients' Global Impression of Change (PGIC). Secondary outcomes were patient satisfaction, work status, consumption of pain medication, the Major Depression Inventory (MDI), Pain Catastrophizing Scale (PCS) and quality of life (QoL) measured using the Short-Form Health Survey (SF-36). For each outcome measure, baseline data were compared to the latest collected data point. RESULTS A significant pain relief was found with a mean reduction in NRS score of 2.4 (95% CI: 1.7-3.0, p < 0.0001). 68.8% reported 'much improved' or 'very much improved' on the PGIC scale. 87.5% would choose SCS again for the same outcome. A significant beneficial impact was found on MDI score, PCS, SF-36 summary scores and consumption of tricyclic antidepressants, antiepileptic drugs and opioids. No statistical effect was found on work status. CONCLUSION Pain intensity, depression, pain catastrophizing, pain medication use and QoL were significantly improved after SCS implantation, with high patient satisfaction rates in CRPS patients. This study supports the continued use of SCS in the treatment of severe CRPS. SIGNIFICANCE This study presents detailed data from a large, well-characterized cohort of Danish CRPS patients treated with SCS, analyzing several outcome measures. The results serve to document SCS as an effective treatment for severe CRPS and expands the cumulative level of evidence in favor of its use. Additionally, analysis of preoperative patient characteristics suggests that SCS treatment should not be withheld in patients with a high degree of psychological distress or high consumption of analgesics.
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Affiliation(s)
- Linda Elise Eriksen
- Department of Neurology and Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Astrid Juhl Terkelsen
- Department of Neurology and Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Rune Blichfeldt-Eckhardt
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Anesthesiology and Critical Care, Odense University Hospital, Odense, Denmark
| | | | - Kaare Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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Schatman ME, Petersen EA, Sayed D. No Zero Sum in Opioids for Chronic Pain: Neurostimulation and the Goal of Opioid Sparing, Not Opioid Eradication. J Pain Res 2021; 14:1809-1812. [PMID: 34163236 PMCID: PMC8215906 DOI: 10.2147/jpr.s323661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/11/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Michael E Schatman
- Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA.,Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.,School of Social Work, North Carolina State University, Raleigh, NC, USA
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
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30
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Han Y, Lu Y, Wang D, Ran M, Ren Q, Xie D, Aziz TZ, Li L, Wang JJ. The Use of Remote Programming for Spinal Cord Stimulation for Patients With Chronic Pain During the COVID-19 Outbreak in China. Neuromodulation 2021; 24:441-447. [PMID: 33751731 PMCID: PMC8250774 DOI: 10.1111/ner.13382] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/14/2021] [Accepted: 02/09/2021] [Indexed: 12/24/2022]
Abstract
ObjectiveS Due to the impact of COVID-19 epidemic, face-to-face follow-up treatments for patients with chronic pain and implanted spinal cord stimulation (SCS) devices are forced to be delayed or stopped. This has led to more follow ups being done remotely. Meanwhile, with the development of 4G/5G networks, smartphones, and novel devices, remote programming has become possible. Here, we investigated the demand and utility of remote follow-ups including remote programming for SCS for patients with chronic pain. Materials and Methods A questionnaire including questions on demographic characteristics, pain history, postimplantation life quality, standard follow-up experience, remote follow-up, and remote programming experience was sent to patients diagnosed as chronic intractable pain and treated with SCS during January 2019 to January 2020. Results A total of 64 participants completed the questionnaire. About 70% of participants expressed demands for remote follow-ups due to the inconvenience, high costs, and time consumption of traditional follow-up visits. Nearly 97% of participants have attempted remote follow-ups, and about 81% of participants have further tried remote programming. Approximately, 96% of them recognized the benefits. Conclusions The remote programming was in high demand among participants. Most of the participants have tried remote follow-ups or even remote programming. The remote programming appeared to be more efficient, economic and were widely recognized among participants.
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Affiliation(s)
- Yan Han
- School of Medicine, Tsinghua University, Beijing, China
| | - 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
| | - Dengyu Wang
- School of Medicine, Tsinghua University, Beijing, China
| | - Mingshan Ran
- Department of Rehabilitation Medicine, Peking University Shougang Hospital, Beijing, China
| | - Qidong Ren
- School of Medicine, Tsinghua University, Beijing, China
| | - Duo Xie
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China
| | - Tipu Z Aziz
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace Engineering, Tsinghua University, Beijing, China.,Precision Medicine & Healthcare Research Center, Tsinghua-Berkeley Shenzhen Institute, Tsinghua University, Shenzhen, China.,IDG/McGovern Institute for Brain Research at Tsinghua University, Beijing, China.,Institute of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - James Jin Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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31
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A Retrospective Review of Lead Migration Rate in Patients Permanently Implanted with Percutaneous Leads and a 10 kHz SCS Device. Pain Res Manag 2021; 2021:6639801. [PMID: 33613793 PMCID: PMC7878096 DOI: 10.1155/2021/6639801] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/12/2020] [Accepted: 01/23/2021] [Indexed: 12/13/2022]
Abstract
Background Spinal cord stimulation (SCS) has been used over decades for pain management, but migration of percutaneous leads has been the most common complication. Better surgical techniques and newer SCS technologies likely reduced the incidence of lead migration requiring surgical revision, although data are sparse. This study aimed to retrospectively evaluate the incidence of clinically significant percutaneous lead migration in patients permanently implanted with a 10 kHz SCS system. Methods Consecutive patients with chronic trunk and/or limb pain, permanently implanted between January 2016 and June 2019, were included in the analysis. Data were collected from the hospital's electronic medical records and the manufacturer's database. Clinically significant lead migration, defined as diminished pain relief followed by surgery to correct lead location, was assessed at the 6-month follow-up. Results At the 6-month follow-up, there were no cases of clinically significant lead migration, average pain relief was 65.2%, 82% of patients had response (≥50% pain relief), improvement of function was noted in 72% of patients, and decrease of medication was observed in 42% of patients. Therapy efficacy was sustained in patients with >12 months follow-up; the average pain relief was 58.5%, and the response rate was 82%. Conclusions The surgical techniques in use today are designed to minimise the risk of percutaneous lead migration and may have reduced its incidence. In addition, new SCS systems may give greater opportunity to mitigate cases of minor lead movement using alternative stimulation programs.
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Predicting the Response of High Frequency Spinal Cord Stimulation in Patients with Failed Back Surgery Syndrome: A Retrospective Study with Machine Learning Techniques. J Clin Med 2020; 9:jcm9124131. [PMID: 33371497 PMCID: PMC7767526 DOI: 10.3390/jcm9124131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/11/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
Despite the proven clinical value of spinal cord stimulation (SCS) for patients with failed back surgery syndrome (FBSS), factors related to a successful SCS outcome are not yet clearly understood. This study aimed to predict responders for high frequency SCS at 10 kHz (HF-10). Data before implantation and the last available data was extracted for 119 FBSS patients treated with HF-10 SCS. Correlations, logistic regression, linear discriminant analysis, classification and regression trees, random forest, bagging, and boosting were applied. Based on feature selection, trial pain relief, predominant pain location, and the number of previous surgeries were relevant factors for predicting pain relief. To predict responders with 50% pain relief, 58.33% accuracy was obtained with boosting, random forest and bagging. For predicting responders with 30% pain relief, 70.83% accuracy was obtained using logistic regression, linear discriminant analysis, boosting, and classification trees. For predicting pain medication decrease, accuracies above 80% were obtained using logistic regression and linear discriminant analysis. Several machine learning techniques were able to predict responders to HF-10 SCS with an acceptable accuracy. However, none of the techniques revealed a high accuracy. The inconsistent results regarding predictive factors in literature, combined with acceptable accuracy of the currently obtained models, might suggest that routinely collected baseline parameters from clinical practice are not sufficient to consistently predict the SCS response with a high accuracy in the long-term.
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Duarte RV, Soliday N, Leitner A, Taylor RS. Health-Related Quality of Life Associated With Pain Health States in Spinal Cord Stimulation for Chronic Neuropathic Pain. Neuromodulation 2020; 24:142-149. [PMID: 32940398 DOI: 10.1111/ner.13267] [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] [Received: 07/21/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES A substantial proportion of patients have recently reported pain reduction levels of ≥80% following treatment with Evoked Compound Action Potential (ECAP) spinal cord stimulation (SCS). The additional health-related quality of life (HRQoL) utility gain that can be achieved in this patient group is unclear. The aim of this study is to quantify the HRQoL utility values seen in a remission health state (defined as ≥80% pain reduction) and contrast with more traditional health states of <50% and ≥50% pain relief. MATERIALS AND METHODS Pain intensity assessed using a 100 mm visual analogue scale (VAS) and EQ-5D-5L questionnaires were collected from 204 patients treated with ECAP SCS for chronic back and leg pain and followed up to 12 months. Utility values were derived using EQ-5D-5L responses crosswalked to EQ-5D-3L. Linear regression models adjusted for baseline utility values and patient demographics were used to compare differences in utility values across health states. RESULTS Patients in the remission health state (i.e., ≥80% pain reduction) consistently reported statistically significant greater utility values (+0.09 to +0.15, all p < 0.003) compared to patients reporting ≥50% pain relief at 3- and 12-month follow-up for overall, back, and leg VAS pain. The gain in utility values per percent unit of pain reduction was statistically significant at 3- and 12-month follow-up with a mean increase in HRQoL utility score between 0.003 and 0.005 observed for each percent of pain reduction. CONCLUSION Our analyses show that patients in a remission health state report statistically and clinically significant better HRQoL than patients experiencing lesser pain relief.
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Affiliation(s)
- Rui V Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | | | | | - Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, Glasgow, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
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