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Chapman KB, Amireh A, van Helmond N, Yousef TA. Evaluation of Washout Periods After Dorsal Root Ganglion Stimulation Trial. Neuromodulation 2024; 27:881-886. [PMID: 38551547 DOI: 10.1016/j.neurom.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE Dorsal root ganglion stimulation (DRG-S) is a novel therapy to treat chronic pain. It has shown efficacy when delivered intermittently, suggesting a delayed washout effect exists. To measure the washout period, and to determine whether there are differences in washout times among different types of treated pain, we measured the time for pain to return at the end of the patients' one-week DRG stimulation trials. MATERIALS AND METHODS Patients who completed a successful DRG-S trial were included. The times until 25% (t25) and 90% (t90) of baseline pain level returned were recorded. The patients were divided into neuropathic, nociceptive, and mixed pain groups for subgroup comparison. t25 and t90 were plotted in the entire cohort and subgroups using reverse Kaplan-Meier plots (failure curves) and compared using a log-rank test. RESULTS In total, 29 consecutive patients were included. Median t25 and t90 times were 7.1 and 19.5 hours, respectively. Median (interquartile range) times were longest for the nociceptive pain group (n = 17) and shortest for the neuropathic pain group (n = 6), with the mixed-pain group (n = 6) in between (t25: 7.1 [1.7-19.4], 3.40 [1.4-8.4], and 5.7 [0.8-17.6]; t90, 22.0 [10.7-71.0], 7.6 [3.6-19.8], and 20.9 [14.2-31.2], respectively). t90 times differed significantly by pain type (p = 0.040). CONCLUSIONS This study showed a prolonged washout period after cessation of DRG-S therapy. Washout times vary according to pain type. The observed effects are possibly due to long-term depression of pain signaling and could allow the implementation of alternative stimulation strategies with DRG-S. Further investigations evaluating DRG-S washout times are warranted.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York City, NY, USA; Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA; The Zucker School of Medicine at Hofstra/Northwell, New York City, NY, USA; Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen, Nijmegen, The Netherlands.
| | - Ahmad Amireh
- The Spine & Pain Institute of New York, New York City, NY, USA
| | - Noud van Helmond
- The Spine & Pain Institute of New York, New York City, NY, USA; Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Tariq A Yousef
- The Spine & Pain Institute of New York, New York City, NY, USA
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Deer TR, Russo M, Grider JS, Sayed D, Lamer TJ, Dickerson DM, Hagedorn JM, Petersen EA, Fishman MA, FitzGerald J, Baranidharan G, De Ridder D, Chakravarthy KV, Al-Kaisy A, Hunter CW, Buchser E, Chapman K, Gilligan C, Hayek SM, Thomson S, Strand N, Jameson J, Simopoulos TT, Yang A, De Coster O, Cremaschi F, Christo PJ, Varshney V, Bojanic S, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for Spinal Cord Stimulation Long-term Outcome Optimization and Salvage Therapy. Neuromodulation 2024:S1094-7159(24)00078-3. [PMID: 38904643 DOI: 10.1016/j.neurom.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION The International Neuromodulation Society (INS) has recognized a need to establish best practices for optimizing implantable devices and salvage when ideal outcomes are not realized. This group has established the Neurostimulation Appropriateness Consensus Committee (NACC)® to offer guidance on matters needed for both our members and the broader community of those affected by neuromodulation devices. MATERIALS AND METHODS The executive committee of the INS nominated faculty for this NACC® publication on the basis of expertise, publications, and career work on the issue. In addition, the faculty was chosen in consideration of diversity and inclusion of different career paths and demographic categories. Once chosen, the faculty was asked to grade current evidence and along with expert opinion create consensus recommendations to address the lapses in information on this topic. RESULTS The NACC® group established informative and authoritative recommendations on the salvage and optimization of care for those with indwelling devices. The recommendations are based on evidence and expert opinion and will be expected to evolve as new data are generated for each topic. CONCLUSIONS NACC® guidance should be considered for any patient with less-than-optimal outcomes with a stimulation device implanted for treating chronic pain. Consideration should be given to these consensus points to salvage a potentially failed device before explant.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dawood Sayed
- The University of Kansas Health System, Kansas City, KS, USA
| | | | | | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Erika A Petersen
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Ganesan Baranidharan
- Leeds Teaching Hospital National Health Service (NHS) Trust, University of Leeds, Leeds, UK
| | - Dirk De Ridder
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | | | - Adnan Al-Kaisy
- Guy's and St Thomas NHS Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Corey W Hunter
- Ainsworth Institute, Ichan School of Medicine, Mt Sinai Hospital, New York, NY, USA
| | | | | | - Chris Gilligan
- Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Simon Thomson
- Pain & Neuromodulation Consulting Ltd, Nuffield Health Brentwood and The London Clinic, Brentwood, UK; Pain & Neuromodulation Centre, Mid & South Essex University NHS Hospitals, Basildon, UK
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Thomas T Simopoulos
- Arnold Warfield Pain Management Center, Harvard Medical School, Boston, MA, USA
| | - Ajax Yang
- Spine and Pain Consultant, PLLC, Staten Island, NY, USA
| | | | - Fabián Cremaschi
- Department of Neurosciences, National University of Cuyo, Mendoza, Argentina
| | - Paul J Christo
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishal Varshney
- Providence Healthcare, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Abd-Elsayed A, Vardhan S, Aggarwal A, Vardhan M, Diwan SA. Mechanisms of Action of Dorsal Root Ganglion Stimulation. Int J Mol Sci 2024; 25:3591. [PMID: 38612402 PMCID: PMC11011701 DOI: 10.3390/ijms25073591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/12/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
The dorsal root ganglion (DRG) serves as a pivotal site for managing chronic pain through dorsal root ganglion stimulation (DRG-S). In recent years, the DRG-S has emerged as an attractive modality in the armamentarium of neuromodulation therapy due to its accessibility and efficacy in alleviating chronic pain refractory to conventional treatments. Despite its therapeutic advantages, the precise mechanisms underlying DRG-S-induced analgesia remain elusive, attributed in part to the diverse sensory neuron population within the DRG and its modulation of both peripheral and central sensory processing pathways. Emerging evidence suggests that DRG-S may alleviate pain by several mechanisms, including the reduction of nociceptive signals at the T-junction of sensory neurons, modulation of pain gating pathways within the dorsal horn, and regulation of neuronal excitability within the DRG itself. However, elucidating the full extent of DRG-S mechanisms necessitates further exploration, particularly regarding its supraspinal effects and its interactions with cognitive and affective networks. Understanding these mechanisms is crucial for optimizing neurostimulation technologies and improving clinical outcomes of DRG-S for chronic pain management. This review provides a comprehensive overview of the DRG anatomy, mechanisms of action of the DRG-S, and its significance in neuromodulation therapy for chronic pain.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA
| | - Swarnima Vardhan
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06605, USA; (S.V.); (A.A.)
- Advanced Spine on Park Avenue, New York, NY 10461, USA;
| | - Abhinav Aggarwal
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06605, USA; (S.V.); (A.A.)
| | - Madhurima Vardhan
- Argonne Leadership Computing Facility, Argonne National Laboratory, Lemont, IL 60439, USA;
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Tabatabaei P, Salomonsson J, Kakas P, Eriksson M. Bilateral T12 Dorsal Root Ganglion Stimulation for the Treatment of Low Back Pain With 20-Hz and 4-Hz Stimulation, a Retrospective Study. Neuromodulation 2024; 27:141-150. [PMID: 37542505 DOI: 10.1016/j.neurom.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Chronic low back pain (CLBP) is one of the most common chronic pain conditions that cause both individual suffering and a burden to society. For these patients, several interventional treatment options such as surgery, blocks, radiofrequency, and spinal cord stimulation are available. Lately, dorsal root ganglion stimulation (DRG-S) also has been mentioned as an option by targeting bilateral T12 dorsal ganglia. In this study, we present the outcome of 11 patients with CLBP treated with bilateral T12 DRG-S. MATERIALS AND METHODS Thirteen patients with CLBP with and without leg pain were treated with bilateral T12 DRG-S. Three of the patients also received a third lumbar lead owing to leg pain. Eleven of the patients had >50% pain relief during the peri- or/and postoperative testing and received a fully implantable neurostimulator. Pain intensity, general health status, quality of life, pain catastrophizing, mental status, sleeping disorder, physical activity, and patient satisfaction were followed using numeric rating scale (NRS), Patient-Reported Outcomes Measurement Information System 29 version 2.1, Pain Catastrophizing Score, Generalized Anxiety Disorder 7-item scale, Patient Health Questionnaire Depression Module, Insomnia Severity Index, and Patient Satisfaction Questionnaire at baseline before implantation and at three months and six months. The results were analyzed on the basis of six domains: pain relief, sleeping disorder, social ability, mental status, physical activity, and satisfaction. To be identified as a responder, the patients should show a significant improvement in the pain relief domain together with at least two other domains. All responders also were given the opportunity to test 4-Hz DRG-S and compare it with traditional 20-Hz stimulation. RESULTS All 11 patients were identified as responders at six months. Five of the patients had >80% pain relief, with an average NRS score reduction of 71% for the whole group. Significant improvement could be observed in three domains for one patient, four domains for three patients, five domains for six patients, and six domains for one patient. Seven patients chose to try 4-Hz stimulation. All seven identified 4-Hz stimulation as at least as good as or better than 20-Hz stimulation and chose to continue with 4-Hz stimulation. CONCLUSIONS Bilateral T12 DRG-S seems to be an effective treatment for chronic low back pain, with significant beneficial effect not only on pain but also on quality of life, pain catastrophizing, mental status, sleeping disorder, and physical activity. 4-Hz DRG-S gave a result comparable with or better than 20-Hz stimulation.
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Affiliation(s)
| | | | - Pavlina Kakas
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Maria Eriksson
- Department of Clinical Science, Umeå University, Umeå, Sweden
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Piedade GS, Gillner S, McPhillips PS, Vesper J, Slotty PJ. Effect of low-frequency dorsal root ganglion stimulation in the treatment of chronic pain. Acta Neurochir (Wien) 2023; 165:947-952. [PMID: 36705762 PMCID: PMC10068636 DOI: 10.1007/s00701-023-05500-1] [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: 10/25/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND The role of stimulation parameters, especially stimulation frequency is not well understood in dorsal root ganglion stimulation. Previous studies documented higher effectiveness for frequencies as low as 20 Hz, but there is evidence that even lower values could lead to better outcomes. In this study, we investigate the influence of low-frequency DRG-S. METHOD This is a randomized double-blind clinical trial with a crossover design. Patients with an already implanted DRG-S system were included and randomly tested with 4 Hz, 20 Hz, 60 Hz, and sham stimulation. Amplitude was adjusted to subthreshold values for each frequency. Each frequency was tested for 5 days, followed by a 2-day washout period. Patients were assessed using VAS, McGill Pain Questionnaire, EQ-5D-5L, and Beck Depression Inventory. RESULTS Seventeen patients were in included. Time between inclusion in this study and primary implant was 32.8 months. Baseline stimulation frequency was 20 Hz in all patients. Mean baseline pain intensity was VAS 3.2 (SD 2.2). With 4-Hz stimulation, VAS was 3.8 (SD 1.9), with 20 Hz VAS 4.2 (SD 2.0) and with 60 Hz VAS 4.6 (SD 2.7). Worst pain control was seen with sham stimulation with a VAS of 5.3 (SD 3.0). Stimulation with 4 Hz achieved lower VAS scores, but this was only statistically significant when compared to sham (p = 0.001). A similar trend favoring 4-Hz stimulation was seen using the Beck Depression Inventory, but in this case no statistical significance was found. Outcomes of McGill Pain Questionnaire and EQ-5D-5L favored 20 Hz stimulation, but again without statistical significance. CONCLUSIONS Low-frequency stimulation was not significantly better than classic 20-Hz stimulation in relieving pain intensity; the study might however be underpowered. Longer washout and observational periods might also be necessary to show clear differences in frequency response.
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Affiliation(s)
- G S Piedade
- Department of Neurosurgery, Helios Universitätsklinikum Wuppertal, Universität Witten/Herdecke, Heusnerstr. 40, 42283, Wuppertal, Germany. .,Department of Neurosurgery, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany.
| | - S Gillner
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - P S McPhillips
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - J Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | - P J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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Chapman KB, Sayed D, Lamer T, Hunter C, Weisbein J, Patel KV, Dickerson D, Hagedorn JM, Lee DW, Amirdelfan K, Deer T, Chakravarthy K. Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience. J Pain Res 2023; 16:839-879. [PMID: 36942306 PMCID: PMC10024474 DOI: 10.2147/jpr.s364370] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 01/17/2023] [Indexed: 03/14/2023] Open
Abstract
With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion stimulation (DRG-S) has significantly improved the treatment of complex regional pain syndrome (CRPS), and it has broad applicability across a wide range of other conditions. Through funding and organizational leadership by the American Society for Pain and Neuroscience (ASPN), this best practices consensus document has been developed for the selection, implantation, and use of DRG stimulation for the treatment of chronic pain syndromes. This document is composed of a comprehensive narrative literature review that has been performed regarding the role of the DRG in chronic pain and the clinical evidence for DRG-S as a treatment for multiple pain etiologies. Best practice recommendations encompass safety management, implantation techniques, and mitigation of the potential complications reported in the literature. Looking to the future of neuromodulation, DRG-S holds promise as a robust intervention for otherwise intractable pain.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, NY, USA
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
- Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA
- Correspondence: Kenneth B Chapman, NYU Langone Medical Center, Zucker School of Medicine at Hofstra/Northwell, Pain Medicine at Staten Island University Hospital, 1360 Hylan Boulevard, Staten Island, NY, 10305, USA, Email
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS, USA
| | - Tim Lamer
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, NY, USA
- Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
- Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA
| | - David Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University Health System, Evanston, IL, USA
- Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA
| | | | - David W Lee
- Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
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Chapman KB, Tupper CJ, Amireh AA, van Helmond N, Yousef TA. Impact of lowering frequency of dorsal root ganglion stimulation on implantable pulse generator consumption. Reg Anesth Pain Med 2022; 48:44-45. [DOI: 10.1136/rapm-2022-103644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/07/2022] [Indexed: 11/04/2022]
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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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Akuamoah LA, Tupper C, Nagrani S, Chapman KB. Dorsal Root Ganglion Stimulation to Treat Focal Postsurgical and Diffuse Chronic Pain: A Case Report. A A Pract 2022; 16:e01589. [DOI: 10.1213/xaa.0000000000001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chapman KB, Yang A, Mogilner AY, Mandelberg N, Patel KV, Lubenow T, Deer T, Kallewaard JW, van Helmond N. Dorsal Root Ganglion Stimulation Device Explantation: A Multicenter Pooled Data Analysis. Pain Pract 2022; 22:522-531. [DOI: 10.1111/papr.13113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/08/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kenneth B. Chapman
- The Spine & Pain Institute of New York, NY NY USA
- Department of Anesthesiology, NYU Langone Medical Center, NY NY USA
- Northwell Health New York City NY USA
| | - Ajax Yang
- The Spine & Pain Institute of New York, NY NY USA
- Northwell Health New York City NY USA
| | - Alon Y. Mogilner
- Department of Neurosurgery, NYU Langone Medical Center, NY NY USA
| | | | - Kiran V. Patel
- The Spine & Pain Institute of New York, NY NY USA
- Northwell Health New York City NY USA
| | - Timothy Lubenow
- Department of Anesthesiology Rush University Medical Center Chicago IL
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias Charleston WV
| | | | - Noud van Helmond
- The Spine & Pain Institute of New York, NY NY USA
- Cooper Medical School of Rowan University Cooper University Hospital Camden NJ USA
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Frequency dependency of therapeutic efficacy in dorsal root ganglion stimulation for neuropathic pain. Acta Neurochir (Wien) 2022; 164:1193-1199. [PMID: 35217898 PMCID: PMC8967770 DOI: 10.1007/s00701-022-05161-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/13/2022] [Indexed: 11/23/2022]
Abstract
Background The influence of the stimulation frequency on the outcomes of dorsal root ganglion stimulation (DRG-S) to treat pain is not well understood. It is assumed that specific neural components dedicated to different tasks in the DRG can be preferably influenced at specific frequencies. The identification of frequencies designed for the type of pain and the ratio of neuropathic versus nociceptive pain might improve overall pain control and open new indications in DRG-S. Method We report on a randomized double-blind clinical trial with a crossover design. Patients with a permanent DRG-S system underwent phases of stimulation with 20 Hz, 40 Hz, 60 Hz, 80 Hz, and sham in a randomized order. Each phase lasted for 4 days and was followed by a 2-day washout period. Pain intensity and quality of life were assessed with visual analog scale (VAS), McGill Pain Questionnaire (MPQ), EQ-5D, and Beck Depression Inventory (BDI). Analgesics intake was assessed. Results Overall 19 patients were included in the study. CRPS was the most frequent pain etiology (7). Five patients had a PainDetect score of 12 or lower at baseline. The mean VAS before the system was implanted was 8.6 and 3.9 at the baseline. Pain intensity was reduced to 3.7 by the stimulation with 20 Hz but increased with higher frequencies reaching 5.8 at 80 Hz. A significant difference among the groups was shown over all variables examined (VAS, MPQ, EQ-5D, BDI). The best results were seen at 20 Hz for all variables, including the smallest increase in pain medication consumption. Conclusions The choice of the stimulation frequency shows a clear influence on pain reduction and quality of life. Lower stimulation frequencies seem to be most effective in neuropathic pain. Further studies are required to determine whether specific frequencies should be preferred based on the condition treated.
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Berfelo T, Doll RJ, Krabbenbos IP, Buitenweg JR. Observing Altered Nociceptive Detection Thresholds in Patients With Persistent Spinal Pain Syndrome Type 2 With a Dorsal Root Ganglion Stimulator. Neuromodulation 2022; 25:1006-1014. [DOI: 10.1016/j.neurom.2021.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/08/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022]
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Intermittent Dorsal Root Ganglion Stimulation Is as Efficacious as Standard Continuous Dosing in Treating Chronic Pain: Results From a Randomized Controlled Feasibility Trial. Neuromodulation 2022; 25:989-997. [DOI: 10.1016/j.neurom.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022]
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Kretzschmar M, Reining M. Dorsal root ganglion stimulation for treatment of central poststroke pain in the lower extremity after medullary infarction. Pain 2021; 162:2682-2685. [PMID: 34354016 DOI: 10.1097/j.pain.0000000000002439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT We report a case of relief in central poststroke pain of the lower extremity by stimulation of the dorsal root ganglion (DRG). Central poststroke pain is a poorly understood and even more poorly managed condition that can greatly impact the quality of life. To the best of our knowledge, this investigation is the first to describe the successful treatment of previously intractable chronic pain caused by stroke using DRG stimulation. Noting the anatomical structures and the physiological function, the efficacy of DRG stimulation in central poststroke pain could be explained in a neurophysiological manner. This clinical observation successfully builds on the existing understanding around the pathophysiology of central pain and offers the possibility of nondrug therapy for the treatment of this often refractory chronic pain syndrome.
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Affiliation(s)
- Michael Kretzschmar
- SRH Wald-Klinikum Gera, Clinic of Pain Medicine and Palliative Care, Gera, Germany
- SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Germany
| | - Marco Reining
- SRH Wald-Klinikum Gera, Clinic of Pain Medicine and Palliative Care, Gera, Germany
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Chapman KB, Spiegel MA, Dickerson DM, Billet B, Patel KV, Hunter C, Antony A, van Helmond N, Deer T, Kallewaard JW, Hagedorn JM, Yang A. A Paramedian Approach for Dorsal Root Ganglion Stimulation Placement Developed to Limit Lead Migration and Fracture. Pain Pract 2021; 21:991-1000. [PMID: 34328256 DOI: 10.1111/papr.13063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S), has demonstrated superiority in the treatment of complex regional pain syndrome and causalgia. Lead migration and fracture impact DRG-S therapeutic stability. Lead anchoring reduces DRG-S lead migration without increasing lead fracture. Lead fracture may be related to lead entrapment in the superficial fascial plane. A novel medialized approach for lead placement and anchoring is presented to address these issues. METHODS We suggest an alternative technique for implanting percutaneous DRG-S leads at the T10-L5 levels. RESULTS A novel medialized ipsilateral technique for lead placement and anchoring for single, bilateral, and adjacent segment placement is presented. The Tuohy needle puncture site is medial to the pedicle and adjacent to the spinous process, two vertebral levels caudad to the target foramen. Trajectory is maintained in the sagittal plane, to access the caudad interlaminar space near the midline. This technique allows for ipsilateral or contralateral lead placement. After epidural access, the introducer sheath is rotated toward the targeted foramen and advanced. The guidewire followed by the lead is passed, and once lead position is confirmed, tension 'S' loops are created, followed by anchoring to the deep fascia. CONCLUSION We describe a new paramedian technique for DRG-S lead placement. We propose it will decrease DRG-S complication rates through anchoring to reduce migration and by avoiding the fascial planes thought to be responsible for fracture. Long-term outcomes applying our proposed techniques are required for determining the true impact, however, early anecdotal results suggest that these new techniques are favorable.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, NY, USA.,Department of Anesthesiology, NYU Langone Medical Center, New York, NY, USA.,Northwell Health, New York, NY
| | - Matthew A Spiegel
- The Spine & Pain Institute of New York, New York, NY, USA.,Northwell Health, New York, NY
| | - David M Dickerson
- Department of Anesthesiology, NorthShore University Health System, Evanston, IL, USA.,Department of Anesthesia & Critical Care, University of Chicago, Chicago, IL, USA
| | - Bart Billet
- Department of Anesthesiology, AZ Delta, Roeselare, Belgium
| | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, NY, USA.,Northwell Health, New York, NY
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | - Noud van Helmond
- Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV
| | | | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ajax Yang
- The Spine & Pain Institute of New York, New York, NY, USA.,Northwell Health, New York, NY
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Chapman KB, Mogilner AY, Yang AH, Yadav A, Patel KV, Lubenow T, van Helmond N, Deer T, Kallewaard JW. Lead migration and fracture rate in dorsal root ganglion stimulation using anchoring and non-anchoring techniques: A multicenter pooled data analysis. Pain Pract 2021; 21:859-870. [PMID: 34145740 DOI: 10.1111/papr.13052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRG-S) is a neuromodulation technique introduced in the last decade with evolving implant methods. Initial prospective research found low incidences of lead migration and lead fracture with DRG-S. However, several recent studies have highlighted high lead migration and lead fracture rates with DRG-S. We investigated the influence of lead anchoring on migrations and fractures. METHODS We performed a retrospective review between 2016 and 2020 of individuals implanted with DRG-S leads by 4 experienced implanters. The implanters independently changed their standard practice regarding lead anchoring over time, with opposing trends (no anchoring > anchoring, anchoring > no anchoring). We compared lead migration and lead fracture rates between anchored and unanchored DRG-S leads in the entire study cohort. Cox regression was performed on lead migration and fracture distributions. RESULTS We included 756 leads (n = 565 anchored and n = 191 unanchored) from 249 patients. In unanchored leads, migration occurred in 16 leads (8.4%) from 13 patients (21.0%). In anchored leads, migration occurred in 8 leads (1.4%) from 5 patients (2.7%). Fracture in unanchored leads occurred in 6 leads (3.1%) from 6 patients (9.7%). Fractures in anchored leads occurred in 11 leads (1.9%) from 9 patients (4.8%). The migration survival distributions for the anchored and unanchored leads were statistically significantly different (p < 0.01) with decreased survival for unanchored leads (hazard ratio = 5.8, 95% confidence interval [CI] = 2.2-15.5). DISCUSSION We found that anchoring DRG-S leads significantly reduces lead migration when compared to leads placed without an anchor. There was no significant difference in fracture rate between anchored and unanchored leads.
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Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, New York, USA.,Department of Anesthesiology, NYU Langone Medical Center, New York, New York, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA
| | - Alon Y Mogilner
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Ajax H Yang
- The Spine & Pain Institute of New York, New York, New York, USA
| | - Abhishek Yadav
- Department of Anesthesiology and Perioperative Medicine, Brown University, Providence, Rhode Island, USA
| | - Kiran V Patel
- The Spine & Pain Institute of New York, New York, New York, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA
| | - Timothy Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Noud van Helmond
- Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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Franken G, Douven P, Debets J, Joosten EAJ. Conventional Dorsal Root Ganglion Stimulation in an Experimental Model of Painful Diabetic Peripheral Neuropathy: A Quantitative Immunocytochemical Analysis of Intracellular γ-Aminobutyric Acid in Dorsal Root Ganglion Neurons. Neuromodulation 2021; 24:639-645. [PMID: 33942947 PMCID: PMC8360133 DOI: 10.1111/ner.13398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/26/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Abstract
Background and Objective The sensory cell somata in the DRG contain all equipment necessary for extensive GABAergic signaling and are able to release GABA upon depolarization. With this study, we hypothesize that pain relief induced by conventional dorsal root ganglion stimulation (Con‐DRGS) in animals with experimental painful diabetic peripheral neuropathy is related to the release of GABA from DRG neurons. With use of quantitative immunocytochemistry, we hypothesize DRGS to result in a decreased intensity of intracellular GABA‐immunostaining in DRG somata. Materials and Methods Female Sprague‐Dawley rats (n = 31) were injected with streptozotocin (STZ) in order to induce Diabetes Mellitus. Animals that developed neuropathic pain after four weeks (Von Frey) were implanted with a unilateral DRGS device at L4 (n = 14). Animals were then stimulated for 30 min with Con‐DRGS (20 Hz, pulse width = 0.2 msec, amplitude = 67% of motor threshold, n = 8) or Sham‐DRGS (n = 6), while pain behavior (von Frey) was measured. DRGs were then collected and immunostained for GABA, and a relation to size of sensory cell soma diameter (small: 12–26 μm, assumed to be C‐fiber related sensory neurons; medium: 26–40 μm, assumed to be Aδ related sensory neurons; and large: 40–54 μm, assumed to be Aβ related sensory neurons) was made. Results DRGS treated animals showed significant reductions in STZ‐induced mechanical hypersensitivity. No significant differences in GABA immunostaining intensity per sensory neuron cell soma type (small‐, medium‐, or large‐sized) were noted in DRGs of stimulated (Con‐DRGS) animals versus Sham animals. No differences in GABA immunostaining intensity per sensory cell soma type in ipsi‐ as compared to contralateral DRGs were observed. Conclusion Con‐DRGS does not affect the average intracellular GABA immunofluorescence staining intensity in DRG sensory neurons of those animals which showed significant pain reduction. Similarly, no soma size related changes in intracellular GABA immunofluorescence were observed following Con‐DRGS.
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Affiliation(s)
- Glenn Franken
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Perla Douven
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Urology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Jacques Debets
- School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Muroidean Facility, School of Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Kuwabara Y, Salavatian S, Howard-Quijano K, Yamaguchi T, Lundquist E, Mahajan A. Neuromodulation With Thoracic Dorsal Root Ganglion Stimulation Reduces Ventricular Arrhythmogenicity. Front Physiol 2021; 12:713717. [PMID: 34690795 PMCID: PMC8528951 DOI: 10.3389/fphys.2021.713717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Sympathetic hyperactivity is strongly associated with ventricular arrhythmias and sudden cardiac death. Neuromodulation provides therapeutic options for ventricular arrhythmias by modulating cardiospinal reflexes and reducing sympathetic output at the level of the spinal cord. Dorsal root ganglion stimulation (DRGS) is a recent neuromodulatory approach; however, its role in reducing ventricular arrhythmias has not been evaluated. The aim of this study was to determine if DRGS can reduce cardiac sympathoexcitation and the indices for ventricular arrhythmogenicity induced by programmed ventricular extrastimulation. We evaluated the efficacy of thoracic DRGS at both low (20 Hz) and high (1 kHz) stimulation frequencies. Methods: Cardiac sympathoexcitation was induced in Yorkshire pigs (n = 8) with ventricular extrastimulation (S1/S2 pacing), before and after DRGS. A DRG-stimulating catheter was placed at the left T2 spinal level, and animals were randomized to receive low-frequency (20 Hz and 0.4 ms) or high-frequency (1 kHz and 0.03 ms) DRGS for 30 min. High-fidelity cardiac electrophysiological recordings were performed with an epicardial electrode array measuring the indices of ventricular arrhythmogenicity-activation recovery intervals (ARIs), electrical restitution curve (Smax), and Tpeak-Tend interval (Tp-Te interval). Results: Dorsal root ganglion stimulation, at both 20 Hz and 1 kHz, decreased S1/S2 pacing-induced ARI shortening (20 Hz DRGS -21±7 ms, Control -50±9 ms, P = 0.007; 1 kHz DRGS -13 ± 2 ms, Control -46 ± 8 ms, P = 0.001). DRGS also reduced arrhythmogenicity as measured by a decrease in Smax (20 Hz DRGS 0.5 ± 0.07, Control 0.7 ± 0.04, P = 0.006; 1 kHz DRGS 0.5 ± 0.04, Control 0.7 ± 0.03, P = 0.007), and a decrease in Tp-Te interval/QTc (20 Hz DRGS 2.7 ± 0.13, Control 3.3 ± 0.12, P = 0.001; 1 kHz DRGS 2.8 ± 0.08, Control; 3.1 ± 0.03, P = 0.007). Conclusions: In a porcine model, we show that thoracic DRGS decreased cardiac sympathoexcitation and indices associated with ventricular arrhythmogenicity during programmed ventricular extrastimulation. In addition, we demonstrate that both low-frequency and high-frequency DRGS can be effective neuromodulatory approaches for reducing cardiac excitability during sympathetic hyperactivity.
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Affiliation(s)
- Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Tomoki Yamaguchi
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eevanna Lundquist
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- *Correspondence: Aman Mahajan
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Chapman KB, Yousef TA, Foster A, D Stanton-Hicks M, van Helmond N. Mechanisms for the Clinical Utility of Low-Frequency Stimulation in Neuromodulation of the Dorsal Root Ganglion. Neuromodulation 2020; 24:738-745. [PMID: 33236811 DOI: 10.1111/ner.13323] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dorsal root ganglion stimulation (DRG-S) involves the electrical modulation of the somata of afferent neural fibers to treat chronic pain. DRG-S has demonstrated clinical efficacy at frequencies lower than typically used with spinal cord stimulation (SCS). In a clinical study, we found that the frequency of DRG-S can be tapered to a frequency as low as 4 Hz with no loss of efficacy. This review discusses possible mechanisms of action underlying effective pain relief with very low-frequency DRG-S. MATERIALS AND METHODS We performed a literature review to explore the role of frequency in neural transmission and the corresponding relevance of frequency settings with neuromodulation. FINDINGS Sensory neural transmission is a frequency-modulated system, with signal frequency determining which mechanisms are activated in the dorsal horn. In the dorsal horn, low-frequency signaling (<20 Hz) activates inhibitory processes while higher frequencies (>25 Hz) are excitatory. Physiologically, low-threshold mechanoreceptors (LTMRs) fibers transmit or modulate innocuous mechanical touch at frequencies as low as 0.5-5 Hz, while nociceptive fibers transmit pain at high frequencies. We postulate that very low-frequency DRG-S, at least partially, harnesses LTMRs and the native endogenous opioid system. Utilizing lower stimulation frequency decreases the total energy delivery used for DRG-S, extends battery life, and facilitates the development of devices with smaller generators.
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Affiliation(s)
- Kenneth B Chapman
- Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, New York University Langone Medical Center, New York City, NY, USA.,Department of Anesthesiology, Zucker School of Medicine at Hofstra Northwell, Northwell Health, Manhasset, NY, USA
| | - Tariq A Yousef
- Spine & Pain Institute of New York, New York City, NY, USA
| | | | | | - Noud van Helmond
- Spine & Pain Institute of New York, New York City, NY, USA.,Department of Anesthesiology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ, USA
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