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Gish B, Langford B, Sobey C, Singh C, Abdullah N, Walker J, Gray H, Hagedorn J, Ghosh P, Patel K, Deer T. Neuromodulation for the management of chronic pelvic pain syndromes: A systematic review. Pain Pract 2024; 24:321-340. [PMID: 37726930 DOI: 10.1111/papr.13295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 05/22/2023] [Accepted: 08/23/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Chronic pelvic pain is a burdensome condition that involves multiple medical sub-specialties and is often difficult to treat. Sacral stimulation for functional bladder disease has been well established, but little large-scale evidence exists regarding utilization of other neuromodulation techniques to treat chronic pelvic pain. Emerging evidence does suggest that neuromodulation is a promising treatment, and we aim to characterize the use and efficacy of such techniques for treating chronic pelvic pain syndromes. MATERIALS AND METHODS A systematic review of the literature demonstrating the treatment of chronic pelvic pain syndromes with neuromodulation. Abstracts were reviewed and selected for inclusion, including case series, prospective studies, and randomized controlled trials (RCTs). Case studies and publications in abstract only were not included. The reporting for this systematic review follows Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The literature search was performed using MEDLINE, Embase, Cochrane Library, PubMed, CINAHL, and Scopus. RESULTS A total of 50 studies were included in this review, three of which were randomized controlled trials, and the remaining were prospective and retrospective case series. The range of pelvic pain conditions treated included interstitial cystitis, peripheral neuralgia, pudendal neuralgia, gastrointestinal pain, urogenital pain, sacroiliac joint pain, and visceral chronic pelvic pain. We reported on outcomes involving pain, functionality, psychosocial improvement, and medication reduction. CONCLUSIONS Neuromodulation is a growing treatment for various chronic pain syndromes. Peripheral nerve stimulation was the least studied form of stimulation. Posterior tibial nerve stimulation appears to offer short-term benefit, but long-term results are challenging. Sacral nerve stimulation is established for use in functional bladder syndromes and appears to offer pain improvement in these patients as well. Dorsal root ganglion stimulation and spinal cord stimulation have been used for a variety of conditions with promising results. Further studies of homogeneous patient populations are necessary before strong recommendations can be made at this time, although pooled analysis may also be impactful.
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Affiliation(s)
- Brandon Gish
- Lexington Clinic Interventional Pain, Lexington, Kentucky, USA
| | - Brendan Langford
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher Sobey
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chahait Singh
- Empire Minimally Invasive Spine and Pain, New York, New York, USA
| | - Newaj Abdullah
- Division of Pain Medicine, Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Jeremy Walker
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hannah Gray
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Kiran Patel
- Lennox Hill Hospital, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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2
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Lu L, Lau M, Akers L, Jones L, Selassie M, Burke M, Barley J, Hillegass M, Gleichgerrcht E. Intraoperative Neurophysiological Monitoring During Lead Placement for Dorsal Root Ganglion Stimulation: A Literature Review and Case Series. Neuromodulation 2024; 27:160-171. [PMID: 37245141 DOI: 10.1016/j.neurom.2023.04.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/23/2023] [Accepted: 04/11/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) is a viable interventional option for intractable pain management. Although systematic data are lacking regarding the immediate neurologic complications of this procedure, intraoperative neurophysiological monitoring (IONM) can be a valuable tool to detect real-time neurologic changes and prompt intervention(s) during DRG-S performed under general anesthesia and deep sedation. MATERIALS AND METHODS In our single-center case series, we performed multimodal IONM, including peripheral nerve somatosensory evoked potentials (pnSSEPs) and dermatomal somatosensory evoked potentials (dSSEPs), spontaneous electromyography (EMG), transcranial motor evoked potentials (MEPs), and electroencephalogram (EEG) for some trials and all permanent DRG-S lead placement per surgeon preference. Alert criteria for each IONM modality were established before data acquisition and collection. An IONM alert was used to implement an immediate repositioning of the lead to reduce any possible postoperative neurologic deficits. We reviewed the literature and summarized the current IONM modalities commonly applied during DRG-S, including somatosensory evoked potentials and EMG. Because DRG-S targets the dorsal roots, we hypothesized that including dSSEP would allow more sensitivity as a proxy for potential sensory changes under generalized anesthesia than would including standard pnSSEPs. RESULTS From our case series of 22 consecutive procedures with 45 lead placements, one case had an alert immediately after DRG-S lead positioning. In this case, dSSEP attenuation was seen, indicating changes in the S1 dermatome, which occurred despite ipsilateral pnSSEP from the posterior tibial nerve remaining at baselines. The dSSEP alert prompted the surgeon to reposition the S1 lead, resulting in immediate recovery of the dSSEP to baseline status. The rate of IONM alerts reported intraoperatively was 4.55% per procedure and 2.22% per lead (n = 1). No neurologic deficits were reported after the procedure, resulting in no postoperative neurologic complications or deficits. No other IONM changes or alerts were observed from pnSSEP, spontaneous EMG, MEPs, or EEG modalities. Reviewing the literature, we noted challenges and potential deficiencies when using current IONM modalities for DRG-S procedures. CONCLUSIONS Our case series suggests dSSEPs offer greater reliability than do pnSSEPs in quickly detecting neurologic changes, and subsequent neural injury, during DRG-S cases. We encourage future studies to focus on adding dSSEP to standard pnSSEP to provide a comprehensive, real-time neurophysiological assessment during lead placement for DRG-S. More investigation, collaboration, and evidence are required to evaluate, compare, and standardize comprehensive IONM protocols for DRG-S.
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Affiliation(s)
- Lei Lu
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.
| | - Martha Lau
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Lindsey Akers
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Lakota Jones
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Meron Selassie
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Martin Burke
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jessica Barley
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Hillegass
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
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Mol F, Scheltinga M, Roumen R, Wille F, Gültuna I, Kallewaard JW, Elzinga L, van de Minkelis J, Nijhuis H, Stronks DL, Huygen FJPM. Comparing the Efficacy of Dorsal Root Ganglion Stimulation With Conventional Medical Management in Patients With Chronic Postsurgical Inguinal Pain: Post Hoc Analyzed Results of the SMASHING Study. Neuromodulation 2023; 26:1788-1794. [PMID: 36456417 DOI: 10.1016/j.neurom.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/28/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Approximately 10% of patients who undergo inguinal hernia repair or Pfannenstiel incision develop chronic (> three months) postsurgical inguinal pain (PSIP). If medication or peripheral nerve blocks fail, a neurectomy is the treatment of choice. However, some patients do not respond to this treatment. In such cases, stimulation of the dorsal root ganglion (DRG) appears to significantly reduce chronic PSIP in selected patients. MATERIALS AND METHODS In this multicenter, randomized controlled study, DRG stimulation was compared with conventional medical management (CMM) (noninvasive treatments, such as medication, transcutaneous electric neurostimulation, and rehabilitation therapy) in patients with PSIP that was resistant to a neurectomy. Patients were recruited at a tertiary referral center for groin pain (SolviMáx, Eindhoven, The Netherlands) between March 2015 and November 2016. Suitability for implantation was assessed according to the Dutch Neuromodulation Association guidelines. The sponsor discontinued the study early owing to slow enrollment. Of 78 planned patients, 18 were randomized (DRG and CMM groups each had nine patients). Six patients with CMM (67%) crossed over to DRG stimulation at the six-month mark. RESULTS Fifteen of the 18 patients met the six-month primary end point with a complete data set for a per-protocol analysis. Three patients with DRG stimulation had a negative trial and were lost to follow-up. The average pain reduction was 50% in the DRG stimulation and crossover group (from 6.60 ± 1.24 to 3.28 ± 2.30, p = 0.0029). Conversely, a 13% increase in pain was observed in patients with CMM (from 6.13 ± 2.24 to 6.89 ± 1.24, p = 0.42). Nine patients with DRG stimulation experienced a total of 19 adverse events, such as lead dislocation and pain at the implantation site. CONCLUSIONS DRG stimulation is a promising effective therapy for pain relief in patients with PSIP resistant to conventional treatment modalities; larger studies should confirm this. The frequency of side effects should be a concern in a new study. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02349659.
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Affiliation(s)
| | | | - Rudi Roumen
- Maxima Medical Center, Eindhoven, The Netherlands
| | - Frank Wille
- Maxima Medical Center, Eindhoven, The Netherlands
| | | | | | - Lars Elzinga
- Maxima Medical Center, Eindhoven, The Netherlands
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4
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Ghorayeb JH, Chitneni A, Rupp A, Parkash A, Abd-Elsayed A. Dorsal root ganglion stimulation for the treatment of chronic pelvic pain: A systematic review. Pain Pract 2023; 23:838-846. [PMID: 37246484 DOI: 10.1111/papr.13255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Chronic pelvic pain (CPP) is a difficult condition to treat. Due to complex pelvic innervation, dorsal column spinal cord stimulation (SCS) has not been shown to produce the same effect as dorsal root ganglion stimulation (DRGS) given emerging evidence suggesting that applying DRGS may result in favorable outcomes for individuals with CPP. The aim of this systematic review is to investigate the clinical use and effectiveness of DRGS for patients with CPP. MATERIALS AND METHODS A systematic review of clinical studies demonstrating the use of DRGS for CPP. Searches were conducted using four electronic databases (PubMed, EMBASE, CINAHL, and Web of Science) across August and September 2022. RESULTS A total of nine studies comprising 65 total patients with variable pelvic pain etiologies met the inclusion criteria. The majority of subjects implanted with DRGS reported >50% mean pain reduction at variable times of follow-up. Secondary outcomes reported throughout studies including quality of life (QOL) and pain medication consumption were reported to be significantly improved. CONCLUSIONS Dorsal root ganglion stimulation for CPP continues to lack supportive evidence from well-designed, high-quality studies and recommendations from consensus committee experts. However, we present consistent evidence from level IV studies showing success with the use of DRGS for CPP in reducing pain symptoms along with reports of improved QOL through periods as short as 2 months to as long as 3 years. Because the available studies at this time are of low quality with a high risk of bias, we strongly recommend the facilitation of high-quality studies with larger sample sizes in order to better ascertain the utility of DRGS for this specific patient population. At the same time, from a clinical perspective, it may be reasonable and appropriate to evaluate patients for DRGS candidacy on a case-by-case basis, especially those patients who report CPP symptoms that are refractory to noninterventional measures and who may not be ideal candidates for other forms of neuromodulation.
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Affiliation(s)
- Joe H Ghorayeb
- University of Medicine and Health Sciences, New York, New York, USA
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, New York, USA
| | - Adam Rupp
- Department of Physical Medicine and Rehabilitation, University of Kansas Health System, Kansas City, Kansas, USA
| | - Anishinder Parkash
- Department of Physical Medicine and Rehabilitation, Tower Health Reading Hospital/Drexel University COM, Redding, Pennsylvania, USA
| | - Alaa Abd-Elsayed
- Division of Pain Medicine, Department of Anesthesia, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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5
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Huntzinger J, Selassie M. Interventional Pain Management in the Treatment of Chronic Pelvic Pain. Curr Urol Rep 2023; 24:165-171. [PMID: 36719535 DOI: 10.1007/s11934-022-01141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Chronic pelvic pain syndrome (CPPS) is a common yet complex disease in the field of urology, gynecology, and pain management. This review article summarizes the anatomy and physiology of CPP with an in-depth discussion of established and emerging interventional treatment options. RECENT FINDINGS Though psychosocial variables play a significant role in the development and propagation of CPPS, interventional treatment strategies are available to ameliorate symptoms. Sympathetic and peripheral nerve blocks along with chemical and radiofrequency denervation are conventional, evidence-based treatments. Recent advances in spinal cord stimulation and dorsal root ganglion stimulation offer novel and effective therapeutic options to treat CPPS. A biopsychosocial model should be employed for effective management of CPPS with advances in neuromodulation offering newfound hope in alleviating symptoms and restoring function.
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Affiliation(s)
- Jake Huntzinger
- Medical University of South Carolina, 167 Ashley Avenue, Suite 301, Charleston, SC, 29425, USA
| | - Meron Selassie
- Department of Anesthesiology, Medical University of South Carolina, 167 Ashley Avenue, Suite 301, Charleston, SC, 29425, USA.
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Chapman KB, Sayed D, Lamer T, Hunter C, Weisbein J, Patel KV, Dickerson D, Hagedorn JM, Lee DW, Amirdelfan K, Deer T, Chakravarthy K. Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience. J Pain Res 2023; 16:839-879. [PMID: 36942306 PMCID: PMC10024474 DOI: 10.2147/jpr.s364370] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 01/17/2023] [Indexed: 03/14/2023] Open
Abstract
With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion stimulation (DRG-S) has significantly improved the treatment of complex regional pain syndrome (CRPS), and it has broad applicability across a wide range of other conditions. Through funding and organizational leadership by the American Society for Pain and Neuroscience (ASPN), this best practices consensus document has been developed for the selection, implantation, and use of DRG stimulation for the treatment of chronic pain syndromes. This document is composed of a comprehensive narrative literature review that has been performed regarding the role of the DRG in chronic pain and the clinical evidence for DRG-S as a treatment for multiple pain etiologies. Best practice recommendations encompass safety management, implantation techniques, and mitigation of the potential complications reported in the literature. Looking to the future of neuromodulation, DRG-S holds promise as a robust intervention for otherwise intractable pain.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, NY, USA
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
- Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA
- Correspondence: Kenneth B Chapman, NYU Langone Medical Center, Zucker School of Medicine at Hofstra/Northwell, Pain Medicine at Staten Island University Hospital, 1360 Hylan Boulevard, Staten Island, NY, 10305, USA, Email
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS, USA
| | - Tim Lamer
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, NY, USA
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
- Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA
| | - David Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University Health System, Evanston, IL, USA
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA
| | | | - David W Lee
- Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
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7
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Hunter CW, Deer TR, Jones MR, Chang Chien GC, D'Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2683-2745. [PMID: 36132996 PMCID: PMC9484571 DOI: 10.2147/jpr.s370469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA.,Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Ryan S D'Souza
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Erica R Eldon
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lissa Hewan-Lowe
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jillian A Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Anthony J Mazzola
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jeanmarie Tari
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Chris Wie
- Interventional Spine and Pain, Dallas, TX, USA
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK, USA
| | - Dawood Sayed
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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8
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Potter ST, Welch S, Tata F, Probert S, Nagpal A. Dorsal Root Ganglion Stimulation. Phys Med Rehabil Clin N Am 2022; 33:359-378. [DOI: 10.1016/j.pmr.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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9
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D'Souza RS, Kubrova E, Her YF, Barman RA, Smith BJ, Alvarez GM, West TE, Abd-Elsayed A. Dorsal Root Ganglion Stimulation for Lower Extremity Neuropathic Pain Syndromes: An Evidence-Based Literature Review. Adv Ther 2022; 39:4440-4473. [PMID: 35994195 PMCID: PMC9464732 DOI: 10.1007/s12325-022-02244-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/23/2022] [Indexed: 01/30/2023]
Abstract
Dorsal root ganglion stimulation (DRG-S) is a form of selective neuromodulation therapy that targets the dorsal root ganglion. DRG-S offers analgesia in a variety of chronic pain conditions and is approved for treatment of complex regional pain syndrome (CRPS) by the US Food and Drug Administration (FDA). There has been increasing utilization of DRG-S to treat various neuropathic pain syndromes of the lower extremity, although evidence remains limited to one randomized controlled trial and 39 observational studies. In this review, we appraised the current evidence for DRG-S in the treatment of lower extremity neuropathic pain using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. The primary outcome was change in pain intensity after DRG-S compared to baseline. We stratified presentation of results based of type of neuropathy (CRPS, painful diabetic neuropathy, mononeuropathy, polyneuropathy) as well as location of neuropathy (hip, knee, foot). Future powered randomized controlled trials with homogeneous participants are warranted.
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Affiliation(s)
- Ryan S D'Souza
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eva Kubrova
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Yeng F Her
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross A Barman
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brandon J Smith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Gabriel M Alvarez
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Tyler E West
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA.
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10
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Dalrymple AN, Ting JE, Bose R, Trevathan JK, Nieuwoudt S, Lempka SF, Franke M, Ludwig KA, Shoffstall AJ, Fisher LE, Weber DJ. Stimulation of the dorsal root ganglion using an Injectrode ®. J Neural Eng 2021; 18. [PMID: 34650008 DOI: 10.1088/1741-2552/ac2ffb] [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: 08/17/2021] [Accepted: 10/14/2021] [Indexed: 01/15/2023]
Abstract
Objective. The goal of this work was to compare afferent fiber recruitment by dorsal root ganglion (DRG) stimulation using an injectable polymer electrode (Injectrode®) and a more traditional cylindrical metal electrode.Approach. We exposed the L6 and L7 DRG in four cats via a partial laminectomy or burr hole. We stimulated the DRG using an Injectrode or a stainless steel (SS) electrode using biphasic pulses at three different pulse widths (80, 150, 300μs) and pulse amplitudes spanning the range used for clinical DRG stimulation. We recorded antidromic evoked compound action potentials (ECAPs) in the sciatic, tibial, and common peroneal nerves using nerve cuffs. We calculated the conduction velocity of the ECAPs and determined the charge-thresholds and recruitment rates for ECAPs from Aα, Aβ, and Aδfibers. We also performed electrochemical impedance spectroscopy measurements for both electrode types.Main results. The ECAP thresholds for the Injectrode did not differ from the SS electrode across all primary afferents (Aα, Aβ, Aδ) and pulse widths; charge-thresholds increased with wider pulse widths. Thresholds for generating ECAPs from Aβfibers were 100.0 ± 32.3 nC using the SS electrode, and 90.9 ± 42.9 nC using the Injectrode. The ECAP thresholds from the Injectrode were consistent over several hours of stimulation. The rate of recruitment was similar between the Injectrodes and SS electrode and decreased with wider pulse widths.Significance. The Injectrode can effectively excite primary afferents when used for DRG stimulation within the range of parameters used for clinical DRG stimulation. The Injectrode can be implanted through minimally invasive techniques while achieving similar neural activation to conventional electrodes, making it an excellent candidate for future DRG stimulation and neuroprosthetic applications.
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Affiliation(s)
- Ashley N Dalrymple
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America.,Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America
| | - Jordyn E Ting
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America
| | - Rohit Bose
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America
| | - James K Trevathan
- Departments of Biomedical Engineering and Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | | | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
| | | | - Kip A Ludwig
- Departments of Biomedical Engineering and Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.,Neuronoff Inc., Cleveland, OH, United States of America.,Wisconsin Institute for Translational Neuroengineering (WITNe), Madison, WI, United States of America
| | - Andrew J Shoffstall
- Neuronoff Inc., Cleveland, OH, United States of America.,Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States of America
| | - Lee E Fisher
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Douglas J Weber
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America.,Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America.,Neuroscience Institute, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America
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11
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Bral P, Smet I, Jerjir A, Devos M, Van Buyten JP. Dorsal root ganglion stimulation for patients with refractory pain due to anterior cutaneous nerve entrapment syndrome: A case series. Pain Pract 2021; 22:288-294. [PMID: 34672088 DOI: 10.1111/papr.13086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/25/2021] [Accepted: 09/25/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Anterior cutaneous nerve entrapment syndrome (ACNES) is a painful condition that can be refractory in a small percentage of patients. Abdominal pain caused by thoracic nerve entrapment in the abdominal wall characterizes ACNES. In the small number of refractory patients to all standard treatments, medication overuse and abuse are serious problems. Dorsal root ganglion (DRG) stimulation might be a good treatment to improve pain scores and to lower medication use. METHODS We describe the retrospective analysis of nine cases of patients who underwent DRG stimulation for refractory ACNES using a treatment algorithm. We focused on reported pain intensity scores, medication use, and adverse events. RESULTS All nine patients experienced a decrease in pain intensity during the trial period and received a permanent pulse generator implantation. Three months after permanent implantation, eight of nine patients showed a pain reduction of more than 50%. Medication use was substantially lower. DISCUSSION AND CONCLUSION This case series shows that DRG stimulation might be a very good treatment for refractory ACNES.
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Affiliation(s)
- Philippe Bral
- Department of Anesthesiology and Pain Medicine, UZ Brussel, Brussels, Belgium
| | - Iris Smet
- Multidisciplinary pain center, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Ali Jerjir
- Multidisciplinary pain center, AZ Nikolaas, Sint-Niklaas, Belgium
| | - Marieke Devos
- Multidisciplinary pain center, AZ Nikolaas, Sint-Niklaas, Belgium
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12
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The role of periradicular infiltration in dorsal root ganglion stimulation for chronic neuropathic pain. Acta Neurochir (Wien) 2021; 163:2135-2140. [PMID: 33564905 PMCID: PMC8270871 DOI: 10.1007/s00701-021-04745-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 01/27/2021] [Indexed: 11/30/2022]
Abstract
Background Targeting the correct spinal level is essential in dorsal root ganglion (DRG) stimulation. Anatomical selection of the DRG alone is not ideal since the pain area is not necessarily confined to the borders of the dermatomes. This study aims to establish the role of periradicular infiltration therapy (PRT) in the preoperative assessment of the correct level for DRG stimulation performed under general anesthesia. Method We report a prospective study of 20 patients selected for DRG stimulation and submitted to a PRT for identification of the spinal level. Lead implantation for the stimulation trial occurred under general anesthesia: 19 patients experienced positive results and underwent implantation of the pulse generator. All patients suffered from chronic neuropathic pain unresponsive to best medical treatment. PRT levels were compared with the levels targeted with DRG leads. Patients were followed for up to 12 months; pain intensity and coverage of the painful area were assessed. Results In 12 patients, the trial leads were placed on the same level as previously tested positive by PRT. In 6 patients, leads were placed in the PRT target and additionally in adjacent spinal levels. In one case, the selected target for the trial diverged from the PRT target because of intense fibrosis in the chosen level. Coverage of the target area of at least 50% was achieved by two-thirds of the patients. For the six subjects with additional implanted leads as a consequence of the PRT results, 80% achieved a coverage of at least 50%. A total of 47.4% of the patients achieved sustained significant pain relief in the last follow-up. None of the patients needed a repeated surgery for implantation of additional leads. Conclusions PRT is a helpful tool to confirm the stimulation targets. A PRT preceding the stimulation trial is an additional opportunity to optimize the coverage of the target area with stimulation-induced paresthesia for patients operated under general anesthesia.
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13
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Char S, Barman RA, Deer TR, Hagedorn JM. Dorsal Root Ganglion Stimulation for Chronic Groin Pain: A Review. Neuromodulation 2021; 25:965-969. [PMID: 34077614 DOI: 10.1111/ner.13468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/19/2021] [Accepted: 05/11/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Chronic neuropathic groin pain develops in a significant number of postsurgical patients; however, multiple etiologies have been identified, and this makes it a challenging condition to treat. While treatment often involves a multimodal approach, advancements in neuromodulation technology, particularly dorsal root ganglion (DRG) stimulation, have benefited patients plagued by chronic pain refractory to standard treatment modalities. Our goal was to provide a definitive source of information for interventional pain physicians regarding groin pain and the use of DRG stimulation for its treatment. MATERIALS AND METHODS In this narrative review, we provide an overview of groin pain and discuss potential pain generators. We also outline appropriate treatment options with particular interest on DRG stimulation. Lastly, we provide a narrative review of the published literature regarding DRG stimulation for chronic groin pain from a variety of etiologies. CONCLUSION DRG stimulation has emerged as an alternative neuromodulatory technique for patients with chronic groin pain. While previous studies suggest substantial sustained pain relief with DRG stimulation in this patient population, prospective randomized controlled studies are necessary before formal recommendations can be made.
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Affiliation(s)
- Steven Char
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ross A Barman
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
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14
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Nagpal A, Clements N, Duszynski B, Boies B. The Effectiveness of Dorsal Root Ganglion Neurostimulation for the Treatment of Chronic Pelvic Pain and Chronic Neuropathic Pain of the Lower Extremity: A Comprehensive Review of the Published Data. PAIN MEDICINE 2021; 22:49-59. [PMID: 33260203 DOI: 10.1093/pm/pnaa369] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of dorsal root ganglion neurostimulation for the treatment of refractory, focal pain in the pelvis and lower extremities. DESIGN Systematic review. OUTCOME MEASURES The primary outcome was ≥50% pain relief. Secondary outcomes were physical function, mood, quality of life, opioid usage, and complications. RESULTS One pragmatic randomized controlled trial, four prospective cohort studies, and eight case series met the inclusion criteria. A worst-case scenario analysis from the randomized controlled trial reported ≥50% pain relief in 74% of patients with dorsal root ganglion neurostimulation vs. 51% of patients who experienced at least 50% relief with spinal cord stimulation at 3 months. Cohort data success rates ranged from 43% to 83% at ≤6 months and 27% to 100% at >6 months. Significant improvements were also reported in the secondary outcomes assessed, including mood, quality of life, opioid usage, and health care utilization, though a lack of available quantitative data limits further statistical analysis. Complication rates vary, though the only randomized controlled trial reported a higher rate of adverse events than that seen with traditional neurostimulation. CONCLUSIONS In accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system, low-quality evidence supports dorsal root ganglion neurostimulation as a more effective treatment than traditional neurostimulation for pain and dysfunction associated with complex regional pain syndrome or causalgia. Very low-quality evidence supports dorsal root ganglion neurostimulation for the treatment of chronic pelvic pain, chronic neuropathic groin pain, phantom limb pain, chronic neuropathic pain of the trunk and/or limbs, and diabetic neuropathy.
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Affiliation(s)
- Ameet Nagpal
- Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Nathan Clements
- Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | - Brian Boies
- Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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15
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Dorsal Root Ganglion Stimulation Alleviates Pain-related Behaviors in Rats with Nerve Injury and Osteoarthritis. Anesthesiology 2020; 133:408-425. [PMID: 32433276 DOI: 10.1097/aln.0000000000003348] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Dorsal root ganglion field stimulation is an analgesic neuromodulation approach in use clinically, but its mechanism is unknown as there is no validated animal model for this purpose. The authors hypothesized that ganglion stimulation is effective in reducing pain-like behaviors in preclinical chronic pain models. METHODS The authors provided ganglion stimulation or spinal cord stimulation to rats with traumatic neuropathy (tibial nerve injury), or osteoarthritis induced by intraarticular knee monosodium iodoacetate, or without injury (naïve). Analgesia was evaluated by testing a battery of pain-related reflexive, functional, and affective behaviors. RESULTS In rats with nerve injury, multilevel L4 and L5 ganglion stimulation decreased hypersensitivity to noxious mechanical stimulation more (area under curve, -1,447 ± 423 min × % response; n = 12) than single level ganglion stimulation at L4 ([-960 ± 251 min × % response; n = 8; P = 0.012] vs. L4 and L5), and L5 ([-676 ± 295 min × % response; n = 8; P < 0.0001] vs. L4 and L5). Spontaneous pain-like behavior, evaluated by conditioned place preference, responded to single L4 (Pretest [-93 ± 65 s] vs. Test [87 ± 82 s]; P = 0.002; n = 9), L5 (Pretest [-57 ± 36 s] vs. Test [137 ± 73 s]; P = 0.001; n = 8), and multilevel L4 and L5 (Pretest: -81 ± 68 s vs. Test: 90 ± 76 s; P = 0.003; n = 8) ganglion stimulation. In rats with osteoarthritis, multilevel L3 and L4 ganglion stimulation reduced sensitivity to knee motion more (-156 ± 28 min × points; n = 8) than L3 ([-94 ± 19 min × points in knee bend test; n = 7; P = 0.002] vs. L3 and L4) or L4 ([-71 ± 22 min × points; n = 7; P < 0.0001] vs. L3 and L4). Conditioned place preference during osteoarthritis revealed analgesic effectiveness for ganglion stimulation when delivered at L3 (Pretest [-78 ± 77 s] vs. Test [68 ± 136 s]; P = 0.048; n = 9), L4 (Pretest [-96 ± 51 s] vs. Test [73 ± 111 s]; P = 0.004; n = 9), and L3 and L4 (Pretest [-69 ± 52 s; n = 7] vs. Test [55 ± 140 s]; P = 0.022; n = 7). CONCLUSIONS Dorsal root ganglion stimulation is effective in neuropathic and osteoarthritic preclinical rat pain models with peripheral pathologic origins, demonstrating effectiveness of ganglion stimulation in a placebo-free setting and justifying this model as a suitable platform for mechanistic studies.
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16
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Antony AB, Schultheis BC, Jolly SM, Bates D, Hunter CW, Levy RM. Neuromodulation of the Dorsal Root Ganglion for Chronic Postsurgical Pain. PAIN MEDICINE 2020; 20:S41-S46. [PMID: 31152174 PMCID: PMC6733040 DOI: 10.1093/pm/pnz072] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective The objective of this study is to review the available evidence for dorsal root ganglion (DRG) stimulation for the treatment of complex regional pain syndrome type II (CRPS II; peripheral causalgia) associated with chronic neuropathic postsurgical pain (NPP). Design Available literature was identified through a search of the US National Library of Medicine’s Medline database, PubMed.gov. References from published articles also were reviewed for relevant citations. Results The data published to date support the use of DRG stimulation to treat chronic NPP of the groin, knee, and foot. NPP following procedures such as thoracotomy, hernia surgery, and knee replacement surgery were identified as some of the conditions for which DRG stimulation is likely to be effective. Conclusion DRG stimulation is known to be an effective treatment for focal neuropathic pain. Currently, NPP of the foot, groin, and knee all appear to be the conditions with the most clinical experience, backed by a limited but growing body of evidence. However, prospective studies lag behind real-world clinical experience and are needed to confirm these findings.
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Affiliation(s)
- Ajay B Antony
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | | | | | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Robert M Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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17
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Esposito MF, Malayil R, Hanes M, Deer T. Unique Characteristics of the Dorsal Root Ganglion as a Target for Neuromodulation. PAIN MEDICINE 2020; 20:S23-S30. [PMID: 31152179 PMCID: PMC6544557 DOI: 10.1093/pm/pnz012] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective The dorsal root ganglion (DRG) is a novel target for neuromodulation, and DRG stimulation is proving to be a viable option in the treatment of chronic intractable neuropathic pain. Although the overall principle of conventional spinal cord stimulation (SCS) and DRG stimulation—in which an electric field is applied to a neural target with the intent of affecting neural pathways to decrease pain perception—is similar, there are significant differences in the anatomy and physiology of the DRG that make it an ideal target for neuromodulation and may account for the superior outcomes observed in the treatment of certain chronic neuropathic pain states. This review highlights the anatomy of the DRG, its function in maintaining homeostasis and its role in neuropathic pain, and the unique value of DRG as a target in neuromodulation for pain. Methods A narrative literature review was performed. Results Overall, the DRG is a critical structure in sensory transduction and modulation, including pain transmission and the maintenance of persistent neuropathic pain states. Unique characteristics including selective somatic organization, specialized membrane characteristics, and accessible and consistent location make the DRG an ideal target for neuromodulation. Because DRG stimulation directly recruits the somata of primary sensory neurons and harnesses the filtering capacity of the pseudounipolar neural architecture, it is differentiated from SCS, peripheral nerve stimulation, and other neuromodulation options. Conclusions There are several advantages to targeting the DRG, including lower energy usage, more focused and posture-independent stimulation, reduced paresthesia, and improved clinical outcomes.
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Affiliation(s)
| | - Rudy Malayil
- St. Mary's Pain Relief Specialists, Huntington, West Virginia
| | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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18
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Huygen FJPM, Kallewaard JW, Nijhuis H, Liem L, Vesper J, Fahey ME, Blomme B, Morgalla MH, Deer TR, Capobianco RA. Effectiveness and Safety of Dorsal Root Ganglion Stimulation for the Treatment of Chronic Pain: A Pooled Analysis. Neuromodulation 2019; 23:213-221. [PMID: 31730273 PMCID: PMC7079258 DOI: 10.1111/ner.13074] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Since it became available in the mid-2010s, dorsal root ganglion (DRG) stimulation has become part of the armamentarium to treat chronic pain. To date, one randomized controlled trial, and several studies of moderate sample size and various etiologies have been published on this topic. We conducted a pooled analysis to investigate the generalizability of individual studies and to identify differences in outcome between chronic pain etiologic subgroups and/or pain location. MATERIALS AND METHODS One prospective, randomized comparative trial and six prospective, single-arm, observational studies were identified that met pre-defined acceptance criteria. Pain scores and patient-reported outcome (PRO) measures were weighted by study sample sizes and pooled. Safety data are reported in aggregate form. RESULTS Our analysis included 217 patients with a permanent implant at 12-month follow-up. Analysis of pooled data showed an overall weighted mean pain score of 3.4, with 63% of patients reporting ≥50% pain relief. Effectiveness sub-analyses in CRPS-I, causalgia, and back pain resulted in a mean reduction in pain intensity of 4.9, 4.6, and 3.9 points, respectively. Our pooled analysis showed a pain score for primary affected region ranging from 1.7 (groin) to 3.0 (buttocks) and responder rates of 80% for foot and groin, 75% for leg, and 70% for back. A substantial improvement in all PROs was observed at 12 months. The most commonly reported procedural or device complications were pain at the IPG pocket site, lead fracture, lead migration, and infection. CONCLUSIONS DRG stimulation is an effective and safe therapy for various etiologies of chronic pain.
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Affiliation(s)
- Frank J P M Huygen
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Velp, The Netherlands
| | | | - Liong Liem
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Bram Blomme
- Neuromodulation Division, Abbott, Austin, TX, USA
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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19
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Vuka I, Marciuš T, Došenović S, Ferhatović Hamzić L, Vučić K, Sapunar D, Puljak L. Neuromodulation with electrical field stimulation of dorsal root ganglion in various pain syndromes: a systematic review with focus on participant selection. J Pain Res 2019; 12:803-830. [PMID: 30881093 PMCID: PMC6398970 DOI: 10.2147/jpr.s168814] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective We conducted a systematic review about patient selection, efficacy, and safety of neuromodulation with electrical field stimulation (EFS) of dorsal root ganglion (DRG) in various painful conditions. We also analyzed conclusion statements as well as conflict of interest and financing of the included studies. Methods All study designs were eligible for inclusion. We searched MEDLINE, CINAHL, Embase, PsycINFO, and clinical trial registries until September 7, 2018. We assessed risk of bias by using Cochrane tool for randomized controlled trials (RCTs). Results Among the 29 included studies, only one was RCT, majority being case series and case reports. The evidence is based on studies with small number of participants (median: 6, range 1–152) with various painful conditions. Neuromodulation with EFS of DRG was mostly performed in participants who have failed other treatment modalities. Most of the authors of the included studies reported positive, but inconclusive, evidence regarding efficacy of neuro-modulation with EFS of DRG. Meta-analysis was not possible since only one RCT was included. Conclusion Available evidence suggest that neuromodulation with EFS of DRG may help highly selected participants with various pain syndromes, who have failed to achieve adequate pain relief with other pharmacological and nonpharmacological interventions. However, these findings should be confirmed in high-quality RCTs with sufficient numbers of participants.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, 21000 Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, 21000 Split, Croatia
| | - Svjetlana Došenović
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, 21000 Split, Croatia
| | - Lejla Ferhatović Hamzić
- Department for Proteomics, Center for Translational and Clinical Research, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
| | - Katarina Vučić
- Department for Safety and Efficacy Assessment of Medicinal Products, Agency for Medicinal Products and Medical Devices, 10000 Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, 21000 Split, Croatia.,Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, 10000 Zagreb, Croatia,
| | - Livia Puljak
- Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, 10000 Zagreb, Croatia,
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Elsamadicy AA, Ashraf B, Ren X, Sergesketter AR, Charalambous L, Kemeny H, Ejikeme T, Yang S, Pagadala P, Parente B, Xie J, Pappas TN, Lad SP. Prevalence and Cost Analysis of Chronic Pain After Hernia Repair: A Potential Alternative Approach With Neurostimulation. Neuromodulation 2018; 22:960-969. [PMID: 30320933 DOI: 10.1111/ner.12871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 08/25/2018] [Accepted: 08/30/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Chronic pain (CP) affects a significant number of patients following hernia repair, ranging from 11 to 54% in the literature. The aim of this study was to assess the prevalence, overall costs, and health care utilization associated with CP after hernia repair. MATERIALS AND METHODS A retrospective longitudinal study was performed using the Truven MarketScan® data base to identify patients who develop chronic neuropathic posthernia repair pain from 2001 to 2012. Patients were grouped into CP and No Chronic Pain (No CP) cohorts. Patients were excluded if they 1) were under 18 years of age; 2) had a previous pain diagnosis; 3) had CP diagnosed <90 days after the index hernia repair; 4) had less than one year of follow-up; or 5) had less than one-year baseline record before hernia repair. Patients were grouped into the CP cohort if their CP diagnosis was made within the two years following index hernia repair. Total, outpatient, and pain prescription costs were collected in the period of five years prehernia to nine years posthernia repair. A longitudinal multivariate analysis was used to model the effects of chronic neuropathic posthernia repair pain on total inpatient/outpatient and pain prescription costs. RESULTS We identified 76,173 patients who underwent hernia repair and met inclusion criteria (CP: n = 14,919, No CP: n = 61,254). There was a trend for increased total inpatient/outpatient and pain prescription costs one-year posthernia repair, when compared to baseline costs for both cohorts. In both cohorts, total inpatient/outpatient costs remained elevated from baseline through nine years posthernia repair, with the CP cohort experiencing significantly higher cumulative median costs (CP: $51,334, No CP: $37,388). The CP diagnosis year was associated with a 1.75-fold increase (p < 0.001) in total inpatient/outpatient costs and a 2.26-fold increase (p < 0.001) in pain prescription costs versus all other years. In the longitudinal analysis, the CP cohort had a 1.14-fold increase (p < 0.001) in total inpatient/outpatient costs and 2.00-fold increase (p < 0.001) in pain prescription costs. CONCLUSIONS Our study demonstrates the prevalence of CP after hernia surgery to be nearly 20%, with significantly increased costs and healthcare resource utilization. While current treatment paradigms are effective for many, there remains a large number of patients that could benefit from an overall approach that includes nonopioid treatments, such as potentially incorporating neurostimulation, for CP that presents posthernia repair.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Bilal Ashraf
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Xinru Ren
- Department of Biostatistics and Bioinformatics, 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
| | - Siyun Yang
- Department of Biostatistics and Bioinformatics, 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 and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Theodore N Pappas
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Deer TR, Pope JE, Lamer TJ, Grider JS, Provenzano D, Lubenow TR, FitzGerald JJ, Hunter C, Falowski S, Sayed D, Baranidharan G, Patel NK, Davis T, Green A, Pajuelo A, Epstein LJ, Harned M, Liem L, Christo PJ, Chakravarthy K, Gilmore C, Huygen F, Lee E, Metha P, Nijhuis H, Patterson DG, Petersen E, Pilitsis JG, Rowe JJ, Rupert MP, Skaribas I, Sweet J, Verrills P, Wilson D, Levy RM, Mekhail N. The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation. Neuromodulation 2018; 22:1-35. [PMID: 30246899 DOI: 10.1111/ner.12845] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/03/2018] [Accepted: 05/29/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. METHODS The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. RESULTS The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation. CONCLUSION The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.
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Affiliation(s)
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - James J FitzGerald
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, PA, USA
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nikunj K Patel
- Institute of Clinical Neurosciences, Department of Neurosurgery, Southmead Hospital, University of Bristol, Bristol, UK
| | | | - Alex Green
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | | | - Michael Harned
- Department of Anesthesiology, University of Kentucky, Lexington, KY, USA
| | - Liong Liem
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | | | - Frank Huygen
- Erasmus University Hospital, Rotterdam, The Netherlands
| | - Eric Lee
- Summit Pain Alliance, Santa Rosa, CA, USA
| | | | | | | | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie G Pilitsis
- Neurosurgery and Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | | | | | | | - Jennifer Sweet
- Case Western Reserve University, Stereotactic & Functional Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Derron Wilson
- Goodman Campbell Brain and Spine, Indiana University School of Medicine Department of Neurological Surgery, Indianapolis, IN, USA
| | | | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, OH, USA
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22
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Huygen FJPM, Liem L, Nijhuis H, Cusack W, Kramer J. Evaluating Dorsal Root Ganglion Stimulation in a Prospective Dutch Cohort. Neuromodulation 2018; 22:80-86. [PMID: 30079622 DOI: 10.1111/ner.12798] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/09/2018] [Accepted: 04/29/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Dorsal root ganglion (DRG) stimulation is a recent neuromodulation option that has delivered safe, effective pain relief for a number of etiologies. This prospective observational study was intended to establish the effectiveness of this treatment in a typical real-world clinical context. MATERIALS AND METHODS Participants with chronic, intractable pain of the trunk or lower limbs were recruited from multiple pain clinics in the Netherlands. Subjects were trialed and implanted with DRG stimulation systems. Pain, function, mood, and quality of life, ratings were collected through 12 months postimplant. RESULTS Of the 66 subjects enrolled, failed back surgery syndrome, peripheral nerve injury, and complex regional pain syndrome formed the largest etiologies. Permanent implants were placed in 86.2% subjects (56/65). After 12 months of treatment, average pain ratings in subjects' primary area of pain decreased from 8.0 cm at baseline to 4.1 cm, and 49% of subjects had ≥50% reduction in pain (visual analog scale). In addition, functional capacity was increased, and mood and quality of life improved. No confirmed lead migrations were observed, and there was a low rate of infection. CONCLUSIONS DRG stimulation significantly reduced the severity of subjects' pain and enabled participatory changes that improved quality of life through 12-months postimplant.
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Affiliation(s)
| | - Liong Liem
- Maastricht University Medical Centre, Maastricht, The Netherlands
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Mol FMU, Roumen RM, Scheltinga MR. Comparing the efficacy of targeted spinal cord stimulation (SCS) of the dorsal root ganglion with conventional medical management (CMM) in patients with chronic post-surgical inguinal pain: the SMASHING trial. BMC Surg 2018; 18:18. [PMID: 29587729 PMCID: PMC5872506 DOI: 10.1186/s12893-018-0349-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/04/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND A significant number of patients who undergo a standard inguinal hernia repair or a Pfannenstiel incision develop chronic (> 3 months) post-surgical inguinal pain (PSIP) due to nerve entrapment. If medication or peripheral nerve blocks fail, surgery including neurectomies may offer relief. However, some patients do not respond to any of the currently available remedial treatment modalities. Targeted spinal cord stimulation (SCS) of the dorsal root ganglion (DRG) is a relatively new type of therapy that has a potential to significantly reduce chronic PSIP. The Axium® SCS System (Spinal Modulation Inc., NY, USA) has been shown to be safe and successful in small cohorts of PSIP patients. Aim of this study is to evaluate targeted spinal cord stimulation therapy in patients with PSIP. METHODS A prospective, multicentre, randomized controlled trial with optional one-way crossover will assess the efficacy of the Axium® SCS system for the treatment of PSIP. Seventy-eight patients with intractable PSIP following open hernia repair or Pfannenstiel incision who did not respond favorably to previous pain treatment regimens including a neurectomy will be randomized to either an Axium® SCS arm or a control arm receiving only conventional medical management (CMM). Primary outcome is the difference in percentage of subjects with ≥50% pain relief after 6 months using a Numerical Pain Rating Scale (NPRS). Data are collected using a daily pain/sleep diary and a number needed to treat (NNT) analysis is performed. Various secondary outcomes will be collected. DISCUSSION Targeted SCS stimulation of the DRG using the Axium® SCS system will possibly offer significant pain reduction in patients with PSIP who are refractory to other treatment modalities. TRIAL REGISTRATION The study protocol is registered at the NIH Clinical Trials Registry ( http://clinicaltrials.gov , ClinicalTrials.gov identifier: NCT02349659 ) on January 29, 2015.
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Affiliation(s)
- Frederique M. U. Mol
- Department of Surgery, Maxima Medical Center, de Run 4600, PO Box 7777, 5500 MB Veldhoven, The Netherlands
| | - Rudi M. Roumen
- Department of Surgery, Maxima Medical Center, de Run 4600, PO Box 7777, 5500 MB Veldhoven, The Netherlands
| | - Marc R. Scheltinga
- Department of Surgery, Maxima Medical Center, de Run 4600, PO Box 7777, 5500 MB Veldhoven, The Netherlands
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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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25
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Dorsal Root Ganglion Stimulation for Pain Control. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00053-x] [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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26
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Zuidema X, Schapendonk JWLC. Dorsal Root Ganglion Stimulation: A Treatment Option for Chronic Pain Due to Refractory Loin Pain Haematuria Syndrome. Neuromodulation 2017; 20:841-843. [DOI: 10.1111/ner.12703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Xander Zuidema
- Department of Anaesthesiology and Pain Management; Diakonessenhuis Utrecht/Zeist, PO Box 80250; 3508 TG Utrecht the Netherlands
| | - Johannes W. L. C. Schapendonk
- Department of Anaesthesiology and Pain Management; Diakonessenhuis Utrecht/Zeist, PO Box 80250; 3508 TG Utrecht the Netherlands
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27
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Morgalla MH, Bolat A, Fortunato M, Lepski G, Chander BS. Dorsal Root Ganglion Stimulation Used for the Treatment of Chronic Neuropathic Pain in the Groin: A Single-Center Study With Long-Term Prospective Results in 34 Cases. Neuromodulation 2017; 20:753-760. [DOI: 10.1111/ner.12713] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 08/15/2017] [Accepted: 09/11/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Anil Bolat
- Department of Neurosurgery; University of Tuebingen; Tuebingen Germany
| | - Marcos Fortunato
- Department of Neurosurgery; University of Tuebingen; Tuebingen Germany
| | - Guilherme Lepski
- Department of Neurosurgery; University of Tuebingen; Tuebingen Germany
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Harrison C, Epton S, Bojanic S, Green AL, FitzGerald JJ. The Efficacy and Safety of Dorsal Root Ganglion Stimulation as a Treatment for Neuropathic Pain: A Literature Review. Neuromodulation 2017; 21:225-233. [PMID: 28960653 DOI: 10.1111/ner.12685] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/26/2017] [Accepted: 07/28/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Dorsal root ganglion stimulation (DRGS) received its first regulatory approval (CE marking in Europe) in late 2011, and so its use is now almost six years old. Several thousand patients have already been treated, and a landmark trial in lower limb complex regional pain syndrome (CRPS) and causalgia has recently been published. METHODS In this review we have summarized the literature to date on the use of DRGS in the treatment of neuropathic pain. RESULTS The results so far are encouraging, with reports of successful use in treating a wide range of indications including postsurgical pain, CRPS, and phantom pain. Treatment of failed back surgery syndrome (FBSS) appears less successful. The therapy is still young, and long term results are not yet available. There is now good randomized clinical trial (RCT) evidence that DRGS provides superior pain relief to spinal cord stimulation for CRPS and causalgia of the lower limb, and produces stimulation that is more posturally stable, with more precise paraesthesia coverage. However evidence of this quality for other indications and pain locations is lacking. CONCLUSION There is now Class A RCT evidence that DRGS provides superior pain relief to SCS for CRPS and causalgia of the lower limb. In the coming years we hope that randomized controlled trials will be performed on an indication-by-indication basis, which, together with the publication of longer term follow-up data, will provide a more complete understanding of the role of DRGS in the treatment of neuropathic pain syndromes.
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Affiliation(s)
- Conrad Harrison
- John Radcliffe Hospital, University of Oxford Medical Sciences Office, Oxford, UK
| | - Sarah Epton
- Vascular Research Department, St George's Hospital, London, UK
| | - Stana Bojanic
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Alexander L Green
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - James J FitzGerald
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Mol FMU, Roumen RMH. DRG Spinal Cord Stimulation as Solution for Patients With Severe Pain Due to Anterior Cutaneous Nerve Entrapment Syndrome: A Case Series. Neuromodulation 2017; 21:317-319. [PMID: 28940994 DOI: 10.1111/ner.12692] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/29/2017] [Accepted: 08/01/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is a debilitating neuropathic pain condition. A small portion of patients do not respond to any currently available treatment modalities. These patients, often young women, might benefit from targeted spinal cord stimulation of the dorsal root ganglion (DRG). METHODS This retrospective case series describes five ACNES patients who were referred from a Dutch dedicated tertiary referral center to collaborating sites with extensive experience in DRG stimulation to be implanted with a DRG Axium System (St. Jude/Abbott, IL, USA) in the period of 2013-2016. Numeric pain rating scores at routine 6- and 12-month follow-up visits were analyzed. RESULTS Three patients experienced >50% pain reduction at 12 months follow-up. Four patients experienced device-related complications, such as lead dislocation, lead breakage, pain at the battery site, and overstimulation. CONCLUSIONS This case series suggests DRG spinal cord stimulation can be safe and effective for some patients with persistent pain due to ACNES.
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Affiliation(s)
- Frédérique Mathilde Ulrike Mol
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands.,Center of Excellence for Abdominal Wall and Groin Pain, SolviMáx, Center of Expertise for ACNES, The Netherlands
| | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands.,Center of Excellence for Abdominal Wall and Groin Pain, SolviMáx, Center of Expertise for ACNES, The Netherlands
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Vancamp T, Levy RM, Peña I, Pajuelo A. Relevant Anatomy, Morphology, and Implantation Techniques of the Dorsal Root Ganglia at the Lumbar Levels. Neuromodulation 2017; 20:690-702. [PMID: 28895256 DOI: 10.1111/ner.12651] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/30/2017] [Accepted: 07/17/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVES While dorsal root ganglion (DRG) stimulation has been available in Europe and Australia for the past five years and in the United States for the past year, there are no published details concerning the optimal procedures for DRG lead implantation. MATERIALS AND METHODS We describe several techniques that can be applied to implant cylindrical leads over the DRG, highlighting some tips and tricks according to our experiences. Focus is mainly shifted toward implantations in the lumbar area. We furthermore give some insights in the results we experienced in Spain as well as some worldwide numbers. IMPLANT TECHNIQUES AND RESULTS A 14-gauge needle is placed using a "2-Level Technique (2-LT)" or exceptionally a "1-Level Technique (1-LT)" or a "Primary- or Secondary Technique" at the level of L5. The delivery sheath, loaded with the lead, is advanced toward the targeted neural foramen. The lead is placed over the dorsal aspect of the DRG. A strain relief loop is created in the epidural space. Sheath and needle are retracted and the lead is secured using an anchor or anchorless technique. In Spain, 87.2% (N = 78) of the selected patients have been successfully implanted. Seven (8.9%) had a negative trial and three (4.2%) were explanted. Average VAS score decreased from 8.8 to 3.3 and on average 94.5% of the pain area was covered. In our center's subjects (N = 47 patients, 60.3% of all implanted patients in Spain), VAS scores decreased from an average of 8.8-1.7 and pain coverage averaged 96.4%. We used an average of 1.8 electrodes. Worldwide more than 4000 permanent cases have been successfully performed. CONCLUSIONS We present implantation techniques whereby a percutaneous lead is placed over the DRG through the use of a special designed delivery sheath. Further investigation of the safety, efficacy, and sustainability of clinical outcomes using these devices is warranted.
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Affiliation(s)
- Tim Vancamp
- BRAI2N, St. Augustinus Hospital, Wilrijk, Belgium
| | | | - Isaac Peña
- Department of Anesthesiology and Pain Management, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Antonio Pajuelo
- Department of Anesthesiology and Pain Management, Virgen del Rocio University Hospital, Sevilla, Spain
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Pan B, Zhang Z, Chao D, Hogan QH. Dorsal Root Ganglion Field Stimulation Prevents Inflammation and Joint Damage in a Rat Model of Rheumatoid Arthritis. Neuromodulation 2017; 21:247-253. [PMID: 28872725 DOI: 10.1111/ner.12648] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Electrical stimulation of the dorsal root ganglion (DRG), referred to here as ganglionic field stimulation (GFS), is effective in reducing clinical pain, probably by interrupting transmission of afferent impulse trains on sensory neurons as they pass through the DRG. We therefore tested whether efferent impulse trains conveyed by sensory neurons, which contribute to neurogenic inflammation, may also be interrupted by GFS. MATERIALS AND METHODS Collagen-induced arthritis, a model of clinical rheumatoid arthritis, was initiated in rats concurrently with the insertion of an electrode for GFS at the fourth lumbar DRG. Continuous GFS (20 Hz pulse rate, current at 80% of the motor threshold) was initiated 6 days later and continued for 14 days. Plantar pain sensitivity, ankle arthritis score, and dimensions of the foot and ankle were determined one hour after termination of GFS. RESULTS The foot/ankle contralateral to GFS developed hypersensitivity to threshold and noxious mechanical stimulation, swelling, and high arthritis score, all of which were normalized in the foot/ankle ipsilateral with GFS. Histology showed GFS limited joint destruction. Electrophysiological recording showed GFS can block efferent impulse trains. CONCLUSIONS Our findings show that GFS can reduce neurogenic inflammation and the resulting joint damage in a model of rheumatoid arthritis, probably by blocking the transit of impulse trains through the DRG. GFS may have clinical utility in limiting joint destruction in inflammatory arthritis such as rheumatoid arthritis.
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Affiliation(s)
- Bin Pan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zhiyong Zhang
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dongman Chao
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Quinn H Hogan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Anesthesiology, Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA
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Hunter CW, Yang A, Davis T. Selective Radiofrequency Stimulation of the Dorsal Root Ganglion (DRG) as a Method for Predicting Targets for Neuromodulation in Patients With Post Amputation Pain: A Case Series. Neuromodulation 2017; 20:708-718. [PMID: 28337820 DOI: 10.1111/ner.12595] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/10/2017] [Accepted: 01/30/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE While spinal cord stimulation (SCS) has established itself as an accepted and validated treatment for neuropathic pain, there are a number of conditions where it has experienced less, long-term success: post amputee pain (PAP) being one of them. Dorsal root ganglion (DRG) stimulation has shown great promise, particularly in conditions where traditional SCS has fallen short. One major difference between DRG stimulation and traditional SCS is the ability to provide focal stimulation over targeted areas. While this may be a contributing factor to its superiority, it can also be a limitation insofar stimulating the wrong DRG(s) can lead to failure. This is particularly relevant in conditions like PAP where neuroplastic maladaptation occurs causing the pain to deviate from expected patterns, thus creating uncertainty and variability in predicting targets for stimulation. We propose selective radiofrequency (RF) stimulation of the DRG as a method for preoperatively predicting targets for neuromodulation in patients with PAP. METHODS We present four patients with PAP of the lower extremities. RF stimulation was used to selectively stimulate individual DRG's, creating areas of paresthesias to see which most closely correlated/overlapped with the painful area(s). RF stimulation to the DRG's that resulted in the desirable paresthesia coverage in the residual or the missing limb(s) was recorded as "positive." Trial DRG leads were placed based on the positive RF stimulation findings. RESULTS In each patient, stimulating one or more DRG(s) produced paresthesias patterns that were contradictory to know dermatomal patterns. Upon completion of a one-week trial all four patients reported 60-90% pain relief, with coverage over the painful areas, and opted for permanent implant. CONCLUSIONS Mapping the DRG via RF stimulation appears to provide improved accuracy for determining lead placement in the setting of PAP where pain patterns are known to deviate from conventional dermatomal mapping.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Ajax Yang
- Department of Physical Medicine & Rehabilitation, Mount Sinai Hospital, New York, NY, USA
| | - Tim Davis
- Orthopedic Pain Specialists, Santa Monica, CA, USA
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Abstract
Chronic neuropathic pain is a widespread problem with negative personal and societal consequences. Despite considerable clinical neuroscience research, the goal of developing effective, reliable, and durable treatments has remained elusive. The critical role played by the dorsal root ganglion (DRG) in the induction and maintenance of chronic pain has been largely overlooked in these efforts, however. It may be that, by targeting this site, robust new options for pain management will be revealed. This review summarizes recent advances in the knowledge base for DRG-targeted treatments for neuropathic pain:• Pharmacological options including the chemical targeting of voltage-dependent calcium channels, transient receptor potential channels, neurotrophin production, potentiation of opioid transduction pathways, and excitatory glutamate receptors.• Ablation or modulation of the DRG via continuous thermal radiofrequency and pulsed radiofrequency treatments.• Implanted electrical neurostimulator technologies.• Interventions involving the modification of DRG cellular function at the genetic level by using viral vectors and gene silencing methods.
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Pan B, Yu H, Fischer GJ, Kramer JM, Hogan QH. Dorsal Root Ganglionic Field Stimulation Relieves Spontaneous and Induced Neuropathic Pain in Rats. THE JOURNAL OF PAIN 2016; 17:1349-1358. [DOI: 10.1016/j.jpain.2016.09.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/23/2016] [Accepted: 09/13/2016] [Indexed: 11/16/2022]
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S3 Dorsal Root Ganglion/Nerve Root Stimulation for Refractory Postsurgical Perineal Pain: Technical Aspects of Anchorless Sacral Transforaminal Lead Placement. Case Rep Neurol Med 2016; 2016:8926578. [PMID: 27123351 PMCID: PMC4829697 DOI: 10.1155/2016/8926578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/03/2016] [Indexed: 11/17/2022] Open
Abstract
Chronic perineal pain limits patients in physical and sexual activities, leading to social and psychological distress. In most cases, this pain develops after surgery in the urogenital area or as a consequence of trauma. Neuromodulation is one of the options in chronic postsurgical perineal pain treatment. We present a case of refractory perineal pain after right sided surgical resection of a Bartholin's cyst which was treated with third sacral nerve root/dorsal root ganglion stimulation using the transforaminal approach. We describe a new anchorless lead placement technique using a unique curved lead delivery sheath. We postulate that this new posterior foraminal technique of lead placement is simple, safe, and reversible and may lower the occurrence of lead related complications.
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Liem L, Mekhail N. Management of Postherniorrhaphy Chronic Neuropathic Groin Pain: A Role for Dorsal Root Ganglion Stimulation. Pain Pract 2016; 16:915-23. [PMID: 26914499 DOI: 10.1111/papr.12424] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/29/2015] [Accepted: 11/11/2015] [Indexed: 12/21/2022]
Abstract
Chronic neuropathic groin pain is a sequela of hernia surgery that occurs at unacceptably high rates, causing widespread impacts on quality of life. Although the medical community is beginning to recognize the role of surgical technique in the initiation and maintenance of postherniorrhaphy neuropathic pain, little information exists regarding pain management strategies for this condition. This review presents a summary of the pain condition state, its treatment options, and treatment recommendations. Both literature review and clinical experience were used to develop a proposed a treatment algorithm for the treatment of postherniorrhaphy pain. The development of chronic pain may be prevented via a number of perioperative measures. For pain that is already established, some surgical approaches including inguinal neurectomy can be effective, in addition to standard pharmacological treatments and local infiltrations. An unmet need may still exist with these options, however, leaving a role for neuromodulation for the treatment of intractable cases. A pain management algorithm for iterative interventions including stimulation of the dorsal root ganglion (DRG) is described. It is expected that cross-disciplinary awareness of surgeons for nonsurgical pain management options in the treatment of chronic neuropathic postherniorrhaphy pain will contribute to better clinical outcomes.
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Affiliation(s)
- Liong Liem
- Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Nagy Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
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