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Chitneni A, Jain E, Sahni S, Mavrocordatos P, Abd-Elsayed A. Spinal Cord Stimulation Waveforms for the Treatment of Chronic Pain. Curr Pain Headache Rep 2024; 28:595-605. [PMID: 38607547 DOI: 10.1007/s11916-024-01247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Since the advent of spinal cord stimulation (SCS), advances in technology have allowed for improvement and treatment of various conditions, especially chronic pain. Additionally, as the system has developed, the ability to provide different stimulation waveforms for patients to treat different conditions has improved. The purpose and objective of the paper is to discuss basics of waveforms and present the most up-to-date literature and research studies on the different types of waveforms that currently exist. During our literature search, we came across over sixty articles that discuss the various waveforms we intend to evaluate. RECENT FINDINGS There are several publications on several waveforms used in clinical practice, but to our knowledge, this is the only educational document teaching on waveforms which provides essential knowledge. There is a gap of knowledge related to understanding wave forms and how they work.
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Affiliation(s)
- Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USA
| | - Esha Jain
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, B6/319 CSC53792-3272, USA.
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Tieppo Francio V, Alm J, Leavitt L, Mok D, Yoon BV, Nazir N, Lam C, Latif U, Sowder T, Braun E, Sack A, Khan T, Sayed D. Variables associated with nonresponders to high-frequency (10 kHz) spinal cord stimulation. Pain Pract 2024; 24:584-599. [PMID: 38078593 DOI: 10.1111/papr.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
INTRODUCTION The use of spinal cord stimulation (SCS) therapy to treat chronic pain continues to rise. Optimal patient selection remains one of the most important factors for SCS success. However, despite increased utilization and the existence of general indications, predicting which patients will benefit from neuromodulation remains one of the main challenges for this therapy. Therefore, this study aims to identify the variables that may correlate with nonresponders to high-frequency (10 kHz) SCS to distinguish the subset of patients less likely to benefit from this intervention. MATERIALS AND METHODS This was a retrospective single-center observational study of patients who underwent 10 kHz SCS implant. Patients were divided into nonresponders and responders groups. Demographic data and clinical outcomes were collected at baseline and statistical analysis was performed for all continuous and categorical variables between the two groups to calculate statistically significant differences. RESULTS The study population comprised of 237 patients, of which 67.51% were responders and 32.49% were nonresponders. There was a statistically significant difference of high levels of kinesiophobia, high self-perceived disability, greater pain intensity, and clinically relevant pain catastrophizing at baseline in the nonresponders compared to the responders. A few variables deemed potentially relevant, such as age, gender, history of spinal surgery, diabetes, alcohol use, tobacco use, psychiatric illness, and opioid utilization at baseline were not statistically significant. CONCLUSION Our study is the first in the neuromodulation literature to raise awareness to the association of high levels of kinesiophobia preoperatively in nonresponders to 10 kHz SCS therapy. We also found statistically significant differences with greater pain intensity, higher self-perceived disability, and clinically relevant pain catastrophizing at baseline in the nonresponders relative to responders. It may be appropriate to screen for these factors preoperatively to identify patients who are less likely to respond to SCS. If these modifiable risk factors are present, it might be prudent to consider a pre-rehabilitation program with pain neuroscience education to address these factors prior to SCS therapy, to enhance successful outcomes in neuromodulation.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - John Alm
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Logan Leavitt
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Daniel Mok
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - B Victor Yoon
- Department of Physical Medicine and Rehabilitation, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Niaman Nazir
- Department of Population Health, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Usman Latif
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy Sowder
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Edward Braun
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrew Sack
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Talal Khan
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
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Higashiyama N, Tamura S, Sugawara T. Efficacy of Spinal Cord Stimulation for Failed Back Surgery Syndrome in Elderly Patients: A Retrospective Study. Pain Res Manag 2023; 2023:2136562. [PMID: 37200968 PMCID: PMC10188261 DOI: 10.1155/2023/2136562] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/16/2023] [Accepted: 05/01/2023] [Indexed: 05/20/2023]
Abstract
Objectives Failed back surgery syndrome (FBSS) refers to a condition where symptoms such as low back pain, leg pain, and numbness persist or recur after lumbar surgery; it has been reported to occur in 10%-40% of patients who have undergone lumbar surgery. Spinal cord stimulation (SCS) has been reported useful for low back and leg pain due to FBSS. In this study, we studied the efficacy and safety of SCS for FBSS in older adults. Methods Among FBSS patients who underwent an SCS trial between November 2017 and December 2020, those with at least 50% pain reduction during the trial phase who requested spinal cord stimulator implantation underwent implantation of a stimulator under local anesthesia. The patients were divided into two groups: patients aged <75 years (<75-year-old group) and patients aged ≥75 years (≥75-year-old group). The male/female ratio, symptom duration, operative duration, visual analog scale (VAS) scores before and after one year of surgery, responder rate (RR), complications one year after surgery, and stimulator removal rate were analyzed. Results There were 27 cases in the <75-year-old group and 46 in the ≥75-year-old group, with no significant differences in male/female ratio, duration of pain, or operative time between the two groups. VAS scores for low back pain, leg pain, and overall pain one year after surgery were improved significantly from respective preoperative scores in both groups (P < 0.001). There were no significant differences in low back pain VAS, leg pain VAS, overall pain VAS, RR, complications one year after surgery, or stimulator removal rate between the two groups. Conclusion SCS reduced pain effectively in both <75-year-old and ≥75-year-old groups with no differences in complications. Therefore, spinal cord stimulator implantation was considered a viable option for FBSS treatment in older adults because it can be performed under local anesthesia and is associated with a low incidence of complications.
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Affiliation(s)
- Naoki Higashiyama
- Department of Spinal Surgery, The Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Shinya Tamura
- Department of Spinal Surgery, The Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Taku Sugawara
- Department of Spinal Surgery, The Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
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Goudman L, Rigoard P, Billot M, De Smedt A, Roulaud M, Consortium D, Moens M, De Keersmaecker K, Gorissen M, De Clerck C, Donck AV, Braems H, Buyse K, Puylaert M, Duyvendak W, De Smet C, Vissers S, Debeuf J, De Beucker K, Ceuppens J, Germonpré PJ, Mortier S, Van Buyten JP, Smet I, Devos M, Vanhauwaert D, Billet B, Hanssens K, Demeyere A, Casier T, Bertrem B, Van Havenbergh T, Van Looy P, Heylen G, de Schryver C, Vangeneugden J, Louis F, Stalmans V, Remacle JM, Remacle T, Mauviel S, Abeloos L, Theys T, Van Hoylandt A, Bruyninckx D, Das J, Callebaut I, Rigoard P, Roulaud M, Lorgeoux B, De Jaeger M, Espinoza AV, Van Hooff RJ. Spinal Cord Stimulation-Naïve Patients vs Patients With Failed Previous Experiences With Standard Spinal Cord Stimulation: Two Distinct Entities or One Population? Neuromodulation 2023; 26:157-163. [PMID: 35551868 DOI: 10.1016/j.neurom.2022.04.037] [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: 11/17/2021] [Revised: 12/25/2021] [Accepted: 01/26/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Nowadays, the success of spinal cord stimulation (SCS) is evaluated separately in patients who have previous experiences with standard SCS and in SCS-naïve patients. Nevertheless, it is yet to be evaluated whether both patient groups are effectively distinct patient groups. Therefore, the aims of this study are twofold: 1) Are there clusters in the data to distinguish between both patient groups? 2) Can we discriminate both patient groups based on routinely collected clinical parameters? MATERIALS AND METHODS Baseline data from the Discover study were used, in which 263 patients with persistent spinal pain syndrome type 2 were included (185 neurostimulation-naïve patients and 78 patients with previous SCS experience). Pain intensity scores for low back and leg pain, functional disability, medication use, and health-related quality of life utility scores were used in the analysis. Model-based clustering was performed on standardized data. Discriminant analysis was performed with linear and quadratic discriminant analysis, with leave-one-out cross-validation to evaluate model performance. RESULTS Model-based clustering revealed two different clusters in the data. None of the clusters clearly separated SCS-naïve patients from patients with previous SCS experience. Linear discriminant analysis resulted in a leave-one-out cross-validation error rate of 30.0% to discriminate between both patient groups, based on routinely collected clinical parameters. CONCLUSIONS Clustering analysis did not result in clusters that separate SCS-naïve patients from patients with previous SCS experience. This may suggest that both patient groups should not be considered as two different patient groups when comparing them on routine clinical parameters, with potentially profound implications for research and clinical settings. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the Discover study is NCT02787265.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders, Brussels, Belgium.
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, Poitiers, France; Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Ann De Smedt
- STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | | | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Giammalva GR, Paolini F, Bonosi L, Meccio F, Basile L, Graziano F, Pino M, Gerardi RM, Umana GE, Iacopino DG, Maugeri R. Spinal Cord Stimulation Meets Them All: An Effective Treatment for Different Pain Conditions. Our Experience and Literature Review. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:179-195. [PMID: 38153468 DOI: 10.1007/978-3-031-36084-8_29] [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: 12/29/2023]
Abstract
IntroductionSpinal Cord Stimulation (SCS) is an emerging minimally invasive technique which uses neuromodulation to manage different forms of intractable pain. SCS is a well-established option for the treatment of various pain conditions, and nowadays, indications are ever increasing.Materials and MethodsIn this study, we present our case series of 49 patients who underwent SCS at our Institution for the treatment of pain from different etiologies, and discuss our 10-year experience in SCS. For the purpose of this study, we also performed a systematic review of current indications and new perspectives in SCS.ResultsAmong our case series, patients were differentiated into two groups upon prior spinal surgery: patients who had undergone prior spinal surgery for back pain were defined as the "FBSS (failed back surgery syndrome) group," instead patient suffering from different types of pain but who had never undergone surgery were defined as the "naive group." As regards clinical response to SCS, 20 patients out of 36 (55.56%) were classified as responders in the FBSS group; in the "naïve" group, 10 patients out of 13 (76.92%) were classified as responders. Among the "not responders" group, several patients suffered from infections.Of the recent literature about SCS, 2124 records were screened and 37 studies were finally included in the qualitative synthesis for our systematic review.DiscussionIn case of FBSS, surgical revision is often associated with a high morbidity and corresponding low rates of success. Unfortunately, patients affected by chronic pain often become refractory to conservative treatments. Spinal Cord Stimulation (SCS) is nowadays considered as an effective therapy for several chronic and neuropathic pain conditions, such as failed back surgery syndrome. As regards the economic impact of SCS, implantation of an SCS system results in short-term costs increase, but the annual cumulative costs decrease during the following years after implantation, when compared to the costs of conventional management. Beyond the application for the treatment of FBSS, SCS has also been used for the treatment of other types of chronic non-oncological pain such as neuropathic pain and chronic back pain ineligible for surgical intervention. This evidence paved the way to establishing the potential role of SCS also for the treatment of oncological pain. However, the effectiveness and relative safety of SCS for cancer-related pain has not yet been adequately established.ConclusionsSpinal Cord Stimulation is a well-established treatment option in for FBSS. Beyond that, SCS has also been used for the treatment of "naive" patients, suffering from other types of chronic, both oncological and non-oncological, medical-refractory pain such as neuropathic pain and chronic back pain ineligible for surgical intervention.
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Affiliation(s)
- Giuseppe Roberto Giammalva
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Federica Paolini
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Lapo Bonosi
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Flavia Meccio
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Luigi Basile
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Francesca Graziano
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
- Department of Neurosurgery, Garibaldi Hospital, Catania, Italy
| | - Mariangela Pino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosa Maria Gerardi
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Giuseppe Emmanuele Umana
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
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Sammak SE, Mualem W, Michalopoulos GD, Romero JM, Ha CT, Hunt CL, Bydon M. Rescue therapy with novel waveform spinal cord stimulation for patients with failed back surgery syndrome refractory to conventional stimulation: a systematic review and meta-analysis. J Neurosurg Spine 2022; 37:670-679. [PMID: 36303477 DOI: 10.3171/2022.4.spine22331] [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: 03/22/2022] [Accepted: 04/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Conventional spinal cord stimulators (SCSs) have demonstrated efficacy in individuals with failed back surgery syndrome (FBSS). However, a subgroup of patients may become refractory to the effects of conventional waveforms over time. The objective of this study was to systematically review and evaluate the current literature on the use of novel waveform spinal cord stimulation for the management of FBSS refractory to conventional SCSs. METHODS A comprehensive electronic search of the literature published in electronic databases, including Ovid MEDLINE and Epub Ahead of Print, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus, was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The outcomes of interest were reduction in back pain and/or leg pain after conversion from conventional to novel SCSs. Risk of bias was assessed with the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria. RESULTS A total of 6 studies with 137 patients with FBSS were identified. Studies were published between 2013 and 2021. The mean ± SD age of the pooled patient sample was 55 ± 10.5 years. All patients who underwent treatment with conventional SCSs were identified. Two studies evaluated the efficacy of high-density spinal cord stimulation, 3 studies evaluated burst spinal cord stimulation, and 1 study assessed multimodal waveforms. The mean difference in back pain scores after conversion from a standard SCS to a novel waveform SCS was 2.55 (95% CI 1.59-4.08), demonstrating a significant reduction in back pain after conversion to novel stimulation. The authors also performed a subgroup analysis to compare burst stimulation to tonic waveforms. In this analysis, the authors found no significant difference in the average reductions in back pain between the 2 groups (p = 0.534).The authors found an I2 statistic equivalent to 98.47% in the meta-regression model used to assess the effect of follow-up duration on study outcome; this value implied that the variability in the data can be attributed to the remaining between-study heterogeneity. The overall certainty was moderate, with a high risk of bias across studies. CONCLUSIONS Rescue therapy with novel waveform spinal cord stimulation is a potential option for pain reduction in patients who become refractory to conventional SCSs. Conversion to novel waveform SCSs may potentially mitigate expenses and complications.
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Affiliation(s)
| | - William Mualem
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
| | | | - Joshua M Romero
- 2Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota; and
| | - Christopher T Ha
- 2Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota; and
| | - Christine L Hunt
- 3Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Jacksonville, Florida
| | - Mohamad Bydon
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
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Dorsal Root Ganglion Stimulation as a Salvage Therapy Following Failed Spinal Cord Stimulation. Neuromodulation 2022; 25:1024-1032. [DOI: 10.1016/j.neurom.2022.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 11/20/2022]
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Hadanny A, Harland T, Khazen O, DiMarzio M, Marchese A, Telkes I, Sukul V, Pilitsis JG. Development of Machine Learning-Based Models to Predict Treatment Response to Spinal Cord Stimulation. Neurosurgery 2022; 90:523-532. [PMID: 35179133 PMCID: PMC9514733 DOI: 10.1227/neu.0000000000001855] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/03/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Despite spinal cord stimulation's (SCS) proven efficacy, failure rates are high with no clear understanding of which patients benefit long term. Currently, patient selection for SCS is based on the subjective experience of the implanting physician. OBJECTIVE To develop machine learning (ML)-based predictive models of long-term SCS response. METHODS A combined unsupervised (clustering) and supervised (classification) ML technique was applied on a prospectively collected cohort of 151 patients, which included 31 features. Clusters identified using unsupervised K-means clustering were fitted with individualized predictive models of logistic regression, random forest, and XGBoost. RESULTS Two distinct clusters were found, and patients in the cohorts significantly differed in age, duration of chronic pain, preoperative numeric rating scale, and preoperative pain catastrophizing scale scores. Using the 10 most influential features, logistic regression predictive models with a nested cross-validation demonstrated the highest overall performance with the area under the curve of 0.757 and 0.708 for each respective cluster. CONCLUSION This combined unsupervised-supervised learning approach yielded high predictive performance, suggesting that advanced ML-derived approaches have potential to be used as a functional clinical tool to improve long-term SCS outcomes. Further studies are needed for optimization and external validation of these models.
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Affiliation(s)
- Amir Hadanny
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
| | - Tessa Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Anthony Marchese
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Ilknur Telkes
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Vishad Sukul
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
| | - Julie G. Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
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9
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Advances in Neuromodulation for Chronic Pain. J Clin Med 2022; 11:jcm11030874. [PMID: 35160325 PMCID: PMC8836608 DOI: 10.3390/jcm11030874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/04/2023] Open
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Paz-Solís J, Thomson S, Jain R, Chen L, Huertas I, Doan Q. Exploration of High and Low Frequency Options for Subperception Spinal Cord Stimulation Using Neural Dosing Parameter Relationships: The HALO Study. Neuromodulation 2021; 25:94-102. [PMID: 33951270 DOI: 10.1111/ner.13390] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/16/2021] [Accepted: 02/23/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Subperception spinal cord stimulation (SCS) is described mostly utilizing waveforms that require high energy. However, the necessity of these waveforms for effective subperception has not been established. We aimed to explore whether effective subperception pain relief can be achieved using frequencies below 1 kHz. MATERIALS AND METHODS Thirty chronic pain patients implanted with SCS were enrolled as part of a multicenter, real-world, consecutive, observational case series. An effective stimulation location was determined using a novel electric field shape designed to preferentially modulate dorsal horn elements. Subsequently, programs at lower frequencies (600, 400, 200, 100, 50, and 10 Hz) were provided with pulse-width and amplitude adjusted to optimize response. RESULTS All tested frequencies (1 kHz down to 10 Hz) provided effective subperception relief, yielding a mean of 66-72% reduction in back, leg, and overall pain. It was found that to maintain analgesia, as frequency was decreased, the electrical or "neural" dose had to be adjusted according to parameter relationships described herein. With the reduction of frequency, we observed a net reduction of charge-per-second, which enabled energy savings of 74% (200 Hz) and 97% (10 Hz) relative to 1 kHz. Furthermore, pain reduction was sustained out to one year, with 85% of patients reporting a preference for frequencies of 400 Hz or below. CONCLUSIONS We have derived an electric field configuration and, along with previous learnings in the kHz range, a set of neural dosing parameter relationships (10-10,000 Hz), which enable the expansion of effective subperception SCS to low frequency and achieve major energy savings.
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Affiliation(s)
| | - Simon Thomson
- Basildon and Thurrock University Hospitals, Basildon, UK
| | - Roshini Jain
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
| | - Lilly Chen
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
| | - Ismael Huertas
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
| | - Que Doan
- Boston Scientific Neuromodulation, Clinical and R&D departments, Valencia, California, USA
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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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Goudman L, De Smedt A, Forget P, Eldabe S, Moens M. High-Dose Spinal Cord Stimulation Reduces Long-Term Pain Medication Use in Patients With Failed Back Surgery Syndrome Who Obtained at Least 50% Pain Intensity and Medication Reduction During a Trial Period: A Registry-Based Cohort Study. Neuromodulation 2021; 24:520-531. [PMID: 33474789 DOI: 10.1111/ner.13363] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES High-dose spinal cord stimulation (HD-SCS) revealed positive results for obtaining pain relief in patients with failed back surgery syndrome (FBSS). However, it is less clear whether HD-SCS also is able to reduce pain medication use. The aim of this registry-based cohort study is to explore the impact of HD-SCS on pain medication use in FBSS patients. MATERIALS AND METHODS Data from the Discover registry was used in which the effectiveness of HD-SCS was explored in neurostimulation-naïve FBSS patients as well as in rescue patients. All neurostimulation-naïve FBSS patients positively responded to a four-week SCS trial period in which at least 50% pain relief and 50% medication reduction were obtained. Medication use was measured with the Medication Quantification Scale III (MQS) in 259 patients at baseline and at 1, 3, and 12 months of HD-SCS. Additionally, defined daily doses (DDD) and morphine milligram equivalents (MME) were calculated as well. RESULTS One hundred thirty patients reached the visit at 12 months. In neurostimulation-naïve patients, a statistically significant decrease in MQS (χ2 = 62.92, p < 0.001), DDD (χ2 = 11.47, p = 0.009), and MME (χ2 = 21.55, p < 0.001) was found. In rescue patients, no statistically significant improvements were found. In both patient groups, statistically significant reductions in the proportion of patients on high-risk MME doses ≥90 were found over time. At the intraindividual level, positive correlations were found between MSQ scores and pain intensity for back (r = 0.56, r = 0.31, p < 0.001) and leg pain (r = 0.61, r = 0.22, p < 0.001) in neurostimulation-naïve and rescue patients, respectively. CONCLUSIONS Registry data on HD-SCS in FBSS patients revealed a statistically significant and sustained decrease in pain medication use, not only on opioids, but also on anti-neuropathic agents in neurostimulation-naïve patients, who positively responded to an SCS trial period with at least 50% pain relief and 50% pain medication decrease, but not in rescue patients.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium.,Pain in Motion International Research Group, Jette, Belgium
| | - Ann De Smedt
- Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Patrice Forget
- Institute of Applied Health Sciences, NHS Grampian, University of Aberdeen, Aberdeen, UK
| | - Sam Eldabe
- Pain Clinic, The James Cook University Hospital, Middlesbrough, UK
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Brussels, Belgium.,Department of Radiology, Universitair Ziekenhuis Brussel, Jette, Belgium
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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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