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Patel J, Deschler E, Galang E. Spinal cord stimulation for the symptomatic treatment of rigidity and painful spasm in a case of stiff person syndrome. Pain Pract 2024; 24:798-804. [PMID: 38185725 DOI: 10.1111/papr.13340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by rigidity and painful spasm primarily affecting the truncal and paraspinal musculature due to autoimmune-mediated neuronal hyperexcitability. Spinal cord stimulation (SCS) is an approved therapy for managing painful neuropathic conditions, including diabetic peripheral neuropathy and refractory angina pectoris. We describe the novel use of SCS for the treatment of spasm and rigidity in a 49-year-old man with seropositive stiff person syndrome (SPS). The patient was treated with intravenous immunoglobulin (IVIG) and oral medications over a 13-month period with minimal improvement, prompting consideration of SCS. To our knowledge, this is the first report of the successful use of SCS in SPS with the demonstration of multifaceted clinical improvement. METHODS Following a successful temporary SCS trial, permanent implantation was performed. Spasm/stiffness (Distribution of Stiffness Index; Heightened Sensitivity Scale; Penn Spasm Frequency Scale, PSFS), disability (Oswestry Disability Index, ODI; Pain Disability Index, PDI), depression (Patient Health Questionnaire-9, PHQ-9), sleep (Pittsburgh Sleep Quality Index, PSQI), fatigue (Fatigue Severity Scale, FSS), pain (Numerical Pain Rating Scale, NPRS), quality of life (EuroQoL 5 Dimension 5 Level, EQ-5D-5L), and medication usage were assessed at baseline, 6-month, and 10-month postimplantation. RESULTS ODI, PHQ-9, FSS, NPRS, PSQI, and EQ-5D-5L scores showed a notable change from baseline and surpassed the defined minimal clinically important difference (MCID) at 6-month and 10-month follow-up. Oral medication dosages were reduced. CONCLUSIONS The novel use of SCS therapy in seropositive SPS resulted in functional improvement and attenuation of symptoms. We present possible mechanisms by which SCS may produce clinical response in patients with SPS and aim to demonstrate proof-of-concept for a future comprehensive pilot study evaluating SCS-mediated response in SPS.
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Affiliation(s)
- Janus Patel
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Emily Deschler
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Enrique Galang
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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2
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Fisher LE, Lempka SF. Neurotechnology for Pain. Annu Rev Biomed Eng 2023; 25:387-412. [PMID: 37068766 DOI: 10.1146/annurev-bioeng-111022-121637] [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] [Indexed: 04/19/2023]
Abstract
Neurotechnologies for treating pain rely on electrical stimulation of the central or peripheral nervous system to disrupt or block pain signaling and have been commercialized to treat a variety of pain conditions. While their adoption is accelerating, neurotechnologies are still frequently viewed as a last resort, after many other treatment options have been explored. We review the pain conditions commonly treated with electrical stimulation, as well as the specific neurotechnologies used for treating those conditions. We identify barriers to adoption, including a limited understanding of mechanisms of action, inconsistent efficacy across patients, and challenges related to selectivity of stimulation and off-target side effects. We describe design improvements that have recently been implemented, as well as some cutting-edge technologies that may address the limitations of existing neurotechnologies. Addressing these challenges will accelerate adoption and change neurotechnologies from last-line to first-line treatments for people living with chronic pain.
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Affiliation(s)
- Lee E Fisher
- Rehab Neural Engineering Labs, Department of Physical Medicine and Rehabilitation, and Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA;
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Scott F Lempka
- Department of Biomedical Engineering, Biointerfaces Institute, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA;
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3
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Chu XL, Song XZ, Li Q, Li YR, He F, Gu XS, Ming D. Basic mechanisms of peripheral nerve injury and treatment via electrical stimulation. Neural Regen Res 2022; 17:2185-2193. [PMID: 35259827 PMCID: PMC9083151 DOI: 10.4103/1673-5374.335823] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Previous studies on the mechanisms of peripheral nerve injury (PNI) have mainly focused on the pathophysiological changes within a single injury site. However, recent studies have indicated that within the central nervous system, PNI can lead to changes in both injury sites and target organs at the cellular and molecular levels. Therefore, the basic mechanisms of PNI have not been comprehensively understood. Although electrical stimulation was found to promote axonal regeneration and functional rehabilitation after PNI, as well as to alleviate neuropathic pain, the specific mechanisms of successful PNI treatment are unclear. We summarize and discuss the basic mechanisms of PNI and of treatment via electrical stimulation. After PNI, activity in the central nervous system (spinal cord) is altered, which can limit regeneration of the damaged nerve. For example, cell apoptosis and synaptic stripping in the anterior horn of the spinal cord can reduce the speed of nerve regeneration. The pathological changes in the posterior horn of the spinal cord can modulate sensory abnormalities after PNI. This can be observed in cases of ectopic discharge of the dorsal root ganglion leading to increased pain signal transmission. The injured site of the peripheral nerve is also an important factor affecting post-PNI repair. After PNI, the proximal end of the injured site sends out axial buds to innervate both the skin and muscle at the injury site. A slow speed of axon regeneration leads to low nerve regeneration. Therefore, it can take a long time for the proximal nerve to reinnervate the skin and muscle at the injured site. From the perspective of target organs, long-term denervation can cause atrophy of the corresponding skeletal muscle, which leads to abnormal sensory perception and hyperalgesia, and finally, the loss of target organ function. The mechanisms underlying the use of electrical stimulation to treat PNI include the inhibition of synaptic stripping, addressing the excessive excitability of the dorsal root ganglion, alleviating neuropathic pain, improving neurological function, and accelerating nerve regeneration. Electrical stimulation of target organs can reduce the atrophy of denervated skeletal muscle and promote the recovery of sensory function. Findings from the included studies confirm that after PNI, a series of physiological and pathological changes occur in the spinal cord, injury site, and target organs, leading to dysfunction. Electrical stimulation may address the pathophysiological changes mentioned above, thus promoting nerve regeneration and ameliorating dysfunction.
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Affiliation(s)
- Xiao-Lei Chu
- Academy of Medical Engineering and Translational Medicine, Tianjin University; Department of Rehabilitation, Tianjin Hospital, Tianjin, China
| | - Xi-Zi Song
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Qi Li
- Academy of Medical Engineering and Translational Medicine, Tianjin University; Department of Rehabilitation, Tianjin Hospital, Tianjin, China
| | - Yu-Ru Li
- College of Exercise & Health Sciences, Tianjin University of Sport, Tianjin, China
| | - Feng He
- College of Precision Instruments & Optoelectronics Engineering, Tianjin University, Tianjin, China
| | - Xiao-Song Gu
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Dong Ming
- Academy of Medical Engineering and Translational Medicine; College of Precision Instruments & Optoelectronics Engineering, Tianjin University, Tianjin, China
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4
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Investigation of the effects of high cervical spinal cord electrical stimulation on improving neurological dysfunction and its potential mechanism in rats with traumatic brain injury. Neuroreport 2022; 33:509-517. [PMID: 35767234 PMCID: PMC9287104 DOI: 10.1097/wnr.0000000000001811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To explore the effects of high cervical spinal cord electrical stimulation (cSCS) on the recovery of neurological function and its possible mechanism in rats with traumatic brain injury (TBI). 72 rats were randomly divided into: (1) a sham group; (2) a traumatic brain injury (TBI) group; (3) a TBI+cSCS group; (4) a LY294002+TBI+cSCS group. The degree of neurological dysfunction was evaluated by modified Neurological severity score (mNSS). The pathological changes of the brain tissue in the injured area were observed by HE staining, and the apoptosis of neuron cells were observed by TUNEL staining. The expressions of BDNF and VEGFmRNA were detected by polymerase chain reaction (PCR), and the expressions of p-AKT, AKT, Bcl-2, Bax and caspase-3 proteins were detected by western blot. Compared with that of the TBI and LY294002+TBI+cSCS groups, the mNSS of the TBI+cSCS group were significantly lower on day 3 and 7 ( P <0.05). Compared with that in the TBI and LY294002+TBI+cSCS groups, the apoptosis of neuron cells in the TBI+cSCS group decreased significantly ( P < 0.05). Compared with the TBI and LY294002+TBI+cSCS group, the expression of Bcl-2 protein increased and the expressions of Bax and Caspase-3 proteins decreased in the TBI+cSCS group ( P < 0.05). Compared with that in the TBI and LY294002+TBI+cSCS groups, the intensity of p-Akt/Akt in the TBI+cSCS group increased ( P < 0.05). We found that cSCS had a protective effect on neuron cells after craniocerebral injury and could improve neurological dysfunction in rats, the mechanism of which might be that cSCS made the PI3K/Akt pathway more active after TBI.
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Howard-Quijano K, Yamaguchi T, Gao F, Kuwabara Y, Puig S, Lundquist E, Salavatian S, Taylor B, Mahajan A. Spinal Cord Stimulation Reduces Ventricular Arrhythmias by Attenuating Reactive Gliosis and Activation of Spinal Interneurons. JACC Clin Electrophysiol 2021; 7:1211-1225. [PMID: 34454884 DOI: 10.1016/j.jacep.2021.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study investigated spinal cord neuronal and glial cell activation during cardiac ischemia-reperfusion (IR)-triggered ventricular arrhythmias and neuromodulation therapy by spinal cord stimulation (SCS). BACKGROUND Myocardial ischemia induces changes in cardiospinal neural networks leading to sudden cardiac death. Neuromodulation with SCS decreases cardiac sympathoexcitation; however, the molecular mechanisms remain unknown. METHODS Yorkshire pigs (n = 16) were randomized to Control, IR, or IR+SCS groups. A 4-pole SCS lead was placed in the T1-T4 epidural space with stimulation for 30 minutes before IR (50 Hz, 0.4-ms duration, 90% motor threshold). Cardiac electrophysiological mapping and Ventricular Arrhythmia Score (VAS) were recorded. Immunohistochemistry of thoracic spinal sections was used to map and identify Fos-positive neuronal and glial cell types during IR with and without SCS. RESULTS IR increased cardiac sympathoexcitation and arrhythmias (VAS = 6.2 ± 0.9) that were attenuated in IR + SCS (VAS = 2.8 ± 0.5; P = 0.017). IR increased spinal cellular Fos expression (#Fos+ cells Control = 23 ± 2 vs IR = 88 ± 5; P < 0.0001) in T1-T4, with the greatest increase localized to T3, and the greatest %Fos+ cells being microglia and astrocytes. Fos expression was attenuated by IR + SCS (62 ± 4; P < 0.01), primarily though a reduction in Fos+ microglia and astrocytes, as SCS also led to increase in Fos+ neurons in deep dorsal laminae. CONCLUSIONS In a porcine model, cardiac IR was associated with astrocyte and microglial cell activation. Our results suggest that preemptive thoracic SCS decreased IR-induced cardiac sympathoexcitation and ventricular arrhythmias through attenuation of reactive gliosis and activation of inhibitory interneurons in the dorsal horn of spinal cord.
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Affiliation(s)
- Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tomoki Yamaguchi
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Fei Gao
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephanie Puig
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eevanna Lundquist
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradley Taylor
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Cedeño DL, Kelley CA, Chakravarthy K, Vallejo R. Modulation of Glia-Mediated Processes by Spinal Cord Stimulation in Animal Models of Neuropathic Pain. FRONTIERS IN PAIN RESEARCH 2021; 2:702906. [PMID: 35295479 PMCID: PMC8915735 DOI: 10.3389/fpain.2021.702906] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/31/2021] [Indexed: 12/23/2022] Open
Abstract
Glial cells play an essential role in maintaining the proper functioning of the nervous system. They are more abundant than neurons in most neural tissues and provide metabolic and catabolic regulation, maintaining the homeostatic balance at the synapse. Chronic pain is generated and sustained by the disruption of glia-mediated processes in the central nervous system resulting in unbalanced neuron–glial interactions. Animal models of neuropathic pain have been used to demonstrate that changes in immune and neuroinflammatory processes occur in the course of pain chronification. Spinal cord stimulation (SCS) is an electrical neuromodulation therapy proven safe and effective for treating intractable chronic pain. Traditional SCS therapies were developed based on the gate control theory of pain and rely on stimulating large Aβ neurons to induce paresthesia in the painful dermatome intended to mask nociceptive input carried out by small sensory neurons. A paradigm shift was introduced with SCS treatments that do not require paresthesia to provide effective pain relief. Efforts to understand the mechanism of action of SCS have considered the role of glial cells and the effect of electrical parameters on neuron–glial interactions. Recent work has provided evidence that SCS affects expression levels of glia-related genes and proteins. This inspired the development of a differential target multiplexed programming (DTMP) approach using electrical signals that can rebalance neuroglial interactions by targeting neurons and glial cells differentially. Our group pioneered the utilization of transcriptomic and proteomic analyses to identify the mechanism of action by which SCS works, emphasizing the DTMP approach. This is an account of evidence demonstrating the effect of SCS on glia-mediated processes using neuropathic pain models, emphasizing studies that rely on the evaluation of large sets of genes and proteins. We show that SCS using a DTMP approach strongly affects the expression of neuron and glia-specific transcriptomes while modulating them toward expression levels of healthy animals. The ability of DTMP to modulate key genes and proteins involved in glia-mediated processes affected by pain toward levels found in uninjured animals demonstrates a shift in the neuron–glial environment promoting analgesia.
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Affiliation(s)
- David L. Cedeño
- Research and Development, Lumbrera LLC, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
- *Correspondence: David L. Cedeño
| | - Courtney A. Kelley
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
| | - Krishnan Chakravarthy
- Deparment of Anesthesiology and Pain Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Ricardo Vallejo
- Research and Development, Lumbrera LLC, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
- Research Department, National Spine and Pain Center, Bloomington, IL, United States
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7
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Smith WJ, Cedeño DL, Thomas SM, Kelley CA, Vetri F, Vallejo R. Modulation of microglial activation states by spinal cord stimulation in an animal model of neuropathic pain: Comparing high rate, low rate, and differential target multiplexed programming. Mol Pain 2021; 17:1744806921999013. [PMID: 33626981 PMCID: PMC7925954 DOI: 10.1177/1744806921999013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
While numerous studies and patient experiences have demonstrated the efficacy of spinal cord stimulation as a treatment for chronic neuropathic pain, the exact mechanism underlying this therapy is still uncertain. Recent studies highlighting the importance of microglial cells in chronic pain and characterizing microglial activation transcriptomes have created a focus on microglia in pain research. Our group has investigated the modulation of gene expression in neurons and glial cells after spinal cord stimulation (SCS), specifically focusing on transcriptomic changes induced by varying SCS stimulation parameters. Previous work showed that, in rodents subjected to the spared nerve injury (SNI) model of neuropathic pain, a differential target multiplexed programming (DTMP) approach provided significantly better relief of pain-like behavior compared to high rate (HRP) and low rate programming (LRP). While these studies demonstrated the importance of transcriptomic changes in SCS mechanism of action, they did not specifically address the role of SCS in microglial activation. The data presented herein utilizes microglia-specific activation transcriptomes to further understand how an SNI model of chronic pain and subsequent continuous SCS treatment with either DTMP, HRP, or LRP affects microglial activation. Genes for each activation transcriptome were identified within our dataset and gene expression levels were compared with that of healthy animals, naïve to injury and interventional procedures. Pearson correlations indicated that DTMP yields the highest significant correlations to expression levels found in the healthy animals across all microglial activation transcriptomes. In contrast, HRP or LRP yielded weak or very weak correlations for these transcriptomes. This work demonstrates that chronic pain and subsequent SCS treatments can modulate microglial activation transcriptomes, supporting previous research on microglia in chronic pain. Furthermore, this study provides evidence that DTMP is more effective than HRP and LRP at modulating microglial transcriptomes, offering potential insight into the therapeutic efficacy of DTMP.
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Affiliation(s)
- William J Smith
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - David L Cedeño
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Samuel M Thomas
- College of Osteopathic Medicine, Des Moines University, Des Moines, IA, USA
| | - Courtney A Kelley
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | | | - Ricardo Vallejo
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,National Spine and Pain Centers, Bloomington, IL, USA
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8
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Shu B, He SQ, Guan Y. Spinal Cord Stimulation Enhances Microglial Activation in the Spinal Cord of Nerve-Injured Rats. Neurosci Bull 2020; 36:1441-1453. [PMID: 32889636 DOI: 10.1007/s12264-020-00568-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Microglia can modulate spinal nociceptive transmission. Yet, their role in spinal cord stimulation (SCS)-induced pain inhibition is unclear. Here, we examined how SCS affects microglial activation in the lumbar cord of rats with chronic constriction injury (CCI) of the sciatic nerve. Male rats received conventional SCS (50 Hz, 80% motor threshold, 180 min, 2 sessions/day) or sham stimulation on days 18-20 post-CCI. SCS transiently attenuated the mechanical hypersensitivity in the ipsilateral hind paw and increased OX-42 immunoreactivity in the bilateral dorsal horns. SCS also upregulated the mRNAs of M1-like markers, but not M2-like markers. Inducible NOS protein expression was increased, but brain-derived neurotrophic factor was decreased after SCS. Intrathecal minocycline (1 μg-100 μg), which inhibits microglial activation, dose-dependently attenuated the mechanical hypersensitivity. Pretreatment with low-dose minocycline (1 μg, 30 min) prolonged the SCS-induced pain inhibition. These findings suggest that conventional SCS may paradoxically increase spinal M1-like microglial activity and thereby compromise its own ability to inhibit pain.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shao-Qiu He
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA. .,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
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9
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Nagel SJ, Hsieh J, Machado AG, Frizon LA, Howard MA, Gillies GT, Wilson S. Biomarker Optimization of Spinal Cord Stimulation Therapies. Neuromodulation 2020; 24:3-12. [PMID: 32881257 DOI: 10.1111/ner.13252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We are in the process of designing and testing an intradural stimulation device that will shorten the distance between the location of the electrode array and the targeted neural tissue, thus improving the efficacy of electrical current delivery. Identifying a biomarker that accurately reflects the response to this intervention is highly valued because of the potential to optimize interventional parameters or predict a response before it is clinically measurable. In this report, we summarize the findings pertaining to the study of biomarkers so that we and others will have an up-to-date reference that critically evaluates the current approaches and select one or several for testing during the development of our device. MATERIALS AND METHODS We have conducted a broad survey of the existing literature to catalogue the biomarkers that could be coupled to intradural spinal cord stimulation. We describe in detail some of the most promising biomarkers, existing limitations, and suitability to managing chronic pain. RESULTS Chronic, intractable pain is an all-encompassing condition that is incurable. Many treatments for managing chronic pain are nonspecific in action and intermittently administered; therefore, patients are particularly susceptible to large fluctuations in pain control over the course of a day. The absence of a reliable biomarker challenges assessment of therapeutic efficacy and contributes to either incomplete and inconsistent pain relief or, alternatively, intolerable side effects. Fluctuations in metabolites or inflammatory markers, signals captured during dynamic imaging, and genomics will likely have a role in governing how a device is modulated. CONCLUSIONS Efforts to identify one or more biomarkers are well underway with some preliminary evidence supporting their efficacy. This has far-reaching implications, including improved outcomes, fewer adverse events, harmonization of treatment and individuals, performance gains, and cost savings. We anticipate that novel biomarkers will be used widely to manage chronic pain.
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Affiliation(s)
- Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Hsieh
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Leonardo A Frizon
- Department of Neurosurgery, Hospital Marcelino Champagnat, Curitiba, PR, Brazil
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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10
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Gupta M, Scowcroft J, Kloster D, Guirguis M, Carlson J, McJunkin T, Chaiban G, Israel A, Subbaroyan J. 10-kHz Spinal Cord Stimulation for Chronic Postsurgical Pain: Results From a 12-Month Prospective, Multicenter Study. Pain Pract 2020; 20:908-918. [PMID: 32585742 PMCID: PMC7754504 DOI: 10.1111/papr.12929] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
Background Chronic postsurgical pain (CPSP) can be caused by peripheral nerve injury (PNI) resulting from surgical procedures and has a significant neuropathic component. This prospective, single‐arm study was conducted to document the effectiveness of 10‐kHz spinal cord stimulation (10‐kHz SCS) as a treatment for patients with CPSP. Methods Subjects with CPSP who were refractory to conventional medical interventions and reported pain scores of ≥5 cm on a 10‐cm VAS underwent trial stimulations lasting up to 14 days. Epidural leads were implanted at locations appropriate for the primary area of pain, and trials resulting in ≥40% pain relief were considered successful. Subjects with successful trials underwent implantation with a permanent 10‐kHz SCS system and were followed for 12 months after implantation. Results Of the 34 subjects who underwent trial stimulation, 1 was withdrawn early and 29 (87.9%) had a successful trial and received a permanent implant. After 12 months of treatment, the mean VAS score decreased by 6.5 cm, the response rate was 88.0% (22/25), and 18 subjects (62.1%) were remitters with VAS scores sustained at ≤3.0 cm. Scores for all components of the short‐form McGill Pain Questionnaire 2 were significantly reduced, including affective descriptors of pain. Pain catastrophizing and vigilance, patient function, physical and mental well‐being, and sleep quality all improved over the course of the study. No neurologic deficits reported in the study. Conclusions 10‐kHz SCS is effective and tolerated in patients with CPSP, and further study of its clinical application in this population is warranted.
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Affiliation(s)
- Mayank Gupta
- Kansas Pain Management, Overland Park, Kansas, U.S.A
| | | | | | | | | | | | | | - Atef Israel
- Menorah Medical Center, Overland Park, Kansas, U.S.A
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11
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Fishman MA, Antony A, Esposito M, Deer T, Levy R. The Evolution of Neuromodulation in the Treatment of Chronic Pain: Forward-Looking Perspectives. PAIN MEDICINE 2020; 20:S58-S68. [PMID: 31152176 PMCID: PMC6600066 DOI: 10.1093/pm/pnz074] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The field of neuromodulation is continually evolving, with the past decade showing significant advancement in the therapeutic efficacy of neuromodulation procedures. The continued evolution of neuromodulation technology brings with it the promise of addressing the needs of both patients and physicians, as current technology improves and clinical applications expand. Design This review highlights the current state of the art of neuromodulation for treating chronic pain, describes key areas of development including stimulation patterns and neural targets, expanding indications and applications, feedback-controlled systems, noninvasive approaches, and biomarkers for neuromodulation and technology miniaturization. Results and Conclusions The field of neuromodulation is undergoing a renaissance of technology development with potential for profoundly improving the care of chronic pain patients. New and emerging targets like the dorsal root ganglion, as well as high-frequency and patterned stimulation methodologies such as burst stimulation, are paving the way for better clinical outcomes. As we look forward to the future, neural sensing, novel target-specific stimulation patterns, and approaches combining neuromodulation therapies are likely to significantly impact how neuromodulation is used. Moreover, select biomarkers may influence and guide the use of neuromodulation and help objectively demonstrate efficacy and outcomes.
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Affiliation(s)
| | | | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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12
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Vallejo R, Platt DC, Rink JA, Jones MA, Kelley CA, Gupta A, Cass CL, Eichenberg K, Vallejo A, Smith WJ, Benyamin R, Cedeño DL. Electrical Stimulation of C6 Glia-Precursor Cells In Vitro Differentially Modulates Gene Expression Related to Chronic Pain Pathways. Brain Sci 2019; 9:brainsci9110303. [PMID: 31683631 PMCID: PMC6896182 DOI: 10.3390/brainsci9110303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/21/2022] Open
Abstract
Glial cells comprise the majority of cells in the central nervous system and exhibit diverse functions including the development of persistent neuropathic pain. While earlier theories have proposed that the applied electric field specifically affects neurons, it has been demonstrated that electrical stimulation (ES) of neural tissue modulates gene expression of the glial cells. This study examines the effect of ES on the expression of eight genes related to oxidative stress and neuroprotection in cultured rodent glioma cells. Concentric bipolar electrodes under seven different ES types were used to stimulate cells for 30 min in the presence and absence of extracellular glutamate. ES consisted of rectangular pulses at 50 Hz in varying proportions of anodic and cathodic phases. Real-time reverse-transcribed quantitative polymerase chain reaction was used to determine gene expression using the ∆∆Cq method. The results demonstrate that glutamate has a significant effect on gene expression in both stimulated and non-stimulated groups. Furthermore, stimulation parameters have differential effects on gene expression, both in the presence and absence of glutamate. ES has an effect on glial cell gene expression that is dependent on waveform composition. Optimization of ES therapy for chronic pain applications can be enhanced by this understanding.
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Affiliation(s)
- Ricardo Vallejo
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - David C Platt
- Department of Chemistry, Illinois State University, Normal, IL 61790, USA.
| | - Jonathan A Rink
- Department of Biology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - Marjorie A Jones
- Department of Chemistry, Illinois State University, Normal, IL 61790, USA.
| | - Courtney A Kelley
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - Ashim Gupta
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
- South Texas Orthopaedic Research Institute, Laredo, TX 78045, USA.
| | - Cynthia L Cass
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - Kirk Eichenberg
- Department of Chemistry, Illinois State University, Normal, IL 61790, USA.
| | | | - William J Smith
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA.
| | - Ramsin Benyamin
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
- College of Medicine, Department of Surgery, University of Illinois at Urbana-Champaign, Champaign-Urbana, IL 61801, USA.
| | - David L Cedeño
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
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13
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Spinal cord stimulation prevents paclitaxel-induced mechanical and cold hypersensitivity and modulates spinal gene expression in rats. Pain Rep 2019; 4:e785. [PMID: 31875188 PMCID: PMC6882571 DOI: 10.1097/pr9.0000000000000785] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 01/28/2023] Open
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Paclitaxel-induced peripheral neuropathy (PIPN) is a common dose-limiting side effect of this cancer treatment drug. Spinal cord stimulation (SCS) has demonstrated efficacy for attenuating some neuropathic pain conditions. Objective: We aim to examine the inhibitory effect of SCS on the development of PIPN pain and changes of gene expression in the spinal cord in male rats after SCS. Methods: We examined whether traditional SCS (50 Hz, 6–8 h/session daily for 14 consecutive days) administered during paclitaxel treatment (1.5 mg/kg, i.p.) attenuates PIPN-related pain behavior. After SCS treatment, we performed RNA-seq of the lumbar spinal cord to examine which genes are differentially expressed after PIPN with and without SCS. Results: Compared to rats treated with paclitaxel alone (n = 7) or sham SCS (n = 6), SCS treatment (n = 11) significantly inhibited the development of paclitaxel-induced mechanical and cold hypersensitivity, without altering open-field exploratory behavior. RNA-seq showed that SCS induced upregulation of 836 genes and downregulation of 230 genes in the spinal cord of paclitaxel-treated rats (n = 3) as compared to sham SCS (n = 5). Spinal cord stimulation upregulated immune responses in paclitaxel-treated rats, including transcription of astrocyte- and microglial-related genes, but repressed transcription of multiple gene networks associated with synapse transmission, neuron projection development, γ-aminobutyric acid reuptake, and neuronal plasticity. Conclusion: Our findings suggest that traditional SCS may attenuate the development of pain-related behaviors in PIPN rats, possibly by causing aggregate inhibition of synaptic plasticity through upregulation and downregulation of gene networks in the spinal cord.
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14
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Caylor J, Reddy R, Yin S, Cui C, Huang M, Huang C, Rao R, Baker DG, Simmons A, Souza D, Narouze S, Vallejo R, Lerman I. Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectron Med 2019; 5:12. [PMID: 31435499 PMCID: PMC6703564 DOI: 10.1186/s42234-019-0023-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/30/2019] [Indexed: 12/30/2022] Open
Abstract
Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.
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Affiliation(s)
- Jacob Caylor
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Rajiv Reddy
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Sopyda Yin
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Christina Cui
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Mingxiong Huang
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
| | - Charles Huang
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Bioengineering, Stanford University, Palo Alto, CA USA
| | - Ramesh Rao
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
| | - Dewleen G. Baker
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Alan Simmons
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Ricardo Vallejo
- Basic Science Research, Millennium Pain Center, Bloomington, IL USA
- School of Biological Sciences, Illinois State University, Normal, IL USA
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL USA
| | - Imanuel Lerman
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
- Present Address: VA San Diego, 3350 La Jolla Village Dr, (MC116A), San Diego, CA 92161 USA
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15
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Kinfe TM, Asif M, Chakravarthy KV, Deer TR, Kramer JM, Yearwood TL, Hurlemann R, Hussain MS, Motameny S, Wagle P, Nürnberg P, Gravius S, Randau T, Gravius N, Chaudhry SR, Muhammad S. Unilateral L4-dorsal root ganglion stimulation evokes pain relief in chronic neuropathic postsurgical knee pain and changes of inflammatory markers: part II whole transcriptome profiling. J Transl Med 2019; 17:205. [PMID: 31217010 PMCID: PMC6585082 DOI: 10.1186/s12967-019-1952-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/09/2019] [Indexed: 01/08/2023] Open
Abstract
Background In our recent clinical trial, increased peripheral concentrations of pro-inflammatory molecular mediators were determined in complex regional pain syndrome (CRPS) patients. After 3 months adjunctive unilateral, selective L4 dorsal root ganglion stimulation (L4-DRGSTIM), significantly decreased serum IL-10 and increased saliva oxytocin levels were assessed along with an improved pain and functional state. The current study extended molecular profiling towards gene expression analysis of genes known to be involved in the gonadotropin releasing hormone receptor and neuroinflammatory (cytokines/chemokines) signaling pathways. Methods Blood samples were collected from 12 CRPS patients for whole-transcriptome profiling in order to assay 18,845 inflammation-associated genes from frozen blood at baseline and after 3 months L4-DRGSTIM using PANTHER™ pathway enrichment analysis tool. Results Pathway enrichment analyses tools (GOrilla™ and PANTHER™) showed predominant involvement of inflammation mediated by chemokines/cytokines and gonadotropin releasing hormone receptor pathways. Further, screening of differentially regulated genes showed changes in innate immune response related genes. Transcriptomic analysis showed that 21 genes (predominantly immunoinflammatory) were significantly changed after L4-DRGSTIM. Seven genes including TLR1, FFAR2, IL1RAP, ILRN, C5, PKB and IL18 were down regulated and fourteen genes including CXCL2, CCL11, IL36G, CRP, SCGB1A1, IL-17F, TNFRSF4, PLA2G2A, CREB3L3, ADAMTS12, IL1F10, NOX1, CHIA and BDKRB1 were upregulated. Conclusions In our sub-group analysis of L4-DRGSTIM treated CRPS patients, we found either upregulated or downregulated genes involved in immunoinflammatory circuits relevant for the pathophysiology of CRPS indicating a possible relation. However, large biobank-based approaches are recommended to establish genetic phenotyping as a quantitative outcome measure in CRPS patients. Trial registration The study protocol was registered at the 15.11.2016 on German Register for Clinical Trials (DRKS ID 00011267). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011267
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Affiliation(s)
- Thomas M Kinfe
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Sigmund-Freud Street 25, 53105, Bonn, Germany. .,Division of Medical Psychology (NEMO Neuromodulation of Emotions), Rheinische Friedrich-Wilhelms University, Bonn, Germany. .,University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.
| | - Maria Asif
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.,Institute of Biochemistry I, Medical Faculty, University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Krishnan V Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California, San Diego, CA, USA.,San Diego Health Sciences, VA San Diego Healthcare System, San Diego, CA, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Rene Hurlemann
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Sigmund-Freud Street 25, 53105, Bonn, Germany.,Division of Medical Psychology (NEMO Neuromodulation of Emotions), Rheinische Friedrich-Wilhelms University, Bonn, Germany.,University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Muhammad Sajid Hussain
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.,Institute of Biochemistry I, Medical Faculty, University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Susanne Motameny
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany
| | - Prerana Wagle
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Peter Nürnberg
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Sascha Gravius
- University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.,Department of Orthopedics and Trauma Surgery, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Thomas Randau
- University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.,Department of Orthopedics and Trauma Surgery, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Nadine Gravius
- University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.,Department of Orthopedics and Trauma Surgery, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Shafqat R Chaudhry
- Dept. of Basic Medical Sciences Shifa College of Pharmaceutical Sciences, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Sajjad Muhammad
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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16
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Vallejo R, Gupta A, Kelley CA, Vallejo A, Rink J, Williams JM, Cass CL, Smith WJ, Benyamin R, Cedeño DL. Effects of Phase Polarity and Charge Balance Spinal Cord Stimulation on Behavior and Gene Expression in a Rat Model of Neuropathic Pain. Neuromodulation 2019; 23:26-35. [PMID: 31070863 DOI: 10.1111/ner.12964] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/12/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Ricardo Vallejo
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
| | - Ashim Gupta
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
- South Texas Orthopaedic Research Institute Laredo TX USA
| | - Courtney A. Kelley
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
| | | | - Jonathan Rink
- Department of BiologyIllinois Wesleyan University Bloomington IL USA
| | | | - Cynthia L. Cass
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
| | - William J. Smith
- Millennium Pain Center Bloomington IL USA
- Geisel School of MedicineDartmouth College Hanover NH USA
| | - Ramsin Benyamin
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
- College of MedicineUniversity of Illinois at Urbana‐Champaign Champaign‐Urbana IL USA
| | - David L. Cedeño
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
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17
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Changes in Dorsal Root Ganglion Gene Expression in Response to Spinal Cord Stimulation. Reg Anesth Pain Med 2018; 42:246-251. [PMID: 28079752 DOI: 10.1097/aap.0000000000000550] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Spinal cord stimulation (SCS) has been shown to influence pain-related genes in the spinal cord directly under the stimulating electrodes. There is limited information regarding changes occurring at the dorsal root ganglion (DRG). This study evaluates gene expression in the DRG in response to SCS therapy. METHODS Rats were randomized into experimental or control groups (n = 6 per group). Experimental animals underwent spared-nerve injury, implantation of lead, and continuous SCS (72 hours). Behavioral assessment for mechanical hyperalgesia was conducted to compare responses after injury and treatment. Ipsilateral DRG tissue was collected, and gene expression quantified for interleukin 1b (IL-1b), interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), GABA B receptor 1 (GABAbr1), substance P (subP), Integrin alpha M (ITGAM), sodium/potassium ATP-ase (Na/K ATPase), fos proto-oncogene (cFOS), serotonin receptor 3A (5HT3r), galanin (Gal), vasoactive intestinal peptide (VIP), neuropeptide Y (NpY), glial fibrillary acidic protein (GFAP), and brain derived neurotropic factor (BDNF) via quantitative polymerase chain reaction. Statistical significance was established using analysis of variance (ANOVA), independent t tests, and Pearson correlation tests. RESULTS Expression of IL-1b and IL-6 was reversed following SCS therapy relative to the increase caused by the injury model. Both GABAbr1 and Na/K ATPase were significantly up-regulated upon implantation of the lead, and SCS therapy reversed their expression to within control levels. Pearson correlation analyses reveal that GABAbr1 and Na/K ATPase expression was dependent on the stimulating current intensity. CONCLUSIONS Spinal cord stimulation modulates expression of key pain-related genes in the DRG. Specifically, SCS led to reversal of IL-1b and IL-6 expression induced by injury. Interleukin 6 expression was still significantly larger than in sham animals, which may correlate to residual sensitivity following continuous SCS treatment. In addition, expression of GABAbr1 and Na/K ATPase was down-regulated to within control levels following SCS and correlates with applied current.
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18
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Pei W, Zou Y, Wang W, Wei L, Zhao Y, Li L. Tizanidine exerts anti-nociceptive effects in spared nerve injury model of neuropathic pain through inhibition of TLR4/NF-κB pathway. Int J Mol Med 2018; 42:3209-3219. [PMID: 30221670 PMCID: PMC6202089 DOI: 10.3892/ijmm.2018.3878] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/12/2018] [Indexed: 01/26/2023] Open
Abstract
Recently, α2-adrenoceptors (α2-AR) agonists have been shown to have anti-nociceptive effects and thus may become a promising therapeutic strategy for neuropathic pain. tizanidine is a highly selective α2-AR agonist, but the effect mechanism of tizanidine in neuropathic pain remains largely unknown. The present study investigated whether tizanidine has anti-nociceptive effects in spared nerve injury (SNI) model of neuropathic pain in rats, as well as explored the underlying molecular mechanism. We found that the rats in SNI group showed significantly higher mechanical and thermal hyperalgesia, accompanied with increased production of proinflammatory cytokines including interleukin-1β (IL-1β), IL-6 and tumor necrosis factor-α (TNF-α), as well as the activation of Toll-like receptor 4 (TLR4)/nuclear factor-κB (NF-κB) signaling. PDTC, an inhibitor of TLR4/NF-κB signaling, could significantly attenuate the SNI-induced mechanical and thermal hyperalgesia and the production of proinflammatory cytokines. Moreover, treatment with tizanidine also attenuated the SNI-induced mechanical and thermal hyperalgesia, suppressed production of the proinflammatory cytokines, and inhibited the activation of TLR4/NF-κB pathway, which could be reversed by pretreatment with BRL44408, a selective α2-AR antagonist. Taken these findings together, we demonstrated that tizanidine has anti-nociceptive effects on neuropathic pain via inhibiting the production of proinflammatory cytokines through suppressing the activation of TLR4/NF-κB p65 signaling pathway.
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Affiliation(s)
- Wanmin Pei
- Department of Anesthesia, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P.R. China
| | - Yi Zou
- Department of Anesthesia, People's Hospital of Hunan Province, Changsha, Hunan 410005, P.R. China
| | - Wenting Wang
- Department of Anesthesia, People's Hospital of Hunan Province, Changsha, Hunan 410005, P.R. China
| | - Lai Wei
- Department of Anesthesia, People's Hospital of Hunan Province, Changsha, Hunan 410005, P.R. China
| | - Yuan Zhao
- Department of Anesthesia, People's Hospital of Hunan Province, Changsha, Hunan 410005, P.R. China
| | - Li Li
- Department of Anesthesia, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P.R. China
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19
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The Current State of Deep Brain Stimulation for Chronic Pain and Its Context in Other Forms of Neuromodulation. Brain Sci 2018; 8:brainsci8080158. [PMID: 30127290 PMCID: PMC6119957 DOI: 10.3390/brainsci8080158] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 12/26/2022] Open
Abstract
Chronic intractable pain is debilitating for those touched, affecting 5% of the population. Deep brain stimulation (DBS) has fallen out of favour as the centrally implantable neurostimulation of choice for chronic pain since the 1970–1980s, with some neurosurgeons favouring motor cortex stimulation as the ‘last chance saloon’. This article reviews the available data and professional opinion of the current state of DBS as a treatment for chronic pain, placing it in the context of other neuromodulation therapies. We suggest DBS, with its newer target, namely anterior cingulate cortex (ACC), should not be blacklisted on the basis of a lack of good quality study data, which often fails to capture the merits of the treatment.
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20
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Sorrell RG, Muhlenfeld J, Moffett J, Stevens G, Kesten S. Evaluation of pulsed electromagnetic field therapy for the treatment of chronic postoperative pain following lumbar surgery: a pilot, double-blind, randomized, sham-controlled clinical trial. J Pain Res 2018; 11:1209-1222. [PMID: 29950893 PMCID: PMC6018879 DOI: 10.2147/jpr.s164303] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background The incidence of chronic postoperative pain following lumbar spinal surgery has increased with the overall increase in the prevalence of lumbar surgery. This study was conducted to evaluate the analgesic effectiveness of pulsed electromagnetic field (PEMF) therapy in subjects with persistent pain following lumbar surgery. Patients and methods A randomized, double-blind, sham-controlled, multicenter study in 36 subjects with persistent low-back and/or radiating leg pain after lumbar surgery was conducted. Eligible subjects were randomized (1:1:1) to receive one of two doses of therapy (42-μs or 38-μs pulse width) or treatment with a sham device. Subjects self-treated twice daily for 60 days. The primary end point was change in pain intensity (∆PI) using the Numerical Pain Rating Scale between average baseline (Days −5 to −1) and end of treatment (Days 56–60) for lumbar and radiating leg pain. Secondary outcome measures included the Oswestry Disability Index, Beck Depression Inventory-II, Patient Global Impression of Change, and consumption of analgesics. Results Low-back pain scores for the 42-μs group decreased by 40.2% (p = 0.028), compared to 18.6% for the 38-μs pulse width group (p = 0.037) and 25.6% for the sham group (p = 0.013 per protocol population). Average leg pain scores decreased by 45.0% (42 μs, p = 0.009), 17.0% (38 μs, p = 0.293), and 24.5% (sham, p = 0.065). The proportion of subjects responding to therapy, time to 30% reduction in pain scores, and Patient Global Impression of Change were improved with the PEMF 42-μs device over the sham control, although results were associated with p-values >0.05. Conclusion PEMF therapy (42-μs pulse width) was associated with trends for a reduction in pain, compared to sham treatment. Secondary endpoints were consistent with an overall beneficial effect of the PEMF 42-μs pulse width device.
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21
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Stephens KE, Chen Z, Sivanesan E, Raja SN, Linderoth B, Taverna SD, Guan Y. RNA-seq of spinal cord from nerve-injured rats after spinal cord stimulation. Mol Pain 2018; 14:1744806918817429. [PMID: 30451078 PMCID: PMC6293371 DOI: 10.1177/1744806918817429] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/28/2018] [Accepted: 11/12/2018] [Indexed: 12/12/2022] Open
Abstract
Spinal cord stimulation has become an important modality in pain treatment especially for neuropathic pain conditions refractory to pharmacotherapy. However, the molecular control of inhibitory and excitatory mechanisms observed after spinal cord stimulation are poorly understood. Here, we used RNA-seq to identify differences in the expression of genes and gene networks in spinal cord tissue from nerve-injured rats with and without repetitive conventional spinal cord stimulation treatment. Five weeks after chronic constrictive injury to the left sciatic nerve, male and female rats were randomized to receive repetitive spinal cord stimulation or no treatment. Rats receiving spinal cord stimulation underwent epidural placement of a miniature stimulating electrode and received seven sessions of spinal cord stimulation (50 Hz, 80% motor threshold, 0.2 ms, constant current bipolar stimulation, 120 min/session) over four consecutive days. Within 2 h after the last spinal cord stimulation treatment, the L4-L6 spinal segments ipsilateral to the side of nerve injury were harvested and used to generate libraries for RNA-seq. Our RNA-seq data suggest further increases of many existing upregulated immune responses in chronic constrictive injury rats after repetitive spinal cord stimulation, including transcription of cell surface receptors and activation of non-neuronal cells. We also demonstrate that repetitive spinal cord stimulation represses transcription of several key synaptic signaling genes that encode scaffold proteins in the post-synaptic density. Our transcriptional studies suggest a potential relationship between specific genes and the therapeutic effects observed in patients undergoing conventional spinal cord stimulation after nerve injury. Furthermore, our results may help identify new therapeutic targets for improving the efficacy of conventional spinal cord stimulation and other chronic pain treatments.
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Affiliation(s)
- Kimberly E Stephens
- Department of Pharmacology and Molecular Sciences,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- Center for Epigenetics, School of Medicine, Johns
Hopkins University, Baltimore, MA, USA
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Zhiyong Chen
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- Institute of Basic Medical Sciences, Department of
Human Anatomy, Histology and Embryology, Neuroscience Center, Chinese
Academy of Medical Sciences, School of Basic Medicine, Peking Union
Medical College, Beijing, China
| | - Eellan Sivanesan
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Srinivasa N Raja
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Bengt Linderoth
- Division of Functional Neurosurgery, Department of
Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sean D Taverna
- Department of Pharmacology and Molecular Sciences,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- Center for Epigenetics, School of Medicine, Johns
Hopkins University, Baltimore, MA, USA
| | - Yun Guan
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- School of Medicine, Department of Neurological
Surgery, Johns Hopkins University, Baltimore, MA, USA
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22
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Linderoth B, Foreman RD. Conventional and Novel Spinal Stimulation Algorithms: Hypothetical Mechanisms of Action and Comments on Outcomes. Neuromodulation 2017; 20:525-533. [PMID: 28568898 DOI: 10.1111/ner.12624] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/18/2017] [Accepted: 05/08/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) emerged as a direct clinical spin-off from the Gate Control Theory from 1965. Over the last decade, several new modes of SCS have appeared. This review discusses these novel techniques and their hypothetical mechanisms of action. MATERIAL AND METHODS A recent literature search on SCS coupled with the most recent data from poster presentations and congress lectures have been used to illustrate new hypothetical ways of modulating pain. RESULTS Several physiological and neurochemical mechanisms for conventional paresthetic SCS have been described in detail. However, much less is known about the novel SCS modes of action. One new algorithm utilizes very high frequencies (up to 10 kHz) intended for direct stimulation of dorsal horns at the T9-T10 level to treat both low back pain and leg pain. Another technique uses bursts of impulses with a high internal frequency delivered to the dorsal spinal cord with a frequency of 40 Hz. Both of these therapies intend to be subparesthetic and effective both for neuropathic and nociceptive pain components. During the last few years, more moderate changes in SCS parameters have been tried in order to increase the amount of electric charge passed from the lead to the neural tissue. This strategy, called "high density SCS," utilizes frequencies up to 1200 Hz or long pulse widths. CONCLUSIONS The present SCS therapies have developed beyond the Gate Control Concept. New hypotheses about mechanisms of action are presented and some improved results are discussed.
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Affiliation(s)
- Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Sweden
| | - Robert D Foreman
- Department of Physiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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23
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Zhang S, Kartha S, Lee J, Winkelstein BA. Techniques for Multiscale Neuronal Regulation via Therapeutic Materials and Drug Design. ACS Biomater Sci Eng 2017; 3:2744-2760. [DOI: 10.1021/acsbiomaterials.7b00012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Sijia Zhang
- Department of Bioengineering, University of Pennsylvania, 210 S. 33rd Street, 240 Skirkanich
Hall, Philadelphia, Pennsylvania 19104, United States
| | - Sonia Kartha
- Department of Bioengineering, University of Pennsylvania, 210 S. 33rd Street, 240 Skirkanich
Hall, Philadelphia, Pennsylvania 19104, United States
| | - Jasmine Lee
- Department of Physics and Astronomy, University of Pennsylvania, 209 S. 33rd Street, David Rittenhouse Laboratory, Philadelphia, Pennsylvania 19104, United States
| | - Beth A. Winkelstein
- Department of Bioengineering, University of Pennsylvania, 210 S. 33rd Street, 240 Skirkanich
Hall, Philadelphia, Pennsylvania 19104, United States
- Department
of Neurosurgery, University of Pennsylvania, Stemmler Hall, 3450 Hamilton Walk, Philadelphia, Pennsylvania 19104, United States
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24
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Surgical Neurostimulation for Spinal Cord Injury. Brain Sci 2017; 7:brainsci7020018. [PMID: 28208601 PMCID: PMC5332961 DOI: 10.3390/brainsci7020018] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 01/07/2023] Open
Abstract
Traumatic spinal cord injury (SCI) is a devastating neurological condition characterized by a constellation of symptoms including paralysis, paraesthesia, pain, cardiovascular, bladder, bowel and sexual dysfunction. Current treatment for SCI involves acute resuscitation, aggressive rehabilitation and symptomatic treatment for complications. Despite the progress in scientific understanding, regenerative therapies are lacking. In this review, we outline the current state and future potential of invasive and non-invasive neuromodulation strategies including deep brain stimulation (DBS), spinal cord stimulation (SCS), motor cortex stimulation (MCS), transcutaneous direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in the context of SCI. We consider the ability of these therapies to address pain, sensorimotor symptoms and autonomic dysregulation associated with SCI. In addition to the potential to make important contributions to SCI treatment, neuromodulation has the added ability to contribute to our understanding of spinal cord neurobiology and the pathophysiology of SCI.
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