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Deer T, Heros R, Tavel E, Wahezi S, Funk R, Buchanan P, Christopher A, Weisbein J, Gilligan C, Patterson D, Antony A, Ibrahim M, Miller N, Scarfo K, Johnson G, Panchalingam T, Okaro U, Yue J. Comparing Conventional Medical Management to Spinal Cord Stimulation for the Treatment of Low Back Pain in a Cohort of DISTINCT RCT Patients. J Pain Res 2024; 17:2741-2752. [PMID: 39193462 PMCID: PMC11348985 DOI: 10.2147/jpr.s472481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/22/2024] [Indexed: 08/29/2024] Open
Abstract
Aim Low Back Pain (LBP) is a prevalent condition. Spinal cord stimulation (SCS) has emerged as a more effective, long-term treatment compared to conventional medical management (CMM). The DISTINCT study enrolled and randomized chronic LBP patients with no indication of traditional spine surgery. This analysis focuses comparing study outcomes on patients initially randomized to receive CMM treatment and subsequently crossed over to SCS after 6 months. Purpose To compare the therapeutic effectiveness and cost-efficiency of passive recharge burst SCS to CMM. Patients and Methods A total of 269 patients were enrolled with 162 randomly assigned to SCS and 107 to CMM. The DISTINCT study design allowed a crossover to the alternative treatment arm after 6 months. Patients underwent a trial and received a permanent implant if they reported ≥50% pain reduction. Outcome analysis included pain (NRS), disability (ODI), catastrophizing (PCS), quality of life (PROMIS-29) and health care utilization. Results Seventy out of eighty-one patients opted to cross over to trial SCS at 6M with 94% (66/70) undergoing a trial. Among those, 88% (58/66) reported a ≥50% or more pain relief and 55 received a permanent implant. At 12M visit, 71.4% reported a ≥50% pain improvement sustained at the 18M visit, with 24.5% (12/49) indicating a ≥80% improvement. Disability reductions (79% meeting the minimally important difference of a 13-point decrease), decreased catastrophizing, and significant improvements in all PROMIS-29 domains were noted. Furthermore, 42% of the patients reported decreased or discontinued opioid usage. Clinical benefits at the 12M visit were sustained through the 18M visit accompanied by a significant reduction in healthcare utilization and a $1214 cost savings. Conclusion SCS demonstrates superior, long-term performance and safety outcomes compared to CMM therapy in LBP patients who received both CMM and SCS therapy. Additionally, SCS patients experienced reduced healthcare resource utilization and lower costs compared to those receiving CMM.
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Affiliation(s)
- Timothy Deer
- Pain Management, The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Robert Heros
- Pain Management, Spinal Diagnostics, Tualatin, OR, USA
| | - Edward Tavel
- Pain Management, Clinical Trials of South Carolina, Charleston, SC, USA
| | - Sayed Wahezi
- Pain Management, Montefiore Medical Center, Bronx, NY, USA
| | - Robert Funk
- Pain Management, Indiana Spine Group, Indianapolis, IN, USA
| | - Patrick Buchanan
- Pain Management, Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA
| | - Anne Christopher
- Pain Management, Saint Louis Pain Consultants, Chesterfield, MO, USA
| | | | - Christopher Gilligan
- Pain Management, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Denis Patterson
- Pain Management, Nevada Advanced Pain Specialists, Reno, NV, USA
| | - Ajay Antony
- Pain Management, the Orthopedic Institute, Gainesville, FL, USA
| | - Mohab Ibrahim
- Pain Management, Coastal Pain & Spinal Diagnostics Medical Group, Carlsbad, CA, USA
| | - Nathan Miller
- Pain Management, Banner University Medical Center, Tucson, AZ, USA
| | - Keith Scarfo
- Pain Management, Rhode Island Hospital, Providence, RI, USA
| | | | | | - Udoka Okaro
- Neuromodulation, Abbott Labs, Austin, TX, USA
| | - James Yue
- Orthopaedic spine Surgery, Connecticut Orthopedics, Hamden, CT, USA
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Saber M, Schwabe D, Park HJ, Tessmer J, Khan Z, Ding Y, Robinson M, Hogan QH, Pawela CP. Tonic, Burst, and Burst-Cycle Spinal Cord Stimulation Lead to Differential Brain Activation Patterns as Detected by Functional Magnetic Resonance Imaging. Neuromodulation 2022; 25:53-63. [PMID: 35041588 DOI: 10.1111/ner.13460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The objective of this preclinical study was to examine the responses of the brain to noxious stimulation in the presence and absence of different modes of spinal cord stimulation (SCS) using blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD-fMRI). MATERIALS AND METHODS Sprague-Dawley rats were randomized to groups based on the mode of SCS delivered which included tonic stimulation (n = 27), burst stimulation (n = 30), and burst-cycle stimulation (n = 29). The control (sham) group (n = 28) received no SCS. The SCS electrode was inserted between T10 and T12 spinal levels prior to fMRI session. The experimental protocol for fMRI acquisition consisted of an initial noxious stimulation phase, a treatment phase wherein the SCS was turned on concurrently with noxious stimulation, and a residual effect phase wherein the noxious stimulation alone was turned on. The responses were statistically analyzed through paired t-test and the results were presented as z-scores for the quantitative analysis of the fMRI data. RESULTS The treatment with different SCS modes attenuated the BOLD brain responses to noxious hindlimb stimulation. The tonic, burst, and burst-cycle SCS treatment attenuated BOLD responses in the caudate putamen (CPu), insula (In), and secondary somatosensory cortex (S2). There was little to no corresponding change in sham control in these three regions. The burst and burst-cycle SCS demonstrated greater attenuation of BOLD signals in CPu, In, and S2 compared to tonic stimulation. CONCLUSION The high-resolution fMRI study using a rat model demonstrated the potential of different SCS modes to act on several pain-matrix-related regions of the brain in response to noxious stimulation. The burst and burst-cycle SCS exhibited greater brain activity reduction in response to noxious hindlimb stimulation in the caudate putamen, insula, and secondary somatosensory cortex compared to tonic stimulation.
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Affiliation(s)
- Mohammad Saber
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Schwabe
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - John Tessmer
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zan Khan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yujie Ding
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Maraika Robinson
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Quinn H Hogan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Burst Stimulation of the Thoracic Spinal Cord near a Cardiac Pacemaker in an Elderly Patient with Postherpetic Neuralgia: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57040337. [PMID: 33916023 PMCID: PMC8067005 DOI: 10.3390/medicina57040337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/17/2021] [Accepted: 03/25/2021] [Indexed: 11/17/2022]
Abstract
New developments in spinal cord stimulation (SCS) have improved the treatment of patients with chronic pain. Although the overall safety of modern SCS has been established, there are no published reports regarding safety considerations when implanting a burst-mode spinal cord stimulator in patients with permanent cardiac pacemakers (PCPs). An 80-year-old man with a complete atrioventricular block implanted with a PCP was considered as a candidate for burst-mode SCS due to well-established postherpetic neuralgia (>180 days after rash). Cardiac monitoring during the burst-mode spinal cord stimulator trial and insertion did not indicate any interference. After the insertion of the burst-mode spinal cord stimulator, the patient showed functional improvement and significant pain relief. The safety of traditional tonic-mode SCS in patients with PCP has been previously reported. This is the first case report describing the safe and effective use of burst-mode SCS in a patient with PCP.
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Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. Burst Spinal Cord Stimulation: A Clinical Review. PAIN MEDICINE 2020; 20:S31-S40. [PMID: 31152175 PMCID: PMC6544556 DOI: 10.1093/pm/pnz003] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective Clinical review on outcomes using burst spinal cord stimulation (SCS) in the treatment of chronic, intractable pain. Design Narrative clinical literature review conducted utilizing a priori search terms including key words for burst spinal cord stimulation. Synthesis and reporting of data from publications including an overview of comparative SCS outcomes. Results Burst SCS demonstrated greater pain relief over tonic stimulation in multiple studies, which included blinded, sham-controlled, randomized trials. Additionally, burst stimulation impacts multiple dimensions of pain, including somatic pain as well as emotional and psychological elements. Patient preference is weighted toward burst over tonic due to increased pain relief, a lack of paresthesias, and impression of change in condition. Conclusion Burst SCS has been shown to be both statistically and clinically superior to tonic stimulation and may provide additional benefits through different mechanisms of action. Further high-quality controlled studies are warranted to not only elucidate the basic mechanisms of burst SCS but also address how this unique stimulation signature/pattern may more adequately handle the multiple affective dimensions of pain in varying patient populations.
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Affiliation(s)
- Terje Kirketeig
- Multidisciplinary Pain Clinic, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Carsten Schultheis
- Departement für Interventionelle Schmerzmedizin, Krankenhaus Neuwerk "Maria von den Aposteln" Muskulo-Skeletales Zentrum Mönchengladbach, Germany
| | - Xander Zuidema
- Department of Anesthesiology and Pain Management, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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Chakravarthy K, Malayil R, Kirketeig T, Deer T. Burst Spinal Cord Stimulation: A Systematic Review and Pooled Analysis of Real-World Evidence and Outcomes Data. PAIN MEDICINE 2020; 20:S47-S57. [PMID: 31152177 PMCID: PMC6544549 DOI: 10.1093/pm/pnz046] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective This review provides a comprehensive assessment of the effectiveness of burst spinal cord stimulation (SCS). Ratings of pain intensity (visual analog scale or numeric rating scale) and patient-reported outcomes (PROs) on functional/psychometric domains such as depression (Beck Depression Index), catastrophizing (Pain Catastrophizing Scale), surveillance (Pain Vigilance and Attention Questionnaire), and others are addressed. Design Articles were identified and selected from the literature according to prospective, replicable methods. Effectiveness data—pain scores and PRO ratings—were weighted by study sample sizes and pooled. The effects of burst SCS were compared against values at baseline and with tonic SCS. For PROs, published population norms were used for comparison. Results Fifteen articles, with a combined sample size of 427, were included. Follow-up ranged from a few hours to two years. A variety of prospective designs were employed, including crossover studies, single-arm cohorts, and a randomized controlled trial, as well as retrospective case reports. The weighted pooled mean pain rating across articles at baseline was 76.7 (±27.4). With tonic SCS, this was reduced to 49.2 (±12.9), and with burst SCS it was further reduced to 36.7 (±11.6), a 12.5-point difference between tonic and burst values. Psychometric analyses of PROs noted preferential improvement with burst SCS. In addition, 65% of subjects stated a preference for burst SCS. Conclusions In pooled analyses that incorporated all available published evidence, the improvement over baseline for burst SCS was shown to have a clinically important incremental benefit over tonic SCS. In addition, burst SCS may support resolution of the emotional or cognitive aspects of pain that are mediated by medial thalamo-cortical pathways. This study highlights the value in considering the entire knowledge base in therapeutic assessments as well as adopting a consistent set of outcome variables within neuromodulation. Burst SCS is a valuable intervention, providing both analgesia and psychometric benefits that warrant further thoughtful applications.
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Affiliation(s)
| | - Rudy Malayil
- St. Mary's Pain Relief Specialists, Huntington, West Virginia
| | - Terje Kirketeig
- Multidisciplinary Pain Clinic, Uppsala University Hospital, Uppsala, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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Pope JE, Schu S, Sayed D, Raslan AM, Baranidharan G, Heros RD, Blomme B, Capobianco RA, Deer TR. Anatomic Lead Placement Without Paresthesia Mapping Provides Effective and Predictable Therapy During the Trial Evaluation Period: Results From the Prospective, Multicenter, Randomized, DELIVERY Study. Neuromodulation 2019; 23:109-117. [DOI: 10.1111/ner.13019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/15/2019] [Accepted: 06/06/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Jason E. Pope
- Evolve Restorative Center, California Society of Interventional Pain Society Santa Rosa CA USA
| | | | - Dawood Sayed
- Department of Anesthesiology and Pain MedicineThe University of Kansas Medical Center Kansas City KS USA
| | - Ahmed M. Raslan
- Department of Neurological SurgeryOregon Health & Science University Portland Oregon
| | | | | | - Bram Blomme
- Abbott (formerly St. Jude Medical), Neuromodulation division Brussels Belgium
| | - Robyn A. Capobianco
- Abbott (formerly St. Jude Medical), Neuromodulation division Brussels Belgium
| | - Timothy R. Deer
- The Spine and Nerve Center of the Virginias Charleston WV USA
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Chakravarthy K, Fishman MA, Zuidema X, Hunter CW, Levy R. Mechanism of Action in Burst Spinal Cord Stimulation: Review and Recent Advances. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:S13-S22. [PMID: 31152180 PMCID: PMC6544550 DOI: 10.1093/pm/pnz073] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This is a comprehensive, structured review synthesizing and summarizing the current experimental data and knowledge about the mechanisms of action (MOA) underlying spinal cord stimulation with the burst waveform (as defined by De Ridder) in chronic pain treatment. METHODS Multiple database queries and article back-searches were conducted to identify the relevant literature and experimental findings for results integration and interpretation. Data from recent peer-reviewed conference presentations were also included for completeness and to ensure that the most up-to-date scientific information was incorporated. Both human and animal data were targeted in the search to provide a translational approach in understanding the clinical relevance of the basic science findings. RESULTS/CONCLUSIONS Burst spinal cord stimulation likely provides pain relief via multiple mechanisms at the level of both the spinal cord and the brain. The specific waveforms and temporal patterns of stimulation both play a role in the responses observed. Differential modulation of neurons in the dorsal horn and dorsal column nuclei are the spinal underpinnings of paresthesia-free analgesia. The burst stimulation pattern also produces different patterns of activation within the brain when compared with tonic stimulation. The latter may have implications for not only the somatic components of chronic pain but also the lateral and affective pathway dimensions as well.
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Affiliation(s)
| | | | - Xander Zuidema
- Department of Anesthesiology and Pain Management, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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High Cervical Spinal Cord Stimulation: A One Year Follow-Up Study on Motor and Non-Motor Functions in Parkinson's Disease. Brain Sci 2019; 9:brainsci9040078. [PMID: 30987170 PMCID: PMC6523357 DOI: 10.3390/brainsci9040078] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/20/2019] [Accepted: 04/02/2019] [Indexed: 01/24/2023] Open
Abstract
Background: The present study investigated the effectiveness of stimulation applied at cervical levels on pain and Parkinson’s disease (PD) symptoms using either tonic or burst stimulation mode. Methods: Tonic high cervical spinal cord stimulation (T-HCSCS) was applied on six PD patients suffering from low back pain and failed back surgery syndrome, while burst HCSCS (B-HCSCS) was applied in twelve PD patients to treat primarily motor deficits. Stimulation was applied percutaneously with quadripolar or octapolar electrodes. Clinical evaluation was assessed by the Unified Parkinson’s Disease Rating Scale (UPDRS) and the Hoehn and Yahr (H&Y) scale. Pain was evaluated by a visual analog scale. Evaluations of gait and of performance in a cognitive motor task were performed in some patients subjected to B-HCSCS. One patient who also suffered from severe autonomic cardiovascular dysfunction was investigated to evaluate the effectiveness of B-HCSCS on autonomic functions. Results: B-HCSCS was more effective and had more consistent effects than T-HCSCS in reducing pain. In addition, B-HCSCS improved UPDRS scores, including motor sub-items and tremor and H&Y score. Motor benefits appeared quickly after the beginning of B-HCSCS, in contrast to long latency improvements induced by T-HCSCS. A slight decrease of effectiveness was observed 12 months after implantation. B-HCSCS also improved gait and ability of patients to correctly perform a cognitive–motor task requiring inhibition of a prepared movement. Finally, B-HCSCS ameliorated autonomic control in the investigated patient. Conclusions: The results support a better usefulness of B-HCSCS compared to T-HCSCS in controlling pain and specific aspects of PD motor and non-motor deficits for at least one year.
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Yousef KR, Monroe BR. A Medically Challenging Case of Chronic Pelvic Pain and the Use of Burst Suppression Spinal Cord Stimulator as a Treatment Modality. Neuromodulation 2019; 22:358-360. [DOI: 10.1111/ner.12863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/30/2022]
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Vesper J, Slotty P, Schu S, Poeggel-Kraemer K, Littges H, Van Looy P, Agnesi F, Venkatesan L, Van Havenbergh T. Burst SCS Microdosing Is as Efficacious as Standard Burst SCS in Treating Chronic Back and Leg Pain: Results From a Randomized Controlled Trial. Neuromodulation 2018; 22:190-193. [PMID: 30456795 DOI: 10.1111/ner.12883] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The burst waveform, a recent innovation in spinal cord stimulation (SCS), can achieve better outcomes than conventional tonic SCS, both for de novo implants and as a salvage therapy. Burst stimulation delivers more energy per second than tonic stimulation, which is a consideration for battery consumption. The clinical effectiveness of an energy-conserving strategy was investigated. METHODS Subjects were experienced users of BurstDR SCS for back and leg pain. Three 2-week stimulation paradigms were presented in blinded random order: standard (continuously delivered) BurstDR, microdosing A: 5 sec of BurstDR alternating with 5 sec of no stimulation, and microdosing B: 5 sec of BurstDR alternating with 10 sec of no stimulation. The primary outcome for each paradigm was change in pain ratings, and secondary outcomes included changes in scores for quality of life, satisfaction, and preference. RESULTS Twenty-five subjects assessed all three stimulation paradigms. There were no significant differences in pain (visual analog scale) or quality of life (EQ-5D) when comparing standard burst outcomes with those of microdosing A and, separately, microdosing B. Microdosing paradigms were graded with slightly higher level of satisfaction and were generally preferred above standard burst stimulation. DISCUSSION These results suggest that the use of energy-efficient burst microdosing stimulation paradigms with alternating stimulation-on and stimulation-off periods can provide clinically equivalent results to standard burst stimulation. This is important for extending SCS battery life. Further research is needed to comprehensively characterize the clinical utility of this approach and the neurophysiological mechanisms for the maintenance of pain relief during stimulation-off periods.
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Affiliation(s)
- Jan Vesper
- Department of Stereotactic and Functional Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Philipp Slotty
- Department of Stereotactic and Functional Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | | | - Katja Poeggel-Kraemer
- Department of Stereotactic and Functional Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Heike Littges
- Department of Stereotactic and Functional Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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