Spinal Cord Stimulation

Diabetic peripheral neuropathy and neuromodulation techniques: a systematic review of progress and prospects

Neuromodulation for diabetic peripheral neuropathy represents a significant area of interest in the management of chronic pain associated with this condition. Diabetic peripheral neuropathy, a common complication of diabetes, is characterized by nerve damage due to high blood sugar levels that lead to symptoms, such as pain, tingling, and numbness, primarily in the hands and feet. The aim of this systematic review was to evaluate the efficacy of neuromodulatory techniques as potential therapeutic interventions for patients with diabetic peripheral neuropathy, while also examining recent developments in this domain. The investigation encompassed an array of neuromodulation methods, including frequency rhythmic electrical modulated systems, dorsal root ganglion stimulation, and spinal cord stimulation. This systematic review suggests that neuromodulatory techniques may be useful in the treatment of diabetic peripheral neuropathy. Understanding the advantages of these treatments will enable physicians and other healthcare providers to offer additional options for patients with symptoms refractory to standard pharmacologic treatments. Through these efforts, we may improve quality of life and increase functional capacity in patients suffering from complications related to diabetic neuropathy.

Evaluating Spinal Cord Stimulation as a Therapeutic Strategy for Postmastectomy Pain Syndrome: A Retrospective Observational Study

BACKGROUND

Postmastectomy pain syndrome (PMPS) is a chronic condition that significantly impacts breast cancer survivors, marked by persistent neuropathic pain that is often unresponsive to conventional therapies. Spinal cord stimulation (SCS) has emerged as a promising intervention for managing this type of pain. This study aimed to assess the clinical efficacy of SCS in managing PMPS and identify patient-specific factors impacting treatment outcomes.

MATERIALS AND METHODS

This retrospective observational study analyzed 78 female patients who underwent SCS implantation between January and October 2023. The efficacy of SCS was assessed by evaluating changes in visual analog scale (VAS) pain scores from baseline to six months after implantation. The influence of factors such as age, body mass index (BMI), prior treatments, and psychologic health on treatment success was explored using binary logistic regression.

RESULTS

Six months after implantation, 61 patients (78.2%) reported significant pain relief, with a decrease in VAS scores by ≥4 points. Statistical analysis revealed several predictors of positive outcomes: younger age (hazard ratio [HR] = 0.882, 95% CI: 0.802-0.970, p = 0.009), lower BMI (HR = 0.659, 95% CI: 0.487-0.891, p = 0.007), and psychologic treatment (HR = 0.015, 95% CI: 0.001-0.377, p = 0.011). Conversely, prior radiotherapy was associated with less favorable outcomes (HR = 2.139, 95% CI: 1.219-5.808, p = 0.029). The receiver operating characteristic curve analysis confirmed the model's accuracy (area under the curve = 0.927).

CONCLUSIONS

SCS is an effective treatment for PMPS, with age, BMI, psychologic treatments, and prior radiotherapy being significant predictors of outcomes. Tailoring treatment plans to these factors can potentially enhance pain management for patients with PMPS.

An Algorithmic Overview of Advanced Pain Therapies: A Narrative Review

PURPOSE OF REVIEW

Quickly referenceable, streamlined, algorithmic approaches for advanced pain management are lacking for patients, trainees, non-pain specialists, and interventional specialists. This manuscript aims to address this gap by proposing a comprehensive, evidence-based algorithm for managing neuropathic, nociceptive, and cancer-associated pain. Such an algorithm is crucial for pain medicine education, offering a structured approach for patient care refractory to conservative management.

RECENT FINDINGS

A comprehensive literary review with PubMed and regulatory documents from the United States Food and Drug Administration were searched for a variety of interventions. Pain syndromes were categorized into nociceptive and neuropathic pain, and an algorithm was constructed. Serving as an educational tool for patients, trainees, and non-pain specialists, and as an accessible reference for pain specialists, this algorithm bridges knowledge gaps, promotes interdisciplinary collaboration, and streamlines the learning curve for new practitioners. The strength of this algorithm lies in integrating extensive clinical data, emphasizing the latest clinical evidence, and providing a structured decision-making pathway.

Weight Trends After Spinal Cord Stimulation Therapy for Chronic Pain

OBJECTIVES

Spinal cord stimulation (SCS) therapy is an effective treatment for chronic pain, particularly in conditions such as postlaminectomy syndrome and complex regional pain syndrome (CRPS). Rare case reports described significant weight loss in patients who underwent dorsal column SCS therapy for chronic pain. Recently, neuromodulation for obesity has become a novel field for research. We aimed to investigate weight trends among patients treated with SCS for chronic pain.

MATERIALS AND METHODS

We conducted a retrospective chart review in 342 patients treated with SCS or dorsal root ganglion stimulators at our institution between 2010 and 2023. Patients had their weight recorded before SCS implantation and at least once within 12 months after surgery. We also conducted interviews with 28 patients who experienced significant weight loss or had revision procedures owing to weight loss.

RESULTS

We found that 105 of 342 patients (30.7%) experienced weight loss of ≥5% within a year of implantation, and 32 of 105 (30.5%, 9.4% of all patients) experienced weight loss of ≥ 10%. A multivariate regression analysis revealed a modest increase in the likelihood of weight loss among patients with CRPS (odds ratio [OR] = 1.17, 95% CI [1.04, 1.30], p = 0.007) and in those who achieved pain relief after implantation (OR = 1.22, 95% CI [1.05,1.40], p = 0.008). Of the 28 patients with significant weight loss who were interviewed, 12 (43%) could not explain the reasons for their weight loss, whereas eight (29%) reported decreased appetite. Leads placed at higher thoracic levels were associated with increased rates of weight loss (37.2% at T6-T8 and 22.3% at T8-T10; p = 0.038).

CONCLUSIONS

Our findings suggest that SCS therapy may affect weight in patients with chronic pain. Further studies are needed to investigate the potential role of SCS in weight modulation.

Pathophysiology of Pain and Mechanisms of Neuromodulation: A Narrative Review (A Neuron Project)

Pain serves as a vital innate defense mechanism that can significantly impact an individual's quality of life. Understanding the physiological effects of pain well plays an important role in developing novel pain treatments. Nociceptor neurons play a key role in pain and inflammation. Interactions between nociceptors and the immune system occur both at the site of injury and within the central nervous system. Modulating chemical mediators and nociceptor activity offers promising new approaches to pain management. Essentially, the sensory nervous system is essential for modulating the body's protective response, making it critical to understand these interactions to discover new pain treatment strategies. New innovations in neuromodulation have led to alternatives to opioids individuals with chronic pain with consequent improvement in disease-based treatment and nerve targeting. New neural targets from cellular and structural perspectives have revolutionized the field of neuromodulation. This narrative review aims to elucidate the mechanisms of pain transmission and processing, examine the characteristics and properties of nociceptors, and explore how the immune system influences pain perception. It further provides an updated overview of the physiology of pain and neuromodulatory mechanisms essential for managing acute and chronic pain. We assess the current understanding of different pain types, focusing on key molecules involved in each type and their physiological effects. Additionally, we compare painful and painless neuropathies and discuss the neuroimmune interactions involved in pain manifestation.

Acupoint Stimulation for Pain Control in Enhanced Recovery After Surgery: Systematic Review and Meta-Analysis

Introduction: Postoperative pain control is a challenge in enhanced recovery after surgery (ERAS). The current study reviewed the efficacy and safety of incorporating acupoint stimulation for postoperative pain control in ERAS. Methods: Ten databases for relevant randomized controlled trials (RCTs) published in English or Mandarin Chinese were searched from 1997 to 2022. The quality of each article was appraised using the Cochrane Collaboration Risk of Bias Criteria and the modified Jadad Scale. The primary outcome was pain control, measured using the visual analog scale 24 h after surgery. Results: Eleven trials met the eligibility criteria and were included in the study. Acupoint stimulation was found more effective than control treatments in terms of pain intensity (standardized mean difference [SMD] -0.94; 95% confidence interval [CI] -1.35 to -0.53), analgesic drug consumption (SMD -1.87; 95% CI -2.98 to -0.75), postoperative nausea (PON; SMD 0.31; 95% CI 0.13 to 0.73), postoperative vomiting (POV; SMD 0.57; 95% CI 0.11 to 2.92), and PON and POV (PONV; SMD 0.29; 95% CI 0.16 to 0.53). The Zusanli (ST36) and Neiguan (PC6) were the most-used acupoints in the included trials (8/11). The reported adverse reaction was only one case of bruising. Discussion: Acupoint stimulation improved pain control in patients undergoing ERAS more than control treatments. The findings provide an evidence-based premise for incorporating acupoint stimulation into ERAS strategies. More rigorous RCTs are needed in the future.

Optimizing Healthcare Expenditure for Spinal Cord Stimulation in Italy: The Value of Battery Longevity Improvement and a Direct-to-Implant Approach

Background: Spinal cord stimulation (SCS) is a treatment for chronic intractable pain powered by an implantable pulse generator that may be rechargeable or not rechargeable (NR). It is performed in 2 stages (a trialing phase followed by permanent device implantation) and necessitates 2 hospitalizations, which may increase infection risk. Objective: This analysis explores the cost impact of improvements in battery longevity and the adoption of 1-step (direct-to-implant [DTI]) SCS implantation. Methods: Since 2019, 3 leading NR-SCS devices have been launched: Device A (2019), Device B (2020), and Device C (2021). The battery longevity of the newest Device C was estimated at comparable stimulation settings for Devices A and B. A Markov model simulated individual patient pathways across 2 scenarios: Device A vs Device C and Device B vs Device C (both with the DTI approach and 2-step approach). Costs considered were the initial device implantation procedure, device replacements, and serious adverse event (SAE) management. Italian diagnosis-related group (DRG) tariffs were applied for costs, and a 15-year time horizon was used. Results: Over 15 years, using a DTI approach, the undiscounted total costs for Device A vs Device C were €26 860 and €22 633, respectively, and €25 111 and €22 399 for Device B vs Device C, respectively. Compared with Devices A and B, Device C offered savings of €4227 and €2712, respectively; similar savings were predicted with a 2-step implant approach. Discussion: The battery longevity of NR-SCS devices directly impacts long-term costs to a payer. The longer the device lasts, the lower mean total cumulative costs the patient will have, especially with regard to device replacement costs. With novel devices and specific programming settings, the lifetime cost per patient to a payer can be decreased without compromising the patient's safety and positive clinical outcome. Conclusions: Extended SCS battery longevity can translate into tangible cost savings for payers. The DTI approach for SCS supports National Healthcare System cost efficiencies and offers the additional benefits of optimizing operating room time while having only one recovery period for the patient.

The Evolution of Surgical Technique in Spinal Cord Stimulation: A Scoping Review

Since the advent of spinal cord stimulation (SCS), its operative technique has consistently advanced. We performed a scoping review of the literature regarding SCS operative techniques to highlight key advancements. To review, summarize, and highlight key changes in SCS implantation techniques since their inception. The authors performed a MEDLINE search inclusive of articles from 1967 to June 2023 including human and modeling studies written in English examining the role of trialing, intraoperative neuromonitoring, and surgical adaptations. Using the Rayyan platform, two reviewers performed a blinded title screen. Of the 960 articles, 197 were included in the title screen, 107 were included in the abstract review, and ultimately 69 articles met inclusion criteria. We examined the utility of trialing and found that historical controls showed significant efficacy, whereas recent results are more equivocal. We discuss the significant improvement in outcomes with intraoperative neuromonitoring for asleep SCS placement. We highlight technique improvements that led to significant reductions in infection, lead migration, and inadequate pain relief. Physicians implanting SCS systems for chronic pain management must continually refine their surgical techniques to keep up with this rapidly evolving therapy. In addition, through collaborative efforts of neuromodulators and industry, SCS is safer and more effective for patients suffering from chronic pain.

Treating Chronic, Intractable Pain with a Miniaturized Spinal Cord Stimulation System: 1-Year Outcomes from the AUS-nPower Study During the COVID-19 Pandemic

Purpose

Spinal cord stimulation (SCS) is a highly effective treatment for chronic neuropathic pain. Despite recent advances in technology, treatment gaps remain. A small SCS system with a miniaturized implantable pulse generator (micro-IPG; <1.5 cm3 in volume) and an externally worn power source may be preferred by patients who do not want a large, implanted battery. We report here the long-term outcomes from the first-in-human study evaluating the safety and performance of a new neurostimulation system.

Patients and Methods

This was a prospective, multi-center, open-label, single-arm study to evaluate this SCS system, in the treatment of chronic, intractable leg and low-back pain. Consented subjects who passed screening continued on to the long-term phase of the study. One-year, patient-reported outcomes (PRO's) such as pain (Numeric Rating Scale, NRS), functional disability, quality of life, and mood were captured.

Results

Twenty-six (26) evaluable subjects with permanent implants were included in this analysis. The average leg pain NRS score decreased from 6.8 ± 1.2 at baseline to 1.1 ± 1.2 at the end of the study (p < 0.001), while the average low-back pain NRS score decreased from 6.8 ± 1.2 to 1.5 ± 1.2 (p < 0.001). The responder rate (proportion with ≥50% pain relief) was 91% in the leg(s) and 82% in the low back. There were significant improvements in functional disability (Oswestry Disability Index) and in mood (Beck Depression Inventory), demonstrating a 46% and 62% improvement, respectively (p < 0.001). Eleven-point Likert scales demonstrated the wearable to be very comfortable and very easy to use.

Conclusion

There were considerable challenges conducting a clinical study during the COVID-19 pandemic, such as missed study programming visits. Nevertheless, subjects had significant PRO improvements through 1-year. The small size of the implanted device, along with a proprietary waveform, may allow for improved SCS outcomes and a drop in incidence of IPG-pocket pain.

Spinal Cord Stimulation and Related Health Information on Social Media: An Analysis of Instagram Posts

INTRODUCTION

Spinal cord stimulation (SCS) has been a well-established, effective, minimally invasive procedure for the treatment of chronic medically refractory neuropathic pain involving the limbs and trunk. Social media platforms, including Instagram, are increasingly being used for medical education and sharing patient experiences. This study aimed to investigate posts related to SCS on Instagram.

METHODS AND MATERIALS

This study presents a comprehensive analysis of Instagram posts utilizing the hashtags #spinalcordneuromodulation, #spinalcordstimulation, #spinalcordstimulationsurgery, #spinalcordstimulationtherapy, and #spinalcordstimulationimplant, all of which were collected on August 1, 2023. The outcomes were organized into four distinct source-based categories: posts generated by medical practitioners (both surgeons and non-surgeons); content shared by medical organizations; content created by patients; and content from indeterminate categories. The content was further classified based on its nature, encompassing educational material and reflections on patient or physician experiences. Moreover, the impact of users was evaluated in terms of their follower count and the count of posts.

RESULTS

The search yielded a total of 4983 posts. The majority of posts were created by medical practitioners (38.53%, n = 1920). The distribution of remaining Instagram posts about SCS was as follows: medical organizations for 35% (n = 1744), patients for 24.12% (n = 1202), and indeterminate categories for 2.35% (n = 117). Among the collected posts, 348 (41.4%) originated from accounts associated with medical practitioners, 286 (34%) from medical organizations, 145 (17.2%) from patients, and 62 (7.4%) remained unspecified. The statistical analysis revealed a significant difference in follower distribution between medical practitioners and all other groups (p<0.001). Reported side effects included pain over the implant (n = 257; 88.92%), lead migration (n = 18; 6.22%), infection (n = 9; 3; 11%), and seroma (n = 5; 1.73%).

CONCLUSIONS

When searching for posts about SCS on Instagram, one is more likely to encounter posts authored by medical practitioners that are mostly focused on educational content. Posts created by medical practitioners may be overshadowed and buried among numerous other posts created by patients. We suggest posting educational medical content with the hashtag #MedEd in an attempt to make educational content more easily accessible.

Spinal Cord Stimulation Efficacy and Erroneous Conclusions of the Cochrane Library Review of Spinal Cord Stimulation for Low Back Pain by Traeger et al

Neuromodulation, through the use of spinal cord stimulation, is an evolving therapeutic alternative for the management of chronic and refractory pain [...].

Neuromodulation Therapy for Chemotherapy-Induced Peripheral Neuropathy: A Systematic Review

Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and painful condition in patients who have received chemotherapy. The role of neuromodulation therapy in treating pain and improving neurological function in CIPN remains unclear and warrants evidence appraisal. In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review to assess change in pain intensity and neurological function after implementation of any neuromodulation intervention for CIPN. Neuromodulation interventions consisted of dorsal column spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), or peripheral nerve stimulation (PNS). In total, 15 studies utilized SCS (16 participants), 7 studies utilized DRG-S (7 participants), and 1 study utilized PNS (50 participants). Per the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria, there was very low-quality GRADE evidence supporting that dorsal column SCS, DRG-S, and PNS are associated with a reduction in pain severity from CIPN. Results on changes in neurological function remained equivocal due to mixed study findings on thermal sensory thresholds and touch sensation or discrimination. Future prospective, well-powered, and comparative studies assessing neuromodulation for CIPN are warranted.