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Mons MR, Edelbroek C, Zuidema X, Bürger K, Elzinga L, de Vries J, van Kuijk S, Joosten EA, Kallewaard JW. Study protocol: Effects of active versus passive recharge burst spinal cord stimulation on pain experience in persistent spinal pain syndrome type 2: a multicentre randomized trial (BURST-RAP study). Trials 2022; 23:749. [PMID: 36064598 PMCID: PMC9446827 DOI: 10.1186/s13063-022-06637-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background Spinal cord stimulation (SCS) has shown to be an effective treatment for patients with persistent spinal pain syndrome type 2 (PSPS Type 2). The method used to deliver electrical charge in SCS is important. One such method is burst stimulation. Within burst stimulation, a recharge pattern is used to prevent buildup of charge in stimulated tissues. Two variations of burst waveforms are currently in use: one that employs active recharge and one that uses passive recharge. It has been suggested that differences exist between active and passive recharge paradigms related to both efficacy of pain relief and their underlying mechanism of action. Active recharge has been shown to activate both the medial spinal pathway, engaging cortical sensorimotor areas involved in location and intensity of pain, and lateral pathway, reaching brain areas involved with cognitive-emotional aspects of pain. Passive recharge has been suggested to act via modulation of thalamic neurons, which fire in a similar electrical pattern, and thereby modulate activity in various cortical areas including those related to motivational and emotional aspects of pain. The objective of this randomized clinical trial is to assess and compare the effect of active versus passive recharge Burst SCS on a wide spectrum of pain in PSPS Type 2 patients. Methods This multicentre randomized clinical trial will take place in 6 Dutch hospitals. PSPS Type 2 patients (n=94) will be randomized into a group receiving either active or passive recharge burst. Following a successful trial period, patients are permanently implanted. Patients complete the Pain Catastrophizing Scale (PCS) (primary outcome at 6 months), Numeric Pain Rating Scale (NRS), Patient Vigilance and Awareness Questionnaire (PVAQ), Hospital Anxiety and Depression Scale (HADS), Quality of Life (EQ-5D), Oswestery Disability Index (ODI), Patient Global Impression of Change (PGIC) and painDETECT questionnaires (secondary outcomes) at baseline, after trial, 1, 3, 6 and 12 months following implantation. Discussion The BURST-RAP trial protocol will shed light on possible clinical differences and effectivity of pain relief, including emotional-motivational aspects between active and passive burst SCS in PSPS Type 2 patients. Trial registration ClinicalTrials.gov registration: NCT05421273. Registered on 16 June 2022. Netherlands Trial Register NL9194. Registered on 23 January 2021.
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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.
| | - Caro Edelbroek
- Department of Anesthesiology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Xander Zuidema
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands.,Department of Anesthesiology, Diakonessen Hospital Utrecht, Utrecht, the Netherlands
| | - Katja Bürger
- Department of Anesthesiology, Alrijne Hospital Leiderdorp, Leiderdorp, the Netherlands
| | - Lars Elzinga
- Department of Anesthesiology, Bravis Hospital Roosendaal, Roosendaal, the Netherlands
| | - Jessica de Vries
- Department of Anesthesiology, Elizabeth TweeSteden Hospital Tilburg, Tilburg, the Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, 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, Rijnstate Hospital Arnhem, Arnhem, the Netherlands.,Departement of Anesthesiology, Amsterdam Universitair Medisch Centrum, Amsterdam, the Netherlands
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Heijmans L, Joosten EA. Mechanisms and mode of action of spinal cord stimulation in chronic neuropathic pain. Postgrad Med 2020; 132:17-21. [PMID: 32403963 DOI: 10.1080/00325481.2020.1769393] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Tonic spinal cord stimulation (SCS) has been used as a treatment for chronic neuropathic pain ever since its discovery in late 1960s. Despite its clinical successes in a subset of chronic neuropathic pain syndromes, several limitations such as insufficient pain relief and uncomfortable paresthesias have led to the development of new targets, the dorsal root ganglion, and new stimulation waveforms, such as burst and high frequency. The aim of this review is to provide a brief overview of the main mechanisms behind the mode of action of the different SCS paradigms. Tonic SCS mainly acts via a segmental spinal mechanism where it induces GABA-release from inhibitory interneurons in the spinal dorsal horn. Tonic SCS concurrently initiates neuropathic pain modulation through a supraspinal-spinal feedback loop and serotonergic descending fibers. Mechanisms of stimulation of the DRG as well as those related to new SCS paradigms are now under investigation, where it seems that burst SCS not only stimulates sensory, discriminative aspects of pain (like Tonic SCS) but also emotional, affective, and motivational aspects of pain. Initial long-term study results on closed-loop SCS systems hold promise for improvement of future SCS treatment.
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Affiliation(s)
- Lonne Heijmans
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre , Maastricht, the Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University , Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre , Maastricht, the Netherlands.,Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University , Maastricht, the Netherlands
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De Ridder D, Vancamp T, Falowski SM, Vanneste S. All bursts are equal, but some are more equal (to burst firing): burstDR stimulation versus Boston burst stimulation. Expert Rev Med Devices 2020; 17:289-295. [PMID: 32129099 DOI: 10.1080/17434440.2020.1736560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Since the introduction of burst spinal cord stimulation for neuropathic pain, several companies have developed their own version of burst stimulation, which is confusing the marketplace and clinicians of what burst stimulation truly is, the value and utilization of the therapy.Areas covered: We review those two burst stimulation designs and notice important differences. The original burstDRTM stimulation tries to mimic physiologic burst firing, which involves closely spaced high frequency sodium spikes nested on a calcium mediated plateau. This is realized by generating a train of 5 monophasic spikes of increasing amplitude with passive charge balance after the last spike, in contrast to the other burst designs which involve a version of cycling 4-5 spikes each being individually actively charge balanced spikes.Expert opinion: Based on the neurobiology of burst firing as well as abductive reasoning we like to clarify that burstDRTM is a true physiologic burst stimulation, and that other versions being called burst stimulation are essentially clustered tonic stimulation. This differentiating terminology will prevent confusion for healthcare providers, regulators, and the marketplace of what burst stimulation is.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | | | | | - Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.,Lab for Clinical and Integrative Neuroscience, School for Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
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Affiliation(s)
- Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Sven Vanneste
- Global Brain Health Institute & Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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