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Bulat E, Chakravarthy V, Crowther J, Rakesh N, Barzilai O, Gulati A. Exceptional Cases of Spinal Cord Stimulation for the Treatment of Refractory Cancer-Related Pain. Neuromodulation 2023; 26:1051-1058. [PMID: 35941017 PMCID: PMC11256305 DOI: 10.1016/j.neurom.2022.06.002] [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: 02/07/2022] [Revised: 06/05/2022] [Accepted: 06/14/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVES Cancer pain has traditionally been managed with opioids, adjuvant medications, and interventions including injections, neural blockade, and intrathecal pump (ITP). Spinal cord stimulation (SCS), although increasingly used for conditions such as failed back surgery syndrome and complex regional pain syndrome, is not currently recommended for cancer pain. However, patients with cancer-related pain have demonstrated benefit with SCS. We sought to better characterize these patients and the benefit of SCS in exceptional cases of refractory pain secondary to progression of disease or evolving treatment-related complications. MATERIALS AND METHODS This was a single-center, retrospective case series at a tertiary cancer center. Adults ≥18 years old with active cancer and evolving pain secondary to disease progression or treatment, whose symptoms were refractory to systemic opioids, and who underwent SCS trial followed by percutaneous implantation between 2016 and 2021 were included. Descriptive statistics included mean, SD, median, and interquartile range (IQR). RESULTS Eight patients met the inclusion criteria. The average age at SCS trial was 60.0 (SD: ±11.6) years, and 50% were men. Compared with baseline, the median (IQR) change in pain score by numeric rating scale (NRS) after trial was -3 (2). At an average of 14 days after implant, the median (IQR) change in NRS and daily oral morphine equivalents were -2 (3.5) and -126 mg (1095 mg), respectively. At a median of 63 days after implant, the corresponding values were -3 (0.75) and -96 mg (711 mg). There was no significant change in adjuvant therapies after SCS implantation at follow-up. Six patients were discharged within two days after implantation. Two patients were readmitted for pain control within the follow-up period. CONCLUSIONS In patients with cancer-related pain, SCS may significantly relieve pain, reduce systemic daily opioid consumption, and potentially decrease hospital length of stay and readmission for pain control. It may be appropriate to consider an SCS trial before ITP in select cases of cancer-related pain.
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Affiliation(s)
- Evgeny Bulat
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Vikram Chakravarthy
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason Crowther
- Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Neal Rakesh
- Pain Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ori Barzilai
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amitabh Gulati
- Pain Service, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Psychiatric screening for spinal cord stimulation for complex regional pain syndrome: A literature review and practical recommendations for implementation. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Neurochirurgia del dolore. Neurologia 2023. [DOI: 10.1016/s1634-7072(22)47347-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Dhruva SS, Murillo J, Ameli O, Morin PE, Spencer DL, Redberg RF, Cohen K. Long-term Outcomes in Use of Opioids, Nonpharmacologic Pain Interventions, and Total Costs of Spinal Cord Stimulators Compared With Conventional Medical Therapy for Chronic Pain. JAMA Neurol 2023; 80:18-29. [PMID: 36441532 PMCID: PMC9706399 DOI: 10.1001/jamaneurol.2022.4166] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
Importance Spinal cord stimulators (SCSs) are increasingly used for the treatment of chronic pain. There is a need for studies with long-term follow-up. Objective To determine the comparative effectiveness and costs of SCSs compared with conventional medical management (CMM) in a large cohort of patients with chronic pain. Design, Setting, and Participants This was a 1:5 propensity-matched retrospective comparative effectiveness research analysis of insured individuals from April 1, 2016, to August 31, 2018. This study used administrative claims data, including longitudinal medical and pharmacy claims, from US commercial and Medicare Advantage enrollees 18 years or older in Optum Labs Data Warehouse. Patients with incident diagnosis codes for failed back surgery syndrome, complex regional pain syndrome, chronic pain syndrome, and other chronic postsurgical back and extremity pain were included in this study. Data were analyzed from February 1, 2021, to August 31, 2022. Exposures SCSs or CMM. Main Outcomes and Measures Surrogate measures for primary chronic pain treatment modalities, including pharmacologic and nonpharmacologic pain interventions (epidural and facet corticosteroid injections, radiofrequency ablation, and spine surgery), as well as total costs. Results In the propensity-matched population of 7560 patients, mean (SD) age was 63.5 (12.5) years, 3080 (40.7%) were male, and 4480 (59.3%) were female. Among matched patients, during the first 12 months, patients treated with SCSs had higher odds of chronic opioid use (adjusted odds ratio [aOR], 1.14; 95% CI, 1.01-1.29) compared with patients treated with CMM but lower odds of epidural and facet corticosteroid injections (aOR, 0.44; 95% CI, 0.39-0.51), radiofrequency ablation (aOR, 0.57; 95% CI, 0.44-0.72), and spine surgery (aOR, 0.72; 95% CI, 0.61-0.85). During months 13 to 24, there was no significant difference in chronic opioid use (aOR, 1.06; 95% CI, 0.94-1.20), epidural and facet corticosteroid injections (aOR, 1.00; 95% CI, 0.87-1.14), radiofrequency ablation (aOR, 0.84; 95% CI, 0.66-1.09), or spine surgery (aOR, 0.91; 95% CI, 0.75-1.09) with SCS use compared with CMM. Overall, 226 of 1260 patients (17.9%) treated with SCS experienced SCS-related complications within 2 years, and 279 of 1260 patients (22.1%) had device revisions and/or removals, which were not always for complications. Total costs of care in the first year were $39 000 higher with SCS than CMM and similar between SCS and CMM in the second year. Conclusions and Relevance In this large, real-world, comparative effectiveness research study comparing SCS and CMM for chronic pain, SCS placement was not associated with a reduction in opioid use or nonpharmacologic pain interventions at 2 years. SCS was associated with higher costs, and SCS-related complications were common.
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Affiliation(s)
- Sanket S. Dhruva
- University of California, San Francisco School of Medicine, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco
- Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Jaime Murillo
- Optum Labs, UnitedHealth Group, Eden Prairie, Minnesota
| | - Omid Ameli
- Optum Center for Research and Innovation
| | | | | | - Rita F. Redberg
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco
| | - Ken Cohen
- Optum Center for Research and Innovation
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Kalia H, Trescot AM, Abd-Elsayed A. Peripheral Nerve Stimulation for Complex Regional Pain Syndrome. PERIPHERAL NERVE STIMULATION 2023:225-232. [DOI: 10.1016/b978-0-323-83007-2.00033-3] [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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Dutch Consensus Paper: A Consensus View on the Place of Neurostimulation Within the Treatment Arsenal of Five Reimbursed Indications for Neurostimulation in The Netherlands. Neuromodulation 2022; 25:1059-1063. [PMID: 35562262 DOI: 10.1016/j.neurom.2022.02.232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION After an interpretation trajectory, the Dutch Quality of Healthcare Institute recommended that for five indications, spinal cord stimulation, dorsal root ganglion stimulation, or occipital nerve stimulation, together referred to as neurostimulation, can be considered effective and be reimbursed in the Netherlands. These five indications are the well and largely studied, accepted neurostimulation indications in scientific literature. As an extension of this, all the scientific societies involved in the Netherlands were required to reach a consensus about the diagnosis and treatment of these five formulated indications to describe the place of neurostimulation within the treatment algorithm. This article describes the development process and content of the consensus paper. MATERIALS AND METHODS A scientific committee, consisting of three anesthesiologists/pain physicians (one of whom acted as the working group's chair), a neurosurgeon, a neurologist, a rehabilitation physician, and three nurse practitioners, participated. A quality advisor of the Knowledge Institute of the Dutch Federation of Medical Specialists supported the committee. The committee participated on behalf of their various scientific and professional societies. Three sessions were organized during which the place of neurostimulation in the treatment algorithm of the five relevant indications was discussed extensively. A narrative literature review and experts' opinions formed the basis of decision-making in the process. RESULTS For all five diagnoses, general and diagnosis-specific treatment requirements, conservative treatments, and minimally invasive treatments are listed. These treatments should be considered in the chronic pain management algorithm before eventually proceeding to neurostimulation. DISCUSSION/CONCLUSION The content of this consensus view was discussed and compared with other literature on cost-effectiveness and the place in the algorithm of treating chronic pain. This Dutch consensus paper could ultimately contribute to the maintenance or expansion of neurostimulation and the reimbursement.
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Forero M, Kamel RA, Chan PL, Maida E. Two years follow-up of continuous erector spinae plane block in a patient with upper extremity complex regional pain syndrome type I. Reg Anesth Pain Med 2022; 47:434-436. [DOI: 10.1136/rapm-2022-103611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/25/2022] [Indexed: 11/04/2022]
Abstract
BackgroundRecalcitrant complex regional pain syndrome (CRPS) type 1 is a devastating condition.Case presentationWe report a case of a patient in their twenties with left hand and forearm CRPS type I, transiently responsive to spinal cord stimulation, thoracic sympathectomy, and multimodal analgesia. The investigators initiated a trial of a single-shot erector spinae plane block at the T2 level, resulting in a clinically significant improvement in pain, function, vasomotor and sudomotor symptoms transiently for a 36-hour interval. As a result, a permanent e-port catheter implantation under combined ultrasound and fluoroscopic guidance was trialed. Two-year follow-up of the continuous erector spinae plane block (CESPB) indicated an 80% reduction in pain scores from baseline, and a 50% reduction in opiate consumption, with a clinically significant reduction in swelling, color changes, allodynia, and temperature asymmetry.ConclusionRecalcitrant CRPS type 1 is a challenging life-altering condition that results in a cyclical triad of chronic pain, disability, and impaired psychosocial health. The profound and prolonged analgesic response to CESPB, highlights the clinical utility of this technique, and warrants more clinical investigation.
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Mamaril-Davis JC, Aguilar-Salinas P, Balogun R, Weinand ME. Spinal cord stimulation for medically refractory sphincter of Oddi dysfunction: A case report. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Desai MJ, Aschenbrener R, Carrera EJ, Thalla N. Spinal Cord Stimulation. Phys Med Rehabil Clin N Am 2022; 33:335-357. [DOI: 10.1016/j.pmr.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fallico N, Padmanabhan R, Rahman S, Somma F, Spagnoli AM. A randomised placebo-controlled clinical trial on the efficacy of local lidocaine injections and oral citalopram for the treatment of complex regional pain syndrome. J Plast Reconstr Aesthet Surg 2021; 75:970-979. [PMID: 34903493 DOI: 10.1016/j.bjps.2021.11.022] [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: 11/13/2020] [Revised: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a neuropathic pain condition with no universally recognised treatment. The study evaluates the efficacy of a therapeutic protocol consisting of oral citalopram and lidocaine injections in patients affected by CRPS. METHODS Between January 2010 and December 2014, 150 consecutive patients with CRPS were enrolled in the study and randomly assigned into three groups: group one - lidocaine injection and oral citalopram; group two - lidocaine injection and oral placebo; and group three - injective and oral placebo. The Impairment Sum Score (ISS) was used to assess the severity of CRPS before, as well as at regular intervals after treatment commenced. Statistical significance (p < 0.05) was determined by paired t-tests. RESULTS The combined treatment proved to be more effective (ISS 47.6 to 12.6) than local anaesthetic alone (ISS 47.5 to 21.5) and to placebo (ISS 47.2 to 29.9). CONCLUSION This study indicates that CRPS may be managed with well-tolerated association of oral citalopram and lidocaine injections.
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Affiliation(s)
- Nefer Fallico
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy; Guy's and St Thomas' Hospital, Department of Plastic Surgery, London, UK
| | | | - Shakeel Rahman
- Guy's and St Thomas' Hospital, Department of Plastic Surgery, London, UK
| | - Francesco Somma
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy
| | - Anna Maria Spagnoli
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy
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Deer T, Wilson D, Schultz D, Falowski S, Tavel E, Moore G, Heros R, Patterson D, Fahey M, Capobianco R, Anitescu M. Ultra-Low Energy Cycled Burst Spinal Cord Stimulation Yields Robust Outcomes in Pain, Function, and Affective Domains: A Subanalysis From Two Prospective, Multicenter, International Clinical Trials. Neuromodulation 2021; 25:137-144. [PMID: 34315191 DOI: 10.1111/ner.13507] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION DeRidder's burst stimulation design has become a key spinal cord stimulation (SCS) waveform because it reduces the intensity of pain as well as its associated emotional distress. The brain pathways underlying these outcomes may also allow for the effects of stimulation to carry over after stimulation is turned off, making it amenable to intermittent application. Here, the utility of intermittently cycled burst was evaluated using data from two large real-world prospective studies (TRIUMPH, REALITY). MATERIALS AND METHODS Subjects used intermittent dosing in a 1:3 ratio (30 sec on, 90 sec off; N = 100) in TRIUMPH and 1:12 ratio in REALITY (30-sec on, 360-sec off; N = 95) for six months. Pain intensity (0-10 numeric rating scale), pain-related emotions on the pain catastrophizing scale (PCS), and physical function on PROMIS questionnaires were compared with preimplant baseline ratings and by group. RESULTS In both groups, mean pain intensity decreased by nearly 50% relative to baseline, PCS scores significantly decreased, and physical function improved. Importantly, no differences between the 1:3 and 1:12 groups were identified. A high proportion, 80% and 77% of the 1:3 and 1:12 groups, respectively, were considered responders on a multiple measures. No adverse events were associated with intermittent stimulation. DISCUSSION Intermittent cycling of burst SCS lowers the overall electric charge delivered to the spinal cord and preserves battery consumption, without compromising pain relief and associated symptoms.
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Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Derron Wilson
- Goodman Campbell Brain and Spine, St. Vincent Health, Indianapolis, IN, USA
| | | | | | - Ed Tavel
- Pain Specialists of Charleston, Charleston, SC, USA
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Bondoc M, Hancu M, DiMarzio M, Sheldon BL, Shao MM, Khazen O, Pilitsis JG. Age as an Independent Predictor of Adult Spinal Cord Stimulation Pain Outcomes. Stereotact Funct Neurosurg 2021; 100:1-7. [PMID: 34280929 DOI: 10.1159/000517426] [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: 03/03/2021] [Accepted: 05/21/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) is an efficacious chronic pain treatment most commonly used in middle-aged patients. Results from previous studies that investigated SCS' effects in older patient populations have been equivocal. We examine whether SCS outcomes correlate with age. METHODS We retrospectively examined prospectively collected outcomes from 189 patients who underwent SCS at Albany Medical Center between 2012 and 2020. The patients completed the Numerical Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) preoperatively and 1 year postoperatively. The mean percent change in each outcome was determined and compared via a regression analysis to determine relationships between patient age and each respective outcome metrics. Demographics were compared between patients aged under 65 versus those aged 65 and older via χ2 tests. RESULTS All subjects demonstrated the expected improvement on NRS, BDI, PCS, and MPQ from baseline to 1-year follow-up, with several demonstrating statistically significant changes: NRS-worst pain (18.66%, p < 0.001), NRS-least pain (26.9%, p < 0.001), NRS-average pain (26.9%, p < 0.01), NRS-current pain (26.4%, p < 0.001), ODI (19.6%, p < 0.001), PCS (29.8%, p < 0.001), and MPQ (29.4%, p < 0.001). There was no significant difference between patients aged under 65 versus those aged 65 and older based on lead type (p = 0.454). Six patients (3.1%) had lead migration, one of whom was 65 or older. Regression analysis revealed improvements in MPQ-sensory and MPQ-affective scores as age increased (p < 0.001, R2 = 0.09; p = 0.046, R2 = 0.05, respectively). Age did not correlate with NRS, ODI, BDI, or PCS. Diagnosis, spinal level of SCS, and lead type were not found to influence any respective outcome measure based on covariate analysis. CONCLUSION This study represents the largest study where age was correlated to specific pain, depression, and disability outcomes following SCS. We provide evidence that SCS outcomes are equivalent, or better, in older patients following SCS. Based on these findings, SCS is a viable option for treatment of chronic pain in elderly patient populations.
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Affiliation(s)
- Melanie Bondoc
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Maria Hancu
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Breanna L Sheldon
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Miriam M Shao
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA.,Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
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Cha M, Lee KH, Kwon M, Lee BH. Possible Therapeutic Options for Complex Regional Pain Syndrome. Biomedicines 2021; 9:biomedicines9060596. [PMID: 34074044 PMCID: PMC8225181 DOI: 10.3390/biomedicines9060596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 11/18/2022] Open
Abstract
Complex regional pain syndrome (CRPS) describes an array of painful conditions that are characterized by continuing regional pain. CRPS comprises severe and inappropriate pain in cases of complete recovery after trauma. Research on the pharmacological treatment of CRPS, however, has not been well investigated. In this study, we compared the pain relief effects of different drugs (URB597, pyrrolidine dithiocarbamate, and hydralazine) in a rat model of chronic post-ischemic pain-induced CRPS. After drug injection, CRPS-induced mechanical allodynia was significantly recovered. After three repetitive drug injections, mechanical sensitivity generally improved as hyper-nociception subsided. Reduced Nav1.7 expression at dorsal root ganglions (DRGs) was observed in the drug treatment groups. Neural imaging analysis revealed decreased neural activity for each drug treatment, compared to vehicle. In addition, treatments significantly reduced IL-1β, IL-6, and TNFα expression in DRGs. These results indicated that drugs could reduce the expression of inflammatory factors and alleviate the symptoms of chronic post-ischemic pain-induced CRPS.
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Affiliation(s)
- Myeounghoon Cha
- Department of Physiology, College of Medicine, Yonsei University, Seoul 03722, Korea
- Correspondence: (M.C.); (B.H.L.); Tel.: +82-2-2228-2729 (M.C.)
| | - Kyung Hee Lee
- Department of Dental Hygiene, Division of Health Science, Dongseo University, Busan 47011, Korea;
| | - Minjee Kwon
- Department of Nursing, Kyungil University, Gyeongsan 38428, Korea;
| | - Bae Hwan Lee
- Department of Physiology, College of Medicine, Yonsei University, Seoul 03722, Korea
- Brain Korea 21 PLUS Project for Medical Science, College of Medicine, Yonsei University, Seoul 03722, Korea
- Correspondence: (M.C.); (B.H.L.); Tel.: +82-2-2228-2729 (M.C.)
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Pain-Administrable Neuron Electrode with Wireless Energy Transmission: Architecture Design and Prototyping. MICROMACHINES 2021; 12:mi12040356. [PMID: 33806220 PMCID: PMC8065446 DOI: 10.3390/mi12040356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 11/17/2022]
Abstract
Back pain resulted from spine disorders reaches 60-80% prevalence in humans, which seriously influences life quality and retards economic production. Conventional electrical pain relief therapy uses radiofrequency to generate a high temperature of 70-85 °C on the electrode tip to destroy the neural transmission and stop the pain. However, due to the larger area of stimulation, eliciting significant side effects, such as paralysis, contraction, and a slightly uncomfortable feeling, our study aimed to design a tiny and stretchable neural stimulatory electrode that could be precisely anchored adjacent to the dorsal root ganglion which needs therapy and properly interfere with the sensory neural transmission. We also designed a subcutaneously implantable wireless power transmission (WPT) device to drive the neural stimulatory electrode. Through the study, we elaborated the design concept and clinical problems, and achieved: (1) the architecture design and simulation of the transdermal wireless power transferred device, (2) a wrap-able pulsed radiofrequency (PRF) stimulatory electrode, (3) an insulation packaging design of the titanium protection box. The feasibility study and hands-on prototype were also carried out.
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Canós-Verdecho A, Abejón D, Robledo R, Izquierdo R, Bermejo A, Gallach E, Argente P, Peraita-Costa I, Morales-Suárez-Varela M. Randomized Prospective Study in Patients With Complex Regional Pain Syndrome of the Upper Limb With High-Frequency Spinal Cord Stimulation (10-kHz) and Low-Frequency Spinal Cord Stimulation. Neuromodulation 2021; 24:448-458. [PMID: 33462918 DOI: 10.1111/ner.13358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this prospective randomized study of cases and controls was to evaluate the efficacy of treatment with low-frequency spinal cord stimulation (LF-SCS) and 10 kHz spinal cord stimulation (10-kHz SCS) in patients diagnosed with complex regional pain syndrome type I (CRPS) with upper limb involvement. MATERIALS AND METHODS Fifty patients were randomized to receive conventional treatment or SCS with a commercially available low-frequency or 10-kHz system. Patients were assessed at 1, 3, 6, and 12 months. The primary endpoint was at 12-months post permanent implantation of the SCS devices. Outcome measures assessed included: Numerical Rating Scale (NRS), 12-Item Short-Format Health Survey (SF-12), Oswestry Disability Index (ODI), Study Sleep Scale medical outcomes (MOS-SS), Douleur Neuropathique 4 questions pain questionnaire (DN4), Patient Global Impression Scale on the impact of treatment improvement (PGI-I), Clinician Global Impression Scale on the impact of improving the patient (CGI-I). RESULTS Forty-one patients were finally included in the analysis, 19 patients in the conventional treatment group, 12 in the LF-SCS group, and 10 in the 10-kHz SCS group. At the primary endpoint, patients treated with LF-SCS presented improvements in the NRS and DN4 outcomes around 2.4 and 1.5 times above the minimal clinically important difference (MCID) thresholds. At the primary endpoint, patients treated with 10-kHz SCS presented improvements in the NRS and DN4 outcomes around 2 and 1.4 times above the MCID thresholds. CONCLUSIONS Patients experienced considerable improvement after SCS. The results show that LF-SCS has very good results when compared with conventional treatment. The results obtained with 10-kHz SCS are encouraging, with the advantages of the absence of paresthesia making it an alternative in the treatment of CRPS.
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Affiliation(s)
- Angeles Canós-Verdecho
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - David Abejón
- Multidisciplinary Pain Management Unit, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Ruth Robledo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rosa Izquierdo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ara Bermejo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Elisa Gallach
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Psychiatry Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Argente
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Surgical Specialities Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Isabel Peraita-Costa
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine, Universitat de València, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP). The Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - María Morales-Suárez-Varela
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine, Universitat de València, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP). The Institute of Health Carlos III (ISCIII), Madrid, Spain
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Meuwissen KPV, van der Toorn A, Gu JW, Zhang TC, Dijkhuizen RM, Joosten EAJ. Active Recharge Burst and Tonic Spinal Cord Stimulation Engage Different Supraspinal Mechanisms: A Functional Magnetic Resonance Imaging Study in Peripherally Injured Chronic Neuropathic Rats. Pain Pract 2020; 20:510-521. [PMID: 32124540 DOI: 10.1111/papr.12879] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To assess the supraspinal working mechanisms of the burst spinal cord stimulation (SCS) mode, we used functional magnetic resonance imaging (fMRI) in chronic neuropathic rats. We hypothesized that active recharge burst SCS would induce a more profound blood oxygenation level-dependent (BOLD) signal increase in areas associated with cognitive-emotional aspects of pain, as compared to tonic SCS. METHODS Sprague Dawley rats (n = 17) underwent a unilateral partial sciatic nerve ligation, which resulted in chronic neuropathic pain. Quadripolar SCS electrodes were epidurally positioned on top of the dorsal columns at Th13. Isoflurane-anesthetized (1.5%) rats received either tonic SCS (n = 8) or burst SCS (n = 9) at 66% of motor threshold. BOLD fMRI was conducted before, during, and after SCS using a 9.4-T horizontal bore scanner. RESULTS Overall, both tonic and burst SCS induced a significant increase of BOLD signal levels in areas associated with the location and intensity of pain, and areas associated with cognitive-emotional aspects of pain. Additionally, burst SCS significantly increased BOLD signal levels in the raphe nuclei, nucleus accumbens, and caudate putamen. Tonic SCS did not induce a significant increase in BOLD signal levels in these areas. CONCLUSIONS In conclusion, active recharge burst and tonic SCS have different effects on the intensity and localization of SCS-induced activation responses in the brain. This work demonstrates that active recharge burst is another waveform that can engage brain areas associated with cognitive-emotional aspects of pain as well as areas associated with location and intensity of pain. Previous studies showing similar engagement used only passive recharge burst.
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Affiliation(s)
- Koen P V Meuwissen
- Department of Anesthesiology and Pain Management, Pain Management and Research Centre, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Annette van der Toorn
- Biomedical MR Imaging and Spectroscopy group, Center for Image Sciences, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jianwen Wendy Gu
- Boston Scientific, Neuromodulation Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Tianhe C Zhang
- Boston Scientific, Neuromodulation Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and Spectroscopy group, Center for Image Sciences, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Pain Management and Research 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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18
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Kallewaard JW, Edelbroek C, Terheggen M, Raza A, Geurts JW. A Prospective Study of Dorsal Root Ganglion Stimulation for Non-Operated Discogenic Low Back Pain. Neuromodulation 2020; 23:196-202. [PMID: 30821901 DOI: 10.1111/ner.12937] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 01/02/2019] [Accepted: 01/09/2019] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Disruptions of lumbar intervertebral discs may lead to severe discogenic low back pain (LBP). Severe pain has a deleterious effect on physical function and quality of life. Spinal cord stimulation (SCS) is a robust treatment for many neuropathic pain conditions. New innovations may be well-suited to treat neuropathic chronic LBP, including discogenic pain. The aim of this prospective study was to determine the effect of dorsal root ganglion (DRG) stimulation for a well-selected group of patients with discogenic LBP with no history of previous back surgeries. METHODS Twenty subjects with confirmed discogenic LBP and no prior history of back surgery underwent trials of DRG stimulation and, if successful with at least 50% pain reduction, were permanently implanted. Subjects rated their pain, disability, quality of life, and mood at baseline, and 14 subjects were followed through 12 months of treatment. RESULTS Treatment with DRG stimulation reduced LBP ratings (68.3% reduction), from mean 7.20 ± 1.3 at baseline to 2.29 ± 2.1 after 12 months (p = < 0.001). Oswestry ratings of disability significantly decreased (p = < 0.001) from 42.09 ± 12.9 at baseline to 21.54 ± 16.4 after six months of treatment and to 20.1 ± 16.6 after 12 months. The average quality of life EQ-5D index score at baseline was 0.61 ± 0.12 and 0.84 ± 0.13 after 12 months. DISCUSSION DRG stimulation treatment for discogenic LBP improved the level of pain, function, and quality of life. Further research is necessary into efficacy of DRG stimulation in patients with chronic discogenic LBP and to determine the place of SCS in the treatment algorithm.
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Affiliation(s)
- Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital Arnhem, Velp, The Netherlands
| | - Caro Edelbroek
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital Arnhem, Velp, The Netherlands
| | - Michel Terheggen
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital Arnhem, Velp, The Netherlands
| | | | - Jose W Geurts
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital Arnhem, Velp, The Netherlands
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19
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Mauck WD, Hunt CL, Olatoye OO, Warner NS, Lamer TJ. Spinal Cord and Peripheral Nerve Stimulation for Painful Disorders. Adv Anesth 2019; 37:163-186. [PMID: 31677655 DOI: 10.1016/j.aan.2019.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- William David Mauck
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Christine L Hunt
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Oludare O Olatoye
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Tim J Lamer
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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20
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Schwarm FP, Stein M, Uhl E, Maxeiner H, Kolodziej MA. Spinal cord stimulation for the treatment of complex regional pain syndrome leads to improvement of quality of life, reduction of pain and psychological distress: a retrospective case series with 24 months follow up. Scand J Pain 2019; 20:253-259. [DOI: 10.1515/sjpain-2019-0081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/18/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background and aims
Complex regional pain syndrome (CRPS) is a common pain condition which is characterized by pain, functional impairment, and trophic changes. Neurosurgical treatment is not widely offered. In this study the treatment with spinal cord stimulation (SCS) was evaluated over 24 months follow up.
Methods
A retrospective case analysis of six patients with severe CRPS was performed. Pain chronicity was recorded with the Mainz Pain Staging System (MPSS). Pain intensity (NRS), activity level and health-related quality of life (EQ-5D-5L), the actual mood state (ASTS), and treatment satisfaction (CSQ-8) were assessed. All patients received conventional pharmacological treatments including multimodal pain therapy through their local pain therapist or in specialized centers as well as physical therapy. A SCS electrode was implanted for trial stimulation. After successful trial a neurostimulator was implanted and connected to the electrode. Patients were retrospectively analyzed before implantation and 6, 12 and 24 months postoperatively. Statistical analysis was performed using Mann–Whitney U and Wilcoxon rank-sum test.
Results
Patients median age was 43 years (IQR25−75 37–43 years). The median MPSS Score was 3 of 3 indicating a high pain chronicity. Median NRS before implantation of the neurostimulator was 8.8 (IQR25−75 7.6–9.3). A reduction to 7.8 (IQR25−75 4.8–8.1; p = 0.14) after 6 months, 6.5 (IQR25−75 3.8–8.1; p = 0.08) after 1 year, and 6.8 (IQR25−75 3.8–8.5; p = 0.15) after 2 years was achieved. Median EQ-5D-5L index value before treatment was 0.27 (IQR25−75 0.25–0.41) indicating a severely lowered quality of life. A significant improvement to 0.53 (IQR25−75 0.26–0.65; p = 0.03) after 6 months, 0.58 (IQR25−75 0.26–0.84; p = 0.03) after 1 year as well as after 2 years was seen. ASTS scale showed an increase of values for positive mood, and a reduction in values for sorrow, fatigue, anger and desperation during the whole follow up period. The treatment satisfaction in the whole cohort with a median CSQ-8 value of 29.5 of 32 was very high.
Conclusion
The results of this small case series showed a significant improvement of the EQ-5D-5L after implantation of a neurostimulator. NRS reduction was not significant but a clear tendency towards reduced values was observed. We therefore conclude that SCS is an alternative option to relieve chronic pain and psychological distress originating from CRPS if non-invasive managements of severe CRPS failed. The preoperative selection plays a crucial role for good results.
Implications
CRPS is difficult to treat. SCS is an alternative option to improve the quality of life and relieve chronic pain originating from severe CRPS if conservative treatment modalities fail. Further psychological distress is reduced in long-term follow up. SCS should be kept in mind for therapy refractory cases.
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Affiliation(s)
| | - Marco Stein
- Department of Neurosurgery , Justus-Liebig-University Giessen , Giessen , Germany
| | - Eberhard Uhl
- Department of Neurosurgery , Justus-Liebig-University Giessen , Giessen , Germany
| | - Hagen Maxeiner
- Department of Anesthesiology, Intensive Care and Pain Therapy , Justus-Liebig-University Giessen , Giessen , Germany
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21
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Herschkowitz D, Kubias J. A case report of wireless peripheral nerve stimulation for complex regional pain syndrome type-I of the upper extremity: 1 year follow up. Scand J Pain 2019; 19:829-835. [DOI: 10.1515/sjpain-2019-0071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Complex regional pain syndrome (CRPS) is a chronic disabling painful disorder with limited options to achieve therapeutic relief. CRPS type I which follows trauma, may not show obvious damage to the nervous structures and remains dubious in its pathophysiology and also its response to conservative treatment or interventional pain management is elusive. Spinal cord and dorsal root ganglion stimulation (SCS, DRGS) provide good relief, mainly for causalgia or CRPS I of lower extremities but not very encouraging for upper extremity CRPS I. we reported earlier, a case of CRPS I of right arm treated successfully by wireless peripheral nerve stimulation (WPNS) with short term follow up. Here we present 1-year follow-up of this patient.
Objective
To present the first case of WPNS for CRPS I with a year follow up. The patient had minimally invasive peripheral nerve stimulation (PNS), without implantable pulse generator (IPG) or its accessories.
Case report
This was a case of refractory CRPS I after blunt trauma to the right forearm of a young female. She underwent placement of two Stimwave electrodes (Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1) in her forearm under intraoperative electrophysiological and ultrasound guidance along radial and median nerves. This WPNS required no IPG. At high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA), patient had shown remarkable relief in pain, allodynia and temperature impairment. At 5 months she started driving without opioid consumption, while allodynia disappeared. At 1 year follow up she was relieved of pain [visual analogue scale (VAS) score of 4 from 7] and Kapanji Index (Score) improved to 7–8. Both hands look similar in color and temperature. She never made unscheduled visits to the clinic or visited emergency room for any complications related to the WPNS.
Conclusions
CRPS I involving upper extremity remain difficult to manage with conventional SCS or DRGS because of equipment related adverse events. Minimally invasive WPNS in this case had shown consistent relief without any complications or side effects related to the wireless technology or the technique at the end of 1 year.
Implications
This is the first case illustration of WPNS for CRPS I, successfully treated and followed up for 1 year.
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Affiliation(s)
| | - Jana Kubias
- Mgr, Parimed GmbH , Unter Sagi 6 , Stansstad 6362 , Switzerland
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22
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Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Proposal of a Standardized Multidisciplinary Team Care Pathway. Pain Res Manag 2019; 2019:8184592. [PMID: 31360272 PMCID: PMC6644221 DOI: 10.1155/2019/8184592] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/29/2019] [Accepted: 06/27/2019] [Indexed: 12/17/2022]
Abstract
Failed back surgery syndrome (FBSS) is a major, worldwide health problem that generates considerable expense for healthcare systems. A number of controversial issues concerning the management of FBSS are regularly debated, but no clear consensus has been reached. This pitfall is the result of lack of a standardized care pathway due to insufficient characterization of underlying pathophysiological mechanisms, which are essential to identify in order to offer appropriate treatment, and the paucity of evidence of treatment outcomes. In an attempt to address the challenges and barriers in the clinical management of FBSS, an international panel of physicians with a special interest in FBSS established the Chronic Back and Leg Pain (CBLP) Network with the primary intention to provide recommendations through consensus on how to optimize outcomes. In the first of a series of two papers, a definition of FBSS was delineated with specification of criteria for patient assessment and identification of appropriate evaluation tools in order to choose the right treatment options. In this second paper, we present a proposal of a standardized care pathway aiming to guide clinicians in their decision-making on how to optimize their management of FBSS patients. The utilization of a multidisciplinary approach is emphasized to ensure that care is provided in a uniform manner to reduce variation in practice and improve patient outcomes.
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23
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Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practising clinician. Br J Anaesth 2019; 123:e424-e433. [PMID: 31056241 DOI: 10.1016/j.bja.2019.03.030] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 12/15/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a life-altering condition that usually affects the extremities after a trauma or nerve injury. The physiologic changes that occur as a result of the inciting injury are complex, as the name of the syndrome implies. The pain and disability associated with CRPS often lead to psychological co-morbidities that create a vicious cycle of pain, isolation, and depression. We review recent developments in the understanding of CRPS and advancements in management of this syndrome. Further research in targeting specific mechanisms involved in the pathophysiology of CRPS should lead to prevention of this condition.
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Affiliation(s)
- H Shim
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - J Rose
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - S Halle
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - P Shekane
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA.
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24
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Gill JS, Asgerally A, Simopoulos TT. High-Frequency Spinal Cord Stimulation at 10 kHz for the Treatment of Complex Regional Pain Syndrome: A Case Series of Patients With or Without Previous Spinal Cord Stimulator Implantation. Pain Pract 2019; 19:289-294. [PMID: 30365222 DOI: 10.1111/papr.12739] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/30/2018] [Accepted: 10/05/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND High-frequency spinal cord stimulation at 10 kHz (HF10-SCS) has been demonstrated to provide enhanced and durable pain relief in patients with chronic back and radiating leg pain. Patients with pain related to complex regional pain syndrome (CRPS) in the chronic stages are commonly challenging to treat and often receive traditional spinal cord stimulation (SCS). Very little information is currently available about the therapeutic outcomes following application of high-frequency stimulation in this cohort of patients. METHODS The purpose of the retrospective case series was to report on the initial experience of HF10-SCS in 13 patients with CRPS, some of whom had been exposed to low-frequency SCS. A temporary trial of HF10-SCS was carried out for 1 week, and those achieving a minimum of 50% pain intensity reduction underwent implantation. Successful responders were those who achieved a 50% decrease in pain intensity on subsequent follow-up. RESULTS Thirteen patients were trialed, 12 of whom went on to receive a permanent implant. Of the patients receiving permanent implants, the responder rate (50% pain relief) was 67% (95% confidence interval [CI] 0.34 to 0.90), with an average follow-up period of 12.1 ± 4.6 months. Of the 5 patients who had sympathetically independent pain, 3 were responders, and of the 7 patients who had sympathetically mediated pain, 5 were responders. There were no adverse events. CONCLUSION This small case series suggests that HF10-SCS may be a viable option for patients with CRPS who have chronic intractable pain, including those who had suboptimal results from traditional SCS.
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Affiliation(s)
- Jatinder S Gill
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Abbas Asgerally
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Thomas T Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
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25
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Lee SJ, Yoo YM, You JA, Shin SW, Kim TK, Abdi S, Kim KH. Successful removal of permanent spinal cord stimulators in patients with complex regional pain syndrome after complete relief of pain. Korean J Pain 2019; 32:47-50. [PMID: 30671203 PMCID: PMC6333578 DOI: 10.3344/kjp.2019.32.1.47] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 02/02/2023] Open
Abstract
Background It is uncommon for patients who have received a permanent implant to remove the spinal cord stimulator (SCS) after discontinuation of medication in complex regional pain syndrome (CRPS) due to their completely painless state. This study evaluated CRPS patients who successfully removed their SCSs. Methods This 10-year retrospective study was performed on patients who had received the permanent implantation of an SCS and had removed it 6 months after discontinuation of stimulation, while halting all medications for neuropathic pain. Age, sex, duration of implantation, site and type of CRPS, and their return to work were compared between the removal and non-removal groups. Results Five (12.5%, M/F = 4/1) of 40 patients (M/F = 33/7) successfully removed the permanent implant. The mean age was younger in the removal group (27.2 ± 6.4 vs. 43.5 ± 10.7 years, P < 0.01). The mean duration of implantation in the removal group was 34.4 ± 18.2 months. Two of 15 patients (13.3%) and 3 of 25 patients (12%) who had upper and lower extremity pain, respectively, had removed the implant. The implants could be removed in 5 of 27 patients (18.5%) with CRPS type 1 (P < 0.01). All 5 patients (100%) who removed their SCS returned to work, while only 5 of 35 (14.3%) in the non-removal group did (P < 0.01). Conclusions Even though this study had limited data, younger patients with CRPS type 1 could remove their SCSs within a 5-year period and return to work with complete pain relief.
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Affiliation(s)
- Su Jung Lee
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Yeong Min Yoo
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Jun A You
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Sang Wook Shin
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Tae Kyun Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Salahadin Abdi
- Department of Pain Medicine, Division of Anesthesia and Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kyung Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
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26
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Yang J, Choi Y, Park J, Jeong J, Lee B, Lee K, Lee J, Choi R. Reversible Horner's syndrome after cervical spinal cord stimulator implantation in a patient with complex regional pain syndrome. J Pain Res 2018; 11:3019-3023. [PMID: 30568482 PMCID: PMC6267498 DOI: 10.2147/jpr.s182345] [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] [Indexed: 11/23/2022] Open
Abstract
We successfully performed cervical spinal cord stimulator (SCS) surgery in a 27-year-old man with complex regional pain syndrome to control intractable pain. The SCS trial was performed twice to adjust the SCS coverage region. After permanent implantation surgery, the patient developed Horner's syndrome when the region near the C4 spinal dorsal root was stimulated. However, Horner's syndrome disappeared after changing the stimulation leads. This case report suggests that cervical SCS can be associated with superior cervical ganglion stimulation.
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Affiliation(s)
- Jaeyoung Yang
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
| | - Yusun Choi
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
| | - Juyoung Park
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
| | - Junhyug Jeong
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
| | - Bousung Lee
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
| | - Kwanghaeng Lee
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
| | - Jaedo Lee
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
| | - Rakmin Choi
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, South Korea,
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27
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Risson EG, Serpa AP, Berger JJ, Koerbel RFH, Koerbel A. Spinal cord stimulation in the treatment of complex regional pain syndrome type 1: Is trial truly required? Clin Neurol Neurosurg 2018; 171:156-162. [DOI: 10.1016/j.clineuro.2018.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/01/2018] [Accepted: 06/09/2018] [Indexed: 11/28/2022]
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28
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Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: a case illustration introducing a novel technology. Scand J Pain 2018; 18:555-560. [DOI: 10.1515/sjpain-2018-0014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/18/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Complex regional pain syndrome (CRPS) is a debilitating painful disorder, cryptic in its pathophysiology and refractory condition with limited therapeutic options. Type I CRPS with its variable relationship to trauma has often no discernible fractures or nerve injuries and remains enigmatic in its response to conservative treatment as well as the other limited interventional therapies. Neuromodulation in the form of spinal cord and dorsal root ganglion stimulation (SCS, DRGS) has shown encouraging results, especially of causalgia or CRPS I of lower extremities. Upper extremity CRPS I is far more difficult.
Objective
To report a case of upper extremity CRPS I treated by wireless peripheral nerve stimulation (WPNS) for its unique features and minimally invasive technique. The system does not involve implantation of battery or its connections.
Case report
A 47 year old female patient presented with refractory CRPS I following a blunt trauma to her right forearm. As interventional treatment in the form of local anesthetics (Anesthesia of peripheral branches of radial nerve) and combined infusions of ketamine/lidocaine failed to provide any significant relief she opted for WPNS treatment. Based on the topographic distribution, two electrodes (Stimwave Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1), were placed along the course of radial and median nerves under ultrasonography monitoring and guided by intraoperative stimulation. This procedure did not involve implantation of extension cables or the power source. At a frequency of 60 Hz and 300 μs the stimulation induced paresthesia along the distribution of the nerves. Therapeutic relief was observed with high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA) reducing her pain from a visual analogue scale (VAS) score of 7–4 postoperatively. Three HF stimulations programs were provided at the time of discharge, as she improved in her sensory impairment to touch, pressure and temperature at her first follow up visit. At 5-months she was able to drive, did not require opioids and allodynia disappeared.
Conclusions
In a case with difficult CRPS I involving upper extremity, a minimally invasive WPNS of radial and median nerves provided good symptomatic relief. The procedure was tolerated well and both electrodes remained in place without any adverse events.
Implications
In view of the very limited options currently available to manage CRPS, WPNS can be a promising therapeutic modality.
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29
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Gee L, Smith HC, Ghulam-Jelani Z, Khan H, Prusik J, Feustel PJ, McCallum SE, Pilitsis JG. Spinal Cord Stimulation for the Treatment of Chronic Pain Reduces Opioid Use and Results in Superior Clinical Outcomes When Used Without Opioids. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy065] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Lucy Gee
- Albany Medical Center Department of Neuroscience and Experimental Therapeutics, Albany, New York
| | - Heather C Smith
- Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Zohal Ghulam-Jelani
- Albany Medical Center Department of Neuroscience and Experimental Therapeutics, Albany, New York
- Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Hirah Khan
- Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Julia Prusik
- Albany Medical Center Department of Neuroscience and Experimental Therapeutics, Albany, New York
- Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Paul J Feustel
- Albany Medical Center Department of Neuroscience and Experimental Therapeutics, Albany, New York
| | - Sarah E McCallum
- Albany Medical Center Department of Neuroscience and Experimental Therapeutics, Albany, New York
| | - Julie G Pilitsis
- Albany Medical Center Department of Neuroscience and Experimental Therapeutics, Albany, New York
- Department of Neurosurgery, Albany Medical Center, Albany, New York
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30
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Stanton-Hicks M, Prager JP. Neurostimulation for the Treatment of Complex Regional Pain Syndrome. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00048-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Spinal Cord Stimulation for Peripheral Neuropathic Pain. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00049-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Schu S, Vancamp T. Clinical Aspects of Burst Stimulation for Pain Control. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00052-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fundamentals and Mechanisms of Dorsal Root Ganglion Stimulation. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Management Strategies for Chronic Pain. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00044-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Elsamadicy AA, Yang S, Sergesketter AR, Ashraf B, Charalambous L, Kemeny H, Ejikeme T, Ren X, Pagadala P, Parente B, Xie J, Lad SP. Prevalence and Cost Analysis of Complex Regional Pain Syndrome (CRPS): A Role for Neuromodulation. Neuromodulation 2017; 21:423-430. [PMID: 28961359 DOI: 10.1111/ner.12691] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/14/2017] [Accepted: 07/31/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The diagnosis and treatment of complex regional pain syndrome (CRPS) is challenging and there is a paucity of data describing its overall cost burden and quantifying its impact on the US healthcare system. The aim of this study was to assess the prevalence and healthcare utilization costs associated with CRPS. MATERIALS AND METHODS A retrospective longitudinal study was performed using the Truven MarketScan® database to identify patients with a new indexed diagnosis of CRPS (Type I, II, or both) from 2001 to 2012. We collected total, outpatient, and pain prescription costs three years prior to CRPS diagnosis (baseline), at year of CRPS diagnosis, and eight-year post-CRPS diagnosis. A longitudinal multivariate analysis was used to model the estimated total and pain prescription cost ratios comparing patients diagnosed before and after CRPS. RESULTS We included 35,316 patients with a newly indexed diagnosis of CRPS (Type I: n = 18,703, Type II: n = 14,599, Unspecified: n = 2014). Baseline characteristics were similar between the CRPS cohorts. Compared to two- and three-year baseline costs, one-year prior to diagnosis for all CRPS patients yielded the highest interquartile median [IQR] costs: total costs $7904[$3469, $16,084]; outpatient costs $6706[$3119, $12,715]; and pain prescription costs $1862[$147, $7649]. At the year of CRPS diagnosis, the median [IQR] costs were significantly higher than baseline costs: total costs $8508[$3943, $16,666]; outpatient costs $7251[$3527, $13,568]; and pain prescription costs $2077[$140, $8856]. Over the eight-year period after CRPS diagnosis, costs between all the years were similar, ranging from the highest (one-year) to lowest (seven-years), $4845 to $3888. The median total cumulative cost 8-years after CRPS diagnosis was $43,026 and $12,037 for pain prescription costs. [Correction added on 06 November 2017 after first online publication: the preceding sentence has been updated to demonstrate the median cumulative cost in replacement of the additive cumulative mean costs.]. During the CRPS diagnosis period, patients are expected to have a total cost 2.17-fold and prescription cost 2.56-fold of their baseline cost annually. CONCLUSIONS Our study demonstrates that there is a significant increase in cost and healthcare resource utilization one-year prior to and around the time of CRPS diagnosis. Furthermore, there is an increased annual cost post-diagnosis compared to baseline costs prior to CRPS diagnosis.
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Affiliation(s)
| | - Siyun Yang
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | | | - Bilal Ashraf
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Lefko Charalambous
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Hanna Kemeny
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Tiffany Ejikeme
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Xinru Ren
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Promila Pagadala
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jichun Xie
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Sokal P, Harat M, Zieliński P, Kierońska S. Tibial nerve stimulation with a miniature, wireless stimulator in chronic peripheral neuropathic pain. J Pain Res 2017; 10:613-619. [PMID: 28352201 PMCID: PMC5359134 DOI: 10.2147/jpr.s128861] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peripheral neuropathic pain (PNP) and complex regional pain syndrome (CRPS) can be effectively treated with peripheral nerve stimulation. In this clinical trial report, effectiveness of novel, miniature, wirelessly controlled microstimulator of tibial nerve in PNP and CRPS was evaluated. In this pilot study the average preoperative visual analog scale (VAS) score in six patients was 7.5, with 1, 3 and 6 months: 2.6 (p=0.03), 1.6 (p=0.03), and 1.3 (p=0.02), respectively. The mean average score in the six patients a week preceding the baseline visit was 7.96, preceding the 1, 3 and 6 month visits: 3.32 (p=0.043), 3.65 (p=0.045), and 2.49 (p=0.002), respectively. The average short-form McGill pain score before surgery was 23.8, and after 1, 3 and 6 months it was 11.0 (p=0.45), 6.3 (p=0.043), and 4.5 (p=0.01), respectively. Applied therapy caused a reduction of pain immediately after its application and clinical improvement was sustained on a similar level in all patients for six months. No complications of the treatment were observed. Intermittent tibial nerve stimulation by using a novel, miniature, wirelessly controlled device can be effective and feasible in PNP and CRPS. It is a safe, minimally invasive, and convenient neuromodulative method.
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Affiliation(s)
- Paweł Sokal
- Department of Neurosurgery, Military Research Hospital, Bydgoszcz
| | - Marek Harat
- Department of Public Health, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń
| | - Piotr Zieliński
- Department of Sports Medicine, University of Physical Education and Sport, Gdansk, Poland
| | - Sara Kierońska
- Department of Neurosurgery, Military Research Hospital, Bydgoszcz
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Deer TR, Pope JE, Hayek SM, Bux A, Buchser E, Eldabe S, De Andrés JA, Erdek M, Patin D, Grider JS, Doleys DM, Jacobs MS, Yaksh TL, Poree L, Wallace MS, Prager J, Rauck R, DeLeon O, Diwan S, Falowski SM, Gazelka HM, Kim P, Leong M, Levy RM, McDowell II G, McRoberts P, Naidu R, Narouze S, Perruchoud C, Rosen SM, Rosenberg WS, Saulino M, Staats P, Stearns LJ, Willis D, Krames E, Huntoon M, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines. Neuromodulation 2017; 20:96-132. [DOI: 10.1111/ner.12538] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 12/13/2022]
Affiliation(s)
| | | | | | - Anjum Bux
- Anesthesia and Chronic Pain Management; Ephraim McDowell Regional Medical Center; Danville KY USA
| | - Eric Buchser
- Anaesthesia and Pain Management Department; EHC Hosptial, Morges, and CHUV University Hospital; Lausanne Switzerland
| | - Sam Eldabe
- The James Cook University Hospital; Middlesbrough UK
| | - Jose A. De Andrés
- Valencia School of Medicine; Hospital General Universitario; Valencia Spain
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine; Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- University of Kentucky College of Medicine, UK HealthCare Pain Services; Lexington KY USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology; University of California; San Diego CA USA
| | - Lawrence Poree
- Pain Clinic of Monterey Bay, University of California at San Francisco; San Francisco CA USA
| | | | - Joshua Prager
- Center for the Rehabilitation Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | - Richard Rauck
- Carolina Pain Institute, Wake Forest Baptist Health; Winston-Salem NC USA
| | - Oscar DeLeon
- Roswell Park Cancer Institute, SUNY; Buffalo NY USA
| | - Sudhir Diwan
- Manhattan Spine and Pain Medicine; Lenox Hill Hospital; New York NY USA
| | | | | | - Philip Kim
- Bryn Mawr Hospital; Bryn Mawr PA, USA
- Christiana Hospital; Newark DE USA
| | | | | | | | | | - Ramana Naidu
- San Francisco Medical Center, University of California; San Francisco CA USA
| | - Samir Narouze
- Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | | | | | | | | | - Peter Staats
- Premier Pain Management Centers; Shrewsbury NJ, USA
- Johns Hopkins University; Baltimore MD USA
| | | | | | - Elliot Krames
- Pacific Pain Treatment Center (ret.); San Francisco CA USA
| | - Marc Huntoon
- Vanderbilt University Medical Center; Nashville TN USA
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Visnjevac O, Costandi S, Patel BA, Azer G, Agarwal P, Bolash R, Mekhail NA. A Comprehensive Outcome-Specific Review of the Use of Spinal Cord Stimulation for Complex Regional Pain Syndrome. Pain Pract 2016; 17:533-545. [PMID: 27739179 DOI: 10.1111/papr.12513] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/27/2016] [Accepted: 07/08/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful, debilitating affliction that is often difficult to treat. It has become common international practice to use spinal cord stimulation (SCS) for the treatment of CRPS as other therapies fail to provide adequate relief, quality of life, or improvement in function. This comprehensive outcome-specific systematic review of the use of SCS for CRPS was performed to elucidate the available evidence with focus on clinically relevant patient-specific outcomes. METHODS A systematic review of the literature was conducted to evaluate the effects of SCS on patients with CRPS for the following outcomes and provide summary levels of evidence in regard to each outcome: perceived pain relief, pain score, resolution of CRPS signs, functional status, quality of life, psychological impact, sleep hygiene, analgesic medication utilization, and patient satisfaction with SCS therapy. Search terms included "complex regional pain syndrome," "spinal cord stimulation," and "reflex sympathetic dystrophy," without restriction of language, date, or type of publication, albeit only original data were included in analyses. Of 30 studies selected, seven systematic reviews were excluded, as were four studies reporting combination therapy that included SCS and other therapies (ie, concurrent peripheral nerve stimulation, intrathecal therapy) without clear delineation to the effect of SCS alone on outcomes. A total of 19 manuscripts were evaluated. RESULTS Perceived pain relief, pain score improvement, quality of life, and satisfaction with SCS were all rated 1B+, reflecting positive high-level (randomized controlled trial) evidence favoring SCS use for the treatment of CRPS. Evidence for functional status improvements and psychological effects of SCS was inconclusive, albeit emanating from a randomized controlled trial (evidence level 2B±), and outcomes evidence for both sleep hygiene and resolution of CRPS signs was either nonexistent or of too low quality from which to draw conclusions (evidence level 0). An analgesic sparing effect was observed in nonrandomized reports, reflecting an evidence level of 2C+. CONCLUSIONS Spinal cord stimulation remains a favorable and effective modality for treating CRPS with high-level evidence (1B+) supporting its role in improving CRPS patients' perceived pain relief, pain score, and quality of life. A paucity of evidence for functional improvements, resolution of CRPS signs, sleep hygiene, psychological impact, and analgesic sparing effects mandate further investigation before conclusions can be drawn for these specific outcomes.
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Affiliation(s)
- Ognjen Visnjevac
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Shrif Costandi
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Bimal A Patel
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Girgis Azer
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Priya Agarwal
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Robert Bolash
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Nagy A Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Alkosha HM, Elkiran YM. Predictors of Long-Term Outcome of Thoracic Sympathectomy in Patients with Complex Regional Pain Syndrome Type 2. World Neurosurg 2016; 92:74-82. [DOI: 10.1016/j.wneu.2016.04.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 11/28/2022]
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Pulsed radiofrequency applied to the dorsal root ganglia for treatment of post-stroke complex regional pain syndrome: A case series. J Clin Anesth 2016; 33:192-7. [PMID: 27555163 DOI: 10.1016/j.jclinane.2016.03.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE Complex regional pain syndrome is a painful and disabling syndrome where the patient presents with neuropathic pain, edema, or vasomotor or pseudomotor abnormalities that are often refractory to treatment. Complex regional pain syndrome type 1 may occurs in stroke patients. Radiofrequency is a therapeutic modality that has been used for years for diseases associated with neuropathic pain. DESIGN Case series report. SETTING Selcuk University Hospital. PATIENTS A 69-year-old woman and a 48-year-old women who suffered post-stroke complex regional pain syndrome type 1. INTERVENTIONS Pulsed radiofrequency current application to the cervical dorsal root ganglia. MEASUREMENTS Pain reduction. MAIN RESULTS The patients had complete resolution of their symptoms, which was maintained at 10 and 5 months of follow-up. CONCLUSIONS These cases illustrates that pulsed radiofrequency applied to cervical dorsal root ganglia might play a significant role in multi-modal approach of complex regional pain syndrome type 1 management after stroke. Further randomized, controlled studies are needed to support this argument.
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Benzon HT, Liu SS, Buvanendran A. Evolving Definitions and Pharmacologic Management of Complex Regional Pain Syndrome. Anesth Analg 2016; 122:601-604. [DOI: 10.1213/ane.0000000000001157] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lamer TJ, Deer TR, Hayek SM. Advanced Innovations for Pain. Mayo Clin Proc 2016; 91:246-58. [PMID: 26848005 DOI: 10.1016/j.mayocp.2015.12.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 01/13/2023]
Abstract
Chronic pain represents one of the most important public health problems in terms of both the number of patients afflicted and health care costs. Most patients with chronic pain are treated with medications as the mainstay of therapy, and yet most medically treated patients continue to report ongoing pain. Additionally, adverse effects from pain medications represent a major challenge for clinicians and patients. Spinal cord stimulation and intrathecal drug delivery systems are well-established techniques that have been utilized for over 25 years. Intrathecal drug delivery systems have proven efficacy for a wide variety of intractable pain conditions and fewer adverse effects than systemic medical therapy in patients with refractory cancer-related pain. Spinal cord stimulation is cost-effective and provides improved pain control compared with medical therapy in patients with a variety of refractory pain conditions including complex regional pain syndrome, painful diabetic neuropathy, and chronic radiculopathy. Patients who have intractable pain that has not responded to reasonable attempts at conservative pain care measures should be referred to a qualified interventional pain specialist to determine candidacy for the procedures discussed in this article.
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Affiliation(s)
- Tim J Lamer
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN.
| | | | - Salim M Hayek
- Department of Anesthesiology, University Hospitals Case Medical Center, Cleveland, OH
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Abstract
Upper extremity neuropathic pain states greatly impact patient functionality and quality of life, despite appropriate surgical intervention. This article focuses on the advanced therapies that may improve pain care, including advanced treatment strategies that are available. The article also surveys therapies on the immediate horizon, such as spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion spinal cord stimulation. As these therapies evolve, so too will their placement within the pain care algorithm grounded by a foundation of evidence to improve patient safety and management of patients with difficult neuropathic pain.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, 392 Tesconi Court, Santa Rosa, CA 95401, USA.
| | - David Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA 15143, USA
| | | | - Timothy Deer
- Center for Pain Relief, Charleston, WV 25304, USA
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Pope JE, Deer TR, McRoberts WP. Intrathecal Therapy: The Burden of Being Positioned as a Salvage Therapy. PAIN MEDICINE 2015; 16:2036-8. [DOI: 10.1111/pme.12782] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/08/2015] [Accepted: 03/29/2015] [Indexed: 02/06/2023]
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Hayek SM, Veizi E, Hanes M. Treatment-Limiting Complications of Percutaneous Spinal Cord Stimulator Implants: A Review of Eight Years of Experience From an Academic Center Database. Neuromodulation 2015; 18:603-8; discussion 608-9. [PMID: 26053499 DOI: 10.1111/ner.12312] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 03/11/2015] [Accepted: 04/22/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The study aims to evaluate the long-term implant survival and complications of spinal cord stimulation (SCS) leading to surgical revision or explant in patients treated for chronic noncancer pain. MATERIALS AND METHODS This is a retrospective study of all patients who underwent a percutaneous spinal cord stimulation trial followed by implant in an academic Pain Medicine division by four practitioners from 2007 to 2013, with follow-up data through April 2014. RESULTS A total of 345 patients were considered candidates for dorsal column stimulation and underwent a trial. Two hundred thirty-four patients were implanted with an implant-to-trial ratio of 67-86% across various chronic pain entities (postlaminectomy syndrome, complex regional pain syndrome, small-fiber peripheral neuropathy, abdominal/pelvic pain, nonsurgical candidates with lumbosacral neuropathy, and neuropathic pain not otherwise specified), with the exception of nonsurgical candidates with lumbosacral neuropathy who had an implant ratio of 43%. The complication rate was 34.6%, with the hardware related being the most common reason, comprising 74.1% of all complications. The revision and explant rates were 23.9% each. The most common reason for explant was loss of therapeutic effect (41.1%). CONCLUSIONS SCS is an effective treatment for chronic noncancer pain. It is a minimally invasive procedure, safe, and with good long-term outcomes. However, the surgical revision and explant rates are relatively high. As the use of SCS continues to grow, research into the causes of and risk factors for SCS-related complications is paramount to decrease complication rates in the future.
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Affiliation(s)
- Salim M Hayek
- Department of Anesthesiology, Division of Pain Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Elias Veizi
- Case Western Reserve University, Cleveland, OH, USA.,Pain Medicine and Spine Care, Louis Stokes Veterans Administration Medical Center, Cleveland, OH, USA
| | - Michael Hanes
- Department of Anesthesiology, Division of Pain Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA
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Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Leong M, Levy RM, Abejon D, Buchser E, Burton A, Buvanendran A, Candido K, Caraway D, Cousins M, DeJongste M, Diwan S, Eldabe S, Gatzinsky K, Foreman RD, Hayek S, Kim P, Kinfe T, Kloth D, Kumar K, Rizvi S, Lad SP, Liem L, Linderoth B, Mackey S, McDowell G, McRoberts P, Poree L, Prager J, Raso L, Rauck R, Russo M, Simpson B, Slavin K, Staats P, Stanton-Hicks M, Verrills P, Wellington J, Williams K, North R. The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:515-50; discussion 550. [PMID: 25112889 DOI: 10.1111/ner.12208] [Citation(s) in RCA: 310] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/07/2014] [Accepted: 02/28/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications. METHODS The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar. RESULTS Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medication-related side effects and has enduring effect. Device-related complications are not uncommon; however, the incidence is becoming less frequent as technology progresses and surgical skills improve. Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated. CONCLUSIONS Appropriate neurostimulation is safe and effective in some chronic pain conditions. Technological refinements and clinical evidence will continue to expand its use. The NACC seeks to facilitate the efficacy and safety of neurostimulation.
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Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Thomson S, Raso L, Burton A, DeAndres J, Buchser E, Buvanendran A, Liem L, Kumar K, Rizvi S, Feler C, Abejon D, Anderson J, Eldabe S, Kim P, Leong M, Hayek S, McDowell G, Poree L, Brooks ES, McJunkin T, Lynch P, Kapural L, Foreman RD, Caraway D, Alo K, Narouze S, Levy RM, North R. The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain. Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:571-97; discussion 597-8. [PMID: 25112891 DOI: 10.1111/ner.12206] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/24/2013] [Accepted: 12/14/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes. METHODS The Neuromodulation Appropriateness Consensus Committee (NACC) reviewed the world literature in English by searching MEDLINE, PubMed, and Google Scholar to evaluate the evidence for ways to reduce risks of neurostimulation therapies. This evidence, obtained from the relevant literature, and clinical experience obtained from the convened consensus panel were used to make final recommendations on improving safety and reducing risks. RESULTS The NACC determined that the ability to reduce risk associated with the use of neurostimulation devices is a valuable goal and possible with best practice. The NACC has recommended several practice modifications that will lead to improved care. The NACC also sets out the minimum training standards necessary to become an implanting physician. CONCLUSIONS The NACC has identified the possibility of improving patient care and safety through practice modification. We recommend that all implanting physicians review this guidance and consider adapting their practice accordingly.
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Epidural spinal cord stimulation for neuropathic pain: a neurosurgical multicentric Italian data collection and analysis. Acta Neurochir (Wien) 2015; 157:711-20. [PMID: 25646850 DOI: 10.1007/s00701-015-2352-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 01/12/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is a technique used worldwide to treat several types of chronic neuropathic pain refractory to any conservative treatment. The aim of this data collection is to enforce evidence of SCS effectiveness on neuropathic chronic pain reported in the literature and to speculate on the usefulness of the trial period in determining the long-term efficacy. Moreover, the very low percentage of undesired side effects and complications reported in our case series suggests that all implants should be performed by similarly well-trained and experienced professionals. METHOD A multicentric data collection on a common database from 11 Italian neurosurgical departments started 3 years ago. Two different types of electrodes (paddle or percutaneous leads) were used. Of 122 patients, 73 % (N = 89) were submitted to a trial period, while the remaining patients underwent the immediate permanent implant (N = 33). Statistical comparisons of continuous variables between groups were performed. RESULTS Most of the patients (80 %) had predominant pain to their lower limbs, while only 17 % of patients had prevalent axial pain. Significant reduction in pain, as measured by variation in visual analogue scale (VAS) score, was observed at least 1 year after implantation in 63.8 % of the cases, 59.5 % of patients who underwent a test trial and 71.4 % of patients who underwent permanent implant at once. No statistical differences were found between the lower-limb pain group and the axial pain group. CONCLUSIONS No relevant differences in long-term outcomes were observed in previously tested patients compared with patients implanted at once. Through this analysis we hope to recruit new centres, to give more scientific value to our results.
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Scranton RA, Skaribas IM, Simpson RK. Spinal stimulator peri-electrode masses: case report. J Neurosurg Spine 2015; 22:70-4. [PMID: 25380541 DOI: 10.3171/2014.10.spine1425] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe a case of delayed spastic quadriparesis caused by a peri-electrode mass following the implantation of a minimally invasive percutaneous spinal cord stimulator (SCS). Prior reports with paddle-type electrodes are reviewed, and a detailed histological and pathophysiological comparison with the present case is made. The patient developed tolerance to a cervical percutaneous SCS 4 months after implantation, followed by the onset of spastic quadriparesis 9 months after implantation. The stimulator was removed, and contrast-enhanced MRI revealed an enhancing epidural mass where the system had been placed, with severe spinal cord compression. Decompression was carried out, and the patient experienced neurological improvement. Pathological examination revealed fibrotic tissue with granulomatous and multinucleated giant cell reactions. No evidence of infection or hemorrhage was found. Professionals treating patients with SCSs or contemplating their insertion should be aware of this delayed complication and associated risk factors.
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Affiliation(s)
- Robert A Scranton
- Department of Neurosurgery, Houston Methodist Neurological Institute; and
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