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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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Waardenburg S, de Meij N, van Kuijk SMJ, Van Zundert J, Brouwer BA. Expectations of treatment outcome in complex cases of patients with chronic pain: A study on the DATAPAIN cohort. Pain Pract 2024; 24:8-17. [PMID: 37477420 DOI: 10.1111/papr.13274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND A better insight in how the biopsychosocial factors influence patient outcome(s) may provide information that helps selecting the optimal pain management for a specific group. METHODS Categorization was made in the prospective DATAPAIN registry, in which patients with pain severity (Numeric Rating Scale [NRS]: 7-10), depression or anxiety (Hospital Anxiety and Depression Scale: > 10), and pain catastrophizing (Pain Catastrophizing Scale: > 31) were identified as complex cases. Patient outcomes; treatment satisfaction on the Patient Global Impression of Change (PGIC), pain relief (NRS), pain interference on the Brief Pain Inventory (BPI) and quality of life indicator General Perceived Health (GPH) were evaluated. Logistic regression analyzed if belonging to the complex cases showed modification in the outcome of the PGIC and GPH. Linear regression was observed if complex cases differed in average reduction in pain relief and interference compared to non-complex cases. RESULTS 1637 patients were included, of which 345 (21.08%) were considered complex cases. The changes in scores of pain relief and BPI active subscale were not significantly different between groups. The BPI affective subscale had a different change in score (-0.509; p: 0.002). The complex cases had an odds ratio (OR) of 0.59 (95% confidence interval [CI]: 0.36-0.77) on treatment satisfaction compared to non-complex cases, and an OR of 0.28 (95% CI: 0.11-0.56) on the GPH. CONCLUSION When treating patients with complex cases, desired treatment outcome(s) should be recognized by specialists and patients, as these may be less likely to occur.
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Affiliation(s)
- Sophie Waardenburg
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre MUMC+, Maastricht, The Netherlands
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre MUMC+, Maastricht, The Netherlands
| | - Nelleke de Meij
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre MUMC+, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre MUMC+, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre MUMC+, Maastricht, The Netherlands
- Department of Anesthesiology and Multidisciplinary Pain Centre, Ziekenhuis Oost Limburg, Genk/Lanaken, Belgium
| | - Brigitte A Brouwer
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre MUMC+, Maastricht, The Netherlands
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Kirketeig T, Söreskog E, Jacobson T, Karlsten R, Zethraeus N, Borgström F. Real-world outcomes in spinal cord stimulation: predictors of reported effect and explantation using a comprehensive registry-based approach. Pain Rep 2023; 8:e1107. [PMID: 38027468 PMCID: PMC10653578 DOI: 10.1097/pr9.0000000000001107] [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: 07/27/2023] [Revised: 09/04/2023] [Accepted: 09/23/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Despite advancements in implanted hardware and development of novel stimulation paradigms in Spinal Cord Stimulation (SCS), real world evidence suggests a large variation in patient reported outcomes and a proportion of patients are later explanted due to loss of analgesia. Possible predictors for outcome have been explored in smaller short-term evaluations, but few clinically applicable robust measures for long term outcome have emerged. Methods We performed a comprehensive retrospective study based on an assembled patient-level aggregated database from multiple local and national registries in Sweden. Variables associated with risk of explantation (due to insufficient analgesia) and analgesic effect was analyzed using a Cox regression analysis and an ordered logit regression model, respectively. Results We found the accumulated risk of explantation due to loss of analgesia to be 10% and 21% at two and ten years follow up, respectively. The use of 10 kHz spinal cord stimulation (compared with Tonic waveform; p = 0.003), and being 60 years or older (reference 18-40 years; p = 0.003) were associated with an increased risk of explantation.At a mean follow up at 1 year, 48% of patients reported a pain intensity reduction from baseline of at least 30%. Secondary (p = 0.030) and post-secondary (p = 0.001) education (compared with primary education) was associated with an increased probability of successful patient reported outcomes. Conclusion This study suggests that a higher educational level and being employed are associated with successful treatment outcome in patients with chronic pain treated with SCS in Sweden.
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Affiliation(s)
- Terje Kirketeig
- Akademiska Sjukhuset, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Emma Söreskog
- Quantify Research, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | | | - Rolf Karlsten
- Akademiska Sjukhuset, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Niklas Zethraeus
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Du T, Ni B, Shu W, Ren Z, Guo S, Zhang X, Zhu H, Hu Y. Dorsal Root Entry Zone Lesioning Following Unresponsive Spinal Cord Stimulation for Post-Traumatic Neuropathic Pain. World Neurosurg 2023; 178:e300-e306. [PMID: 37473865 DOI: 10.1016/j.wneu.2023.07.048] [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: 05/20/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) and dorsal root entry zone (DREZ) lesioning are important therapeutic options for intractable post-traumatic neuropathic pain (PNP). However, surgical choice is controversial due to the need to maximize pain relief and reduce complications. This study aims to retrospectively analyze the effect and complications of DREZ lesioning for patients with PNP who were unresponsive to SCS and provide a surgical reference. METHODS Demographic data and surgical characteristics of patients with PNP who underwent DREZ lesioning after an unresponsive SCS were reviewed. Long-term outcomes including numeric rating scale, global impression of change, and long-term complications were assessed. Kaplan-Meier analysis was used to evaluate pain-free survival. RESULTS Of 19 patients with PNP, 8 had brachial plexus injury (BPI), 7 had spinal cord injury, 2 had cauda equina injury, 1 had intercostal nerve injury, and 1 had lumbosacral plexus injury. All patients were unresponsive or had a recurrence of pain after SCS, with an average pain-relief rate of 9.3%. After DREZ lesioning, the mean numeric rating scale scores significantly decreased from 7.6 ± 1.5 to 1.8 ± 1.7, with an average pain-relief rate of 75.3%. Seven patients (36.8%) experienced worsened neurologic dysfunction at the last follow-up. Patients with BPI had a significantly better outcome than other pathologies (P < 0.001) after DREZ lesioning. CONCLUSIONS DREZ lesioning is an effective alternative procedure to SCS for patients with PNP who have lost limb function. Particularly for those with BPI, DREZ lesioning has shown good efficacy and can be considered a preferred surgical option.
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Affiliation(s)
- Tao Du
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bing Ni
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wei Shu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhiwei Ren
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Song Guo
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaohua Zhang
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongwei Zhu
- Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongsheng Hu
- Beijing Institute of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Fujiwara A, Watanabe K, Yoshimura K, Yamamura Y, Ida M, Kawaguchi M. Correlation between pain catastrophizing in acute herpes zoster and postherpetic neuralgia: a retrospective analysis. J Anesth 2023; 37:589-595. [PMID: 37285023 DOI: 10.1007/s00540-023-03208-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/26/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE The objective of this study was to examine the association between pain catastrophizing in acute phase herpes zoster and the development of postherpetic neuralgia. METHODS The medical records of all patients diagnosed with herpes zoster between February 2016 and December 2021 were retrieved. Inclusion criteria were patients aged > 50 years who visited our pain center within 60 days after rash onset and reported a pain intensity of ≥ 3 in a numerical rating scale. Patients with a score of 30 or more in the pain catastrophizing scale at baseline were assigned to the catastrophizer group, and those with a score < 30 were assigned to the non-catastrophizer group. We defined patients with "postherpetic neuralgia" and "severe postherpetic neuralgia" as those with a numerical rating scale score of 3 or more and 7 or more at 3 months after baseline, respectively. RESULTS Data of 189 patients were available for complete analysis. Age, baseline numerical rating scale, and prevalence of anxiety and depression were significantly higher in the catastrophizer than those in the non-catastrophizer group. Incidence of postherpetic neuralgia did not differ significantly between the groups (p = 0.26). Multiple logistic regression analysis showed that age, severe pain at baseline, and immunosuppressive state were the factors which were independently associated with developing postherpetic neuralgia. Severe pain at baseline was the only factor related to developing severe postherpetic neuralgia. CONCLUSION Pain catastrophizing in the acute phase of herpes zoster may not be related to the development of postherpetic neuralgia.
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Affiliation(s)
- Aki Fujiwara
- Department of Anesthesiology, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan.
| | - Keisuke Watanabe
- Department of Anesthesiology, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Kie Yoshimura
- Department of Anesthesiology, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Yuji Yamamura
- Department of Anesthesiology, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
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Shanthanna H, Eldabe S, Provenzano DA, Bouche B, Buchser E, Chadwick R, Doshi TL, Duarte R, Hunt C, Huygen FJPM, Knight J, Kohan L, North R, Rosenow J, Winfree CJ, Narouze S. Evidence-based consensus guidelines on patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain. Reg Anesth Pain Med 2023; 48:273-287. [PMID: 37001888 PMCID: PMC10370290 DOI: 10.1136/rapm-2022-104097] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/18/2023] [Indexed: 04/03/2023]
Abstract
Spinal cord stimulation (SCS) has demonstrated effectiveness for neuropathic pain. Unfortunately, some patients report inadequate long-term pain relief. Patient selection is emphasized for this therapy; however, the prognostic capabilities and deployment strategies of existing selection techniques, including an SCS trial, have been questioned. After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, a steering committee was formed to develop evidence-based guidelines for patient selection and the role of an SCS trial. Representatives of professional organizations with clinical expertize were invited to participate as committee members. A comprehensive literature review was carried out by the steering committee, and the results organized into narrative reports, which were circulated to all the committee members. Individual statements and recommendations within each of seven sections were formulated by the steering committee and circulated to members for voting. We used a modified Delphi method wherein drafts were circulated to each member in a blinded fashion for voting. Comments were incorporated in the subsequent revisions, which were recirculated for voting to achieve consensus. Seven sections with a total of 39 recommendations were approved with 100% consensus from all the members. Sections included definitions and terminology of SCS trial; benefits of SCS trial; screening for psychosocial characteristics; patient perceptions on SCS therapy and the use of trial; other patient predictors of SCS therapy; conduct of SCS trials; and evaluation of SCS trials including minimum criteria for success. Recommendations included that SCS trial should be performed before a definitive SCS implant except in anginal pain (grade B). All patients must be screened with an objective validated instrument for psychosocial factors, and this must include depression (grade B). Despite some limitations, a trial helps patient selection and provides patients with an opportunity to experience the therapy. These recommendations are expected to guide practicing physicians and other stakeholders and should not be mistaken as practice standards. Physicians should continue to make their best judgment based on individual patient considerations and preferences.
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Affiliation(s)
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | | | | | - Eric Buchser
- Pain Management and Neuromodulation Centre, EHC, Morges, Switzerland
- Pain, EHC, Morges, Switzerland
| | | | - Tina L Doshi
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rui Duarte
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Christine Hunt
- Anesthesiology - Pain Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | | | - Judy Knight
- Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Richard North
- Neurosurgery, Anesthesiology and Critical Care Medicine (ret.), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua Rosenow
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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Shanthanna H, Eldabe S, Provenzano DA, Chang Y, Adams D, Kashir I, Goel A, Tian C, Couban RJ, Levit T, Hagedorn JM, Narouze S. Role of patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain: a comprehensive narrative review. Reg Anesth Pain Med 2023; 48:251-272. [PMID: 37001887 DOI: 10.1136/rapm-2022-103820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/22/2022] [Indexed: 04/03/2023]
Abstract
Background/importancePatient selection for spinal cord stimulation (SCS) therapy is crucial and is traditionally performed with clinical selection followed by a screening trial. The factors influencing patient selection and the importance of trialing have not been systematically evaluated.ObjectiveWe report a narrative review conducted to synthesize evidence regarding patient selection and the role of SCS trials.Evidence reviewMedline, EMBASE and Cochrane databases were searched for reports (any design) of SCS in adult patients, from their inception until March 30, 2022. Study selection and data extraction were carried out using DistillerSR. Data were organized into tables and narrative summaries, categorized by study design. Importance of patient variables and trialing was considered by looking at their influence on the long-term therapy success.FindingsAmong 7321 citations, 201 reports consisting of 60 systematic reviews, 36 randomized controlled trials (RCTs), 41 observational studies (OSs), 51 registry-based reports, and 13 case reports on complications during trialing were included. Based on RCTs and OSs, the median trial success rate was 72% and 82%, and therapy success was 65% and 61% at 12 months, respectively. Although several psychological and non-psychological determinants have been investigated, studies do not report a consistent approach to patient selection. Among psychological factors, untreated depression was associated with poor long-term outcomes, but the effect of others was inconsistent. Most RCTs except for chronic angina involved trialing and only one RCT compared patient selection with or without trial. The median (range) trial duration was 10 (0–30) and 7 (0–56) days among RCTs and OSs, respectively.ConclusionsDue to lack of a consistent approach to identify responders for SCS therapy, trialing complements patient selection to exclude patients who do not find the therapy helpful and/or intolerant of the SCS system. However, more rigorous and large studies are necessary to better evaluate its role.
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Affiliation(s)
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | | | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Adams
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Imad Kashir
- University of Waterloo, Waterloo, Ontario, Canada
| | - Akash Goel
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chenchen Tian
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Tal Levit
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan M Hagedorn
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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Goudman L, Putman K, Van Doorslaer L, Billot M, Roulaud M, Rigoard P, Moens M. Proportion of clinical holistic responders in patients with persistent spinal pain syndrome type II treated by subthreshold spinal cord stimulation compared to best medical treatment: a study protocol for a multicentric randomised controlled trial (TRADITION). Trials 2023; 24:120. [PMID: 36803412 PMCID: PMC9940414 DOI: 10.1186/s13063-023-07140-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Integrating information on bodily functions, pain intensity and quality of life into one composite measure of a holistic responder has recently been proposed as a useful method to evaluate treatment efficacy of spinal cord stimulation (SCS) in patients with therapy-refractory persistent spinal pain syndrome type II (PSPS-T2). Previous studies already demonstrated the efficacy of standard SCS over best medical treatment (BMT) and the superiority of new subthreshold (i.e. paresthesia free) SCS paradigms compared to standard SCS. Nevertheless, the efficacy of subthreshold SCS compared to BMT has not yet been investigated in patients with PSPS-T2, neither with unidimensional outcomes nor with a composite measure. The current objective is to examine whether subthreshold SCS, compared to BMT, provided to patients with PSPS-T2 results in a different proportion of clinical holistic responders (as composite measure) at 6 months. METHODS A two-arm multicentre randomised controlled trial will be conducted whereby 114 patients will be randomised (1:1) to (a) BMT or (b) paresthesia-free SCS. After a follow-up period of 6 months (primary time endpoint), patients receive the opportunity to cross over towards the other treatment group. The primary outcome is the proportion of clinical holistic responders at 6 months (i.e. a composite measure of pain intensity, medication, disability, health-related quality of life and patient satisfaction). The secondary outcomes are work status, self-management, anxiety, depression and healthcare expenditure. DISCUSSION Within the TRADITION project, we propose to shift the focus from a unidimensional outcome measure towards a composite measure as primary outcome measure to evaluate the efficacy of currently used subthreshold SCS paradigms. The lack of methodologically rigorous trials exploring the clinical efficacy and socio-economic consequences of subthreshold SCS paradigms is pressing, especially in light of the growing burden of PSPS-T2 on the society. TRIAL REGISTRATION ClinicalTrials.gov NCT05169047. Registered on December 23, 2021.
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Affiliation(s)
- Lisa Goudman
- STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium. .,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Physiotherapy, Pain in Motion Research Group (PAIN), Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Research Foundation Flanders (FWO), Egmontstraat 5, 1000, Brussels, Belgium.
| | - Koen Putman
- grid.8767.e0000 0001 2290 8069Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Interuniversity Centre for Health Economics Research (I-CHER), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Leen Van Doorslaer
- grid.8767.e0000 0001 2290 8069STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Maxime Billot
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Manuel Roulaud
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Philippe Rigoard
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France ,grid.411162.10000 0000 9336 4276Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France ,grid.434217.70000 0001 2178 9782Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360 Chasseneuil-du-Poitou, France
| | | | - Maarten Moens
- grid.8767.e0000 0001 2290 8069STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.411326.30000 0004 0626 3362Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Department of Physiotherapy, Pain in Motion Research Group (PAIN), Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.411326.30000 0004 0626 3362Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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Meier K, Glavind J, Milidou I, Sørensen JCH, Sandager P. Burst Spinal Cord Stimulation in Pregnancy: First Clinical Experiences. Neuromodulation 2023; 26:224-232. [PMID: 35697598 DOI: 10.1016/j.neurom.2022.03.008] [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: 11/23/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) is a treatment for chronic neuropathic pain. It is based on the delivery of electric impulses to the spinal cord, traditionally in a regular square-wave pattern ("tonic" stimulation) and, more recently, in a rhythmic train-of-five "BurstDR" pattern. The safety of active SCS therapy in pregnancy is not established, and recommendations are based on limited casuistic evidence. We present in this study clinical data on a case series of six women treated with burst SCS during pregnancy. In addition, we present the ultrasonographic flow measurements of fetal and uteroplacental blood flow in a pregnant patient. MATERIALS AND METHODS Patients were included if they had been implanted with a full SCS system at Aarhus University Hospital, Denmark, between 2006 and 2020 and received active burst SCS stimulation during a pregnancy. Telephone interviews were conducted, including details on SCS therapy, medication, pregnancy course and outcome, and health status of the offspring. In one patient, the uteroplacental and fetal blood flow was assessed in gestational week 29 by Doppler flow measurements performed during both ON and OFF phases of the SCS system. RESULTS Six patients were included with a total of 11 pregnancies. Three pregnancies ended in miscarriages, all in the same patient who had preexisting significant risk factors for miscarriage. Eight resulted in a live-born child with normal birth weight for gestational age; seven were born at term, and one was born late preterm, in gestational week 36. Ultrasonographic Doppler flow, measured in one patient, was normal and did not reveal any immediate changes between burst SCS ON and OFF. Seven children were reported healthy with normal neurodevelopment and one physically healthy but with developmental delays. CONCLUSIONS The data presented in this study add to the accumulating evidence of the safety of SCS in pregnancy.
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Affiliation(s)
- Kaare Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark; Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; Center for Experimental Neuroscience, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Julie Glavind
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Ioanna Milidou
- Department of Pediatrics and Adolescent Medicine, Regional Hospital West Jutland, Herning, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Christian Hedemann Sørensen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark; Center for Experimental Neuroscience, Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Puk Sandager
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark
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Beletsky A, Liu C, Vickery K, Winston N, Loomba M, Gabriel RA, Chen J. Spinal Cord Stimulator (SCS) Placement: Examining Outcomes Between the Open and Percutaneous Approach. Neuromodulation 2022:S1094-7159(22)01372-1. [DOI: 10.1016/j.neurom.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/27/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022]
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11
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Brill S, Defrin R, Aryeh IG, Zusman AM, Benyamini Y. Short- and long-term effects of conventional spinal cord stimulation on chronic pain and health perceptions: A longitudinal controlled trial. Eur J Pain 2022; 26:1849-1862. [PMID: 35761769 PMCID: PMC9543320 DOI: 10.1002/ejp.2002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/03/2022] [Accepted: 06/25/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The effectiveness and long-term outcomes of spinal cord stimulation (SCS) are not fully established, especially considering that data from patients who withdrew from the trial are rarely analysed, which may lead to overestimation of SCS efficacy. We evaluated short- and long-term effects of SCS on chronic pain and perceived health, beyond natural variability in these outcomes. METHODS In a prospective design, 176 chronic pain patients referred to SCS were evaluated five times (baseline; retest ~6 weeks later; post-SCS trial; 8 and 28 weeks post-permanent implantation). Patients whose SCS trial failed (Temp group) were followed up and compared to those who underwent permanent SCS (Perm group). RESULTS Analyses revealed a non-linear (U-shaped) trend significantly different between the two groups. In the Perm group, a significant improvement occurred post-SCS implantation in pain severity, pain interference, health-related quality of life and self-rated health, which was followed by gradual worsening and return to baseline values at end of follow-up. In the Temp group, only minor changes occurred in these outcomes over time. On average, baseline and end of follow-up values in the Perm and Temp groups were similar: ~40% in each group exhibited an increase in pain severity over time and 38% and 33%, respectively, exhibited reductions in pain severity over time. CONCLUSIONS Since the greatest improvement in the outcome measures occurred from baseline to post-SCS trial (T1-T3) followed by a gradual decline in the effect, it appears that SCS may not be effective for the majority of chronic pain patients. SIGNIFICANCE This longitudinal study evaluated short and long term effects of spinal cord stimulation (SCS) on chronic pain outcome measures, beyond their natural variation in time. Despite significant short term improvements, by the end of the seven months' follow-up, the outcomes in the treatment group (people who received the permanent implantation) were similar to those of the control group (people whose SCS trial failed and did not continue to permanent implantation) suggesting SCS may not be cost-effective for chronic pain patients.
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Affiliation(s)
- Silviu Brill
- Department of Anesthesia and Critical Care Medicine, Institute of Pain MedicineTel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Ruth Defrin
- Department of Physical Therapy, Sagol School of Neuroscience, School of Health Professions, Sackler Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Itay Goor Aryeh
- Pain Medicine Institute, Sheba Medical CenterTel HashomerRamat GanIsrael
| | | | - Yael Benyamini
- Bob Shapell School of Social WorkTel Aviv UniversityTel AvivIsrael
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12
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Thomson S, Helsen N, Prangnell S, Paroli M, Baranidharan G, Belaïd H, Billet B, Eldabe S, De Carolis G, Demartini L, Gatzinsky K, Kallewaard JW, Winkelmüller M, Huygen F, Stoevelaar H. Patient selection for spinal cord stimulation: The importance of an integrated assessment of clinical and psychosocial factors. Eur J Pain 2022; 26:1873-1881. [PMID: 35856311 DOI: 10.1002/ejp.2009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND A previously developed educational e-health tool considers both clinical and psychosocial factors when selecting patients with chronic pain for spinal cord stimulation (SCS). The validity of the composite recommendations was evaluated in a retrospective study, demonstrating a strong relationship with patient outcomes after SCS. METHODS An additional retrospective analysis was performed to determine the added value of a psychosocial evaluation as part of the decision-making process on SCS. Data concerned 482 patients who were considered for SCS in 2018-2019. Analysis focused on the relationship between the different layers of the tool recommendations (clinical, psychosocial, composite) with trial results and patient outcomes at 6 months after SCS. Of the initial study population, 381 patients underwent SCS and had follow-up data on at least one of three pain-related outcome measures. RESULTS Pain improvement was observed in 76% of the patients for whom SCS was strongly recommended based on merely the clinical aspects. This percentage varied by the level of psychosocial problems and ranged from 86% in patients without any compromising psychosocial factors to 60% in those with severe problems. Similarly, the severity of psychosocial problems affected trial results in patients for whom SCS was either recommended or strongly recommended. CONCLUSIONS The strong relationship between psychosocial factors embedded in the SCS e-health tool and patient outcomes supports an integrated and multidisciplinary approach in the selection of patients for SCS. The educational e-health tool, combining both clinical and psychosocial aspects, is believed to be helpful for further education and implementation of this approach.
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Affiliation(s)
- Simon Thomson
- Mid and South Essex University Hospitals, Basildon, United Kingdom
| | - Nicky Helsen
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
| | - Simon Prangnell
- Clinical Neuropsychology Service, Oxford University Hospitals, Oxford, United Kingdom
| | - Mery Paroli
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Hayat Belaïd
- Department of Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Bart Billet
- Department of Anaesthesiology, AZ Delta, Roeselare, Belgium
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, United Kingdom
| | - Giuliano De Carolis
- FederDolore-SICD; Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | | | - Kliment Gatzinsky
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Willem Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, The Netherlands.,Department of Anaesthesiology and Pain Treatment, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Frank Huygen
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Herman Stoevelaar
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
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Poulsen DM, Nikolajsen L, Blichfeldt-Eckhardt MR, Gulisano HA, Hedemann Sørensen JC, Meier K. Comparison of Spinal Cord Stimulation Outcomes Between Preoperative Opioid Users and Nonusers: A Cohort Study of 467 Patients. Neuromodulation 2022; 25:700-709. [DOI: 10.1016/j.neurom.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/25/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
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14
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Eriksen LE, Terkelsen AJ, Blichfeldt-Eckhardt MR, Sørensen JCH, Meier K. Spinal cord stimulation in severe cases of complex regional pain syndrome: A retrospective cohort study with long-term follow-up. Eur J Pain 2021; 25:2212-2225. [PMID: 34196075 DOI: 10.1002/ejp.1834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a debilitating pain condition often resistant to standard treatment modalities. In these cases, spinal cord stimulation (SCS) can be an option, but the effect on CRPS remains disputed. We aimed to assess the long-term effect of SCS on CRPS. METHODS We retrospectively analysed 51 CRPS patients implanted with an SCS system at the University Hospitals in Aarhus or Odense, Denmark, with a median follow-up time of 4.4 years. Primary outcomes were pain intensity on a numeric rating scale (NRS) and the Patients' Global Impression of Change (PGIC). Secondary outcomes were patient satisfaction, work status, consumption of pain medication, the Major Depression Inventory (MDI), Pain Catastrophizing Scale (PCS) and quality of life (QoL) measured using the Short-Form Health Survey (SF-36). For each outcome measure, baseline data were compared to the latest collected data point. RESULTS A significant pain relief was found with a mean reduction in NRS score of 2.4 (95% CI: 1.7-3.0, p < 0.0001). 68.8% reported 'much improved' or 'very much improved' on the PGIC scale. 87.5% would choose SCS again for the same outcome. A significant beneficial impact was found on MDI score, PCS, SF-36 summary scores and consumption of tricyclic antidepressants, antiepileptic drugs and opioids. No statistical effect was found on work status. CONCLUSION Pain intensity, depression, pain catastrophizing, pain medication use and QoL were significantly improved after SCS implantation, with high patient satisfaction rates in CRPS patients. This study supports the continued use of SCS in the treatment of severe CRPS. SIGNIFICANCE This study presents detailed data from a large, well-characterized cohort of Danish CRPS patients treated with SCS, analyzing several outcome measures. The results serve to document SCS as an effective treatment for severe CRPS and expands the cumulative level of evidence in favor of its use. Additionally, analysis of preoperative patient characteristics suggests that SCS treatment should not be withheld in patients with a high degree of psychological distress or high consumption of analgesics.
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Affiliation(s)
- Linda Elise Eriksen
- Department of Neurology and Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Astrid Juhl Terkelsen
- Department of Neurology and Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Rune Blichfeldt-Eckhardt
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark.,Department of Anesthesiology and Critical Care, Odense University Hospital, Odense, Denmark
| | | | - Kaare Meier
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
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