1
|
Martin SC, Baranidharan G, Thomson S, Gulve A, Manfield JH, Mehta V, Love-Jones S, Strachan R, Bojanić S, Eldabe S, FitzGerald JJ. Spinal Cord Stimulation Improves Quality of Life for Patients With Chronic Pain-Data From the UK and Ireland National Neuromodulation Registry. Neuromodulation 2024:S1094-7159(24)00646-9. [PMID: 39152988 DOI: 10.1016/j.neurom.2024.06.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/11/2024] [Accepted: 06/28/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) is a well-established treatment for chronic pain and is supported by numerous studies. However, some recent articles have questioned its efficacy. This article examines a cohort of >1800 patients with SCS from the UK and Ireland National Neuromodulation Registry. It is intended to provide a "real-world" assessment of efficacy and compare its effects with other procedures performed for painful indications. MATERIALS AND METHODS Quality of life (QoL) data (EuroQoL five-level [EQ5D]) and demographic data were extracted from the National Neuromodulation Registry for all patients (N = 1811) who underwent SCS for chronic pain in 27 centers in the UK between February 2018 and July 2022. These were compared with data from the published literature for other commonly performed elective surgical procedures. RESULTS The EQ5D utility index increased by a mean of 0.202 in the 1236 patients with paired pre- and postoperative utility scores. The median utility was 0.263 (interquartile range [IQR] = 0.384; n = 1811) preoperatively, whereas at six months after the operation, it was 0.550 (IQR = 0.396; n = 1025), p < 0.0001, Wilcoxon rank sum test. The median utility score at 12 months postoperation was 0.548 (IQR = 0.417; n = 970). There was no difference in utility scores at six months and 12 months after implantation (p = 0.15, Wilcoxon rank sum test). There was a significant improvement in QoL in all five domains of the five-level EQ5D tool at six months after baseline (p < 0.01, for all subcategories), and this was sustained at one year after implantation. The baseline utility was lower than in patients who underwent elective surgery for other painful conditions, and the absolute (and proportionate) increase in utility produced by SCS was greater than that achieved with most other interventions. CONCLUSIONS SCS increases the QoL in patients requiring surgery for pain. Similar results were seen regardless of SCS indication. When comparing analogous data bases, SCS produces a greater percentage improvement in EQ5D utility than do many other elective surgical procedures for painful conditions, including spinal surgery and some joint replacements.
Collapse
Affiliation(s)
- Sean C Martin
- Neuromodulation Society of UK and Ireland; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Ganesan Baranidharan
- Neuromodulation Society of UK and Ireland; Leeds Neuromodulation Centre, Leeds Teaching Hospitals National Health Service Trust, Leeds, UK
| | - Simon Thomson
- Neuromodulation Society of UK and Ireland; Department of Pain Medicine and Neuromodulation, Mid & South Essex University Hospitals National Health Service Foundation Trust, Essex, UK
| | - Ashish Gulve
- Neuromodulation Society of UK and Ireland; Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| | - James H Manfield
- Department of Neurosurgery, Institute of Neurological Sciences, Glasgow, UK
| | - Vivek Mehta
- Neuromodulation Society of UK and Ireland; Department of Pain Medicine and Neuromodulation, St Bartholomew's Hospital, London, UK
| | - Sarah Love-Jones
- Neuromodulation Society of UK and Ireland; The Pain Clinic, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Roger Strachan
- Neuromodulation Society of UK and Ireland; Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Stana Bojanić
- Neuromodulation Society of UK and Ireland; Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Sam Eldabe
- Neuromodulation Society of UK and Ireland; Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| | - James J FitzGerald
- Neuromodulation Society of UK and Ireland; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.
| |
Collapse
|
2
|
Malinowski MN, Gish BE, Moreira AM, Karcz M, Bracero LA, Deer TR. Electrical neuromodulation for the treatment of chronic pain: derivation of the intrinsic barriers, outcomes and considerations of the sustainability of implantable spinal cord stimulation therapies. Expert Rev Med Devices 2024; 21:741-753. [PMID: 39044340 DOI: 10.1080/17434440.2024.2382234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 07/16/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION For over 60 years, spinal cord stimulation has endured as a therapy through innovation and novel developments. Current practice of neuromodulation requires proper patient selection, risk mitigation and use of innovation. However, there are tangible and intangible challenges in physiology, clinical science and within society. AREAS COVERED We provide a narrative discussion regarding novel topics in the field especially over the last decade. We highlight the challenges in the patient care setting including selection, as well as economic and socioeconomic challenges. Physician training challenges in neuromodulation is explored as well as other factors related to the use of neuromodulation such as novel indications and economics. We also discuss the concepts of technology and healthcare data. EXPERT OPINION Patient safety and durable outcomes are the mainstay goal for neuromodulation. Substantial work is needed to assimilate data for larger and more relevant studies reflecting a population. Big data and global interconnectivity efforts provide substantial opportunity to reinvent our scientific approach, data analysis and its management to maximize outcomes and minimize risk. As improvements in data analysis become the standard of innovation and physician training meets demand, we expect to see an expansion of novel indications and its use in broader cohorts.
Collapse
Affiliation(s)
| | - Brandon E Gish
- Lexington Clinic Interventional Pain, Lexington, KY, USA
| | - Alexandra M Moreira
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
| | - Marcin Karcz
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Lucas A Bracero
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| |
Collapse
|
3
|
Buonanno P, Servillo G, Visser-Vandewalle V, Matis G. 10 kHz stimulation as rescue therapy for spinal cord stimulation trial failure or loss of efficacy: A retrospective study. Pain Pract 2024; 24:845-851. [PMID: 38558532 DOI: 10.1111/papr.13369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/25/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) is currently used for the management of pain of different origin, and since its inception, many waveforms have been developed. Some patients experience no pain relief already during SCS trial, while other patients go through a loss of efficacy due to habituation after a variable period of satisfying pain control. Our retrospective study represents the first report exploring the potential role of 10 kHz stimulation as rescue therapy for patients who did not benefit not only from conventional stimulation but even from other waveforms during SCS trial or follow-up. METHODS This study was conducted in Germany; we retrospectively enrolled patients with no pain relief during SCS trial or with loss of efficacy of other waveforms over time; and we recorded visual analogic scale (VAS), Oswestry Disability Index (ODI), and daily opioid consumption expressed as morphine milligram equivalents (MME), right before and 12 months after the switching to 10 kHz simulation. RESULTS The rate of successful switching to 10 kHz stimulation was comparable in patients enrolled during the SCS trial and during the follow-up (43% vs. 40%, respectively); notably, the highest rate of failed rescue was recorded in case of persistent spinal pain syndrome (PSPS) II. Patients who responded to the switching showed a significant improvement in VAS and ODI after 12 months of treatment compared to baseline (3.6 ± 1.0 vs. 8.2 ± 0.9, p < 0.00001 and 34.0 ± 7.8 vs. 64.3 ± 8.7, p < 0.0001, respectively), whereas there was no reduction in the consumption of opioids in terms of MME (3 (0-16) vs. 5 (0-8.75), p = 0.1003). CONCLUSIONS Rescue therapy with 10 kHz stimulation could be an important strategy to avoid SCS explant in both patients non-responsive during trial or experiencing a loss of efficacy during the years with other waveforms.
Collapse
Affiliation(s)
- Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Georgios Matis
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| |
Collapse
|
4
|
Yeo J. Failed back surgery syndrome-terminology, etiology, prevention, evaluation, and management: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2024; 41:166-178. [PMID: 38853538 PMCID: PMC11294787 DOI: 10.12701/jyms.2024.00339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/08/2024] [Accepted: 05/16/2024] [Indexed: 06/11/2024]
Abstract
Amid the worldwide increase in spinal surgery rates, a significant proportion of patients continue to experience refractory chronic pain, resulting in reduced quality of life and escalated healthcare demands. Failed back surgery syndrome (FBSS) is a clinical condition characterized by persistent or recurrent pain after one or more spinal surgeries. The diverse characteristics and stigmatizing descriptions of FBSS necessitate a reevaluation of its nomenclature to reflect its complexity more accurately. Accurate identification of the cause of FBSS is hampered by the complex nature of the syndrome and limitations of current diagnostic labels. Management requires a multidisciplinary approach that may include pharmacological treatment, physical therapy, psychological support, and interventional procedures, emphasizing realistic goal-setting and patient education. Further research is needed to increase our understanding, improve diagnostic accuracy, and develop more effective management strategies.
Collapse
Affiliation(s)
- Jinseok Yeo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| |
Collapse
|
5
|
Sokal P, Palus D, Jabłońska M, Puk O, Kieronska-Siwak S. Spinal Cord Stimulation for Central Neuropathic Pain After Spinal Cord Injury: A Single-Center Case Series. J Pain Res 2024; 17:2029-2035. [PMID: 38881761 PMCID: PMC11177860 DOI: 10.2147/jpr.s462587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/20/2024] [Indexed: 06/18/2024] Open
Abstract
Purpose Central neuropathic pain (CNP) following spinal cord injury (SCI) presents a formidable therapeutic challenge, affecting over 50% of the patients post-SCI. For those who experience CNP, conventional treatments often prove insufficient. Spinal cord stimulation (SCS) emerges as a potential intervention for chronic pain after SCI that is unresponsive to pharmacotherapy and supportive measures. However, the efficacy of SCS in alleviating CNP is notably limited. The objective of our study was to evaluate novel stimulation paradigms in SCS for patients with severe CNP after SCI, based on our extensive experience. Patients and Methods From a pool of 112 patients treated with SCS for chronic neuropathic pain in the Department of Neurosurgery and Neurology, we selected eight individuals (4 males and 4 females) with CNP for our case series. Burst and high frequency SCS was applied. The assessment involved utilizing the Numeric Rating Scale (NRS), the Neuropathic Pain Symptom Inventory (NPSI), and the EQ-5D quality of life scale before surgery and during a 12-month follow-up period. Results Over the course of the one-year follow-up, only two patients experienced satisfactory relief from pain, demonstrating the effectiveness of the stimulation. Moreover, high-frequency and burst SCS failed to show improvement in the remaining six patients. Conclusion Our findings suggest that, despite the incorporation of new stimulation paradigms such as burst stimulation and high-frequency stimulation, SCS does not exhibit significant effectiveness in treating neuropathic pain in patients after SCI. These findings highlight the ongoing challenge of treating CNP and emphasize the importance of investigating alternative therapeutic strategies for this group.
Collapse
Affiliation(s)
- Paweł Sokal
- Department of Neurosurgery and Neurology, Faculty of Health Sciences, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, 85-168, Poland
| | - Damian Palus
- Department of Neurosurgery and Neurology, Faculty of Health Sciences, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, 85-168, Poland
| | - Magdalena Jabłońska
- Doctoral School Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, 85-168, Poland
| | - Oskar Puk
- Doctoral School Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, 85-168, Poland
| | - Sara Kieronska-Siwak
- Department of Neurosurgery and Neurology, Faculty of Health Sciences, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, 85-168, Poland
| |
Collapse
|
6
|
da Cunha PHM, de Andrade DC. The deep and the deeper: Spinal cord and deep brain stimulation for neuropathic pain. Presse Med 2024; 53:104231. [PMID: 38636785 DOI: 10.1016/j.lpm.2024.104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Neuropathic pain occurs in people experiencing lesion or disease affecting the somatosensorial system. It is present in 7 % of the general population and may not fully respond to first- and second-line treatments in up to 40 % of cases. Neuromodulation approaches are often proposed for those not tolerating or not responding to usual pharmacological management. These approaches can be delivered surgically (invasively) or non-invasively. Invasive neuromodulation techniques were the first to be employed in neuropathic pain. Among them is spinal cord stimulation (SCS), which consists of the implantation of epidural electrodes over the spinal cord. It is recommended in some guidelines for peripheral neuropathic pain. While recent studies have called into question its efficacy, others have provided promising data, driven by advances in techniques, battery capabilities, programming algorithms and software developments. Deep brain stimulation (DBS) is another well-stablished neuromodulation therapy routinely used for movement disorders; however, its role in pain management remains limited to specific research centers. This is not only due to variable results in the literature contesting its efficacy, but also because several different brain targets have been explored in small trials, compromising comparisons between these studies. Structures such as the periaqueductal grey, posterior thalamus, anterior cingulate cortex, ventral striatum/anterior limb of the internal capsule and the insula are the main targets described to date in literature. SCS and DBS present diverse rationales for use, mechanistic backgrounds, and varying levels of support from experimental studies. The present review aims to present their methodological details, main mechanisms of action for analgesia and their place in the current body of evidence in the management of patients with neuropathic pain, as well their particularities, effectiveness, safety and limitations.
Collapse
Affiliation(s)
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
| |
Collapse
|
7
|
van de Minkelis J, Peene L, Cohen SP, Staats P, Al-Kaisy A, Van Boxem K, Kallewaard JW, Van Zundert J. 6. Persistent spinal pain syndrome type 2. Pain Pract 2024. [PMID: 38616347 DOI: 10.1111/papr.13379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Persistent Spinal Pain Syndrome (PSPS) refers to chronic axial pain and/or extremity pain. Two subtypes have been defined: PSPS-type 1 is chronic pain without previous spinal surgery and PSPS-type 2 is chronic pain, persisting after spine surgery, and is formerly known as Failed Back Surgery Syndrome (FBSS) or post-laminectomy syndrome. The etiology of PSPS-type 2 can be gleaned using elements from the patient history, physical examination, and additional medical imaging. Origins of persistent pain following spinal surgery may be categorized into an inappropriate procedure (eg a lumbar fusion at an incorrect level or for sacroiliac joint [SIJ] pain); technical failure (eg operation at non-affected levels, retained disk fragment, pseudoarthrosis), biomechanical sequelae of surgery (eg adjacent segment disease or SIJ pain after a fusion to the sacrum, muscle wasting, spinal instability); and complications (eg battered root syndrome, excessive epidural fibrosis, and arachnoiditis), or undetermined. METHODS The literature on the diagnosis and treatment of PSPS-type 2 was retrieved and summarized. RESULTS There is low-quality evidence for the efficacy of conservative treatments including exercise, rehabilitation, manipulation, and behavioral therapy, and very limited evidence for the pharmacological treatment of PSPS-type 2. Interventional treatments such as pulsed radiofrequency (PRF) of the dorsal root ganglia, epidural adhesiolysis, and spinal endoscopy (epiduroscopy) might be beneficial in patients with PSPS-type 2. Spinal cord stimulation (SCS) has been shown to be an effective treatment for chronic, intractable neuropathic limb pain, and possibly well-selected candidates with axial pain. CONCLUSIONS The diagnosis of PSPS-type 2 is based on patient history, clinical examination, and medical imaging. Low-quality evidence exists for conservative interventions. Pulsed radiofrequency, adhesiolysis and SCS have a higher level of evidence with a high safety margin and should be considered as interventional treatment options when conservative treatment fails.
Collapse
Affiliation(s)
- Johan van de Minkelis
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Anesthesiology and Pain Medicine, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Laurens Peene
- Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Peter Staats
- Anesthesiology and Pain Medicine, National Spine and Pain Centers, Shrewsbury, New Jersey, USA
| | - Adnan Al-Kaisy
- Pain Management Department, Gassiot House, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Koen Van Boxem
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Jan Willem Kallewaard
- Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Van Zundert
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| |
Collapse
|
8
|
Sammartino F, MacDonell J, North RB, Krishna V, Poree L. Disease applications of spinal cord stimulation: Chronic nonmalignant pain. Neurotherapeutics 2024; 21:e00314. [PMID: 38184449 PMCID: PMC11103216 DOI: 10.1016/j.neurot.2023.e00314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/23/2023] [Accepted: 12/27/2023] [Indexed: 01/08/2024] Open
Abstract
Neuropathic pain is a chronic condition representing a significant burden for society. It is estimated 1 out of 10 people over the age of 30 that in the US have been diagnosed with neuropathic pain. Most of the available treatments for neuropathic pain have moderate efficacy over time which limit their use; therefore, other therapeutic approaches are needed for patients. Spinal cord stimulation is an established and cost-effective modality for treating severe chronic pain. In this article we will review the current approved indications for the use of spinal cord stimulation in the US and the novel therapeutic options which are now available using this therapy.
Collapse
Affiliation(s)
- Francesco Sammartino
- The Ohio State University, Department of Physical Medicine and Rehabilitation, Columbus OH, USA.
| | | | | | - Vibhor Krishna
- UNC School of Medicine, Department of Neurosurgery, Chapel Hill NC, USA
| | - Lawrence Poree
- University of California San Francisco, Division of Pain Medicine, San Francisco CA, USA
| |
Collapse
|
9
|
Jagrit V, Koffler J, Dulin JN. Combinatorial strategies for cell transplantation in traumatic spinal cord injury. Front Neurosci 2024; 18:1349446. [PMID: 38510468 PMCID: PMC10951004 DOI: 10.3389/fnins.2024.1349446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024] Open
Abstract
Spinal cord injury (SCI) substantially reduces the quality of life of affected individuals. Recovery of function is therefore a primary concern of the patient population and a primary goal for therapeutic interventions. Currently, even with growing numbers of clinical trials, there are still no effective treatments that can improve neurological outcomes after SCI. A large body of work has demonstrated that transplantation of neural stem/progenitor cells (NSPCs) can promote regeneration of the injured spinal cord by providing new neurons that can integrate into injured host neural circuitry. Despite these promising findings, the degree of functional recovery observed after NSPC transplantation remains modest. It is evident that treatment of such a complex injury cannot be addressed with a single therapeutic approach. In this mini-review, we discuss combinatorial strategies that can be used along with NSPC transplantation to promote spinal cord regeneration. We begin by introducing bioengineering and neuromodulatory approaches, and highlight promising work using these strategies in integration with NSPCs transplantation. The future of NSPC transplantation will likely include a multi-factorial approach, combining stem cells with biomaterials and/or neuromodulation as a promising treatment for SCI.
Collapse
Affiliation(s)
- Vipin Jagrit
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Jacob Koffler
- Department of Neurosciences, University of California, San Diego, La Jolla, CA, United States
- Veterans Affairs Medical Center, San Diego, CA, United States
| | - Jennifer N. Dulin
- Department of Biology, Texas A&M University, College Station, TX, United States
- Texas A&M Institute for Neuroscience, Texas A&M University, College Station, TX, United States
| |
Collapse
|
10
|
Zhu C, Esteller R, Block J, Lechleiter K, Frey R, Moffitt MA. Exploratory evaluation of spinal cord stimulation with dynamic pulse patterns: a promising approach to improve stimulation sensation, coverage of pain areas, and expected pain relief. FRONTIERS IN PAIN RESEARCH 2024; 4:1339892. [PMID: 38361978 PMCID: PMC10867969 DOI: 10.3389/fpain.2023.1339892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/28/2023] [Indexed: 02/17/2024] Open
Abstract
Background The societal burden of chronic pain and the contribution-in-part to the opioid crisis, is a strong motivation to improve and expand non-addictive treatments, including spinal cord stimulation (SCS). For several decades standard SCS has consisted in delivery of tonic pulses with static parameter settings in frequency, pulse width, and amplitude. These static parameters have limited ability to personalize the quality of paresthesia, the dermatomal coverage, and thus may affect SCS efficacy. Further, static settings may contribute to the build-up of tolerance or loss of efficacy of the therapy over time in some patients. Methods We conducted an acute exploratory study to evaluate the effects of SCS using time-dynamic pulses as compared to time-static (conventional tonic) stimulation pulses, with the hypotheses that dynamic pulse SCS may enable beneficial tailoring of the sensation and the patient's expectation for better pain relief with SCS. During a single clinic visit, consented subjects undergoing a standard SCS trial had their implanted leads temporarily connected to an investigational external stimulator capable of delivering time-static and six categories of time-dynamic pulse sequences, each characterized by continuously varying a stimulation parameter. Study subjects provided several assessments while blinded to the stimulation pattern, including: drawing of paresthesia maps, descriptions of sensation, and ratings for comfort and helpfulness to pain relief. Results Even without optimization of the field location, a majority of subjects rated sensations from dynamic stimulation as better or equal to that of static stimulation for comfortableness and for helpfulness to pain relief. The initial data showed a gender and/or pain dermatomal location related preference to a stimulation pattern. In particular, female subjects and subjects with pain at higher dermatomes tended to rank the sensation from dynamic stimulation better. Dynamic stimulation produced greater pain coverage without optimization; in 70% (9/13) of subjects, maximal pain coverage was achieved with a dynamic stimulation pattern. There was also greater variety in the words used by patients to describe stimulation sensation in the free text and free form verbal descriptions associated with dynamic stimulation. Conclusions With the same electrode configuration and comparable parameter settings, acute SCS using dynamic pulses produced more positive ratings, expanded paresthesia coverage, and greater variation in sensation as compared to SCS using static pulses, suggesting that dynamic stimulation has the potential to improve capabilities of SCS for the treatment of chronic pain. Further study is warranted. Trial Registration This study was registered at ClinicalTrials.gov under ID NCT02988713, November 2016 (URL: https://clinicaltrials.gov/ct2/show/NCT02988713).
Collapse
Affiliation(s)
- Changfang Zhu
- Research and Development, Boston Scientific Neuromodulation, Valencia, CA, United States
| | - Rosana Esteller
- Research and Development, Boston Scientific Neuromodulation, Valencia, CA, United States
| | - Jessica Block
- Research and Development, Boston Scientific Neuromodulation, Valencia, CA, United States
| | - Kristen Lechleiter
- Clinical Research, Boston Scientific Neuromodulation, Valencia, CA, United States
| | - Robert Frey
- Pacific Pain Management Inc., Ventura, CA, United States
| | - Michael A. Moffitt
- Research and Development, Boston Scientific Neuromodulation, Valencia, CA, United States
| |
Collapse
|
11
|
Yeung AM, Huang J, Nguyen KT, Xu NY, Hughes LT, Agrawal BK, Ejskjaer N, Klonoff DC. Spinal Cord Stimulation for Painful Diabetic Neuropathy. J Diabetes Sci Technol 2024; 18:168-192. [PMID: 36384312 PMCID: PMC10899837 DOI: 10.1177/19322968221133795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Spinal cord stimulation (SCS) technology has been recently approved by the US Food and Drug Administration (FDA) for painful diabetic neuropathy (PDN). The treatment involves surgical implantation of electrodes and a power source that delivers electrical current to the spinal cord. This treatment decreases the perception of pain in many chronic pain conditions, such as PDN. The number of patients with PDN treated with SCS and the amount of data describing their outcomes is expected to increase given four factors: (1) the large number of patients with this diagnosis, (2) the poor results that have been obtained for pain relief with pharmacotherapy and noninvasive non-pharmacotherapy, (3) the results to date with investigational SCS technology, and (4) the recent FDA approval of systems that deliver this treatment. Whereas traditional SCS replaces pain with paresthesias, a new form of SCS, called high-frequency 10-kHz SCS, first used for pain in 2015, can relieve PDN pain without causing paresthesias, although not all patients experience pain relief by SCS. This article describes (1) an overview of SCS technology, (2) the use of SCS for diseases other than diabetes, (3) the use of SCS for PDN, (4) a comparison of high-frequency 10-kHz and traditional SCS for PDN, (5) other SCS technology for PDN, (6) deployment of SCS systems, (7) barriers to the use of SCS for PDN, (8) risks of SCS technology, (9) current recommendations for using SCS for PDN, and (10) future developments in SCS.
Collapse
Affiliation(s)
| | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | - Lorenzo T. Hughes
- Balance Health, San Francisco, CA, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | | | - Niels Ejskjaer
- Steno Diabetes Center North Denmark and Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - David C. Klonoff
- Diabetes Technology Society, Burlingame, CA, USA
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| |
Collapse
|
12
|
Fishman MA, Chitneni A, Abd-Elsayed A, Grodofsky S, Scherer AM, Schetzner B, Klusek M, Popielarski SR, Meloni S, Falowski S, Kim P, Slavin KV, Silberstein SD. Drug-Free Noninvasive Thermal Nerve Block: Validation of Sham Devices. Brain Sci 2023; 13:1718. [PMID: 38137166 PMCID: PMC10741966 DOI: 10.3390/brainsci13121718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
Headache is a leading cause of disability and suffering. One major challenge in developing device treatments is demonstrating their efficacy given devices' often-high placebo rate. This paper reviews the importance of validating sham devices as part of finalizing the design for larger-scale prospective randomized controlled trials in patients with chronic headache as well as the results of a prospective, single-blind trial to validate two potential sham noninvasive thermal nerve block devices. Study participants were trained to self-administer thermal nerve block treatment using sham devices in an office visit. Two different sham systems with different temperature profiles were assessed. Devices were offered for patients to use daily at-home for one week to assess the durability of sham placebo effects before participants were given active treatment in a second office visit followed by another optional week of self-administered active treatment at-home use. Sham treatments reduced pain scores by an average of 31% from 6.0 ± 2.3 to 4.3 ± 3.3, including two participants who fell asleep during the in-office treatment and woke up with no pain, but whose pain recurred after returning home during at-home use of the sham system. In-office active treatments reduced pain scores by 52% from 6.7 ± 2.1 to 3.3 ± 2.9 with sustained pain relief during optional at-home use. Successful blinding for the study was confirmed with an ideal Bang's Blinding Index of 0 and an ideal James' Blinding Index of 1. Both the sham and active treatments were viewed by participants as highly credible, and credibility increased from the beginning to end of sham treatments on average.
Collapse
Affiliation(s)
- Michael A. Fishman
- Center for Pain Control PC, Lancaster, PA 19610, USA; (M.A.F.); (A.M.S.)
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital—Columbia and Cornell, New York, NY 10065, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA;
| | | | - Ashley M. Scherer
- Center for Pain Control PC, Lancaster, PA 19610, USA; (M.A.F.); (A.M.S.)
| | - Brendan Schetzner
- Department of Anesthesiology, St Elizabeths Medical Center, Brighton, MA 02135, USA;
| | - Malvina Klusek
- Peconic Bay Medical Center/Northwell Health, New York, NY 10065, USA;
| | | | - Stephen Meloni
- Thermaquil, Inc., Philadelphia, PA 19610, USA; (S.R.P.); (S.M.)
| | - Steven Falowski
- Neurosurgical Associates of Lancaster, Lancaster, PA 19610, USA;
| | - Philip Kim
- Center for Interventional Pain Spine, LLC, Wilmington, DE 19803, USA;
| | - Konstantin V. Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA;
- Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago, IL 60612, USA
| | | |
Collapse
|
13
|
Arciero E, Coury JR, Dionne A, Reyes J, Lombardi JM, Sardar ZM. Optimizing Preoperative Chronic Pain Management in Elective Spine Surgery Patients: A Narrative Review of Outcomes with Opioid and Adjuvant Pain Therapies. JBJS Rev 2023; 11:01874474-202312000-00006. [PMID: 38100612 DOI: 10.2106/jbjs.rvw.23.00156] [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: 12/17/2023]
Abstract
» Chronic preoperative opioid use negatively affects outcomes after spine surgery, with increased complications and reoperations, longer hospital stays, decreased return-to-work rates, worse patient-reported outcomes, and a higher risk of continued opioid use postoperatively.» The definition of chronic opioid use is not consistent across studies, and a more specific and consistent definition will aid in stratifying patients and understanding their risk of inferior outcomes.» Preoperative weaning periods and maximum dose thresholds are being established, which may increase the likelihood of achieving a meaningful improvement after surgery, although higher level evidence studies are needed.» Spinal cord stimulators and intrathecal drug delivery devices are increasingly used to manage chronic back pain and are equivalent or perhaps even superior to opioid treatment, although few studies exist examining how patients with these devices do after subsequent spine surgery.» Further investigation is needed to determine whether a true mechanistic explanation exists for spine-related analgesia related to spinal cord stimulators and intrathecal drug delivery devices.
Collapse
Affiliation(s)
- Emily Arciero
- The Och Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | | | | | | | | | | |
Collapse
|
14
|
Christiansen S, Yates J, Sdrulla A. A novel workflow with mid-trial X-rays for spinal cord stimulator trials. INTERVENTIONAL PAIN MEDICINE 2023; 2:100373. [PMID: 39239229 PMCID: PMC11372882 DOI: 10.1016/j.inpm.2023.100373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 11/26/2023] [Accepted: 11/26/2023] [Indexed: 09/07/2024]
Affiliation(s)
- Sandy Christiansen
- Anesthesiology and Perioperative Medicine, School of Medicine Oregon Health & Science University, 3303 SW Bond Avenue Mail Code CH15P, Portland, OR, 97239, USA
| | - Janice Yates
- Anesthesiology and Pain Medicine, 4150 V Street, Sacramento, CA, 95817, USA
- University of California Davis Health, USA
| | - Andrei Sdrulla
- Anesthesiology and Perioperative Medicine, School of Medicine Oregon Health & Science University, 3303 SW Bond Avenue Mail, Portland, OR, 97239, USA
| |
Collapse
|
15
|
Staats PS, Taylor RS, Gilligan C, Sheth S, Patel KV, Duarte RV, Eldabe S. Limitations of the Cochrane review of spinal cord stimulation for low back pain. Pain Pract 2023; 23:868-872. [PMID: 37427805 DOI: 10.1111/papr.13263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/05/2023] [Accepted: 06/18/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Peter S Staats
- National Spine and Pain Centers, Shrewsbury, New Jersey, USA
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Christopher Gilligan
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts, USA
| | - Samir Sheth
- Sutter Health System, Roseville, California, USA
| | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, New York, USA
- Department of Anesthesiology, NYU Langone Medical Center, New York, New York, USA
| | - Rui V Duarte
- Saluda Medical Pty Ltd., Artarmon, New South Wales, Australia
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
16
|
Russo MA, Bhatia A, Hayek S, Doshi T, Eldabe S, Huygen F, Levy RM. Problems With O'Connell et al, "Implanted Spinal Neuromodulation Interventions for Chronic Pain in Adults" (Cochrane Review). Neuromodulation 2023; 26:897-904. [PMID: 37029022 PMCID: PMC10330605 DOI: 10.1016/j.neurom.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/01/2023] [Accepted: 03/05/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Marc A Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia; Genesis Research Services, Broadmeadow, New South Wales, Australia; University of Newcastle, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Tina Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Frank Huygen
- Center of Pain Medicine Erasmus Medical Center, Rotterdam, The Netherlands; Center of Pain Medicine University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert M Levy
- International Neuromodulation Society, Neuromodulation: Technology at the Neural Interface, San Francisco, CA, USA
| |
Collapse
|
17
|
Shanthanna H, Eldabe S, Provenzano DA, Chang Y, Adams D, Kashir I, Goel A, Tian C, Couban RJ, Levit T, Hagedorn JM, Narouze S. Role of patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain: a comprehensive narrative review. Reg Anesth Pain Med 2023; 48:251-272. [PMID: 37001887 DOI: 10.1136/rapm-2022-103820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/22/2022] [Indexed: 04/03/2023]
Abstract
Background/importancePatient selection for spinal cord stimulation (SCS) therapy is crucial and is traditionally performed with clinical selection followed by a screening trial. The factors influencing patient selection and the importance of trialing have not been systematically evaluated.ObjectiveWe report a narrative review conducted to synthesize evidence regarding patient selection and the role of SCS trials.Evidence reviewMedline, EMBASE and Cochrane databases were searched for reports (any design) of SCS in adult patients, from their inception until March 30, 2022. Study selection and data extraction were carried out using DistillerSR. Data were organized into tables and narrative summaries, categorized by study design. Importance of patient variables and trialing was considered by looking at their influence on the long-term therapy success.FindingsAmong 7321 citations, 201 reports consisting of 60 systematic reviews, 36 randomized controlled trials (RCTs), 41 observational studies (OSs), 51 registry-based reports, and 13 case reports on complications during trialing were included. Based on RCTs and OSs, the median trial success rate was 72% and 82%, and therapy success was 65% and 61% at 12 months, respectively. Although several psychological and non-psychological determinants have been investigated, studies do not report a consistent approach to patient selection. Among psychological factors, untreated depression was associated with poor long-term outcomes, but the effect of others was inconsistent. Most RCTs except for chronic angina involved trialing and only one RCT compared patient selection with or without trial. The median (range) trial duration was 10 (0–30) and 7 (0–56) days among RCTs and OSs, respectively.ConclusionsDue to lack of a consistent approach to identify responders for SCS therapy, trialing complements patient selection to exclude patients who do not find the therapy helpful and/or intolerant of the SCS system. However, more rigorous and large studies are necessary to better evaluate its role.
Collapse
Affiliation(s)
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | | | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Adams
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Imad Kashir
- University of Waterloo, Waterloo, Ontario, Canada
| | - Akash Goel
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chenchen Tian
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Tal Levit
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan M Hagedorn
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| |
Collapse
|
18
|
Medina R, Ho A, Reddy R, Chen J, Castellanos J. Narrative review of current neuromodulation modalities for spinal cord injury. FRONTIERS IN PAIN RESEARCH 2023; 4:1143405. [PMID: 36969918 PMCID: PMC10033643 DOI: 10.3389/fpain.2023.1143405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Neuromodulation is a developing field of medicine that includes a vast array of minimally invasive and non-invasive therapies including transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), vagus nerve stimulation (VNS), peripheral nerve stimulation, and spinal cord stimulation (SCS). Although the current literature surrounding the use of neuromodulation in managing chronic pain is abundant, there is an insufficient amount of evidence specifically regarding neuromodulation in patients with spinal cord injury (SCI). Given the pain and functional deficits that these patients face, that are not amenable to other forms conservative therapy, the purpose of this narrative review is to examine and assess the use of various neuromodulation modalities to manage pain and restore function in the SCI population. Currently, high-frequency spinal cord stimulation (HF-SCS) and burst spinal cord stimulation (B-SCS) have been shown to have the most promising effect in improving pain intensity and frequency. Additionally, dorsal root ganglion stimulation (DRG-S) and TMS have been shown to effectively increase motor responses and improve limb strength. Although these modalities carry the potential to enhance overall functionality and improve a patient's degree of disability, there is a lack of long-term, randomized-controlled trials in the current space. Additional research is warranted to further support the clinical use of these emerging modalities to provide improved pain management, increased level of function, and ultimately an overall better quality of life in the SCI population.
Collapse
Affiliation(s)
- Roi Medina
- Department of Physical Medicine and Rehabilitation, Lake Erie College of Osteopathic Medicine-Bradenton, Bradenton, FL, United States
- Correspondence: Roi Medina
| | - Alison Ho
- Department of Physical Medicine and Rehabilitation, Baylor University Medical Center, Dallas, TX, United States
| | - Rajiv Reddy
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Jeffrey Chen
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Joel Castellanos
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| |
Collapse
|
19
|
Abstract
BACKGROUND Spinal cord stimulation (SCS) is a surgical intervention used to treat persistent low back pain. SCS is thought to modulate pain by sending electrical signals via implanted electrodes into the spinal cord. The long term benefits and harms of SCS for people with low back pain are uncertain. OBJECTIVES To assess the effects, including benefits and harms, of SCS for people with low back pain. SEARCH METHODS On 10 June 2022, we searched CENTRAL, MEDLINE, Embase, and one other database for published trials. We also searched three clinical trials registers for ongoing trials. SELECTION CRITERIA We included all randomised controlled trials and cross-over trials comparing SCS with placebo or no treatment for low back pain. The primary comparison was SCS versus placebo, at the longest time point measured in the trials. Major outcomes were mean low back pain intensity, function, health-related quality of life, global assessment of efficacy, withdrawals due to adverse events, adverse events, and serious adverse events. Our primary time point was long-term follow-up (≥ 12 months). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 studies with 699 participants: 55% of participants were female; mean age ranged from 47 to 59 years; and all participants had chronic low back pain with mean duration of symptoms ranging from five to 12 years. Ten cross-over trials compared SCS with placebo. Three parallel-group trials assessed the addition of SCS to medical management. Most studies were at risk of performance and detection bias from inadequate blinding and selective reporting bias. The placebo-controlled trials had other important biases, including lack of accounting for period and carryover effects. Two of the three parallel trials assessing SCS as an addition to medical management were at risk of attrition bias, and all three had substantial cross-over to the SCS group for time points beyond six months. In the parallel-group trials, we considered the lack of placebo control to be an important source of bias. None of our included studies evaluated the impact of SCS on mean low back pain intensity in the long term (≥ 12 months). The studies most often assessed outcomes in the immediate term (less than one month). At six months, the only available evidence was from a single cross-over trial (50 participants). There was moderate-certainty evidence that SCS probably does not improve back or leg pain, function, or quality of life compared with placebo. Pain was 61 points (on a 0- to 100-point scale, 0 = no pain) at six months with placebo, and 4 points better (8.2 points better to 0.2 points worse) with SCS. Function was 35.4 points (on a 0- to 100-point scale, 0 = no disability or best function) at six months with placebo, and 1.3 points better (3.9 points better to 1.3 points worse) with SCS. Health-related quality of life was 0.44 points out of 1 (0 to 1 index, 0 = worst quality of life) at six months with placebo, and 0.04 points better (0.16 points better to 0.08 points worse) with SCS. In that same study, nine participants (18%) experienced adverse events and four (8%) required revision surgery. Serious adverse events with SCS included infections, neurological damage, and lead migration requiring repeated surgery. We could not provide effect estimates of the relative risks as events were not reported for the placebo period. In parallel trials assessing SCS as an addition to medical management, it is uncertain whether, in the medium or long term, SCS can reduce low back pain, leg pain, or health-related quality of life, or if it increases the number of people reporting a 50% improvement or better, because the certainty of the evidence was very low. Low-certainty evidence suggests that adding SCS to medical management may slightly improve function and slightly reduce opioid use. In the medium term, mean function (0- to 100-point scale; lower is better) was 16.2 points better with the addition of SCS to medical management compared with medical management alone (95% confidence interval (CI) 19.4 points better to 13.0 points better; I2 = 95%; 3 studies, 430 participants; low-certainty evidence). The number of participants reporting opioid medicine use was 15% lower with the addition of SCS to medical management (95% CI 27% lower to 0% lower; I2 = 0%; 2 studies, 290 participants; low-certainty evidence). Adverse events with SCS were poorly reported but included infection and lead migration. One study found that, at 24 months, 13 of 42 people (31%) receiving SCS required revision surgery. It is uncertain to what extent the addition of SCS to medical management increases the risk of withdrawals due to adverse events, adverse events, or serious adverse events, because the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Data in this review do not support the use of SCS to manage low back pain outside a clinical trial. Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention.
Collapse
Affiliation(s)
- Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Stephen E Gilbert
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| |
Collapse
|
20
|
Mons MR, Chapman KB, Terwiel C, Joosten EA, Kallewaard JW. A prospective study of BurstDR™ spinal cord stimulation for non-operated discogenic low back pain. Pain Pract 2023; 23:234-241. [PMID: 36373868 DOI: 10.1111/papr.13181] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/22/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Chronic discogenic low back pain (CD-LBP) is caused by degeneration of the disc due to trauma to the annulus or by unprovoked degeneration, resulting in chronic pain. Spinal cord stimulation (SCS) employing the BurstDR™ waveform has been shown to be an effective treatment in a variety of chronic pain conditions. The aim of this prospective case study was to determine the effect of BurstDR™ SCS on pain relief, disability, and patient satisfaction in a population with CD-LBP. METHODS Seventeen subjects with CD-LBP received a SCS trial with BurstDR™ stimulation. Patients with >50% pain relief after a trial period of 2 weeks were permanently implanted (n = 15). Patients then rated LBP and leg pain using the numeric rating scale (NRS), Oswestry disability index (ODI), patient global impression of change (PGIC), EQ-5D quality of life, and painDETECT for neuropathic pain at baseline following trial, 3, 6, and 12 months after permanent implantation. RESULTS Treatment with BurstDR™ SCS resulted in significant reduction of LBP as the NRS was reduced from 71.7 ± 7.3 at baseline to 42.5 ± 18.1 at 12 months. Average pain relief at 12 months was 42.5%. In patients with leg pain (n = 8), pain was significantly reduced from 66.9 ± 8.2 to 11.7 ± 10.4 at 12 months. PainDETECT scores for neuropathic pain significantly reduced from 18.9 ± 4.8 at baseline, and 14.8 ± 3.2 at 12 months. Baseline ODI score significantly reduced from 41.2 ± 12.8 to 25.8 ± 8.6 at 12 months. PGIC scores remained low from 2.6 ± 1.6 at 3 months, 2.5 ± 1.0 at 6 months, and 2.5 ± 1.3 at 12 months. EQ-5D-5L rates remained constant from baseline 56.10 ± 23.9 to 68.6 ± 12.9 at 12 months. CONCLUSION BurstDR™ SCS resulted in significant reduction of back pain, leg pain, and quality of life in patients with CD-LBP and decreased the level of disability and generated positive patient satisfaction scores.
Collapse
Affiliation(s)
- Martijn R Mons
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, The Netherlands
| | - Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York City, New York, USA.,Departement of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Chris Terwiel
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, The Netherlands
| | - Jan-Willem Kallewaard
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Anesthesiology and Pain Managmenent, Amsterdam University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
21
|
Baranidharan G, Bretherton B, Comer C, Duarte R, Cromie K. Neuropathic pain questionnaires for back pain, what do we know? Musculoskelet Sci Pract 2023; 63:102714. [PMID: 36610828 DOI: 10.1016/j.msksp.2022.102714] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Low back pain is a global public health concern, with an estimated lifetime prevalence of 84%. Axial low back pain refers to pain confined to an area in the low back and is different to radicular pain which radiates to extremities. Axial low back pain has traditionally been considered as nociceptive. However, research suggests it may have neuropathic components. Neuropathic axial low back pain is an unresolved, hotly contested topic due to controversies surrounding its aetiology, diagnosis, clinical course, prognosis and treatment options. PURPOSE The reference standard for diagnosing neuropathic pain is by medical history and clinical assessment (i.e., sensory testing), with optional neuropathic screening tools and selective, further diagnostic tests when clinically needed. Neuropathic screening tools are not always specific for neuropathic radiating low back pain, let alone neuropathic axial low back pain. Additionally, not all have been validated for the English language (e.g., PainDETECT). Research also suggests the percentage of patients identified as having neuropathic radiating low back pain may be dependent on the combination of reference standards used. IMPLICATIONS There is a need for research that works towards improving understanding of neuropathic axial low back pain and developing a standardised, validated and reliable system for assessing and identifying this condition. This body of research will promote earlier stratification and more rapid referral for appropriate treatment, and improve awareness, assessment and visibility of this condition amongst healthcare practitioners and in healthcare settings. This will lead to transformations in Pathways and health guidelines, ultimately improving patient outcomes.
Collapse
Affiliation(s)
- Ganesan Baranidharan
- Pain Management Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.
| | - Beatrice Bretherton
- Pain Management Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Christine Comer
- Musculoskeletal and Rehabilitation Service, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Kirsten Cromie
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| |
Collapse
|
22
|
Kannan P, Bello UM, Winser SJ. Physiotherapy interventions for pain relief in individuals with peripheral neuropathic pain: A systematic review and meta-analyses of randomized controlled trials. Contemp Clin Trials 2023; 125:107055. [PMID: 36535605 DOI: 10.1016/j.cct.2022.107055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/10/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of physiotherapy interventions on peripheral neuropathic pain (pNeP) due to any underlying cause. METHODS Multiple databases were searched from database inception until Dec 2021. Studies on physiotherapy interventions for pain relief assessed using the visual analogue scale among individuals with pNeP of any underlying cause were included. Methodological quality was assessed using the PEDro scale and the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. RESULTS The searches yielded 1498 articles. Seventeen studies met the inclusion criteria and were included in the review. Meta-analysis revealed a significant benefit for laser therapy compared to sham laser on pNeP (weighted mean difference [WMD] -1.27; 95% CI: -2.29 to -0.25; p = 0.01) in people with carpal tunnel syndrome. The pooled analyses revealed a significant effect of spinal cord stimulation compared to control for failed back syndrome (standardised mean difference [SMD; Hedges'g] -0.73; 95% CI: -1.17 to -0.30; p = 0.001) and diabetic neuropathy (SMD -1.63; 95% CI -2.06--1.21; p < 0.001). The effect of acupuncture on chemotherapy-induced pain (SMD - 2.09; 95% CI: -4.27-0.09; p = 0.06) and electromagnetic stimulation on diabetic neuropathic pain (Hedges' g - 0.77; 95% CI: -1.82-0.27; p = 0.15) were insignificant. CONCLUSION Evidence supports the use of spinal cord stimulation for the treatment of pNeP secondary to failed back surgery syndrome and diabetic neuropathy. Laser therapy was more effective than sham laser for alleviating pain due to carpal tunnel syndrome. The efficacy of acupuncture and electromagnetic therapy for chemotherapy-induced pain and diabetic neuropathy, respectively remains inconclusive.
Collapse
Affiliation(s)
- Priya Kannan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong.
| | - Umar Muhammad Bello
- Department of Physiotherapy and Paramedicine, Glasgow Caledonian University, Glasgow, United Kingdom.
| | - Stanley John Winser
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; Research Centre for SHARP Vision (RCSV), The Hong Kong Polytechnic University, Hong Kong.
| |
Collapse
|
23
|
Shen Z, Beckel J, de Groat WC, Tai C. Effect of high-frequency membrane potential alternation between depolarization and hyperpolarization on dorsal root ganglion neurons of rats. Physiol Rep 2023; 11:e15582. [PMID: 36695759 PMCID: PMC9875814 DOI: 10.14814/phy2.15582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 06/17/2023] Open
Abstract
The purpose of this study was to determine how sensory neurons respond to high-frequency membrane potential alternation between depolarization and hyperpolarization. Membrane currents were recorded from dissociated dorsal root ganglion (DRG) neurons of adult rats using the whole cell patch clamp technique in voltage clamp mode. Stepwise depolarization of the membrane was applied first to determine the threshold membrane potential for inducing an action potential (AP) current. Then, membrane potential alternation between depolarization (to +20 mV) and hyperpolarization (to -110 mV) was applied to the neuron for 10 s at different frequencies (10 Hz to 1 kHz). The tested DRG neurons had APs of either a long duration (>10 ms) or a short duration (<10 ms). Membrane potential alternation at ≥500 Hz completely disrupted the AP generation, disabled the ion channel gating function, and produced membrane current alternating symmetrically across zero. Replacing extracellular sodium with potassium increased the amplitude of the membrane current response and caused the membrane current to be larger during hyperpolarization than during depolarization. These results support the hypothesis that high-frequency biphasic stimulation blocks axonal conduction by driving the potassium channel open constantly. Understanding neural membrane response to high-frequency membrane potential alternation is important to reveal the possible mechanisms underlying axonal conduction block induced by high-frequency biphasic stimulation.
Collapse
Affiliation(s)
- Zhijun Shen
- Department of UrologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Jonathan Beckel
- Department of Pharmacology and Chemical BiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - William C. de Groat
- Department of Pharmacology and Chemical BiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Changfeng Tai
- Department of UrologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Department of Pharmacology and Chemical BiologyUniversity of PittsburghPittsburghPennsylvaniaUSA
- Department of BioengineeringUniversity of PittsburghPittsburghPennsylvaniaUSA
| |
Collapse
|
24
|
Eldabe S, Nevitt S, Griffiths S, Gulve A, Thomson S, Baranidharan G, Houten R, Brookes M, Kansal A, Earle J, Bell J, Taylor RS, Duarte RV. Does a Screening Trial for Spinal Cord Stimulation in Patients With Chronic Pain of Neuropathic Origin Have Clinical Utility (TRIAL-STIM)? 36-Month Results From a Randomized Controlled Trial. Neurosurgery 2023; 92:75-82. [PMID: 36226961 PMCID: PMC10158909 DOI: 10.1227/neu.0000000000002165] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Screening trials before full implantation of a spinal cord stimulation device are recommended by clinical guidelines and regulators, although there is limited evidence for their use. The TRIAL-STIM study showed that a screening trial strategy does not provide superior patient pain outcome at 6-month follow-up compared with not doing a screening trial and that it was not cost-effective. OBJECTIVE To report the long-term follow-up results of the TRIAL-STIM study. METHODS The primary outcome of this pragmatic randomized controlled trial was pain intensity as measured on a numerical rating scale (NRS) and secondary outcomes were the proportion of patients achieving at least 50% and 30% pain relief at 6 months, health-related quality of life, and complication rates. RESULTS Thirty patients allocated to the "Trial Group" (TG) and 36 patients allocated to the "No Trial Group" (NTG) completed outcome assessment at 36-month follow-up. Although there was a reduction in NRS pain and improvements in utility scores from baseline to 36 months in both groups, there was no difference in the primary outcome of pain intensity NRS between TG and NTG (adjusted mean difference: -0.60, 95% CI: -1.83 to 0.63), EuroQol-5 Dimension utility values (adjusted mean difference: -0.02, 95% CI: -0.13 to 0.10), or proportion of pain responders (33% TG vs 31% NTG). No differences were observed between the groups for the likelihood of spinal cord stimulation device explant or reporting an adverse advent up to 36-month follow-up. CONCLUSION The long-term results show no patient outcome benefit in undertaking an SCS screening trial.
Collapse
Affiliation(s)
- Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Sarah Nevitt
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Sara Griffiths
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Simon Thomson
- Department of Pain Medicine and Neuromodulation, Mid and South Essex University Hospitals, Essex,UK
| | | | - Rachel Houten
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Morag Brookes
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Anu Kansal
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Jenny Earle
- Patient and Public Involvement Representatives, Middlesbrough, UK
| | - Jill Bell
- Patient and Public Involvement Representatives, Middlesbrough, UK
| | - Rod S. Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Rui V. Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| |
Collapse
|
25
|
Novel Spinal Cord Stimulation Waveforms for Treating Back and Leg Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Neuromodulation 2022:S1094-7159(22)01364-2. [DOI: 10.1016/j.neurom.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 12/14/2022]
|
26
|
Papalia GF, Russo F, Vadalà G, Pascarella G, De Salvatore S, Ambrosio L, Di Martino S, Sammartini D, Sammartini E, Carassiti M, Papalia R, Denaro V. Non-Invasive Treatments for Failed Back Surgery Syndrome: A Systematic Review. Global Spine J 2022; 13:1153-1162. [PMID: 36412047 DOI: 10.1177/21925682221141385] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVES The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS). METHODS Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups. RESULTS The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS. CONCLUSIONS Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.
Collapse
Affiliation(s)
| | - Fabrizio Russo
- Department of Orthopaedic and Trauma Surgery, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Gianluca Vadalà
- Department of Orthopaedic and Trauma Surgery, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Sergio De Salvatore
- Department of Orthopaedic and Trauma Surgery, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Luca Ambrosio
- Department of Orthopaedic and Trauma Surgery, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Sara Di Martino
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Davide Sammartini
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Emanuele Sammartini
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Massimiliano Carassiti
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, 9317Campus Bio-Medico University of Rome, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, 9317Campus Bio-Medico University of Rome, Rome, Italy
| |
Collapse
|
27
|
Hara S, Andresen H, Solheim O, Carlsen SM, Sundstrøm T, Lønne G, Lønne VV, Taraldsen K, Tronvik EA, Øie LR, Gulati AM, Sagberg LM, Jakola AS, Solberg TK, Nygaard ØP, Salvesen ØO, Gulati S. Effect of Spinal Cord Burst Stimulation vs Placebo Stimulation on Disability in Patients With Chronic Radicular Pain After Lumbar Spine Surgery: A Randomized Clinical Trial. JAMA 2022; 328:1506-1514. [PMID: 36255427 PMCID: PMC9579901 DOI: 10.1001/jama.2022.18231] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The use of spinal cord stimulation for chronic pain after lumbar spine surgery is increasing, yet rigorous evidence of its efficacy is lacking. OBJECTIVE To investigate the efficacy of spinal cord burst stimulation, which involves the placement of an implantable pulse generator connected to electrodes with leads that travel into the epidural space posterior to the spinal cord dorsal columns, in patients with chronic radiculopathy after surgery for degenerative lumbar spine disorders. DESIGN, SETTING, AND PARTICIPANTS This placebo-controlled, crossover, randomized clinical trial in 50 patients was conducted at St Olavs University Hospital in Norway, with study enrollment from September 5, 2018, through April 28, 2021. The date of final follow-up was May 20, 2022. INTERVENTIONS Patients underwent two 3-month periods with spinal cord burst stimulation and two 3-month periods with placebo stimulation in a randomized order. Burst stimulation consisted of closely spaced, high-frequency electrical stimuli delivered to the spinal cord. The stimulus consisted of a 40-Hz burst mode of constant-current stimuli with 4 spikes per burst and an amplitude corresponding to 50% to 70% of the paresthesia perception threshold. MAIN OUTCOMES AND MEASURES The primary outcome was difference in change from baseline in the self-reported Oswestry Disability Index (ODI; range, 0 points [no disability] to 100 points [maximum disability]; the minimal clinically important difference was 10 points) score between periods with burst stimulation and placebo stimulation. The secondary outcomes were leg and back pain, quality of life, physical activity levels, and adverse events. RESULTS Among 50 patients who were randomized (mean age, 52.2 [SD, 9.9] years; 27 [54%] were women), 47 (94%) had at least 1 follow-up ODI score and 42 (84%) completed all stimulation randomization periods and ODI measurements. The mean ODI score at baseline was 44.7 points and the mean changes in ODI score were -10.6 points for the burst stimulation periods and -9.3 points for the placebo stimulation periods, resulting in a mean between-group difference of -1.3 points (95% CI, -3.9 to 1.3 points; P = .32). None of the prespecified secondary outcomes showed a significant difference. Nine patients (18%) experienced adverse events, including 4 (8%) who required surgical revision of the implanted system. CONCLUSIONS AND RELEVANCE Among patients with chronic radicular pain after lumbar spine surgery, spinal cord burst stimulation, compared with placebo stimulation, after placement of a spinal cord stimulator resulted in no significant difference in the change from baseline in self-reported back pain-related disability. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03546738.
Collapse
Affiliation(s)
- Sozaburo Hara
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hege Andresen
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- National Advisory Unit on Spinal Surgery, St Olavs University Hospital, Trondheim, Norway
| | - Ole Solheim
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sven M. Carlsen
- Department of Endocrinology, St Olavs University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Terje Sundstrøm
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Greger Lønne
- National Advisory Unit on Spinal Surgery, St Olavs University Hospital, Trondheim, Norway
- Department of Orthopedics, Innlandet Hospital Trust, Lillehammer, Norway
| | - Vetle V. Lønne
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Erling A. Tronvik
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurology, St Olavs University Hospital, Trondheim, Norway
| | - Lise R. Øie
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurology, St Olavs University Hospital, Trondheim, Norway
| | - Agnete M. Gulati
- Department of Rheumatology, St Olavs University Hospital, Trondheim, Norway
- Office of Medical Education, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lisa M. Sagberg
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Asgeir S. Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tore K. Solberg
- Department of Neurosurgery, University Hospital of North Norway, Tromsø
- Department of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Øystein P. Nygaard
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- National Advisory Unit on Spinal Surgery, St Olavs University Hospital, Trondheim, Norway
| | - Øyvind O. Salvesen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sasha Gulati
- Department of Neurosurgery, St Olavs University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- National Advisory Unit on Spinal Surgery, St Olavs University Hospital, Trondheim, Norway
| |
Collapse
|
28
|
Girão AF, Serrano MC, Completo A, Marques PAAP. Is Graphene Shortening the Path toward Spinal Cord Regeneration? ACS NANO 2022; 16:13430-13467. [PMID: 36000717 PMCID: PMC9776589 DOI: 10.1021/acsnano.2c04756] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Along with the development of the next generation of biomedical platforms, the inclusion of graphene-based materials (GBMs) into therapeutics for spinal cord injury (SCI) has potential to nourish topmost neuroprotective and neuroregenerative strategies for enhancing neural structural and physiological recovery. In the context of SCI, contemplated as one of the most convoluted challenges of modern medicine, this review first provides an overview of its characteristics and pathophysiological features. Then, the most relevant ongoing clinical trials targeting SCI, including pharmaceutical, robotics/neuromodulation, and scaffolding approaches, are introduced and discussed in sequence with the most important insights brought by GBMs into each particular topic. The current role of these nanomaterials on restoring the spinal cord microenvironment after injury is critically contextualized, while proposing future concepts and desirable outputs for graphene-based technologies aiming to reach clinical significance for SCI.
Collapse
Affiliation(s)
- André F. Girão
- Centre
for Mechanical Technology and Automation (TEMA), Department of Mechanical
Engineering, University of Aveiro (UA), Aveiro, 3810-193, Portugal
- Instituto
de Ciencia de Materiales de Madrid (ICMM), Consejo Superior de Investigaciones Científicas (CSIC), Calle Sor Juana Inés de la
Cruz 3, Madrid, 28049, Spain
- (A.F.G.)
| | - María Concepcion Serrano
- Instituto
de Ciencia de Materiales de Madrid (ICMM), Consejo Superior de Investigaciones Científicas (CSIC), Calle Sor Juana Inés de la
Cruz 3, Madrid, 28049, Spain
- (M.C.S.)
| | - António Completo
- Centre
for Mechanical Technology and Automation (TEMA), Department of Mechanical
Engineering, University of Aveiro (UA), Aveiro, 3810-193, Portugal
| | - Paula A. A. P. Marques
- Centre
for Mechanical Technology and Automation (TEMA), Department of Mechanical
Engineering, University of Aveiro (UA), Aveiro, 3810-193, Portugal
- (P.A.A.P.M.)
| |
Collapse
|
29
|
|
30
|
O'Connell NE, Ferraro MC, Gibson W, Rice AS, Vase L, Coyle D, Eccleston C. Implanted spinal neuromodulation interventions for chronic pain in adults. Cochrane Database Syst Rev 2021; 12:CD013756. [PMID: 34854473 PMCID: PMC8638262 DOI: 10.1002/14651858.cd013756.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Implanted spinal neuromodulation (SNMD) techniques are used in the treatment of refractory chronic pain. They involve the implantation of electrodes around the spinal cord (spinal cord stimulation (SCS)) or dorsal root ganglion (dorsal root ganglion stimulation (DRGS)), and a pulse generator unit under the skin. Electrical stimulation is then used with the aim of reducing pain intensity. OBJECTIVES To evaluate the efficacy, effectiveness, adverse events, and cost-effectiveness of implanted spinal neuromodulation interventions for people with chronic pain. SEARCH METHODS We searched CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science (ISI), Health Technology Assessments, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry from inception to September 2021 without language restrictions, searched the reference lists of included studies and contacted experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing SNMD interventions with placebo (sham) stimulation, no treatment or usual care; or comparing SNMD interventions + another treatment versus that treatment alone. We included participants ≥ 18 years old with non-cancer and non-ischaemic pain of longer than three months duration. Primary outcomes were pain intensity and adverse events. Secondary outcomes were disability, analgesic medication use, health-related quality of life (HRQoL) and health economic outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently screened database searches to determine inclusion, extracted data and evaluated risk of bias for prespecified results using the Risk of Bias 2.0 tool. Outcomes were evaluated at short- (≤ one month), medium- four to eight months) and long-term (≥12 months). Where possible we conducted meta-analyses. We used the GRADE system to assess the certainty of evidence. MAIN RESULTS We included 15 unique published studies that randomised 908 participants, and 20 unique ongoing studies. All studies evaluated SCS. We found no eligible published studies of DRGS and no studies comparing SCS with no treatment or usual care. We rated all results evaluated as being at high risk of bias overall. For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as low or very low, downgraded due to limitations of studies, imprecision and in some cases, inconsistency. Active stimulation versus placebo SCS versus placebo (sham) Results were only available at short-term follow-up for this comparison. Pain intensity Six studies (N = 164) demonstrated a small effect in favour of SCS at short-term follow-up (0 to 100 scale, higher scores = worse pain, mean difference (MD) -8.73, 95% confidence interval (CI) -15.67 to -1.78, very low certainty). The point estimate falls below our predetermined threshold for a clinically important effect (≥10 points). No studies reported the proportion of participants experiencing 30% or 50% pain relief for this comparison. Adverse events (AEs) The quality and inconsistency of adverse event reporting in these studies precluded formal analysis. Active stimulation + other intervention versus other intervention alone SCS + other intervention versus other intervention alone (open-label studies) Pain intensity Mean difference Three studies (N = 303) demonstrated a potentially clinically important mean difference in favour of SCS of -37.41 at short term (95% CI -46.39 to -28.42, very low certainty), and medium-term follow-up (5 studies, 635 participants, MD -31.22 95% CI -47.34 to -15.10 low-certainty), and no clear evidence for an effect of SCS at long-term follow-up (1 study, 44 participants, MD -7 (95% CI -24.76 to 10.76, very low-certainty). Proportion of participants reporting ≥50% pain relief We found an effect in favour of SCS at short-term (2 studies, N = 249, RR 15.90, 95% CI 6.70 to 37.74, I2 0% ; risk difference (RD) 0.65 (95% CI 0.57 to 0.74, very low certainty), medium term (5 studies, N = 597, RR 7.08, 95 %CI 3.40 to 14.71, I2 = 43%; RD 0.43, 95% CI 0.14 to 0.73, low-certainty evidence), and long term (1 study, N = 87, RR 15.15, 95% CI 2.11 to 108.91 ; RD 0.35, 95% CI 0.2 to 0.49, very low certainty) follow-up. Adverse events (AEs) Device related No studies specifically reported device-related adverse events at short-term follow-up. At medium-term follow-up, the incidence of lead failure/displacement (3 studies N = 330) ranged from 0.9 to 14% (RD 0.04, 95% CI -0.04 to 0.11, I2 64%, very low certainty). The incidence of infection (4 studies, N = 548) ranged from 3 to 7% (RD 0.04, 95%CI 0.01, 0.07, I2 0%, very low certainty). The incidence of reoperation/reimplantation (4 studies, N =5 48) ranged from 2% to 31% (RD 0.11, 95% CI 0.02 to 0.21, I2 86%, very low certainty). One study (N = 44) reported a 55% incidence of lead failure/displacement (RD 0.55, 95% CI 0.35, 0 to 75, very low certainty), and a 94% incidence of reoperation/reimplantation (RD 0.94, 95% CI 0.80 to 1.07, very low certainty) at five-year follow-up. No studies provided data on infection rates at long-term follow-up. We found reports of some serious adverse events as a result of the intervention. These included autonomic neuropathy, prolonged hospitalisation, prolonged monoparesis, pulmonary oedema, wound infection, device extrusion and one death resulting from subdural haematoma. Other No studies reported the incidence of other adverse events at short-term follow-up. We found no clear evidence of a difference in otherAEs at medium-term (2 studies, N = 278, RD -0.05, 95% CI -0.16 to 0.06, I2 0%) or long term (1 study, N = 100, RD -0.17, 95% CI -0.37 to 0.02) follow-up. Very limited evidence suggested that SCS increases healthcare costs. It was not clear whether SCS was cost-effective. AUTHORS' CONCLUSIONS We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to conventional medical management or physical therapy. SCS is associated with complications including infection, electrode lead failure/migration and a need for reoperation/re-implantation. The level of certainty regarding the size of those risks is very low. SNMD may lead to serious adverse events, including death. We found no evidence to support or refute the use of DRGS for chronic pain.
Collapse
Affiliation(s)
- Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Andrew Sc Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Doug Coyle
- Epidemiology and Community Medicine, Ottawa Health Research Institute, Ottawa, Canada
- Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences, Brunel University London, Uxbridge, UK
| | | |
Collapse
|
31
|
Success with dorsal root entry zone lesioning after a failed trial of spinal cord stimulation in a patient with pain due to brachial plexus avulsion. Pain Rep 2021; 6:e973. [PMID: 34841182 PMCID: PMC8613335 DOI: 10.1097/pr9.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/10/2021] [Accepted: 09/30/2021] [Indexed: 10/28/2022] Open
Abstract
Pain caused by brachial plexopathy (BP) represents a challenging clinical problem with few effective therapeutic options. Here, we present a patient with severe, painful BP after a high-impact motor vehicle accident who failed conservative treatments. A trial of cervical spinal cord stimulation was completed using multiple waveforms (tonic, BurstDR, and 10 kHz) over 14 days with only 30% to 40% pain reduction. Subsequently, he underwent dorsal root entry zone lesioning with a significant decrease in his pain 1 year later. Surgical exploration revealed extensive damage and avulsion of his cervical roots that was not observed on a previous brachial plexus magnetic resonance imaging. We discuss the etiology and diagnosis of traumatic BP, possible reasons for the failed spinal cord stimulation trial, and implications for management.
Collapse
|
32
|
Provenzano D, Tate J, Gupta M, Yu C, Verrills P, Guirguis M, Harrison N, Smith T, Azalde R, Bradley K. Pulse Dosing of 10 kHz Paresthesia-Independent Spinal Cord Stimulation Provides Same Efficacy with Substantial Reduction of Device Recharge Time. PAIN MEDICINE 2021; 23:152-163. [PMID: 34601597 PMCID: PMC8723142 DOI: 10.1093/pm/pnab288] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/02/2021] [Accepted: 09/24/2021] [Indexed: 11/26/2022]
Abstract
Objective This study was designed to assess whether using pulse dosing (PD) (regularly cycled intermittent stimulation) of high-frequency 10-kHz spinal cord stimulation (10-kHz SCS) can reduce device recharge time while maintaining efficacy in patients with chronic intractable back pain with or without leg pain. Design Prospective, multicenter, observational study. Methods Patients successfully using 10-kHz SCS at 100%ON (i.e., continuously with no PD) for >3 months were consecutively enrolled. After a 1-week baseline period of documenting their pain twice daily on a 0–10 numerical rating scale (NRS) using 100%ON of their “favorite” program, all subjects were reprogrammed to 14%PD for 10–14 days. If subjects preferred 14%PD to 100%ON, they were programmed to 3%PD; otherwise, they were programmed to 50%PD. Subjects used this next program for another 10–14 days. Subjects then entered a 3-month observational period during which they were requested to use but not limited to their most preferred %PD program. Toward the end of 3 months, subjects completed a 7-day NRS diary and indicated a final %PD program preference. Study endpoints included %PD preference, mean diary NRS by %PD, and daily minutes and patterns of charging. Results Of 31 subjects completing the study, 81% preferred less than 100%ON. Among the subjects, 39% preferred 3%PD, 32% preferred 14%PD, 10% preferred 50%PD, and 19% preferred 100%ON. Average daily charge durations were 8.3 ± 3.1 minutes for 3%PD, 13.9 ± 4.9 minutes for 14%PD, 26.2 ± 7.4 minutes for 50%PD, and 43.8 ± 10.9 minutes for 100%ON. Regression modeling suggested that pain relief was weighted as more than twice as influential as charging in preference for reduced %PD. Conclusions This prospective study suggests that 10-kHz SCS therapy with PD may be successfully used in a large majority of 10-kHz SCS responders, maintaining efficacy while reducing device charging time by nearly two thirds.
Collapse
Affiliation(s)
| | | | | | - Cong Yu
- Swedish Medical Center, Seattle, WA
| | | | | | | | - Thomas Smith
- Guy's and St. Thomas' Hospital NHS Trust, London, UK
| | | | | |
Collapse
|
33
|
Motov S, Aftahy K, Jörger AK, Wagner A, Meyer B, Shiban E. High-frequency spinal cord stimulation in failed back surgery syndrome patients with predominant low back pain-single-center experience. Neurosurg Rev 2021; 44:2809-2818. [PMID: 33454835 PMCID: PMC8490248 DOI: 10.1007/s10143-020-01462-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/27/2020] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
Treatment of patients with failed back surgery syndrome (FBSS) with predominant low back pain (LBP) remains challenging. High-frequency spinal cord stimulation (HF10 SCS) is believed to achieve significant pain reduction. We aimed to evaluate the real-life efficacy of HF-10 SCS in a tertiary spine center. A prospective observational study of all patients with FBSS and predominant LBP who underwent HF-10 SCS surgery was performed between 2016 and 2018. Patients > 18 years with Visual Analogue Scale (VAS) scores of ≥ 5 for LBP and pain duration > 6 months under stable medication were implanted percutaneous under general anesthesia and a trial phase of 7-14 days was accomplished. Primary end point was a successful trial defined as ≥ 50% VAS score reduction for LBP. Thirty-four of 39 (85%) subjects had a successful trial. Fifty-three percent were female and the mean age was 69 years. Median follow-up lasted for 10 months. Devices were removed after a median of 10 months in 5 cases. Remaining 29 patients stated significant VAS score reduction for LBP from 8.1 to 2.9 and VAS for leg pain from 4.9 to 2.2. Twenty-four percent of all patients were able to discontinue their opioids. Eight of 9 patients (89%) with signs of adjacent disc disease and 7 of 10 (70%) patients with hardware failure were successfully implanted with significant VAS reduction for LBP. HF-10 SCS achieves significant pain reduction in most patients with FBSS and predominant LBP. It might be an efficient alternative to revision surgery.
Collapse
Affiliation(s)
- Stefan Motov
- Department of Neurosurgery, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- Department of Neurosurgery, University hospital of Augsburg, Augsburg, Germany.
| | - Kaywan Aftahy
- Department of Neurosurgery, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ann-Kathrin Jörger
- Department of Neurosurgery, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Arthur Wagner
- Department of Neurosurgery, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University hospital of Augsburg, Augsburg, Germany
| |
Collapse
|
34
|
Traeger AC, Gilbert S, Moeschler S, Harris IA, Maher CG. Spinal cord stimulation for low back pain. Hippokratia 2021. [DOI: 10.1002/14651858.cd014789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Adrian C Traeger
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health, Faculty of Medicine and Health; The University of Sydney; Sydney Australia
| | - Stephen Gilbert
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health, Faculty of Medicine and Health; The University of Sydney; Sydney Australia
| | - Susan Moeschler
- Department of Anesthesiology; Mayo Clinic College of Medicine; Rochester MN USA
| | - Ian A Harris
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- South West Sydney Clinical School; University of New South Wales; Liverpool Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
- School of Public Health; Faculty of Medicine and Health, The University of Sydney; Sydney Australia
| |
Collapse
|
35
|
Eckermann JM, Pilitsis JG, Vannaboutathong C, Wagner BJ, Province-Azalde R, Bendel MA. Systematic Literature Review of Spinal Cord Stimulation in Patients With Chronic Back Pain Without Prior Spine Surgery. Neuromodulation 2021; 25:648-656. [PMID: 34407288 DOI: 10.1111/ner.13519] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/09/2021] [Accepted: 07/19/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Low back pain is the leading cause of disability worldwide and one of the most common reasons for seeking healthcare. Despite numerous care strategies, patients with low back pain continue to exhibit poor outcomes. Spinal cord stimulation (SCS) is an evidence-based therapeutic modality for patients with failed back surgery syndrome. For patients without a surgical lesion or history, minimally invasive interventions that provide long-term reduction of chronic back pain are needed. Therefore, we conducted a systematic review of the evidence on SCS therapy in patients with chronic back pain who have not undergone spinal surgery. MATERIALS AND METHODS A systematic literature search was performed to identify studies reporting outcomes for SCS in chronic back pain patients (with or without secondary radicular leg pain) without prior surgery using date limits from database inception to February 2021. Study results were analyzed and described qualitatively. RESULTS A total of ten primary studies (16 publications) were included. The included studies consistently demonstrated favorable outcomes in terms of pain reduction and functional improvement following SCS therapy. Improvements also occurred in quality of life scores; however, not all studies reported statistically significant findings. Additionally, the studies reported that SCS resulted in high patient satisfaction, reductions in opioid use, and an acceptable safety profile, although these data were more limited. CONCLUSION Findings suggest that SCS is a promising, safe, minimally invasive, and reversible alternative option for managing chronic back pain in patients who have not undergone spinal surgery.
Collapse
Affiliation(s)
| | | | | | | | | | - Markus A Bendel
- Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
36
|
Spinal cord stimulation for neuropathic pain. Rev Neurol (Paris) 2021; 177:838-842. [PMID: 34384626 DOI: 10.1016/j.neurol.2021.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 07/28/2021] [Indexed: 01/20/2023]
Abstract
Spinal cord stimulation (SCS) is used for more than 40years to treat localized chronic medically refractory neuropathic pain involving limb(s) and trunk. The most frequent indications remain complex regional pain syndrome (CRPS) failed back surgery syndrome (FBSS), and peripheral neuropathy. Stimulation-induced paresthesias, perceived by the patient, prevent blinded evaluation and increase the placebo effect, decreasing the credibility of the tonic SCS efficacy. Retrospective studies reported that about 50% of the patients are improved more than 50% at short-term, but long-term improvement is less. Several comparative randomized trials (RCT) are now available. In CRPS, a RCT demonstrated the superiority of SCS plus physiotherapy compared to physiotherapy alone. In FBSS, two RCTs have shown that SCS was superior to reoperation and conventional medical treatment, (CMM) respectively. New stimulation waveforms, namely burst, high frequency (10KHz) stimulation and close-loop SCS, have been proposed recently to avoid the perception of paresthesias and/or increase the pain relief. RCTs in FBSS have suggested that these new SCS modalities were as least as efficient than conventional tonic SCS and perhaps slightly superior. Two RCTs confirmed SCS efficacy in painful diabetic neuropathy in comparison with CMM. Complications are frequent (hardware dysfunction or migration, superficial infection) but exceptionally serious. Consequently, the risk/benefit ratio is favorable to SCS, considering that chronic pain patients undergoing this procedure are usually resistant to all the other therapies.
Collapse
|
37
|
Blackburn AZ, Chang HH, DiSilvestro K, Veeramani A, McDonald C, Zhang AS, Daniels A. Spinal Cord Stimulation via Percutaneous and Open Implantation: Systematic Review and Meta-Analysis Examining Complication Rates. World Neurosurg 2021; 154:132-143.e1. [PMID: 34343680 DOI: 10.1016/j.wneu.2021.07.077] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS) has become a successful therapeutic option for combating chronic pain and can be implanted via percutaneous or open (laminotomy/laminectomy) techniques. This study aimed to systematically review the complications that occur after SCS placement via percutaneous and open (laminotomy/laminectomy) in failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), and chronic back (lumbosacral)/leg pain. METHODS The PubMed and Embase databases were searched from inception to June 2020; prospective studies using SCS in patients with FBSS, CRPS, and chronic low back pain that reported both complications and the implantation method used were included. Effects and results from each study were combined using a random-effects model and were structured for subgroup analysis between open implantation and percutaneous implantation. Meta-regression was performed by calculating a mean difference and weighted by inverse variance and 95% confidence intervals (CIs). RESULTS Thirty-two articles were included in this systematic review and meta-analysis. Using several different patient- and event-based metrics, our meta-analysis revealed an overall average complication rate of 21.1% (95% CI, 14.9-27.2). Equipment, technical, and medical complications occurred at rates of 12.1%, 1.1%, and 6.3%, respectively. Lead migration and infection rates were 5.6% and 3.8%, respectively. When comparing the 2 implant techniques, medical-related surgical reinterventions and explants due to infection were more common in open compared with percutaneous SCS procedures. CONCLUSIONS Equipment-related complications accounted for the majority of SCS complications. Percutaneous SCS resulted in less reintervention and fewer explants caused by medical-related complications and infection, respectively. These conclusions may provide a general understanding of the SCS complications profile for physicians who care for SCS patients.
Collapse
Affiliation(s)
- Amy Z Blackburn
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hunter H Chang
- Department of Mathematics, Northwestern University, Evanston, Illinois, USA
| | - Kevin DiSilvestro
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University/University Orthopedics, Providence, Rhode Island, USA
| | - Ashwin Veeramani
- Division of Applied Mathematics, Brown University, Providence, Rhode Island, USA
| | - Christopher McDonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University/University Orthopedics, Providence, Rhode Island, USA
| | - Andrew S Zhang
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University/University Orthopedics, Providence, Rhode Island, USA
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University/University Orthopedics, Providence, Rhode Island, USA.
| |
Collapse
|
38
|
Katz N, Dworkin RH, North R, Thomson S, Eldabe S, Hayek SM, Kopell BH, Markman J, Rezai A, Taylor RS, Turk DC, Buchser E, Fields H, Fiore G, Ferguson M, Gewandter J, Hilker C, Jain R, Leitner A, Loeser J, McNicol E, Nurmikko T, Shipley J, Singh R, Trescot A, van Dongen R, Venkatesan L. Research design considerations for randomized controlled trials of spinal cord stimulation for pain: Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials/Institute of Neuromodulation/International Neuromodulation Society recommendations. Pain 2021; 162:1935-1956. [PMID: 33470748 PMCID: PMC8208090 DOI: 10.1097/j.pain.0000000000002204] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022]
Abstract
ABSTRACT Spinal cord stimulation (SCS) is an interventional nonpharmacologic treatment used for chronic pain and other indications. Methods for evaluating the safety and efficacy of SCS have evolved from uncontrolled and retrospective studies to prospective randomized controlled trials (RCTs). Although randomization overcomes certain types of bias, additional challenges to the validity of RCTs of SCS include blinding, choice of control groups, nonspecific effects of treatment variables (eg, paresthesia, device programming and recharging, psychological support, and rehabilitative techniques), and safety considerations. To address these challenges, 3 professional societies (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials, Institute of Neuromodulation, and International Neuromodulation Society) convened a meeting to develop consensus recommendations on the design, conduct, analysis, and interpretation of RCTs of SCS for chronic pain. This article summarizes the results of this meeting. Highlights of our recommendations include disclosing all funding source and potential conflicts; incorporating mechanistic objectives when possible; avoiding noninferiority designs without internal demonstration of assay sensitivity; achieving and documenting double-blinding whenever possible; documenting investigator and site experience; keeping all information provided to patients balanced with respect to expectation of benefit; disclosing all information provided to patients, including verbal scripts; using placebo/sham controls when possible; capturing a complete set of outcome assessments; accounting for ancillary pharmacologic and nonpharmacologic treatments in a clear manner; providing a complete description of intended and actual programming interactions; making a prospective ascertainment of SCS-specific safety outcomes; training patients and researchers on appropriate expectations, outcome assessments, and other key aspects of study performance; and providing transparent and complete reporting of results according to applicable reporting guidelines.
Collapse
Affiliation(s)
- Nathaniel Katz
- Corresponding author. Address: WCG Analgesic Solutions, Wayland, MA, USA. Tel.: 1-617-948-5161. E-mail address: (N. Katz)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Conger A, Schuster NM, Cheng DS, Sperry BP, Joshi AB, Haring RS, Duszynski B, McCormick ZL. The Effectiveness of Intraosseous Basivertebral Nerve Radiofrequency Neurotomy for the Treatment of Chronic Low Back Pain in Patients with Modic Changes: A Systematic Review. PAIN MEDICINE 2021; 22:1039-1054. [PMID: 33544851 DOI: 10.1093/pm/pnab040] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Determine the effectiveness of intraosseous basivertebral nerve radiofrequency neurotomy for the treatment of chronic low back pain with type 1 or 2 Modic changes. DESIGN Systematic review. POPULATION Persons aged ≥18 years with chronic low back pain with type 1 or 2 Modic changes. INTERVENTION Intraosseous basivertebral nerve radiofrequency neurotomy. COMPARISON Sham, placebo procedure, active standard care treatment, or none. OUTCOMES The primary outcome of interest was the proportion of individuals with ≥50% pain reduction. Secondary outcomes included ≥10-point improvement in function as measured by Oswestry Disability Index as well as ≥2-point reduction in pain score on the Visual Analog Scale or Numeric Rating Scale, and decreased use of pain medication. METHODS Three reviewers independently assessed publications before May 15, 2020, in MEDLINE and Embase and the quality of evidence was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation framework. RESULTS Of the 725 publications screened, seven publications with 321 participants were ultimately included. The reported 3-month success rate for ≥50% pain reduction ranged from 45% to 63%. Rates of functional improvement (≥10-point Oswestry Disability Index improvement threshold) ranged from 75% to 93%. For comparison to sham treatment, the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 1.25 (95% confidence interval [CI]: .88-1.77) and 1.38 (95% CI: 1.10-1.73), respectively. For comparison to continued standard care treatment the relative risk of treatment success defined by ≥50% pain reduction and ≥10-point Oswestry Disability Index improvement was 4.16 (95% CI: 2.12-8.14) and 2.32 (95% CI: 1.52-3.55), respectively. CONCLUSIONS There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Nathaniel M Schuster
- Center for Pain Medicine, Department of Anesthesiology, University of California, San Diego, La Jolla, California, USA
| | - David S Cheng
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
| | - Beau P Sperry
- University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Anand B Joshi
- Department of Orthopaedic Surgery, Emory University, Atlanta, Georgia
| | - R Sterling Haring
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
40
|
Knotkova H, Hamani C, Sivanesan E, Le Beuffe MFE, Moon JY, Cohen SP, Huntoon MA. Neuromodulation for chronic pain. Lancet 2021; 397:2111-2124. [PMID: 34062145 DOI: 10.1016/s0140-6736(21)00794-7] [Citation(s) in RCA: 186] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/23/2022]
Abstract
Neuromodulation is an expanding area of pain medicine that incorporates an array of non-invasive, minimally invasive, and surgical electrical therapies. In this Series paper, we focus on spinal cord stimulation (SCS) therapies discussed within the framework of other invasive, minimally invasive, and non-invasive neuromodulation therapies. These therapies include deep brain and motor cortex stimulation, peripheral nerve stimulation, and the non-invasive treatments of repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation. SCS methods with electrical variables that differ from traditional SCS have been approved. Although methods devoid of paraesthesias (eg, high frequency) should theoretically allow for placebo-controlled trials, few have been done. There is low-to-moderate quality evidence that SCS is superior to reoperation or conventional medical management for failed back surgery syndrome, and conflicting evidence as to the superiority of traditional SCS over sham stimulation or between different SCS modalities. Peripheral nerve stimulation technologies have also undergone rapid development and become less invasive, including many that are placed percutaneously. There is low-to-moderate quality evidence that peripheral nerve stimulation is effective for neuropathic pain in an extremity, low quality evidence that it is effective for back pain with or without leg pain, and conflicting evidence that it can prevent migraines. In the USA and many areas in Europe, deep brain and motor cortex stimulation are not approved for chronic pain, but are used off-label for refractory cases. Overall, there is mixed evidence supporting brain stimulation, with most sham-controlled trials yielding negative findings. Regarding non-invasive modalities, there is moderate quality evidence that repetitive transcranial magnetic stimulation does not provide meaningful benefit for chronic pain in general, but conflicting evidence regarding pain relief for neuropathic pain and headaches. For transcranial direct current stimulation, there is low-quality evidence supporting its benefit for chronic pain, but conflicting evidence regarding a small treatment effect for neuropathic pain and headaches. For transcutaneous electrical nerve stimulation, there is low-quality evidence that it is superior to sham or no treatment for neuropathic pain, but conflicting evidence for non-neuropathic pain. Future research should focus on better evaluating the short-term and long-term effectiveness of all neuromodulation modalities and whether they decrease health-care use, and on refining selection criteria and treatment variables.
Collapse
Affiliation(s)
- Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Harquail Centre for Neuromodulation, University of Toronto, Toronto, ON, Canada
| | - Eellan Sivanesan
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Jee Youn Moon
- Department of Anesthesiology, Seoul National University, Seoul, South Korea
| | - Steven P Cohen
- Department of Neurology, Department of Physical Medicine & Rehabilitation, and Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Marc A Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
41
|
Conger A, Sperry BP, Cheney CW, Burnham TM, Mahan MA, Onofrei LV, Cushman DM, Wagner GE, Shipman H, Teramoto M, McCormick ZL. The Effectiveness of Spinal Cord Stimulation for the Treatment of Axial Low Back Pain: A Systematic Review with Narrative Synthesis. PAIN MEDICINE 2021; 21:2699-2712. [PMID: 32472130 DOI: 10.1093/pm/pnaa142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Determine the effectiveness of spinal cord stimulation (SCS) for the treatment of axial low back pain (LBP) with or without leg pain. DESIGN Systematic review. SUBJECTS Persons aged ≥18 with axial LBP with or without accompanying leg pain. INTERVENTION Traditional low-frequency, burst, or high-frequency SCS. COMPARISON Sham, active standard of care treatment, or none. OUTCOMES The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement measured six or more months after treatment intervention. METHODS Publications in PubMed, MEDLINE, and Cochrane databases were reviewed through September 19, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Cochrane Risk of Bias Tool and GRADE system were used to assess individual study characteristics and overall quality. RESULTS Query identified 262 publications; 17 were suitable for inclusion. For high-frequency SCS, the only level 1 study showed that 79% (95% confidence interval = 70-87%) of patients reported ≥50% pain improvement. For low-frequency SCS, the only level 1 study reported no categorical data for axial LBP-specific outcomes; axial LBP improved by a mean 14 mm on the visual analog scale at six months. Meta-analysis was not performed due to study heterogeneity. CONCLUSIONS According to GRADE, there is low-quality evidence that high-frequency SCS compared with low-frequency SCS is effective in patients with axial LBP with concomitant leg pain. There is very low-quality evidence for low-frequency SCS for the treatment of axial LBP in patients with concomitant leg pain. There is insufficient evidence addressing the effectiveness of burst SCS to apply a GRADE rating.
Collapse
Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Beau P Sperry
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cole W Cheney
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Taylor M Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark A Mahan
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ligia V Onofrei
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Daniel M Cushman
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Graham E Wagner
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Hank Shipman
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
42
|
Paz-Solís J, Thomson S, Jain R, Chen L, Huertas I, Doan Q. Exploration of High and Low Frequency Options for Subperception Spinal Cord Stimulation Using Neural Dosing Parameter Relationships: The HALO Study. Neuromodulation 2021; 25:94-102. [PMID: 33951270 DOI: 10.1111/ner.13390] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Subperception spinal cord stimulation (SCS) is described mostly utilizing waveforms that require high energy. However, the necessity of these waveforms for effective subperception has not been established. We aimed to explore whether effective subperception pain relief can be achieved using frequencies below 1 kHz. MATERIALS AND METHODS Thirty chronic pain patients implanted with SCS were enrolled as part of a multicenter, real-world, consecutive, observational case series. An effective stimulation location was determined using a novel electric field shape designed to preferentially modulate dorsal horn elements. Subsequently, programs at lower frequencies (600, 400, 200, 100, 50, and 10 Hz) were provided with pulse-width and amplitude adjusted to optimize response. RESULTS All tested frequencies (1 kHz down to 10 Hz) provided effective subperception relief, yielding a mean of 66-72% reduction in back, leg, and overall pain. It was found that to maintain analgesia, as frequency was decreased, the electrical or "neural" dose had to be adjusted according to parameter relationships described herein. With the reduction of frequency, we observed a net reduction of charge-per-second, which enabled energy savings of 74% (200 Hz) and 97% (10 Hz) relative to 1 kHz. Furthermore, pain reduction was sustained out to one year, with 85% of patients reporting a preference for frequencies of 400 Hz or below. CONCLUSIONS We have derived an electric field configuration and, along with previous learnings in the kHz range, a set of neural dosing parameter relationships (10-10,000 Hz), which enable the expansion of effective subperception SCS to low frequency and achieve major energy savings.
Collapse
Affiliation(s)
| | - Simon Thomson
- Basildon and Thurrock University Hospitals, Basildon, UK
| | - Roshini Jain
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
| | - Lilly Chen
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
| | - Ismael Huertas
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
| | - Que Doan
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
| |
Collapse
|
43
|
Spinal cord stimulation in chronic neuropathic pain: mechanisms of action, new locations, new paradigms. Pain 2021; 161 Suppl 1:S104-S113. [PMID: 33090743 PMCID: PMC7434213 DOI: 10.1097/j.pain.0000000000001854] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
44
|
Boakye M, Ugiliweneza B, Madrigal F, Mesbah S, Ovechkin A, Angeli C, Bloom O, Wecht JW, Ditterline B, Harel NY, Kirshblum S, Forrest G, Wu S, Harkema S, Guest J. Clinical Trial Designs for Neuromodulation in Chronic Spinal Cord Injury Using Epidural Stimulation. Neuromodulation 2021; 24:405-415. [PMID: 33794042 DOI: 10.1111/ner.13381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/11/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN This is a narrative review focused on specific challenges related to adequate controls that arise in neuromodulation clinical trials involving perceptible stimulation and physiological effects of stimulation activation. OBJECTIVES 1) To present the strengths and limitations of available clinical trial research designs for the testing of epidural stimulation to improve recovery after spinal cord injury. 2) To describe how studies can control for the placebo effects that arise due to surgical implantation, the physical presence of the battery, generator, control interfaces, and rehabilitative activity aimed to promote use-dependent plasticity. 3) To mitigate Hawthorne effects that may occur in clinical trials with intensive supervised participation, including rehabilitation. MATERIALS AND METHODS Focused literature review of neuromodulation clinical trials with integration to the specific context of epidural stimulation for persons with chronic spinal cord injury. CONCLUSIONS Standard of care control groups fail to control for the multiple effects of knowledge of having undergone surgical procedures, having implanted stimulation systems, and being observed in a clinical trial. The irreducible effects that have been identified as "placebo" require sham controls or comparison groups in which both are implanted with potentially active devices and undergo similar rehabilitative training.
Collapse
Affiliation(s)
- Maxwell Boakye
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Health Management and Systems Sciences, University of Louisville, Louisville, KY, USA
| | - Fabian Madrigal
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Samineh Mesbah
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Alexander Ovechkin
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Claudia Angeli
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Bioengineering, University of Louisville, Louisville, KY, USA.,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA
| | - Ona Bloom
- Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Molecular Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.,Department of Physical Medicine and Rehabilitation, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.,James J Peters VA Medical Center, Bronx, NY, USA
| | - Jill W Wecht
- James J Peters VA Medical Center, Bronx, NY, USA.,The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bonnie Ditterline
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Noam Y Harel
- James J Peters VA Medical Center, Bronx, NY, USA.,The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NY, USA.,Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, USA
| | - Gail Forrest
- Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Samuel Wu
- Department of Biostatistics, CTSI Data Coordinating Center, University of Florida, Gainesville, FL, USA
| | - Susan Harkema
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA
| | - James Guest
- Neurological Surgery, and the Miami Project to Cure Paralysis, Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
45
|
Hatheway JA, Mangal V, Fishman MA, Kim P, Shah B, Vogel R, Galan V, Severyn S, Weaver TE, Provenzano DA, Chang E, Verdolin MH, Howes G, Villarreal A, Falowski S, Hendrickson K, Stromberg K, Davies L, Johanek L, Kelly MT. Long-Term Efficacy of a Novel Spinal Cord Stimulation Clinical Workflow Using Kilohertz Stimulation: Twelve-Month Results From the Vectors Study. Neuromodulation 2021; 24:556-565. [PMID: 33296127 PMCID: PMC8246544 DOI: 10.1111/ner.13324] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/22/2020] [Accepted: 10/28/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Multiple variables play a role in spinal cord stimulation (SCS) treatment outcomes, including patient anatomy, pain pattern, lead location, stimulation parameters, and so on. A wide range of stimulation parameters are considered safe and on-label, and as a result a growing number of new frequencies and frequency-combinations are being incorporated into standard practice. A standardized approach to therapy delivery may provide more consistent outcomes for more patients. The Vectors study evaluated whether there is significant sustained improvement in pain and functional outcomes when therapy is delivered using a standardized approach. MATERIALS AND METHODS Vectors, a post-market, single-arm study evaluated the safety and efficacy of SCS with an implantable neurostimulator starting with 1 kHz stimulation, targeting the T9-T10 disc space following paresthesia mapping. Subjects with chronic intractable low back and leg pain (visual analogue scale [VAS] ≥ 50 mm) were enrolled. The primary endpoint was change in overall pain (VAS) at the three-month visit compared to baseline. Subjects were followed through 12 months. Secondary endpoints included changes in low back and leg pain, quality of life (European Quality of Life - Five Dimensions, EQ-5D-5L), disability (Oswestry Disability Index, ODI), individual subject goals, and subject satisfaction. RESULTS There was a significant reduction in overall pain (VAS; 45.4 mm) through the three-month visit, which was sustained through 12 months. At 12 months, 79% of subjects had ≥50% improvement in at least one pain domain (overall, lowback or leg) with 85% of subjects reporting therapy satisfaction. There was a decrease in disability and an improvement in quality of life with 70% of subjects achieving a personal activity goal by the three-month visit. CONCLUSIONS Long-term pain relief and improvement in quality of life and function were achieved when following a standardized workflow. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT03345472.
Collapse
Affiliation(s)
| | - Vipul Mangal
- National Spine & Pain CenterNational HarborMDUSA
| | | | - Philip Kim
- Center for Interventional Pain & SpineWilmingtonDEUSA
| | | | - Rainer Vogel
- Comprehensive and Interventional Pain ManagementHendersonNVUSA
| | | | - Steven Severyn
- The Ohio State University Wexner Medical CenterColumbusOHUSA
| | | | | | - Eric Chang
- Restore Orthopedics & Spine CenterOrangeCAUSA
| | | | | | - Armando Villarreal
- University of Rochester Neurosurgery Partners Pain ManagementRochesterNYUSA
| | | | | | | | | | | | | |
Collapse
|
46
|
High frequency spinal cord stimulation for chronic back and leg pain. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
47
|
Provenzano DA, Heller JA, Hanes MC. Current Perspectives on Neurostimulation for the Management of Chronic Low Back Pain: A Narrative Review. J Pain Res 2021; 14:463-479. [PMID: 33628045 PMCID: PMC7899039 DOI: 10.2147/jpr.s249580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/16/2020] [Indexed: 01/29/2023] Open
Abstract
Neurostimulation techniques for the treatment of chronic low back pain (LBP) have been rapidly evolving; however, questions remain as to which modalities provide the most efficacious and durable treatment for intractable axial symptoms. Modalities of spinal cord stimulation, such as traditional low-frequency paresthesia based, high-density or high dose (HD), burst, 10-kHz high-frequency therapy, closed-loop, and differential target multiplexed, have been limitedly studied to determine their efficacy for the treatment of axial LBP. In addition, stimulation methods that target regions other than the spinal cord, such as medial branch nerve stimulation of the multifidus muscles and the dorsal root ganglion may also be viable treatment options. Here, current scientific evidence behind neurostimulation techniques have been reviewed with a focus on the management of chronic axial LBP.
Collapse
Affiliation(s)
- David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA, USA.,Western PA Surgery Center, Wexford, PA, USA
| | | | | |
Collapse
|
48
|
|
49
|
Multicentre, clinical trial of burst spinal cord stimulation for neck and upper limb pain NU-BURST: a trial protocol. Neurol Sci 2021; 42:3285-3296. [PMID: 33387056 DOI: 10.1007/s10072-020-04907-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain and most frequently utilised for Failed Back Surgery Syndrome (FBSS). BurstDR™ also known as DeRidder Burst-SCS, a novel waveform, has demonstrated superiority to conventional tonic stimulation of the thoracic spine in FBSS. There are case reports of an improvement in multidimensional pain outcomes using DeRidder Burst-SCS in the cervical spine for chronic neck and cervical radicular pain. The safety and efficacy of cervical DeRidder Burst-SCS stimulation still however remain undetermined. METHODS/DESIGN This is a prospective, multicentre feasibility trial evaluating the safety and therapeutic efficacy of DeRidder Burst-SCS stimulation for the treatment of chronic intractable neck pain with or without radiation to the arm, shoulder, and upper back. After baseline evaluation, subjects will undergo an SCS trial using the Abbott Invisible Trial system according to standard clinical procedures. During the trial phase, SCS leads will be implanted in the cervical epidural space. At the end of the SCS trial, subjects experiencing at least 50% pain relief will be considered for permanent implant. Pain intensity, medication usage, and other multidimensional pain outcomes will be collected. The timing of these will be at baseline, end of the SCS trial and at 3-, 6-, and 12-month visits. Incidence of adverse events will be collected throughout the study duration. DISCUSSION The results of this feasibility study will validate the efficacy and safety of DeRidder Burst-SCS stimulation in the cervical spine. The results obtained in this study will potentially be used to generate a level 1 evidence-based study with formal statistical hypotheses testing. TRIAL REGISTRATION www.clinicaltrials.gov Identifier: NCT03159169.
Collapse
|
50
|
Ranjan M, Kumar P, Konrad P, Rezai AR. Finding Optimal Neuromodulation for Chronic Pain: Waves, Bursts, and Beyond. Neurol India 2020; 68:S218-S223. [PMID: 33318354 DOI: 10.4103/0028-3886.302465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Spinal cord stimulation (SCS) has emerged as state-of-the-art evidence-based treatment for chronic intractable pain related to spinal and peripheral nerve disorders. Traditionally delivered as steady-state, paraesthesia-producing electrical stimulation, newer technology has augmented the SCS option and outcome in the last decade. Objective To present an overview of the traditional and newer SCS waveforms. Materials and Methods We present a short literature review of SCS waveforms in reference to newer waveforms and describing paraesthesia-free, high frequency, and burst stimulation methods as well as advances in waveform paradigms and programming modalities. Pertinent literature was reviewed, especially in the context of evolution in the waveforms of SCS and stimulation parameters. Results Conventional tonic SCS remains one of the most utilized and clinically validated SCS waveforms. Newer waveforms such as burst stimulation, high-frequency stimulation, and the sub-perception SCS have emerged in the last decades with favorable results with no or minimal paraesthesia, including in cases otherwise intractable to conventional tonic SCS. The recent evolution and experience of closed-loop SCS is promising and appealing. The experience and validation of the newer SCS waveforms, however, remain limited but optimistic. Conclusions Advances in SCS device technology and waveforms have improved patient outcomes, leading to its increased utilization of SCS for chronic pain. These improvements and the development of closed-loop SCS have been increasingly promising development and foster a clinical translation of improved pain relief as the years of research and clinical study beyond conventional SCS waveform come to fruition.
Collapse
Affiliation(s)
- Manish Ranjan
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
| | - Pranab Kumar
- Department of Anaesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto
| | - Peter Konrad
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
| | - Ali R Rezai
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
| |
Collapse
|