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Deer TR, Russo M, Grider JS, Sayed D, Lamer TJ, Dickerson DM, Hagedorn JM, Petersen EA, Fishman MA, FitzGerald J, Baranidharan G, De Ridder D, Chakravarthy KV, Al-Kaisy A, Hunter CW, Buchser E, Chapman K, Gilligan C, Hayek SM, Thomson S, Strand N, Jameson J, Simopoulos TT, Yang A, De Coster O, Cremaschi F, Christo PJ, Varshney V, Bojanic S, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for Spinal Cord Stimulation Long-Term Outcome Optimization and Salvage Therapy. Neuromodulation 2024; 27:951-976. [PMID: 38904643 DOI: 10.1016/j.neurom.2024.04.006] [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] [Received: 02/19/2024] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has recognized a need to establish best practices for optimizing implantable devices and salvage when ideal outcomes are not realized. This group has established the Neurostimulation Appropriateness Consensus Committee (NACC)® to offer guidance on matters needed for both our members and the broader community of those affected by neuromodulation devices. MATERIALS AND METHODS The executive committee of the INS nominated faculty for this NACC® publication on the basis of expertise, publications, and career work on the issue. In addition, the faculty was chosen in consideration of diversity and inclusion of different career paths and demographic categories. Once chosen, the faculty was asked to grade current evidence and along with expert opinion create consensus recommendations to address the lapses in information on this topic. RESULTS The NACC® group established informative and authoritative recommendations on the salvage and optimization of care for those with indwelling devices. The recommendations are based on evidence and expert opinion and will be expected to evolve as new data are generated for each topic. CONCLUSIONS NACC® guidance should be considered for any patient with less-than-optimal outcomes with a stimulation device implanted for treating chronic pain. Consideration should be given to these consensus points to salvage a potentially failed device before explant.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dawood Sayed
- The University of Kansas Health System, Kansas City, KS, USA
| | | | | | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erika A Petersen
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Ganesan Baranidharan
- Leeds Teaching Hospital National Health Service (NHS) Trust, University of Leeds, Leeds, UK
| | - Dirk De Ridder
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Adnan Al-Kaisy
- Guy's and St Thomas NHS Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Corey W Hunter
- Ainsworth Institute, Ichan School of Medicine, Mt Sinai Hospital, New York, NY, USA
| | | | | | - Chris Gilligan
- Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Simon Thomson
- Pain & Neuromodulation Consulting Ltd, Nuffield Health Brentwood and The London Clinic, Brentwood, UK; Pain & Neuromodulation Centre, Mid & South Essex University NHS Hospitals, Basildon, UK
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Thomas T Simopoulos
- Arnold Warfield Pain Management Center, Harvard Medical School, Boston, MA, USA
| | - Ajax Yang
- Spine and Pain Consultant, PLLC, Staten Island, NY, USA
| | | | - Fabián Cremaschi
- Department of Neurosciences, National University of Cuyo, Mendoza, Argentina
| | - Paul J Christo
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishal Varshney
- Providence Healthcare, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Ufondu W, Robinson CL, Hussain N, D'Souza RS, Karri J, Emerick T, Orhurhu VJ. Intradiscal Autologous Biologics for the Treatment of Chronic Discogenic Low Back Pain. Curr Pain Headache Rep 2024:10.1007/s11916-024-01294-8. [PMID: 39017984 DOI: 10.1007/s11916-024-01294-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE OF REVIEW: The purpose of this narrative review is to evaluate the efficacy of the most commonly studied intradiscal biologics used for the treatment and alleviation of chronic intractable discogenic low back pain. Additionally, it explores the therapeutic potential and durability of these novel treatment options. RECENT FINDINGS: Recently published literature highlights the therapeutic potential of intradiscal biologics, such as mesenchymal stem cells, platelet-rich plasma, and alpha-2-macroglobulin, in promoting chondrogenesis within the lumbar intervertebral discs to treat discogenic low back pain. Studies demonstrate significant improvements in pain relief, physical function, and quality of life post-treatment. A comprehensive review of the literature evaluating the efficacy of intradiscal biologics suggests some evidence supporting its efficacy in treating discogenic low back pain. However, more rigorous studies into mechanistic modulation and large-scale randomized trials as well as a more thorough understanding of adverse events will be instrumental for including these therapies into clinical practice paradigms.
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Affiliation(s)
- Wisdom Ufondu
- Department of Biology, Program in Liberal Medical Education (PLME), Brown University, Providence, RI, USA
| | - Christopher L Robinson
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay Karri
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Trent Emerick
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vwaire J Orhurhu
- University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA.
- MVM Health, East Stroudsburg, PA, USA.
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Campos-Fajardo S, Sierra-Peña JA, Suárez-Monsalve S, Acevedo-González JC. Effectiveness of Dorsal Root Ganglion Stimulation in Chronic Pain Management: A Systematic Review. World Neurosurg 2024; 190:157-171. [PMID: 38945208 DOI: 10.1016/j.wneu.2024.06.138] [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: 05/17/2024] [Revised: 06/24/2024] [Accepted: 06/25/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE This systematic review aims to determine the effectiveness of dorsal root ganglion stimulation (DRGS) in chronic pain management. METHODS In 2023, a comprehensive systematic review was undertaken utilizing various electronic databases, employing MeSH terms and free search terms tailored to the study's aims. This review included primary research such as cohorts, case-control studies, and clinical trials, all focusing on the efficacy of DRGS in treating various chronic pain conditions. Nonhuman or animal studies were omitted from the selection process. A review of study quality was conducted, followed by a meticulous analysis of the findings to synthesize the evidence. This review represents the most current research, with updates extending to 2024. A total of 400 articles were reviewed. Twenty-nine articles were included in our review after meticulous screening. RESULTS Twenty-nine articles published in the last five years meeting selection criteria were identified, encompassing patients with various diagnoses warranting the use of DRGS beyond complex regional pain syndrome. Additionally, the analysis includes different outcome measurement tools, emphasizing improvements in pain management, functionality, and quality of life. Finally, common complications such as surgical site infections and issues with electrodes are highlighted. CONCLUSIONS This systematic review affirms the effectiveness of DRGS therapy in managing diverse chronic pain conditions, highlighting improvements in quality of life, functionality, and mood states, making it a viable alternative for patients unresponsive to traditional treatments.
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Affiliation(s)
- Santiago Campos-Fajardo
- Neurosurgery Research Group, Faculty of Medicine, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia.
| | - Julián Alfonso Sierra-Peña
- Neurosurgery Research Group, Faculty of Medicine, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Silvia Suárez-Monsalve
- Neurosurgery Research Group, Faculty of Medicine, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia; Clinical Epidemiology Master's Degree, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Juan Carlos Acevedo-González
- Neurosurgery Research Group, Faculty of Medicine, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia; Neurosurgeon Specialized in Functional Neurosurgery and Management of Pain and Spasticity. Professor, Department of Neurosciences, Hospital Universitario San Ignacio, Bogotá, Colombia
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Lai A, Iliff D, Zaheer K, Gansau J, Laudier DM, Zachariou V, Iatridis JC. Annulus Fibrosus Injury Induces Acute Neuroinflammation and Chronic Glial Response in Dorsal Root Ganglion and Spinal Cord-An In Vivo Rat Discogenic Pain Model. Int J Mol Sci 2024; 25:1762. [PMID: 38339040 PMCID: PMC10855200 DOI: 10.3390/ijms25031762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
Chronic painful intervertebral disc (IVD) degeneration (i.e., discogenic pain) is a major source of global disability needing improved knowledge on multiple-tissue interactions and how they progress in order improve treatment strategies. This study used an in vivo rat annulus fibrosus (AF) injury-driven discogenic pain model to investigate the acute and chronic changes in IVD degeneration and spinal inflammation, as well as sensitization, inflammation, and remodeling in dorsal root ganglion (DRG) and spinal cord (SC) dorsal horn. AF injury induced moderate IVD degeneration with acute and broad spinal inflammation that progressed to DRG to SC changes within days and weeks, respectively. Specifically, AF injury elevated macrophages in the spine (CD68) and DRGs (Iba1) that peaked at 3 days post-injury, and increased microglia (Iba1) in SC that peaked at 2 weeks post-injury. AF injury also triggered glial responses with elevated GFAP in DRGs and SC at least 8 weeks post-injury. Spinal CD68 and SC neuropeptide Substance P both remained elevated at 8 weeks, suggesting that slow and incomplete IVD healing provides a chronic source of inflammation with continued SC sensitization. We conclude that AF injury-driven IVD degeneration induces acute spinal, DRG, and SC inflammatory crosstalk with sustained glial responses in both DRGs and SC, leading to chronic SC sensitization and neural plasticity. The known association of these markers with neuropathic pain suggests that therapeutic strategies for discogenic pain need to target both spinal and nervous systems, with early strategies managing acute inflammatory processes, and late strategies targeting chronic IVD inflammation, SC sensitization, and remodeling.
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Affiliation(s)
- Alon Lai
- Leni and Peter W. May Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.I.); (K.Z.); (J.G.); (D.M.L.); (J.C.I.)
| | - Denise Iliff
- Leni and Peter W. May Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.I.); (K.Z.); (J.G.); (D.M.L.); (J.C.I.)
| | - Kashaf Zaheer
- Leni and Peter W. May Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.I.); (K.Z.); (J.G.); (D.M.L.); (J.C.I.)
| | - Jennifer Gansau
- Leni and Peter W. May Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.I.); (K.Z.); (J.G.); (D.M.L.); (J.C.I.)
| | - Damien M. Laudier
- Leni and Peter W. May Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.I.); (K.Z.); (J.G.); (D.M.L.); (J.C.I.)
| | - Venetia Zachariou
- Department of Pharmacology, Physiology and Biophysics, Chobanian and Avedisian School of Medicine at Boston University, Boston, MA 02118, USA;
| | - James C. Iatridis
- Leni and Peter W. May Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.I.); (K.Z.); (J.G.); (D.M.L.); (J.C.I.)
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Mons MR, Chapman KB, Terwiel C, Joosten EA, Kallewaard JW. Burst Spinal Cord Stimulation as Compared With L2 Dorsal Root Ganglion Stimulation in Pain Relief for Nonoperated Discogenic Low Back Pain: Analysis of Two Prospective Studies. Neuromodulation 2024; 27:172-177. [PMID: 37191612 DOI: 10.1016/j.neurom.2023.04.464] [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: 11/03/2022] [Revised: 03/26/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Chronic discogenic low back pain (CD-LBP) is caused by degenerated disks marked by neural and vascular ingrowth. Spinal cord stimulation (SCS) has been shown to be effective for pain relief in patients who are not responsive to conventional treatments. Previously, the pain-relieving effect of two variations of SCS has been evaluated in CD-LBP: Burst SCS and L2 dorsal root ganglion stimulation (DRGS). The aim of this study is to compare the effectivity in pain relief and pain experience of Burst SCS with that of conventional L2 DRGS in patients with CD-LBP. MATERIALS AND METHODS Subjects were implanted with either Burst SCS (n = 14) or L2 DRGS with conventional stimulation (n = 15). Patients completed the numeric pain rating score (NRS) for back pain and Oswestry disability index (ODI) and EuroQoL 5D (EQ-5D) questionnaires at baseline, and at three, six, and 12 months after implantation. Data were compared between time points and between groups. RESULTS Both Burst SCS and L2 DRGS significantly decreased NRS, ODI, and EQ-5D scores as compared with baseline. L2 DRGS resulted in significantly lower NRS scores at 12 months and significantly increased EQ-5D scores at six and 12 months. CONCLUSIONS Both L2 DRGS and Burst SCS resulted in reduction of pain and disability, and increased quality of life in patients with CD-LBP. L2 DRGS provided significantly increased pain relief and improvement in quality of life when compared with Burst SCS. CLINICAL TRIAL REGISTRATION The clinical trial registration numbers for the study are NCT03958604 and NL54405.091.15.
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Affiliation(s)
- Martijn R Mons
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Translational Neuroscience, School for Mental Health and Neuroscience, University of Maastricht, Maastricht, The Netherlands.
| | - Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA; Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Chris Terwiel
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Translational Neuroscience, School for Mental Health and Neuroscience, University of Maastricht, Maastricht, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands; Department of Anesthesiology and Pain Management, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Tabatabaei P, Salomonsson J, Kakas P, Eriksson M. Bilateral T12 Dorsal Root Ganglion Stimulation for the Treatment of Low Back Pain With 20-Hz and 4-Hz Stimulation, a Retrospective Study. Neuromodulation 2024; 27:141-150. [PMID: 37542505 DOI: 10.1016/j.neurom.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Chronic low back pain (CLBP) is one of the most common chronic pain conditions that cause both individual suffering and a burden to society. For these patients, several interventional treatment options such as surgery, blocks, radiofrequency, and spinal cord stimulation are available. Lately, dorsal root ganglion stimulation (DRG-S) also has been mentioned as an option by targeting bilateral T12 dorsal ganglia. In this study, we present the outcome of 11 patients with CLBP treated with bilateral T12 DRG-S. MATERIALS AND METHODS Thirteen patients with CLBP with and without leg pain were treated with bilateral T12 DRG-S. Three of the patients also received a third lumbar lead owing to leg pain. Eleven of the patients had >50% pain relief during the peri- or/and postoperative testing and received a fully implantable neurostimulator. Pain intensity, general health status, quality of life, pain catastrophizing, mental status, sleeping disorder, physical activity, and patient satisfaction were followed using numeric rating scale (NRS), Patient-Reported Outcomes Measurement Information System 29 version 2.1, Pain Catastrophizing Score, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire Depression Module, Insomnia Severity Index, and Patient Satisfaction Questionnaire at baseline before implantation and at three months and six months. The results were analyzed on the basis of six domains: pain relief, sleeping disorder, social ability, mental status, physical activity, and satisfaction. To be identified as a responder, the patients should show a significant improvement in the pain relief domain together with at least two other domains. All responders also were given the opportunity to test 4-Hz DRG-S and compare it with traditional 20-Hz stimulation. RESULTS All 11 patients were identified as responders at six months. Five of the patients had >80% pain relief, with an average NRS score reduction of 71% for the whole group. Significant improvement could be observed in three domains for one patient, four domains for three patients, five domains for six patients, and six domains for one patient. Seven patients chose to try 4-Hz stimulation. All seven identified 4-Hz stimulation as at least as good as or better than 20-Hz stimulation and chose to continue with 4-Hz stimulation. CONCLUSIONS Bilateral T12 DRG-S seems to be an effective treatment for chronic low back pain, with significant beneficial effect not only on pain but also on quality of life, pain catastrophizing, mental status, sleeping disorder, and physical activity. 4-Hz DRG-S gave a result comparable with or better than 20-Hz stimulation.
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Affiliation(s)
| | | | - Pavlina Kakas
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Maria Eriksson
- Department of Clinical Science, Umeå University, Umeå, Sweden
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Jha R, Bernstock JD, Chalif JI, Hoffman SE, Gupta S, Guo H, Lu Y. Updates on Pathophysiology of Discogenic Back Pain. J Clin Med 2023; 12:6907. [PMID: 37959372 PMCID: PMC10647359 DOI: 10.3390/jcm12216907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Discogenic back pain, a subset of chronic back pain, is caused by intervertebral disc (IVD) degeneration, and imparts a notable socioeconomic health burden on the population. However, degeneration by itself does not necessarily imply discogenic pain. In this review, we highlight the existing literature on the pathophysiology of discogenic back pain, focusing on the biomechanical and biochemical steps that lead to pain in the setting of IVD degeneration. Though the pathophysiology is incompletely characterized, the current evidence favors a framework where degeneration leads to IVD inflammation, and subsequent immune milieu recruitment. Chronic inflammation serves as a basis of penetrating neovascularization and neoinnervation into the IVD. Hence, nociceptive sensitization emerges, which manifests as discogenic back pain. Recent studies also highlight the complimentary roles of low virulence infections and central nervous system (CNS) metabolic state alteration. Targeted therapies that seek to disrupt inflammation, angiogenesis, and neurogenic pathways are being investigated. Regenerative therapy in the form of gene therapy and cell-based therapy are also being explored.
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Affiliation(s)
- Rohan Jha
- Harvard Medical School, Boston, MA 02115, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Joshua I. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Samantha E. Hoffman
- Harvard Medical School, Boston, MA 02115, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Saksham Gupta
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Hong Guo
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Yi Lu
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
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Shlobin NA, Wu C. Current Neurostimulation Therapies for Chronic Pain Conditions. Curr Pain Headache Rep 2023; 27:719-728. [PMID: 37728863 DOI: 10.1007/s11916-023-01168-5] [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: 08/09/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation treatment options have become more commonly used for chronic pain conditions refractory to these options. In this review, we characterize current neurostimulation therapies for chronic pain conditions and provide an analysis of their effectiveness and clinical adoption. This manuscript will inform clinicians of treatment options for chronic pain. RECENT FINDINGS Non-invasive neurostimulation includes transcranial direct current stimulation and repetitive transcranial magnetic stimulation, while more invasive options include spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), dorsal root ganglion stimulation, motor cortex stimulation, and deep brain stimulation. Developments in transcranial direct current stimulation, repetitive transcranial magnetic stimulation, spinal cord stimulation, and peripheral nerve stimulation render these modalities most promising for the alleviating chronic pain. Neurostimulation for chronic pain involves non-invasive and invasive modalities with varying efficacy. Well-designed randomized controlled trials are required to delineate the outcomes of neurostimulatory modalities more precisely.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Floor 2, Philadelphia, PA, 19107, USA.
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Remotti E, Nduaguba C, Woolley PA, Ricciardelli R, Phung A, Kim R, Urits I, Kaye AD, Hasoon J, Simopoulos T, Yazdi C, Robinson CL. Review: Discogenic Back Pain: Update on Treatment. Orthop Rev (Pavia) 2023; 15:84649. [PMID: 37641793 PMCID: PMC10460631 DOI: 10.52965/001c.84649] [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] [Indexed: 08/31/2023] Open
Abstract
Purpose of Review Lower back pain (LBP) has a lifetime prevalence of 80% in the United States population. Discogenic back pain (DBP), a subcategory of LBP, occurs as a result of the interverbal disc degeneration without disc herniation. Diagnosis relies on history, physical exam, and imaging such as MRI, provocative discography, or CT discography. Recent Findings Treatment of DBP involves a multifaceted approach with an emphasis on conservative measures including behavioral modification, pharmacologic management, and other non-pharmacologic interventions with invasive therapy reserved for select patients. Due to the paucity of data on the treatment of DBP, treatment also relies on data derived from treatment of chronic LBP (CLBP). Summary Despite the scarcity of data for the treatment of DBP, treatments do exist with varying efficacy for DBP. Novel techniques such as the use of biologics may provide another avenue for treatment though further studies are needed to better evaluate the most efficacious regimen for both novel and existing treatments.
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Affiliation(s)
- Edgar Remotti
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Chinoso Nduaguba
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Parker A Woolley
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Ryan Ricciardelli
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Anh Phung
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Rosa Kim
- Georgetown University Hospital, Department of General Surgery, Medstar, Washington, DC
| | | | - Alan David Kaye
- Louisiana State University Shreveport, Department of Anesthesiology, Shreveport, LA
| | - Jamal Hasoon
- UTHealth McGovern Medical School, Department of Anesthesiology, Critical Care and Pain Medicine, Houston, TX
| | - Thomas Simopoulos
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Cyrus Yazdi
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Christopher L Robinson
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
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West T, ElSaban M, Hussain N, Schappell J, Rogers K, Orhurhu V, Prokop LJ, D'Souza RS. Incidence of Lead Migration With Loss of Efficacy or Paresthesia Coverage After Spinal Cord Stimulator Implantation: Systematic Review and Proportional Meta-Analysis of Prospective Studies and Randomized Clinical Trials. Neuromodulation 2023:S1094-7159(23)00150-2. [PMID: 37204361 DOI: 10.1016/j.neurom.2023.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/15/2023] [Accepted: 03/24/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The objective of this meta-analysis was to approximate the incidence of overall lead migration, clinically significant lead migration, and asymptomatic lead migration in patients who have undergone spinal cord stimulator implantation. MATERIALS AND METHODS A comprehensive literature search was performed for studies published before May 31, 2022. Only randomized controlled trials and prospective observational studies with more than ten patients were included. Two reviewers analyzed the articles from the literature search for final inclusion, after which, study characteristics and outcome data were extracted. The primary dichotomous categorical outcome variables were the incidence of overall lead migration, clinically significant lead migration (defined as lead migration resulting in loss of efficacy), and asymptomatic lead migration (defined as lead migration discovered incidentally on follow-up imaging) in patients with spinal cord stimulator implant. Freeman-Tukey arcsine square root transformation for meta-analysis of proportions using random effects (DerSimonian and Laird method) was used to calculate incidence rates for the outcome variables. Pooled incidence rates and 95% CIs were calculated for the outcome variables. RESULTS Fifty-three studies met the inclusion criteria, with a total of 2932 patients having received spinal cord stimulator implants. The pooled incidence of overall lead migration was 9.97% (95% CI of 7.62%-12.59%). Only 24 of the included studies commented on the clinical significance of reported lead migrations, of which every lead migration was clinically significant. In these 24 studies, 96% of the reported lead migrations required a revision procedure or explant. Unfortunately, no studies that reported lead migration commented on asymptomatic lead migrations; therefore, the incidence of asymptomatic lead migrations could not be defined. CONCLUSIONS This meta-analysis found that the rate of lead migration in patients who have received spinal cord stimulator implants is approximately one in ten patients. This likely closely approximates the incidence of clinically significant lead migration owing to the included studies not routinely performing follow-up imaging. Therefore, lead migrations were primarily discovered owing to loss of efficacy, and no included studies clearly reported asymptomatic lead migration. The results of this meta-analysis can be used to inform patients more accurately on the risks and benefits of spinal cord stimulator implantation.
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Affiliation(s)
- Tyler West
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mariam ElSaban
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University, Columbus, OH, USA
| | - Justin Schappell
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Kristopher Rogers
- Department of Anesthesiology, University of Illinois Chicago, Chicago, IL, USA
| | - Vwaire Orhurhu
- Department of Anesthesiology, University of Pittsburgh Medical Center, Williamsport, PA, USA
| | | | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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11
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Chapman KB, Tupper C, Vissers KC, van Helmond N, Yousef T. Dorsal root ganglion stimulation for the treatment of joint pain with predominantly nociceptive characteristics: A case series. Pain Pract 2023; 23:317-324. [PMID: 36334041 DOI: 10.1111/papr.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 09/28/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) has recently emerged as a novel therapy in neuromodulation that demonstrated a higher rate of success than spinal cord stimulation (SCS) in a prospective, head-to-head randomized comparative trial to treat complex regional pain syndrome (CRPS) and causalgia. In contrast to SCS, DRG-S also shows promise in treating conditions that are not purely neuropathic such as axial low back pain, which has a prominent nociplastic pain component. It is not known to what extent the effectiveness of DRG-S for such indications is due to effective treatment of the neuropathic pain component versus the effects of DRG-S on mechanical pain. Although rarely studied, reporting outcomes of DRG-S to treat predominantly mechanical/nociceptive pain may help point toward expanding the utility of this therapy. Here, we present five cases of refractory mechanical pain treated with DRG-S. METHODS A retrospective analysis of all patients who underwent a successful DRG-S trial and implant between September 2017 and September 2021 at our institute was performed. Patients who had intractable joint pain without strong evidence of neuropathic pain were included in this case series. The Budapest criteria for CRPS, the Douleur Neuropathique 4 Questions (DN4) survey, or a definable nerve injury were used to determine the presence of neuropathic pain. Baseline assessments for pain (Numeric Rating Scale [NRS]), function (Oswestry Disability Index [ODI]), quality of life (EuroQol-5 Dimension [EQ-5D]), and other applicable joint surveys were extracted from pre-trial baseline and follow-up appointments. RESULTS Five patients were identified and included. Patient diagnoses consisted of refractory joint pain of the hip, knee, or ankle. Mean NRS pain scores improved by 74% from 9.2 at baseline to 2.4 at the last follow-up (mean = 28 months post-implant). From baseline to the last follow-up, mean ODI scores improved by 65% from 66 to 23 and EQ-5D scores more than doubled from an average of 0.371 to 0.797. CONCLUSION This clinical report illustrates the potential utility DRG-S has in treating pain that clinically presents as predominantly refractory mechanical joint pain without a significant neuropathic component. The physiological reasons for our observations may be that DRG-S is able to directly influence the conduction of nociceptive signaling at the DRG and within the spinal cord. Further investigations are warranted to determine if DRG-S is a potential treatment option for chronic mechanical pain.
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Affiliation(s)
- Kenneth B Chapman
- Spine & Pain Institute of New York, New York, New York, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York, New York, USA.,Departement of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.,Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Connor Tupper
- Creighton University Medical College, Omaha, Nebraska, USA
| | - Kris C Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Noud van Helmond
- Spine & Pain Institute of New York, New York, New York, USA.,Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Tariq Yousef
- Spine & Pain Institute of New York, New York, New York, USA
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12
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Mons MR, Chapman KB, Terwiel C, Joosten EA, Kallewaard JW. A prospective study of BurstDR™ spinal cord stimulation for non-operated discogenic low back pain. Pain Pract 2023; 23:234-241. [PMID: 36373868 DOI: 10.1111/papr.13181] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/22/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Chronic discogenic low back pain (CD-LBP) is caused by degeneration of the disc due to trauma to the annulus or by unprovoked degeneration, resulting in chronic pain. Spinal cord stimulation (SCS) employing the BurstDR™ waveform has been shown to be an effective treatment in a variety of chronic pain conditions. The aim of this prospective case study was to determine the effect of BurstDR™ SCS on pain relief, disability, and patient satisfaction in a population with CD-LBP. METHODS Seventeen subjects with CD-LBP received a SCS trial with BurstDR™ stimulation. Patients with >50% pain relief after a trial period of 2 weeks were permanently implanted (n = 15). Patients then rated LBP and leg pain using the numeric rating scale (NRS), Oswestry disability index (ODI), patient global impression of change (PGIC), EQ-5D quality of life, and painDETECT for neuropathic pain at baseline following trial, 3, 6, and 12 months after permanent implantation. RESULTS Treatment with BurstDR™ SCS resulted in significant reduction of LBP as the NRS was reduced from 71.7 ± 7.3 at baseline to 42.5 ± 18.1 at 12 months. Average pain relief at 12 months was 42.5%. In patients with leg pain (n = 8), pain was significantly reduced from 66.9 ± 8.2 to 11.7 ± 10.4 at 12 months. PainDETECT scores for neuropathic pain significantly reduced from 18.9 ± 4.8 at baseline, and 14.8 ± 3.2 at 12 months. Baseline ODI score significantly reduced from 41.2 ± 12.8 to 25.8 ± 8.6 at 12 months. PGIC scores remained low from 2.6 ± 1.6 at 3 months, 2.5 ± 1.0 at 6 months, and 2.5 ± 1.3 at 12 months. EQ-5D-5L rates remained constant from baseline 56.10 ± 23.9 to 68.6 ± 12.9 at 12 months. CONCLUSION BurstDR™ SCS resulted in significant reduction of back pain, leg pain, and quality of life in patients with CD-LBP and decreased the level of disability and generated positive patient satisfaction scores.
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Affiliation(s)
- Martijn R Mons
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, The Netherlands
| | - Kenneth B Chapman
- Department of Anesthesiology, New York University Langone Medical Center, New York City, New York, USA.,Departement of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Chris Terwiel
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, The Netherlands
| | - Jan-Willem Kallewaard
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Arnhem, The Netherlands.,Department of Anesthesiology and Pain Managmenent, Amsterdam University Medical Center, Amsterdam, The Netherlands
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13
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Bielewicz J, Kamieniak M, Szymoniuk M, Litak J, Czyżewski W, Kamieniak P. Diagnosis and Management of Neuropathic Pain in Spine Diseases. J Clin Med 2023; 12:jcm12041380. [PMID: 36835916 PMCID: PMC9961043 DOI: 10.3390/jcm12041380] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Neuropathic pain is generally defined as a non-physiological pain experience caused by damage to the nervous system. It can occur spontaneously, as a reaction to a given stimulus, or independently of its action, leading to unusual pain sensations usually referred to as firing, burning or throbbing. In the course of spine disorders, pain symptoms commonly occur. According to available epidemiological studies, a neuropathic component of pain is often present in patients with spinal diseases, with a frequency ranging from 36% to 55% of patients. Distinguishing between chronic nociceptive pain and neuropathic pain very often remains a challenge. Consequently, neuropathic pain is often underdiagnosed in patients with spinal diseases. In reference to current guidelines for the treatment of neuropathic pain, gabapentin, serotonin and norepinephrine reuptake inhibitors and tricyclic antidepressants constitute first-line therapeutic agents. However, long-term pharmacologic treatment often leads to developing tolerance and resistance to used medications. Therefore, in recent years, a plethora of therapeutic methods for neuropathic pain have been developed and investigated to improve clinical outcomes. In this review, we briefly summarized current knowledge about the pathophysiology and diagnosis of neuropathic pain. Moreover, we described the most effective treatment approaches for neuropathic pain and discussed their relevance in the treatment of spinal pain.
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Affiliation(s)
- Joanna Bielewicz
- Department of Neurology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Maciej Kamieniak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Michał Szymoniuk
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
- Correspondence:
| | - Jakub Litak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
- Department of Clinical Immunology, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland
| | - Wojciech Czyżewski
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
- Department of Didactics and Medical Simulation, Medical University of Lublin, Chodźki 4, 20-093 Lublin, Poland
| | - Piotr Kamieniak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
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14
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Chapman KB, Sayed D, Lamer T, Hunter C, Weisbein J, Patel KV, Dickerson D, Hagedorn JM, Lee DW, Amirdelfan K, Deer T, Chakravarthy K. Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience. J Pain Res 2023; 16:839-879. [PMID: 36942306 PMCID: PMC10024474 DOI: 10.2147/jpr.s364370] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 01/17/2023] [Indexed: 03/14/2023] Open
Abstract
With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion stimulation (DRG-S) has significantly improved the treatment of complex regional pain syndrome (CRPS), and it has broad applicability across a wide range of other conditions. Through funding and organizational leadership by the American Society for Pain and Neuroscience (ASPN), this best practices consensus document has been developed for the selection, implantation, and use of DRG stimulation for the treatment of chronic pain syndromes. This document is composed of a comprehensive narrative literature review that has been performed regarding the role of the DRG in chronic pain and the clinical evidence for DRG-S as a treatment for multiple pain etiologies. Best practice recommendations encompass safety management, implantation techniques, and mitigation of the potential complications reported in the literature. Looking to the future of neuromodulation, DRG-S holds promise as a robust intervention for otherwise intractable pain.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, NY, USA
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
- Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA
- Correspondence: Kenneth B Chapman, NYU Langone Medical Center, Zucker School of Medicine at Hofstra/Northwell, Pain Medicine at Staten Island University Hospital, 1360 Hylan Boulevard, Staten Island, NY, 10305, USA, Email
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS, USA
| | - Tim Lamer
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, NY, USA
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
- Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA
| | - David Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University Health System, Evanston, IL, USA
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA
| | | | - David W Lee
- Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
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15
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Dorsal Root Ganglion Stimulation as a Salvage Therapy Following Failed Spinal Cord Stimulation. Neuromodulation 2022; 25:1024-1032. [DOI: 10.1016/j.neurom.2022.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 11/20/2022]
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16
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Chapman KB, Yang A, Mogilner AY, Mandelberg N, Patel KV, Lubenow T, Deer T, Kallewaard JW, van Helmond N. Dorsal Root Ganglion Stimulation Device Explantation: A Multicenter Pooled Data Analysis. Pain Pract 2022; 22:522-531. [DOI: 10.1111/papr.13113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/08/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kenneth B. Chapman
- The Spine & Pain Institute of New York, NY NY USA
- Department of Anesthesiology, NYU Langone Medical Center, NY NY USA
- Northwell Health New York City NY USA
| | - Ajax Yang
- The Spine & Pain Institute of New York, NY NY USA
- Northwell Health New York City NY USA
| | - Alon Y. Mogilner
- Department of Neurosurgery, NYU Langone Medical Center, NY NY USA
| | | | - Kiran V. Patel
- The Spine & Pain Institute of New York, NY NY USA
- Northwell Health New York City NY USA
| | - Timothy Lubenow
- Department of Anesthesiology Rush University Medical Center Chicago IL
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias Charleston WV
| | | | - Noud van Helmond
- The Spine & Pain Institute of New York, NY NY USA
- Cooper Medical School of Rowan University Cooper University Hospital Camden NJ USA
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17
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Koetsier E, van Kuijk SMJ, Maino P, Dukanac J, Scascighini L, Cianfoni A, Scarone P, Kuhlen DE, Hollman MW, Kallewaard JW. Efficacy of the Gelstix nucleus augmentation device for the treatment of chronic discogenic low back pain: protocol for a randomised, sham-controlled, double-blind, multicentre trial. BMJ Open 2022; 12:e053772. [PMID: 35354635 PMCID: PMC8968527 DOI: 10.1136/bmjopen-2021-053772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Discogenic pain is the cause of pain in 26%-40% of patients with for low back pain. Consensus about treatment of chronic discogenic low back pain is lacking and most treatment alternatives are supported by limited evidence. The percutaneous implantation of hydrogels into the nucleus pulposus represents a promising regenerative intradiscal therapy. The hydrogel 'GelStix' is composed primarily of hydrolyzed polyacrylonitrile and acts as a reservoir of hydration, producing increased pressure and improved pH balance, potentially leading to disc preservation. We hypothesise that treatment with GelStix will lead to greater reduction in pain intensity at 6 months post-treatment compared with patients receiving sham treatment. METHODS AND ANALYSIS This is a parallel group, randomised sham-controlled double-blind, multicentre trial to assess whether the GelStix device is superior to sham in reducing pain intensity in patients with chronic discogenic low back pain. The study will be conducted in two regional hospitals in Europe. Seventy-two participants will be randomised in a 1:1 ratio. The primary outcome will be the change in pain intensity between preoperative baseline and at 6 months postintervention. Secondary outcomes were disability, quality of life, the patient's global impression of change scale, the use of pain medication and the disc degeneration process assessed by means of MRI. For change in pain intensity, disability, health-related quality of life and disc height, mean values will be compared between groups using linear regression analysis, adjusted for treatment centre. ETHICS AND DISSEMINATION Ethics approval was obtained from the Ethics Committee of the Canton Ticino, Switzerland (CE2982) and by the Medical Ethical Committee Arnhem-Nijmegen, the Netherlands (2016-2944). All patients that agree to participate will be asked to sign an informed consent form. Results will be disseminated through international publications in peer-reviewed journals, in addition to international conference presentations. TRIAL REGISTRATION NUMBER NCT02763956. PROTOCOL VERSION 7.1, 18 November 2020.
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Affiliation(s)
- Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Sander M J van Kuijk
- Clinical Epidemiology and Medical Technology Assessment, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Jasmina Dukanac
- Pain Management Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - Luca Scascighini
- Department of Health Sciences, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - Alessandro Cianfoni
- Service of Diagnostic and Interventional Neuroradiology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Department of Neuroradiology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Pietro Scarone
- Clinic of Neurosurgery, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - Dominique E Kuhlen
- Clinic of Neurosurgery, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - Markus W Hollman
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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18
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Intermittent Dorsal Root Ganglion Stimulation Is as Efficacious as Standard Continuous Dosing in Treating Chronic Pain: Results From a Randomized Controlled Feasibility Trial. Neuromodulation 2022; 25:989-997. [DOI: 10.1016/j.neurom.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022]
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19
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Chapman KB, Spiegel MA, Dickerson DM, Billet B, Patel KV, Hunter C, Antony A, van Helmond N, Deer T, Kallewaard JW, Hagedorn JM, Yang A. A Paramedian Approach for Dorsal Root Ganglion Stimulation Placement Developed to Limit Lead Migration and Fracture. Pain Pract 2021; 21:991-1000. [PMID: 34328256 DOI: 10.1111/papr.13063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S), has demonstrated superiority in the treatment of complex regional pain syndrome and causalgia. Lead migration and fracture impact DRG-S therapeutic stability. Lead anchoring reduces DRG-S lead migration without increasing lead fracture. Lead fracture may be related to lead entrapment in the superficial fascial plane. A novel medialized approach for lead placement and anchoring is presented to address these issues. METHODS We suggest an alternative technique for implanting percutaneous DRG-S leads at the T10-L5 levels. RESULTS A novel medialized ipsilateral technique for lead placement and anchoring for single, bilateral, and adjacent segment placement is presented. The Tuohy needle puncture site is medial to the pedicle and adjacent to the spinous process, two vertebral levels caudad to the target foramen. Trajectory is maintained in the sagittal plane, to access the caudad interlaminar space near the midline. This technique allows for ipsilateral or contralateral lead placement. After epidural access, the introducer sheath is rotated toward the targeted foramen and advanced. The guidewire followed by the lead is passed, and once lead position is confirmed, tension 'S' loops are created, followed by anchoring to the deep fascia. CONCLUSION We describe a new paramedian technique for DRG-S lead placement. We propose it will decrease DRG-S complication rates through anchoring to reduce migration and by avoiding the fascial planes thought to be responsible for fracture. Long-term outcomes applying our proposed techniques are required for determining the true impact, however, early anecdotal results suggest that these new techniques are favorable.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, NY, USA.,Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA.,Northwell Health, New York, NY
| | - Matthew A Spiegel
- The Spine & Pain Institute of New York, New York, NY, USA.,Northwell Health, New York, NY
| | - David M Dickerson
- Department of Anesthesiology, NorthShore University Health System, Evanston, IL, USA.,Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA
| | - Bart Billet
- Department of Anesthesiology, AZ Delta, Roeselare, Belgium
| | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, NY, USA.,Northwell Health, New York, NY
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | - Noud van Helmond
- Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV
| | | | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ajax Yang
- The Spine & Pain Institute of New York, New York, NY, USA.,Northwell Health, New York, NY
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20
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Chapman KB, Patel KV, van Helmond N, Chien GCC. Dorsal Root Ganglion Stimulation Lead Fracture Within the Superficial Fascial Layers in 4 Cases. A A Pract 2021; 14:e01307. [PMID: 32935950 PMCID: PMC7523575 DOI: 10.1213/xaa.0000000000001307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
We present 4 cases of dorsal root ganglion stimulation lead fracture. In these cases, the surgical technique involved (1) traversing fascial layers for placement of leads via a Tuohy needle in the upper low back, (2) subcutaneous tunneling from the implantable pulse generator site to the lead puncture site without dissecting below the superficial fascial plane at the puncture site, and (3) connection of the lead/extension with the generator. All fractures occurred adjacent to the original lead puncture site. These cases suggest lead entrapment within the membranous fascial plane, with tension on a thin lead, is a mechanism underlying lead fracture.
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Affiliation(s)
- Kenneth B Chapman
- From the The Spine & Pain Institute of New York, New York City, New York.,Department of Anesthesiology, NYU Langone Medical Center, New York City, New York.,Department of Anesthesiology, Zucker School of Medicine at Hostra/Northwell Health, New York City, New York
| | - Kiran V Patel
- From the The Spine & Pain Institute of New York, New York City, New York.,Department of Anesthesiology, NYU Langone Medical Center, New York City, New York
| | - Noud van Helmond
- From the The Spine & Pain Institute of New York, New York City, New York.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
| | - George C Chang Chien
- Department of Pain Medicine, Ventura County Medical Center, Ventura, California; and.,GCC Institute, Regenerative Medicine, Irvine, California
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21
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Chapman KB, Mogilner AY, Yang AH, Yadav A, Patel KV, Lubenow T, van Helmond N, Deer T, Kallewaard JW. Lead migration and fracture rate in dorsal root ganglion stimulation using anchoring and non-anchoring techniques: A multicenter pooled data analysis. Pain Pract 2021; 21:859-870. [PMID: 34145740 DOI: 10.1111/papr.13052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) is a neuromodulation technique introduced in the last decade with evolving implant methods. Initial prospective research found low incidences of lead migration and lead fracture with DRG-S. However, several recent studies have highlighted high lead migration and lead fracture rates with DRG-S. We investigated the influence of lead anchoring on migrations and fractures. METHODS We performed a retrospective review between 2016 and 2020 of individuals implanted with DRG-S leads by 4 experienced implanters. The implanters independently changed their standard practice regarding lead anchoring over time, with opposing trends (no anchoring > anchoring, anchoring > no anchoring). We compared lead migration and lead fracture rates between anchored and unanchored DRG-S leads in the entire study cohort. Cox regression was performed on lead migration and fracture distributions. RESULTS We included 756 leads (n = 565 anchored and n = 191 unanchored) from 249 patients. In unanchored leads, migration occurred in 16 leads (8.4%) from 13 patients (21.0%). In anchored leads, migration occurred in 8 leads (1.4%) from 5 patients (2.7%). Fracture in unanchored leads occurred in 6 leads (3.1%) from 6 patients (9.7%). Fractures in anchored leads occurred in 11 leads (1.9%) from 9 patients (4.8%). The migration survival distributions for the anchored and unanchored leads were statistically significantly different (p < 0.01) with decreased survival for unanchored leads (hazard ratio = 5.8, 95% confidence interval [CI] = 2.2-15.5). DISCUSSION We found that anchoring DRG-S leads significantly reduces lead migration when compared to leads placed without an anchor. There was no significant difference in fracture rate between anchored and unanchored leads.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, New York, USA.,Department of Anesthesiology, NYU Langone Medical Center, New York, New York, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA
| | - Alon Y Mogilner
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Ajax H Yang
- The Spine & Pain Institute of New York, New York, New York, USA
| | - Abhishek Yadav
- Department of Anesthesiology and Perioperative Medicine, Brown University, Providence, Rhode Island, USA
| | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, New York, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA
| | - Timothy Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Noud van Helmond
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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22
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Berger AA, Liu Y, Possoit H, Rogers AC, Moore W, Gress K, Cornett EM, Kaye AD, Imani F, Sadegi K, Varrassi G, Viswanath O, Urits I. Dorsal Root Ganglion (DRG) and Chronic Pain. Anesth Pain Med 2021; 11:e113020. [PMID: 34336621 PMCID: PMC8314073 DOI: 10.5812/aapm.113020] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 12/12/2022] Open
Abstract
Context Chronic neuropathic pain is a common condition, and up to 11.9% of the population have been reported to suffer from uncontrolled neuropathic pain. Chronic pain leads to significant morbidity, lowered quality of life, and loss of workdays, and thus carries a significant price tag in healthcare costs and lost productivity. dorsal root ganglia (DRG) stimulation has been recently increasingly reported and shows promising results in the alleviation of chronic pain. This paper reviews the background of DRG stimulation, anatomical, and clinical consideration and reviews the clinical evidence to support its use. Evidence Acquisition The DRG span the length of the spinal cord and house the neurons responsible for sensation from the periphery. They may become irritated by direct compression or local inflammation. Glial cells in the DRG respond to nerve injury, producing inflammatory markers and contribute to the development of chronic pain, even after the resolution of the original insult. While the underlying mechanism is still being explored, recent studies explored the efficacy of DRG stimulation and neuromodulation for chronic pain treatment. Results Several reported cases and a small number of randomized trials were published in recent years, describing different methods of DRG stimulation and neuromodulation with promising results. Though evidence quality is mostly low, these results provide evidence to support the utilization of this technique. Conclusions Chronic neuropathic pain is a common condition and carries significant morbidity and impact on the quality of life. Recent evidence supports the use of DRG neuromodulation as an effective technique to control chronic pain. Though studies are still emerging, the evidence appears to support this technique. Further studies, including large randomized trials evaluating DRG modulation versus other interventional and non-interventional techniques, are needed to further elucidate the efficacy of this method. These studies are also likely to inform the patient selection and the course of treatment.
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Affiliation(s)
- Amnon A. Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
- Corresponding Author: Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Yao Liu
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - HarLee Possoit
- LSU Health Shreveport, School of Medicine, Shreveport, LA, USA
| | - Anna C. Rogers
- LSU Health Shreveport, School of Medicine, Shreveport, LA, USA
| | - Warner Moore
- LSU Health Shreveport, School of Medicine, Shreveport, LA, USA
| | - Kyle Gress
- Georgetown University School of Medicine, Washington, DC, USA
| | - Elyse M. Cornett
- LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Alan David Kaye
- LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Kambiz Sadegi
- Department of Anesthesiology, Zabol University of Medical Sciences, Zabol, Iran
- Corresponding Author: Department of Anesthesiology, Zabol University of Medical Sciences, Zabol, Iran.
| | | | - Omar Viswanath
- Georgetown University School of Medicine, Washington, DC, USA
- University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
- Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA
- Valley Anesthesiology and Pain Consultants – Envision Physician Services, Phoenix, AZ, USA
| | - Ivan Urits
- Georgetown University School of Medicine, Washington, DC, USA
- Southcoast Health, Southcoast Health Physicians Group Pain Medicine, Wareham, MA, USA
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23
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Provenzano DA, Heller JA, Hanes MC. Current Perspectives on Neurostimulation for the Management of Chronic Low Back Pain: A Narrative Review. J Pain Res 2021; 14:463-479. [PMID: 33628045 PMCID: PMC7899039 DOI: 10.2147/jpr.s249580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/16/2020] [Indexed: 01/29/2023] Open
Abstract
Neurostimulation techniques for the treatment of chronic low back pain (LBP) have been rapidly evolving; however, questions remain as to which modalities provide the most efficacious and durable treatment for intractable axial symptoms. Modalities of spinal cord stimulation, such as traditional low-frequency paresthesia based, high-density or high dose (HD), burst, 10-kHz high-frequency therapy, closed-loop, and differential target multiplexed, have been limitedly studied to determine their efficacy for the treatment of axial LBP. In addition, stimulation methods that target regions other than the spinal cord, such as medial branch nerve stimulation of the multifidus muscles and the dorsal root ganglion may also be viable treatment options. Here, current scientific evidence behind neurostimulation techniques have been reviewed with a focus on the management of chronic axial LBP.
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Affiliation(s)
- David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA, USA.,Western PA Surgery Center, Wexford, PA, USA
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24
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Chapman KB, Roosendaal B, Yousef TA, Vissers KC, Helmond N. Dorsal Root Ganglion Stimulation Normalizes Measures of Pain Processing in Patients with Chronic Low‐Back Pain: A Prospective Pilot Study using Quantitative Sensory Testing. Pain Pract 2021; 21:568-577. [DOI: 10.1111/papr.12992] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Kenneth B. Chapman
- The Spine & Pain Institute of New York New York City New YorkU.S.A
- Department of Anesthesiology New York University Langone Medical Center New York City New YorkU.S.A
- Department of Anesthesiology and Pain Medicine Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Northwell Health Hempstead New York U.S.A
| | - Bert‐Kristian Roosendaal
- The Spine & Pain Institute of New York New York City New YorkU.S.A
- Department of Anesthesiology, Pain, and Palliative Medicine Radboud University Nijmegen The Netherlands
| | - Tariq A. Yousef
- The Spine & Pain Institute of New York New York City New YorkU.S.A
| | - Kris C. Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine Radboud University Nijmegen The Netherlands
| | - Noud Helmond
- The Spine & Pain Institute of New York New York City New YorkU.S.A
- Department of Anesthesiology Cooper University Hospital Cooper Medical School of Rowan University Camden New Jersey U.S.A
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25
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Chapman KB, Yousef TA, Foster A, D Stanton-Hicks M, van Helmond N. Mechanisms for the Clinical Utility of Low-Frequency Stimulation in Neuromodulation of the Dorsal Root Ganglion. Neuromodulation 2020; 24:738-745. [PMID: 33236811 DOI: 10.1111/ner.13323] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dorsal root ganglion stimulation (DRG-S) involves the electrical modulation of the somata of afferent neural fibers to treat chronic pain. DRG-S has demonstrated clinical efficacy at frequencies lower than typically used with spinal cord stimulation (SCS). In a clinical study, we found that the frequency of DRG-S can be tapered to a frequency as low as 4 Hz with no loss of efficacy. This review discusses possible mechanisms of action underlying effective pain relief with very low-frequency DRG-S. MATERIALS AND METHODS We performed a literature review to explore the role of frequency in neural transmission and the corresponding relevance of frequency settings with neuromodulation. FINDINGS Sensory neural transmission is a frequency-modulated system, with signal frequency determining which mechanisms are activated in the dorsal horn. In the dorsal horn, low-frequency signaling (<20 Hz) activates inhibitory processes while higher frequencies (>25 Hz) are excitatory. Physiologically, low-threshold mechanoreceptors (LTMRs) fibers transmit or modulate innocuous mechanical touch at frequencies as low as 0.5-5 Hz, while nociceptive fibers transmit pain at high frequencies. We postulate that very low-frequency DRG-S, at least partially, harnesses LTMRs and the native endogenous opioid system. Utilizing lower stimulation frequency decreases the total energy delivery used for DRG-S, extends battery life, and facilitates the development of devices with smaller generators.
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Affiliation(s)
- Kenneth B Chapman
- Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Northwell Health, Manhasset, NY, USA
| | - Tariq A Yousef
- Spine & Pain Institute of New York, New York City, NY, USA
| | | | | | - Noud van Helmond
- Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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26
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Chapman KB, Yousef TA, Vissers KC, van Helmond N, D Stanton-Hicks M. Very Low Frequencies Maintain Pain Relief From Dorsal Root Ganglion Stimulation: An Evaluation of Dorsal Root Ganglion Neurostimulation Frequency Tapering. Neuromodulation 2020; 24:746-752. [PMID: 33227827 DOI: 10.1111/ner.13322] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/09/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dorsal root ganglion neurostimulation (DRG-S) is effective in treating various refractory chronic pain syndromes. In preclinical studies, DRG-S at very low frequencies (<5 Hz) reduces excitatory output in the superficial dorsal horn. Clinically, we have also observed the effectiveness of DRG-S at low frequencies. We conducted a case series to describe the effect of very low-frequency DRG-S stimulation on clinical outcomes. MATERIALS AND METHODS DRG-S for refractory low back pain was initiated at parameters consistent with published values. Thereafter, the stimulation frequency of DRG-S was reduced in a stepwise fashion to the lowest frequency that maintained pain relief. Pain intensity, disability, and general health status data were collected at baseline, prior to initiation of tapering, and at four weeks after each patient's lowest effective stimulation frequency was reached. RESULTS After device activation (N = 20), DRG-S frequency was tapered from 16 to 4 Hz over a 4- to 17-week period, reducing charge-per-second by nearly two-thirds. Even so, pain relief was maintained at more than 75%, with consistent findings in the other measures. CONCLUSION DRG-S may have utility in treating chronic pain at lower stimulation frequencies than previously recognized. We have previously theorized that the mechanism of action may involve preferential recruitment of low-threshold mechanoreceptor fibers via the endogenous opioid system. Of clinical relevance, lower frequency stimulation maintains DRG-S efficacy regarding improvements in pain, disability, and quality of life. It can extend battery life and may potentially lead to the development of smaller implantable pulse generators.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Northwell Health, Manhasset, NY, USA
| | - Tariq A Yousef
- The Spine & Pain Institute of New York, New York City, NY, USA
| | - Kris C Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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27
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Chapman KB, Schirripa F, Yousef T, Deygoo J, Helmond N. Lumbar Radiofrequency Ablation Interfering With S1 Dorsal Root Ganglion Stimulation Systems: Experience From Two Cases. Pain Pract 2020; 20:780-786. [DOI: 10.1111/papr.12901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/08/2020] [Accepted: 04/14/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Kenneth B. Chapman
- The Spine & Pain Institute of New York New York New York U.S.A
- Department of Anesthesiology New York University Langone Medical Center New York New York U.S.A
- Department of Anesthesiology Northwell Health System New York New York U.S.A
| | - Frank Schirripa
- Department of Rehabilitation & Regenerative Medicine New York‐Presbyterian Hospital New York New York U.S.A
| | - Tariq Yousef
- The Spine & Pain Institute of New York New York New York U.S.A
| | - Jeffrey Deygoo
- Department of Anesthesiology Northwell Health System New York New York U.S.A
| | - Noud Helmond
- The Spine & Pain Institute of New York New York New York U.S.A
- Department of Anesthesiology Cooper Medical School of Rowan University Cooper University Health Care Camden New Jersey U.S.A
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28
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Chapman KB, Groenen PS, Vissers KC, van Helmond N, Stanton-Hicks MD. The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment. Neuromodulation 2020; 24:610-621. [PMID: 32329155 DOI: 10.1111/ner.13150] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Dorsal root ganglion stimulation (DRG-S) is a novel approach to treat chronic pain. Lead placement at L2 has been reported to be an effective treatment for axial low back pain (LBP) primarily of discogenic etiology. We have recently shown, in a diverse cohort including cases of multilevel instrumentation following extensive prior back surgeries, that DRG-S lead placement at T12 is another promising target. Local effects at the T12 DRG, alone, are insufficient to explain these results. MATERIALS AND METHODS We performed a literature review to explore the mechanisms of LBP relief with T12 DRG-S. FINDINGS Branches of individual spinal nerve roots innervate facet joints and posterior spinal structures, while the discs and anterior vertebrae are carried via L2, and converge in the dorsal horn (DH) of the spinal cord at T8-T9. The T12 nerve root contains cutaneous afferents from the low back and enters the DH of the spinal cord at T10. Low back Aδ and C-fibers then ascend via Lissauer's tract (LT) to T8-T9, converging with other low back afferents. DRG-S at T12, then, results in inhibition of the converged low back fibers via endorphin-mediated and GABAergic frequency-dependent mechanisms. Therefore, T12 lead placement may be the optimal location for DRG-S to treat LBP.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Northwell Health Systems, New York City, NY, USA
| | - Pauline S Groenen
- The Spine & Pain Institute of New York, New York City, NY, USA.,College of Medicine, Radboud University, Nijmegen, the Netherlands
| | - Kris C Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University, Nijmegen, the Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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29
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Huygen FJPM, Kallewaard JW, Nijhuis H, Liem L, Vesper J, Fahey ME, Blomme B, Morgalla MH, Deer TR, Capobianco RA. Effectiveness and Safety of Dorsal Root Ganglion Stimulation for the Treatment of Chronic Pain: A Pooled Analysis. Neuromodulation 2019; 23:213-221. [PMID: 31730273 PMCID: PMC7079258 DOI: 10.1111/ner.13074] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Since it became available in the mid-2010s, dorsal root ganglion (DRG) stimulation has become part of the armamentarium to treat chronic pain. To date, one randomized controlled trial, and several studies of moderate sample size and various etiologies have been published on this topic. We conducted a pooled analysis to investigate the generalizability of individual studies and to identify differences in outcome between chronic pain etiologic subgroups and/or pain location. MATERIALS AND METHODS One prospective, randomized comparative trial and six prospective, single-arm, observational studies were identified that met pre-defined acceptance criteria. Pain scores and patient-reported outcome (PRO) measures were weighted by study sample sizes and pooled. Safety data are reported in aggregate form. RESULTS Our analysis included 217 patients with a permanent implant at 12-month follow-up. Analysis of pooled data showed an overall weighted mean pain score of 3.4, with 63% of patients reporting ≥50% pain relief. Effectiveness sub-analyses in CRPS-I, causalgia, and back pain resulted in a mean reduction in pain intensity of 4.9, 4.6, and 3.9 points, respectively. Our pooled analysis showed a pain score for primary affected region ranging from 1.7 (groin) to 3.0 (buttocks) and responder rates of 80% for foot and groin, 75% for leg, and 70% for back. A substantial improvement in all PROs was observed at 12 months. The most commonly reported procedural or device complications were pain at the IPG pocket site, lead fracture, lead migration, and infection. CONCLUSIONS DRG stimulation is an effective and safe therapy for various etiologies of chronic pain.
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Affiliation(s)
- Frank J P M Huygen
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management Arnhem, Rijnstate Hospital, Velp, The Netherlands
| | | | - Liong Liem
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Bram Blomme
- Neuromodulation Division, Abbott, Austin, TX, USA
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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30
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Chapman KB, Groenen PS, Patel KV, Vissers KC, van Helmond N. T12 Dorsal Root Ganglion Stimulation to Treat Chronic Low Back Pain: A Case Series. Neuromodulation 2019; 23:203-212. [PMID: 31588662 DOI: 10.1111/ner.13047] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/13/2019] [Accepted: 08/19/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) is a neuromodulation technique for treating neuropathic pain syndromes. Research has demonstrated DRG-S to be more effective than conventional SCS in treating RSD/CRPS, particularly of the lower extremities. Results from recent case series and prospective studies suggest that DRG-S may be effective in treatment of pain syndromes considered to have non-neuropathic components and characteristics (e.g. nociceptive). There have been multiple, small studies demonstrating efficacy of DRG-S for axial low back pain. There has, however, been no consensus regarding the best location for DRG lead placement in the treatment of low back pain. METHODS Patients presenting with refractory low back pain in a private pain management practice were considered for DRG-S. Patients were provided a trial stimulator prior to potential implantation. Per standard practice, pain intensity, disability, general health status, and quality of life were followed using the visual analog scale (VAS), Oswestry Disability Index, EQ-5D index, and the SF-36 survey, respectively. Data were collected prior to implantation and at variable follow-ups after DRG-S initiation. RESULTS Seventeen consecutive patients presented with predominantly axial low back pain with/without a secondary component of lower extremity pain. All were trialed and subsequently implanted for DRG-S. Leads were placed at T12 to target the low back. Stimulation levels were set very low, below that of which patients experienced paresthesias. Last follow-up times averaged 8.3 months. More than half of the patients experienced pain relief ≥80%, with an average low back pain relief of 78% at last follow-up. Additionally, substantial improvements in physical and mental functioning, disability, and quality of life were reported. CONCLUSIONS T12 DRG-S can be an effective treatment for chronic axial low back pain. Stimulation results in reduced pain and disability, while improving quality of life. These outcomes can be achieved without paresthesias.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Pauline S Groenen
- The Spine & Pain Institute of New York, New York City, NY, USA.,College of Medicine, Radboud University, Nijmegen, The Netherlands
| | - Kiran V Patel
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Kris C Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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31
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Rapid onset and short washout periods of dorsal root ganglion stimulation facilitate multiphase crossover study designs. Brain Stimul 2019; 12:1617-1618. [PMID: 31519493 DOI: 10.1016/j.brs.2019.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/27/2019] [Indexed: 11/24/2022] Open
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32
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The Chinese Association for the Study of Pain (CASP): Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain. Pain Res Manag 2019; 2019:8957847. [PMID: 31511784 PMCID: PMC6714323 DOI: 10.1155/2019/8957847] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 06/06/2019] [Accepted: 07/11/2019] [Indexed: 02/05/2023]
Abstract
Chronic nonspecific low back pain (CNLBP) is defined as pain or discomfort originating from the waist, which lasts for at least 12 weeks, but no radiculopathy or specific spinal diseases. CNLBP is a complicated medical problem and places a huge burden on healthcare systems. Clinical manifestation of CNLBP includes discogenic LBP, zygapophyseal joint pain, sacroiliac joint pain, and lumbar muscle strain. Further evaluation should be completed to confirm the diagnosis including auxiliary examination, functional assessment, and clinical assessment. The principle of the management is to relieve pain, restore function, and avoid recurrence. Treatment includes conservative treatment, minimally invasive treatment, and rehabilitation. Pharmacologic therapy is the first-line treatment of nonspecific LBP, and it is most widely used in clinical practice. Interventional therapy should be considered only after failure of medication and physical therapy. Multidisciplinary rehabilitation can improve physical function and alleviate short-term and long-term pain. The emphasis should be put on the prevention of NLBP and reducing relevant risk factors.
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