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Deer TR, Russo MA, Sayed D, Pope JE, Grider JS, Hagedorn JM, Falowski SM, Al-Kaisy A, Slavin KV, Li S, Poree LR, Eldabe S, Meier K, Lamer TJ, Pilitsis JG, De Andrés J, Perruchoud C, Carayannopoulos AG, Moeschler SM, Hadanny A, Lee E, Varshney VP, Desai MJ, Pahapill P, Osborn J, Bojanic S, Antony A, Piedimonte F, Hayek SM, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation. Neuromodulation 2024; 27:977-1007. [PMID: 38878054 DOI: 10.1016/j.neurom.2024.04.004] [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: 01/30/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety. MATERIALS AND METHODS Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant. RESULTS The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | | | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Adnan Al-Kaisy
- Guy's and St. Thomas National Health Service (NHS) Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA; Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA
| | - Sean Li
- National Spine & Pain Centers, Shrewsbury, NJ, USA
| | - Lawrence R Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Kaare Meier
- Department of Anesthesiology (OPINord), Aarhus University Hospital, Aarhus, Arhus, Denmark; Department of Neurosurgery (Afd. NK), Aarhus University Hospital, Aarhus, Arhus, Denmark
| | | | | | - Jose De Andrés
- Valencia School of Medicine, Anesthesia Critical Care and Pain Management Department, General University Hospital, Valencia, Spain
| | | | - Alexios G Carayannopoulos
- Department of Physical Medicine and Rehabilitation and Comprehensive Spine Center, Rhode Island Hospital, Providence, RI, USA; Brown University Warren Alpert Medical School (Neurosurgery), Providence, RI, USA
| | - Susan M Moeschler
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amir Hadanny
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Eric Lee
- Mililani Pain Center, Mililani, HI, USA
| | - Vishal P Varshney
- Anesthesiology and Pain Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Mehul J Desai
- International Spine, Pain & Performance Center, Virginia Hospital Center, Monument Research Institute, George Washington University School of Medicine, Arlington, VA, USA
| | - Peter Pahapill
- Functional Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Osborn
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ajay Antony
- The Orthopaedic Institute, Gainesville, FL, USA
| | - Fabian Piedimonte
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Cheung CK, Lee KW, Yong RJ. Use of a Sheath and Stylet for a Difficult Dorsal Root Ganglion Stimulation Lead Extraction: A Case Report. A A Pract 2024; 18:e01766. [PMID: 38502524 DOI: 10.1213/xaa.0000000000001766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Dorsal root ganglion stimulation (DRG-S) is a relatively new neuromodulation technique that has shown promising results in the treatment of chronic pain conditions. We present a case of a difficult lead extraction during the explantation of a DRG-S device. The lead was unable to be removed despite multiple attempts until a sheath and stylet were used to facilitate extraction. As DRG-S utilization becomes more widespread, DRG-S device explantation will inevitably become more common. The technique described in this report may be beneficial in certain cases of difficult DRG-S lead extraction.
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Affiliation(s)
- Christopher K Cheung
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Lu L, Lau M, Akers L, Jones L, Selassie M, Burke M, Barley J, Hillegass M, Gleichgerrcht E. Intraoperative Neurophysiological Monitoring During Lead Placement for Dorsal Root Ganglion Stimulation: A Literature Review and Case Series. Neuromodulation 2024; 27:160-171. [PMID: 37245141 DOI: 10.1016/j.neurom.2023.04.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/23/2023] [Accepted: 04/11/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) is a viable interventional option for intractable pain management. Although systematic data are lacking regarding the immediate neurologic complications of this procedure, intraoperative neurophysiological monitoring (IONM) can be a valuable tool to detect real-time neurologic changes and prompt intervention(s) during DRG-S performed under general anesthesia and deep sedation. MATERIALS AND METHODS In our single-center case series, we performed multimodal IONM, including peripheral nerve somatosensory evoked potentials (pnSSEPs) and dermatomal somatosensory evoked potentials (dSSEPs), spontaneous electromyography (EMG), transcranial motor evoked potentials (MEPs), and electroencephalogram (EEG) for some trials and all permanent DRG-S lead placement per surgeon preference. Alert criteria for each IONM modality were established before data acquisition and collection. An IONM alert was used to implement an immediate repositioning of the lead to reduce any possible postoperative neurologic deficits. We reviewed the literature and summarized the current IONM modalities commonly applied during DRG-S, including somatosensory evoked potentials and EMG. Because DRG-S targets the dorsal roots, we hypothesized that including dSSEP would allow more sensitivity as a proxy for potential sensory changes under generalized anesthesia than would including standard pnSSEPs. RESULTS From our case series of 22 consecutive procedures with 45 lead placements, one case had an alert immediately after DRG-S lead positioning. In this case, dSSEP attenuation was seen, indicating changes in the S1 dermatome, which occurred despite ipsilateral pnSSEP from the posterior tibial nerve remaining at baselines. The dSSEP alert prompted the surgeon to reposition the S1 lead, resulting in immediate recovery of the dSSEP to baseline status. The rate of IONM alerts reported intraoperatively was 4.55% per procedure and 2.22% per lead (n = 1). No neurologic deficits were reported after the procedure, resulting in no postoperative neurologic complications or deficits. No other IONM changes or alerts were observed from pnSSEP, spontaneous EMG, MEPs, or EEG modalities. Reviewing the literature, we noted challenges and potential deficiencies when using current IONM modalities for DRG-S procedures. CONCLUSIONS Our case series suggests dSSEPs offer greater reliability than do pnSSEPs in quickly detecting neurologic changes, and subsequent neural injury, during DRG-S cases. We encourage future studies to focus on adding dSSEP to standard pnSSEP to provide a comprehensive, real-time neurophysiological assessment during lead placement for DRG-S. More investigation, collaboration, and evidence are required to evaluate, compare, and standardize comprehensive IONM protocols for DRG-S.
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Affiliation(s)
- Lei Lu
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.
| | - Martha Lau
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Lindsey Akers
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Lakota Jones
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Meron Selassie
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Martin Burke
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jessica Barley
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Hillegass
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
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Isagulyan ED, Semenov DE, Polushkin AA, Asriants SV, Sergeenko EV, Aslakhanova KS, Tomsky AA. [Electrical dorsal root ganglion stimulation (DRGS) for the treatment of refractory postherpetic neuralgia]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:21-27. [PMID: 38334727 DOI: 10.17116/neiro20248801121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
Postherpetic neuralgia (PHN) is a rare complication of herpes zoster characterized by prolonged and excruciating pain. Traditional treatments for PHN, such as analgesics, anticonvulsants and antidepressants, do not always bring the desired result. One promising alternative that is attracting the attention of the scientific community is dorsal root ganglion stimulation (DRGS). This method focuses on targeted and precise targeting of the source of pain, providing a new level of effectiveness in the treatment of PHN. OBJECTIVE A retrospective analysis of the technique and results of implantation of a permanent device for stimulating the spinal ganglia in patients with refractory PHN at the Burdenko Neurosurgical Center. MATERIAL AND METHODS The study was conducted in 7 patients (5 men, 2 women) with refractory PHN in the period from 2018 to 2020. The age of the patients ranged from 57 to 84 years (average age 74±8.4). All patients were implanted with Boston systems (Precision or Spectra versions). Stimulation parameters: pulse width - 120-210 μs, frequency - 30-130 Hz, amplitude at the lower limit of the appearance of paresthesia with the possibility of increasing with increased pain up to 5 mA. The position of the electrode depended on the location of the pain. All systems were implanted under X-ray guidance. RESULTS The duration of follow-up observation was more than 2.5 years. The average pain intensity one year after treatment was 3.42±2.45 points on the visual analogue scale (VAS) (a 62.3% decrease in intensity compared to baseline). In 3 (42.8%) patients, the result was characterized by us as «excellent» (intensity according to VAS decreased by 75% or more), in 1 (14.2%) - as «good» (intensity according to VAS decreased by 50-74%), in 1 (14.2%) - as «moderate» (VAS intensity decreased by 25-49% and in 2 (28.5%) as «unsatisfactory» (VAS intensity decreased by less than 25%, or postoperative complications occurred). CONCLUSION Given the complicated nature of PHN, the use of dorsal ganglion stimulation appears to be a promising and innovative treatment approach. Further research is needed to introduce this technique into clinical practice for the treatment of patients suffering from PHN.
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Affiliation(s)
| | - D E Semenov
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | | | - A A Tomsky
- Burdenko Neurosurgical Center, Moscow, Russia
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Graca MJ, Lubenow TR, Landphair WR, McCarthy RJ. Efficacy and Safety of Cervical and High-Thoracic Dorsal Root Ganglion Stimulation Therapy for Complex Regional Pain Syndrome of the Upper Extremities. Neuromodulation 2023; 26:1781-1787. [PMID: 36402657 DOI: 10.1016/j.neurom.2022.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/05/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate analgesic and safety considerations for high thoracic and cervical dorsal root ganglion (DRG) neuromodulation for complex regional pain syndrome (CRPS). We hypothesized that DRG neuromodulation would provide sustained analgesia with complications like that of low thoracic or lumbar electrode implantation. MATERIALS AND METHODS A single-center, retrospective study was conducted of patients with CRPS I or II of the upper extremities, refractory to previous therapies, who were treated with DRG neuromodulation in the upper thoracic and cervical spine. The primary outcome was successful DRG therapy, defined as ≥ 50% pain relief on a Numeric Rating Scale (NRS) 0 to 10 pain scale at six months after implantation. A secondary outcome was a reduction in daily opioid use after DRG therapy. RESULTS After a DRG stimulation trial, 17 of 20 patients (85%) had ≥ 50% improvement in NRS pain and underwent a permanent pulse generator implant, with 100% endorsing ≥ 50% pain relief at six months. Mean NRS pain scores before DRG neuromodulation were 9.3 ± 1.1, with a mean reduction of 5.5 (95% CI, 4.5-6.6; p < 0.001) at six months. Ten patients were taking opioids at baseline; the median (interquartile range) dose was 45 mg (23 to 120) morphine equivalents (MME), which was reduced to 20 MME (15 to 40) at six months. The median reduction in daily MME use was -25 (95% CI, -100 to 20; p = 0.099). Six of 20 patients (30%) experienced a complication: three had lead migration; two experienced paresthesias; and one had a reduction in shoulder mobility. One patient had symptoms of a reversible spinal cord compression immediately after implant, requiring emergent electrode removal. CONCLUSIONS DRG neuromodulation for patients with CRPS of the upper extremities produced clinically important analgesia and reduced opioid use for ≥ six months but was associated with one serious complication.
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Affiliation(s)
- Mateusz J Graca
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
| | - Timothy R Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA.
| | - William R Landphair
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
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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: 11] [Impact Index Per Article: 11.0] [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
| | - 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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Wolff Fernandes F, Saryyeva A, Runge J, Krauss JK. Thoracic ganglionectomy: A rescue technique for failed dorsal root ganglion stimulation. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2022.101695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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8
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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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Chauhan G, Srinivasan SK, Khanduja S. Dorsal Root Ganglion Stimulation Therapy for Refractory Idiopathic Pudendal Neuralgia. Cureus 2023; 15:e34681. [PMID: 36909041 PMCID: PMC9994636 DOI: 10.7759/cureus.34681] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/09/2023] Open
Abstract
Dorsal root ganglion stimulation is a relatively new treatment option for chronic pain conditions such as pudendal neuralgia, which is a chronic pain condition affecting the pudendal nerve in the pelvic region. Pudendal neuralgia is a debilitating condition that can significantly affect the patient's quality of life. In dorsal root ganglion stimulation, a small device is implanted that delivers electrical impulses to the dorsal root ganglion to modulate pain signals coming from the pudendal nerve. The procedure is considered investigational and has been investigated in case series and case reports with promising results. However, more research is needed to fully understand its safety and effectiveness. This case report highlights the potential of dorsal root ganglion stimulation as a treatment option for pudendal neuralgia and the need for further research to establish it as a standard treatment option.
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Affiliation(s)
- Gaurav Chauhan
- Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, USA
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Ferreira-Silva N, Ferreira-Dos-Santos G, Gupta S, Hunt CL, Eldrige JS, Pingree MJ, Clendenen SR, B Hurdle MF. A case for ultrasound-guided peripheral nerve stimulation in intractable anterior cutaneous nerve entrapment syndrome. Pain Manag 2022; 12:813-819. [PMID: 36065884 DOI: 10.2217/pmt-2022-0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This case report documents the use of peripheral nerve stimulation in the setting of entrapment of the anterior cutaneous branches of the intercostal nerves, with pain rated by the patient as severe during exacerbation episodes. Materials & methods: Under ultrasound guidance, two permanent leads were implanted caudad to cephalad, along and superficial to the lateral aspect of the rectus abdominis, distal to the umbilicus (1 lead per side). Results: At the 6 month follow-up, the patient reported near complete resolution of baseline pain, as well as fewer, sporadic pain exacerbation episodes, rated as mild-to-moderate. Conclusion: This case report suggests that peripheral nerve stimulation might be a valuable treatment option for previously intractable abdominal pain due to entrapment of the anterior cutaneous branches.
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Affiliation(s)
- Nuno Ferreira-Silva
- Department of Physical Medicine & Rehabilitation, Hospital Professor Doctor Fernando Fonseca, Amadora, Portugal
| | - Guilherme Ferreira-Dos-Santos
- Department of Anesthesiology & Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, M5T 2S8, Canada
| | - Sahil Gupta
- Department of Pain Medicine, Mayo Clinic Jacksonville, FL 32224, USA
| | - Christine L Hunt
- Department of Pain Medicine, Mayo Clinic Jacksonville, FL 32224, USA
| | - Jason S Eldrige
- Department of Pain Medicine, Mayo Clinic Jacksonville, FL 32224, USA
| | - Matthew J Pingree
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Steven R Clendenen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
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11
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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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12
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A prospective long-term follow-up of dorsal root ganglion stimulation for the management of chronic intractable pain. Pain 2022; 163:702-710. [PMID: 35302973 DOI: 10.1097/j.pain.0000000000002405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/25/2021] [Indexed: 01/19/2023]
Abstract
ABSTRACT Initial clinical studies have shown that the stimulation of the dorsal root ganglion (DRG) can significantly reduce chronic intractable pain. However, clinical data on long-term results and complications of these systems are limited. The aim of this prospective study is to report on a single center long-term follow-up of DRG stimulation for intractable chronic pain. Participants were implanted with DRG stimulation devices between 2013 and 2015 with an observation period of 24 months. Patients were contacted again in 2020 for a final follow-up (ie, between 5 and 7 years postimplantation). Forty-two participants were recruited, of whom 32 received the fully implantable pulse generator (IPG). At the final follow-up, 50% (16/32) of participants were still using DRG stimulation. Two participants still had the original IPG and 14 had received a replacement IPG. Pain scores were significantly reduced at 24 months, mean difference 1.7 (95% confidence interval: 0.2-3.3, P = 0.03), and at the last follow-up, mean difference 2.1 (95% confidence interval: 0.3-4, P = 0.03). Significant improvements were observed for health-related quality of life. The findings were generally robust to imputation methods of missing data. Implantable pulse generators of 8 patients were explanted because of dissatisfaction with pain relief. In conclusion, DRG stimulation can provide effective pain relief and improved quality of life in patients suffering with neuropathic pain, although this study had a revision rate of 42% within the first 24 months, and 56% of IPGs that were replaced because of battery depletion had a shorter than expected battery life.
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13
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Deer TR, Russo MA, Grider JS, Pope J, Rigoard P, Hagedorn JM, Naidu R, Patterson DG, Wilson D, Lubenow TR, Buvanendran A, Sheth SJ, Abdallah R, Knezevic NN, Schu S, Nijhuis H, Mehta P, Vallejo R, Shah JM, Harned ME, Jassal N, Gonzalez JM, Pittelkow TP, Patel S, Bojanic S, Chapman K, Strand N, Green AL, Pahapill P, Dario A, Piedimonte F, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations for Surgical Technique for Spinal Cord Stimulation. Neuromodulation 2022; 25:1-34. [PMID: 35041578 DOI: 10.1016/j.neurom.2021.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 09/21/2021] [Accepted: 10/06/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice. MATERIALS AND METHODS Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant. RESULTS This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion. CONCLUSIONS The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA.
| | - Marc A Russo
- Hunter Pain Specialists, Newcastle, New South Wales, Australia
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
| | - Philippe Rigoard
- Department of Spine Surgery and Neuromodulation, PRISMATICS Lab, Poitiers University Hospital, Poitiers, France
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ramana Naidu
- California Orthopedics & Spine, Larkspur, CA, USA
| | | | - Derron Wilson
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Timothy R Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
| | | | - Samir J Sheth
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Davis, CA, USA
| | - Rany Abdallah
- Center for Interventional Pain and Spine, Milford, DE, USA
| | - N Nick Knezevic
- Department of Anesthesiology and Surgery at University of Illinois, Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Stefan Schu
- Leitender Arzt Neuromodulation, Neurochirurgie, Sana Kliniken Duisburg GmbH, Duisburg, Germany
| | - Harold Nijhuis
- Department of Anesthesiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Jay M Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Michael E Harned
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Jose Manuel Gonzalez
- Hospital Clínico Universitario Virgen de la Victoria, Servicio Andaluz de Salud, Málaga, Spain
| | - Thomas P Pittelkow
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | - Stana Bojanic
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, England, UK
| | - Kenneth Chapman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, The Pain and Spine Institute of New York, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, Oxford University, Oxford, England, UK
| | - Peter Pahapill
- Functional Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alessandro Dario
- Department of Neurosurgery, ASST Settelaghi, Insubria University, Varese, Italy
| | | | - Robert M Levy
- International Neuromodulation Society, Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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14
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Chapman KB, van Helmond N. Response to: "Single-Center Retrospective Analysis of Device-Related Complications Related to Dorsal Root Ganglion Stimulation for Pain Relief in 31 Patients". Neuromodulation 2021; 24:1501-1502. [PMID: 34748680 DOI: 10.1111/ner.13541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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, Northwell Health, Manhasset, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York, NY, USA.,Department of Anesthesiology, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
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15
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Dalrymple AN, Ting JE, Bose R, Trevathan JK, Nieuwoudt S, Lempka SF, Franke M, Ludwig KA, Shoffstall AJ, Fisher LE, Weber DJ. Stimulation of the dorsal root ganglion using an Injectrode ®. J Neural Eng 2021; 18. [PMID: 34650008 DOI: 10.1088/1741-2552/ac2ffb] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/14/2021] [Indexed: 01/15/2023]
Abstract
Objective. The goal of this work was to compare afferent fiber recruitment by dorsal root ganglion (DRG) stimulation using an injectable polymer electrode (Injectrode®) and a more traditional cylindrical metal electrode.Approach. We exposed the L6 and L7 DRG in four cats via a partial laminectomy or burr hole. We stimulated the DRG using an Injectrode or a stainless steel (SS) electrode using biphasic pulses at three different pulse widths (80, 150, 300μs) and pulse amplitudes spanning the range used for clinical DRG stimulation. We recorded antidromic evoked compound action potentials (ECAPs) in the sciatic, tibial, and common peroneal nerves using nerve cuffs. We calculated the conduction velocity of the ECAPs and determined the charge-thresholds and recruitment rates for ECAPs from Aα, Aβ, and Aδfibers. We also performed electrochemical impedance spectroscopy measurements for both electrode types.Main results. The ECAP thresholds for the Injectrode did not differ from the SS electrode across all primary afferents (Aα, Aβ, Aδ) and pulse widths; charge-thresholds increased with wider pulse widths. Thresholds for generating ECAPs from Aβfibers were 100.0 ± 32.3 nC using the SS electrode, and 90.9 ± 42.9 nC using the Injectrode. The ECAP thresholds from the Injectrode were consistent over several hours of stimulation. The rate of recruitment was similar between the Injectrodes and SS electrode and decreased with wider pulse widths.Significance. The Injectrode can effectively excite primary afferents when used for DRG stimulation within the range of parameters used for clinical DRG stimulation. The Injectrode can be implanted through minimally invasive techniques while achieving similar neural activation to conventional electrodes, making it an excellent candidate for future DRG stimulation and neuroprosthetic applications.
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Affiliation(s)
- Ashley N Dalrymple
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America.,Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America
| | - Jordyn E Ting
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America
| | - Rohit Bose
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America
| | - James K Trevathan
- Departments of Biomedical Engineering and Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | | | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
| | | | - Kip A Ludwig
- Departments of Biomedical Engineering and Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.,Neuronoff Inc., Cleveland, OH, United States of America.,Wisconsin Institute for Translational Neuroengineering (WITNe), Madison, WI, United States of America
| | - Andrew J Shoffstall
- Neuronoff Inc., Cleveland, OH, United States of America.,Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States of America
| | - Lee E Fisher
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Douglas J Weber
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America.,Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America.,Neuroscience Institute, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America
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16
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Naidu RK, Chaturvedi R, Engle AM, Mehta P, Su B, Chakravarthy K, Amirdelfan K, Henn J, Sayed D, Grider J, Deer T. Interventional Spine and Pain Procedure Credentialing: Guidelines from the American Society of Pain & Neuroscience. J Pain Res 2021; 14:2777-2791. [PMID: 34531681 PMCID: PMC8439288 DOI: 10.2147/jpr.s309705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/22/2021] [Indexed: 01/18/2023] Open
Abstract
Background The discipline of interventional pain management has changed significantly over the past decade with an expected greater evolution in the next decade. Not only have the number of procedures increased, some of the procedures that were created for spine surgeons are becoming more facile in the hands of the interventional pain physician. Such change has outpaced academic institutions, societies, and boards. When a pain physician is in the credentialing process for novel procedure privileges, it can leave the healthcare system in a challenging situation with little to base their decision upon. Methods This paper was developed by a consensus working group from the American Society of Pain and Neuroscience from various disciplines. The goal was to develop processes and resources to aid in the credentialing process. Results These guidelines from the American Society of Pain and Neuroscience provide background information to help facilities create a process to appropriately credential physicians on novel procedures. They are not intended to serve as a standard or legal precedent. Conclusion This paper serves as a guide for facilities to credential physicians on novel procedures.
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Affiliation(s)
| | - Rahul Chaturvedi
- School of Medicine, University of California - San Diego, San Diego, CA, USA
| | - Alyson M Engle
- The Spine & Nerve Centers of the Virginias, Charleston, WV, USA
| | | | - Brian Su
- California Orthopedics & Spine, Larkspur, CA, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology, University of California - San Diego, San Diego, CA, USA
| | | | - Jeffrey Henn
- Joint Implant Surgeons of Florida, Fort Myers, FL, USA
| | - Dawood Sayed
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jay Grider
- Department of Anesthesiology, University of Kentucky, Lexington, KY, USA
| | - Timothy Deer
- The Spine & Nerve Centers of the Virginias, Charleston, WV, USA
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17
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Moman RN, Peterson AA, Maher DP, Eli I, Hagedorn JM, Bendel MA, Gerberi D, Murad MH, Hooten WM. Infectious Complications of Dorsal Root Ganglion Stimulation: A Systematic Review and Pooled Analysis of Incidence. Neuromodulation 2021; 25:956-964. [PMID: 34096135 DOI: 10.1111/ner.13473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/16/2021] [Accepted: 05/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Dorsal root ganglion stimulation (DRGS) is a newer form of neuromodulation that targets the dorsal root ganglion. DRGS has superior efficacy in complex regional pain syndrome compared to spinal cord stimulation (SCS) and may have efficacy in other forms of chronic pain. While decades of safety data are available for SCS, there is less available safety information for DRGS. The objectives of this systematic review and pooled analysis of incidence are to determine the overall incidence of DRGS infections, incidence at each stage (trial vs. implant vs. revision), infection characteristics, and outcomes. MATERIALS AND METHODS A comprehensive search of databases from January 1980 to January 2021 was conducted. RESULTS Ten studies met inclusion criteria. Eight studies reported patients with trial data (n = 291), ten studies reported patients with implant data (n = 250), and seven studies reported data with revisions (n = 26). The pooled incidence of trial infections was 1.03% (95% CI 0.35-2.99%), implant infections was 4.80% (95% CI 2.77-8.20%), revision infections was 3.85% (95% CI 0.20-21.59%), and overall infections was 2.82% (95% CI 1.62-4.54%). There was a statistically significant difference in infection rates between the trial, implant, and revision stages, X2 (2, N = 567) = 8.9839, p = 0.01. CONCLUSIONS This is the first systematic review and pooled analysis that followed PRISMA guidelines to report infectious complications of DRGS by stage (trial vs. implant vs. revision). DRGS trial appears to be low risk for infection but that risk is significantly increased with DRGS implant. Our findings highlight the need for further study of infectious complications, their risks, and optimal prophylaxis.
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Affiliation(s)
- Rajat N Moman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ashley A Peterson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dermot P Maher
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins, Baltimore, MD, USA
| | - Ilhan Eli
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jonathan M Hagedorn
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Markus A Bendel
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - M Hassan Murad
- Division of Preventive Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - W Michael Hooten
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins, Baltimore, MD, USA
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18
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Soloukey S, de Rooij JD, Osterthun R, Drenthen J, De Zeeuw CI, Huygen FJPM, Harhangi BS. The Dorsal Root Ganglion as a Novel Neuromodulatory Target to Evoke Strong and Reproducible Motor Responses in Chronic Motor Complete Spinal Cord Injury: A Case Series of Five Patients. Neuromodulation 2021; 24:779-793. [PMID: 32706445 PMCID: PMC8359424 DOI: 10.1111/ner.13235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Current strategies for motor recovery after spinal cord injury (SCI) aim to facilitate motor performance through modulation of afferent input to the spinal cord using epidural electrical stimulation (EES). The dorsal root ganglion (DRG) itself, the first relay station of these afferent inputs, has not yet been targeted for this purpose. The current study aimed to determine whether DRG stimulation can facilitate clinically relevant motor response in motor complete SCI. MATERIALS AND METHODS Five patients with chronic motor complete SCI were implanted with DRG leads placed bilaterally on level L4 during five days. Based on personalized stimulation protocols, we aimed to evoke dynamic (phase 1) and isotonic (phase 2) motor responses in the bilateral quadriceps muscles. On days 1 and 5, EMG-measurements (root mean square [RMS] values) and clinical muscle force measurements (MRC scoring) were used to measure motor responses and their reproducibility. RESULTS In all patients, DRG-stimulation evoked significant phase 1 and phase 2 motor responses with an MRC ≥4 for all upper leg muscles (rectus femoris, vastus lateralis, vastus medialis, and biceps femoris) (p < 0.05 and p < 0.01, respectively), leading to a knee extension movement strong enough to facilitate assisted weight bearing. No significant differences in RMS values were observed between days 1 and 5 of the study, indicating that motor responses were reproducible. CONCLUSION The current paper provides first evidence that bilateral L4 DRG stimulation can evoke reproducible motor responses in the upper leg, sufficient for assisted weight bearing in patients with chronic motor complete SCI. As such, a new target for SCI treatment has surfaced, using existing stimulation devices, making the technique directly clinically accessible.
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Affiliation(s)
- Sadaf Soloukey
- Department of NeurosurgeryErasmus MC RotterdamRotterdamThe Netherlands
- Department of NeuroscienceErasmus MC RotterdamRotterdamThe Netherlands
| | - Judith D. de Rooij
- Center for Pain Medicine, Department of AnesthesiologyErasmus MC RotterdamRotterdamThe Netherlands
- Unit of Physiotherapy, Department of OrthopedicsErasmus MC RotterdamRotterdamThe Netherlands
| | - Rutger Osterthun
- Department of Rehabilitation MedicineErasmus MC RotterdamRotterdamThe Netherlands
- Spinal Cord Injury DepartmentRijndam Rehabilitation CenterRotterdamThe Netherlands
| | - Judith Drenthen
- Department of Clinical NeurophysiologyErasmus MC RotterdamRotterdamThe Netherlands
| | - Chris I. De Zeeuw
- Department of NeuroscienceErasmus MC RotterdamRotterdamThe Netherlands
- Netherlands Institute for NeuroscienceRoyal Dutch Academy for Arts and SciencesAmsterdamThe Netherlands
| | - Frank J. P. M. Huygen
- Center for Pain Medicine, Department of AnesthesiologyErasmus MC RotterdamRotterdamThe Netherlands
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19
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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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20
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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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21
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Chapman KB, Kloosterman J, Schor JA, Girardi GE, van Helmond N, Yousef TA. Objective Improvements in Peripheral Arterial Disease from Dorsal Root Ganglion Stimulation: A Case Series. Ann Vasc Surg 2021; 74:519.e7-519.e16. [PMID: 33549777 DOI: 10.1016/j.avsg.2021.01.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/02/2021] [Accepted: 01/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The sympathetic nervous system (SNS) is important in the regulation of perfusion. Dorsal root ganglion stimulation (DRG-S) modulates sympathetic tone and is approved to treat complex regional pain syndrome, a disorder related to SNS dysfunction. We herein present 3 cases of DRG-S therapy to improve blood flow and symptoms of ischemia in peripheral arterial disease (PAD). METHODS Patient 1 is a 44-year-old female with dry gangrene of the third and fourth digits of her right hand due to Raynaud's syndrome who was scheduled for amputation of the affected digits. DRG-S leads were placed at the right C6, 7, and 8 DRG. Pulse volume recordings (PVR) were measured at baseline and after DRG-S. Patient 2 is a 55-year-old female with a non-healing ulcer of her left foot secondary to PAD scheduled for a below the knee amputation who underwent a DRG-S trial with leads placed at the left L4 and L5 DRG followed by a spinal cord stimulation trial with leads placed at the T9-T10 spinal levels for comparison. Transcutaneous oximetry (TcPO2) was measured at baseline and after 3 days of each therapy. Patient 3 is a 69-year-old female with persistent left foot pain at rest secondary to PAD with DRG-S leads placed at the left L4 and S1 levels. RESULTS All 3 patients experienced a significant reduction in pain with DRG-S, along with improvements in blood flow of the involved extremities, avoiding or limiting amputation. PVR improved dramatically with DRG-S in patient 1. A greater improvement in TcPO2 was seen with the DRG-S trial compared to spinal cord stimulation trial in patient 2. Patient 3 experienced an increase in walking distance and demonstrated long term efficacy and limb salvage at 32 months postimplantation. CONCLUSIONS Modulation of SNS output from DRG-S through orthodromic and antidromic autonomic pathways is likely responsible for improving blood flow. DRG-S may be a treatment option for PAD.
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Affiliation(s)
- Kenneth B Chapman
- Spine & Pain Institute of New York, New York City, NY; Department of Anesthesiology, New York University Langone Medical Center, New York City, NY; Zucker School of Medicine at Hofstra/Northwell, New York City, NY.
| | - Jaap Kloosterman
- College of Medicine, Radboud University, Nijmegen, The Netherlands
| | - Jonathan A Schor
- Department of Surgery, Division of Vascular Surgery, Staten Island University Hospital, New York, NY
| | | | - Noud van Helmond
- Spine & Pain Institute of New York, New York City, NY; Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ
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22
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Hagedorn JM, Deer TR, Falowski SM, Yadav A, Comer A, Al-Asadi Z, Engle AM. An Observational Study of Intraoperative Neuromonitoring as a Safety Mechanism in Placement of Percutaneous Dorsal Root Ganglion Stimulation and Spinal Cord Stimulation Systems. J Pain Res 2020; 13:3349-3353. [PMID: 33324094 PMCID: PMC7733403 DOI: 10.2147/jpr.s289416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/26/2020] [Indexed: 12/24/2022] Open
Abstract
Introduction Percutaneous neurostimulator device placement, specifically dorsal root ganglion (DRG) stimulation and spinal cord stimulation (SCS), involves the placement of thin wires within the spinal canal at specific locations, the DRG or dorsal column of the spinal cord, respectively, to provide an electrical current that modifies the pain signal as it enters the central nervous system from the periphery. Placement of neurostimulator devices is generally safe overall, but not without risk of major and minor complications. In this study, we assess the use of intraoperative neuromonitoring (IONM) as a tool to improve the safety of placing neurostimulator devices and subsequently minimizing postoperative complications. Methods After IRB approval, an observational study was performed in 115 procedures to evaluate safety during placement of both temporary and permanent DRG and SCS systems and to document retrospectively any long-standing adverse events. Results The rate of intraoperative neuromonitoring abnormal activity was 1.7% (n = 2), which allowed prompt recognition of nerve irritation and lead repositioning. Of the 115 consecutive implant cases performed with IONM, the postoperative minor adverse event rate was 1.7% (n = 2), which were transient and corrected with reprogramming. There were no long-standing neurological complications. Conclusion In the largest observational study to date, we show that IONM creates a safe environment for patients undergoing SCS and DRG neurostimulator placement with the potential to decrease neurological complication rates. The use of IONM may be an alternative method to improve patient safety and outcomes as compared to monitor anesthesia care.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Steven M Falowski
- Argires-Marotti Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Abhishek Yadav
- Department of Anesthesiology and Perioperative Medicine, Brown University, Providence, RI, USA
| | - Ashley Comer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | - Alyson M Engle
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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23
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Horan M, Blichfeldt‐Eckhardt MR. Response to Letter to the Editor Regarding “Complications and Effects of Dorsal Root Ganglion Stimulation in the Treatment of Chronic Neuropathic Pain: A Nationwide Cohort Study in Denmark”. Neuromodulation 2020; 23:1047. [DOI: 10.1111/ner.13269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Mattias Horan
- Department of Neurosurgery Odense University Hospital Odense Denmark
- Department of Clinical Research, Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Morten Rune Blichfeldt‐Eckhardt
- Department of Neurosurgery Odense University Hospital Odense Denmark
- Department of Clinical Research, Faculty of Health Sciences University of Southern Denmark Odense Denmark
- Department of Anesthesiology and Intensive Care Odense University Hospital Odense Denmark
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24
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Lubenow T, Nijhuis H. Response to "Complications and Effects of Dorsal Root Ganglion Stimulation in the Treatment of Chronic Neuropathic Pain: A Nationwide Cohort Study in Denmark". Neuromodulation 2020; 23:1046. [PMID: 32892423 DOI: 10.1111/ner.13268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Timothy Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
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25
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Abbass M, Santyr BG, Parrent AG, MacDougall KW, Staudt MD. Paresthesia-Free Spinal Nerve Root Stimulation for the Treatment of Chronic Neuropathic Pain. Neuromodulation 2020; 23:831-837. [PMID: 32725757 DOI: 10.1111/ner.13236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/23/2020] [Accepted: 06/15/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Stimulation of the dorsal spinal roots, or spinal nerve root stimulation (SNRS), is a neuromodulation modality that can target pain within specific dermatomal distributions. The use of paresthesia-free stimulation has been described with conventional dorsal column spinal cord stimulation, although has yet to be described for SNRS. This objective of this study was to investigate the efficacy of paresthesia-free high-frequency (1000-1200 Hz) SNRS in the treatment of intractable, dermatomal neuropathic pain. MATERIALS AND METHODS A retrospective chart review was performed on 14 patients implanted with SNRS in varying distributions: Ten patients initially received tonic stimulation and crossed over to a paresthesia-free paradigm and four patients received only paresthesia-free stimulation. The primary outcome was reduction in pain severity (visual analog scale [VAS]), measured at baseline and follow-up to 24 months with paresthesia-free stimulation. RESULTS All 14 patients who received paresthesia-free stimulation had significant improvement in pain severity at a mean follow-up of 1.39 ± 0.15 years (VAS 7.46 at baseline vs. 3.25 at most recent follow-up, p < 0.001). Ten patients were initially treated with tonic stimulation and crossed over to paresthesia-free stimulation after a mean of 61.7 months. Baseline pain in these crossover patients was significantly improved at last follow-up with tonic stimulation (VAS 7.65 at baseline vs. 2.83 at 48 months, p < 0.001), although all patients developed uncomfortable paresthesias. There was no significant difference in pain severity between patients receiving tonic and paresthesia-free stimulation. CONCLUSIONS We present real-world outcomes of patients with intractable dermatomal neuropathic pain treated with paresthesia-free, high-frequency SNRS. We demonstrate its effectiveness in providing pain reduction at a level comparable to tonic SNRS up to 24 months follow-up, without producing uncomfortable paresthesias.
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Affiliation(s)
- Mohamad Abbass
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Brendan G Santyr
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Andrew G Parrent
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Keith W MacDougall
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
| | - Michael D Staudt
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada
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26
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Hagedorn JM, Demian PS, Scarfo KA, Engle AM, Deer TR. Proclaim™ DRG Neurostimulator System for the management of chronic, intractable pain. Pain Manag 2020; 10:225-233. [DOI: 10.2217/pmt-2020-0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic pain is consistently listed as one of the most costly and disabling health problems worldwide. In an effort to treat these suffering individuals, significant amounts of time and energy have been devoted to discover safe and effective pain relieving treatments. Dorsal root ganglion stimulation is the newest treatment modality to be created for chronic intractable pain. In this manuscript, we review the history and development, published research and safety profile of the Proclaim™ DRG Neurostimulator System (Abbott, TX, USA). At last, we offer our outlook on future developments with dorsal root ganglion stimulation.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology & Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Pavli S Demian
- The Pain Management Center, 2271 NJ-33 #103, Hamilton Township, NJ 08690, USA
| | - Keith-Austin Scarfo
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, 593 Eddy Street, George 1st Floor, Providence, RI 02903, USA
| | - Alyson M Engle
- Department of Anesthesiology, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Suite 402, Pittsburgh, PA 15213, USA
| | - Timothy R Deer
- The Spine & Nerve Center of The Virginias, 400 Court Street, Suite 100, Charleston, WV 25301, USA
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27
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Kretzschmar M, Reining M, Schwarz MA. Three-Year Outcomes After Dorsal Root Ganglion Stimulation in the Treatment of Neuropathic Pain After Peripheral Nerve Injury of Upper and Lower Extremities. Neuromodulation 2020; 24:700-707. [PMID: 32573868 DOI: 10.1111/ner.13222] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Traumatic peripheral nerve injuries (PNI) often result in severe neuropathic pain which typically becomes chronic, is recalcitrant to common analgesics, and is associated with sleep disturbances, anxiety, and depression. Pharmacological treatments proven to be effective against neuropathic pain are not well tolerated due to side effects. Neuromodulative interventions such as peripheral nerve or spinal cord stimulation have generated mixed results and may be limited by reduced somatotopic specificity. Dorsal root ganglion (DRG) stimulation may be more effective in this etiology. MATERIALS AND METHODS Twenty-seven patients were trialed with a DRG neurostimulation system for PNI; trial success (defined as ≥50% pain relief) was 85%, and 23 patients received a permanent stimulator. However, 36-month outcome data was only available for 21 patients. Pain, quality of life, mental and physical function, and opioid usage were assessed at baseline and at 3-, 6-, 12-, 18-, 24-, and 36 months post-permanent implant. Implant-related complications were also documented. RESULTS Compared to baseline, we observed a significant pain relief (p < 0.001) at 3 (58%), 12 (66%), 18 (69%), 24 (71%), and 36 months (73%) in 21 patients (52.5 ± 14.2 years; 12 female), respectively. Mental and physical function showed immediate and sustained improvements. Participants reported improvements in quality of life. Opioid dosage reduced significantly (p < 0.001) at 3 (30%), 12 (93%), 18 (98%), 24 (99%), and 36 months (99%), and 20 of 21 patients were completely opioid-free after 36 months. There were five lead migrations and two electrode fractures (corrected by surgical intervention) and one wound infection (conservatively managed). CONCLUSIONS DRG neuromodulation appears to be a safe, effective, and durable option for treating neuropathic pain caused by PNI. The treatment allows cessation of often ineffective pharmacotherapy (including opioid misuse) and significantly improves quality of life.
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Affiliation(s)
- Michael Kretzschmar
- SRH Wald-Klinikum Gera, Department of Pain Medicine and Palliative Care, Gera, Strasse des Friedens 122, D-07548, Germany.,SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Neue Strasse 30-32, D-07548, Germany
| | - Marco Reining
- SRH Wald-Klinikum Gera, Department of Pain Medicine and Palliative Care, Gera, Strasse des Friedens 122, D-07548, Germany
| | - Marcus A Schwarz
- SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Neue Strasse 30-32, D-07548, Germany
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28
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Horan M, Jacobsen AH, Scherer C, Rosenlund C, Gulisano HA, Søe M, Sørensen JCH, Meier K, Blichfeldt-Eckhardt MR. Complications and Effects of Dorsal Root Ganglion Stimulation in the Treatment of Chronic Neuropathic Pain: A Nationwide Cohort Study in Denmark. Neuromodulation 2020; 24:729-737. [PMID: 32539189 DOI: 10.1111/ner.13171] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Dorsal root ganglion (DRG) stimulation is a novel treatment of chronic neuropathic pain and has been shown to be efficacious across several case reports and randomized trials. However, long-term follow-up is limited, as are reports of complication rates. This study presents efficacy and complications for patients treated with DRG stimulation. MATERIALS AND METHODS We performed an observational, multicenter cohort study of all patients in Denmark implanted with FDA-approved DRG stimulation systems to treat chronic, neuropathic pain between 2014 and 2018. Follow-up period was one to three years. RESULTS Forty-three patients underwent trial DRG stimulation; 33 were subsequently fully implanted. Pain location: 58% lower extremity; 21% upper extremity; 21% thoracic/abdominal. At the end of the observation period, 58% of fully implanted patients were still implanted; 42% had fully functional systems. In these patients, average Numerical Rating Scale (NRS)-score of pain was reduced from 6.8 to 3.5 (p = 0.00049) and worst NRS-score was reduced from 8.6 to 6.0 (p = 0.0039) at 12 months follow-up. Pain Catastrophizing Score was reduced from 32 to 15 (p = 0.0039). Thirteen patients experienced complications related to defect leads (39% of implanted systems). In four patients (12%), lead removal left fragments in the root canal due to lead fracture, and three patients suffered permanent nerve damage during attempts to replace broken leads. CONCLUSIONS This study suggests a significant, clinically relevant effect of DRG stimulation on neuropathic pain, but also demonstrates substantial problems with maintenance and revision of currently available systems. Consequently, treatment with equipment marketed specifically for DRG stimulation is currently paused in Denmark.
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Affiliation(s)
- Mattias Horan
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | | | - Christian Scherer
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Morten Søe
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | - Kaare Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Rune Blichfeldt-Eckhardt
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
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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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朱 时, 刘 丹, 胡 卫, 杨 红. [Effect of cinobufagin on transient outward potassium current in dorsal root ganglion cells of rats with cancer-induced bone pain]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:1078-1082. [PMID: 31640967 PMCID: PMC6881743 DOI: 10.12122/j.issn.1673-4254.2019.09.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To observe the effect of cinobufagin on transient outward potassium current (IA) in rat dorsal root ganglion cells of cancer-induced bone pain (CIBP) and explore the possible analgesic mechanism of cinobufagin. METHODS Whole cell patch clamp technique was used to examine the effect of cionbufagin on IA in acutely isolated dorsal root ganglion (DRG) cells from normal SD rats and rats with bone cancer pain. RESULTS The DRG cells from rats with CIBP showed obviously decreased IA current density, an activation curve shift to the right, and an inactivation curve shift to the left. Cinobufagin treatment significantly increased the IA current density and reversed the changes in the activation and inactivation curves in the DRG cells. CONCLUSIONS IA current is decreased in DRG neurons from rats with CIBP. Cinobufagin can regulate the activation and inactivation of IA current in the DRG cells, which may be related to its analgesic mechanism.
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Affiliation(s)
- 时钰 朱
- />三峡大学医学院,湖北 宜昌 443002Medical College of China Three Gorges University, Yichang 443002, China
| | - 丹 刘
- />三峡大学医学院,湖北 宜昌 443002Medical College of China Three Gorges University, Yichang 443002, China
| | - 卫 胡
- />三峡大学医学院,湖北 宜昌 443002Medical College of China Three Gorges University, Yichang 443002, China
| | - 红卫 杨
- />三峡大学医学院,湖北 宜昌 443002Medical College of China Three Gorges University, Yichang 443002, China
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31
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Deer TR, Hunter C. Response to the Letter from Dr. Sivanesan and Dr. Cohen. Neuromodulation 2019; 22:505-506. [DOI: 10.1111/ner.12972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Timothy R. Deer
- The Spine and Nerve Center of The Virginias Charleston WV USA
| | - Corey Hunter
- Icahn School of Medicine at Mount Sinai Medical Center New York NY USA
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32
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Sivanesan E, Cohen SP. Response to "Safety Analysis of Dorsal Root Ganglion Stimulation in the Treatment of Chronic Pain". Neuromodulation 2019; 22:503-504. [PMID: 31124205 DOI: 10.1111/ner.12971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Eellan Sivanesan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Departments of Neurology and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Departments of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD, USA
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