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Chitneni A, Jain E, Sahni S, Mavrocordatos P, Abd-Elsayed A. Spinal Cord Stimulation Waveforms for the Treatment of Chronic Pain. Curr Pain Headache Rep 2024; 28:595-605. [PMID: 38607547 DOI: 10.1007/s11916-024-01247-1] [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] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Since the advent of spinal cord stimulation (SCS), advances in technology have allowed for improvement and treatment of various conditions, especially chronic pain. Additionally, as the system has developed, the ability to provide different stimulation waveforms for patients to treat different conditions has improved. The purpose and objective of the paper is to discuss basics of waveforms and present the most up-to-date literature and research studies on the different types of waveforms that currently exist. During our literature search, we came across over sixty articles that discuss the various waveforms we intend to evaluate. RECENT FINDINGS There are several publications on several waveforms used in clinical practice, but to our knowledge, this is the only educational document teaching on waveforms which provides essential knowledge. There is a gap of knowledge related to understanding wave forms and how they work.
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Affiliation(s)
- Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USA
| | - Esha Jain
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, B6/319 CSC53792-3272, USA.
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Patel J, Deschler E, Galang E. Spinal cord stimulation for the symptomatic treatment of rigidity and painful spasm in a case of stiff person syndrome. Pain Pract 2024; 24:798-804. [PMID: 38185725 DOI: 10.1111/papr.13340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by rigidity and painful spasm primarily affecting the truncal and paraspinal musculature due to autoimmune-mediated neuronal hyperexcitability. Spinal cord stimulation (SCS) is an approved therapy for managing painful neuropathic conditions, including diabetic peripheral neuropathy and refractory angina pectoris. We describe the novel use of SCS for the treatment of spasm and rigidity in a 49-year-old man with seropositive stiff person syndrome (SPS). The patient was treated with intravenous immunoglobulin (IVIG) and oral medications over a 13-month period with minimal improvement, prompting consideration of SCS. To our knowledge, this is the first report of the successful use of SCS in SPS with the demonstration of multifaceted clinical improvement. METHODS Following a successful temporary SCS trial, permanent implantation was performed. Spasm/stiffness (Distribution of Stiffness Index; Heightened Sensitivity Scale; Penn Spasm Frequency Scale, PSFS), disability (Oswestry Disability Index, ODI; Pain Disability Index, PDI), depression (Patient Health Questionnaire-9, PHQ-9), sleep (Pittsburgh Sleep Quality Index, PSQI), fatigue (Fatigue Severity Scale, FSS), pain (Numerical Pain Rating Scale, NPRS), quality of life (EuroQoL 5 Dimension 5 Level, EQ-5D-5L), and medication usage were assessed at baseline, 6-month, and 10-month postimplantation. RESULTS ODI, PHQ-9, FSS, NPRS, PSQI, and EQ-5D-5L scores showed a notable change from baseline and surpassed the defined minimal clinically important difference (MCID) at 6-month and 10-month follow-up. Oral medication dosages were reduced. CONCLUSIONS The novel use of SCS therapy in seropositive SPS resulted in functional improvement and attenuation of symptoms. We present possible mechanisms by which SCS may produce clinical response in patients with SPS and aim to demonstrate proof-of-concept for a future comprehensive pilot study evaluating SCS-mediated response in SPS.
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Affiliation(s)
- Janus Patel
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Emily Deschler
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Enrique Galang
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Peene L, Cohen SP, Kallewaard JW, Wolff A, Huygen F, Gaag AVD, Monique S, Vissers K, Gilligan C, Van Zundert J, Van Boxem K. 1. Lumbosacral radicular pain. Pain Pract 2024; 24:525-552. [PMID: 37985718 DOI: 10.1111/papr.13317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. METHODS The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. RESULTS Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. CONCLUSIONS The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andre Wolff
- Department of Anesthesiology UMCG Pain Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Huygen
- Department of Anesthesiology and Pain Medicine, Erasmusmc, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antal van de Gaag
- Department of Anesthesiology and Pain Medicine, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steegers Monique
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Chris Gilligan
- Department of Anesthesiology and Pain Medicine, Brigham & Women's Spine Center, Boston, Massachusetts, USA
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Versantvoort EM, Dietz BE, Mugan D, Vuong QC, Luli S, Obara I. Evoked compound action potential (ECAP)-controlled closed-loop spinal cord stimulation in an experimental model of neuropathic pain in rats. Bioelectron Med 2024; 10:2. [PMID: 38195618 PMCID: PMC10777641 DOI: 10.1186/s42234-023-00134-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/29/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Preclinical models of spinal cord stimulation (SCS) are lacking objective measurements to inform translationally applicable SCS parameters. The evoked compound action potential (ECAP) represents a measure of dorsal column fiber activation. This measure approximates the onset of SCS-induced sensations in humans and provides effective analgesia when used with ECAP-controlled closed-loop (CL)-SCS systems. Therefore, ECAPs may provide an objective surrogate for SCS dose in preclinical models that may support better understanding of SCS mechanisms and further translations to the clinics. This study assessed, for the first time, the feasibility of recording ECAPs and applying ECAP-controlled CL-SCS in freely behaving rats subjected to an experimental model of neuropathic pain. METHODS Adult male Sprague-Dawley rats (200-300 g) were subjected to spared nerve injury (SNI). A custom-made six-contact lead was implanted epidurally covering T11-L3, as confirmed by computed tomography or X-ray. A specially designed multi-channel system was used to record ECAPs and to apply ECAP-controlled CL-SCS for 30 min at 50 Hz 200 µs. The responses of dorsal column fibers to SCS were characterized and sensitivity towards mechanical and cold stimuli were assessed to determine analgesic effects from ECAP-controlled CL-SCS. Comparisons between SNI rats and their controls as well as between stimulation parameters were made using omnibus analysis of variance (ANOVA) tests and t-tests. RESULTS The recorded ECAPs showed the characteristic triphasic morphology and the ECAP amplitude (mV) increased as higher currents (mA) were applied in both SNI animals and controls (SNI SCS-ON and sham SCS-ON). Importantly, the use of ECAP-based SCS dose, implemented in ECAP-controlled CL-SCS, significantly reduced mechanical and cold hypersensitivity in SNI SCS-ON animals through the constant and controlled activation of dorsal column fibers. An analysis of conduction velocities of the evoked signals confirmed the involvement of large, myelinated fibers. CONCLUSIONS The use of ECAP-based SCS dose implemented in ECAP-controlled CL-SCS produced analgesia in animals subjected to an experimental model of neuropathic pain. This approach may offer a better method for translating SCS parameters between species that will improve understanding of the mechanisms of SCS action to further advance future clinical applications.
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Affiliation(s)
- Eline M Versantvoort
- School of Pharmacy, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK
| | - Birte E Dietz
- School of Pharmacy, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK
- Saluda Medical Europe Ltd, Harrogate, HG2 8NB, UK
| | - Dave Mugan
- School of Pharmacy, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK
- Saluda Medical Europe Ltd, Harrogate, HG2 8NB, UK
| | - Quoc C Vuong
- Bioscience Institute, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK
| | - Saimir Luli
- Preclinical In Vivo Imaging, Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, NE2 4HH, UK
| | - Ilona Obara
- School of Pharmacy, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK.
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU, UK.
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Paladini A, Vallejo R, Guerrero M, Pasqualucci A, Peppin JF, Pergolizzi J, Varrassi G. Answering Big Questions in Pain Medicine. Cureus 2023; 15:e43561. [PMID: 37719539 PMCID: PMC10502917 DOI: 10.7759/cureus.43561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
The future of pain medicine is marked by many questions. What can other nations around the world learn from the opioid crisis that is still affecting the United States? The American opioid experience was mischaracterized and wrongly described, and its causes were misdiagnosed from the outset, leading to its mismanagement and the abandonment of many chronic pain patients to their suffering. There are a few new drugs in the analgesic armamentarium. What new targets do we have in pain medicine? There are many breakthroughs, discoveries, and potential new targets that could add to our analgesic prescribing choices. These include sigma receptors, d-amino acid oxidase, endoplasmic reticulum stress receptors, histone deacetylase, and others. Neuromodulation had been used with varying degrees of success for years, but with a simplistic approach based on the gate theory of pain. Despite our familiarity with neuromodulation and spinal cord stimulators, neuromodulation research indicates that the activation of glial cells may activate the immune system and enhance analgesia. Neuromodulation studies have concentrated on how electricity affects neuronal activity rather than how electrical activity could reduce pain. There are still more frontiers in our battle against pain and some promising avenues for treatments. This narrative review will try to summarize what can be done from the perspective of recent technological and pharmacological developments.
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Affiliation(s)
- Antonella Paladini
- Department of Life, Health & Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | - Ricardo Vallejo
- Department of Research, Millennium Pain Center, Bloomington, USA
| | - Marixa Guerrero
- Department of Pain Medicine/ Pain Management, Clínica del Country, Bogota, COL
| | - Alberto Pasqualucci
- Department of Anesthesia and Critical Care, University of Perugia, Perugia, ITA
| | - John F Peppin
- Department of Osteopathic Medicine, Marian University, Indianapolis, USA
| | - Joseph Pergolizzi
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Nema Research, Naples, USA
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Pawlik K, Mika J. Targeting Members of the Chemokine Family as a Novel Approach to Treating Neuropathic Pain. Molecules 2023; 28:5766. [PMID: 37570736 PMCID: PMC10421203 DOI: 10.3390/molecules28155766] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Neuropathic pain is a debilitating condition that affects millions of people worldwide. Numerous studies indicate that this type of pain is a chronic condition with a complex mechanism that tends to worsen over time, leading to a significant deterioration in patients' quality of life and issues like depression, disability, and disturbed sleep. Presently used analgesics are not effective enough in neuropathy treatment and may cause many side effects due to the high doses needed. In recent years, many researchers have pointed to the important role of chemokines not only in the development and maintenance of neuropathy but also in the effectiveness of analgesic drugs. Currently, approximately 50 chemokines are known to act through 20 different seven-transmembrane G-protein-coupled receptors located on the surface of neuronal, glial, and immune cells. Data from recent years clearly indicate that more chemokines than initially thought (CCL1/2/3/5/7/8/9/11, CXCL3/9/10/12/13/14/17; XCL1, CX3CL1) have pronociceptive properties; therefore, blocking their action by using neutralizing antibodies, inhibiting their synthesis, or blocking their receptors brings neuropathic pain relief. Several of them (CCL1/2/3/7/9/XCL1) have been shown to be able to reduce opioid drug effectiveness in neuropathy, and neutralizing antibodies against them can restore morphine and/or buprenorphine analgesia. The latest research provides irrefutable evidence that chemokine receptors are promising targets for pharmacotherapy; chemokine receptor antagonists can relieve pain of different etiologies, and most of them are able to enhance opioid analgesia, for example, the blockade of CCR1 (J113863), CCR2 (RS504393), CCR3 (SB328437), CCR4 (C021), CCR5 (maraviroc/AZD5672/TAK-220), CXCR2 (NVPCXCR220/SB225002), CXCR3 (NBI-74330/AMG487), CXCR4 (AMD3100/AMD3465), and XCR1 (vMIP-II). Recent research has shown that multitarget antagonists of chemokine receptors, such as CCR2/5 (cenicriviroc), CXCR1/2 (reparixin), and CCR2/CCR5/CCR8 (RAP-103), are also very effective painkillers. A multidirectional strategy based on the modulation of neuronal-glial-immune interactions by changing the activity of the chemokine family can significantly improve the quality of life of patients suffering from neuropathic pain. However, members of the chemokine family are still underestimated pharmacological targets for pain treatment. In this article, we review the literature and provide new insights into the role of chemokines and their receptors in neuropathic pain.
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Affiliation(s)
| | - Joanna Mika
- Department of Pain Pharmacology, Maj Institute of Pharmacology Polish Academy of Sciences, 12 Smetna Str., 31-343 Cracow, Poland;
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Tanei T, Maesawa S, Nishimura Y, Nagashima Y, Ishizaki T, Ando M, Kuwatsuka Y, Hashizume A, Kurasawa S, Saito R. Differential target multiplexed spinal cord stimulation using a paddle-type lead placed at the appropriate site for neuropathic pain after spinal cord injury in patients with past spinal surgical histories: study protocol for an exploratory clinical trial. Trials 2023; 24:395. [PMID: 37308986 DOI: 10.1186/s13063-023-07433-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/05/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Neuropathic pain after spinal cord injury (SCI), both traumatic and non-traumatic, is refractory to various treatments. Spinal cord stimulation (SCS) is one of the neuromodulation therapies for neuropathic pain, although SCS has insufficient efficacy for neuropathic pain after SCI. The reasons are presumed to be inappropriate locations of SCS leads and conventional tonic stimulation itself does not have a sufficient analgesic effect for the pain. In patients with past spinal surgical histories, the cylinder-type leads are likely to be placed on the caudal side of the SCI because of surgical adhesions. Differential target multiplexed (DTM) stimulation is one of the latest new stimulation patterns that is superior to conventional stimulation. METHODS A single-center, open-label, randomized, two-way crossover trial is planned to investigate the efficacy of SCS using DTM stimulation placing a paddle lead at the appropriate site for neuropathic pain after SCI in patients with spinal surgical histories. The paddle-type lead delivers energy more efficiently than a cylinder-type lead. This study consists of two steps: SCS trial (first step) and SCS system implantation (second step). The primary outcome is rates of achieving pain improvement with more than 33% reduction 3 months after SCS system implantation. The secondary outcomes are to be evaluated as follows: (1) effectiveness of DTM and tonic stimulations during the SCS trial; (2) changes of assessment items from 1 to 24 months; (3) relationships between the result of the SCS trial and the effects 3 months after SCS system implantation; (4) preoperative factors associated with a long-term effect, defined as continuing for more than 12 months; and (5) whether gait function improves from 1 to 24 months. DISCUSSION A paddle-type lead placed on the rostral side of SCI and using DTM stimulation may provide significant pain relief for patients with intractable neuropathic pain after SCI in patients with past spinal surgical histories. TRIAL REGISTRATION Japan Registry of Clinical Trials (jRCT) jRCT 1042220093. Registered on 21 November 2022, and last modified on 6 January 2023. jRCT is approved as a member of the Primary Registry Network of WHO ICTRP.
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Affiliation(s)
- Takafumi Tanei
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Satoshi Maesawa
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yoshitaka Nagashima
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Tomotaka Ishizaki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Atsushi Hashizume
- Department of Clinical Research Education, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Shimon Kurasawa
- Department of Clinical Research Education, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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Alini M, Diwan AD, Erwin WM, Little CB, Melrose J. An update on animal models of intervertebral disc degeneration and low back pain: Exploring the potential of artificial intelligence to improve research analysis and development of prospective therapeutics. JOR Spine 2023; 6:e1230. [PMID: 36994457 PMCID: PMC10041392 DOI: 10.1002/jsp2.1230] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 08/31/2022] [Accepted: 09/11/2022] [Indexed: 02/03/2023] Open
Abstract
Animal models have been invaluable in the identification of molecular events occurring in and contributing to intervertebral disc (IVD) degeneration and important therapeutic targets have been identified. Some outstanding animal models (murine, ovine, chondrodystrophoid canine) have been identified with their own strengths and weaknesses. The llama/alpaca, horse and kangaroo have emerged as new large species for IVD studies, and only time will tell if they will surpass the utility of existing models. The complexity of IVD degeneration poses difficulties in the selection of the most appropriate molecular target of many potential candidates, to focus on in the formulation of strategies to effect disc repair and regeneration. It may well be that many therapeutic objectives should be targeted simultaneously to effect a favorable outcome in human IVD degeneration. Use of animal models in isolation will not allow resolution of this complex issue and a paradigm shift and adoption of new methodologies is required to provide the next step forward in the determination of an effective repairative strategy for the IVD. AI has improved the accuracy and assessment of spinal imaging supporting clinical diagnostics and research efforts to better understand IVD degeneration and its treatment. Implementation of AI in the evaluation of histology data has improved the usefulness of a popular murine IVD model and could also be used in an ovine histopathological grading scheme that has been used to quantify degenerative IVD changes and stem cell mediated regeneration. These models are also attractive candidates for the evaluation of novel anti-oxidant compounds that counter inflammatory conditions in degenerate IVDs and promote IVD regeneration. Some of these compounds also have pain-relieving properties. AI has facilitated development of facial recognition pain assessment in animal IVD models offering the possibility of correlating the potential pain alleviating properties of some of these compounds with IVD regeneration.
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Affiliation(s)
- Mauro Alini
- AO Research Institute Davos Platz Switzerland
| | - Ashish D. Diwan
- Spine Service, Department of Orthopedic Surgery, St. George & Sutherland Campus, Clinical School University of New South Wales Sydney New South Wales Australia
| | - W. Mark Erwin
- Department of Surgery University of Toronto Ontario Canada
| | - Chirstopher B. Little
- Raymond Purves Bone and Joint Research Laboratory Kolling Institute, Sydney University Faculty of Medicine and Health, Northern Sydney Area Health District, Royal North Shore Hospital St. Leonards New South Wales Australia
| | - James Melrose
- Raymond Purves Bone and Joint Research Laboratory Kolling Institute, Sydney University Faculty of Medicine and Health, Northern Sydney Area Health District, Royal North Shore Hospital St. Leonards New South Wales Australia
- Graduate School of Biomedical Engineering The University of New South Wales Sydney New South Wales Australia
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de Geus TJ, Franken G, Joosten EA. Conventional, high frequency and differential targeted multiplexed spinal cord stimulation in experimental painful diabetic peripheral neuropathy: Pain behavior and role of the central inflammatory balance. Mol Pain 2023; 19:17448069231193368. [PMID: 37488684 PMCID: PMC10504849 DOI: 10.1177/17448069231193368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
Spinal cord stimulation (SCS) is a last resort treatment for pain relief in painful diabetic peripheral neuropathy (PDPN) patients. However, the effectivity of SCS in PDPN is limited. New SCS paradigms such as high frequency (HF) and differential target multiplexed (DTM) might improve responder rates and efficacy of SCS-induced analgesia in PDPN patients, and are suggested to modulate the inflammatory balance and glial response in the spinal dorsal horn. The aim of this study was to research the effects of Con-, HF- and DTM-SCS on pain behavior and the spinal inflammatory balance in an animal model of PDPN. Streptozotocin-induced PDPN animals were stimulated for 48 hours with either Con-SCS (50Hz), HF-SCS (1200Hz) or DTM-SCS (combination of Con- and HF-SCS). Mechanical hypersensitivity was assessed using Von Frey (VF) test and the motivational aspects of pain were assessed using the mechanical conflict avoidance system (MCAS). The inflammatory balance and glial response were analyzed in the dorsal spinal cord based on RNA expression of pro- and anti-inflammatory cytokines (Tnf-α, Il-1ß, Il-4, Il-10), a microglia marker (Itgam), an astrocyte marker (Gfap), a T-cell marker (Cd3d), microglia proliferation markers (Irf8, Adgre1) and P2X4, p13-MAPK, BDNF signaling markers (P2x4, Mapk14, Bdnf). The results show that Con-, HF-, and DTM-SCS significantly decreased hypersensitivity after 48 hours of stimulation compared to Sham-SCS in PDPN animals, but at the same time did not affect escape latency in the MCAS. At the molecular level, Con-SCS resulted in a significant increase in spinal pro-inflammatory cytokine Tnf-α after 48 hours compared to DTM-SCS and Sham-SCS. In summary, Con-SCS showed a shift of the inflammatory balance towards a pro-inflammatory state whilst HF- and DTM-SCS shifted the balance towards an anti-inflammatory state. These findings suggest that the underlying mechanism of Con-SCS induced pain relief in PDPN differs from that induced by HF- and DTM-SCS.
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Affiliation(s)
- Thomas J. de Geus
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Glenn Franken
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Elbert A Joosten
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
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de Geus TJ, Franken G, Joosten EAJ. Spinal Cord Stimulation Paradigms and Pain Relief: A Preclinical Systematic Review on Modulation of the Central Inflammatory Response in Neuropathic Pain. Neuromodulation 2023; 26:25-34. [PMID: 35931643 DOI: 10.1016/j.neurom.2022.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/11/2022] [Accepted: 04/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) is a last-resort treatment for patients with chronic neuropathic pain. The mechanism underlying SCS and pain relief is not yet fully understood. Because the inflammatory balance between pro- and anti-inflammatory molecules in the spinal nociceptive network is pivotal in the development and maintenance of neuropathic pain, the working mechanism of SCS is suggested to be related to the modulation of this balance. The aim of this systematic review is to summarize and understand the effects of different SCS paradigms on the central inflammatory balance in the spinal cord. MATERIALS AND METHODS A systematic literature search was conducted using MEDLINE, Embase, and PubMed. All articles studying the effects of SCS on inflammatory or glial markers in neuropathic pain models were included. A quality assessment was performed on predetermined entities of bias. RESULTS A total of 11 articles were eligible for this systematic review. In general, induction of neuropathic pain in rats results in a proinflammatory state and at the same time an increased activity/expression of microglial and astroglial cells in the spinal cord dorsal horn. Conventional SCS seems to further enhance this proinflammatory state and increase the messenger RNA expression of microglial markers, but it also results in a decrease in microglial protein marker levels. High-frequency and especially differential targeted multiplexed SCS can not only restore the balance between pro- and anti-inflammatory molecules but also minimize the overexpression/activation of glial cells. Quality assessment and risk of bias analysis of the studies included make it clear that the results of these preclinical studies must be interpreted with caution. CONCLUSIONS In summary, the preclinical findings tend to indicate that there is a distinct SCS paradigm-related effect in the modulation of the central inflammatory balance of the spinal dorsal horn.
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Affiliation(s)
- Thomas J de Geus
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands.
| | - Glenn Franken
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
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11
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Wu D, Zhang Y, Zhao C, Li Q, Zhang J, Han J, Xu Z, Li J, Ma Y, Wang P, Xu H. Disruption of C/EBPβ-Clec7a axis exacerbates neuroinflammatory injury via NLRP3 inflammasome-mediated pyroptosis in experimental neuropathic pain. J Transl Med 2022; 20:583. [PMID: 36503542 PMCID: PMC9743596 DOI: 10.1186/s12967-022-03779-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Growing evidence shows that C-Type Lectin Domain Containing 7A (Clec7a) may be involved into neuroinflammatory injury of various neurological diseases. However, its roles in neuropathic pain remain unclear. METHODS A chronic constriction injury (CCI) rat model was constructed, and gene expression profilings in spinal cord tissues of CCI-insulted rats were detected by both microarray and RNA-seq studies. A series of bioinformatics analyses identified C/EBPβ-Clec7a to be a candidate axis involved into neuropathic pain. Then, its roles in mechanical allodynia, and pathological and molecular changes during CCI progression were determined by various gain-of-function and loss-of-function experiments in vivo and in vitro. RESULTS Significant upregulation of Clec7a at both mRNA and protein levels were verified in spinal cord tissues of CCI-insulted rats. Clec7a knockdown markedly attenuated CCI-induced mechanical allodynia, obstructed Syk, ERK and JNK phosphorylation, inhibited NLRP3 inflammasome and caspase-1 activation, GSDMD cleavage, and consequently reduced the release of pro-inflammatory cytokines (all P < 0.05). Mechanically, the rat Clec7a promoter was predicted to bind with transcription factor C/EBPβ, confirmed by Luciferase assay and ChIP-qPCR. Both in vivo and in vitro assays demonstrated that C/EBPβ knockdown significantly suppressed CCI- or LPS/ATP-induced Clec7a upregulation, and subsequently reduced Syk, ERK and JNK phosphorylation, NLRP3 oligomerization, caspase-1 activation, GSDMD expression and pyroptosis, which were markedly reversed by the co-transfection of Clec7a expression vector. CONCLUSIONS This pre-clinical investigation reveals that C/EBPβ-Clec7a axis may be a potential target for relieving neuropathic pain through alleviating neuroinflammation, paving its way for clinical translation as a promising approach for neuropathic pain therapy.
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Affiliation(s)
- Dan Wu
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Yanqiong Zhang
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Chunhui Zhao
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Qiuyue Li
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Junhong Zhang
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Jiaxin Han
- grid.419093.60000 0004 0619 8396Drug Discovery and Design Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203 China
| | - Zhijian Xu
- grid.419093.60000 0004 0619 8396Drug Discovery and Design Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203 China
| | - Junfang Li
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Yan Ma
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China
| | - Ping Wang
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China ,grid.419093.60000 0004 0619 8396Drug Discovery and Design Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203 China
| | - Haiyu Xu
- grid.410318.f0000 0004 0632 3409Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing, 100700 China ,grid.410318.f0000 0004 0632 3409Key Laboratory for Research and Evaluation of Traditional Chinese Medicine, National Medical Products Administration, China Academy of Chinese Medical Sciences, Beijing, 100700 China
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12
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Su PYP, Zhang L, He L, Zhao N, Guan Z. The Role of Neuro-Immune Interactions in Chronic Pain: Implications for Clinical Practice. J Pain Res 2022; 15:2223-2248. [PMID: 35957964 PMCID: PMC9359791 DOI: 10.2147/jpr.s246883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Po-Yi Paul Su
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Lingyi Zhang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Liangliang He
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
- Department of Pain Management, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Na Zhao
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
- Correspondence: Zhonghui Guan, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA, Tel +415.885.7246, Fax +415.885.7575, Email
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13
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Cedeño DL, Tilley DM, Vetri F, Platt DC, Vallejo R. Proteomic and Phosphoproteomic Changes of MAPK-Related Inflammatory Response in an Animal Model of Neuropathic Pain by Differential Target Multiplexed SCS and Low-Rate SCS. J Pain Res 2022; 15:895-907. [PMID: 35392631 PMCID: PMC8983055 DOI: 10.2147/jpr.s348738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/24/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction Neuropathic pain initiates an interplay of pathways, involving MAP kinases and NFκB-signaling, leading to expression of immune response factors and activation and inactivation of proteins via phosphorylation. Neuropathic pain models demonstrated that spinal cord stimulation (SCS) may provide analgesia by modulating gene and protein expression in neuroinflammatory processes. A differential target multiplexed programming (DTMP) approach was more effective than conventional SCS treatments at modulating these. This work investigated the effect of DTMP and low rate SCS (LR-SCS) on proteins associated with MAP kinases and NFκB-signaling relevant to neuroinflammation. Methods Animals subjected to the spared nerve injury model (SNI) of neuropathic pain were treated continuously (48h) with either DTMP or LR-SCS. No-SNI and No-SCS groups were included as controls. Proteomics and phosphoproteomics of stimulated spinal cord tissues were performed via liquid chromatography/tandem mass spectrometry. Proteins were identified from mass spectra using bioinformatics. Expression levels and fold changes (No-SCS/No-SNI and SCS/No-SCS) were obtained from spectral intensities. Results Analyses identified 7192 proteins, with 1451 and 705 significantly changed by DTMP and LR-SCS, respectively. Eighty-one proteins, including MAP kinases, facilitating NFκB-signaling as part of inflammatory processes were identified. The pain model significantly increased expression levels of complement pathway-related proteins (LBP, NRG1, APP, CFH, C3, C5), which were significantly reversed by DTMP. Expression levels of other complement pathway-related proteins (HMGB1, S100A8, S100A9, CRP, C4) were decreased by DTMP, although not significantly affected by SNI. Other proteins (ORM1, APOE, NG2, CNTF) involved in NFκB-signaling were increased by SNI and decreased by DTMP. Expression levels of phosphorylated protein kinases involved in NFκB-signaling (including MAP kinases, PKC, MARK1) were affected by the pain model and reverse modulated by DTMP. LR-SCS modulated inflammatory-related proteins although to a lesser extent than DTMP. Conclusion Proteomic analyses support the profound effect of the DTMP approach on neuroinflammation via MAP kinases and NFκB-mediated signaling to alleviate neuropathic pain.
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Affiliation(s)
- David L Cedeño
- Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
- Research and Development, SGX Medical, Bloomington, IL, USA
| | - Dana M Tilley
- Research and Development, SGX Medical, Bloomington, IL, USA
| | - Francesco Vetri
- Research Department, National Spine and Pain Centers, Bloomington, IL, USA
| | - David C Platt
- Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
- Research and Development, SGX Medical, Bloomington, IL, USA
| | - Ricardo Vallejo
- Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
- Research and Development, SGX Medical, Bloomington, IL, USA
- Research Department, National Spine and Pain Centers, Bloomington, IL, USA
- Correspondence: Ricardo Vallejo; David L Cedeño, Email ;
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14
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Graham RD, Sankarasubramanian V, Lempka SF. Dorsal Root Ganglion Stimulation for Chronic Pain: Hypothesized Mechanisms of Action. THE JOURNAL OF PAIN 2022; 23:196-211. [PMID: 34425252 PMCID: PMC8943693 DOI: 10.1016/j.jpain.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 07/20/2021] [Indexed: 02/03/2023]
Abstract
Dorsal root ganglion stimulation (DRGS) is a neuromodulation therapy for chronic pain that is refractory to conventional medical management. Currently, the mechanisms of action of DRGS-induced pain relief are unknown, precluding both our understanding of why DRGS fails to provide pain relief to some patients and the design of neurostimulation technologies that directly target these mechanisms to maximize pain relief in all patients. Due to the heterogeneity of sensory neurons in the dorsal root ganglion (DRG), the analgesic mechanisms could be attributed to the modulation of one or many cell types within the DRG and the numerous brain regions that process sensory information. Here, we summarize the leading hypotheses of the mechanisms of DRGS-induced analgesia, and propose areas of future study that will be vital to improving the clinical implementation of DRGS. PERSPECTIVE: This article synthesizes the evidence supporting the current hypotheses of the mechanisms of action of DRGS for chronic pain and suggests avenues for future interdisciplinary research which will be critical to fully elucidate the analgesic mechanisms of the therapy.
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Affiliation(s)
- Robert D. Graham
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Vishwanath Sankarasubramanian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Scott F. Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States,Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109, United States,Corresponding author: Scott F. Lempka, PhD, Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, NCRC 14-184, Ann Arbor, MI 48109-2800,
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15
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Tilley DM, Cedeño DL, Vetri F, Platt DC, Vallejo R. Differential target multiplexed spinal cord stimulation programming modulates proteins involved in ion regulation in an animal model of neuropathic pain. Mol Pain 2022; 18:17448069211060181. [PMID: 35048719 PMCID: PMC8785327 DOI: 10.1177/17448069211060181] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The effect of spinal cord stimulation (SCS) using differential target multiplexed programming (DTMP) on proteins involved in the regulation of ion transport in spinal cord (SC) tissue of an animal model of neuropathic pain was evaluated in comparison to low rate (LR) SCS. Rats subjected to the spared nerve injury model (SNI) and implanted with a SCS lead were assigned to DTMP or LR and stimulated for 48 h. A No-SCS group received no stimulation, and a Sham group received no SNI or stimulation. Proteins in the dorsal ipsilateral quadrant of the stimulated SC were identified and quantified using mass spectrometry. Proteins significantly modulated by DTMP or LR relative to No-SCS were identified. Bioinformatic tools were used to identify proteins related to ion transport regulation. DTMP modulated a larger number of proteins than LR. More than 40 proteins significantly involved in the regulation of chloride (Cl-), potassium (K+), sodium (Na+), or calcium (Ca2+) ions were identified. SNI affected proteins that promote the increase of intracellular Ca2+, Na+, and K+ and decrease of intracellular Cl-. DTMP modulated proteins involved in glial response to neural injury that affect Ca2+ signaling. DTMP decreased levels of proteins related to Ca2+ transport that may result in the reduction of intracellular Ca2+. Presynaptic proteins involved in GABA vesicle formation and release were upregulated by DTMP. DTMP also upregulated postsynaptic proteins involved with elevated intracellular Cl-, while modulating proteins, expressed by astrocytes, that regulate postsynaptic Cl- inhibition. DTMP downregulated K+ regulatory proteins affected by SNI that affect neuronal depolarization, and upregulated proteins that are associated with a decrease of intracellular neuronal K+ and astrocyte uptake of extracellular K+. DTMP treatment modulated the expression of proteins with the potential to facilitate a reversal of dysregulation of ion transport and signaling associated with a model of neuropathic pain.
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Affiliation(s)
| | - David L Cedeño
- SGX Medical LLC, Bloomington, IL, USA.,Department of Psychology, 1770Illinois Wesleyan University, Bloomington, IL, USA
| | | | - David C Platt
- SGX Medical LLC, Bloomington, IL, USA.,Department of Psychology, 1770Illinois Wesleyan University, Bloomington, IL, USA
| | - Ricardo Vallejo
- SGX Medical LLC, Bloomington, IL, USA.,Department of Psychology, 1770Illinois Wesleyan University, Bloomington, IL, USA.,National Spine and Pain Centers, Bloomington, IL, USA
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16
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Fishman M, Cordner H, Justiz R, Provenzano D, Merrell C, Shah B, Naranjo J, Kim P, Calodney A, Carlson J, Bundschu R, Sanapati M, Mangal V, Vallejo R. Twelve-Month results from multicenter, open-label, randomized controlled clinical trial comparing differential target multiplexed spinal cord stimulation and traditional spinal cord stimulation in subjects with chronic intractable back pain and leg pain. Pain Pract 2021; 21:912-923. [PMID: 34363307 PMCID: PMC9290817 DOI: 10.1111/papr.13066] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/18/2022]
Abstract
Background Spinal cord stimulation (SCS) is a well‐established treatment for chronic intractable pain of the trunk and/or limbs; however, low back pain (LBP) is difficult to treat using traditional SCS. Differential Target Multiplexed spinal cord stimulation (DTM SCS) is an advanced approach inspired from animal studies demonstrating improved pain‐related behavior and pain‐relevant biological processes. Objective The purpose of this study was to compare the effectiveness of DTM SCS and traditional SCS in treating chronic LBP and leg pain (LP). Methods This prospective, postmarket randomized controlled trial compared DTM SCS to traditional SCS in patients with chronic LBP and LP. Primary end point was LBP responder rate (percentage of subjects with ≥ 50% relief) at 3 months. Noninferiority and superiority were assessed. Other outcomes included mean change in back and leg pain, responder rates, disability, global health, satisfaction, and safety profile throughout the 12‐month follow‐up. Results One hundred twenty‐eight subjects were randomized across 12 centers (67 DTM SCS and 61 traditional SCS). Of the 94 patients implanted, 46 subjects in each group completed the 3‐month assessment. LBP responder rate of 80.1% with DTM SCS was superior to 51.2% with traditional SCS (p = 0.0010). Mean LBP reduction (5.36 cm) with DTM SCS was greater than reduction (3.37 cm) with traditional SCS (p < 0.0001). These results were sustained at 6 months and 12 months. Safety profiles were similar between treatment groups. Conclusion Superiority of DTM SCS compared with traditional SCS for chronic LBP was demonstrated. Clinical improvements provided by DTM SCS were sustained over 12 months and are expected to significantly impact the management of chronic LBP.
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Affiliation(s)
- Michael Fishman
- Center for Interventional Pain and Spine, Exton, Pennsylvania, USA
| | - Harold Cordner
- Florida Pain Management Associates, Sebastian, Florida, USA
| | - Rafael Justiz
- Oklahoma Pain Physicians, Oklahoma City, Oklahoma, USA
| | - David Provenzano
- Pain Diagnostics and Interventional Care, LLC, Sewickly, Pennsylvania, USA
| | | | - Binit Shah
- Carolinas Research Institute, PLLC, Huntersville, North Carolina, USA
| | - Julian Naranjo
- South Florida Clinical Research, South Miami, Florida, USA
| | - Philip Kim
- Center for Interventional Pain and Spine, Exton, Pennsylvania, USA
| | | | | | | | | | - Vipul Mangal
- National Spine and Pain Center, Oxon Hill, Maryland, USA
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17
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Echeverria-Villalobos M, Mitchell J, Fiorda-Diaz J, Weaver T. Effects of Dorsal Column Spinal Cord Stimulation on Neuroinflammation: Revisiting Molecular Mechanisms and Clinical Outcomes on Chronic Lumbar/Leg Pain and Failed Back Surgery Syndrome. J Pain Res 2021; 14:2337-2345. [PMID: 34354373 PMCID: PMC8331196 DOI: 10.2147/jpr.s309872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/26/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE In this narrative review, we reviewed and discussed current literature describing the molecular mechanisms leading to neuroinflammation and its role in the onset and progression of chronic neuropathic lumbar and leg pain in patients with persistent spinal pain syndrome. In addition, we reviewed the proposed mechanisms and impact of spinal cord stimulation (SCS) on neuroinflammation. METHODS A broad search of current literature in PubMed, Embase, Scopus, Cochrane library, Medline/Ovid, and Web of Science was performed using the following terms and their combinations: "biomarkers", "chronic back and leg pain", "cytokines", "neuroinflammation", "spinal cord stimulation (scs)," and "spinal cord modulation". We selected: 1) articles published in the English language between January 2000 and July 2020 2) preclinical and clinical data 3) case reports 4) meta-analysis and systematic reviews and 5) conference abstracts. Manuscripts not disclosing methodology or without full-text availability were excluded. DISCUSSION SCS techniques have gradually evolved since inception to include novel methods such as burst-SCS, high frequency SCS, and differential targeted multiplexed SCS. The incidence of chronic pain after spine surgery is highly variable, with at least one third of patients developing persistent spinal pain syndrome. Novel SCS techniques have been associated with improved clinical and functional outcomes thus increasing patient quality of life. CONCLUSION Currently, health care providers rely on different options and methods for SCS when treating patients with refractory chronic lumbar pain and persistent spinal pain syndrome. Nevertheless, compelling clinical trials remain necessary to elucidate the long-term benefits and mechanisms of neuromodulation of all different types of SCS.
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Affiliation(s)
| | - Justin Mitchell
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Tristan Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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18
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Cedeño DL, Smith WJ, Kelley CA, Vallejo R. Spinal cord stimulation using differential target multiplexed programming modulates neural cell-specific transcriptomes in an animal model of neuropathic pain. Mol Pain 2021; 16:1744806920964360. [PMID: 33050770 PMCID: PMC7710394 DOI: 10.1177/1744806920964360] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Spinal cord stimulation is a proven effective therapy for treating chronic
neuropathic pain. Previous work in our laboratory demonstrated that spinal cord
stimulation based on a differential target multiplexed programming approach
provided significant relief of pain-like behavior in rodents subjected to the
spared nerve injury model of neuropathic pain. The relief was significantly
better than obtained using high rate and low rate programming. Furthermore,
transcriptomics-based results implied that differential target multiplexed
programming modulates neuronal–glial interactions that have been perturbed by
the pain process. Although differential target multiplexed programming was
developed to differentially target neurons and glial cells, our previous work
did not address this. This work presents transcriptomes, specific to each of the
main neural cell populations (neurons, microglia, astrocytes, and
oligodendrocytes), obtained from spinal cord subjected to continuous spinal cord
stimulation treatment with differential target multiplexed programming, high
rate programming, or low rate programming compared with no spinal cord
stimulation treatment, using the spared nerve injury model. To assess the effect
of each spinal cord stimulation treatment on these cell-specific transcriptomes,
gene expression levels were compared with that of healthy animals, naïve to
injury and interventional procedures. Pearson correlations and cell population
analysis indicate that differential target multiplexed programming yielded
strong and significant correlations to expression levels found in the healthy
animals across every evaluated cell-specific transcriptome. In contrast, high
rate programming only yielded a strong correlation for the microglia-specific
transcriptome, while low rate programming did not yield strong correlations with
any cell types. This work provides evidence that differential target multiplexed
programming distinctively targeted and modulated the expression of cell-specific
genes in the direction of the healthy state thus supporting its previously
established action on regulating neuronal–glial interaction processes in a pain
model.
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Affiliation(s)
- David L Cedeño
- Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - William J Smith
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Courtney A Kelley
- Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Ricardo Vallejo
- Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,National Spine and Pain Centers, Bloomington, IL, USA
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Cedeño DL, Kelley CA, Chakravarthy K, Vallejo R. Modulation of Glia-Mediated Processes by Spinal Cord Stimulation in Animal Models of Neuropathic Pain. FRONTIERS IN PAIN RESEARCH 2021; 2:702906. [PMID: 35295479 PMCID: PMC8915735 DOI: 10.3389/fpain.2021.702906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/31/2021] [Indexed: 12/23/2022] Open
Abstract
Glial cells play an essential role in maintaining the proper functioning of the nervous system. They are more abundant than neurons in most neural tissues and provide metabolic and catabolic regulation, maintaining the homeostatic balance at the synapse. Chronic pain is generated and sustained by the disruption of glia-mediated processes in the central nervous system resulting in unbalanced neuron–glial interactions. Animal models of neuropathic pain have been used to demonstrate that changes in immune and neuroinflammatory processes occur in the course of pain chronification. Spinal cord stimulation (SCS) is an electrical neuromodulation therapy proven safe and effective for treating intractable chronic pain. Traditional SCS therapies were developed based on the gate control theory of pain and rely on stimulating large Aβ neurons to induce paresthesia in the painful dermatome intended to mask nociceptive input carried out by small sensory neurons. A paradigm shift was introduced with SCS treatments that do not require paresthesia to provide effective pain relief. Efforts to understand the mechanism of action of SCS have considered the role of glial cells and the effect of electrical parameters on neuron–glial interactions. Recent work has provided evidence that SCS affects expression levels of glia-related genes and proteins. This inspired the development of a differential target multiplexed programming (DTMP) approach using electrical signals that can rebalance neuroglial interactions by targeting neurons and glial cells differentially. Our group pioneered the utilization of transcriptomic and proteomic analyses to identify the mechanism of action by which SCS works, emphasizing the DTMP approach. This is an account of evidence demonstrating the effect of SCS on glia-mediated processes using neuropathic pain models, emphasizing studies that rely on the evaluation of large sets of genes and proteins. We show that SCS using a DTMP approach strongly affects the expression of neuron and glia-specific transcriptomes while modulating them toward expression levels of healthy animals. The ability of DTMP to modulate key genes and proteins involved in glia-mediated processes affected by pain toward levels found in uninjured animals demonstrates a shift in the neuron–glial environment promoting analgesia.
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Affiliation(s)
- David L. Cedeño
- Research and Development, Lumbrera LLC, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
- *Correspondence: David L. Cedeño
| | - Courtney A. Kelley
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
| | - Krishnan Chakravarthy
- Deparment of Anesthesiology and Pain Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Ricardo Vallejo
- Research and Development, Lumbrera LLC, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
- Research Department, National Spine and Pain Center, Bloomington, IL, United States
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20
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Pilitsis JG, Chakravarthy KV, Will AJ, Trutnau KC, Hageman KN, Dinsmoor DA, Litvak LM. The Evoked Compound Action Potential as a Predictor for Perception in Chronic Pain Patients: Tools for Automatic Spinal Cord Stimulator Programming and Control. Front Neurosci 2021; 15:673998. [PMID: 34335157 PMCID: PMC8320888 DOI: 10.3389/fnins.2021.673998] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/21/2021] [Indexed: 12/21/2022] Open
Abstract
Objectives Spinal cord stimulation (SCS) is a drug free treatment for chronic pain. Recent technological advances have enabled sensing of the evoked compound action potential (ECAP), a biopotential that represents neural activity elicited from SCS. The amplitudes of many SCS paradigms – both sub- and supra-threshold – are programmed relative to the patient’s perception of SCS. The objective of this study, then, is to elucidate relationships between the ECAP and perception thresholds across posture and SCS pulse width. These relationships may be used for the automatic control and perceptually referenced programming of SCS systems. Methods ECAPs were acquired from 14 subjects across a range of postures and pulse widths with swept amplitude stimulation. Perception (PT) and discomfort (DT) thresholds were recorded. A stimulation artifact reduction scheme was employed, and growth curves were constructed from the sweeps. An estimate of the ECAP threshold (ET), was calculated from the growth curves using a novel approach. Relationships between ET, PT, and DT were assessed. Results ETs were estimated from 112 separate growth curves. For the postures and pulse widths assessed, the ET tightly correlated with both PT (r = 0.93; p < 0.0001) and DT (r = 0.93; p < 0.0001). The median accuracy of ET as a predictor for PT across both posture and pulse width was 0.5 dB. Intra-subject, ECAP amplitudes at DT varied up to threefold across posture. Conclusion We provide evidence that the ET varies across both different positions and varying pulse widths and suggest that this variance may be the result of postural dependence of the recording electrode-tissue spacing. ET-informed SCS holds promise as a tool for SCS parameter configuration and may offer more accuracy over alternative approaches for neural and perceptual control in closed loop SCS systems.
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Affiliation(s)
- Julie G Pilitsis
- Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | - Krishnan V Chakravarthy
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, United States
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21
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Smith WJ, Cedeño DL, Thomas SM, Kelley CA, Vetri F, Vallejo R. Modulation of microglial activation states by spinal cord stimulation in an animal model of neuropathic pain: Comparing high rate, low rate, and differential target multiplexed programming. Mol Pain 2021; 17:1744806921999013. [PMID: 33626981 PMCID: PMC7925954 DOI: 10.1177/1744806921999013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
While numerous studies and patient experiences have demonstrated the efficacy of spinal cord stimulation as a treatment for chronic neuropathic pain, the exact mechanism underlying this therapy is still uncertain. Recent studies highlighting the importance of microglial cells in chronic pain and characterizing microglial activation transcriptomes have created a focus on microglia in pain research. Our group has investigated the modulation of gene expression in neurons and glial cells after spinal cord stimulation (SCS), specifically focusing on transcriptomic changes induced by varying SCS stimulation parameters. Previous work showed that, in rodents subjected to the spared nerve injury (SNI) model of neuropathic pain, a differential target multiplexed programming (DTMP) approach provided significantly better relief of pain-like behavior compared to high rate (HRP) and low rate programming (LRP). While these studies demonstrated the importance of transcriptomic changes in SCS mechanism of action, they did not specifically address the role of SCS in microglial activation. The data presented herein utilizes microglia-specific activation transcriptomes to further understand how an SNI model of chronic pain and subsequent continuous SCS treatment with either DTMP, HRP, or LRP affects microglial activation. Genes for each activation transcriptome were identified within our dataset and gene expression levels were compared with that of healthy animals, naïve to injury and interventional procedures. Pearson correlations indicated that DTMP yields the highest significant correlations to expression levels found in the healthy animals across all microglial activation transcriptomes. In contrast, HRP or LRP yielded weak or very weak correlations for these transcriptomes. This work demonstrates that chronic pain and subsequent SCS treatments can modulate microglial activation transcriptomes, supporting previous research on microglia in chronic pain. Furthermore, this study provides evidence that DTMP is more effective than HRP and LRP at modulating microglial transcriptomes, offering potential insight into the therapeutic efficacy of DTMP.
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Affiliation(s)
- William J Smith
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - David L Cedeño
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Samuel M Thomas
- College of Osteopathic Medicine, Des Moines University, Des Moines, IA, USA
| | - Courtney A Kelley
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | | | - Ricardo Vallejo
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,National Spine and Pain Centers, Bloomington, IL, USA
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22
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Vallejo R, Kelley CA, Gupta A, Smith WJ, Vallejo A, Cedeño DL. Modulation of neuroglial interactions using differential target multiplexed spinal cord stimulation in an animal model of neuropathic pain. Mol Pain 2021; 16:1744806920918057. [PMID: 32290778 PMCID: PMC7160773 DOI: 10.1177/1744806920918057] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The development and maintenance of chronic neuropathic pain involves distorted
neuroglial interactions, which result in prolonged perturbations of immune and
inflammatory response, as well as disrupted synapses and cellular interactions.
Spinal cord stimulation (SCS) has proven effective and safe for more than
40 years, but comprehensive understanding of its mode of action remains elusive.
Previous work in our laboratory provided evidence that conventional SCS
parameters modulate biological processes associated with neuropathic pain in
animals. This inspired the development of differential target multiplexed
programming (DTMP) in which multiple electrical signals are used for modulating
glial cells and neurons in order to rebalance their interactions. This work
compares DTMP with both low rate and high rate programming using an animal model
of neuropathic pain. The spared nerve injury model was implemented in 48 rats
equally randomized into four experimental groups: No-SCS, DTMP, low rate, and
high rate. Naive animals (N = 7) served as a reference control. SCS was applied
continuously for 48 h and pain-related behavior assessed before and after SCS.
RNA from the spinal cord exposed to SCS was sequenced to determine changes in
gene expression as a result of injury (No-SCS vs. naïve) and as a result of SCS
(SCS vs. No-SCS). Bioinformatics tools (Weighted Gene Co-expression Network
Analysis and Gene Ontology Enrichment Analysis) were used to evaluate the
significance of the results. All three therapies significantly reduced
mechanical hypersensitivity, although DTMP provided statistically better results
overall. DTMP also reduced thermal hypersensitivity significantly.
RNA-sequencing corroborated the complex effects of nerve injury on the
transcriptome. In addition, DTMP provided significantly more effective
modulation of genes associated with pain-related processes in returning their
expression toward levels observed in naïve, noninjured animals. DTMP provides a
more effective way of modulating the expression of genes involved in
pain-relevant biological processes associated with neuroglial interactions.
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Affiliation(s)
- Ricardo Vallejo
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Courtney A Kelley
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Ashim Gupta
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,Department of Research, South Texas Orthopaedic Research Institute, Laredo, TX, USA
| | - William J Smith
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Alejandro Vallejo
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA
| | - David L Cedeño
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
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23
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Adaptive trial designs for spinal cord injury clinical trials directed to the central nervous system. Spinal Cord 2020; 58:1235-1248. [DOI: 10.1038/s41393-020-00547-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 02/08/2023]
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24
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Shu B, He SQ, Guan Y. Spinal Cord Stimulation Enhances Microglial Activation in the Spinal Cord of Nerve-Injured Rats. Neurosci Bull 2020; 36:1441-1453. [PMID: 32889636 DOI: 10.1007/s12264-020-00568-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Microglia can modulate spinal nociceptive transmission. Yet, their role in spinal cord stimulation (SCS)-induced pain inhibition is unclear. Here, we examined how SCS affects microglial activation in the lumbar cord of rats with chronic constriction injury (CCI) of the sciatic nerve. Male rats received conventional SCS (50 Hz, 80% motor threshold, 180 min, 2 sessions/day) or sham stimulation on days 18-20 post-CCI. SCS transiently attenuated the mechanical hypersensitivity in the ipsilateral hind paw and increased OX-42 immunoreactivity in the bilateral dorsal horns. SCS also upregulated the mRNAs of M1-like markers, but not M2-like markers. Inducible NOS protein expression was increased, but brain-derived neurotrophic factor was decreased after SCS. Intrathecal minocycline (1 μg-100 μg), which inhibits microglial activation, dose-dependently attenuated the mechanical hypersensitivity. Pretreatment with low-dose minocycline (1 μg, 30 min) prolonged the SCS-induced pain inhibition. These findings suggest that conventional SCS may paradoxically increase spinal M1-like microglial activity and thereby compromise its own ability to inhibit pain.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shao-Qiu He
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA. .,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
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25
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Nagel SJ, Hsieh J, Machado AG, Frizon LA, Howard MA, Gillies GT, Wilson S. Biomarker Optimization of Spinal Cord Stimulation Therapies. Neuromodulation 2020; 24:3-12. [PMID: 32881257 DOI: 10.1111/ner.13252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We are in the process of designing and testing an intradural stimulation device that will shorten the distance between the location of the electrode array and the targeted neural tissue, thus improving the efficacy of electrical current delivery. Identifying a biomarker that accurately reflects the response to this intervention is highly valued because of the potential to optimize interventional parameters or predict a response before it is clinically measurable. In this report, we summarize the findings pertaining to the study of biomarkers so that we and others will have an up-to-date reference that critically evaluates the current approaches and select one or several for testing during the development of our device. MATERIALS AND METHODS We have conducted a broad survey of the existing literature to catalogue the biomarkers that could be coupled to intradural spinal cord stimulation. We describe in detail some of the most promising biomarkers, existing limitations, and suitability to managing chronic pain. RESULTS Chronic, intractable pain is an all-encompassing condition that is incurable. Many treatments for managing chronic pain are nonspecific in action and intermittently administered; therefore, patients are particularly susceptible to large fluctuations in pain control over the course of a day. The absence of a reliable biomarker challenges assessment of therapeutic efficacy and contributes to either incomplete and inconsistent pain relief or, alternatively, intolerable side effects. Fluctuations in metabolites or inflammatory markers, signals captured during dynamic imaging, and genomics will likely have a role in governing how a device is modulated. CONCLUSIONS Efforts to identify one or more biomarkers are well underway with some preliminary evidence supporting their efficacy. This has far-reaching implications, including improved outcomes, fewer adverse events, harmonization of treatment and individuals, performance gains, and cost savings. We anticipate that novel biomarkers will be used widely to manage chronic pain.
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Affiliation(s)
- Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Hsieh
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Leonardo A Frizon
- Department of Neurosurgery, Hospital Marcelino Champagnat, Curitiba, PR, Brazil
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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26
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Fishman MA, Antony A, Esposito M, Deer T, Levy R. The Evolution of Neuromodulation in the Treatment of Chronic Pain: Forward-Looking Perspectives. PAIN MEDICINE 2020; 20:S58-S68. [PMID: 31152176 PMCID: PMC6600066 DOI: 10.1093/pm/pnz074] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The field of neuromodulation is continually evolving, with the past decade showing significant advancement in the therapeutic efficacy of neuromodulation procedures. The continued evolution of neuromodulation technology brings with it the promise of addressing the needs of both patients and physicians, as current technology improves and clinical applications expand. Design This review highlights the current state of the art of neuromodulation for treating chronic pain, describes key areas of development including stimulation patterns and neural targets, expanding indications and applications, feedback-controlled systems, noninvasive approaches, and biomarkers for neuromodulation and technology miniaturization. Results and Conclusions The field of neuromodulation is undergoing a renaissance of technology development with potential for profoundly improving the care of chronic pain patients. New and emerging targets like the dorsal root ganglion, as well as high-frequency and patterned stimulation methodologies such as burst stimulation, are paving the way for better clinical outcomes. As we look forward to the future, neural sensing, novel target-specific stimulation patterns, and approaches combining neuromodulation therapies are likely to significantly impact how neuromodulation is used. Moreover, select biomarkers may influence and guide the use of neuromodulation and help objectively demonstrate efficacy and outcomes.
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Affiliation(s)
| | | | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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27
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Suppression of Superficial Microglial Activation by Spinal Cord Stimulation Attenuates Neuropathic Pain Following Sciatic Nerve Injury in Rats. Int J Mol Sci 2020; 21:ijms21072390. [PMID: 32235682 PMCID: PMC7177766 DOI: 10.3390/ijms21072390] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 12/29/2022] Open
Abstract
We evaluated the mechanisms underlying the spinal cord stimulation (SCS)-induced analgesic effect on neuropathic pain following spared nerve injury (SNI). On day 3 after SNI, SCS was performed for 6 h by using electrodes paraspinally placed on the L4-S1 spinal cord. The effects of SCS and intraperitoneal minocycline administration on plantar mechanical sensitivity, microglial activation, and neuronal excitability in the L4 dorsal horn were assessed on day 3 after SNI. The somatosensory cortical responses to electrical stimulation of the hind paw on day 3 following SNI were examined by using in vivo optical imaging with a voltage-sensitive dye. On day 3 after SNI, plantar mechanical hypersensitivity and enhanced microglial activation were suppressed by minocycline or SCS, and L4 dorsal horn nociceptive neuronal hyperexcitability was suppressed by SCS. In vivo optical imaging also revealed that electrical stimulation of the hind paw-activated areas in the somatosensory cortex was decreased by SCS. The present findings suggest that SCS could suppress plantar SNI-induced neuropathic pain via inhibition of microglial activation in the L4 dorsal horn, which is involved in spinal neuronal hyperexcitability. SCS is likely to be a potential alternative and complementary medicine therapy to alleviate neuropathic pain following nerve injury.
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28
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Tilley DM, Lietz CB, Cedeno DL, Kelley CA, Li L, Vallejo R. Proteomic Modulation in the Dorsal Spinal Cord Following Spinal Cord Stimulation Therapy in an In Vivo Neuropathic Pain Model. Neuromodulation 2020; 24:22-32. [PMID: 32157770 DOI: 10.1111/ner.13103] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/12/2019] [Accepted: 12/18/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) provides relief for patients suffering from chronic neuropathic pain although its mechanism may not be as dependent on electrical interference as classically considered. Recent evidence has been growing regarding molecular changes that are induced by SCS as being a key player in reversing the pain process. Here, we observed the effect of SCS on altering protein expression in spinal cord tissue using a proteomic analysis approach. METHODS A microlead was epidurally implanted following induction of an animal neuropathic pain model. After the model was established, stimulation was applied for 72 hours continuously followed by tissue collection and proteomic analysis via tandem mass spectroscopy. Identified proteins were run through online data bases for protein identification and classification of biological processes. RESULTS A significant improvement in mechanical sensitivity was observed following 48 hours of SCS therapy. Proteomic analysis identified 5840 proteins, of which 155 were significantly affected by SCS. Gene ontology data bases indicated that a significant number of proteins were associated to stress response, oxidation/reduction, or extracellular matrix pathways. Additionally, many of the proteins identified also play a role in neuron-glial interactions and are involved in nociception. CONCLUSIONS The development of an injury unbalances the proteome of the local neural tissue, neurons, and glial cells, and shifts the proteomic profile to a pain producing state. This study demonstrates the reversal of the injury-induced proteomic state by applying conventional SCS therapy. Additional studies looking at variations in electrical parameters are needed to optimize SCS.
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Affiliation(s)
| | | | - David L Cedeno
- Lumbrera LLC, Bloomington, IL, USA.,Stimgenics LLC, Bloomington, IL, USA
| | | | - Lingjun Li
- University of Wisconsin-Madison, Madison, WI, USA
| | - Ricardo Vallejo
- Lumbrera LLC, Bloomington, IL, USA.,Stimgenics LLC, Bloomington, IL, USA.,National Spine and Pain Center, Bloomington, IL, USA
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29
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De Andrés J, Navarrete-Rueda F, Fabregat G, García-Gutiérrez MS, Monsalve-Dolz V, Harutyunyan A, Mínguez-Martí A, Rodriguez-Lopez R, Manzanares J. Differences in Gene Expression of Endogenous Opioid Peptide Precursor, Cannabinoid 1 and 2 Receptors and Interleukin Beta in Peripheral Blood Mononuclear Cells of Patients With Refractory Failed Back Surgery Syndrome Treated With Spinal Cord Stimulation: Markers of Therapeutic Outcomes? Neuromodulation 2020; 24:49-60. [PMID: 32027775 DOI: 10.1111/ner.13111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The use of spinal cord stimulation for patients with failed back surgery syndrome (FBSS) is very common. In order to better understand the mechanisms of action of spinal cord stimulation (SCS), our aim was to determine potential changes in relative gene and protein expression in the peripheral blood mononuclear cells (PBMCs) of patients as potential biomarkers of disease outcomes and potential new targets for therapy. METHODS Twenty-four patients with diagnosis of FBSS refractory to conservative therapy for at least six months were included in the study. Clinical evaluation in this study included validated questionnaires. Blood samples (10 mL) were collected five times from baseline until two months after implant of the leads. Proenkephalin (PENK), cannabinoid receptors CB1 and CB2, and interleukin 1β (IL 1β) were analyzed. Each patient served as his/her own control by comparing the samples collected at different time points against the baseline sample collected at T0. RESULTS A total of 16 patients met all relevant criteria during the whole study and were assessed. Only PENK showed significant changes over time (Friedman p = 0.000). A positive correlation was observed between changes in visual analog scale (VAS) scores and PENK and a negative correlation between changes in PENK and Short Form-12 (SF-12) mental component score (MCS) scores, as well as between changes in IL 1β and Pain Detect Questionnaire (PD-Q) scores. As PENK changes increased, so did pain (VAS). As changes in PENK increased, SF-12 MCS health worsened. As changes in IL 1β increased, PD-Q values decreased. No severe adverse events occurred. CONCLUSIONS Previously unknown effects of SCS on levels of PBMCs biomarkers are demonstrated. The findings of our research suggest a potential for useful integration of genome analysis and lymphocyte expression in the daily practice of neurostimulation for pain management and represent a novel road map in the light of the important questions that remain unanswered.
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Affiliation(s)
- Jose De Andrés
- Anesthesia Unit-Surgical specialties department. Valencia University Medical School. Department of Anesthesiology, Critical Care and Pain Management. General University Hospital, Valencia, Spain
| | | | - Gustavo Fabregat
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | | | - Vincente Monsalve-Dolz
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | - Anushik Harutyunyan
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | - Ana Mínguez-Martí
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | | | - Jorge Manzanares
- Institute of Neurosciences, Miguel Hernández University, CSIC, Alicante, Spain
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30
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Vallejo R, Platt DC, Rink JA, Jones MA, Kelley CA, Gupta A, Cass CL, Eichenberg K, Vallejo A, Smith WJ, Benyamin R, Cedeño DL. Electrical Stimulation of C6 Glia-Precursor Cells In Vitro Differentially Modulates Gene Expression Related to Chronic Pain Pathways. Brain Sci 2019; 9:brainsci9110303. [PMID: 31683631 PMCID: PMC6896182 DOI: 10.3390/brainsci9110303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/21/2022] Open
Abstract
Glial cells comprise the majority of cells in the central nervous system and exhibit diverse functions including the development of persistent neuropathic pain. While earlier theories have proposed that the applied electric field specifically affects neurons, it has been demonstrated that electrical stimulation (ES) of neural tissue modulates gene expression of the glial cells. This study examines the effect of ES on the expression of eight genes related to oxidative stress and neuroprotection in cultured rodent glioma cells. Concentric bipolar electrodes under seven different ES types were used to stimulate cells for 30 min in the presence and absence of extracellular glutamate. ES consisted of rectangular pulses at 50 Hz in varying proportions of anodic and cathodic phases. Real-time reverse-transcribed quantitative polymerase chain reaction was used to determine gene expression using the ∆∆Cq method. The results demonstrate that glutamate has a significant effect on gene expression in both stimulated and non-stimulated groups. Furthermore, stimulation parameters have differential effects on gene expression, both in the presence and absence of glutamate. ES has an effect on glial cell gene expression that is dependent on waveform composition. Optimization of ES therapy for chronic pain applications can be enhanced by this understanding.
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Affiliation(s)
- Ricardo Vallejo
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - David C Platt
- Department of Chemistry, Illinois State University, Normal, IL 61790, USA.
| | - Jonathan A Rink
- Department of Biology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - Marjorie A Jones
- Department of Chemistry, Illinois State University, Normal, IL 61790, USA.
| | - Courtney A Kelley
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - Ashim Gupta
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
- South Texas Orthopaedic Research Institute, Laredo, TX 78045, USA.
| | - Cynthia L Cass
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
| | - Kirk Eichenberg
- Department of Chemistry, Illinois State University, Normal, IL 61790, USA.
| | | | - William J Smith
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA.
| | - Ramsin Benyamin
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
- College of Medicine, Department of Surgery, University of Illinois at Urbana-Champaign, Champaign-Urbana, IL 61801, USA.
| | - David L Cedeño
- Millennium Pain Center, Bloomington, IL 61704, USA.
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL 61701, USA.
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31
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Ruiz-Sauri A, Orduña-Valls JM, Blasco-Serra A, Tornero-Tornero C, Cedeño DL, Bejarano-Quisoboni D, Valverde-Navarro AA, Benyamin R, Vallejo R. Glia to neuron ratio in the posterior aspect of the human spinal cord at thoracic segments relevant to spinal cord stimulation. J Anat 2019; 235:997-1006. [PMID: 31347695 DOI: 10.1111/joa.13061] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2019] [Indexed: 12/30/2022] Open
Abstract
Spinal cord stimulation (SCS) applied between T8 and T11 segments has been shown to be effective for the treatment of chronic pain of the lower back and limbs. However, the mechanism of the analgesic effect at these medullary levels remains unclear. Numerous studies relate glial cells with development and maintenance of chronic neuropathic pain. Glial cells are electrically excitable, which makes them a potential therapeutic target using SCS. The aim of this study is to report glia to neuron ratio in thoracic segments relevant to SCS, as well as to characterize the glia cell population at these levels. Dissections from gray and white matter of posterior spinal cord segments (T8, T9, intersection T9/T10, T10 and T11) were obtained from 11 human cadavers for histological analyses. Neuronal bodies and glial cells (microglia, astrocytes and oligodendrocytes) were immunostained, microphotographed and counted using image analysis software. Statistical analyses were carried out to establish significant differences of neuronal and glial populations among the selected segments, between the glial cells in a segment, and glial cells in white and gray matter. Results show that glia to neuron ratio in the posterior gray matter of the human spinal cord within the T8-T11 vertebral region is in the range 11 : 1 to 13 : 1, although not significantly different among vertebral segments. Glia cells are more abundant in gray matter than in white matter, whereas astrocytes and oligodendrocytes are more abundant than microglia (40 : 40 : 20). Interestingly, the population of oligodendrocytes in the T9/T10 intersection is significantly larger than in any other segment. In conclusion, glial cells are the predominant bodies in the posterior gray and white matter of the T8-T11 segments of the human spinal cord. Given the crucial role of glial cells in the development and maintenance of neuropathic pain, and their electrophysiological characteristics, anatomical determination of the ratio of different cell populations in spinal segments commonly exposed to SCS is fundamental to understand fully the biological effects observed with this therapy.
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Affiliation(s)
| | - Jorge M Orduña-Valls
- Department of Anesthesiology, Intensive Care, and Pain Management, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Clínica Indolor, Valencia, Spain
| | - Arantxa Blasco-Serra
- Department of Human Anatomy and Embryology, University of Valencia, Valencia, Spain
| | - Carlos Tornero-Tornero
- Department of Anesthesiology, Intensive Care, and Pain Management, Hospital Clínico Universitario de Valencia, Valencia, Spain.,Clínica Indolor, Valencia, Spain
| | - David L Cedeño
- Basic Science Research, Millennium Pain Center, Bloomington, IL, USA.,Stimgenics, Research and Development, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Daniel Bejarano-Quisoboni
- Department of Anesthesiology, Intensive Care, and Pain Management, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Ramsin Benyamin
- Clínica Indolor, Valencia, Spain.,Basic Science Research, Millennium Pain Center, Bloomington, IL, USA.,Stimgenics, Research and Development, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Ricardo Vallejo
- Clínica Indolor, Valencia, Spain.,Basic Science Research, Millennium Pain Center, Bloomington, IL, USA.,Stimgenics, Research and Development, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
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Caylor J, Reddy R, Yin S, Cui C, Huang M, Huang C, Rao R, Baker DG, Simmons A, Souza D, Narouze S, Vallejo R, Lerman I. Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectron Med 2019; 5:12. [PMID: 31435499 PMCID: PMC6703564 DOI: 10.1186/s42234-019-0023-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/30/2019] [Indexed: 12/30/2022] Open
Abstract
Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.
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Affiliation(s)
- Jacob Caylor
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Rajiv Reddy
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Sopyda Yin
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Christina Cui
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Mingxiong Huang
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
| | - Charles Huang
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Bioengineering, Stanford University, Palo Alto, CA USA
| | - Ramesh Rao
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
| | - Dewleen G. Baker
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Alan Simmons
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Ricardo Vallejo
- Basic Science Research, Millennium Pain Center, Bloomington, IL USA
- School of Biological Sciences, Illinois State University, Normal, IL USA
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL USA
| | - Imanuel Lerman
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
- Present Address: VA San Diego, 3350 La Jolla Village Dr, (MC116A), San Diego, CA 92161 USA
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Kinfe TM, Asif M, Chakravarthy KV, Deer TR, Kramer JM, Yearwood TL, Hurlemann R, Hussain MS, Motameny S, Wagle P, Nürnberg P, Gravius S, Randau T, Gravius N, Chaudhry SR, Muhammad S. Unilateral L4-dorsal root ganglion stimulation evokes pain relief in chronic neuropathic postsurgical knee pain and changes of inflammatory markers: part II whole transcriptome profiling. J Transl Med 2019; 17:205. [PMID: 31217010 PMCID: PMC6585082 DOI: 10.1186/s12967-019-1952-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/09/2019] [Indexed: 01/08/2023] Open
Abstract
Background In our recent clinical trial, increased peripheral concentrations of pro-inflammatory molecular mediators were determined in complex regional pain syndrome (CRPS) patients. After 3 months adjunctive unilateral, selective L4 dorsal root ganglion stimulation (L4-DRGSTIM), significantly decreased serum IL-10 and increased saliva oxytocin levels were assessed along with an improved pain and functional state. The current study extended molecular profiling towards gene expression analysis of genes known to be involved in the gonadotropin releasing hormone receptor and neuroinflammatory (cytokines/chemokines) signaling pathways. Methods Blood samples were collected from 12 CRPS patients for whole-transcriptome profiling in order to assay 18,845 inflammation-associated genes from frozen blood at baseline and after 3 months L4-DRGSTIM using PANTHER™ pathway enrichment analysis tool. Results Pathway enrichment analyses tools (GOrilla™ and PANTHER™) showed predominant involvement of inflammation mediated by chemokines/cytokines and gonadotropin releasing hormone receptor pathways. Further, screening of differentially regulated genes showed changes in innate immune response related genes. Transcriptomic analysis showed that 21 genes (predominantly immunoinflammatory) were significantly changed after L4-DRGSTIM. Seven genes including TLR1, FFAR2, IL1RAP, ILRN, C5, PKB and IL18 were down regulated and fourteen genes including CXCL2, CCL11, IL36G, CRP, SCGB1A1, IL-17F, TNFRSF4, PLA2G2A, CREB3L3, ADAMTS12, IL1F10, NOX1, CHIA and BDKRB1 were upregulated. Conclusions In our sub-group analysis of L4-DRGSTIM treated CRPS patients, we found either upregulated or downregulated genes involved in immunoinflammatory circuits relevant for the pathophysiology of CRPS indicating a possible relation. However, large biobank-based approaches are recommended to establish genetic phenotyping as a quantitative outcome measure in CRPS patients. Trial registration The study protocol was registered at the 15.11.2016 on German Register for Clinical Trials (DRKS ID 00011267). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011267
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Affiliation(s)
- Thomas M Kinfe
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Sigmund-Freud Street 25, 53105, Bonn, Germany. .,Division of Medical Psychology (NEMO Neuromodulation of Emotions), Rheinische Friedrich-Wilhelms University, Bonn, Germany. .,University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.
| | - Maria Asif
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.,Institute of Biochemistry I, Medical Faculty, University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Krishnan V Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California, San Diego, CA, USA.,San Diego Health Sciences, VA San Diego Healthcare System, San Diego, CA, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Rene Hurlemann
- Department of Psychiatry, Rheinische Friedrich-Wilhelms University, Sigmund-Freud Street 25, 53105, Bonn, Germany.,Division of Medical Psychology (NEMO Neuromodulation of Emotions), Rheinische Friedrich-Wilhelms University, Bonn, Germany.,University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany
| | - Muhammad Sajid Hussain
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.,Institute of Biochemistry I, Medical Faculty, University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Susanne Motameny
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany
| | - Prerana Wagle
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Peter Nürnberg
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Sascha Gravius
- University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.,Department of Orthopedics and Trauma Surgery, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Thomas Randau
- University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.,Department of Orthopedics and Trauma Surgery, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Nadine Gravius
- University Hospital Bonn, Rheinische Friedrich-Wilhelms University, Bonn, Germany.,Department of Orthopedics and Trauma Surgery, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Shafqat R Chaudhry
- Dept. of Basic Medical Sciences Shifa College of Pharmaceutical Sciences, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Sajjad Muhammad
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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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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Du H, Shi J, Wang M, An S, Guo X, Wang Z. Analyses of gene expression profiles in the rat dorsal horn of the spinal cord using RNA sequencing in chronic constriction injury rats. J Neuroinflammation 2018; 15:280. [PMID: 30253787 PMCID: PMC6156955 DOI: 10.1186/s12974-018-1316-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/18/2018] [Indexed: 12/29/2022] Open
Abstract
Background Neuropathic pain is caused by damage to the nervous system, resulting in aberrant pain, which is associated with gene expression changes in the sensory pathway. However, the molecular mechanisms are not fully understood. Methods Wistar rats were employed for the establishment of the chronic constriction injury (CCI) models. Using the Illumina HiSeq 4000 platform, we examined differentially expressed genes (DEGs) in the rat dorsal horn by RNA sequencing (RNA-seq) between CCI and control groups. Then, enrichment analyses were performed for these DEGs using Gene Ontology (GO) function, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway, Hierarchical Cluster, and protein-protein interaction (PPI) network. Results A total of 63 DEGs were found significantly changed with 56 upregulated (e.g., Cxcl13, C1qc, Fcgr3a) and 7 downregulated (e.g., Dusp1) at 14 days after CCI. Quantitative reverse-transcribed PCR (qRT-PCR) verified changes in 13 randomly selected DEGs. GO and KEGG biological pathway analyses showed that the upregulated DEGs were mostly enriched in immune response-related biological processes, as well as 14 immune- and inflammation-related pathways. The downregulated DEGs were enriched in inactivation of mitogen-activated protein kinase (MAPK) activity. PPI network analysis showed that Cd68, C1qc, C1qa, Laptm5, and Fcgr3a were crucial nodes with high connectivity degrees. Most of these genes which have previously been linked to immune and inflammation-related pathways have not been reported in neuropathic pain (e.g., Laptm5, Fcgr3a). Conclusions Our results revealed that immune and defense pathways may contribute to the generation of neuropathic pain after CCI. These mRNAs may represent new therapeutic targets for the treatment of neuropathic pain. Electronic supplementary material The online version of this article (10.1186/s12974-018-1316-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hui Du
- Department of Histology and Embryology, Taishan Medical University, Taian, 271000, China
| | - Juan Shi
- Department of Human Anatomy, Taishan Medical University, Taian, 271000, China
| | - Ming Wang
- Department of Human Anatomy, Taishan Medical University, Taian, 271000, China
| | - Shuhong An
- Department of Human Anatomy, Taishan Medical University, Taian, 271000, China
| | - Xingjing Guo
- Department of Physiology, Taishan Medical University, Taian, 271000, China
| | - Zhaojin Wang
- Department of Human Anatomy, Taishan Medical University, Taian, 271000, China.
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Changes in Dorsal Root Ganglion Gene Expression in Response to Spinal Cord Stimulation. Reg Anesth Pain Med 2018; 42:246-251. [PMID: 28079752 DOI: 10.1097/aap.0000000000000550] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Spinal cord stimulation (SCS) has been shown to influence pain-related genes in the spinal cord directly under the stimulating electrodes. There is limited information regarding changes occurring at the dorsal root ganglion (DRG). This study evaluates gene expression in the DRG in response to SCS therapy. METHODS Rats were randomized into experimental or control groups (n = 6 per group). Experimental animals underwent spared-nerve injury, implantation of lead, and continuous SCS (72 hours). Behavioral assessment for mechanical hyperalgesia was conducted to compare responses after injury and treatment. Ipsilateral DRG tissue was collected, and gene expression quantified for interleukin 1b (IL-1b), interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), GABA B receptor 1 (GABAbr1), substance P (subP), Integrin alpha M (ITGAM), sodium/potassium ATP-ase (Na/K ATPase), fos proto-oncogene (cFOS), serotonin receptor 3A (5HT3r), galanin (Gal), vasoactive intestinal peptide (VIP), neuropeptide Y (NpY), glial fibrillary acidic protein (GFAP), and brain derived neurotropic factor (BDNF) via quantitative polymerase chain reaction. Statistical significance was established using analysis of variance (ANOVA), independent t tests, and Pearson correlation tests. RESULTS Expression of IL-1b and IL-6 was reversed following SCS therapy relative to the increase caused by the injury model. Both GABAbr1 and Na/K ATPase were significantly up-regulated upon implantation of the lead, and SCS therapy reversed their expression to within control levels. Pearson correlation analyses reveal that GABAbr1 and Na/K ATPase expression was dependent on the stimulating current intensity. CONCLUSIONS Spinal cord stimulation modulates expression of key pain-related genes in the DRG. Specifically, SCS led to reversal of IL-1b and IL-6 expression induced by injury. Interleukin 6 expression was still significantly larger than in sham animals, which may correlate to residual sensitivity following continuous SCS treatment. In addition, expression of GABAbr1 and Na/K ATPase was down-regulated to within control levels following SCS and correlates with applied current.
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A Proof-of-Concept Study of Transcutaneous Magnetic Spinal Cord Stimulation for Neurogenic Bladder. Sci Rep 2018; 8:12549. [PMID: 30135433 PMCID: PMC6105631 DOI: 10.1038/s41598-018-30232-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/25/2018] [Indexed: 01/01/2023] Open
Abstract
Patients with chronic spinal cord injury (SCI) cannot urinate at will and must empty the bladder by self-catheterization. We tested the hypothesis that non-invasive, transcutaneous magnetic spinal cord stimulation (TMSCS) would improve bladder function in individuals with SCI. Five individuals with American Spinal Injury Association Impairment Scale A/B, chronic SCI and detrusor sphincter dyssynergia enrolled in this prospective, interventional study. After a two-week assessment to determine effective stimulation characteristics, each patient received sixteen weekly TMSCS treatments and then received “sham” weekly stimulation for six weeks while bladder function was monitored. Bladder function improved in all five subjects, but only during and after repeated weekly sessions of 1 Hz TMSCS. All subjects achieved volitional urination. The volume of urine produced voluntarily increased from 0 cc/day to 1120 cc/day (p = 0.03); self-catheterization frequency decreased from 6.6/day to 2.4/day (p = 0.04); the capacity of the bladder increased from 244 ml to 404 ml (p = 0.02); and the average quality of life ranking increased significantly (p = 0.007). Volitional bladder function was re-enabled in five individuals with SCI following intermittent, non-invasive TMSCS. We conclude that neuromodulation of spinal micturition circuitry by TMSCS may be used to ameliorate bladder function.
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Cesar ASM, Regitano LCA, Reecy JM, Poleti MD, Oliveira PSN, de Oliveira GB, Moreira GCM, Mudadu MA, Tizioto PC, Koltes JE, Fritz-Waters E, Kramer L, Garrick D, Beiki H, Geistlinger L, Mourão GB, Zerlotini A, Coutinho LL. Identification of putative regulatory regions and transcription factors associated with intramuscular fat content traits. BMC Genomics 2018; 19:499. [PMID: 29945546 PMCID: PMC6020320 DOI: 10.1186/s12864-018-4871-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 06/14/2018] [Indexed: 12/21/2022] Open
Abstract
Background Integration of high throughput DNA genotyping and RNA-sequencing data allows for the identification of genomic regions that control gene expression, known as expression quantitative trait loci (eQTL), on a whole genome scale. Intramuscular fat (IMF) content and carcass composition play important roles in metabolic and physiological processes in mammals because they influence insulin sensitivity and consequently prevalence of metabolic diseases such as obesity and type 2 diabetes. However, limited information is available on the genetic variants and mechanisms associated with IMF deposition in mammals. Thus, our hypothesis was that eQTL analyses could identify putative regulatory regions and transcription factors (TFs) associated with intramuscular fat (IMF) content traits. Results We performed an integrative eQTL study in skeletal muscle to identify putative regulatory regions and factors associated with intramuscular fat content traits. Data obtained from skeletal muscle samples of 192 animals was used for association analysis between 461,466 SNPs and the transcription level of 11,808 genes. This yielded 1268 cis- and 10,334 trans-eQTLs, among which we identified nine hotspot regions that each affected the expression of > 119 genes. These putative regulatory regions overlapped with previously identified QTLs for IMF content. Three of the hotspots respectively harbored the transcription factors USF1, EGR4 and RUNX1T1, which are known to play important roles in lipid metabolism. From co-expression network analysis, we further identified modules significantly correlated with IMF content and associated with relevant processes such as fatty acid metabolism, carbohydrate metabolism and lipid metabolism. Conclusion This study provides novel insights into the link between genotype and IMF content as evident from the expression level. It thereby identifies genomic regions of particular importance and associated regulatory factors. These new findings provide new knowledge about the biological processes associated with genetic variants and mechanisms associated with IMF deposition in mammals. Electronic supplementary material The online version of this article (10.1186/s12864-018-4871-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aline S M Cesar
- Department of Animal Science, University of São Paulo, Piracicaba, SP, 13418-900, Brazil.,Department of Animal Science, Iowa State University, Ames, IA, 50011, USA
| | | | - James M Reecy
- Department of Animal Science, Iowa State University, Ames, IA, 50011, USA
| | - Mirele D Poleti
- Department of Animal Science, University of São Paulo, Piracicaba, SP, 13418-900, Brazil
| | | | | | - Gabriel C M Moreira
- Department of Animal Science, University of São Paulo, Piracicaba, SP, 13418-900, Brazil
| | | | - Polyana C Tizioto
- Department of Animal Science, University of São Paulo, Piracicaba, SP, 13418-900, Brazil
| | - James E Koltes
- Department of Animal Science, Iowa State University, Ames, IA, 50011, USA
| | - Elyn Fritz-Waters
- Department of Animal Science, Iowa State University, Ames, IA, 50011, USA
| | - Luke Kramer
- Department of Animal Science, Iowa State University, Ames, IA, 50011, USA
| | - Dorian Garrick
- School of Agriculture, Massey University, Ruakura, Hamilton, New Zealand
| | - Hamid Beiki
- Department of Animal Science, Iowa State University, Ames, IA, 50011, USA
| | | | - Gerson B Mourão
- Department of Animal Science, University of São Paulo, Piracicaba, SP, 13418-900, Brazil
| | | | - Luiz L Coutinho
- Department of Animal Science, University of São Paulo, Piracicaba, SP, 13418-900, Brazil.
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Sorrell RG, Muhlenfeld J, Moffett J, Stevens G, Kesten S. Evaluation of pulsed electromagnetic field therapy for the treatment of chronic postoperative pain following lumbar surgery: a pilot, double-blind, randomized, sham-controlled clinical trial. J Pain Res 2018; 11:1209-1222. [PMID: 29950893 PMCID: PMC6018879 DOI: 10.2147/jpr.s164303] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background The incidence of chronic postoperative pain following lumbar spinal surgery has increased with the overall increase in the prevalence of lumbar surgery. This study was conducted to evaluate the analgesic effectiveness of pulsed electromagnetic field (PEMF) therapy in subjects with persistent pain following lumbar surgery. Patients and methods A randomized, double-blind, sham-controlled, multicenter study in 36 subjects with persistent low-back and/or radiating leg pain after lumbar surgery was conducted. Eligible subjects were randomized (1:1:1) to receive one of two doses of therapy (42-μs or 38-μs pulse width) or treatment with a sham device. Subjects self-treated twice daily for 60 days. The primary end point was change in pain intensity (∆PI) using the Numerical Pain Rating Scale between average baseline (Days −5 to −1) and end of treatment (Days 56–60) for lumbar and radiating leg pain. Secondary outcome measures included the Oswestry Disability Index, Beck Depression Inventory-II, Patient Global Impression of Change, and consumption of analgesics. Results Low-back pain scores for the 42-μs group decreased by 40.2% (p = 0.028), compared to 18.6% for the 38-μs pulse width group (p = 0.037) and 25.6% for the sham group (p = 0.013 per protocol population). Average leg pain scores decreased by 45.0% (42 μs, p = 0.009), 17.0% (38 μs, p = 0.293), and 24.5% (sham, p = 0.065). The proportion of subjects responding to therapy, time to 30% reduction in pain scores, and Patient Global Impression of Change were improved with the PEMF 42-μs device over the sham control, although results were associated with p-values >0.05. Conclusion PEMF therapy (42-μs pulse width) was associated with trends for a reduction in pain, compared to sham treatment. Secondary endpoints were consistent with an overall beneficial effect of the PEMF 42-μs pulse width device.
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Molecular mechanisms of the analgesic action of Wu-tou Decoction on neuropathic pain in mice revealed using microarray and network analysis. Acta Pharmacol Sin 2018; 39:988-997. [PMID: 28816231 DOI: 10.1038/aps.2017.110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
Wu-tou Decoction (WTD) is a classic herbal formula in traditional Chinese medicine for the treatment of joint diseases, neuropathic pain (NP) and inflammatory pain. In this study we investigated whether WTD produced analgesic action in a mouse spinal nerve ligation (SNL) model and elucidated the underlying molecular mechanisms. Mice were subjected to SNL and orally treated with WTD (3.15, 6.30 or 12.60 g·kg-1·d-1) for 21 d. SNL induced mechanical hyperalgesia and heat hyperalgesia characterized by rapid and persistent pain hypersensitivity. In addition, the expression levels of IL-1β, TNF-α, CCL2 and CXCL1 in the spinal cord dorsal horn were dramatically increased on the 10th d post-surgery. Oral administration of WTD dose-dependently suppressed both mechanical and heat hyperalgesia as well as the expression levels of inflammatory cytokines in the spinal cord dorsal horn on the 21st d post-surgery. Then whole-genome microarray analyses were conducted to detect the gene expression profiles of spinal cord dorsal horn in SNL mice with or without WTD treatment. After construction of the WTD-SNL-network and topological analysis, a list of candidate target genes of WTD acting on SNL-induced NP was identified and found to be functionally enriched in several glial cell activation-related pathways and neuroinflammatory pathways. Our data have clarified the gene expression patterns in the mouse spinal cord under the NP condition. We also demonstrate the analgesic action of WTD through suppression of glial cell activation and neuroinflammation, which suggest the potential of WTD as a promising candidate for the treatment of NP.
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van Beek M, Hermes D, Honig WM, Linderoth B, van Kuijk SMJ, van Kleef M, Joosten EA. Long-Term Spinal Cord Stimulation Alleviates Mechanical Hypersensitivity and Increases Peripheral Cutaneous Blood Perfusion in Experimental Painful Diabetic Polyneuropathy. Neuromodulation 2018. [PMID: 29522270 PMCID: PMC6099481 DOI: 10.1111/ner.12757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives This study utilizes a model of long‐term spinal cord stimulation (SCS) in experimental painful diabetic polyneuropathy (PDPN) to investigate the behavioral response during and after four weeks of SCS (12 hours/day). Second, we investigated the effect of long‐term SCS on peripheral cutaneous blood perfusion in experimental PDPN. Methods Mechanical sensitivity was assessed in streptozotocin induced diabetic rats (n = 50) with von Frey analysis. Hypersensitive rats (n = 24) were implanted with an internal SCS battery, coupled to an SCS electrode covering spinal levels L2–L5. The effects of four weeks of daily conventional SCS for 12 hours (n = 12) or Sham SCS (n = 12) were evaluated with von Frey assessment, and laser Doppler imaging (LDI). Results Average paw withdrawal thresholds (PWT) increased during long‐term SCS in the SCS group, in contrast to a decrease in the Sham group (Sham vs. SCS; p = 0.029). Twenty‐four hours after long‐term SCS average PWT remained higher in the SCS group. Furthermore, the SCS group showed a higher cutaneous blood perfusion during long‐term SCS compared to the Sham group (Sham vs. SCS; p = 0.048). Forty‐eight hours after long‐term SCS, no differences in skin perfusion were observed. Discussion We demonstrated that long‐term SCS results in decreased baseline mechanical hypersensitivity and results in increased peripheral blood perfusion during stimulation in a rat model of PDPN. Together, these findings indicate that long‐term SCS results in modulation of the physiological circuitry related to the nociceptive system in addition to symptomatic treatment of painful symptoms.
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Affiliation(s)
- Maarten van Beek
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Denise Hermes
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Wiel M Honig
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Bengt Linderoth
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, the Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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Stephens KE, Chen Z, Sivanesan E, Raja SN, Linderoth B, Taverna SD, Guan Y. RNA-seq of spinal cord from nerve-injured rats after spinal cord stimulation. Mol Pain 2018; 14:1744806918817429. [PMID: 30451078 PMCID: PMC6293371 DOI: 10.1177/1744806918817429] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/28/2018] [Accepted: 11/12/2018] [Indexed: 12/12/2022] Open
Abstract
Spinal cord stimulation has become an important modality in pain treatment especially for neuropathic pain conditions refractory to pharmacotherapy. However, the molecular control of inhibitory and excitatory mechanisms observed after spinal cord stimulation are poorly understood. Here, we used RNA-seq to identify differences in the expression of genes and gene networks in spinal cord tissue from nerve-injured rats with and without repetitive conventional spinal cord stimulation treatment. Five weeks after chronic constrictive injury to the left sciatic nerve, male and female rats were randomized to receive repetitive spinal cord stimulation or no treatment. Rats receiving spinal cord stimulation underwent epidural placement of a miniature stimulating electrode and received seven sessions of spinal cord stimulation (50 Hz, 80% motor threshold, 0.2 ms, constant current bipolar stimulation, 120 min/session) over four consecutive days. Within 2 h after the last spinal cord stimulation treatment, the L4-L6 spinal segments ipsilateral to the side of nerve injury were harvested and used to generate libraries for RNA-seq. Our RNA-seq data suggest further increases of many existing upregulated immune responses in chronic constrictive injury rats after repetitive spinal cord stimulation, including transcription of cell surface receptors and activation of non-neuronal cells. We also demonstrate that repetitive spinal cord stimulation represses transcription of several key synaptic signaling genes that encode scaffold proteins in the post-synaptic density. Our transcriptional studies suggest a potential relationship between specific genes and the therapeutic effects observed in patients undergoing conventional spinal cord stimulation after nerve injury. Furthermore, our results may help identify new therapeutic targets for improving the efficacy of conventional spinal cord stimulation and other chronic pain treatments.
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Affiliation(s)
- Kimberly E Stephens
- Department of Pharmacology and Molecular Sciences,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- Center for Epigenetics, School of Medicine, Johns
Hopkins University, Baltimore, MA, USA
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Zhiyong Chen
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- Institute of Basic Medical Sciences, Department of
Human Anatomy, Histology and Embryology, Neuroscience Center, Chinese
Academy of Medical Sciences, School of Basic Medicine, Peking Union
Medical College, Beijing, China
| | - Eellan Sivanesan
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Srinivasa N Raja
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
| | - Bengt Linderoth
- Division of Functional Neurosurgery, Department of
Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sean D Taverna
- Department of Pharmacology and Molecular Sciences,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- Center for Epigenetics, School of Medicine, Johns
Hopkins University, Baltimore, MA, USA
| | - Yun Guan
- Department of Anesthesia and Critical Care Medicine,
School of Medicine, Johns Hopkins University, Baltimore, MA, USA
- School of Medicine, Department of Neurological
Surgery, Johns Hopkins University, Baltimore, MA, USA
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Abstract
STUDY DESIGN Literature review. OBJECTIVE A review of the literature that presents a perspective on mechanisms of actions behind spinal cord stimulation (SCS) therapy for chronic pain. SUMMARY OF BACKGROUND DATA SCS is an effective therapeutic alternative for the treatment of intractable chronic pain. Its application has been mostly based on the gate control theory of pain. Computational models have been fundamental on the understanding of clinical observations and the design of therapies that provide optimal neuromodulation. Research has provided insight into the involvement of specific neurotransmitters that support segmental and supraspinal mechanisms of action. METHODS A literature review was performed with emphasis on mechanisms of action for SCS including the effects of electrical fields on spinal cord structures based on computational models and preclinical and clinical explorations. RESULTS This review provides background on the development of SCS, which has been driven around a paresthesia-based paradigm as a result of the gate control theory. A review of computational models emphasizes their importance on our current understanding of the mechanism of action and clinical optimization of therapy. Electrophysiology and molecular biology have provided a closer, yet narrow, view of the effect of SCS on neurotransmitters and their receptors, which have led to the formulation of segmental and supraspinal mechanisms. Literature supporting the involvement of glial cells in chronic pain and their characteristic response to electrical fields should motivate further investigation of mechanisms involving neuroglia. Finally, a review of recent results paresthesia-free strategies should encourage research on mechanisms of action. CONCLUSION The mechanisms of SCS have been extensively studied and several consistent phenomena have emerged. The activation of A-beta fibers to induce paresthesia also involve neurotransmitter release via segmental and supraspinal pathways. Despite advancements, much remains to be understood, particularly as new stimulation strategies are developed. LEVEL OF EVIDENCE N /A.
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Fortune RD, Grill RJ, Beeton C, Tanner M, Huq R, Loose DS. Changes in Gene Expression and Metabolism in the Testes of the Rat following Spinal Cord Injury. J Neurotrauma 2016; 34:1175-1186. [PMID: 27750479 DOI: 10.1089/neu.2016.4641] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Spinal cord injury (SCI) results in devastating changes to almost all aspects of a patient's life. In addition to a permanent loss of sensory and motor function, males also will frequently exhibit a profound loss of fertility through poorly understood mechanisms. We demonstrate that SCI causes measureable pathology in the testis both acutely (24 h) and chronically up to 1.5 years post-injury, leading to loss in sperm motility and viability. SCI has been shown in humans and rats to induce leukocytospermia, with the presence of inflammatory cytokines, anti-sperm antibodies, and reactive oxygen species found within the ejaculate. Using messenger RNA and metabolomic assessments, we describe molecular and cellular changes that occur within the testis of adult rats over an acute to chronic time period. From 24 h, 72 h, 28 days, and 90 days post-SCI, the testis reveal a distinct time course of pathological events. The testis show an acute drop in normal sexual organ processes, including testosterone production, and establishment of a pro-inflammatory environment. This is followed by a subacute initiation of an innate immune response and loss of cell cycle regulation, possibly due to apoptosis within the seminiferous tubules. At 1.5 years post-SCI, there is a chronic low level immune response as evidenced by an elevation in T cells. These data suggest that SCI elicits a wide range of pathological processes within the testes, the actions of which are not restricted to the acute phase of injury but rather extend chronically, potentially through the lifetime of the subject. The multiplicity of these pathological events suggest a single therapeutic intervention is unlikely to be successful.
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Affiliation(s)
- Ryan D Fortune
- 1 Department of Integrative Biology and Pharmacology, UTHealth , Houston, Texas
| | - Raymond J Grill
- 1 Department of Integrative Biology and Pharmacology, UTHealth , Houston, Texas
| | - Christine Beeton
- 2 Department of Molecular Physiology and Biophysics, Baylor College of Medicine , Houston, Texas
| | - Mark Tanner
- 2 Department of Molecular Physiology and Biophysics, Baylor College of Medicine , Houston, Texas
| | - Redwan Huq
- 2 Department of Molecular Physiology and Biophysics, Baylor College of Medicine , Houston, Texas
| | - David S Loose
- 1 Department of Integrative Biology and Pharmacology, UTHealth , Houston, Texas
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