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Yamamoto S, Duong A, Kim A, Hu C, Wiemers B, Wang J, Chung JM, La JH. Intraoperative Spinal Cord Stimulation Mitigates Central Sensitization After Spine Surgery in Mice. Spine (Phila Pa 1976) 2023; 48:E169-E176. [PMID: 36940259 PMCID: PMC10175162 DOI: 10.1097/brs.0000000000004631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/08/2023] [Indexed: 03/22/2023]
Abstract
STUDY DESIGN Double-blinded, prospective laboratory animal study. OBJECTIVE To examine whether intraoperative spinal cord stimulation (SCS) inhibits the development of spine surgery-induced hypersensitivity. SUMMARY OF BACKGROUND DATA Managing postoperative pain after spine surgery is challenging, and as many as 40% of patients may develop failed back surgery syndrome. Although SCS has been shown to effectively reduce chronic pain symptoms, it is unknown whether intraoperative SCS can mitigate the development of central sensitization that causes postoperative pain hypersensitivity and potentially leads to failed back surgery syndrome after spine surgery. MATERIALS AND METHODS Mice were randomly stratified into three experimental groups: (1) sham surgery, (2) laminectomy alone, and (3) laminectomy plus SCS. Secondary mechanical hypersensitivity was measured in hind paws using von Frey assay one day before and at predetermined times after surgery. In addition, we also performed a conflict avoidance test to capture the affective-motivational domain of pain at selected time points postlaminectomy. RESULTS Mice that underwent unilateral T13 laminectomy developed mechanical hypersensitivity in both hind paws. Intraoperative SCS applied to the exposed side of the dorsal spinal cord significantly inhibited the development of hind paw mechanical hypersensitivity on the SCS-applied side. Sham surgery did not produce any obvious secondary mechanical hypersensitivity in the hind paws. CONCLUSIONS These results demonstrate that spine surgery for unilateral laminectomy induces central sensitization that results in postoperative pain hypersensitivity. Intraoperative SCS after laminectomy may be able to mitigate the development of this hypersensitivity in appropriately selected cases.
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Affiliation(s)
- Satoshi Yamamoto
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Alexander Duong
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Alex Kim
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Chengrui Hu
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Blaine Wiemers
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jigong Wang
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jin Mo Chung
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jun-Ho La
- Department of Neurobiology, University of Texas Medical Branch, Galveston, TX, USA
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Yang S, Zhong S, Fan Y, Zhu Y, Xu N, Liao Y, Fan G, Liao X, He S. Research hotspots and trends on spinal cord stimulation for pain treatment: a two-decade bibliometric analysis. Front Neurosci 2023; 17:1158712. [PMID: 37304039 PMCID: PMC10248081 DOI: 10.3389/fnins.2023.1158712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 05/04/2023] [Indexed: 06/13/2023] Open
Abstract
Background Chronic pain poses a significant social burden. Spinal cord stimulation (SCS) is considered to be the most promising treatment for refractory pain. The aim of this study was to summarize the current research hotspots on SCS for pain treatment during the past two decades and to predict the future research trends by bibliometric analysis. Methods The literature over the last two decades (2002-2022) which was related to SCS in pain treatment was obtained from the Web of Science Core Collection. Bibliometric analyses were conducted based on the following aspects: (1) Annual publication and citation trends; (2) Annual publication changes of different publication types; (3) Publications and citations/co-citations of different country/institution/journal/author; (4) Citations/co-citation and citation burst analysis of different literature; and (5) Co-occurrence, cluster, thematic map, trend topics, and citation burst analysis of different keywords. (6) Comparison between the United States and Europe. All analyses were performed on CiteSpace, VOSviewer, and R bibliometrix package. Results A total of 1,392 articles were included in this study, with an increasing number of publications and citations year by year. The most highly published type of literature was clinical trial. United States was the country with the most publications and citations; Johns Hopkins University was the institution with the most publications; NEUROMODULATION published the most papers; the most published author was Linderoth B; and the most cited paper was published in the PAIN by Kumar K in 2007. The most frequently occurring keywords were "spinal cord stimulation," "neuropathic pain," and "chronic pain," etc. Conclusion The positive effect of SCS on pain treatment has continued to arouse the enthusiasm of researchers in this field. Future research should focus on the development of new technologies, innovative applications, and clinical trials for SCS. This study might facilitate researchers to comprehensively understand the overall perspective, research hotspots, and future development trends in this field, as well as seek collaboration with other researchers.
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Affiliation(s)
- Sheng Yang
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Sen Zhong
- Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunshan Fan
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yanjie Zhu
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ningze Xu
- Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yue Liao
- Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guoxin Fan
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical school, Shenzhen, China
- Department of Spine Surgery, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiang Liao
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical school, Shenzhen, China
| | - Shisheng He
- Department of Orthopedic, Spinal Pain Research Institute, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
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Wang ZB, Liu YD, Wang S, Zhao P. High-frequency spinal cord stimulation produces long-lasting analgesic effects by restoring lysosomal function and autophagic flux in the spinal dorsal horn. Neural Regen Res 2022; 17:370-377. [PMID: 34269212 PMCID: PMC8463971 DOI: 10.4103/1673-5374.317989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
High-frequency spinal cord stimulation (HF-SCS) has been established as an effective therapy for neuropathic pain. However, the analgesic mechanisms involved in HF-SCS remain to be clarified. In our study, adult rat neuropathic pain was induced by spinal nerve ligation. Two days after modeling, the rats were subjected to 4 hours of HF-SCS (motor threshold 50%, frequency 10,000 Hz, and pulse width 0.024 ms) in the dorsal horn of the spinal cord. The results revealed that the tactile allodynia of spinal nerve-injured rats was markedly alleviated by HF-SCS, and the effects were sustained for 3 hours after the stimulation had ceased. HF-SCS restored lysosomal function, increased the levels of lysosome-associated membrane protein 2 (LAMP2) and the mature form of cathepsin D (matu-CTSD), and alleviated the abnormally elevated levels of microtubule-associated protein 1A/B-light chain 3 (LC3)-II and sequestosome 1 (P62) in spinal nerve-injured rats. HF-SCS also mostly restored the immunoreactivity of LAMP2, which was localized in neurons in the superficial layers of the spinal dorsal horn in spinal nerve-injured rats. In addition, intraperitoneal administration of 15 mg/kg chloroquine for 60 minutes reversed the expression of the aforementioned proteins and shortened the timing of the analgesic effects of HF-SCS. These findings suggest that HF-SCS may exhibit long-lasting analgesic effects on neuropathic pain in rats through improving lysosomal dysfunction and alleviating autophagic flux. This study was approved by the Laboratory Animal Ethics Committee of China Medical University, Shenyang, China (approval No. 2017PS196K) on March 1, 2017.
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Affiliation(s)
- Zhi-Bin Wang
- Department of Anesthesiology and Pain Management, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yong-Da Liu
- Department of Anesthesiology and Pain Management, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Shuo Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping Zhao
- Department of Anesthesiology and Pain Management, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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Spinal cord stimulation in chronic neuropathic pain: mechanisms of action, new locations, new paradigms. Pain 2021; 161 Suppl 1:S104-S113. [PMID: 33090743 PMCID: PMC7434213 DOI: 10.1097/j.pain.0000000000001854] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Saito A, Wada K, Suzuki Y, Nakasono S. The response of the neuronal activity in the somatosensory cortex after high-intensity intermediate-frequency magnetic field exposure to the spinal cord in rats under anesthesia and waking states. Brain Res 2020; 1747:147063. [PMID: 32818531 DOI: 10.1016/j.brainres.2020.147063] [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: 02/06/2020] [Revised: 08/08/2020] [Accepted: 08/14/2020] [Indexed: 12/01/2022]
Abstract
Novel technologies using the intermediate-frequency magnetic field (IF-MF) in living environments are becoming popular with the advance in electricity utilization. However, the biological effects induced by the high-intensity and burst-type IF-MF exposure used in the wireless power transfer technologies for electric vehicles or medical devices, such as the magnetic stimulation techniques, are not well understood. Here, we developed an experimental platform using rats, that combined an 18 kHz, high-intensity (Max. 88 mT), Gaussian-shaped burst IF-MF exposure system with an in vivo extracellular recording system. In this paper, we aimed to report the qualitative differences in stimulus responses in the regions of the somatosensory cortex and peripheral nerve fibers that were induced by the IF-MF exposure to the rat spinal cord. We also report the modulation of the stimulus responses in the somatosensory cortex under anesthesia or waking states. Using this experimental platform, we succeeded in the detection of the motor evoked potentials or the neuronal activity in the somatosensory cortex that was induced by the IF-MF exposure to the spinal cord in rats. Compared to the state of anesthesia, the neuronal activities in the somatosensory cortex was enhanced during the waking state. On the other hand, these neuronal responses could not be confirmed by the IF-MF exposure-related coil sound only. Our experimental results indicated the basic knowledge of the biological responses and excitation mechanisms of the spinal cord stimulation by the IF-MF exposure.
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Affiliation(s)
- Atsushi Saito
- Biological Environment Sector, Environmental Science Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), 1646 Abiko, Abiko-shi, Chiba, Japan.
| | - Keiji Wada
- Department of Electrical Engineering and Computer Science, Graduate School of Systems Design, Tokyo Metropolitan University, 1-1 Minami-Osawa, Hachioji-shi, Tokyo, Japan.
| | - Yukihisa Suzuki
- Department of Electrical Engineering and Computer Science, Graduate School of Systems Design, Tokyo Metropolitan University, 1-1 Minami-Osawa, Hachioji-shi, Tokyo, Japan.
| | - Satoshi Nakasono
- Biological Environment Sector, Environmental Science Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), 1646 Abiko, Abiko-shi, Chiba, Japan.
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Kent AR, Weisshaar CL, Venkatesan L, Winkelstein BA. Burst & High-Frequency Spinal Cord Stimulation Differentially Effect Spinal Neuronal Activity After Radiculopathy. Ann Biomed Eng 2019; 48:112-120. [DOI: 10.1007/s10439-019-02336-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/30/2019] [Indexed: 01/21/2023]
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Vallejo R, Gupta A, Kelley CA, Vallejo A, Rink J, Williams JM, Cass CL, Smith WJ, Benyamin R, Cedeño DL. Effects of Phase Polarity and Charge Balance Spinal Cord Stimulation on Behavior and Gene Expression in a Rat Model of Neuropathic Pain. Neuromodulation 2019; 23:26-35. [PMID: 31070863 DOI: 10.1111/ner.12964] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/12/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Ricardo Vallejo
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
| | - Ashim Gupta
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
- South Texas Orthopaedic Research Institute Laredo TX USA
| | - Courtney A. Kelley
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
| | | | - Jonathan Rink
- Department of BiologyIllinois Wesleyan University Bloomington IL USA
| | | | - Cynthia L. Cass
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
| | - William J. Smith
- Millennium Pain Center Bloomington IL USA
- Geisel School of MedicineDartmouth College Hanover NH USA
| | - Ramsin Benyamin
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
- College of MedicineUniversity of Illinois at Urbana‐Champaign Champaign‐Urbana IL USA
| | - David L. Cedeño
- Millennium Pain Center Bloomington IL USA
- Department of PsychologyIllinois Wesleyan University Bloomington IL USA
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De Groote S, Goudman L, Peeters R, Linderoth B, Vanschuerbeek P, Sunaert S, De Jaeger M, De Smedt A, Moens M. Magnetic Resonance Imaging Exploration of the Human Brain During 10 kHz Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Resting State Functional Magnetic Resonance Imaging Study. Neuromodulation 2019; 23:46-55. [PMID: 30974016 DOI: 10.1111/ner.12954] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/08/2019] [Accepted: 02/27/2019] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Apart from the clinical efficacy of high frequency spinal cord stimulation at 10 kHz, the underlying mechanism of action remains unclear. In parallel with spinal or segmental theories, supraspinal hypotheses have been recently proposed. In order to unveil hidden altered brain connectome patterns, a resting state functional magnetic resonance imaging (rsfMRI) protocol was performed in subjects routinely treated for back and/or leg pain with high-frequency spinal cord stimulation (HF-SCS) HF-SCS at 10 kHz. METHODS RsfMRI imaging was obtained from ten patients with failed back surgery syndrome who were eligible for HF-SCS at 10 kHz. Specifically-chosen regions of interest with different connectivity networks have been investigated over time. Baseline measurements were compared with measurements after 1 month and 3 months of HF-SCS at 10 kHz. Additionally, clinical parameters on pain intensity, central sensitization, pain catastrophizing, and sleep quality were correlated with the functional connectivity strengths. RESULTS The study results demonstrate an increased connectivity over time between the anterior insula (affective salience network) and regions of the frontoparietal network and the central executive network. After 3 months of HF-SCS, the increased strength in functional connectivity between the left dorsolateral prefrontal cortex and the right anterior insula was significantly correlated with the minimum clinically important difference (MCID) value of the Pittsburgh sleep quality index. CONCLUSION These findings support the hypothesis that HF-SCS at 10 kHz might influence the salience network and therefore also the emotional awareness of pain.
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Affiliation(s)
- Sander De Groote
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussel, Belgium
| | - Ronald Peeters
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ, Leuven, Belgium
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | | | - Stefan Sunaert
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ, Leuven, Belgium
| | - Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ann De Smedt
- Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Sivanesan E, Maher D, Raja SN, Linderoth B, Guan Y. Supraspinal Mechanisms of Spinal Cord Stimulation for Modulation of Pain: Five Decades of Research and Prospects for the Future. Anesthesiology 2019; 130:651-665. [PMID: 30556812 PMCID: PMC6338535 DOI: 10.1097/aln.0000000000002353] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The field of spinal cord stimulation is expanding rapidly, with new waveform paradigms asserting supraspinal sites of action. The scope of treatment applications is also broadening from chronic pain to include cerebral ischemia, dystonia, tremor, multiple sclerosis, Parkinson disease, neuropsychiatric disorders, memory, addiction, cognitive function, and other neurologic diseases. The role of neurostimulation as an alternative strategy to opioids for chronic pain treatment is under robust discussion in both scientific and public forums. An understanding of the supraspinal mechanisms underlying the beneficial effects of spinal cord stimulation will aid in the appropriate application and development of optimal stimulation strategies for modulating pain signaling pathways. In this review, the authors focus on clinical and preclinical studies that indicate the role of supraspinal mechanisms in spinal cord stimulation-induced pain inhibition, and explore directions for future investigations.
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Affiliation(s)
- Eellan Sivanesan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Dermot Maher
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Srinivasa N. Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Tomtebodavägen 18A:05, SE 171 77 Stockholm, Sweden
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
- Department of Neurological Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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FallahRad M, Zannou AL, Khadka N, Prescott SA, Ratté S, Zhang T, Esteller R, Hershey B, Bikson M. Electrophysiology equipment for reliable study of kHz electrical stimulation. J Physiol 2019; 597:2131-2137. [PMID: 30816558 DOI: 10.1113/jp277654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/19/2019] [Indexed: 12/27/2022] Open
Abstract
Characterizing the cellular targets of kHz (1-10 kHz) electrical stimulation remains a pressing topic in neuromodulation because expanding interest in clinical application of kHz stimulation has surpassed mechanistic understanding. The presumed cellular targets of brain stimulation do not respond to kHz frequencies according to conventional electrophysiology theory. Specifically, the low-pass characteristics of cell membranes are predicted to render kHz stimulation inert, especially given the use of limited-duty-cycle biphasic pulses. Precisely because kHz frequencies are considered supra-physiological, conventional instruments designed for neurophysiological studies such as stimulators, amplifiers and recording microelectrodes do not operate reliably at these high rates. Moreover, for pulsed waveforms, the signal frequency content is well above the pulse repetition rate. Thus, the very tools used to characterize the effects of kHz electrical stimulation may themselves be confounding factors. We illustrate custom equipment design that supports reliable electrophysiological recording during kHz-rate stimulation. Given the increased importance of kHz stimulation in clinical domains and compelling possibilities that mechanisms of actions may reflect yet undiscovered neurophysiological phenomena, attention to suitable performance of electrophysiological equipment is pivotal.
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Affiliation(s)
- Mohamad FallahRad
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY, USA
| | - Adantchede Louis Zannou
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY, USA
| | - Niranjan Khadka
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY, USA
| | - Steven A Prescott
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Physiology and Institute of Biomaterials and Biomedical Engineering, University of Toronto, ON, Canada
| | - Stéphanie Ratté
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Physiology and Institute of Biomaterials and Biomedical Engineering, University of Toronto, ON, Canada
| | - Tianhe Zhang
- Boston Scientific Neuromodulation, Valencia, CA, USA
| | | | - Brad Hershey
- Boston Scientific Neuromodulation, Valencia, CA, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York of CUNY, New York, NY, USA
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Chen Z, Huang Q, Yang F, Shi C, Sivanesan E, Liu S, Chen X, Sarma SV, Vera-Portocarrero LP, Linderoth B, Raja SN, Guan Y. The Impact of Electrical Charge Delivery on Inhibition of Mechanical Hypersensitivity in Nerve-Injured Rats by Sub-Sensory Threshold Spinal Cord Stimulation. Neuromodulation 2018; 22:163-171. [PMID: 30556616 DOI: 10.1111/ner.12910] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/22/2018] [Accepted: 11/12/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) represents an important neurostimulation therapy for pain. A new ultra-high frequency (10,000 Hz) SCS paradigm has shown improved pain relief without eliciting paresthesia. We aim to determine whether sub-sensory threshold SCS of lower frequencies also can inhibit mechanical hypersensitivity in nerve-injured rats and examine how electric charge delivery of stimulation may affect pain inhibition by different patterns of subthreshold SCS. MATERIALS AND METHODS We used a custom-made quadripolar electrode (Medtronic Inc., Minneapolis, MN, USA) to provide bipolar SCS epidurally at the T10 to T12 vertebral level. According to previous findings, SCS was tested at 40% of the motor threshold, which is considered to be a sub-sensory threshold intensity in rats. Paw withdrawal thresholds to punctate mechanical stimulation were measured before and after SCS in rats that received an L5 spinal nerve ligation. RESULTS Both 10,000 Hz (10 kHz, 0.024 msec) and lower frequencies (200 Hz, 1 msec; 500 Hz, 0.5 msec; 1200 Hz; 0.2 msec) of subthreshold SCS (120 min) attenuated mechanical hypersensitivity, as indicated by increased paw withdrawal thresholds after stimulation in spinal nerve ligation rats. Pain inhibition from different patterns of subthreshold SCS was not governed by individual stimulation parameters. However, correlation analysis suggests that pain inhibition from 10 kHz subthreshold SCS in individual animals was positively correlated with the electric charges delivered per second (electrical dose). CONCLUSIONS Inhibition of neuropathic mechanical hypersensitivity can be achieved with low-frequency subthreshold SCS by optimizing the electric charge delivery, which may affect the effect of SCS in individual animals.
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Affiliation(s)
- Zhiyong Chen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Qian Huang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Fei Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Neurobiology, Capital Medical University, Beijing, China
| | - Christine Shi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Eellan Sivanesan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Shuguang Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Orthopedics, Hong Hui Hospital, Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Xueming Chen
- Department of Orthopedics, Luhe Hospital, Capital Medical University, Beijing, China
| | - Sridevi V Sarma
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Neurological Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Abstract
Objectives: Paresthesia-free stimulation such as high frequency and burst have been demonstrated as effective therapies for neuropathic pain. The aim of this meta-analysis was to evaluate the efficacy and safety of conventional spinal cord stimulation (SCS) in the treatment of refractory angina pectoris (RAP). Materials and Methods: Relevant randomized controlled trials that investigated SCS for patients with RAP were comprehensively searched in Medline, Pubmed, Embase, and Cochrane Library. Five meta-analyses were performed examining the changes in Canadian Cardiovascular Society classes, exercise time, Visual Analog Scale (VAS) scores of pain, Seattle Angina Questionnaire, and nitroglycerin use in RAP patients after SCS therapy. We analyzed standardized mean differences (MD) and 95% confidence intervals (CIs) for each outcome by Review Manager 5.0 and STATA 12.0. Results: A total of 12 randomized controlled trials involving 476 RAP patients were identified. A trend of reduction in the angina frequency (MD=−9.03, 95% CI, −15.70 to −2.36) and nitroglycerin consumption (MD=−0.64, 95% CI, −0.84 to −0.45) could be observed in the SCS group. Compared with the control group, SCS showed benefit on increasing exercise time (MD=0.49, 95% CI, 0.13-0.85) and treatment satisfaction (MD=6.87, 95% CI, 2.07-11.66) with decreased VAS scores of pain (MD=−0.50, 95% CI, −0.81 to −0.20) and disease perception (MD=−8.34, 95% CI, −14.45 to −2.23). However, the result did not reach the significance level in terms of physical limitation (95% CI, −8.75 to 3.38; P=0.39) or angina stability (95% CI, −7.55 to 3.67; P=0.50). Discussion: The current meta-analysis suggested that SCS was a potential alternative in the treatment of PAP patients. Further investigation for finding the appropriate intensity of stimulation is required before this treatment should be widely recommended and applied.
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14
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Li S, Farber JP, Linderoth B, Chen J, Foreman RD. Spinal Cord Stimulation With "Conventional Clinical" and Higher Frequencies on Activity and Responses of Spinal Neurons to Noxious Stimuli: An Animal Study. Neuromodulation 2017; 21:440-447. [PMID: 29164752 DOI: 10.1111/ner.12725] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 09/08/2017] [Accepted: 10/03/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) at both conventional and higher frequencies may effectively reduce pain, but optimal parameters need to be established. This study investigated how SCS at different frequencies and pulse widths acutely modulates nociceptive activity of wide dynamic range (WDR) and high threshold (HT) dorsal horn neurons in rats at a stimulus amplitude that influences both local circuits and dorsal column fibers. MATERIALS AND METHODS L2 -L3 and L6 -S2 spinal segments were exposed for SCS and spinal neuronal recordings, respectively. Responses to pinch of a hindpaw were recorded before and after SCS (40 or 200 µsec pulse width at 50, 500, 1 kHz and 10 kHz, amplitude: 90% of motor threshold) for 5 or 20 min. Pinch responses were tested within 30 s after SCS ceased (first pinch) and at ∼4 min intervals until response recovery. RESULTS 1) SCS for 5 min suppressed averaged first pinch responses, except for 40 µsec/50 Hz. 2) Only SCS with 40 µs/1 kHz suppressed more spinal neurons than 200 µsec/50 Hz. 3) All SCS parameters at 5 min increased pinch responses for a small population of cells, with the incidence being greater for WDR than for HT neurons. 4) SCS at 1 kHz (40 or 200 µsec) for 20 min reduced the response to the second pinch as compared with baseline responses. In addition, no neurons exhibited increased pinch responses. CONCLUSIONS Compared with a typical low frequency SCS (200 µs/50 Hz) or high-frequency SCS at 10 kHz, at an amplitude designed to influence both local spinal circuits and dorsal column fiber tracts, 1 kHz SCS suppressed nociceptive responses of more spinal neurons and/or demonstrated longer persisting suppressive effects. SCS at 1 kHz surpassed both low-frequency (50 Hz) and high-frequency (10 kHz) SCS application in this normal animal model.
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Affiliation(s)
- Shiying Li
- Veterans Research Education Foundation, VA Medical Center, Oklahoma City, OK, USA.,Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Jay P Farber
- Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Bengt Linderoth
- Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jiande Chen
- Veterans Research Education Foundation, VA Medical Center, Oklahoma City, OK, USA.,Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
| | - Robert D Foreman
- Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.,Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
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15
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Linderoth B, Foreman RD. Conventional and Novel Spinal Stimulation Algorithms: Hypothetical Mechanisms of Action and Comments on Outcomes. Neuromodulation 2017; 20:525-533. [PMID: 28568898 DOI: 10.1111/ner.12624] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/18/2017] [Accepted: 05/08/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) emerged as a direct clinical spin-off from the Gate Control Theory from 1965. Over the last decade, several new modes of SCS have appeared. This review discusses these novel techniques and their hypothetical mechanisms of action. MATERIAL AND METHODS A recent literature search on SCS coupled with the most recent data from poster presentations and congress lectures have been used to illustrate new hypothetical ways of modulating pain. RESULTS Several physiological and neurochemical mechanisms for conventional paresthetic SCS have been described in detail. However, much less is known about the novel SCS modes of action. One new algorithm utilizes very high frequencies (up to 10 kHz) intended for direct stimulation of dorsal horns at the T9-T10 level to treat both low back pain and leg pain. Another technique uses bursts of impulses with a high internal frequency delivered to the dorsal spinal cord with a frequency of 40 Hz. Both of these therapies intend to be subparesthetic and effective both for neuropathic and nociceptive pain components. During the last few years, more moderate changes in SCS parameters have been tried in order to increase the amount of electric charge passed from the lead to the neural tissue. This strategy, called "high density SCS," utilizes frequencies up to 1200 Hz or long pulse widths. CONCLUSIONS The present SCS therapies have developed beyond the Gate Control Concept. New hypotheses about mechanisms of action are presented and some improved results are discussed.
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Affiliation(s)
- Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm Sweden
| | - Robert D Foreman
- Department of Physiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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16
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Chen CF, Bikson M, Chou LW, Shan C, Khadka N, Chen WS, Fregni F. Higher-order power harmonics of pulsed electrical stimulation modulates corticospinal contribution of peripheral nerve stimulation. Sci Rep 2017; 7:43619. [PMID: 28256638 PMCID: PMC5335254 DOI: 10.1038/srep43619] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/13/2017] [Indexed: 12/14/2022] Open
Abstract
It is well established that electrical-stimulation frequency is crucial to determining the scale of induced neuromodulation, particularly when attempting to modulate corticospinal excitability. However, the modulatory effects of stimulation frequency are not only determined by its absolute value but also by other parameters such as power at harmonics. The stimulus pulse shape further influences parameters such as excitation threshold and fiber selectivity. The explicit role of the power in these harmonics in determining the outcome of stimulation has not previously been analyzed. In this study, we adopted an animal model of peripheral electrical stimulation that includes an amplitude-adapted pulse train which induces force enhancements with a corticospinal contribution. We report that the electrical-stimulation-induced force enhancements were correlated with the amplitude of stimulation power harmonics during the amplitude-adapted pulse train. In an exploratory analysis, different levels of correlation were observed between force enhancement and power harmonics of 20–80 Hz (r = 0.4247, p = 0.0243), 100–180 Hz (r = 0.5894, p = 0.0001), 200–280 Hz (r = 0.7002, p < 0.0001), 300–380 Hz (r = 0.7449, p < 0.0001), 400–480 Hz (r = 0.7906, p < 0.0001), 500–600 Hz (r = 0.7717, p < 0.0001), indicating a trend of increasing correlation, specifically at higher order frequency power harmonics. This is a pilot, but important first demonstration that power at high order harmonics in the frequency spectrum of electrical stimulation pulses may contribute to neuromodulation, thus warrant explicit attention in therapy design and analysis.
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Affiliation(s)
- Chiun-Fan Chen
- Spaulding Neuromodulation Center, Department of Physical Medicine &Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Engineering Science, Loyola University Chicago, IL, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of the City University of New York, NY, USA
| | - Li-Wei Chou
- Department of Physical Therapy and Assistive Technologies, National Yang-Ming University, Taipei, Taiwan
| | - Chunlei Shan
- Spaulding Neuromodulation Center, Department of Physical Medicine &Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Niranjan Khadka
- Department of Biomedical Engineering, The City College of the City University of New York, NY, USA
| | - Wen-Shiang Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan
| | - Felipe Fregni
- Spaulding Neuromodulation Center, Department of Physical Medicine &Rehabilitation, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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17
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van Beek M, van Kleef M, Linderoth B, van Kuijk SMJ, Honig WM, Joosten EA. Spinal cord stimulation in experimental chronic painful diabetic polyneuropathy: Delayed effect of High-frequency stimulation. Eur J Pain 2016; 21:795-803. [PMID: 27891705 PMCID: PMC5412908 DOI: 10.1002/ejp.981] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2016] [Indexed: 12/12/2022]
Abstract
Background Spinal cord stimulation (SCS) has been shown to provide pain relief in painful diabetic polyneuropathy (PDPN). As the vasculature system plays a great role in the pathophysiology of PDPN, a potential beneficial side‐effect of SCS is peripheral vasodilation, with high frequency (HF) SCS in particular. We hypothesize that HF‐SCS (500 Hz), compared with conventional (CON) or low frequency (LF)‐SCS will result in increased alleviation of mechanical hypersensitivity in chronic experimental PDPN. Methods Diabetes was induced in 8‐week‐old female Sprague–Dawley rats with an intraperitoneal injection of 65 mg/kg of streptozotocin (n = 44). Rats with a significant decrease in mechanical withdrawal response to von Frey filaments over a period of 20 weeks were implanted with SCS electrodes (n = 18). Rats were assigned to a cross‐over design with a random order of LF‐, CON‐, HF‐ and sham SCS and mechanical withdrawal thresholds were assessed with von Frey testing. Results Compared with sham treatment, the average 50% WT score for 5 Hz was 4.88 g higher during stimulation (p = 0.156), and 1.77 g higher post‐stimulation (p = 0.008). CON‐SCS resulted in 50% WT scores 5.7 g, and 2.51 g higher during (p = 0.064) and after stimulation (p < 0.004), respectively. HF‐SCS started out with an average difference in 50% WT score compared with sham of 1.87 g during stimulation (p = 0.279), and subsequently the steepest rise to a difference of 5.47 g post‐stimulation (p < 0.001). Conclusions We demonstrated a delayed effect of HF‐SCS on mechanical hypersensitivity in chronic PDPN animals compared with LF‐, or CON‐SCS. Significance This study evaluates the effect of SCS frequency (5–500 Hz) on mechanical hypersensitivity in the chronic phase of experimental PDPN. High frequency (500 Hz) – SCS resulted in a delayed effect‐ on pain‐related behavioural outcome in chronic PDPN.
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Affiliation(s)
- M van Beek
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands.,Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands
| | - M van Kleef
- Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands
| | - B Linderoth
- Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands.,Department of Clinical Neuroscience, (Functional Neurosurgery), Karolinska Institutet, Stockholm, Sweden
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, The Netherlands
| | - W M Honig
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands
| | - E A Joosten
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands.,Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands
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18
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Crosby ND, Janik JJ, Grill WM. Modulation of activity and conduction in single dorsal column axons by kilohertz-frequency spinal cord stimulation. J Neurophysiol 2016; 117:136-147. [PMID: 27760823 DOI: 10.1152/jn.00701.2016] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/12/2016] [Indexed: 11/22/2022] Open
Abstract
Kilohertz-frequency spinal cord stimulation (KHF-SCS) is a potential paresthesia-free treatment for chronic pain. However, the effects of KHF-SCS on spinal dorsal column (DC) axons and its mechanisms of action remain unknown. The objectives of this study were to quantify activation and conduction block of DC axons by KHF-SCS across a range of frequencies (1, 5, 10, or 20 kHz) and waveforms (biphasic pulses or sinusoids). Custom platinum electrodes delivered SCS to the T10/T11 dorsal columns of anesthetized male Sprague-Dawley rats. Single DC axons and compound action potentials were recorded during KHF-SCS to evaluate SCS-evoked activity. Responses to KHF-SCS in DC axons included brief onset firing, slowly accommodating asynchronous firing, and conduction block. The effects of KHF-SCS mostly occurred well above motor thresholds, but isolated units were activated at amplitudes shown to reduce behavioral sensitivity in rats. Activity evoked by SCS was similar across a range of frequencies (5-20 kHz) and waveforms (biphasic and sinusoidal). Stimulation at 1-kHz SCS evoked more axonal firing that was also more phase-synchronized to the SCS waveform, but only at amplitudes above motor threshold. These data quantitatively characterize the central nervous system activity that may modulate pain perception and paresthesia, and thereby provide a foundation for continued investigation of the mechanisms of KHF-SCS and its optimization as a therapy for chronic pain. Given the asynchronous and transient nature of DC activity, it is unlikely that the same mechanisms underlying conventional SCS (i.e., persistent, periodic DC activation) apply to KHF-SCS. NEW & NOTEWORTHY Kilohertz-frequency spinal cord stimulation (KHF-SCS) is a new mode of SCS that may offer better pain relief than conventional SCS. However, the mechanism of action is poorly characterized, especially the effects of stimulation on dorsal column (DC) axons, which are the primary target of stimulation. This study provides the first recordings of single DC axons during KHF-SCS to quantify DC activity that has the potential to mediate the analgesic effects of KHF-SCS.
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Affiliation(s)
- Nathan D Crosby
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | | | - Warren M Grill
- Department of Biomedical Engineering, Duke University, Durham, North Carolina; .,Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina.,Department of Neurobiology, Duke University, Durham, North Carolina.,Department of Surgery, Duke University, Durham, North Carolina; and
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19
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Bicket MC, Dunn RY, Ahmed SU. High-Frequency Spinal Cord Stimulation for Chronic Pain: Pre-Clinical Overview and Systematic Review of Controlled Trials. PAIN MEDICINE 2016; 17:2326-2336. [PMID: 28025366 DOI: 10.1093/pm/pnw156] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the evidence base for high-frequency spinal cord stimulation (HFSCS). HFSCS has the potential to provide paresthesia-free pain relief for patients with chronic pain, in contrast to conventional spinal cord stimulation, which produces distracting and potentially unpleasant paresthesias. DESIGN A systematic review following standard methodological guidelines (Prospero #CRD42015029215). METHODS We searched PubMed to March 14, 2016 without language restriction and hand-checked reference lists. Two authors independently performed study selection, bias evaluations, and data extraction. The pre-clinical review selected studies focusing on the mechanism and non-human experience with HFSCS. Clinically, any prospective study of adults using HFSCS (≥ 1000 Hz) was included. RESULTS Pre-clinical studies have characterized many aspects underlying the mechanism of HFSCS. For the clinical systematic review, eight trials (236 participants randomized or 160 followed prospectively) met inclusion criteria. All trials of HFSCS focused on patients with chronic low back pain with one exception, which included patients with chronic migraine. All but one trial documented funding by industry. Performance bias due to unmasked participants, physicians, and outcome assessors limited the quality of all but one study. CONCLUSIONS Significant growth in the preclinical and clinical evidence base for HFSCS suggests that HFSCS may differ from conventional SCS in mechanism of action and efficacy of treatment, respectively. Addressing current knowledge gaps in clinical evidence will require standardization in trial reporting and leveraging the paresthesia-free characteristic of HFSCS to enable masking in high-quality randomized controlled trials.
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Affiliation(s)
- Mark C Bicket
- *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Roger Y Dunn
- Tufts University School of Medicine, Boston, Massachusetts
| | - Shihab U Ahmed
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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20
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Miller JP, Eldabe S, Buchser E, Johanek LM, Guan Y, Linderoth B. Parameters of Spinal Cord Stimulation and Their Role in Electrical Charge Delivery: A Review. Neuromodulation 2016; 19:373-84. [DOI: 10.1111/ner.12438] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/07/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Jonathan P. Miller
- Functional and Restorative Neurosurgery Center and Department of Neurological Surgery, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center; Cleveland OH USA
| | - Sam Eldabe
- The James Cook University Hospital; Middlesbrough UK
| | - Eric Buchser
- Anaesthesia and Pain Management Services at the Neuromodulation Centre; Hospital de Morges, Morges; Switzerland
| | - Lisa M. Johanek
- Department of Medical Affairs, Medtronic, PLC; Minneapolis MN USA
| | - Yun Guan
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Bengt Linderoth
- Functional Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet; Stockholm Sweden
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