1
|
West T, Hussain N, Bhatia A, ElSaban M, Kilgore AE, Palettas M, Abdel-Rasoul M, Javed S, D'Souza RS. Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis. Reg Anesth Pain Med 2024:rapm-2024-105704. [PMID: 39060006 DOI: 10.1136/rapm-2024-105704] [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: 05/23/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE Peripheral nerve stimulation (PNS) is an emerging neuromodulation modality, yet there remains limited data highlighting its long-term effectiveness. The objective of this study was to report real-world data on pain intensity and opioid consumption after temporary and permanent PNS for chronic pain up to 24 months postimplantation. METHODS A retrospective study was conducted on all patients who received PNS implants at a multi-centered enterprise between January 1, 2014 and February 24, 2022. The two co-primary outcomes were: (1) change in pain intensity (11-point Numerical Rating Scale) from baseline to 12 months postimplant; and (2) comparison of the change in pain intensity between temporary and permanent PNS cohorts 12 months postimplant. RESULTS 126 patients were included in this analysis. Pain intensity significantly decreased 12 months postimplant in the overall cohort (mean difference (MD) -3.0 (95% CI -3.5 to -2.4), p<0.0001). No significant difference in this reduction was identified between temporary and permanent PNS cohorts (MD 0.0 (95% CI -1.1 to 1.0), p=1.00) 12 months postimplantation. Pain intensity significantly decreased in the overall, temporary, and permanent cohorts at all secondary time points (3, 6, and 24 months). No change in daily opioid consumption was observed at 6 and 12 months postimplant in the overall cohort. CONCLUSION This study found that both temporary and permanent PNS may be effective for reducing pain intensity in patients with chronic pain up to 24 months postimplantation, although no changes in opioid consumption were observed. The decrease in pain intensity was comparable between patients receiving temporary versus permanent implants, highlighting that temporary PNS may achieve long-lasting clinical benefits. However, given the substantial loss to follow-up, further large-scale studies are needed to solidify conclusions about the efficacy of PNS.
Collapse
Affiliation(s)
- Tyler West
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anuj Bhatia
- Anesthesia and Pain Medicine, University of Toronto Health Policy Management and Evaluation, Toronto, Ontario, Canada
| | - Mariam ElSaban
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony E Kilgore
- Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Marilly Palettas
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Saba Javed
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Hoffmann CM, Butler CS, Pingree MJ, Moeschler SM, Mauck WD, D'Souza RS. Is Response to a Pre-implant Diagnostic Peripheral Nerve Block Associated With Efficacy After Peripheral Nerve Stimulation Implantation? A Ten-Year Enterprise-Wide Analysis. Neuromodulation 2024; 27:873-880. [PMID: 37943242 DOI: 10.1016/j.neurom.2023.10.003] [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: 07/10/2023] [Revised: 09/11/2023] [Accepted: 10/09/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES This study aimed to assess whether patient response to targeted diagnostic peripheral nerve block before peripheral nerve stimulator (PNS) device implantation is associated with efficacy after PNS implantation. MATERIALS AND METHODS The electronic medical records from the Mayo Clinic Enterprise (three quarternary care medical centers and additional satellite medical centers) were reviewed to identify patients who underwent PNS implantation between January 2014 and January 2023. A primary outcome of interest was to assess whether administration of a preimplant diagnostic peripheral nerve block predicted pain relief at three months and six months after temporary and permanent PNS implantation. Another primary outcome was to investigate whether there was an association between the pain relief from a preimplant diagnostic peripheral nerve block and pain relief after three and six months after temporary or permanent PNS therapy. Linear regression analysis was conducted for outcomes of interest. RESULTS Of 193 eligible patients who underwent PNS therapy, a total of 173 patients were included in the final analysis and were stratified into either the temporary PNS cohort (n = 112) or the permanent PNS cohort (n = 61). Overall, 77.5% of all patients (134/173) underwent a preimplant diagnostic peripheral nerve block and reported a mean percentage relief of 70.1 ± 27.0 from the diagnostic block. Of patients in the temporary PNS cohort, there was no difference in postimplant percentage pain relief between patients who received a diagnostic block (n = 93) and control patients (n = 19) at three months (35.4 ± 36.0 vs 49.8 ± 36.1, respectively; β -14.45, 95% CI -32.98 to 4.07, p = 0.125) or at six months (23.3 ± 30.8 vs 45.7 ± 40.0, respectively; β -22.39, 95% CI -46.86 to 2.08, p = 0.072). Of patients in the permanent PNS cohort, there was no difference in postimplant percentage pain relief between patients who received a diagnostic block (n = 41) and control patients (n = 20) at three months (42.4 ± 34.3 vs 43.2 ± 42.4, respectively; β -0.79, 95% CI -23.56 to 21.99, p = 0.945) or at six months (44.3 ± 35.0 vs 38.8 ± 40.9, respectively; β 5.42, 95% CI -20.04 to 30.88, p = 0.669). Pain relief from preimplant diagnostic blocks was associated with postimplant pain relief from temporary PNS at three months (β 0.33, 95% CI 0.04-0.61, p = 0.025). However, pain relief from preimplant diagnostic blocks did not predict postimplant pain relief from temporary PNS at six months, or permanent PNS at three months and six months. CONCLUSIONS Administration of a diagnostic block is not associated with superior pain relief at three or six months after PNS implantation to that of an approach without diagnostic block. Pain relief from a diagnostic block may potentially predict short-term pain relief after temporary PNS therapy, although future prospective studies are warranted to evaluate the prognostic utility of diagnostic blocks.
Collapse
Affiliation(s)
- Chelsey M Hoffmann
- Mayo Clinic School of Health Science, Mayo Clinic Physician Assistant Program, Rochester, MN, USA
| | - Casey S Butler
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Matthew J Pingree
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Susan M Moeschler
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - William D Mauck
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
3
|
Goree JH, Grant SA, Dickerson DM, Ilfeld BM, Eshraghi Y, Vaid S, Valimahomed AK, Shah JR, Smith GL, Finneran JJ, Shah NN, Guirguis MN, Eckmann MS, Antony AB, Ohlendorf BJ, Gupta M, Gilbert JE, Wongsarnpigoon A, Boggs JW. Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement. Neuromodulation 2024; 27:847-861. [PMID: 38739062 DOI: 10.1016/j.neurom.2024.03.001] [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: 12/26/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.
Collapse
Affiliation(s)
- Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Stuart A Grant
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Yashar Eshraghi
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Sandeep Vaid
- Better Health Clinical Research, Newnan, GA, USA
| | | | - Jarna R Shah
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - G Lawson Smith
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Nirav N Shah
- Department of Anesthesiology, Critical Care, and Pain Medicine, Endeavor Health, Evanston, IL, USA; The University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Maged N Guirguis
- Department of Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Maxim S Eckmann
- Department of Anesthesiology, University of Texas San Antonio, San Antonio, TX, USA
| | | | - Brian J Ohlendorf
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Mayank Gupta
- Neuroscience Research Center, Overland Park, KS, USA
| | | | | | | |
Collapse
|
4
|
Parikh S, Echevarria AC, Cemenski BR, Small T. The Relevance of Implanted Percutaneous Electrical Nerve Stimulation in Orthopedics Surgery: A Systematic Review. J Clin Med 2024; 13:3699. [PMID: 38999266 PMCID: PMC11242780 DOI: 10.3390/jcm13133699] [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: 05/02/2024] [Revised: 05/17/2024] [Accepted: 05/30/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Percutaneous peripheral nerve stimulation (PNS) is a form of neuromodulation that involves the transmission of electrical energy via metal contacts known as leads or electrodes. PNS has gained popularity in orthopedic surgery as several studies have supported its use as a pain control device for patients suffering from pain due to orthopedic pathologies involving the knee, shoulder, and foot. The purpose of this systematic review is to summarize the literature involving peripheral nerve stimulation in orthopedic surgery. The existing body of literature provides support for further research regarding the use of PNS in the management of knee pain, hip pain, shoulder pain, foot pain, and orthopedic trauma. Notably, the evidence for its efficacy in addressing knee and shoulder pain is present. Methods: This study was conducted following PRISMA guidelines. Seven hundred and forty-five unique entries were identified. Two blinded reviewers assessed each article by title and abstract to determine its relevance and categorized them as "include", "exclude", and "maybe". After a preliminary review was completed, reviewers were unblinded and a third reviewer retrieved articles labeled as "maybe" and those with conflicting labels to determine their relevance. Twenty-eight articles were included, and seven hundred and seventeen articles were excluded. Articles discussing the use of PNS in the field of orthopedic surgery in patients > 18 years of age after 2010 were included. Exclusion criteria included neuropathic pain, phantom limb pain, amputation, non-musculoskeletal related pathology, non-orthopedic surgery related pathology, spinal cord stimulator, no reported outcomes, review articles, abstracts only, non-human subjects. Results: A total of 16 studies analyzing 69 patients were included. All studies were either case series or case reports. Most articles involved the application of PNS in the knee (8) and shoulder (6) joint. Few articles discussed its application in the foot and orthopedic trauma. All studies demonstrated that PNS was effective in reducing pain. Discussion: Peripheral nerve stimulation can be effective in managing postoperative or chronic pain in patients suffering from orthopedic pathology. This systematic review is limited by the scarcity of robust studies with substantial sample sizes and extended follow up periods in the existing literature.
Collapse
Affiliation(s)
- Sarthak Parikh
- Saint Francis Health Systems, Tulsa, OK 74136, USA
- Department of Orthopedic Surgery, Oklahoma State University, Tulsa, OK 74078, USA
- Orthopedic and Trauma Services of Oklahoma, Tulsa, OK 74135, USA
| | - Alexandra C Echevarria
- Kiran Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, FL 33328, USA
| | - Brandon R Cemenski
- College of Osteopathic Medicine, Des Moines University, Des Moines, IA 50266, USA
| | - Travis Small
- Saint Francis Health Systems, Tulsa, OK 74136, USA
- Department of Orthopedic Surgery, Oklahoma State University, Tulsa, OK 74078, USA
| |
Collapse
|
5
|
McCullough M, Kenney D, Curtin C, Ottestad E. Peripheral nerve stimulation for saphenous neuralgia. Reg Anesth Pain Med 2024; 49:455-460. [PMID: 38050145 DOI: 10.1136/rapm-2023-104538] [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: 05/08/2023] [Accepted: 09/15/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Injury to saphenous nerve branches is frequent during knee surgery and can result in chronic pain. This saphenous neuralgia remains challenging to treat. Peripheral nerve stimulation (PNS) is a new potential non-pharmacologic treatment option. We present our outcomes experience using this technology in 12 patients. METHODS We retrospectively reviewed PNS placement for saphenous neuralgia between 2000 and 2022 at a single institution. Demographic information was collected as well as response to the device. Four-question short-form Patient-Reported Outcome Measurement Information System (PROMIS) Scores were collected before and 2 weeks, 6 weeks, and 6 months postprocedure. Specific scores included pain interference and behavior, functional mobility, depression, anxiety, and sleep impairment. Change in pain interference measured by the short-form PROMIS tool at 6 months was chosen as the primary outcome. RESULTS Twelve patients met inclusion criteria, with 10 patients having the full 6-month follow-up. In these 10 patients, the mean change from baseline in the short-form adjusted pain interference score (greater difference means improved pain) at 6 months was 5.8 (SD 6.5). Among all patients, average follow-up was 11.5 months (range 3-35 months). Most patients' symptoms developed after knee surgery (84%). Prior to PNS, patients underwent other treatments including cryoablation (8%), radiofrequency ablation (16%), saphenous neurectomy (16%), or surgical release of adjacent nerves (25%). Ten patients (83%) reported any improvement in symptoms while two reported no benefit. Complications occurred in four patients (33%). Two patients had the device removed and a third discontinued use. PROMIS Scores for pain, functional mobility, mood, and sleep impairment all improved. DISCUSSION Limited effective treatments exist for saphenous neuralgia. Our case series demonstrates the potential of PNS as a treatment for saphenous neuralgia. Comparative effectiveness studies are warranted to assess whether our effect size is clinically relevant.
Collapse
Affiliation(s)
- Meghan McCullough
- Surgery, Plastic and Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deborah Kenney
- Orthopedic Surgery, Stanford University, Palo Alto, California, USA
| | - Catherine Curtin
- Surgery, Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Einar Ottestad
- Anesthesiology and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
6
|
Dalili D, Holzwanger DJ, Fleming JW, Igbinoba Z, Dalili DE, Beall DP, Isaac A, Yoon ES. Advanced Interventional Procedures for Knee Osteoarthritis: What Is the Current Evidence? Semin Musculoskelet Radiol 2024; 28:267-281. [PMID: 38768592 DOI: 10.1055/s-0044-1781432] [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: 05/22/2024]
Abstract
The prevalence of knee osteoarthritis (OA) is the highest among all joints and likely to increase over the coming decades. Advances in the repertoire of diagnostic capabilities of imaging and an expansion in the availability and range of image-guided interventions has led to development of more advanced interventional procedures targeting pain related to OA pain while improving the function of patients presenting with this debilitating condition. We review the spectrum of established advanced interventional procedures for knee OA, describe the techniques used to perform these procedures safely, and discuss the clinical evidence supporting each of them.
Collapse
Affiliation(s)
- Danoob Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Dorking Road, Epsom, London, United Kingdom
- Department of Diagnostic and Interventional Radiology, Epsom and St Helier University Hospitals NHS Trust, Dorking Road, Epsom, London, United Kingdom
| | - Daniel J Holzwanger
- Division of Vascular and Interventional Radiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Jacob W Fleming
- Comprehensive Specialty Care, Edmond, Oklahoma City, Oklahoma
| | - Zenas Igbinoba
- Department of Radiology, Hospital for Special Surgery, New York, New York
| | - Daniel E Dalili
- Department of Radiology, Southend University Hospital, Mid and South Essex NHS Trust, United Kingdom
| | - Douglas P Beall
- Comprehensive Specialty Care, Edmond, Oklahoma City, Oklahoma
| | - Amanda Isaac
- School of Biomedical Engineering & Imaging Sciences, Kings College London, London, United Kingdom
| | - Edward S Yoon
- Department of Radiology, Hospital for Special Surgery, New York, New York
| |
Collapse
|
7
|
Vu PD, Gul F, Robinson CL, Chen GH, Hasoon J. Peripheral Nerve Stimulation After Total Knee Arthroplasty and Non-Operable Patella Fracture. Orthop Rev (Pavia) 2024; 16:115599. [PMID: 38586247 PMCID: PMC10994825 DOI: 10.52965/001c.115599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/01/2024] [Indexed: 04/09/2024] Open
Abstract
Chronic knee pain, affecting over 25% of adults in the United States, has surged by 65% over the past two decades leading to rising functional deficits, mobility problems, and a diminished quality of life. While conservative management with pharmacologic and minimally invasive injections are pursued early in the disease process, total knee arthroplasty for refractory osteoarthritis of the knee is often considered. This procedure usually improves pain and functionality within the first three months. However, a significant portion of patients often suffer from postoperative pain that can become chronic and debilitating. We detail the case of a patient with a previous TKA as well as a non-operable patella fracture who obtained significant relief with PNS despite prior conservative and minimally invasive management.
Collapse
Affiliation(s)
- Peter D Vu
- Department of Physical Medicine & Rehabilitation The University of Texas Health Science Center at Houston
| | | | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine Beth Israel Deaconess Medical Center
| | - Grant H Chen
- Department of Anesthesiology, Critical Care, and Pain Medicine The University of Texas Health Science Center at Houston
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine The University of Texas Health Science Center at Houston
| |
Collapse
|
8
|
Ilfeld BM, Finneran JJ, Alexander B, Abramson WB, Sztain JF, Ball ST, Gonzales FB, Abdullah B, Cha BJ, Said ET. Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following total knee arthroplasty: a randomized, double-masked, sham-controlled pilot study. Reg Anesth Pain Med 2024:rapm-2023-105028. [PMID: 38388019 DOI: 10.1136/rapm-2023-105028] [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: 09/19/2023] [Accepted: 12/08/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Percutaneous auricular nerve stimulation (neuromodulation) is an analgesic technique involving the percutaneous implantation of multiple leads at various points on/around the ear followed by the delivery of electric current using an external pulse generator. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized, controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following total knee arthroplasty. METHODS Within the recovery room following primary, unilateral, total knee arthroplasty, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied using three percutaneous leads and one ground electrode. Participants were randomized to 5 days of either electrical stimulation or sham stimulation in a double-masked fashion. Participants were discharged with the stimulator in situ and removed the disposable devices at home. The dual primary treatment effect outcome measures were the cumulative opioid use (oral oxycodone) and the mean of the "average" daily pain measured with the Numeric Rating Scale for the first 5 postoperative days. RESULTS During the first five postoperative days, oxycodone consumption in participants given active stimulation (n=15) was a median (IQR) of 4 mg (2-12) vs 13 mg (5-23) in patients given sham (n=15) treatment (p=0.039). During this same period, the average pain intensity in patients given active stimulation was a median (IQR) of 2.5 (1.5-3.3) vs 4.0 (3.6-4.8) in those given sham (p=0.014). Awakenings due to pain over all eight postoperative nights in participants given active stimulation was a median (IQR) of 5 (3-8) vs 11 (4-14) in those given sham (p<0.001). No device-related localized cutaneous irritation, systemic side effects, or other adverse events were identified. CONCLUSIONS Percutaneous auricular neuromodulation reduced pain scores and opioid requirements during the initial week after total knee arthroplasty. Given the ease of application as well as the lack of systemic side effects and reported complications, a definitive clinical trial appears warranted. TRIAL REGISTRATION NUMBER NCT05521516.
Collapse
Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Scott T Ball
- Department of Orthopedic Surgery, University California San Diego, San Diego, California, USA
| | - Francis B Gonzales
- Department of Orthopedic Surgery, University California San Diego, San Diego, California, USA
| | - Baharin Abdullah
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Brannon J Cha
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, La Jolla, California, USA
| |
Collapse
|
9
|
Macres S, Aldwinckle RJ, Saldahna U, Pritzlaff SG, Jung M, Santos J, Kotova M, Bishop R. Reconceptualizing Acute Pain Management in the 21st Century. Adv Anesth 2023; 41:87-110. [PMID: 38251624 DOI: 10.1016/j.aan.2023.06.006] [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] [Indexed: 01/23/2024]
Abstract
Acute pain can have many etiologies that include surgical procedures, trauma (motor vehicle accident), musculoskeletal injuries (rib fracture) and, burns among others. Valuable components of a multimodal approach to acute pain management include both opioid and non-opioid medications, procedure specific regional anesthesia techniques (peripheral nerve blocks and neuraxial approaches), and interventional approaches (eg, peripheral nerve stimulation and cryo-neurolysis). Overall, successful acute perioperative pain management requires a multimodal, multidisciplinary approach that involves a coordinated effort between the surgical team, the anesthesia team, nursing, and pharmacy staff using Enhanced Recovery After Surgery (ERAS) protocols.
Collapse
Affiliation(s)
- Stephen Macres
- Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, 4150 V. Street, Sacramento, CA 95817, USA.
| | - Robin J Aldwinckle
- Anesthesiology, Department of Anesthesiology & Pain Medicine, 4150 V. Street, PSSB Suite 1200, Sacramento, CA 95817, USA
| | - Usha Saldahna
- Regional Anesthesia Fellowship, Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, 4150 V. Street, Sacramento, CA 95817, USA
| | - Scott G Pritzlaff
- Division of Pain Medicine, Pain Medicine Fellowship, Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, 4860 Y. Street, Suite 3020, Sacramento CA 95817, USA
| | - Michael Jung
- Pain Fellowship, Department of Anesthesiology and Pain Medicine, UC Davis Medical Center, 4860 Y. Street, Suite 3020, Sacramento CA 95817, USA
| | - Josh Santos
- Pre-Anesthesia Readiness & Education Program, 4150 V. Street, Sacramento, CA 95817, USA
| | - Mariya Kotova
- Department of Pharmacy, UC Davis Medical Center, 1240 47th Avenue, Sacramento, CA 95831, USA
| | - Robert Bishop
- Department of Anesthesiology and Pain Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| |
Collapse
|
10
|
Kelly TD, Pazzol ML, Rahimi Darabad R. Peripheral Nerve Stimulation in Chronic Knee Pain: A Case Series. Cureus 2023; 15:e50127. [PMID: 38186428 PMCID: PMC10771261 DOI: 10.7759/cureus.50127] [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] [Accepted: 12/06/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Chronic knee pain is increasing in prevalence and is associated with substantial limitations in functional mobility. Peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. However, there is a paucity of research exploring the potential therapeutic benefit of PNS for chronic knee pain. Methods This research is a retrospective case series of all patients who received PNS for the treatment of chronic knee pain performed at a single-center academic medical institution between March 2021 and June 2022. The primary outcome was percent pain reduction six months after implantation. Outcome data was obtained via chart review and phone calls to patients. Secondary outcomes included percent pain reduction two weeks and two months after implantation and adverse medical events related to the procedure and nerve stimulation. Results Fourteen individual patients received PNS for chronic knee pain during the study period. Three of these patients received bilateral PNS for a total of 17 cases. The mean percent pain reduction six months after implantation was 52% (SD=28.2) (N=12). A total of 75.0% of participants (9/12) reported ≥50% reductions in pain six months after implantation. No adverse events were reported relating to the implantation procedure and/or nerve stimulation. Conclusion PNS is a safe and efficacious treatment modality for chronic knee pain with demonstrated long-term benefit. Further research should clarify patient factors associated with improved treatment response.
Collapse
Affiliation(s)
- Timothy D Kelly
- Department of Emergency Medicine Residency, Indiana University School of Medicine, Indianapolis, USA
| | - Michael L Pazzol
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, USA
| | | |
Collapse
|
11
|
Pellegrino PR, Are M. Pain management in cancer surgery: Global inequities and strategies to address them. J Surg Oncol 2023; 128:1032-1037. [PMID: 37818914 DOI: 10.1002/jso.27441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 10/13/2023]
Abstract
Among patients undergoing surgical oncologic operations, patients in low- and middle-income countries are at particularly high risk for inadequate perioperative analgesia. This article reviews some of the guiding pillars of pain management for cancer surgery, including use of regional analgesia and acute pain service consultation, multimodal adjunctive analgesia, and judicious opioid use while presenting data on international disparities for each pillar and proposing strategies to address these inequities.
Collapse
Affiliation(s)
- Peter Ricci Pellegrino
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Madhuri Are
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| |
Collapse
|
12
|
Leal NTB, de Araújo NM, Silva SDO, Cabral MAL, da Silva BVS, Pinheiro TBM, Dantas RAN, Dantas DV. Pain management in the postoperative period of amputation surgeries: A scoping review. J Clin Nurs 2023; 32:7718-7729. [PMID: 37605033 DOI: 10.1111/jocn.16846] [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: 09/22/2022] [Revised: 06/01/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Pain in the postoperative period of amputation surgeries, when not managed correctly, can have consequences for the patient. PURPOSES AND OBJECTIVES The aim of this study was to map the scientific evidence on pain management in patients in the postoperative period of amputation surgeries. DESIGN Scoping review with elaboration based on the recommendations of the Joanna Briggs Institute, supported by The PAGER framework and guided by the PRISMA-ScR Checklist. METHODS The survey was conducted in August 2022 in 10 data sources. The 3300 publications found were analysed by two independent reviewers, after applying inclusion and exclusion criteria, 16 studies were selected. RESULTS Publications occurred between the years 1997 and 2022 and mainly dealt with the management of residual pain and phantom limb through pharmacological measures with pain assessment made by numerical scales. CONCLUSIONS The literature pointed out strategic uses of analgesics and highlighted technologies for neurostimulation through catheters. The need for new studies with non-pharmacological measures and with designs that can prove their effectiveness is reinforced. RELEVANCE TO CLINICAL PRACTICE The knowledge of these strategies by health professionals allows adequate pain management and patient follow-up for a less traumatic recovery. PATIENT OR PUBLIC CONTRIBUTION To patient or public involvement in this scoping review.
Collapse
|
13
|
Cho AM, Xiong JS, Burns SL. The Emerging Role of Peripheral Nerve Stimulation in Postoperative Analgesia. Curr Pain Headache Rep 2023; 27:601-605. [PMID: 37556045 DOI: 10.1007/s11916-023-01159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE OF REVIEW Though peripheral nerve stimulation has long been utilized in the field of chronic pain management, its use in acute pain management in the postoperative period is relatively novel and warrants further consideration. RECENT FINDINGS In the postsurgical period, peripheral nerve stimulation may offer an additional low-risk, opioid-sparing analgesic option, which is particularly pertinent in the setting of the ongoing opioid epidemic, as inadequate postsurgical analgesia has been shown to increase the risk of developing persistent or chronic postsurgical pain. In this review, we discuss the current literature that illustrate the emerging role of peripheral nerve stimulation as an effective treatment modality in the postoperative period for the management of acute pain, as various studies have recently been conducted evaluating the feasibility of utilizing percutaneous peripheral nerve stimulation as an adjunct in postsurgical analgesia. Nonetheless, future studies are necessary to continue to elucidate the short- and long-term impacts of peripheral nerve stimulation use in acute postsurgical analgesia.
Collapse
Affiliation(s)
- Annie M Cho
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jennifer S Xiong
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Stacey L Burns
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| |
Collapse
|
14
|
Smith BJ, Twohey EE, Dean KP, D'Souza RS. Peripheral Nerve Stimulation for the Treatment of Postamputation Pain: A Systematic Review. Am J Phys Med Rehabil 2023; 102:846-854. [PMID: 36917030 DOI: 10.1097/phm.0000000000002237] [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: 03/16/2023]
Abstract
ABSTRACT Despite numerous first-line treatment interventions, adequately managing a patient's postamputation pain can be difficult. Peripheral nerve stimulation has emerged as a safe neuromodulatory intervention that can be used for many etiologies of chronic pain. We performed a systemic review to appraise the evidence of peripheral nerve stimulation use for improvement in postamputation pain. This was performed in Ovid, Cochrane databases, OVID, Scopus, Web of Science Core Collection, and PubMed. The primary outcome was improvement in postamputation pain after use of peripheral nerve stimulation. Secondary outcomes included improvements in functional status, opioid usage, and mood. Data extraction and risk of bias assessments were performed independently in a blinded manner. Of the 989 studies identified, 13 studies were included consisting of three randomized control trials, seven observational studies, and three case series. While large heterogeneity limited definitive conclusions, the included studies generally demonstrated favorable outcomes regarding pain reduction. Each included study that used an objective pain scale demonstrated clinically significant pain improvements. Per the Grading of Recommendations, Assessment, Development, and Evaluations criteria, there is very low-quality Grading of Recommendations, Assessment, Development, and Evaluations evidence supporting that peripheral nerve stimulation is associated with improvements in pain intensity for postamputation pain. Future prospective, comparative, and well-powered studies assessing the use of peripheral nerve stimulation for postamputation pain are warranted.
Collapse
Affiliation(s)
- Brandon J Smith
- From the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota (BJS, EET, KPD); and Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota (RSD)
| | | | | | | |
Collapse
|
15
|
Moka E, Allam AES, Rekatsina M, Abed L, Paladini A, AlKharabsheh A, Vadalouca A, Varrassi G. Current Approaches to Four Challenging Pain Syndromes. Cureus 2023; 15:e45573. [PMID: 37868397 PMCID: PMC10586888 DOI: 10.7759/cureus.45573] [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: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
During a conference of pain specialists, some of the experts addressed the potential management of four prevalent but difficult painful conditions, namely, chronic postsurgical pain (CPSP), knee osteoarthritis, chest trauma, and facet joint arthropathy. In all cases, the conditions posed challenges in accurate diagnoses as well as safe, effective treatments, especially using locoregional blocks. It is not clear why some surgical patients develop CPSP and others do not, although some risk factors have been identified. More importantly, the transitional phase of pain from acute to chronic deserves greater scrutiny. It appears as if more aggressive and more effective perioperative and postoperative analgesia could help mitigate or possibly prevent CPSP. Knee osteoarthritis is prevalent but is often managed pharmacologically and then with joint replacement; many patients simply live with the condition which can be viewed as a disease of the entire joint. New approaches with intra-articular injections of hyaluronic acid, platelet-rich plasma, and botulinum toxin may provide safe, effective, and durable pain control. Chest trauma can be extremely painful and a source of morbidity, but its management tends to rely on watchful waiting and drug therapy. New approaches to regional nerve blocks can be beneficial and may reduce troublesome symptoms such as the inability to cough or clear the lungs. Facet joint arthropathy is very prevalent among older people but is not completely clarified. It may be the source of intense pain with limited management strategies. The role of nerve blocks in facet joint arthropathy is an important new addition to the armamentarium of pain management, particularly for geriatric patients.
Collapse
Affiliation(s)
- Eleni Moka
- Department of Anesthesiology, Creta InterClinic Hospital, Herakleion, GRC
| | - Abdallah El-Sayed Allam
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, ESP
- Physical Medicine, Rheumatology and Rehabilitation, Tanta University Hospitals & Faculty of Medicine, Tanta University, Tanta, EGY
| | | | - Lynda Abed
- Anesthesia and Intensive Care, Djilali Bounaama Douera Hospital University, Algiers, DZA
| | - Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA, University of L'Aquila, L'Aquila, ITA
| | - Abdullah AlKharabsheh
- King Abdullah University Hospital, Jordan University of Science and Technology, Amman, JOR
| | - Athina Vadalouca
- Pain and Palliative Care Center, Athens Medical Hospital, Athens, GRC
| | | |
Collapse
|
16
|
Tsui BCH, Gupta RK. Role of neuromodulation in acute pain settings. Reg Anesth Pain Med 2023; 48:338-342. [PMID: 37080583 DOI: 10.1136/rapm-2022-103837] [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: 06/01/2022] [Accepted: 11/15/2022] [Indexed: 04/22/2023]
Abstract
Peripheral nerve stimulation (PNS), a type of neuromodulatory technique, is increasingly used to treat chronic pain syndromes. PNS has also recently gained popularity as a viable adjunct analgesic modality in acute pain settings, where the practice primarily relies on using boluses or infusion of local anesthetics for nerve blockade, followed by stimulation to extend the analgesia. There is some early promise in PNS for perioperative analgesic control, but considerable obstacles must be addressed before it can be implemented into standard practice. In this daring discourse, we explore the possibilities and constraints of using the PNS paradigm in acute pain.
Collapse
Affiliation(s)
- Ban C H Tsui
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California, USA
| | - Rajnish K Gupta
- Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
17
|
Li AHY, Bhatia A, Gulati A, Ottestad E. Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts. Reg Anesth Pain Med 2023; 48:312-318. [PMID: 37080584 DOI: 10.1136/rapm-2022-104073] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 04/22/2023]
Abstract
Interventional pain management (IPM) options for refractory neuropathic pain (NP) have recently increased with availability of peripheral nerve stimulation (PNS) equipment and expertise. Given a lack of high-quality evidence and guidelines on this topic, we sought to understand the perception of physicians with expertise in treating NP regarding IPM and the role of PNS. We emailed a survey in March 2022 to international NP experts including pain medicine physicians, researchers, and leaders of 11 professional pain societies. No representatives from vendors of PNS systems were included in the design of the survey nor as respondents. Among 24 respondents (67% of those contacted), the distal common peroneal, tibial, and sural nerves were most frequently targeted (60%) with PNS. Persistent postsurgical pain of more than 3 months was the most common indication for PNS (84%). The aggregate NP treatment algorithm in order of median rank was non-opioid medications as first line, IPM including epidural/perineural steroid injections tied with transcutaneous electrical nerve stimulation as second line, pulsed radiofrequency (RF) tied with RF ablation/denervation as third line, temporary then permanent PNS as fourth line, followed by spinal cord stimulation, opioids, cryoablation, botulinum, peripheral nerve field stimulation, intrathecal targeted drug delivery, and others. Before offering PNS, 12 respondents (50%) indicated their preference for trialing non-neuromodulation treatments for 1-3 months. Twenty-two respondents (92%) agreed PNS should be offered early in the treatment of neuropathic pain. The most common barriers to PNS use were cost, lack of high-quality evidence in support of its use, lack of exposure to PNS in training programs, and lack of familiarity with the use of ultrasound guidance. PNS appears to have an increasing role in the treatment of NP but more research is needed on the outcomes of PNS to elucidate its role.
Collapse
Affiliation(s)
- Alice Huai-Yu Li
- Department of Anesthesia, Stanford University, Stanford, California, USA
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amit Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Einar Ottestad
- Anesthesiology and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| |
Collapse
|
18
|
Gargya A, Dhaliwal S, Haider N. Peripheral Nerve Stimulator for Chronic Pain From Quadriceps Tendon Rupture: A Case Report. Cureus 2023; 15:e39916. [PMID: 37287822 PMCID: PMC10241987 DOI: 10.7759/cureus.39916] [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] [Accepted: 06/03/2023] [Indexed: 06/09/2023] Open
Abstract
Chronic pain from quadriceps tendon rupture (QTR) presents a significant challenge for both orthopedic surgeons and pain management physicians. Current treatment options include physical therapy and medication management. Patients with refractory pain often end up using opioids and suffer from a prolonged disability that affects the quality of their life. A peripheral nerve stimulator is a novel treatment option for QTR. It is a minimally invasive treatment option that can be used to manage refractory cases in the future. We report a case of successful management of chronic pain in a patient with bilateral QTR with a femoral peripheral nerve stimulator.
Collapse
Affiliation(s)
- Akshat Gargya
- Anesthesia and Pain Medicine, University of Vermont, South Burlington, USA
| | - Sampreet Dhaliwal
- Anesthesia, Trinity Health Oakland/Wayne State University, Oakland, USA
| | - Naeem Haider
- Anesthesia and Pain Medicine, University of Vermont, South Burlington, USA
| |
Collapse
|
19
|
Zhu CC, Gargya A, Haider N. A Case Report of Three Patients Who Underwent Temporary Peripheral Nerve Stimulation for Treatment of Knee Pain Secondary to Osteoarthritis. Cureus 2023; 15:e40473. [PMID: 37333044 PMCID: PMC10270311 DOI: 10.7759/cureus.40473] [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] [Accepted: 06/15/2023] [Indexed: 06/20/2023] Open
Abstract
Knee osteoarthritis affects millions of people worldwide. There remains a role for novel therapies to manage pain for patients who are unable or unwilling to undergo knee arthroplasty. A peripheral nerve stimulator (PNS) may be beneficial in this population. We present a case report of three patients who received temporary femoral or saphenous PNS and were either unwilling or unable to undergo knee arthroplasty. Two of the three patients reported significantly reduced pain and improved functioning. Our case report demonstrates that temporary PNS may offer a safe and effective treatment for chronic knee pain secondary to knee osteoarthritis.
Collapse
Affiliation(s)
- Cheng-Cheng Zhu
- Anesthesiology and Pain Management, The Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, USA
| | - Akshat Gargya
- Anesthesiology and Pain Management, The Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, USA
| | - Naeem Haider
- Anesthesiology and Pain Management, The Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, USA
| |
Collapse
|
20
|
Lee MT, Mackie K, Chiou LC. Alternative pain management via endocannabinoids in the time of the opioid epidemic: Peripheral neuromodulation and pharmacological interventions. Br J Pharmacol 2023; 180:894-909. [PMID: 34877650 PMCID: PMC9170838 DOI: 10.1111/bph.15771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 11/23/2021] [Accepted: 11/27/2021] [Indexed: 01/18/2023] Open
Abstract
The use of opioids in pain management is hampered by the emergence of analgesic tolerance, which leads to increased dosing and side effects, both of which have contributed to the opioid epidemic. One promising potential approach to limit opioid analgesic tolerance is activating the endocannabinoid system in the CNS, via activation of CB1 receptors in the descending pain inhibitory pathway. In this review, we first discuss preclinical and clinical evidence revealing the potential of pharmacological activation of CB1 receptors in modulating opioid tolerance, including activation by phytocannabinoids, synthetic CB1 receptor agonists, endocannabinoid degradation enzyme inhibitors, and recently discovered positive allosteric modulators of CB1 receptors. On the other hand, as non-pharmacological pain relief is advocated by the US-NIH to combat the opioid epidemic, we also discuss contributions of peripheral neuromodulation, involving the electrostimulation of peripheral nerves, in addressing chronic pain and opioid tolerance. The involvement of supraspinal endocannabinoid systems in peripheral neuromodulation-induced analgesia is also discussed. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.
Collapse
Grants
- MOST 108-2321-B-002-005 Ministry of Science and Technology, Taiwan
- MOST 107-2811-B-002-008 Ministry of Science and Technology, Taiwan
- R01 DA041229 NIDA NIH HHS
- MOST 107-2321-B-002-010 Ministry of Science and Technology, Taiwan
- R01 DA047858 NIDA NIH HHS
- 107M4022-3 Ministry of Education, Taiwan
- MOST 106-2321-B-002-019 Ministry of Science and Technology, Taiwan
- NHRI-EX111-11114NI National Health Research Institutes, Taiwan
- FRGS/1/2021/WAB13/UCSI/02/1 Ministry of Higher Education, Malaysia
- R21 DA042584 NIDA NIH HHS
- REIG-FPS-2020/065 UCSI University Research Excellence and Innovation Grant, Malaysia
- NHRI-EX109-10733NI National Health Research Institutes, Taiwan
- MOST 104-2745-B-002-004 Ministry of Science and Technology, Taiwan
- MOST 109-2320-B-002-042-MY3 Ministry of Science and Technology, Taiwan
- MOST 107-2811-B-002 -008 Ministry of Science and Technology, Taiwan
- MOST 108-2320-B-002-029-MY3 Ministry of Science and Technology, Taiwan
Collapse
Affiliation(s)
- Ming Tatt Lee
- Department of Pharmacology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur 56000, Malaysia
| | - Ken Mackie
- Gill Center for Biomolecular Research, Indiana University, Bloomington, Indiana 47405, USA
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana 47405, USA
| | - Lih-Chu Chiou
- Department of Pharmacology, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei 10051, Taiwan
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 40402, Taiwan
| |
Collapse
|
21
|
Infection of a Retained Peripheral Nerve Stimulation Lead: A Case Report. A A Pract 2022; 16:e01626. [PMID: 36599038 DOI: 10.1213/xaa.0000000000001626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Percutaneous peripheral nerve stimulation is used to provide analgesia for weeks or even months. While infection of any percutaneously implanted object is a concern, it is exceedingly rare for helically coiled leads, with a reported incidence of less than 1 infection for every 32,000 indwelling days. We now report an infected helically coiled lead requiring sedation for extraction and complicated by lead fracture during removal, leaving a remnant in situ. The infection was successfully treated with oral antibiotics. We speculate on the cause of this infection and propose steps to prevent this complication, including the avoidance of sling-to-lead insertion site overlap.
Collapse
|
22
|
Percutaneous Auricular Nerve Stimulation (Neuromodulation) for Analgesia and Opioid-Sparing Following Knee and Hip Arthroplasty: A Proof-of-Concept Case Series. A A Pract 2022; 16:e01621. [PMID: 36240466 PMCID: PMC9616600 DOI: 10.1213/xaa.0000000000001621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We present a case series to demonstrate proof-of-concept for the off-label use of an auricular neuromodulation device-originally developed to treat symptoms associated with opioid withdrawal-to instead provide analgesia and opioid-sparing following knee and hip arthroplasties. Within the recovery room, an auricular neuromodulation device (near-field stimulator system 2 [NSS-2] Bridge, Masimo) was applied to 5 patients. Average daily pain at rest and while moving was a median of 0 to 2 as measured on the 0 to 10 numeric rating scale, while median daily oxycodone use was 0 to 2.5 mg until device removal at home on postoperative day 5. One patient avoided opioid use entirely.
Collapse
|
23
|
Gabriel RA, Ilfeld BM. Extending Perioperative Analgesia with Ultrasound-Guided, Percutaneous Cryoneurolysis, and Peripheral Nerve Stimulation (Neuromodulation). Anesthesiol Clin 2022; 40:469-479. [PMID: 36049875 DOI: 10.1016/j.anclin.2022.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The use of regional anesthesia is key to a successful approach to improving postoperative analgesia, which involves local anesthetic deposition either around peripheral nerves or within a fascial plane. Unfortunately, the realistic duration even with continuous peripheral nerve blocks usually does not match the duration of surgical pain, comprising a major limitation. Here, the use of 2 interventional modalities-ultrasound-guided percutaneous cryoneurolysis and peripheral nerve stimulation-is discussed, both of which may be used to treat acute and subacute pain and may therefore have a positive impact on the incidence and severity of chronic pain development.
Collapse
Affiliation(s)
- Rodney A Gabriel
- Division of Regional Anesthesia and Acute Pain medicine, Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103-8990, USA
| | - Brian M Ilfeld
- Division of Regional Anesthesia and Acute Pain medicine, Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103-8990, USA; Department of Anesthesiology, 9500 Gilman Drive, MC 0898, La Jolla, CA 92093-0898, USA.
| |
Collapse
|
24
|
Strand N, D'Souza RS, Hagedorn JM, Pritzlaff S, Sayed D, Azeem N, Abd-Elsayed A, Escobar A, Huntoon MA, Lam CM, Deer TR. Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain. J Pain Res 2022; 15:2483-2504. [PMID: 36039168 PMCID: PMC9419727 DOI: 10.2147/jpr.s362204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/29/2022] [Indexed: 12/17/2022] Open
Abstract
The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.
Collapse
Affiliation(s)
- Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Scott Pritzlaff
- Department of Anesthesiology and Pain Medicine, Division of Pain Medicine, University of California-Davis, Sacramento, CA, USA
| | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | - Nomen Azeem
- Florida Spine & Pain Specialists, Bradenton, FL, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | | | - Mark A Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Henrico, VA, USA
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| |
Collapse
|
25
|
Peripheral Nerve Stimulation for Lower Extremity Pain. Biomedicines 2022; 10:biomedicines10071666. [PMID: 35884969 PMCID: PMC9313008 DOI: 10.3390/biomedicines10071666] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 11/22/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is rapidly increasing in use. This interventional pain treatment modality involves modulating peripheral nerves for a variety of chronic pain conditions. This review evaluated its use specifically in the context of chronic lower extremity pain. Studies continue to elucidate the utility of PNS and better define indications, contraindications, as well as short- and long-term benefits of the procedure for the lower extremity. While large, prospective evidence is still lacking, the best available evidence suggests that improvements may be seen in pain scores, functionality, and opioid consumption. Overall, evidence synthesis suggests that PNS for the lower extremities may be a viable option for patients with chronic lower extremity pain.
Collapse
|
26
|
Sciatic nerve stimulation alleviates acute neuropathic pain via modulation of neuroinflammation and descending pain inhibition in a rodent model. J Neuroinflammation 2022; 19:153. [PMID: 35706025 PMCID: PMC9199305 DOI: 10.1186/s12974-022-02513-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background Neuropathic pain (NP) is characterized by abnormal activation of pain conducting pathways and manifests as mechanical allodynia and thermal hypersensitivity. Peripheral nerve stimulation is used for treatment of medically refractory chronic NP and has been shown to reduce neuroinflammation. However, whether sciatic nerve stimulation (SNS) is of therapeutic benefit to NP remains unclear. Moreover, the optimal frequency for SNS is unknown. To address this research gap, we investigated the effect of SNS in an acute NP rodent model. Methods Rats with right L5 nerve root ligation (NRL) or Sham surgery were used. Ipsilateral SNS was performed at 2 Hz, 20 Hz, and 60 Hz frequencies. Behavioral tests were performed to assess pain and thermal hypersensitivity before and after NRL and SNS. Expression of inflammatory proteins in the L5 spinal cord and the immunohistochemical alterations of spinal cord astrocytes and microglia were examined on post-injury day 7 (PID7) following NRL and SNS. The involvement of the descending pain modulatory pathway was also investigated. Results Following NRL, the rats showed a decreased pain threshold and latency on the von Frey and Hargreaves tests. The immunofluorescence results indicated hyperactivation of superficial spinal cord dorsal horn (SCDH) neurons. Both 2-Hz and 20-Hz SNS alleviated pain behavior and hyperactivation of SCDH neurons. On PID7, NRL resulted in elevated expression of spinal cord inflammatory proteins including NF-κB, TNF-α, IL-1β, and IL-6, which was mitigated by 2-Hz and 20-Hz SNS. Furthermore, 2-Hz and 20-Hz SNS suppressed the activation of spinal cord astrocytes and microglia following NRL on PID7. Activity of the descending serotoninergic pain modulation pathway showed an increase early on PID1 following 2-Hz and 20-Hz SNS. Conclusions Our results support that both 2-Hz and 20-Hz SNS can alleviate NP behaviors and hyperactivation of pain conducting pathways. We showed that SNS regulates neuroinflammation and reduces inflammatory protein expression, astrocytic gliosis, and microglia activation. During the early post-injury period, SNS also facilitates the descending pain modulatory pathway. Taken together, these findings support the therapeutic potential of SNS for acute NP. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-022-02513-y.
Collapse
|
27
|
Percutaneous Auricular Nerve Stimulation (Neuromodulation) for the Treatment of Pain: A Proof-of-Concept Case Report using Total Joint Arthroplasty as a Surrogate for Battlefield Trauma. J Trauma Acute Care Surg 2022; 93:S165-S168. [PMID: 35594419 PMCID: PMC9323550 DOI: 10.1097/ta.0000000000003706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In 2 cases we show that ambulatory percutaneous auricular nerve stimulation is feasible after joint arthroplasty. This off-label use appears to have markedly reduced pain and opioid use free of systemic side effects. It is thus a possible analgesic for use on the battlefield. There are few effective pain treatments following trauma on the battlefield other than opioids, which are limited by respiratory depression. Ultrasound-guided percutaneous peripheral nerve stimulation (“neuromodulation”) has been proposed as an analgesic, but requires physician-level skills, advanced equipment, and an hour to administer. In contrast, percutaneous auricular neuromodulation may be placed by a medic in the field under nonsterile conditions in a few minutes, theoretically provides analgesia for any anatomic location, has no side effects, and no significant risks. It therefore offers the potential to be applied quickly on the battlefield without any of the limitations of opioids. We propose total joint replacement as a surrogate for battlefield trauma and here present a case report to demonstrate proof of concept.
Collapse
|
28
|
Pingree MJ, Hurdle MF, Spinner DA, Valimahomed A, Crosby ND, Boggs JW. Real-world evidence of sustained improvement following 60-day peripheral nerve stimulation treatment for pain: a cross-sectional follow-up survey. Pain Manag 2022; 12:611-621. [PMID: 35510333 DOI: 10.2217/pmt-2022-0005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: This study presents real-world data from a cross-sectional follow-up survey of patients who previously received 60-day peripheral nerve stimulation (PNS) treatment for pain. Materials & methods: A survey including validated pain and other related outcome measures was distributed to patients who previously underwent implantation of temporary PNS leads for 60-day PNS treatment. Results: Among survey respondents who were at least 3 months from the start of treatment, most reported sustained clinically significant improvements in pain and/or quality of life, with the length of follow-up at the time of survey completion ranging from 3 to 30 months. Conclusion: These real-world data support recent prospective studies indicating that 60-day percutaneous PNS provides significant and sustained relief across a wide range of pain conditions.
Collapse
Affiliation(s)
- Matthew J Pingree
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55901, USA
| | - Mark Fb Hurdle
- Pain Medicine & Spine Care, Mayo Clinic, Jacksonville, FL 32224, USA
| | - David A Spinner
- Rehabilitation Medicine, Mount Sinai Health System, New York, NY 10029, USA
| | | | | | | |
Collapse
|
29
|
Fogel HP, Winfree CJ. What’s New in Peripheral Nerve Stimulation. Neurosurg Clin N Am 2022; 33:323-330. [DOI: 10.1016/j.nec.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
30
|
Naidu R, Li S, Desai MJ, Sheth S, Crosby ND, Boggs JW. 60-Day PNS Treatment May Improve Identification of Delayed Responders and Delayed Non-Responders to Neurostimulation for Pain Relief. J Pain Res 2022; 15:733-743. [PMID: 35310895 PMCID: PMC8932923 DOI: 10.2147/jpr.s349101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Conventional neurostimulation typically involves a brief (eg, ≤10-day) trial to assess presumed effectiveness prior to permanent implantation. Low trial conversion rates and high explant rates due to inadequate pain relief highlight the need for improved patient identification strategies. The development of a 60-day percutaneous peripheral nerve stimulation (PNS) system enables evaluation of outcomes following an extended temporary treatment period of up to 60 days, that may obviate or validate the need for permanent implant. The present study provides the first real-world evidence regarding patient response throughout a 60-day PNS treatment period. Methods Anonymized data listings were compiled from patients who underwent implantation of temporary percutaneous leads and opted-in to provide real-world data to the device manufacturer during routine interactions with device representatives throughout the 60-day treatment. Results Overall, 30% (222/747) of patients were early responders (≥50% pain relief throughout treatment). Another 31% (231/747) of patients initially presented as non-responders but surpassed 50% pain relief by the end of treatment. Conversely, 32% (239/747) of patients were non-responders throughout treatment. An additional 7% (55/747) of patients initially presented as responders but fell below 50% relief by the end of the treatment period. Conclusion An extended, 60-day PNS treatment may help identify delayed responders, providing the opportunity for sustained relief and improving access to effective PNS treatment. Compared to a conventionally short trial of ≤10 days, a longer 60-day PNS treatment may also help reduce explant rates by identifying delayed non-responders unlikely to benefit long-term. These scenarios support the importance of an extended 60-day temporary PNS stimulation period to help inform stepwise treatment strategies that may optimize outcomes and cost-effectiveness.
Collapse
Affiliation(s)
- Ramana Naidu
- California Orthopedics & Spine, Larkspur, CA, USA
- Correspondence: Ramana Naidu, California Orthopedics & Spine, 2 Bon Air Road #120, Larkspur, CA, 94939, USA, Tel +1 608-695-7266, Email
| | - Sean Li
- Premier Pain Centers, Shrewsbury, NJ, USA
| | - Mehul J Desai
- International Spine Pain & Performance Center, Washington, DC, USA
- George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Samir Sheth
- Sutter Roseville Pain Management, Roseville, CA, USA
| | | | | |
Collapse
|
31
|
Li AH, Gulati A, Leong MS, Aggarwal AK, Salmasi V, Spinner D, Ottestad E. Considerations in Permanent Implantation of Peripheral Nerve Stimulation (PNS) for Chronic Neuropathic Pain: An International Cross Sectional Survey of Implanters. Pain Pract 2022; 22:508-515. [PMID: 35178863 DOI: 10.1111/papr.13105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/11/2022] [Accepted: 02/14/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Novel minimally invasive short-term and long-term peripheral nerve stimulation (PNS) systems have revolutionized targeted treatment of chronic neuropathic pain. We present an international survey of PNS-implanting pain physicians to assess what factors they consider when offering permanent PNS. METHODS This cross-sectional study consisted of a survey (Qualtrics) that was distributed to PNS-implanting physicians in a device supplier's entire email database on November 13, 2020, with 3 weeks of response time. Physicians' contact information in the form of their email addresses had been previously collected by the supplier upon device distribution with permission to use survey responses for research. RESULTS Of 2,032 database physicians, 40 physicians representing 37 institutions responded to the survey. The most common application of PNS was mononeuropathic pain (57%). The most frequently targeted nerve was the suprascapular nerve (29%). 14% of physicians reported 81-100% of their implants were dual-lead. The representative physicians ranged broadly in their most frequently-targeted nerves. Although mononeuropathic pain was the most common indication for PNS, there was still varied response regarding other indications such as CRPS and post-surgical chronic pain. CONCLUSION In context of a low response rate, identifying such factors can help update the prevailing treatment algorithm for interventional therapies, assist pain physicians in better identifying which patients are the best candidates for PNS, and inform future clinical trial design on PNS efficacy.
Collapse
Affiliation(s)
- Alice H Li
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford Stanford, CA, USA
| | - Amitabh Gulati
- Department of Chronic Pain, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY, USA
| | - Michael S Leong
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford Stanford, CA, USA
| | - Anuj K Aggarwal
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford Stanford, CA, USA
| | - Vafi Salmasi
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford Stanford, CA, USA
| | - David Spinner
- Department of Rehabilitation and Human Performance, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | - Einar Ottestad
- Department of Anesthesiology Perioperative and Pain Medicine, Stanford Stanford, CA, USA
| |
Collapse
|
32
|
Hoffmann CM, Coy DS, Moeschler SM, Pingree MJ, Mauck WD. Incidence of Temporary Peripheral Nerve Stimulator Lead Tip Retention: A Retrospective Review of 80 Lead Placements. Neuromodulation 2022; 26:690-693. [PMID: 35227583 DOI: 10.1016/j.neurom.2022.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/26/2021] [Accepted: 01/08/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The primary objective of this study was to determine the current rate of lead fracture during temporary percutaneous peripheral nerve stimulator (PNS) lead removal at the Mayo Clinic Rochester Division of Pain Medicine. MATERIALS AND METHODS A retrospective review of electronic medical records was performed for patients implanted with a temporary percutaneous PNS device between January 1, 2018, and December 31, 2020. Patients were included if they underwent temporary percutaneous PNS system implant, with planned lead removal at 60 days. Data collection included date of implant, diagnosis, peripheral nerve target(s), number of leads, and lead tip status at the time of removal (intact vs fractured). RESULTS Fifty patients underwent a total of 80 temporary percutaneous PNS leads placed during the time frame analyzed. Of the 80 temporary percutaneous PNS leads implanted, there were five lead fractures at the time of intentional lead removal. CONCLUSIONS This retrospective review of 50 patients with 80 temporary percutaneous PNS leads implanted for chronic peripheral neuropathic pain resulted in a 6.25% rate of retained lead fragment at the time of lead removal by the provider at the end of 60-day treatment. This fracture and retention rate is consistent with previous published retrospective data on PNS, which has shown a 3% to 21% lead fracture rate during intentional lead removal.
Collapse
|
33
|
Linko YV, Rokyta TG, Rokyta VG. THE ADVANTAGES OF MINIMAL BONE CUTS RESECTION IN TOTAL KNEE REPLACEMENT. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2022. [DOI: 10.29254/2077-4214-2022-3-166-324-331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
34
|
Abd-Elsayed A, D’Souza RS. Peripheral Nerve Stimulation: The Evolution in Pain Medicine. Biomedicines 2021; 10:biomedicines10010018. [PMID: 35052698 PMCID: PMC8773238 DOI: 10.3390/biomedicines10010018] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 01/12/2023] Open
Abstract
Electrical stimulation of peripheral nerves has been utilized for a variety of indications for over five decades [...].
Collapse
Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53711, USA
- Correspondence:
| | - Ryan S. D’Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic Hospital, Rochester, MN 55905, USA;
| |
Collapse
|
35
|
Juncker RB, Mirza FM, Gagnier JJ. Reduction in opioid use with perioperative non-pharmacologic analgesia in total knee arthroplasty and ACL reconstruction: a systematic review. SICOT J 2021; 7:63. [PMID: 34928208 PMCID: PMC8686827 DOI: 10.1051/sicotj/2021063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: The world’s opioid epidemic has gotten increasingly severe over the last several decades and projects to continue worsening. Orthopedic surgery is the largest contributor to this epidemic, accounting for 8.8% of postoperative opioid dependence cases. Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction are commonly performed orthopedic operations heavily reliant on opioids as the primary analgesic in the peri- and immediate postoperative period. These downfalls highlight the pressing need for an alternate, non-pharmacologic analgesic to reduce postoperative opioid use in orthopedic patients. The presented systematic review aimed to analyze and compare the most promising non-pharmacologic analgesic interventions in the available literature to guide future research in such a novel field. Methods: A systematic search of PubMed, MEDLINE, Embase, Cochrane, and Web of Science was performed for studies published before July 2020 based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, and the obtained manuscripts were evaluated for inclusion or exclusion against strict, pre-determined criteria. Risk-of-bias and GRADE (grades of recommendation, assessment, development, and evaluation) assessments were then performed on all included studies. Results: Six studies were deemed fit for inclusion, investigating three non-pharmacologic analgesics: percutaneous peripheral nerve stimulation, cryoneurolysis, and auricular acupressure. All three successfully reduced postoperative opioid use while simultaneously maintaining the safety and efficacy of the procedure. Discussion: The results indicate that all three presented non-pharmacologic analgesic interventions are viable and warrant future research. That said, because of its slight advantages in postoperative pain control and operational outcomes, cryoneurolysis seems to be the most promising. Further research and eventual clinical implementation of these analgesics is not only warranted but should be a priority because of their vast potential to reduce orthopedics surgeries’ contribution to the opioid epidemic.
Collapse
Affiliation(s)
- Ryan B Juncker
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), 615 Charles E Young Dr S, Rm. 410, Los Angeles, CA 90095, USA
| | - Faisal M Mirza
- Coastal Health Partners, 65 Nielson St #102, Watsonville, CA 95076, USA
| | - Joel J Gagnier
- Department of Orthopaedic Surgery, Department of Epidemiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA
| |
Collapse
|
36
|
Peripheral Nerve Stimulation: A Review of Techniques and Clinical Efficacy. Pain Ther 2021; 10:961-972. [PMID: 34331668 PMCID: PMC8586305 DOI: 10.1007/s40122-021-00298-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/19/2021] [Indexed: 12/21/2022] Open
Abstract
Chronic pain is a common source of morbidity in many patient populations worldwide. There are growing concerns about the potential side effects of currently prescribed medications and a continued need for effective treatment. Related to these concerns, peripheral nerve stimulation has been regaining popularity as a potential treatment modality. Peripheral nerve stimulation components include helically coiled electrical leads, which direct an applied current to afferent neurons providing sensory innervation to the painful area. In theory, the applied current to the peripheral nerve will alter the large-diameter myelinated afferent nerve fibers, which interfere with the central processing of pain signals through small-diameter afferent fibers at the level of the spinal cord. Multiple studies have shown success in the use of peripheral nerve stimulation for acute post-surgical pain for orthopedic surgery, including post total knee arthroplasty and anterior cruciate ligament surgery, and chronic knee pain. Many studies have investigated the utility of peripheral nerve stimulation for the management of chronic shoulder pain. Peripheral nerve stimulation also serves as one of the potential non-pharmacologic therapies to treat back pain along with physical therapy, application of transcutaneous electrical neurostimulation unit, radiofrequency ablation, epidural steroid injections, permanently implanted neurostimulators, and surgery. Studies regarding back pain treatment have shown that peripheral nerve stimulation led to significant improvement in all pain and quality-of-life measures and a reduction in the use of opioids. Further studies are needed as the long-term risks and benefits of peripheral nerve stimulation have not been well studied as most information available on the effectiveness of peripheral nerve stimulation is based on shorter-term improvements in chronic pain.
Collapse
|
37
|
Albright-Trainer B, Phan T, Trainer RJ, Crosby ND, Murphy DP, Disalvo P, Amendola M, Lester DD. Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial. Pain Manag 2021; 12:357-369. [PMID: 34761694 DOI: 10.2217/pmt-2021-0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction & aim: Temporary (60-day) percutaneous peripheral nerve stimulation (PNS) has demonstrated effectiveness for the treatment of chronic post-amputation pain, and this pilot study aims to evaluate the feasibility of temporary percutaneous PNS for the treatment of acute post-amputation pain. Patients & methods: Sixteen veterans undergoing lower extremity amputation received PNS and standard medical therapy or standard medical therapy alone. Results: The PNS group reported greater reductions in average phantom limb pain, residual limb pain and daily opioid consumption, and there were fewer participants taking opioids through 3 months post-amputation. Conclusion: This pilot study suggests that PNS is feasible in the acute postoperative period following lower limb amputation and may provide a non-pharmacologic analgesic therapy that lowers pain scores and reduces opioid consumption, and thus warrants further investigation.
Collapse
Affiliation(s)
- Brooke Albright-Trainer
- Department of Anesthesiology, Central Virginia VA Health Care System, Richmond, VA 23249, USA.,Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA 23249, USA
| | - Thomas Phan
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Robert J Trainer
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | | | - Douglas P Murphy
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Peter Disalvo
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Michael Amendola
- Department of Surgery, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Denise D Lester
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| |
Collapse
|
38
|
Chitneni A, Berger AA, Orhurhu V, Kaye AD, Hasoon J. Peripheral Nerve Stimulation of the Saphenous and Superior Lateral Genicular Nerves for Chronic Pain After Knee Surgery. Orthop Rev (Pavia) 2021; 13:24435. [PMID: 34745463 DOI: 10.52965/001c.24435] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/21/2021] [Indexed: 11/06/2022] Open
Abstract
Total knee arthroplasty (TKA) is one of the most commonly conducted surgeries in the United States. Typically, TKA is conducted to relieve pain from patients with long-standing osteoarthritis. Postoperative knee pain is a common issue after TKA. For some patients, postoperative knee pain exceeds the normal 3-6-month phase and becomes chronic. Pain is typically managed with the use of medications and physical therapy. In this case, we describe the use of peripheral nerve stimulation (PNS) of the saphenous and superior lateral genicular nerves for a patient experiencing chronic postoperative knee pain utilizing SPRINT PNS technology.
Collapse
Affiliation(s)
| | | | - Vwaire Orhurhu
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Shreveport, LA
| | - Jamal Hasoon
- Beth Israel Deaconess Medical Center, Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA; Pain Specialists of America, Austin, TX
| |
Collapse
|
39
|
Ilfeld BM, Plunkett A, Vijjeswarapu AM, Hackworth R, Dhanjal S, Turan A, Cohen SP, Eisenach JC, Griffith S, Hanling S, Sessler DI, Mascha EJ, Han Y, Boggs JW, Wongsarnpigoon A, Gelfand H. Percutaneous Neuromodulation of the Brachial Plexus and Sciatic Nerve for the Treatment of Acute Pain Following Surgery: Secondary Outcomes From a Multicenter, Randomized, Controlled Pilot Study. Neuromodulation 2021; 26:638-649. [PMID: 34343394 DOI: 10.1111/ner.13492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We recently reported that percutaneous peripheral nerve stimulation (PNS or "neuromodulation") decreased pain and opioid consumption within the first two weeks following ambulatory surgery. However, the anatomic lead locations were combined for the analysis, and benefits for each location remain unknown. We therefore now report the effects of percutaneous PNS for brachial plexus and sciatic nerve leads separately. MATERIALS AND METHODS Before surgery, leads were implanted percutaneously to target the brachial plexus (N = 21) for rotator cuff repair or sciatic nerve (N = 40) for foot/ankle surgery, followed by a single injection of local anesthetic. Postoperatively, subjects were randomized in a double masked fashion to 14 days of electrical stimulation (N = 30) or sham/placebo (N = 31) using an external pulse generator. The primary outcome of interest was opioid consumption and pain scores evaluated jointly. Thus, stimulation was deemed effective if superior on either outcome and at least noninferior on the other. RESULTS For brachial plexus leads, during the first seven postoperative days pain measured with the numeric rating scale in participants given active stimulation was a median [interquartile range ] of 0.8 [0.5, 1.6] versus 3.2 [2.7, 3.5] in patients given sham (p < 0.001). For this same group, opioid consumption in participants given active stimulation was 10 mg [5, 20] versus 71 mg [35, 125] in patients given sham (p = 0.043). For sciatic nerve leads, pain scores for the active treatment group were 0.7 [0, 1.4] versus 2.8 [1.6, 4.6] in patients given sham (p < 0.001). During this same period, participants given active stimulation consumed 5 mg [0, 30] of opioids versus 40 mg [20, 105] in patients given sham (p = 0.004). Treatment effects did not differ statistically between the two locations. CONCLUSIONS Ambulatory percutaneous PNS of both the brachial plexus and sciatic nerve is an effective treatment for acute pain free of systemic side-effects following painful orthopedic surgery.
Collapse
Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University California San Diego, San Diego, CA, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Anthony Plunkett
- Department of Anesthesiology, Womack Army Medical Center, Fayetteville, NC, USA
| | | | - Robert Hackworth
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, USA
| | - Sandeep Dhanjal
- Department of Anesthesiology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Alparslan Turan
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, MD, USA
| | - James C Eisenach
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Scott Griffith
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Steven Hanling
- Department of Physical Medicine and Rehabilitation, Columbia Veterans Affairs Health Care System, Columbia, SC, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Edward J Mascha
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Yanyan Han
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Harold Gelfand
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | |
Collapse
|
40
|
Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study. Anesthesiology 2021; 135:95-110. [PMID: 33856424 DOI: 10.1097/aln.0000000000003776] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Percutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption. METHODS Preoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days. RESULTS During the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001). CONCLUSIONS Percutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery. EDITOR’S PERSPECTIVE
Collapse
|
41
|
Ye Y, Gabriel RA, Mariano ER. The expanding role of chronic pain interventions in multimodal perioperative pain management: a narrative review. Postgrad Med 2021; 134:449-457. [PMID: 34033737 DOI: 10.1080/00325481.2021.1935281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Surgery is a risk factor for chronic pain and long-term opioid use. As perioperative pain management continues to evolve, treatment modalities traditionally used for chronic pain therapy may provide additional benefit to patients undergoing surgery. Interventions such as radiofrequency ablation, cryoneurolysis, and neuromodulation may potentially be used in conjunction with acute pain procedures such as nerve blocks and multimodal analgesia. Pharmacological agents associated with chronic pain medicine, including gabapentinoids, ketamine, and selective serotonin reuptake inhibitors, may be useful adjuncts in perioperative pain management when indicated. There may also be a role for acupuncture, music therapy, and other integrative medicine therapies. A transitional pain service can help coordinate outpatient care with inpatient perioperative pain management and promote a more personalized and comprehensive approach that can improve postoperative outcomes.
Collapse
Affiliation(s)
- Ying Ye
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine; Stanford, California, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia, University of California, San Diego; California, USA.,Department of Medicine, Division of Biomedical Informatics, University of California, San Diego; California, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System; Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine; Stanford, California, USA
| |
Collapse
|
42
|
Cryoneurolysis and Peripheral Nerve Stimulation: Reply. Anesthesiology 2021; 134:818-819. [PMID: 33721910 DOI: 10.1097/aln.0000000000003740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
43
|
Hasoon J, Chitneni A, Urits I, Viswanath O, Kaye AD. Peripheral Stimulation of the Saphenous and Superior Lateral Genicular Nerves for Chronic Knee Pain. Cureus 2021; 13:e14753. [PMID: 34084679 PMCID: PMC8163353 DOI: 10.7759/cureus.14753] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Chronic knee pain continues to cause increasing levels of functional deficits, mobility issues, and decreased quality of life in the United States. Initial treatment for knee pain consists of physical therapy, weight loss, medication management, injections, and radiofrequency ablation (RFA). Definitive treatment usually requires surgical management. Peripheral nerve stimulation (PNS) has been effective in the treatment of a variety of chronic pain conditions including the treatment of postoperative pain related to knee surgery. We describe the case of a patient who refused operative management as well as RFA of the genicular nerves and obtained significant pain relief from PNS of the superior lateral genicular nerve and the saphenous nerve for severe knee pain caused by osteoarthritis.
Collapse
Affiliation(s)
- Jamal Hasoon
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Ahish Chitneni
- Department of Anesthesiology, A.T. Still University School of Medicine, Mesa, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Omar Viswanath
- Department of Anesthesia and Pain Management, Valley Anesthesiology and Pain Consultants, Phoenix, USA
| | - Alan D Kaye
- Department of Anesthesia and Pain Management, Louisiana State University Health Sciences Center, Shreveport, USA
| |
Collapse
|
44
|
Beeve AT, Shen I, Zhang X, Magee K, Yan Y, MacEwan MR, Scheller EL. Neuroskeletal Effects of Chronic Bioelectric Nerve Stimulation in Health and Diabetes. Front Neurosci 2021; 15:632768. [PMID: 33935630 PMCID: PMC8080454 DOI: 10.3389/fnins.2021.632768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/16/2021] [Indexed: 12/02/2022] Open
Abstract
Background/Aims Bioelectric nerve stimulation (eStim) is an emerging clinical paradigm that can promote nerve regeneration after trauma, including within the context of diabetes. However, its ability to prevent the onset of diabetic peripheral neuropathy (DPN) has not yet been evaluated. Beyond the nerve itself, DPN has emerged as a potential contributor to sarcopenia and bone disease; thus, we hypothesized that eStim could serve as a strategy to simultaneously promote neural and musculoskeletal health in diabetes. Methods To address this question, an eStim paradigm pre-optimized to promote nerve regeneration was applied to the sciatic nerve, which directly innervates the tibia and lower limb, for 8 weeks in control and streptozotocin-induced type 1 diabetic (T1D) rats. Metabolic, gait, nerve and bone assessments were used to evaluate the progression of diabetes and the effect of sciatic nerve eStim on neuropathy and musculoskeletal disease, while also considering the effects of cuff placement and chronic eStim in otherwise healthy animals. Results Rats with T1D exhibited increased mechanical allodynia in the hindpaw, reduced muscle mass, decreased cortical and cancellous bone volume fraction (BVF), reduced cortical bone tissue mineral density (TMD), and decreased bone marrow adiposity. Type 1 diabetes also had an independent effect on gait. Placement of the cuff electrode alone resulted in altered gait patterns and unilateral reductions in tibia length, cortical BVF, and bone marrow adiposity. Alterations in gait patterns were restored by eStim and tibial lengthening was favored unilaterally; however, eStim did not prevent T1D-induced changes in muscle, bone, marrow adiposity or mechanical sensitivity. Beyond this, chronic eStim resulted in an independent, bilateral reduction in cortical TMD. Conclusion Overall, these results provide new insight into the pathogenesis of diabetic neuroskeletal disease and its regulation by eStim. Though eStim did not prevent neural or musculoskeletal complications in T1D, our results demonstrate that clinical applications of peripheral neuromodulation ought to consider the impact of device placement and eStim on long-term skeletal health in both healthy individuals and those with metabolic disease. This includes monitoring for compounded bone loss to prevent unintended consequences including decreased bone mineral density and increased fracture risk.
Collapse
Affiliation(s)
- Alec T Beeve
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States.,Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Ivana Shen
- Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Xiao Zhang
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States.,Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Kristann Magee
- Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Ying Yan
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Matthew R MacEwan
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Erica L Scheller
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States.,Department of Internal Medicine, Division of Bone and Mineral Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| |
Collapse
|
45
|
Pérez-Neri I, González-Aguilar A, Sandoval H, Pineda C, Ríos C. Therapeutic Potential of Ultrasound Neuromodulation in Decreasing Neuropathic Pain: Clinical and Experimental Evidence. Curr Neuropharmacol 2021; 19:334-348. [PMID: 32691714 PMCID: PMC8033967 DOI: 10.2174/1570159x18666200720175253] [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: 04/13/2020] [Revised: 05/23/2020] [Accepted: 07/07/2020] [Indexed: 01/01/2023] Open
Abstract
Background For more than seven decades, ultrasound has been used as an imaging and diagnostic tool. Today, new technologies, such as focused ultrasound (FUS) neuromodulation, have revealed some innovative, potential applications. However, those applications have been barely studied to deal with neuropathic pain (NP), a cluster of chronic pain syndromes with a restricted response to conventional pharmaceuticals. Objective To analyze the therapeutic potential of low-intensity (LIFUS) and high-intensity (HIFUS) FUS for managing NP. Methods We performed a narrative review, including clinical and experimental ultrasound neuromodulation studies published in three main database repositories. Discussion Evidence shows that FUS may influence several mechanisms relevant for neuropathic pain management such as modulation of ion channels, glutamatergic neurotransmission, cerebral blood flow, inflammation and neurotoxicity, neuronal morphology and survival, nerve regeneration, and remyelination. Some experimental models have shown that LIFUS may reduce allodynia after peripheral nerve damage. At the same time, a few clinical studies support its beneficial effect on reducing pain in nerve compression syndromes. In turn, Thalamic HIFUS ablation can reduce NP from several etiologies with minor side-effects, but some neurological sequelae might be permanent. HIFUS is also useful in lowering non-neuropathic pain in several disorders. Conclusion Although an emerging set of studies brings new evidence on the therapeutic potential of both LIFUS and HIFUS for managing NP with minor side-effects, we need more controlled clinical trials to conclude about its safety and efficacy.
Collapse
Affiliation(s)
- Iván Pérez-Neri
- Department of Neurochemistry, National Institute of Neurology and Neurosurgery, Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City, 14269, Mexico
| | - Alberto González-Aguilar
- Neuro-oncology Unit, Instituto Nacional de Neurología y Neurocirugia Manuel Velasco Suarez, Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City, 14269, Mexico
| | - Hugo Sandoval
- Sociomedical Research Unit, Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra, Calzada México-Xochimilco 289, Col, Arenal de Guadalupe, Alcaldia Tlalpan, C.P. 14389, Mexico City, Mexico
| | - Carlos Pineda
- Division of Musculoskeletal and Rheumatic Disorders, Instituto Nacional de Rehabilitacion Luis Guillermo Ibarra Ibarra, Calzada Mexico-Xochimilco 289, Col, Arenal de Guadalupe, Alcaldia Tlalpan, C.P.14389, Mexico City, Mexico
| | - Camilo Ríos
- Department of Neurochemistry, National Institute of Neurology and Neurosurgery, Insurgentes Sur 3877, La Fama, Tlalpan, Mexico City, 14269, Mexico
| |
Collapse
|
46
|
Deer TR, Eldabe S, Falowski SM, Huntoon MA, Staats PS, Cassar IR, Crosby ND, Boggs JW. Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. J Pain Res 2021; 14:721-736. [PMID: 33737830 PMCID: PMC7966353 DOI: 10.2147/jpr.s297091] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is an effective tool for the treatment of chronic pain, although its efficacy and utilization have previously been significantly limited by technology. In recent years, purpose-built percutaneous PNS devices have been developed to overcome the limitations of conventional permanently implanted neurostimulation devices. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period, outcomes that have not previously been observed with conventional permanently implanted neurostimulation devices. This narrative review summarizes mechanistic processes that contribute to chronic pain, and the potential mechanisms by which selective large diameter afferent fiber activation may reverse these changes to induce a prolonged reduction in pain. The interplay of these mechanisms, supported by data in chronic pain states that have been effectively treated with percutaneous PNS, will also be discussed in support of a new theory of pain management in neuromodulation: Peripherally Induced Reconditioning of the Central Nervous System (CNS).
Collapse
Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Steven M Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Marc A Huntoon
- Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | | | | | | | | |
Collapse
|
47
|
Xu J, Sun Z, Wu J, Rana M, Garza J, Zhu AC, Chakravarthy KV, Abd-Elsayed A, Rosenquist E, Basi H, Christo P, Cheng J. Peripheral Nerve Stimulation in Pain Management: A Systematic Review. Pain Physician 2021; 24:E131-E152. [PMID: 33740342 PMCID: PMC8897810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. OBJECTIVES To assess the clinical evidence of PNS in the treatment of acute or chronic pain. STUDY DESIGN A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. METHODS Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data syntheses: 227 studies met inclusion criteria and were included in qualitative synthesis. RESULTS Evidence synthesis based on randomized controlled trials (RCTs) and observational studies showed Level I and II evidence of PNS in chronic migraine headache; Level II evidence in cluster headache, postamputation pain, chronic pelvic pain, chronic low back and lower extremity pain; and Level IV evidence in peripheral neuropathic pain, and postsurgical pain. Peripheral field stimulation has Level II evidence in chronic low back pain, and Level IV evidence in cranial pain. LIMITATIONS Lack of high-quality RCTs. Meta-analysis was not possible due to wide variations in experimental design, research protocol, and heterogeneity of study population. CONCLUSIONS The findings of this systematic review suggest that PNS may be effective in managing chronic headaches, postamputation pain, chronic pelvic pain, and chronic low back and lower extremity pain, with variable levels of evidence in favor of this technique.
Collapse
Affiliation(s)
- Jijun Xu
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Zhuo Sun
- Department of Anesthesiology and Perioperative Medicine, Augusta University Medical Center, Medical College of Georgia, Augusta, GA
| | - Jiang Wu
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
| | - Maunak Rana
- Department of Anesthesiology and Critical Care, The University of Chicago, Chicago, IL
| | - Joshua Garza
- Department of Anesthesiology and Critical Care, The University of Chicago, Chicago, IL
| | - Alyssa C. Zhu
- Department of Anesthesiology and Pain Medicine, University of California San Diego, VA San Diego Healthcare System, La Jolla, CA
| | - Krishnan V. Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego, VA San Diego Healthcare System, La Jolla, CA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ellen Rosenquist
- Center for Spine Health and Pain Management, Cleveland Clinic, Cleveland, OH
| | - Hersimren Basi
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Paul Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jianguo Cheng
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
- Department of Neuroscience, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
48
|
Gabriel RA, Ilfeld BM. Acute postoperative pain management with percutaneous peripheral nerve stimulation: the SPRINT neuromodulation system. Expert Rev Med Devices 2021; 18:145-150. [PMID: 33446005 DOI: 10.1080/17434440.2021.1877134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Ultrasound-guided percutaneous peripheral nerve stimulation (PNS) may be used to treat acute postoperative pain for various types of surgeries. This modality avoids several limitations of traditional local anesthetic-based peripheral nerve blocks including avoidance of motor blockade and sensory deficits. AREAS COVERED In this review, we discuss the use of SPRINT (SPR Therapeutics, Cleveland, OH) neuromodulation system in the setting of acute postoperative pain management. EXPERT OPINION PNS is a novel modality in regional anesthesia that has much promise in reducing overall opioid use after surgery. Placement of PNS is very similar to that of catheter-based regional anesthesia techniques. Ultrasound is used to guide the percutaneously placed introducer needle in proximity to the target nerve. There are several benefits of PNS over catheter-based approaches, including: 1) avoidance of motor or sensory blockade; 2) no medication bag required to be carried; and 3) electric leads may be kept in situ safely for up to 60 days. While several proof-of-concept studies have been published highlighting its use in various types of surgeries, large high-quality randomized controlled trials are still needed.
Collapse
Affiliation(s)
- Rodney A Gabriel
- Division of Regional Anesthesia and Acute Pain Medicine, Medical Director, Koman Outpatient Pavilion, Department of Anesthesiology, University of California, San Diego. United States
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, United States
| |
Collapse
|
49
|
Mainkar O, Singh H, Gargya A, Lee J, Valimahomed A, Gulati A. Ultrasound-Guided Peripheral Nerve Stimulation of Cervical, Thoracic, and Lumbar Spinal Nerves for Dermatomal Pain: A Case Series. Neuromodulation 2020; 24:1059-1066. [PMID: 33314509 DOI: 10.1111/ner.13334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES With the development of percutaneously inserted devices, peripheral nerve stimulation (PNS) has been gaining attention within chronic pain literature as a less invasive neurostimulation alternative to spinal column and dorsal root ganglion stimulation. A majority of current PNS literature focuses on targeting individual distal nerves to treat individual peripheral mononeuropathies, limiting its applications. This article discusses our experience treating dermatomal pain with neurostimulation without needing to access the epidural space by targeting the proximal spinal nerve with peripheral nerve stimulation under ultrasound-guidance. MATERIALS AND METHODS A temporary, percutaneous PNS was used to target the proximal spinal nerve in 11 patients to treat various dermatomal pain syndromes in patients seen in an outpatient chronic pain clinic. Four patients received stimulation targeting the lumbar spinal nerves and seven patient received stimulation targeting the cervical or thoracic spinal nerves. RESULTS The case series presents 11 cases of PNS of the proximal spinal nerve. Seven patients, including a majority of the patients with lumbar radiculopathy, had analgesia during PNS. Four patients, all of whom targeted the cervical or thoracic spinal nerves, did not receive analgesia from PNS. CONCLUSION PNS of the proximal spinal nerve may be an effective modality to treat dermatomal pain in patients who are not candidates for other therapies that require access to the epidural space. This technique was used to successfully treat lumbar radiculopathy, post-herpetic neuralgia, and complex regional pain syndrome.
Collapse
Affiliation(s)
- Ojas Mainkar
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Harmandeep Singh
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Akshat Gargya
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Jane Lee
- New York Presbyterian/Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA
| | - Ali Valimahomed
- Advanced Orthopedics and Sports Medicine Institute, Freehold, NJ, USA
| | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, Department of Anesthesiology, New York, NY, USA
| |
Collapse
|
50
|
Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain. Anesthesiology 2020; 133:1127-1149. [PMID: 32898231 DOI: 10.1097/aln.0000000000003532] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
Collapse
|