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Mittal R, McKenna K, Keith G, McKenna E, Lemos JRN, Mittal J, Hirani K. Diabetic peripheral neuropathy and neuromodulation techniques: a systematic review of progress and prospects. Neural Regen Res 2025; 20:2218-2230. [PMID: 39359078 DOI: 10.4103/nrr.nrr-d-24-00270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/06/2024] [Indexed: 10/04/2024] Open
Abstract
Neuromodulation for diabetic peripheral neuropathy represents a significant area of interest in the management of chronic pain associated with this condition. Diabetic peripheral neuropathy, a common complication of diabetes, is characterized by nerve damage due to high blood sugar levels that lead to symptoms, such as pain, tingling, and numbness, primarily in the hands and feet. The aim of this systematic review was to evaluate the efficacy of neuromodulatory techniques as potential therapeutic interventions for patients with diabetic peripheral neuropathy, while also examining recent developments in this domain. The investigation encompassed an array of neuromodulation methods, including frequency rhythmic electrical modulated systems, dorsal root ganglion stimulation, and spinal cord stimulation. This systematic review suggests that neuromodulatory techniques may be useful in the treatment of diabetic peripheral neuropathy. Understanding the advantages of these treatments will enable physicians and other healthcare providers to offer additional options for patients with symptoms refractory to standard pharmacologic treatments. Through these efforts, we may improve quality of life and increase functional capacity in patients suffering from complications related to diabetic neuropathy.
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Affiliation(s)
- Rahul Mittal
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Keelin McKenna
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Grant Keith
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Evan McKenna
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joana R N Lemos
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jeenu Mittal
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Khemraj Hirani
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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Abd-Elsayed A, Stark CW, Topoluk N, Isaamullah M, Uzodinma P, Viswanath O, Gyorfi MJ, Fattouh O, Schlidt KC, Dyara O. A brief review of complex regional pain syndrome and current management. Ann Med 2024; 56:2334398. [PMID: 38569195 PMCID: PMC10993759 DOI: 10.1080/07853890.2024.2334398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/28/2024] [Indexed: 04/05/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating chronic pain condition that, although exceedingly rare, carries a significant burden for the affected patient population. The complex and ambiguous pathophysiology of this condition further complicates clinical management and therapeutic interventions. Furthermore, being a diagnosis of exclusion requires a diligent workup to ensure an accurate diagnosis and subsequent targeted management. The development of the Budapest diagnostic criteria helped to consolidate existing definitions of CRPS but extensive work remains in identifying the underlying pathways. Currently, two distinct types are identified by the presence (CRPS type 1) or absence (CRPS type 2) of neuronal injury. Current management directed at this disease is broad and growing, ranging from non-invasive modalities such as physical and psychological therapy to more invasive techniques such as dorsal root ganglion stimulation and potentially amputation. Ideal therapeutic interventions are multimodal in nature to address the likely multifactorial pathological development of CRPS. Regardless, a significant need remains for continued studies to elucidate the pathways involved in developing CRPS as well as more robust clinical trials for various treatment modalities.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of WI School of Medicine and Public Health, Madison, WI, USA
| | - Cain W. Stark
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Natasha Topoluk
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Mir Isaamullah
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Paul Uzodinma
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Omar Viswanath
- Anesthesiology, LSU Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Michael J. Gyorfi
- Department of Anesthesiology, University of WI School of Medicine and Public Health, Madison, WI, USA
| | - Osama Fattouh
- Department of Neurobiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Kevin C. Schlidt
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Omar Dyara
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
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Her YF, Churchill RA. Case Report: Rescue of Relapsed Pain in a Patient with Complex Regional Pain Syndrome Type II by Adding Another Dorsal Root Ganglion Lead. Int Med Case Rep J 2024; 17:765-769. [PMID: 39220373 PMCID: PMC11363934 DOI: 10.2147/imcrj.s477303] [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: 05/08/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024] Open
Abstract
We present on a patient with complex regional pain syndrome (CRPS) following ankle surgery. Pain was refractory to both conservative and surgical measures including neurotomies, ankle fusion, hardware removal, and spinal cord stimulation (SCS) trial. A dorsal root ganglion (DRG) stimulation trial with lead placements at L4, L5, and S1 provided significant pain and functional improvement. However, during the implantation, we were able to place only two DRG leads at L4 and L5 and not S1 due to difficulties with advancing the lead to the desired location. Nonetheless, the two DRG leads provided 90% pain relief and 75% functional improvement for 9 months. However, the patient experienced pain symptoms similar to that of pre-implant without a clear trigger after 9 months despite no DRG stimulator hardware malfunction or lead migration. A decision was made to re-try implanting the S1 DRG lead, which was successful and provided significant pain relief.
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Affiliation(s)
- Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert A Churchill
- Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, Rochester, MN, 55905, USA
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Ting JE, Hooper CA, Dalrymple AN, Weber DJ. Tonic Stimulation of Dorsal Root Ganglion Results in Progressive Decline in Recruitment of Aα/β-Fibers in Rats. Neuromodulation 2024:S1094-7159(24)00631-7. [PMID: 39046395 DOI: 10.1016/j.neurom.2024.06.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 06/26/2024] [Accepted: 06/26/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVES In this study, we aimed to characterize the recruitment and maintenance of action potential firing in Aα/β-fibers generated during tonic dorsal root ganglion stimulation (DRGS) applied over a range of clinically relevant stimulation parameters. MATERIALS AND METHODS We delivered electrical stimulation to the L5 dorsal root ganglion and recorded antidromic evoked compound action potentials (ECAPs) in the sciatic nerve during DRGS in Sprague Dawley rats. We measured charge thresholds to elicit ECAPs in Aα/β-fibers during DRGS applied at multiple pulse widths (50, 150, 300, 500 μs) and frequencies (5, 20, 50, 100 Hz). We measured the peak-to-peak amplitudes, latencies, and widths of ECAPs generated during 180 seconds of DRGS, and excitation threshold changes to investigate potential mechanisms of ECAP suppression. RESULTS Tonic DRGS produced ECAPs in Aα/β-fibers at charge thresholds below the motor threshold. Increasing the pulse width of DRGS led to a significant increase in the charge required to elicit ECAPs in Aα/β-fibers, while varying DRGS frequency did not influence ECAP thresholds. Over the course of 180 seconds, ECAP peak-to-peak amplitude decreased progressively in a frequency-dependent manner, where 5- and 100-Hz DRGS resulted in 22% and 87% amplitude reductions, respectively, and ECAP latencies increased from baseline measurements during DRGS at 10, 20, 50, and 100 Hz. Regardless of DRGS frequency, ECAP amplitudes recovered within 120 seconds after turning DRGS off. We determined that ECAP suppression may be attributed to increasing excitation thresholds for individual fibers during DRGS. Following 180 seconds of DRGS, an average of 7.33% increase in stimulation amplitude was required to restore the ECAP to baseline amplitude. CONCLUSIONS DRGS produces a progressive and frequency-dependent reduction in ECAP amplitude that occurs within and above the frequency range used clinically to relieve pain. If DRGS-mediated analgesia relies on Aβ-fiber activation, then the frequency or duty cycle of stimulation should be set to the lowest effective level to maintain sufficient activation of Aβ-fibers.
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Affiliation(s)
- Jordyn E Ting
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charli Ann Hooper
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Ashley N Dalrymple
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA; Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA; Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Douglas J Weber
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA; Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA, USA.
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Marciuš T, Deftu AF, Vuka I, Braeken D, Sapunar D. Electrophysiological properties of dorsal root ganglion neurons cultured on 3D silicon micro-pillar substrates. J Neurosci Methods 2024; 407:110143. [PMID: 38670536 DOI: 10.1016/j.jneumeth.2024.110143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/27/2024] [Accepted: 04/20/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Silicon-based micro-pillar substrates (MPS), as three-dimensional cell culture platforms with vertically aligned micro-patterned scaffolding structures, are known to facilitate high-quality growth and morphology of dorsal root ganglion (DRG) sensory neurons, promote neurite outgrowth and enhance neurite alignment. However, the electrophysiological aspects of DRG neurons cultured on silicon MPSs have not been thoroughly investigated, which is of greatest importance to ensure that such substrates do not disrupt neuronal homeostasis and function before their widespread adoption in diverse biomedical applications. NEW METHOD We conducted whole-cell patch-clamp recordings to explore the electrophysiological properties of DRG neurons cultured on MPS arrays, utilizing a custom-made upright patch-clamp setup. RESULTS Our findings revealed that DRG neurons exhibited similar electrophysiological responses on patterned MPS samples when compared to the control planar glass surfaces. Notably, there were no significant differences observed in the action potential parameters or firing patterns of action potentials between neurons grown on either substrate. COMPARISON WITH EXISTING METHODS In the current study we for the first time confirmed that successful electrophysiological recordings can be obtained from the cells grown on MPS. CONCLUSION Our results imply that, despite the potential alterations caused by the cumulative trauma of tissue harvest and cell dissociation, essential functional cell properties of DRG neurons appear to be relatively maintained on MPS surfaces. Therefore, vertically aligned silicon MPSs could be considered as a potentially effective three-dimensional system for supporting a controlled cellular environment in culture.
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Affiliation(s)
- Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, Split 21000, Croatia
| | - Alexandru-Florian Deftu
- Pain Center, Department of Anesthesiology, Lausanne University Hospital and Department of Fundamental Neurosciences, University of Lausanne, Lausanne 1011, Switzerland
| | - Ivana Vuka
- Technology Transfer Office, Department of Science and Innovation, University of Split, Split 21000, Croatia
| | - Dries Braeken
- Life Sciences Technologies, Imec, Leuven 3001, Belgium
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Split 21000, Croatia.
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Chapman KB, Amireh A, van Helmond N, Yousef TA. Evaluation of Washout Periods After Dorsal Root Ganglion Stimulation Trial. Neuromodulation 2024; 27:881-886. [PMID: 38551547 DOI: 10.1016/j.neurom.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE Dorsal root ganglion stimulation (DRG-S) is a novel therapy to treat chronic pain. It has shown efficacy when delivered intermittently, suggesting a delayed washout effect exists. To measure the washout period, and to determine whether there are differences in washout times among different types of treated pain, we measured the time for pain to return at the end of the patients' one-week DRG stimulation trials. MATERIALS AND METHODS Patients who completed a successful DRG-S trial were included. The times until 25% (t25) and 90% (t90) of baseline pain level returned were recorded. The patients were divided into neuropathic, nociceptive, and mixed pain groups for subgroup comparison. t25 and t90 were plotted in the entire cohort and subgroups using reverse Kaplan-Meier plots (failure curves) and compared using a log-rank test. RESULTS In total, 29 consecutive patients were included. Median t25 and t90 times were 7.1 and 19.5 hours, respectively. Median (interquartile range) times were longest for the nociceptive pain group (n = 17) and shortest for the neuropathic pain group (n = 6), with the mixed-pain group (n = 6) in between (t25: 7.1 [1.7-19.4], 3.40 [1.4-8.4], and 5.7 [0.8-17.6]; t90, 22.0 [10.7-71.0], 7.6 [3.6-19.8], and 20.9 [14.2-31.2], respectively). t90 times differed significantly by pain type (p = 0.040). CONCLUSIONS This study showed a prolonged washout period after cessation of DRG-S therapy. Washout times vary according to pain type. The observed effects are possibly due to long-term depression of pain signaling and could allow the implementation of alternative stimulation strategies with DRG-S. Further investigations evaluating DRG-S washout times are warranted.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York City, NY, USA; Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA; The Zucker School of Medicine at Hofstra/Northwell, New York City, NY, USA; Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen, Nijmegen, The Netherlands.
| | - Ahmad Amireh
- The Spine & Pain Institute of New York, New York City, NY, USA
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York City, NY, USA; Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Tariq A Yousef
- The Spine & Pain Institute of New York, New York City, NY, USA
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Yang A, Yousef TA, Aggarwal N, Chapman KB. Dorsal Root Ganglion Stimulation for the Management of Inflammatory Bowel Disease: A Case Report. A A Pract 2024; 18:e01804. [PMID: 38904332 PMCID: PMC11213498 DOI: 10.1213/xaa.0000000000001804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/22/2024]
Abstract
This case report presents the successful use of dorsal root ganglion stimulation (DRGS) in a 30-year-old female patient with Crohn's disease. Despite extensive treatments, the patient experienced chronic abdominal pain, diarrhea, bloating, cramping, fatigue, and other debilitating symptoms. After a successful DRGS trial with leads placed on the right T6 and T10, she was implanted with a permanent system. At 18 months she continues to experience significant improvement in symptoms, including reduced abdominal pain, decreased defecation frequency, better stool consistency, less pain with eating and bowel evacuation, and enhanced quality of life.
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Affiliation(s)
- Ajax Yang
- From the Interventional Pain Medicine, The Spine and Pain Institute of New York, New York, New York
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York
| | - Tariq A Yousef
- From the Interventional Pain Medicine, The Spine and Pain Institute of New York, New York, New York
| | - Nitish Aggarwal
- From the Interventional Pain Medicine, The Spine and Pain Institute of New York, New York, New York
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York
| | - Kenneth B Chapman
- From the Interventional Pain Medicine, The Spine and Pain Institute of New York, New York, New York
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York
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Kim JH, Cetinkaya-Fisgin A, Zahn N, Sari MC, Hoke A, Barman I. Label-Free Visualization and Morphological Profiling of Neuronal Differentiation and Axonal Degeneration through Quantitative Phase Imaging. Adv Biol (Weinh) 2024; 8:e2400020. [PMID: 38548657 PMCID: PMC11090721 DOI: 10.1002/adbi.202400020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Indexed: 05/15/2024]
Abstract
Understanding the intricate processes of neuronal growth, degeneration, and neurotoxicity is paramount for unraveling nervous system function and holds significant promise in improving patient outcomes, especially in the context of chemotherapy-induced peripheral neuropathy (CIPN). These processes are influenced by a broad range of entwined events facilitated by chemical, electrical, and mechanical signals. The progress of each process is inherently linked to phenotypic changes in cells. Currently, the primary means of demonstrating morphological changes rely on measurements of neurite outgrowth and axon length. However, conventional techniques for monitoring these processes often require extensive preparation to enable manual or semi-automated measurements. Here, a label-free and non-invasive approach is employed for monitoring neuronal differentiation and degeneration using quantitative phase imaging (QPI). Operating on unlabeled specimens and offering little to no phototoxicity and photobleaching, QPI delivers quantitative maps of optical path length delays that provide an objective measure of cellular morphology and dynamics. This approach enables the visualization and quantification of axon length and other physical properties of dorsal root ganglion (DRG) neuronal cells, allowing greater understanding of neuronal responses to stimuli simulating CIPN conditions. This research paves new avenues for the development of more effective strategies in the clinical management of neurotoxicity.
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Affiliation(s)
- Jeong Hee Kim
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Aysel Cetinkaya-Fisgin
- Department of Neurology, Neuromuscular Division, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Noah Zahn
- Department Chemical & Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Mehmet Can Sari
- Department of Neurology, Neuromuscular Division, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Ahmet Hoke
- Department of Neurology, Neuromuscular Division, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Ishan Barman
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, 21218, USA
- Department of Oncology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
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9
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Han YF, Cong X. Comparison of the efficacy of spinal cord stimulation and dorsal root ganglion stimulation in the treatment of painful diabetic peripheral neuropathy: a prospective, cohort-controlled study. Front Neurol 2024; 15:1366796. [PMID: 38660091 PMCID: PMC11039825 DOI: 10.3389/fneur.2024.1366796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024] Open
Abstract
Objective The aim of this study was to compare the clinical outcomes of spinal cord stimulation (SCS) and dorsal root ganglion stimulation (DRG-S) in the treatment of painful diabetic peripheral neuropathy (PDPN). Methods In this prospective cohort study, 55 patients received dorsal column spinal cord stimulation (SCS group) and 51 patients received dorsal root spinal cord stimulation (DRG-S group). The primary outcome was a Numerical Rating Scale (NRS) remission rate of ≥50%, and secondary outcomes included the effects of SCS and DRG-S on quality of life scores (EQ-5D-3L), nerve conduction velocity, and HbA1c, respectively. Results The percentage of NRS remission rate ≥ 50% at 6 months was 80.43 vs. 79.55%, OR (95% CI): 1.06 (0.38-2.97) in the SCS and DRG-S groups, respectively, and the percentage of VAS remission rate ≥ 50% at 12 months was 79.07 vs. 80.95%, OR (95% CI): 0.89 (0.31-2.58). Compared with baseline, there were significant improvements in EQ-5D and EQ-VAS at 6 and 12 months (p < 0.05), but there was no difference in improvement between the SCS and DRG-S groups (p > 0.05). Nerve conduction velocities of the common peroneal, peroneal, superficial peroneal, and tibial nerves were significantly improved at 6 and 12 months compared with the preoperative period in both the SCS and PND groups (p < 0.05). However, at 6 and 12 months, there was no difference in HbA1c between the two groups (p > 0.05). Conclusion Both SCS and DRG-S significantly improved pain, quality of life, and lower extremity nerve conduction velocity in patients with PDPN, and there was no difference between the two treatments at 12 months.
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Affiliation(s)
| | - Xi Cong
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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10
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Abd-Elsayed A, Vardhan S, Aggarwal A, Vardhan M, Diwan SA. Mechanisms of Action of Dorsal Root Ganglion Stimulation. Int J Mol Sci 2024; 25:3591. [PMID: 38612402 PMCID: PMC11011701 DOI: 10.3390/ijms25073591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/12/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
The dorsal root ganglion (DRG) serves as a pivotal site for managing chronic pain through dorsal root ganglion stimulation (DRG-S). In recent years, the DRG-S has emerged as an attractive modality in the armamentarium of neuromodulation therapy due to its accessibility and efficacy in alleviating chronic pain refractory to conventional treatments. Despite its therapeutic advantages, the precise mechanisms underlying DRG-S-induced analgesia remain elusive, attributed in part to the diverse sensory neuron population within the DRG and its modulation of both peripheral and central sensory processing pathways. Emerging evidence suggests that DRG-S may alleviate pain by several mechanisms, including the reduction of nociceptive signals at the T-junction of sensory neurons, modulation of pain gating pathways within the dorsal horn, and regulation of neuronal excitability within the DRG itself. However, elucidating the full extent of DRG-S mechanisms necessitates further exploration, particularly regarding its supraspinal effects and its interactions with cognitive and affective networks. Understanding these mechanisms is crucial for optimizing neurostimulation technologies and improving clinical outcomes of DRG-S for chronic pain management. This review provides a comprehensive overview of the DRG anatomy, mechanisms of action of the DRG-S, and its significance in neuromodulation therapy for chronic pain.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA
| | - Swarnima Vardhan
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06605, USA; (S.V.); (A.A.)
- Advanced Spine on Park Avenue, New York, NY 10461, USA;
| | - Abhinav Aggarwal
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06605, USA; (S.V.); (A.A.)
| | - Madhurima Vardhan
- Argonne Leadership Computing Facility, Argonne National Laboratory, Lemont, IL 60439, USA;
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Markewych AN, Suvar T, Swanson MA, Graca MJ, Lubenow TR, McCarthy RJ, Buvanendran A, Kurlander DE. Approaches to neuropathic amputation-related pain: narrative review of surgical, interventional, and medical treatments. Reg Anesth Pain Med 2024:rapm-2023-105089. [PMID: 38307612 DOI: 10.1136/rapm-2023-105089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/26/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND/IMPORTANCE Neuropathic amputation-related pain can consist of phantom limb pain (PLP), residual limb pain (RLP), or a combination of both pathologies. Estimated of lifetime prevalence of pain and after amputation ranges between 8% and 72%. OBJECTIVE This narrative review aims to summarize the surgical and non-surgical treatment options for amputation-related neuropathic pain to aid in developing optimized multidisciplinary and multimodal treatment plans that leverage multidisciplinary care. EVIDENCE REVIEW A search of the English literature using the following keywords was performed: PLP, amputation pain, RLP. Abstract and full-text articles were evaluated for surgical treatments, medical management, regional anesthesia, peripheral block, neuromodulation, spinal cord stimulation, dorsal root ganglia, and peripheral nerve stimulation. FINDINGS The evidence supporting most if not all interventions for PLP are inconclusive and lack high certainty. Targeted muscle reinnervation and regional peripheral nerve interface are the leading surgical treatment options for reducing neuroma formation and reducing PLP. Non-surgical options include pharmaceutical therapy, regional interventional techniques and behavioral therapies that can benefit certain patients. There is a growing evidence that neuromodulation at the spinal cord or the dorsal root ganglia and/or peripheral nerves can be an adjuvant therapy for PLP. CONCLUSIONS Multimodal approaches combining pharmacotherapy, surgery and invasive neuromodulation procedures would appear to be the most promising strategy for preventive and treating PLP and RLP. Future efforts should focus on cross-disciplinary education to increase awareness of treatment options exploring best practices for preventing pain at the time of amputation and enhancing treatment of chronic postamputation pain.
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Affiliation(s)
| | - Tolga Suvar
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Marco A Swanson
- Department of Plastic & Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mateusz J Graca
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy R Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - David E Kurlander
- Department of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois, USA
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12
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Rahimibarghani S, Morgan R, Diaz JJ. Neuromodulation Techniques in Chronic Refractory Coccydynia: A Narrative Review. Pain Ther 2024; 13:53-67. [PMID: 38175492 PMCID: PMC10796902 DOI: 10.1007/s40122-023-00572-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
Refractory coccydynia is a condition characterized by severe coccygeal pain and poses a challenging management dilemma for clinicians. Advancements in neuromodulation (NM) technology have provided benefits to people experiencing chronic pain that is resistant to standard treatments. This review aims to summarize the spectrum of current NM techniques employed in the treatment of refractory coccydynia along with their effectiveness. A review of studies in the scientific literature from 2012 to 2023 was conducted, revealing a limited number of case reports. Although the available evidence at this time suggests significant pain relief with the utilization of NM techniques, the limited scope and nature of the studies reviewed emphasize the need for large-scale, rigorous, high-level research in this domain in order to establish a comprehensive understanding of the role of NM and its effectiveness in the management of intractable coccydynia.
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Affiliation(s)
- Sarvenaz Rahimibarghani
- Physical Medicine and Rehabilitation Department, Tehran University of Medical Sciences, Tehran, Iran.
| | - Richard Morgan
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Jose Juan Diaz
- Physical Medicine and Rehabilitation Department, Larkin Community Hospital, South Miami Campus, South Miami, FL, USA
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Mons MR, Chapman KB, Terwiel C, Joosten EA, Kallewaard JW. Burst Spinal Cord Stimulation as Compared With L2 Dorsal Root Ganglion Stimulation in Pain Relief for Nonoperated Discogenic Low Back Pain: Analysis of Two Prospective Studies. Neuromodulation 2024; 27:172-177. [PMID: 37191612 DOI: 10.1016/j.neurom.2023.04.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/26/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Chronic discogenic low back pain (CD-LBP) is caused by degenerated disks marked by neural and vascular ingrowth. Spinal cord stimulation (SCS) has been shown to be effective for pain relief in patients who are not responsive to conventional treatments. Previously, the pain-relieving effect of two variations of SCS has been evaluated in CD-LBP: Burst SCS and L2 dorsal root ganglion stimulation (DRGS). The aim of this study is to compare the effectivity in pain relief and pain experience of Burst SCS with that of conventional L2 DRGS in patients with CD-LBP. MATERIALS AND METHODS Subjects were implanted with either Burst SCS (n = 14) or L2 DRGS with conventional stimulation (n = 15). Patients completed the numeric pain rating score (NRS) for back pain and Oswestry disability index (ODI) and EuroQoL 5D (EQ-5D) questionnaires at baseline, and at three, six, and 12 months after implantation. Data were compared between time points and between groups. RESULTS Both Burst SCS and L2 DRGS significantly decreased NRS, ODI, and EQ-5D scores as compared with baseline. L2 DRGS resulted in significantly lower NRS scores at 12 months and significantly increased EQ-5D scores at six and 12 months. CONCLUSIONS Both L2 DRGS and Burst SCS resulted in reduction of pain and disability, and increased quality of life in patients with CD-LBP. L2 DRGS provided significantly increased pain relief and improvement in quality of life when compared with Burst SCS. CLINICAL TRIAL REGISTRATION The clinical trial registration numbers for the study are NCT03958604 and NL54405.091.15.
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Affiliation(s)
- Martijn R Mons
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Translational Neuroscience, School for Mental Health and Neuroscience, University of Maastricht, Maastricht, The Netherlands.
| | - Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA; Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Chris Terwiel
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Translational Neuroscience, School for Mental Health and Neuroscience, University of Maastricht, Maastricht, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands; Department of Anesthesiology and Pain Management, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Wahezi SE, Caparo MA, Malhotra R, Sundaram L, Batti K, Ejindu P, Veeramachaneni R, Anitescu M, Hunter CW, Naeimi T, Farah F, Kohan L. Current Waveforms in Spinal Cord Stimulation and Their Impact on the Future of Neuromodulation: A Scoping Review. Neuromodulation 2024; 27:47-58. [PMID: 38184341 DOI: 10.1016/j.neurom.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/16/2023] [Accepted: 11/13/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Neuromodulation is a standard and well-accepted treatment for chronic refractory neuropathic pain. There has been progressive innovation in the field over the last decade, particularly in areas of spinal cord stimulation (SCS) and dorsal root ganglion stimulation. Improved outcomes using proprietary waveforms have become customary in the field, leading to an unprecedented expansion of these products and a plethora of options for the management of pain. Although advances in waveform technology have improved our fundamental understanding of neuromodulation, a scoping review describing new energy platforms and their associated clinical effects and outcomes is needed. The authors submit that understanding electrophysiological neuromodulation may be important for clinical decision-making and programming selection for personalized patient care. OBJECTIVE This review aims to characterize ways differences in mechanism of action and clinical outcomes of current spinal neuromodulation products may affect contemporary clinical decision-making while outlining a possible path for the future SCS. STUDY DESIGN The study is a scoping review of the literature about newer generation SCS waveforms. MATERIALS AND METHODS A literature report was performed on PubMed and chapters to include articles on spine neuromodulation mechanism of action and efficacy. RESULTS A total of 8469 studies were identified, 75 of which were included for the scoping review after keywords defining recent waveform technology were added. CONCLUSIONS Clinical data suggest that neuromodulation remains a promising tool in the treatment of chronic pain. The evidence for SCS for treating chronic pain seems compelling; however, more long-term and comparative data are needed for a comparison of waveforms when it comes to the etiology of pain. In addition, an exploration into combination waveform therapy and waveform cycling may be paramount for future clinical studies and the development of new technologies.
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Affiliation(s)
- Sayed E Wahezi
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA.
| | - Moorice A Caparo
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Ria Malhotra
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Lakshman Sundaram
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Kevin Batti
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Prince Ejindu
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | | | - Magdalena Anitescu
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Corey W Hunter
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Tahereh Naeimi
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Fadi Farah
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Lynn Kohan
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
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15
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Zhou S, Nerusu LA, Hussain N, Abd-Elsayed A. Sacral neuromodulation. NEUROMODULATION TECHNIQUES FOR THE SPINE 2024:137-149. [DOI: 10.1016/b978-0-323-87584-4.00026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Tabatabaei P, Salomonsson J, Kakas P, Eriksson M. Bilateral T12 Dorsal Root Ganglion Stimulation for the Treatment of Low Back Pain With 20-Hz and 4-Hz Stimulation, a Retrospective Study. Neuromodulation 2024; 27:141-150. [PMID: 37542505 DOI: 10.1016/j.neurom.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Chronic low back pain (CLBP) is one of the most common chronic pain conditions that cause both individual suffering and a burden to society. For these patients, several interventional treatment options such as surgery, blocks, radiofrequency, and spinal cord stimulation are available. Lately, dorsal root ganglion stimulation (DRG-S) also has been mentioned as an option by targeting bilateral T12 dorsal ganglia. In this study, we present the outcome of 11 patients with CLBP treated with bilateral T12 DRG-S. MATERIALS AND METHODS Thirteen patients with CLBP with and without leg pain were treated with bilateral T12 DRG-S. Three of the patients also received a third lumbar lead owing to leg pain. Eleven of the patients had >50% pain relief during the peri- or/and postoperative testing and received a fully implantable neurostimulator. Pain intensity, general health status, quality of life, pain catastrophizing, mental status, sleeping disorder, physical activity, and patient satisfaction were followed using numeric rating scale (NRS), Patient-Reported Outcomes Measurement Information System 29 version 2.1, Pain Catastrophizing Score, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire Depression Module, Insomnia Severity Index, and Patient Satisfaction Questionnaire at baseline before implantation and at three months and six months. The results were analyzed on the basis of six domains: pain relief, sleeping disorder, social ability, mental status, physical activity, and satisfaction. To be identified as a responder, the patients should show a significant improvement in the pain relief domain together with at least two other domains. All responders also were given the opportunity to test 4-Hz DRG-S and compare it with traditional 20-Hz stimulation. RESULTS All 11 patients were identified as responders at six months. Five of the patients had >80% pain relief, with an average NRS score reduction of 71% for the whole group. Significant improvement could be observed in three domains for one patient, four domains for three patients, five domains for six patients, and six domains for one patient. Seven patients chose to try 4-Hz stimulation. All seven identified 4-Hz stimulation as at least as good as or better than 20-Hz stimulation and chose to continue with 4-Hz stimulation. CONCLUSIONS Bilateral T12 DRG-S seems to be an effective treatment for chronic low back pain, with significant beneficial effect not only on pain but also on quality of life, pain catastrophizing, mental status, sleeping disorder, and physical activity. 4-Hz DRG-S gave a result comparable with or better than 20-Hz stimulation.
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Affiliation(s)
| | | | - Pavlina Kakas
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Maria Eriksson
- Department of Clinical Science, Umeå University, Umeå, Sweden
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17
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Koetsier E, Vacchi E, Maino P, Dukanac J, Melli G, van Kuijk SMJ. Dorsal Root Ganglion Stimulation in Chronic Painful Polyneuropathy: A Potential Modulator for Small Nerve Fiber Regeneration. Neuromodulation 2023; 26:1772-1780. [PMID: 36192280 DOI: 10.1016/j.neurom.2022.08.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/02/2022] [Accepted: 08/23/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Neuromodulatory treatments like spinal cord stimulation and dorsal root ganglion stimulation (DRGS) have emerged as effective treatments to relieve pain in painful polyneuropathy. Animal studies have demonstrated that neurostimulation can enhance nerve regeneration. This study aimed to investigate if DRGS may impact intraepidermal nerve fiber regeneration and sensory nerve function. MATERIALS AND METHODS Nine patients with chronic, intractable painful polyneuropathy were recruited. Intraepidermal nerve fiber density (IENFD) quantification in 3 mm punch skin biopsy was performed 1 month before DRGS (placed at the level of the L5 and S1 dorsal root ganglion) and after 12- and 24-month follow-up. Quantitative sensory testing, nerve conduction studies, and a clinical scale score were also performed at the same time points. RESULTS In 7 of 9 patients, DRGS was successful (defined as a reduction of ≥ 50% in daytime and/or night-time pain intensity), allowing a definitive implantable pulse generator implantation. The median baseline IENFD among these 7 patients was 1.6 fibers/mm (first and third quartile: 1.2; 4.3) and increased to 2.6 fibers/mm (2.5; 2.9) and 1.9 fibers/mm (1.6; 2.4) at 1- and 2-years follow-up, respectively. These changes were not statistically significant (p = 1.000 and 0.375). Sensory nerve tests did not show substantial changes. CONCLUSIONS Although not significant, the results of this study showed that in most of the patients with implants, there was a slight increase of the IENFD at the 1- and 2-year follow-up. Larger-scale clinical trials are warranted to explore the possible role of DRGS in reversing the progressive neurodegeneration over time. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02435004; Swiss National Clinical Trials Portal: SNCTP000001376.
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Affiliation(s)
- Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| | - Elena Vacchi
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Laboratories for Translational Research, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Jasmina Dukanac
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giorgia Melli
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Laboratories for Translational Research, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Sander M J van Kuijk
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
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18
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Chapman KB, Tupper C, Yousef T, van Helmond N. Dorsal Root Ganglion Stimulation to Treat Chronic Shoulder Pain: A Case Report. A A Pract 2023; 17:e01718. [PMID: 37966349 DOI: 10.1213/xaa.0000000000001718] [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: 11/16/2023]
Abstract
A 67-year-old man presented with severe 9 of 10 intractable pain of the left shoulder joint after arthroplasty and revision surgeries, with associated weakness, atrophy, and limited range of motion in all directions. Dorsal root ganglion stimulation (DRG-S) at the left C4, C5, and C6 levels was used after failed conservative and interventional measures, resulting in significant improvement in pain, function, and quality of life measures through 6 months postimplantation. Larger studies should examine if DRG-S is effective in treating chronic arthritic joint pain as well as chronic postsurgical pain of the shoulder that is not predominantly neuropathic.
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Affiliation(s)
- Kenneth B Chapman
- Pain Management, The Spine & Pain Institute of New York, New York, New York
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York
- Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | - Connor Tupper
- Pain Management, The Spine & Pain Institute of New York, New York, New York
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Tariq Yousef
- Pain Management, The Spine & Pain Institute of New York, New York, New York
| | - Noud van Helmond
- Pain Management, The Spine & Pain Institute of New York, New York, New York
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
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19
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Ghorayeb JH, Chitneni A, Rupp A, Parkash A, Abd-Elsayed A. Dorsal root ganglion stimulation for the treatment of chronic pelvic pain: A systematic review. Pain Pract 2023; 23:838-846. [PMID: 37246484 DOI: 10.1111/papr.13255] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Chronic pelvic pain (CPP) is a difficult condition to treat. Due to complex pelvic innervation, dorsal column spinal cord stimulation (SCS) has not been shown to produce the same effect as dorsal root ganglion stimulation (DRGS) given emerging evidence suggesting that applying DRGS may result in favorable outcomes for individuals with CPP. The aim of this systematic review is to investigate the clinical use and effectiveness of DRGS for patients with CPP. MATERIALS AND METHODS A systematic review of clinical studies demonstrating the use of DRGS for CPP. Searches were conducted using four electronic databases (PubMed, EMBASE, CINAHL, and Web of Science) across August and September 2022. RESULTS A total of nine studies comprising 65 total patients with variable pelvic pain etiologies met the inclusion criteria. The majority of subjects implanted with DRGS reported >50% mean pain reduction at variable times of follow-up. Secondary outcomes reported throughout studies including quality of life (QOL) and pain medication consumption were reported to be significantly improved. CONCLUSIONS Dorsal root ganglion stimulation for CPP continues to lack supportive evidence from well-designed, high-quality studies and recommendations from consensus committee experts. However, we present consistent evidence from level IV studies showing success with the use of DRGS for CPP in reducing pain symptoms along with reports of improved QOL through periods as short as 2 months to as long as 3 years. Because the available studies at this time are of low quality with a high risk of bias, we strongly recommend the facilitation of high-quality studies with larger sample sizes in order to better ascertain the utility of DRGS for this specific patient population. At the same time, from a clinical perspective, it may be reasonable and appropriate to evaluate patients for DRGS candidacy on a case-by-case basis, especially those patients who report CPP symptoms that are refractory to noninterventional measures and who may not be ideal candidates for other forms of neuromodulation.
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Affiliation(s)
- Joe H Ghorayeb
- University of Medicine and Health Sciences, New York, New York, USA
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, New York, USA
| | - Adam Rupp
- Department of Physical Medicine and Rehabilitation, University of Kansas Health System, Kansas City, Kansas, USA
| | - Anishinder Parkash
- Department of Physical Medicine and Rehabilitation, Tower Health Reading Hospital/Drexel University COM, Redding, Pennsylvania, USA
| | - Alaa Abd-Elsayed
- Division of Pain Medicine, Department of Anesthesia, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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20
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Intisar A, Woo H, Kang HG, Kim WH, Shin HY, Kim MY, Kim YS, Mo YJ, Lee YI, Kim MS. Electroceutical approach ameliorates intracellular PMP22 aggregation and promotes pro-myelinating pathways in a CMT1A in vitro model. Biosens Bioelectron 2023; 224:115055. [PMID: 36630746 DOI: 10.1016/j.bios.2022.115055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 01/01/2023]
Abstract
Charcot-Marie-Tooth disease subtype 1A (CMT1A) is one of the most prevalent demyelinating peripheral neuropathies worldwide, caused by duplication of the peripheral myelin protein 22 (PMP22) gene, which is expressed primarily in Schwann cells (SCs). PMP22 overexpression in SCs leads to intracellular aggregation of the protein, which eventually results in demyelination. Unfortunately, previous biochemical approaches have not resulted in an approved treatment for CMT1A disease, compelling the pursuit for a biophysical approach such as electrical stimulation (ES). However, the effects of ES on CMT1A SCs have remained unexplored. In this study, we established PMP22-overexpressed Schwannoma cells as a CMT1A in vitro model, and investigated the biomolecular changes upon applying ES via a custom-made high-throughput ES platform, screening for the condition that delivers optimal therapeutic effects. While PMP22-overexpressed Schwannoma exhibited intracellular PMP22 aggregation, ES at 20 Hz for 1 h improved this phenomenon, bringing PMP22 distribution closer to healthy condition. ES at this condition also enhanced the expression of the genes encoding myelin basic protein (MBP) and myelin-associated glycoprotein (MAG), which are essential for assembling myelin sheath. Furthermore, ES altered the gene expression for myelination-regulating transcription factors Krox-20, Oct-6, c-Jun and Sox10, inducing pro-myelinating effects in PMP22-overexpressed Schwannoma. While electroceuticals has previously been applied in the peripheral nervous system towards acquired peripheral neuropathies such as pain and nerve injury, this study demonstrates its effectiveness towards ameliorating biomolecular abnormalities in an in vitro model of CMT1A, an inherited peripheral neuropathy. These findings will facilitate the clinical translation of an electroceutical treatment for CMT1A.
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Affiliation(s)
- Aseer Intisar
- Department of New Biology, DGIST, Daegu, 42988, Republic of Korea
| | - Hanwoong Woo
- Department of New Biology, DGIST, Daegu, 42988, Republic of Korea
| | - Hyun Gyu Kang
- Department of New Biology, DGIST, Daegu, 42988, Republic of Korea
| | - Woon-Hae Kim
- Department of New Biology, DGIST, Daegu, 42988, Republic of Korea; CTCELLS Corp., Daegu, 42988, Republic of Korea
| | - Hyun Young Shin
- Department of New Biology, DGIST, Daegu, 42988, Republic of Korea; CTCELLS Corp., Daegu, 42988, Republic of Korea; SBCure Corp., Daegu, 43017, Republic of Korea
| | - Min Young Kim
- Department of New Biology, DGIST, Daegu, 42988, Republic of Korea
| | - Yu Seon Kim
- Well Aging Research Center, DGIST, Daegu, 42988, Republic of Korea
| | - Yun Jeoung Mo
- Well Aging Research Center, DGIST, Daegu, 42988, Republic of Korea
| | - Yun-Il Lee
- Well Aging Research Center, DGIST, Daegu, 42988, Republic of Korea
| | - Minseok S Kim
- Department of New Biology, DGIST, Daegu, 42988, Republic of Korea; CTCELLS Corp., Daegu, 42988, Republic of Korea; Translational Responsive Medicine Center (TRMC), DGIST, Daegu, 42988, Republic of Korea; New Biology Research Center (NBRC), DGIST, Daegu, 42988, Republic of Korea.
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21
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Medina R, Ho A, Reddy R, Chen J, Castellanos J. Narrative review of current neuromodulation modalities for spinal cord injury. FRONTIERS IN PAIN RESEARCH 2023; 4:1143405. [PMID: 36969918 PMCID: PMC10033643 DOI: 10.3389/fpain.2023.1143405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Neuromodulation is a developing field of medicine that includes a vast array of minimally invasive and non-invasive therapies including transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), vagus nerve stimulation (VNS), peripheral nerve stimulation, and spinal cord stimulation (SCS). Although the current literature surrounding the use of neuromodulation in managing chronic pain is abundant, there is an insufficient amount of evidence specifically regarding neuromodulation in patients with spinal cord injury (SCI). Given the pain and functional deficits that these patients face, that are not amenable to other forms conservative therapy, the purpose of this narrative review is to examine and assess the use of various neuromodulation modalities to manage pain and restore function in the SCI population. Currently, high-frequency spinal cord stimulation (HF-SCS) and burst spinal cord stimulation (B-SCS) have been shown to have the most promising effect in improving pain intensity and frequency. Additionally, dorsal root ganglion stimulation (DRG-S) and TMS have been shown to effectively increase motor responses and improve limb strength. Although these modalities carry the potential to enhance overall functionality and improve a patient's degree of disability, there is a lack of long-term, randomized-controlled trials in the current space. Additional research is warranted to further support the clinical use of these emerging modalities to provide improved pain management, increased level of function, and ultimately an overall better quality of life in the SCI population.
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Affiliation(s)
- Roi Medina
- Department of Physical Medicine and Rehabilitation, Lake Erie College of Osteopathic Medicine-Bradenton, Bradenton, FL, United States
| | - Alison Ho
- Department of Physical Medicine and Rehabilitation, Baylor University Medical Center, Dallas, TX, United States
| | - Rajiv Reddy
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Jeffrey Chen
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Joel Castellanos
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
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22
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Parkash A, Ghorayeb JH, Levy I, Upadhyay A, Srinivasan S, Chauhan G. Dorsal root ganglion stimulation for treatment of chronic postsurgical pain secondary to triple neurectomy. INTERVENTIONAL PAIN MEDICINE 2023; 2:100245. [PMID: 39239604 PMCID: PMC11372865 DOI: 10.1016/j.inpm.2023.100245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 09/07/2024]
Abstract
Triple neurectomy (resection of Ilioinguinal, Iliohypogastric, and Genitofemoral nerves) is performed in cases of inguinal neuralgia, refractory to conservative management. However, this procedure comes with several adverse effects, including but not limited to ectopic afferent firing and tactile allodynia. In such a scenario, the inguinal pain can become chronic and debilitating and can be classified as chronic post-surgical pain. Spinal neuromodulation techniques have been employed for treating such refractory, intractable chronic groin, pelvic and abdominal pain. One such technique is dorsal root ganglion stimulation which is designed to manage difficult-to-treat chronic pain in specific areas of the lower body, such as the foot, knee, hip, or groin. The authors present a case in which the patient underwent a laparoscopic neurectomy of ilioinguinal, Iliohypogastric, and genitofemoral nerves that failed to resolve her pain-related symptoms. The patient presented to the authors' pain clinic with severe inguinal pain and allodynia, refractory to multiple analgesic agents. The patient underwent a successful trial and subsequent implant with ipsilateral dorsal root ganglion stimulation at L1& L2. At six months post-implant, the patient continues to report 80-90% improvement in her pain and physical function.
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Affiliation(s)
- Anishinder Parkash
- Department of Physical Medicine and Rehabilitation, Tower Health Reading Hospital/Drexel, University COM, 420 S 5th Ave, West Reading, PA, 19611, USA
| | - Joe H Ghorayeb
- University of Medicine and Health Sciences, 275 7th Ave 26th Floor, New York, NY, 10001, USA
| | - Isaiah Levy
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Aman Upadhyay
- Department of Anesthesiology and Perioperative Medicine, McLaren Oakland Hospital 50 Perry St, Pontiac, MI, 48342, USA
| | - Suresh Srinivasan
- Department of Pain Medicine, 000 Johnson Rd, Steubenville, OH, 43952, USA
| | - Gaurav Chauhan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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23
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Does Fibromyalgia Affect the Outcomes of Spinal Cord Stimulation: An 11-Year, Multicenter, Retrospective Matched Cohort Study. Neuromodulation 2023; 26:206-214. [PMID: 35840522 DOI: 10.1016/j.neurom.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/21/2022] [Accepted: 05/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Fibromyalgia is a prevalent disorder manifesting with widespread musculoskeletal pain and central sensitization, as well as fatigue, sleep issues, psychologic distress, and poor quality of life. Patients with fibromyalgia also may be diagnosed with other painful conditions amenable to treatment with spinal cord stimulation (SCS), although it is unclear how these patients respond to SCS compared with patients without fibromyalgia. MATERIALS AND METHODS We performed an 11-year, multicenter, retrospective matched cohort study comparing SCS-treated patients with fibromyalgia and those without fibromyalgia. The primary outcome was comparison in mean calculated percentage pain relief between cohorts at six months after SCS implantation. Secondary outcomes included comparison of patient satisfaction between six and 12 months after SCS implantation, and percentage of patients reporting opioid intake and neuropathic medication intake at six months and 12 months after SCS implantation. Adjusted regression analysis was performed to make comparisons while adjusting for age, sex, body mass index, Charlson comorbidity index, preoperative opioid intake, and preoperative neuropathic medication intake. RESULTS Of 90 patients with fibromyalgia who underwent SCS trial, 18 patients (20%) failed their SCS trial and did not proceed toward implantation. Sixty-eight patients with fibromyalgia were matched to 141 patients in the control cohort based on age, sex, Charlson comorbidity index, and the American Society of Anesthesiologists physical status score. At six months after SCS implantation, there was no statistical difference in calculated percentage change in pain intensity between the fibromyalgia cohort (46.6 ± 29.0) and the control cohort (50.9 ± 32.8; β, -18.4; 95% CI, -44.3 to 7.6; p = 0.157). At baseline, a greater percentage of patients in the fibromyalgia cohort reported preoperative opioid intake (51.5% vs 22.7%, p < 0.001) and preoperative neuropathic medication intake (67.6% vs 15.6%, p < 0.001). However, there was no difference between cohorts in the percentage of patients taking opioid or neuropathic medications at six months and 12 months after SCS implantation. Similarly, there was no difference between cohorts in the percentage of patients reporting satisfaction between six and 12 months. CONCLUSION Patients with fibromyalgia who received a diagnosis approved for treatment with SCS may expect similar post-SCS-implantation pain relief, overall satisfaction, and analgesic use rate to those of patients without fibromyalgia.
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Intisar A, Shin HY, Kim W, Kang HG, Kim MY, Kim YS, Cho Y, Mo YJ, Lim H, Lee S, Lu QR, Lee Y, Kim MS. Implantable Electroceutical Approach Improves Myelination by Restoring Membrane Integrity in a Mouse Model of Peripheral Demyelinating Neuropathy. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2201358. [PMID: 35975427 PMCID: PMC9661852 DOI: 10.1002/advs.202201358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/22/2022] [Indexed: 06/15/2023]
Abstract
Although many efforts are undertaken to treat peripheral demyelinating neuropathies based on biochemical interventions, unfortunately, there is no approved treatment yet. Furthermore, previous studies have not shown improvement of the myelin membrane at the biomolecular level. Here, an electroceutical treatment is introduced as a biophysical intervention to treat Charcot-Marie-Tooth (CMT) disease-the most prevalent peripheral demyelinating neuropathy worldwide-using a mouse model. The specific electrical stimulation (ES) condition (50 mV mm-1 , 20 Hz, 1 h) for optimal myelination is found via an in vitro ES screening system, and its promyelinating effect is validated with ex vivo dorsal root ganglion model. Biomolecular investigation via time-of-flight secondary ion mass spectrometry shows that ES ameliorates distribution abnormalities of peripheral myelin protein 22 and cholesterol in the myelin membrane, revealing the restoration of myelin membrane integrity. ES intervention in vivo via flexible implantable electrodes shows not only gradual rehabilitation of mouse behavioral phenotypes (balance and endurance), but also restored myelin thickness, compactness, and membrane integrity. This study demonstrates, for the first time, that an electroceutical approach with the optimal ES condition has the potential to treat CMT disease and restore impaired myelin membrane integrity, shifting the paradigm toward practical interventions for peripheral demyelinating neuropathies.
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Affiliation(s)
- Aseer Intisar
- Department of New BiologyDGISTDaegu42988Republic of Korea
| | - Hyun Young Shin
- CTCELLS Corp.Daegu42988Republic of Korea
- SBCure Corp.Daegu43017Republic of Korea
| | | | - Hyun Gyu Kang
- Department of New BiologyDGISTDaegu42988Republic of Korea
| | - Min Young Kim
- Department of New BiologyDGISTDaegu42988Republic of Korea
| | - Yu Seon Kim
- Well Aging Research CenterDGISTDaegu42988Republic of Korea
| | - Youngjun Cho
- Department of Robotics and Mechatronics EngineeringDGISTDaegu42988Republic of Korea
| | - Yun Jeoung Mo
- Well Aging Research CenterDGISTDaegu42988Republic of Korea
| | - Heejin Lim
- Department of New BiologyDGISTDaegu42988Republic of Korea
| | - Sanghoon Lee
- Department of Robotics and Mechatronics EngineeringDGISTDaegu42988Republic of Korea
| | - Q. Richard Lu
- Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOH45229USA
| | - Yun‐Il Lee
- Well Aging Research CenterDGISTDaegu42988Republic of Korea
| | - Minseok S. Kim
- Department of New BiologyDGISTDaegu42988Republic of Korea
- CTCELLS Corp.Daegu42988Republic of Korea
- Translational Responsive Medicine Center (TRMC)DGISTDaegu42988Republic of Korea
- New Biology Research Center (NBRC)DGISTDaegu42988Republic of Korea
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25
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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: 38] [Impact Index Per Article: 19.0] [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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Itson-Zoske B, Shin SM, Xu H, Qiu C, Fan F, Hogan QH, Yu H. Selective block of sensory neuronal T-type/Cav3.2 activity mitigates neuropathic pain behavior in a rat model of osteoarthritis pain. Arthritis Res Ther 2022; 24:168. [PMID: 35842727 PMCID: PMC9287929 DOI: 10.1186/s13075-022-02856-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Peripheral and central nociceptive sensitization is a critical pathogenetic component in osteoarthritis (OA) chronic pain. T-type calcium channel 3.2 (CaV3.2) regulates neuronal excitability and plays important roles in pain processing. We previously identified that enhanced T-type/CaV3.2 activity in the primary sensory neurons (PSNs) of dorsal root ganglia (DRG) is associated with neuropathic pain behavior in a rat model of monosodium iodoacetate (MIA)-induced knee OA. PSN-specific T-type/CaV3.2 may therefore represent an important mediator in OA painful neuropathy. Here, we test the hypothesis that the T-type/CaV3.2 channels in PSNs can be rationally targeted for pain relief in MIA-OA. METHODS MIA model of knee OA was induced in male and female rats by a single injection of 2 mg MIA into intra-knee articular cavity. Two weeks after induction of knee MIA-OA pain, recombinant adeno-associated viruses (AAV)-encoding potent CaV3.2 inhibitory peptide aptamer 2 (CaV3.2iPA2) that have been characterized in our previous study were delivered into the ipsilateral lumbar 4/5 DRG. Effectiveness of DRG-CaV3.2iPA2 treatment on evoked (mechanical and thermal) and spontaneous (conditioned place preference) pain behavior, as well as weight-bearing asymmetry measured by Incapacitance tester, in the arthritic limbs of MIA rats were evaluated. AAV-mediated transgene expression in DRG was determined by immunohistochemistry. RESULTS AAV-mediated expression of CaV3.2iPA2 selective in the DRG-PSNs produced significant and comparable mitigations of evoked and spontaneous pain behavior, as well as normalization of weight-bearing asymmetry in both male and female MIA-OA rats. Analgesia of DRG-AAV-CaV3.2iPA1, another potent CaV3.2 inhibitory peptide, was also observed. Whole-cell current-clamp recordings showed that AAV-mediated CaV3.2iPA2 expression normalized hyperexcitability of the PSNs dissociated from the DRG of MIA animals, suggesting that CaV3.2iPA2 attenuated pain behavior by reversing MIA-induced neuronal hyperexcitability. CONCLUSIONS Together, our results add therapeutic support that T-type/CaV3.2 in primary sensory pathways contributes to MIA-OA pain pathogenesis and that CaV3.2iPAs are promising analgesic leads that, combined with AAV-targeted delivery in anatomically segmental sensory ganglia, have the potential for further development as a peripheral selective T-type/CaV3.2-targeting strategy in mitigating chronic MIA-OA pain behavior. Validation of the therapeutic potential of this strategy in other OA models may be valuable in future study.
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Affiliation(s)
- Brandon Itson-Zoske
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Seung Min Shin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Hao Xu
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
- Department of Orthopedic Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chensheng Qiu
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
- Department of Orthopedic Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fan Fan
- Department of Pharmacology and Toxicology, Mississippi University Medical Center, Jackson, MS, 39216, USA
| | - Quinn H Hogan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Hongwei Yu
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.
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27
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Potter ST, Welch S, Tata F, Probert S, Nagpal A. Dorsal Root Ganglion Stimulation. Phys Med Rehabil Clin N Am 2022; 33:359-378. [DOI: 10.1016/j.pmr.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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28
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Chen L, Guo T, Zhang S, Smith PP, Feng B. Blocking peripheral drive from colorectal afferents by subkilohertz dorsal root ganglion stimulation. Pain 2022; 163:665-681. [PMID: 34232925 PMCID: PMC8720331 DOI: 10.1097/j.pain.0000000000002395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 06/16/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Clinical evidence indicates dorsal root ganglion (DRG) stimulation effectively reduces pain without the need to evoke paresthesia. This paresthesia-free anesthesia by DRG stimulation can be promising to treat pain from the viscera, where paresthesia usually cannot be produced. Here, we explored the mechanisms and parameters for DRG stimulation using an ex vivo preparation with mouse distal colon and rectum (colorectum), pelvic nerve, L6 DRG, and dorsal root in continuity. We conducted single-fiber recordings from split dorsal root filaments and assessed the effect of DRG stimulation on afferent neural transmission. We determined the optimal stimulus pulse width by measuring the chronaxies of DRG stimulation to be below 216 µs, indicating spike initiation likely at attached axons rather than somata. Subkilohertz DRG stimulation significantly attenuates colorectal afferent transmission (10, 50, 100, 500, and 1000 Hz), of which 50 and 100 Hz show superior blocking effects. Synchronized spinal nerve and DRG stimulation reveals a progressive increase in conduction delay by DRG stimulation, suggesting activity-dependent slowing in blocked fibers. Afferents blocked by DRG stimulation show a greater increase in conduction delay than the unblocked counterparts. Midrange frequencies (50-500 Hz) are more efficient at blocking transmission than lower or higher frequencies. In addition, DRG stimulation at 50 and 100 Hz significantly attenuates in vivo visceromotor responses to noxious colorectal balloon distension. This reversible conduction block in C-type and Aδ-type afferents by subkilohertz DRG stimulation likely underlies the paresthesia-free anesthesia by DRG stimulation, thereby offering a promising new approach for managing chronic visceral pain.
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Affiliation(s)
- Longtu Chen
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269
| | - Tiantian Guo
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269
| | - Shaopeng Zhang
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269
| | - Phillip P. Smith
- School of Medicine, University of Connecticut Health Center, Farmington, CT 06030
| | - Bin Feng
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269
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29
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Graham RD, Sankarasubramanian V, Lempka SF. Dorsal Root Ganglion Stimulation for Chronic Pain: Hypothesized Mechanisms of Action. THE JOURNAL OF PAIN 2022; 23:196-211. [PMID: 34425252 PMCID: PMC8943693 DOI: 10.1016/j.jpain.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 07/20/2021] [Indexed: 02/03/2023]
Abstract
Dorsal root ganglion stimulation (DRGS) is a neuromodulation therapy for chronic pain that is refractory to conventional medical management. Currently, the mechanisms of action of DRGS-induced pain relief are unknown, precluding both our understanding of why DRGS fails to provide pain relief to some patients and the design of neurostimulation technologies that directly target these mechanisms to maximize pain relief in all patients. Due to the heterogeneity of sensory neurons in the dorsal root ganglion (DRG), the analgesic mechanisms could be attributed to the modulation of one or many cell types within the DRG and the numerous brain regions that process sensory information. Here, we summarize the leading hypotheses of the mechanisms of DRGS-induced analgesia, and propose areas of future study that will be vital to improving the clinical implementation of DRGS. PERSPECTIVE: This article synthesizes the evidence supporting the current hypotheses of the mechanisms of action of DRGS for chronic pain and suggests avenues for future interdisciplinary research which will be critical to fully elucidate the analgesic mechanisms of the therapy.
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Affiliation(s)
- Robert D. Graham
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Vishwanath Sankarasubramanian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Scott F. Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States,Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109, United States,Corresponding author: Scott F. Lempka, PhD, Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, NCRC 14-184, Ann Arbor, MI 48109-2800,
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30
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Stress-related dysautonomias and neurocardiology-based treatment approaches. Auton Neurosci 2022; 239:102944. [DOI: 10.1016/j.autneu.2022.102944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 10/13/2021] [Accepted: 01/16/2022] [Indexed: 11/21/2022]
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31
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Graham RD, Jhand AS, Lempka SF. Dorsal root ganglion stimulation produces differential effects on action potential propagation across a population of biophysically distinct C-neurons. FRONTIERS IN PAIN RESEARCH 2022; 3:1017344. [PMID: 36387415 PMCID: PMC9643723 DOI: 10.3389/fpain.2022.1017344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022] Open
Abstract
Dorsal root ganglion stimulation (DRGS) is a neurostimulation therapy used to manage chronic pain that does not respond to conventional therapies. Unfortunately, not all patients receive sufficient pain relief from DRGS, leaving them with few other treatment options. Presently, our understanding of the mechanisms of action of DRGS is incomplete, preventing us from determining why some patients do not receive analgesia from the therapy. One hypothesis suggests that DRGS augments the filtering of action potentials (APs) at the T-junction of nociceptive C-neurons. To test this hypothesis, we utilized a computational modeling approach in which we developed a population of one thousand biophysically distinct C-neuron models which each produced electrophysiological characteristics (e.g., AP height, AP duration) reported in previous experimental studies. We used this population of model C-neurons to study how morphological and electrophysiological characteristics affected the propagation of APs through the T-junction. We found that trains of APs can propagate through the T-junction in the orthodromic direction at a higher frequency than in the antidromic direction due to the decrease in axonal diameter from the peripheral to spinal axon. Including slow outward conductances in the axonal compartments near the T-junction reduced following frequencies to ranges measured experimentally. We next used the population of C-neuron models to investigate how DRGS affected the orthodromic propagation of APs through the T-junction. Our data suggest that suprathreshold DRGS augmented the filtering of APs at the T-junction of some model C-neurons while increasing the activity of other model C-neurons. However, the stimulus pulse amplitudes required to induce activity in C-neurons (i.e., several mA) fell outside the range of stimulation pulse amplitudes used clinically (i.e., typically ≤1 mA). Furthermore, our data suggest that somatic GABA currents activated directly or indirectly by the DRGS pulse may produce diverse effects on orthodromic AP propagation in C-neurons. These data suggest DRGS may produce differential effects across a population of C-neurons and indicate that understanding how inherent biological variability affects a neuron's response to therapeutic electrical stimulation may be helpful in understanding its mechanisms of action.
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Affiliation(s)
- Robert D Graham
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, United States
| | - Amolak S Jhand
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, United States
| | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, United States.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
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32
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D'Souza RS, Kubrova E, Her YF, Barman RA, Smith BJ, Alvarez GM, West TE, Abd-Elsayed A. Dorsal Root Ganglion Stimulation for Lower Extremity Neuropathic Pain Syndromes: An Evidence-Based Literature Review. Adv Ther 2022; 39:4440-4473. [PMID: 35994195 PMCID: PMC9464732 DOI: 10.1007/s12325-022-02244-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/23/2022] [Indexed: 01/30/2023]
Abstract
Dorsal root ganglion stimulation (DRG-S) is a form of selective neuromodulation therapy that targets the dorsal root ganglion. DRG-S offers analgesia in a variety of chronic pain conditions and is approved for treatment of complex regional pain syndrome (CRPS) by the US Food and Drug Administration (FDA). There has been increasing utilization of DRG-S to treat various neuropathic pain syndromes of the lower extremity, although evidence remains limited to one randomized controlled trial and 39 observational studies. In this review, we appraised the current evidence for DRG-S in the treatment of lower extremity neuropathic pain using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. The primary outcome was change in pain intensity after DRG-S compared to baseline. We stratified presentation of results based of type of neuropathy (CRPS, painful diabetic neuropathy, mononeuropathy, polyneuropathy) as well as location of neuropathy (hip, knee, foot). Future powered randomized controlled trials with homogeneous participants are warranted.
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Affiliation(s)
- Ryan S D'Souza
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eva Kubrova
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Yeng F Her
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross A Barman
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon J Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Gabriel M Alvarez
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Tyler E West
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA.
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Intermittent Dorsal Root Ganglion Stimulation Is as Efficacious as Standard Continuous Dosing in Treating Chronic Pain: Results From a Randomized Controlled Feasibility Trial. Neuromodulation 2022; 25:989-997. [DOI: 10.1016/j.neurom.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022]
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34
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Intisar A, Kim WH, Shin HY, Kim MY, Kim YS, Lim H, Kang HG, Mo YJ, Aly MAS, Lee YI, Kim MS. An electroceutical approach enhances myelination via upregulation of lipid biosynthesis in the dorsal root ganglion. Biofabrication 2021; 14. [PMID: 34933294 DOI: 10.1088/1758-5090/ac457c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/21/2021] [Indexed: 11/12/2022]
Abstract
As the myelin sheath is crucial for neuronal saltatory conduction, loss of myelin in the peripheral nervous system (PNS) leads to demyelinating neuropathies causing muscular atrophy, numbness, foot deformities and paralysis. Unfortunately, few interventions are available for such neuropathies, because previous pharmaceuticals have shown severe side effects and failed in clinical trials. Therefore, exploring new strategies to enhance PNS myelination is critical to provide solution for such intractable diseases. This study aimed to investigate the effectiveness of electrical stimulation (ES) to enhance myelination in the mouse dorsal root ganglion (DRG) - an ex vivo model of the PNS. Mouse embryonic DRGs were extracted at E13 and seeded onto Matrigel-coated surfaces. After sufficient growth and differentiation, screening was carried out by applying ES in the 1-100 Hz range at the beginning of the myelination process. DRG myelination was evaluated via immunostaining at the intermediate (19 DIV) and mature (30 DIV) stages. Further biochemical analyses were carried out by utilizing RNA sequencing, qPCR and biochemical assays at both intermediate and mature myelination stages. Imaging of DRG myelin lipids was carried out via time-of-flight secondary ion mass spectrometry (ToF-SIMS). With screening ES conditions, optimal condition was identified at 20 Hz, which enhanced the percentage of myelinated neurons and average myelin length not only at intermediate (129% and 61%) but also at mature (72% and 17%) myelination stages. Further biochemical analyses elucidated that ES promoted lipid biosynthesis in the DRG. ToF-SIMS imaging showed higher abundance of the structural lipids, cholesterol and sphingomyelin, in the myelin membrane. Therefore, promotion of lipid biosynthesis and higher abundance of myelin lipids led to ES-mediated myelination enhancement. Given that myelin lipid deficiency is culpable for most demyelinating PNS neuropathies, the results might pave a new way to treat such diseases via electroceuticals.
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Affiliation(s)
- Aseer Intisar
- New Biology, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Woon-Hae Kim
- CTCELLS Corp., 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Hyun Young Shin
- CTCELLS Corp., 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Min Young Kim
- New Biology, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Yu Seon Kim
- Well Aging Research Center, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Heejin Lim
- New Biology, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Hyun Gyu Kang
- New Biology, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Yun Jeoung Mo
- Well Aging Research Center, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Mohamed Aly Saad Aly
- New Biology, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Yun-Il Lee
- Well Aging Research Center, DGIST, 333 Techno Jungang-daero, Hyeonpung-eup, Dalseong-gun, Daegu, 42988, Korea (the Republic of)
| | - Minseok S Kim
- New Biology, DGIST, Room 313, Building E5, DGIST, Daegu, 42988, Korea (the Republic of)
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Vuka I, Marciuš T, Kovačić D, Šarolić A, Puljak L, Sapunar D. Implantable, Programmable, and Wireless Device for Electrical Stimulation of the Dorsal Root Ganglion in Freely-Moving Rats: A Proof of Concept Study. J Pain Res 2021; 14:3759-3772. [PMID: 34916842 PMCID: PMC8668248 DOI: 10.2147/jpr.s332438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This was a proof of concept study, based on systematic reviews of the efficacy and safety of the dorsal root ganglion (DRG) stimulation. The main objective was to develop an implantable, programmable, and wireless device for electrical stimulation of DRG and a methodology that can be used in translational research, especially to understand the mechanism of neuromodulation and to test new treatment modalities in animal models of pain. Methods We developed and tested a stimulator that uses a battery-powered microelectronic circuit, to generate constant current square biphasic or monophasic pulsed waveform of variable amplitudes and duration. It is controlled by software and an external controller that allows radio frequency communication with the stimulator. The stimulator was implanted in Sprague–Dawley (SD) rats. The lead was positioned at the L5 DRG level, while the stimulator was placed in the skin pocket at the ipsilateral side. Forty-five animals were used and divided into six groups: spinal nerve ligation (SNL), chronic compression injury of the DRG (CCD), SNL + active DRG stimulation, intact control group, group with the implanted sham stimulator, and sham lead. Behavioral testing was performed on the day preceding surgery and three times postoperatively (1st, 3rd, and 7th day). Results In animals with SNL, neurostimulation reduced pain-related behavior, tested with pinprick hyperalgesia, pinprick withdrawal test, and cold test, while the leads per se did not cause DRG compression. The rats well tolerated the stimulator. It did not hinder animal movement, and it enabled the animals to be housed under regular conditions. Conclusion A proof-of-concept experiment with our stimulator verified the usability of the device. The stimulator enables a wide range of research applications from adjusting stimulation parameters for different pain conditions, studying new stimulation methods with different frequencies and waveforms to obtain knowledge about analgesic mechanisms of DRG stimulation.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Damir Kovačić
- Laboratory for Biophysics and Medical Neuroelectronics, University of Split Faculty of Science, Split, Croatia
| | - Antonio Šarolić
- Laboratory for Applied Electromagnetics (EMLab), FESB, University of Split, Split, Croatia
| | - Livia Puljak
- Centre for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
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Parker T, Raghu A, Huang Y, Gillies MJ, FitzGerald JJ, Aziz T, Green AL. Paired Acute Invasive/Non-invasive Stimulation (PAINS) study: A phase I/II randomized, sham-controlled crossover trial in chronic neuropathic pain. Brain Stimul 2021; 14:1576-1585. [PMID: 34673258 DOI: 10.1016/j.brs.2021.10.384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 10/09/2021] [Accepted: 10/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Dorsal root ganglion (DRG) stimulation, an invasive method of neuromodulation, and transcranial direct current stimulation (tDCS), a non-invasive method of altering cortical excitability, have both proven effective in relieving chronic pain. OBJECTIVE We employed a randomized, sham-controlled crossover study design to investigate whether single-session tDCS would have an additive therapeutic effect alongside DRG stimulation (DRGS) in the treatment of chronic pain. METHODS Sixteen neuropathic pain patients who were previously implanted with DRG stimulators were recruited. Baseline pain scores were established with DRGS-OFF. Pain scores were then recorded with DRGS-ON, after paired sham tDCS stimulation, and after paired active anodal tDCS (a-tDCS) stimulation. For active tDCS, patients were randomized to 'MEG (magnetoencephalography) localized' tDCS or contralateral motor cortex (M1) tDCS for 30 min. EEG recordings and evaluations of tDCS adverse effects were also collected. RESULTS All participants reported the interventions to be tolerable with no significant adverse effects during the session. Paired DRGS/active tDCS resulted in a significant reduction in pain scores compared to paired DRGS-ON/sham tDCS or DRGS alone. There was no difference in the additive effect of M1 vs. MEG-localized tDCS. Significant augmentation of beta activity was observed between DRGS-OFF and DRGS-ON conditions, as well as between paired DRGS-ON/sham tDCS and paired DRGS-ON/active tDCS. CONCLUSION Our results indicate that a single session of tDCS alongside DRGS is safe and can significantly reduce pain acutely in neuropathic pain patients. Paired invasive/non-invasive neuromodulation is a promising new treatment strategy for pain management and should be evaluated further to assess long-term benefits.
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Affiliation(s)
- Tariq Parker
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; Neurosurgery Department, Massachusetts General Hospital, Boston, MA, USA.
| | - Ashley Raghu
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Yongzhi Huang
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China
| | - Martin J Gillies
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - James J FitzGerald
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Tipu Aziz
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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Dai Z, Xu X, Chen Y, Lin C, Lin F, Liu R. Effects of High-Voltage Pulsed Radiofrequency on the Ultrastructure and Nav1.7 Level of the Dorsal Root Ganglion in Rats With Spared Nerve Injury. Neuromodulation 2021; 25:980-988. [PMID: 34487572 DOI: 10.1111/ner.13527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 07/18/2021] [Accepted: 08/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the analgesic effect of high-voltage pulsed radiofrequency (HV-PRF) on the dorsal root ganglion (DRG) for neuropathic pain induced by spared nerve injury (SNI) in rats, especially the influence of this treatment on the DRG ultrastructure and voltage-gated sodium channel 1.7 (Nav1.7) level in the DRG. MATERIALS AND METHODS One hundred fifty adult male Sprague-Dawley rats were randomly divided into five groups: Sham, SNI, Free-PRF, standard-voltage PRF (SV-PRF), and HV-PRF. The 45V-PRF and 85V-PRF procedures applied to the left L5 DRG were performed in SV-PRF group and the HV-PRF group respectively on day 7 after SNI, whereas no PRF was concurrently delivered in Free-PRF group. The paw mechanical withdrawal threshold (PMWT) was detected before SNI (baseline) and on days 1, 3, 7, 8, 10, 14, and 21. The changes of left L5 DRG ultrastructure were analyzed with transmission electron microscopy on days 14 and 21. The expression levels of Nav1.7 in left L5 DRG were detected by immunofluorescence and Western blot. RESULTS Compared with the Free-PRF group, PMWT in the SV-PRF group and HV-PRF group were both significantly increased after PRF (all p < 0.05). Meanwhile, the PMWT was significantly higher in the HV-PRF group than that in the SV-PRF group on days 14 and 21 all (p < 0.05). There were statistically significant differences between the SV-PRF and Free-PRF groups (p < 0.05). Similarly, statistically significant difference was found between the HV-PRF and Free-PRF groups (p < 0.05). Especially, comparison of the SV-PRF group and the HV-PRF group revealed statistically significant difference (p < 0.05). The Nav1.7 levels were significantly down-regulated in the SV-PRF group and HV-PRF groups compared to that in the Free-PRF group (all p < 0.01). A significantly lower Nav1.7 level was also found in the HV-PRF group compared to that in the SV-PRF group (p < 0.05). CONCLUSIONS The HV-PRF produces a better analgesic effect than SV-PRF applied to the DRG in SNI rats. The underlying mechanisms may be associated with improving the histopathological prognosis and the downregulation of Nav1.7 levels in the DRG.
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Affiliation(s)
- Zhisen Dai
- Department of Pain Management, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Xueru Xu
- Department of Pain Management, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Yanqin Chen
- Department of Pain Management, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Chun Lin
- Laboratory of Pain Research, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Fan Lin
- Fujian Key Laboratory of Geriatrics, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Rongguo Liu
- Department of Pain Management, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
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Hines K, Swaminathan V, Thalheimer S, Kogan M, Wu C, Sharan A. Single-Center Retrospective Analysis of Device-Related Complications Related to Dorsal Root Ganglion Stimulation for Pain Relief in 31 Patients. Neuromodulation 2021; 25:1040-1044. [PMID: 34309131 DOI: 10.1111/ner.13498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/29/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Dorsal root ganglion (DRG) stimulation is a form of neuromodulation used to treat neuropathic pain due to a myriad of etiologies. Though this relatively new therapy has been shown to be quite effective, complications associated with the implantation of this therapy have not been well documented. OBJECTIVES The primary objective of this study was to describe the device-related complications associated with DRG stimulator implantations. MATERIALS AND METHODS This was a single-center retrospective analysis of 31 patients who underwent full implantation of neuromodulation hardware marketed for DRG stimulation. The predefined endpoints included device-related complications associated with DRG implantations, such as hardware failure, explantation procedures, and revision surgery. Additional endpoints included percentage of patients receiving therapy and pain as measured using the visual analog scale (VAS) pain scale at initial, six-month, and 12-month follow-up after hardware implantation. RESULTS Thirty-one patients were included out of 42 patients trialed. Baseline VAS in patients was 7.7 (31 patients). At initial follow-up, six-month follow-up, and one-year follow-up, VAS scores were 4.7 (31 patients), 5.3 (20 patients), and 5.5 (13 patients), respectively. Paired t-test between preoperative VAS (mean 7.3) and one-year follow-up VAS (5.5) demonstrated statistical significance (p = 0.027). At initial, six-month, and one-year follow-up, 30/31 (97%), 19/24 (79%), and 18/23 (78%) patients were confirmed to be receiving DRG stimulation therapy after permanent implant. Of the 31 patients who were implanted with a permanent system, 8 (26%) were explanted and an additional 10 (29%) required revision surgery. CONCLUSION In this study, we examine the various device-related complications associated with DRG stimulation requiring repeat surgery. High rates of hardware failure, revision surgery, and explantation of stimulators illustrate the need for hardware optimization to improve patient outcomes.
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Affiliation(s)
- Kevin Hines
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vishal Swaminathan
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sara Thalheimer
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Kogan
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ashwini Sharan
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
Electric currents can produce quick, reversible control of neural activity. Externally applied electric currents have been used in inhibiting certain ganglion cells in clinical practices. Via electromagnetic induction, a miniature-sized magnetic coil could provide focal stimulation to the ganglion neurons. Here we report that high-frequency stimulation with the miniature coil could reversibly block ganglion cell activity in marine mollusk Aplysia californica, regardless the firing frequency of the neurons, or concentration of potassium ions around the ganglion neurons. Presence of the ganglion sheath has minimal impact on the inhibitory effects of the coil. The inhibitory effect was local to the soma, and was sufficient in blocking the neuron's functional output. Biophysical modeling confirmed that the miniature coil induced a sufficient electric field in the vicinity of the targeted soma. Using a multi-compartment model of Aplysia ganglion neuron, we found that the high-frequency magnetic stimuli altered the ion channel dynamics that were essential for the sustained firing of action potentials in the soma. Results from this study produces several critical insights to further developing the miniature coil technology for neural control by targeting ganglion cells. The miniature coil provides an interesting neural modulation strategy in clinical applications and laboratory research.
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Affiliation(s)
- Hui Ye
- Department of Biology, Quinlan Life Sciences Education and Research Center, Loyola University Chicago, 1032 W. Sheridan Rd., Chicago, IL, 60660, USA.
| | - Lauryn Barrett
- Department of Biology, Quinlan Life Sciences Education and Research Center, Loyola University Chicago, 1032 W. Sheridan Rd., Chicago, IL, 60660, USA
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Char S, Barman RA, Deer TR, Hagedorn JM. Dorsal Root Ganglion Stimulation for Chronic Groin Pain: A Review. Neuromodulation 2021; 25:965-969. [PMID: 34077614 DOI: 10.1111/ner.13468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/19/2021] [Accepted: 05/11/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Chronic neuropathic groin pain develops in a significant number of postsurgical patients; however, multiple etiologies have been identified, and this makes it a challenging condition to treat. While treatment often involves a multimodal approach, advancements in neuromodulation technology, particularly dorsal root ganglion (DRG) stimulation, have benefited patients plagued by chronic pain refractory to standard treatment modalities. Our goal was to provide a definitive source of information for interventional pain physicians regarding groin pain and the use of DRG stimulation for its treatment. MATERIALS AND METHODS In this narrative review, we provide an overview of groin pain and discuss potential pain generators. We also outline appropriate treatment options with particular interest on DRG stimulation. Lastly, we provide a narrative review of the published literature regarding DRG stimulation for chronic groin pain from a variety of etiologies. CONCLUSION DRG stimulation has emerged as an alternative neuromodulatory technique for patients with chronic groin pain. While previous studies suggest substantial sustained pain relief with DRG stimulation in this patient population, prospective randomized controlled studies are necessary before formal recommendations can be made.
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Affiliation(s)
- Steven Char
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ross A Barman
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
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Analgesic dorsal root ganglionic field stimulation blocks conduction of afferent impulse trains selectively in nociceptive sensory afferents. Pain 2021; 161:2872-2886. [PMID: 32658148 DOI: 10.1097/j.pain.0000000000001982] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Increased excitability of primary sensory neurons after peripheral nerve injury may cause hyperalgesia and allodynia. Dorsal root ganglion field stimulation (GFS) is effective in relieving clinical pain associated with nerve injury and neuropathic pain in animal models. However, its mechanism has not been determined. We examined effects of GFS on transmission of action potentials (APs) from the peripheral to central processes by in vivo single-unit recording from lumbar dorsal roots in sham injured rats and rats with tibial nerve injury (TNI) in fiber types defined by conduction velocity. Transmission of APs directly generated by GFS (20 Hz) in C-type units progressively abated over 20 seconds, whereas GFS-induced Aβ activity persisted unabated, while Aδ showed an intermediate pattern. Activity generated peripherally by electrical stimulation of the sciatic nerve and punctate mechanical stimulation of the receptive field (glabrous skin) was likewise fully blocked by GFS within 20 seconds in C-type units, whereas Aβ units were minimally affected and a subpopulation of Aδ units was blocked. After TNI, the threshold to induce AP firing by punctate mechanical stimulation (von Frey) was reduced, which was reversed to normal during GFS. These results also suggest that C-type fibers, not Aβ, mainly contribute to mechanical and thermal hypersensitivity (von Frey, brush, acetone) after injury. Ganglion field stimulation produces use-dependent blocking of afferent AP trains, consistent with enhanced filtering of APs at the sensory neuron T-junction, particularly in nociceptive units.
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Nagpal A, Clements N, Duszynski B, Boies B. The Effectiveness of Dorsal Root Ganglion Neurostimulation for the Treatment of Chronic Pelvic Pain and Chronic Neuropathic Pain of the Lower Extremity: A Comprehensive Review of the Published Data. PAIN MEDICINE 2021; 22:49-59. [PMID: 33260203 DOI: 10.1093/pm/pnaa369] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of dorsal root ganglion neurostimulation for the treatment of refractory, focal pain in the pelvis and lower extremities. DESIGN Systematic review. OUTCOME MEASURES The primary outcome was ≥50% pain relief. Secondary outcomes were physical function, mood, quality of life, opioid usage, and complications. RESULTS One pragmatic randomized controlled trial, four prospective cohort studies, and eight case series met the inclusion criteria. A worst-case scenario analysis from the randomized controlled trial reported ≥50% pain relief in 74% of patients with dorsal root ganglion neurostimulation vs. 51% of patients who experienced at least 50% relief with spinal cord stimulation at 3 months. Cohort data success rates ranged from 43% to 83% at ≤6 months and 27% to 100% at >6 months. Significant improvements were also reported in the secondary outcomes assessed, including mood, quality of life, opioid usage, and health care utilization, though a lack of available quantitative data limits further statistical analysis. Complication rates vary, though the only randomized controlled trial reported a higher rate of adverse events than that seen with traditional neurostimulation. CONCLUSIONS In accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system, low-quality evidence supports dorsal root ganglion neurostimulation as a more effective treatment than traditional neurostimulation for pain and dysfunction associated with complex regional pain syndrome or causalgia. Very low-quality evidence supports dorsal root ganglion neurostimulation for the treatment of chronic pelvic pain, chronic neuropathic groin pain, phantom limb pain, chronic neuropathic pain of the trunk and/or limbs, and diabetic neuropathy.
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Affiliation(s)
- Ameet Nagpal
- Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Nathan Clements
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | - Brian Boies
- Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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Franken G, Douven P, Debets J, Joosten EAJ. Conventional Dorsal Root Ganglion Stimulation in an Experimental Model of Painful Diabetic Peripheral Neuropathy: A Quantitative Immunocytochemical Analysis of Intracellular γ-Aminobutyric Acid in Dorsal Root Ganglion Neurons. Neuromodulation 2021; 24:639-645. [PMID: 33942947 PMCID: PMC8360133 DOI: 10.1111/ner.13398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/26/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Abstract
Background and Objective The sensory cell somata in the DRG contain all equipment necessary for extensive GABAergic signaling and are able to release GABA upon depolarization. With this study, we hypothesize that pain relief induced by conventional dorsal root ganglion stimulation (Con‐DRGS) in animals with experimental painful diabetic peripheral neuropathy is related to the release of GABA from DRG neurons. With use of quantitative immunocytochemistry, we hypothesize DRGS to result in a decreased intensity of intracellular GABA‐immunostaining in DRG somata. Materials and Methods Female Sprague‐Dawley rats (n = 31) were injected with streptozotocin (STZ) in order to induce Diabetes Mellitus. Animals that developed neuropathic pain after four weeks (Von Frey) were implanted with a unilateral DRGS device at L4 (n = 14). Animals were then stimulated for 30 min with Con‐DRGS (20 Hz, pulse width = 0.2 msec, amplitude = 67% of motor threshold, n = 8) or Sham‐DRGS (n = 6), while pain behavior (von Frey) was measured. DRGs were then collected and immunostained for GABA, and a relation to size of sensory cell soma diameter (small: 12–26 μm, assumed to be C‐fiber related sensory neurons; medium: 26–40 μm, assumed to be Aδ related sensory neurons; and large: 40–54 μm, assumed to be Aβ related sensory neurons) was made. Results DRGS treated animals showed significant reductions in STZ‐induced mechanical hypersensitivity. No significant differences in GABA immunostaining intensity per sensory neuron cell soma type (small‐, medium‐, or large‐sized) were noted in DRGs of stimulated (Con‐DRGS) animals versus Sham animals. No differences in GABA immunostaining intensity per sensory cell soma type in ipsi‐ as compared to contralateral DRGs were observed. Conclusion Con‐DRGS does not affect the average intracellular GABA immunofluorescence staining intensity in DRG sensory neurons of those animals which showed significant pain reduction. Similarly, no soma size related changes in intracellular GABA immunofluorescence were observed following Con‐DRGS.
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Affiliation(s)
- Glenn Franken
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Perla Douven
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Urology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Jacques Debets
- School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Muroidean Facility, School of Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Spinal cord stimulation in chronic neuropathic pain: mechanisms of action, new locations, new paradigms. Pain 2021; 161 Suppl 1:S104-S113. [PMID: 33090743 PMCID: PMC7434213 DOI: 10.1097/j.pain.0000000000001854] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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45
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Grabnar M, Kim C. Dorsal Root Ganglion Stimulation for Treatment of Chemotherapy-Induced Neuropathy. Am J Phys Med Rehabil 2021; 100:e52-e54. [PMID: 32701635 DOI: 10.1097/phm.0000000000001542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Chemotherapy-induced neuropathy has limited treatment options, and conventional medications used to treat neuropathic pain often do not provide adequate pain relief for patients with a history of cancer. Neuromodulation such as dorsal root ganglion stimulation remains a treatment that has been studied for chronic painful conditions such as low back pain, pelvic pain, complex regional pain syndrome, and phantom limb pain. Dorsal root ganglion stimulation has been presented for treatment of chemotherapy-induced neuropathy, but with limited duration of follow-up. We present a case of pain resolution after placement of a dorsal root ganglion stimulation for persistent chemotherapy-induced neuropathy. Our patient developed burning pain and allodynia in both feet 3 mos into her chemotherapy regimen, with worsened symptoms after cessation of chemotherapy. After failure of conservative pharmacotherapies, a 7-day dorsal root ganglion stimulation trial was implanted, resulting in 100% pain relief. A dorsal root ganglion stimulation was then implanted permanently, and our patient reported continued resolution of symptoms at evaluation 3 yrs after placement. To the author's knowledge, this is the first case of sustained relief with dorsal root ganglion stimulation placement for chemotherapy-induced neuropathy and presents a treatment option that warrants further investigation.
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Affiliation(s)
- Maria Grabnar
- From the Case Western Reserve University/MetroHealth, Cleveland, Ohio
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Berke IM, McGrath TM, Stivers JJ, Gui C, Barcellona MN, Gayoso MG, Tang SY, Cao YQ, Gupta MC, Setton LA. Electric Field Stimulation for the Functional Assessment of Isolated Dorsal Root Ganglion Neuron Excitability. Ann Biomed Eng 2021; 49:1110-1118. [PMID: 33479787 PMCID: PMC8204591 DOI: 10.1007/s10439-021-02725-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
Genetically encoded calcium indicators have proven useful for characterizing dorsal root ganglion neuron excitability in vivo. Challenges persist in achieving high spatial-temporal resolutions in vivo, however, due to deep tissue imaging and motion artifacts that may be limiting technical factors in obtaining measurements. Here we report an ex vivo imaging method, using a peripheral neuron-specific Advillin-GCaMP mouse line and electric field stimulation of dorsal root ganglion tissues, to assess the sensitivity of neurons en bloc. The described method rapidly characterizes Ca2+ activity in hundreds of dorsal root ganglion neurons (221 ± 64 per dorsal root ganglion) with minimal perturbation to the in situ soma environment. We further validate the method for use as a drug screening platform with the voltage-gated sodium channel inhibitor, tetrodotoxin. Drug treatment led to decreased evoked Ca2+ activity; half-maximal response voltage (EV50) increased from 13.4 V in untreated tissues to 21.2, 23.3, 51.5 (p < 0.05), and 60.6 V (p < 0.05) at 0.01, 0.1, 1, and 10 µM doses, respectively. This technique may help improve an understanding of neural signaling while retaining tissue structural organization and serves as a tool for the rapid ex vivo recording and assessment of neural activity.
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Affiliation(s)
- Ian M Berke
- Department of Biomedical Engineering, Washington University in St. Louis, One Brookings Drive, Campus Box 1097, St. Louis, MO, 63130, USA
| | - Tom M McGrath
- Department of Biomedical Engineering, Washington University in St. Louis, One Brookings Drive, Campus Box 1097, St. Louis, MO, 63130, USA
| | - J Jordan Stivers
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Chang Gui
- Department of Biomedical Engineering, Washington University in St. Louis, One Brookings Drive, Campus Box 1097, St. Louis, MO, 63130, USA
| | - Marcos N Barcellona
- Department of Biomedical Engineering, Washington University in St. Louis, One Brookings Drive, Campus Box 1097, St. Louis, MO, 63130, USA
| | - Matthew G Gayoso
- Department of Biomedical Engineering, Washington University in St. Louis, One Brookings Drive, Campus Box 1097, St. Louis, MO, 63130, USA
| | - Simon Y Tang
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
- Musculoskeletal Research Center, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Yu-Qing Cao
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Munish C Gupta
- Musculoskeletal Research Center, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Lori A Setton
- Department of Biomedical Engineering, Washington University in St. Louis, One Brookings Drive, Campus Box 1097, St. Louis, MO, 63130, USA.
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA.
- Musculoskeletal Research Center, Washington University School of Medicine, St. Louis, MO, 63110, USA.
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Chapman KB, Yousef TA, Foster A, D Stanton-Hicks M, van Helmond N. Mechanisms for the Clinical Utility of Low-Frequency Stimulation in Neuromodulation of the Dorsal Root Ganglion. Neuromodulation 2020; 24:738-745. [PMID: 33236811 DOI: 10.1111/ner.13323] [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: 08/20/2020] [Revised: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dorsal root ganglion stimulation (DRG-S) involves the electrical modulation of the somata of afferent neural fibers to treat chronic pain. DRG-S has demonstrated clinical efficacy at frequencies lower than typically used with spinal cord stimulation (SCS). In a clinical study, we found that the frequency of DRG-S can be tapered to a frequency as low as 4 Hz with no loss of efficacy. This review discusses possible mechanisms of action underlying effective pain relief with very low-frequency DRG-S. MATERIALS AND METHODS We performed a literature review to explore the role of frequency in neural transmission and the corresponding relevance of frequency settings with neuromodulation. FINDINGS Sensory neural transmission is a frequency-modulated system, with signal frequency determining which mechanisms are activated in the dorsal horn. In the dorsal horn, low-frequency signaling (<20 Hz) activates inhibitory processes while higher frequencies (>25 Hz) are excitatory. Physiologically, low-threshold mechanoreceptors (LTMRs) fibers transmit or modulate innocuous mechanical touch at frequencies as low as 0.5-5 Hz, while nociceptive fibers transmit pain at high frequencies. We postulate that very low-frequency DRG-S, at least partially, harnesses LTMRs and the native endogenous opioid system. Utilizing lower stimulation frequency decreases the total energy delivery used for DRG-S, extends battery life, and facilitates the development of devices with smaller generators.
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Affiliation(s)
- Kenneth B Chapman
- Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Northwell Health, Manhasset, NY, USA
| | - Tariq A Yousef
- Spine & Pain Institute of New York, New York City, NY, USA
| | | | | | - Noud van Helmond
- Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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Chapman KB, Yousef TA, Vissers KC, van Helmond N, D Stanton-Hicks M. Very Low Frequencies Maintain Pain Relief From Dorsal Root Ganglion Stimulation: An Evaluation of Dorsal Root Ganglion Neurostimulation Frequency Tapering. Neuromodulation 2020; 24:746-752. [PMID: 33227827 DOI: 10.1111/ner.13322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/09/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dorsal root ganglion neurostimulation (DRG-S) is effective in treating various refractory chronic pain syndromes. In preclinical studies, DRG-S at very low frequencies (<5 Hz) reduces excitatory output in the superficial dorsal horn. Clinically, we have also observed the effectiveness of DRG-S at low frequencies. We conducted a case series to describe the effect of very low-frequency DRG-S stimulation on clinical outcomes. MATERIALS AND METHODS DRG-S for refractory low back pain was initiated at parameters consistent with published values. Thereafter, the stimulation frequency of DRG-S was reduced in a stepwise fashion to the lowest frequency that maintained pain relief. Pain intensity, disability, and general health status data were collected at baseline, prior to initiation of tapering, and at four weeks after each patient's lowest effective stimulation frequency was reached. RESULTS After device activation (N = 20), DRG-S frequency was tapered from 16 to 4 Hz over a 4- to 17-week period, reducing charge-per-second by nearly two-thirds. Even so, pain relief was maintained at more than 75%, with consistent findings in the other measures. CONCLUSION DRG-S may have utility in treating chronic pain at lower stimulation frequencies than previously recognized. We have previously theorized that the mechanism of action may involve preferential recruitment of low-threshold mechanoreceptor fibers via the endogenous opioid system. Of clinical relevance, lower frequency stimulation maintains DRG-S efficacy regarding improvements in pain, disability, and quality of life. It can extend battery life and may potentially lead to the development of smaller implantable pulse generators.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Northwell Health, Manhasset, NY, USA
| | - Tariq A Yousef
- The Spine & Pain Institute of New York, New York City, NY, USA
| | - Kris C Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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Tolba R, Wickboldt AT, Peairs A, Mohamed HE, Storey M, Abd-Elsayed A. Dorsal root ganglion stimulation for the treatment of severe intractable pain related to obturator nerve entrapment neuropathy: A case report. Clin Neurol Neurosurg 2020; 198:106138. [DOI: 10.1016/j.clineuro.2020.106138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/24/2020] [Accepted: 08/04/2020] [Indexed: 11/28/2022]
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Vigneri S, Sindaco G, La Grua M, Zanella M, Paci V, Vinci FM, Sciacca C, Merlini A, Pari G. Long-term Inhibition of Soleus H-reflex with Epidural Adhesiolysis and Pulsed Radiofrequency in Lumbosacral Neuropathic Pain. Pain Pract 2020; 21:277-284. [PMID: 32970918 DOI: 10.1111/papr.12955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/01/2020] [Accepted: 09/11/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Scientific data about neurophysiological changes subsequent to pulsed radiofrequency (PRF) are still lacking. The goal of this study was to evaluate sural nerve conduction and Hoffmann reflex (H-reflex) in soleus muscle following adhesiolysis and PRF in patients with unilateral chronic lumbosacral L5-S1 neuropathic radiating pain. METHODS Seventeen patients received two cycles of 240 seconds high-voltage PRF and epidural adhesiolysis. Sural nerve action potential (SNAP) and the ratio of maximum H-reflex to maximum M response (H/M ratio) as well as pain scores were collected in both lower limbs before, immediately following, and 1 month after the treatment. RESULTS At follow-up, a significant reduction in numeric rating scale (NRS) and Douleur Neuropathique 4 Questions (DN4) scores was observed in 53% of patients reporting pain improvement of ≥ 30% over baseline. The H/M ratio was decreased in the affected limb following PRF (P = 0.01) and 1 month after the treatment (P = 0.04). A direct correlation was observed between H/M ratio variation and NRS score at follow-up in the treated limb (P = 0.04). No significant difference in sural nerve latency, amplitude, and velocity was detected between affected and normal side after treatment and at follow-up. CONCLUSIONS Epidural adhesiolysis and PRF of the dorsal root ganglion seem to significantly affect spinal reflexes in patients with lumbosacral neuropathic radiating pain.
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Affiliation(s)
- Simone Vigneri
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | - Gianfranco Sindaco
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | - Marco La Grua
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | - Matteo Zanella
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | - Valentina Paci
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | | | - Chiara Sciacca
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | - Alberto Merlini
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
| | - Gilberto Pari
- Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Italy
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