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Rogers ER, Capogrosso M, Lempka SF. Biophysics of Frequency-Dependent Variation in Paresthesia and Pain Relief during Spinal Cord Stimulation. J Neurosci 2024; 44:e2199232024. [PMID: 38744531 PMCID: PMC11211721 DOI: 10.1523/jneurosci.2199-23.2024] [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] [Received: 11/20/2023] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024] Open
Abstract
The neurophysiological effects of spinal cord stimulation (SCS) for chronic pain are poorly understood, resulting in inefficient failure-prone programming protocols and inadequate pain relief. Nonetheless, novel stimulation patterns are regularly introduced and adopted clinically. Traditionally, paresthetic sensation is considered necessary for pain relief, although novel paradigms provide analgesia without paresthesia. However, like pain relief, the neurophysiological underpinnings of SCS-induced paresthesia are unknown. Here, we paired biophysical modeling with clinical paresthesia thresholds (of both sexes) to investigate how stimulation frequency affects the neural response to SCS relevant to paresthesia and analgesia. Specifically, we modeled the dorsal column (DC) axonal response, dorsal column nucleus (DCN) synaptic transmission, conduction failure within DC fiber collaterals, and dorsal horn network output. Importantly, we found that high-frequency stimulation reduces DC fiber activation thresholds, which in turn accurately predicts clinical paresthesia perception thresholds. Furthermore, we show that high-frequency SCS produces asynchronous DC fiber spiking and ultimately asynchronous DCN output, offering a plausible biophysical basis for why high-frequency SCS is less comfortable and produces qualitatively different sensation than low-frequency stimulation. Finally, we demonstrate that the model dorsal horn network output is sensitive to SCS-inherent variations in spike timing, which could contribute to heterogeneous pain relief across patients. Importantly, we show that model DC fiber collaterals cannot reliably follow high-frequency stimulation, strongly affecting the network output and typically producing antinociceptive effects at high frequencies. Altogether, these findings clarify how SCS affects the nervous system and provide insight into the biophysics of paresthesia generation and pain relief.
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Affiliation(s)
- Evan R Rogers
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109
- Biointerfaces Institute, University of Michigan, Ann Arbor, Michigan 48109
| | - Marco Capogrosso
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Rehab and Neural Engineering Labs, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109
- Biointerfaces Institute, University of Michigan, Ann Arbor, Michigan 48109
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan 48109
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2
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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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Wang D, Lee KY, Kagan ZB, Bradley K, Lee D. Frequency-Dependent Neural Modulation of Dorsal Horn Neurons by Kilohertz Spinal Cord Stimulation in Rats. Biomedicines 2024; 12:1346. [PMID: 38927553 PMCID: PMC11201430 DOI: 10.3390/biomedicines12061346] [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: 04/26/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Kilohertz high-frequency spinal cord stimulation (kHF-SCS) is a rapidly advancing neuromodulatory technique in the clinical management of chronic pain. However, the precise cellular mechanisms underlying kHF-SCS-induced paresthesia-free pain relief, as well as the neural responses within spinal pain circuits, remain largely unexplored. In this study, using a novel preparation, we investigated the impact of varying kilohertz frequency SCS on dorsal horn neuron activation. Employing calcium imaging on isolated spinal cord slices, we found that extracellular electric fields at kilohertz frequencies (1, 3, 5, 8, and 10 kHz) induce distinct patterns of activation in dorsal horn neurons. Notably, as the frequency of extracellular electric fields increased, there was a clear and significant monotonic escalation in neuronal activity. This phenomenon was observed not only in superficial dorsal horn neurons, but also in those located deeper within the dorsal horn. Our study demonstrates the unique patterns of dorsal horn neuron activation in response to varying kilohertz frequencies of extracellular electric fields, and we contribute to a deeper understanding of how kHF-SCS induces paresthesia-free pain relief. Furthermore, our study highlights the potential for kHF-SCS to modulate sensory information processing within spinal pain circuits. These insights pave the way for future research aimed at optimizing kHF-SCS parameters and refining its therapeutic applications in the clinical management of chronic pain.
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da Cunha PHM, de Andrade DC. The deep and the deeper: Spinal cord and deep brain stimulation for neuropathic pain. Presse Med 2024; 53:104231. [PMID: 38636785 DOI: 10.1016/j.lpm.2024.104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Neuropathic pain occurs in people experiencing lesion or disease affecting the somatosensorial system. It is present in 7 % of the general population and may not fully respond to first- and second-line treatments in up to 40 % of cases. Neuromodulation approaches are often proposed for those not tolerating or not responding to usual pharmacological management. These approaches can be delivered surgically (invasively) or non-invasively. Invasive neuromodulation techniques were the first to be employed in neuropathic pain. Among them is spinal cord stimulation (SCS), which consists of the implantation of epidural electrodes over the spinal cord. It is recommended in some guidelines for peripheral neuropathic pain. While recent studies have called into question its efficacy, others have provided promising data, driven by advances in techniques, battery capabilities, programming algorithms and software developments. Deep brain stimulation (DBS) is another well-stablished neuromodulation therapy routinely used for movement disorders; however, its role in pain management remains limited to specific research centers. This is not only due to variable results in the literature contesting its efficacy, but also because several different brain targets have been explored in small trials, compromising comparisons between these studies. Structures such as the periaqueductal grey, posterior thalamus, anterior cingulate cortex, ventral striatum/anterior limb of the internal capsule and the insula are the main targets described to date in literature. SCS and DBS present diverse rationales for use, mechanistic backgrounds, and varying levels of support from experimental studies. The present review aims to present their methodological details, main mechanisms of action for analgesia and their place in the current body of evidence in the management of patients with neuropathic pain, as well their particularities, effectiveness, safety and limitations.
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Affiliation(s)
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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van de Minkelis J, Peene L, Cohen SP, Staats P, Al-Kaisy A, Van Boxem K, Kallewaard JW, Van Zundert J. 6. Persistent spinal pain syndrome type 2. Pain Pract 2024. [PMID: 38616347 DOI: 10.1111/papr.13379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Persistent Spinal Pain Syndrome (PSPS) refers to chronic axial pain and/or extremity pain. Two subtypes have been defined: PSPS-type 1 is chronic pain without previous spinal surgery and PSPS-type 2 is chronic pain, persisting after spine surgery, and is formerly known as Failed Back Surgery Syndrome (FBSS) or post-laminectomy syndrome. The etiology of PSPS-type 2 can be gleaned using elements from the patient history, physical examination, and additional medical imaging. Origins of persistent pain following spinal surgery may be categorized into an inappropriate procedure (eg a lumbar fusion at an incorrect level or for sacroiliac joint [SIJ] pain); technical failure (eg operation at non-affected levels, retained disk fragment, pseudoarthrosis), biomechanical sequelae of surgery (eg adjacent segment disease or SIJ pain after a fusion to the sacrum, muscle wasting, spinal instability); and complications (eg battered root syndrome, excessive epidural fibrosis, and arachnoiditis), or undetermined. METHODS The literature on the diagnosis and treatment of PSPS-type 2 was retrieved and summarized. RESULTS There is low-quality evidence for the efficacy of conservative treatments including exercise, rehabilitation, manipulation, and behavioral therapy, and very limited evidence for the pharmacological treatment of PSPS-type 2. Interventional treatments such as pulsed radiofrequency (PRF) of the dorsal root ganglia, epidural adhesiolysis, and spinal endoscopy (epiduroscopy) might be beneficial in patients with PSPS-type 2. Spinal cord stimulation (SCS) has been shown to be an effective treatment for chronic, intractable neuropathic limb pain, and possibly well-selected candidates with axial pain. CONCLUSIONS The diagnosis of PSPS-type 2 is based on patient history, clinical examination, and medical imaging. Low-quality evidence exists for conservative interventions. Pulsed radiofrequency, adhesiolysis and SCS have a higher level of evidence with a high safety margin and should be considered as interventional treatment options when conservative treatment fails.
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Affiliation(s)
- Johan van de Minkelis
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Anesthesiology and Pain Medicine, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Laurens Peene
- Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Peter Staats
- Anesthesiology and Pain Medicine, National Spine and Pain Centers, Shrewsbury, New Jersey, USA
| | - Adnan Al-Kaisy
- Pain Management Department, Gassiot House, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Koen Van Boxem
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Jan Willem Kallewaard
- Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Van Zundert
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
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Rigoard P, Billot M, Bougeard R, Llopis JE, Raoul S, Matis G, Vesper J, Belaïd H. Improved Outcomes and Therapy Longevity after Salvage Using a Novel Spinal Cord Stimulation System for Chronic Pain: Multicenter, Observational, European Case Series. J Clin Med 2024; 13:1079. [PMID: 38398392 PMCID: PMC10889739 DOI: 10.3390/jcm13041079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Spinal cord stimulation (SCS) is proven to effectively relieve chronic neuropathic pain. However, some implanted patients may face loss of efficacy (LoE) over time, and conversion to more recent devices may rescue SCS therapy. Recent SCS systems offer novel stimulation capabilities, such as temporal modulation and spatial neural targeting, and can be used to replace previous neurostimulators without changing existing leads. Our multicenter, observational, consecutive case series investigated real-world clinical outcomes in previously implanted SCS patients who were converted to a new implantable pulse generator. Data from 58 patients in seven European centers were analyzed (total follow-up 7.0 years, including 1.4 years after conversion). In the Rescue (LoE) subgroup (n = 51), the responder rate was 58.5% at the last follow-up, and overall pain scores (numerical rating scale) had decreased from 7.3 ± 1.7 with the previous SCS system to 3.5 ± 2.5 (p < 0.0001). Patients who converted for improved battery longevity (n = 7) had their pain scores sustained below 3/10 with their new neurostimulator. Waveform preferences were diverse and patient dependent (34.4% standard rate; 44.8% sub-perception modalities; 20.7% combination therapy). Our results suggest that patients who experience LoE over time may benefit from upgrading to a more versatile SCS system.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab, Poitiers University Hospital, 86021 Poitiers, France;
| | - Maxime Billot
- PRISMATICS Lab, Poitiers University Hospital, 86021 Poitiers, France;
| | | | | | - Sylvie Raoul
- CHU de Nantes-Hopital Laennec, 44800 Saint-Herblain, France;
| | | | - Jan Vesper
- Universitaetsklinikum Dusseldorf, 40225 Dusseldorf, Germany;
| | - Hayat Belaïd
- Fondation Adolphe de Rothschild, 75019 Paris, France;
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Sagalajev B, Zhang T, Abdollahi N, Yousefpour N, Medlock L, Al-Basha D, Ribeiro-da-Silva A, Esteller R, Ratté S, Prescott SA. Absence of paresthesia during high-rate spinal cord stimulation reveals importance of synchrony for sensations evoked by electrical stimulation. Neuron 2024; 112:404-420.e6. [PMID: 37972595 DOI: 10.1016/j.neuron.2023.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/24/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023]
Abstract
Electrically activating mechanoreceptive afferents inhibits pain. However, paresthesia evoked by spinal cord stimulation (SCS) at 40-60 Hz becomes uncomfortable at high pulse amplitudes, limiting SCS "dosage." Kilohertz-frequency SCS produces analgesia without paresthesia and is thought, therefore, not to activate afferent axons. We show that paresthesia is absent not because axons do not spike but because they spike asynchronously. In a pain patient, selectively increasing SCS frequency abolished paresthesia and epidurally recorded evoked compound action potentials (ECAPs). Dependence of ECAP amplitude on SCS frequency was reproduced in pigs, rats, and computer simulations and is explained by overdrive desynchronization: spikes desychronize when axons are stimulated faster than their refractory period. Unlike synchronous spikes, asynchronous spikes fail to produce paresthesia because their transmission to somatosensory cortex is blocked by feedforward inhibition. Our results demonstrate how stimulation frequency impacts synchrony based on axon properties and how synchrony impacts sensation based on circuit properties.
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Affiliation(s)
- Boriss Sagalajev
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Tianhe Zhang
- Boston Scientific Neuromodulation, Valencia, CA 25155, USA
| | - Nooshin Abdollahi
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Noosha Yousefpour
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC H3G 1Y6, Canada
| | - Laura Medlock
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada
| | - Dhekra Al-Basha
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Alfredo Ribeiro-da-Silva
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC H3G 1Y6, Canada; Department of Anatomy and Cell Biology, McGill University, Montreal, QC H3A 0C7, Canada
| | | | - Stéphanie Ratté
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Steven A Prescott
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada; Department of Physiology, University of Toronto, Toronto, ON M5S 1A8, Canada.
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8
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Zhao H, Li Y, Zhang Y, Zhang C. Changes in myelinated nerve fibers induced by pulsed electrical stimulation: A microstructural perspective on the causes of electrical stimulation side effects. Biochem Biophys Res Commun 2024; 691:149331. [PMID: 38039835 DOI: 10.1016/j.bbrc.2023.149331] [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: 10/13/2023] [Revised: 10/17/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
Electrical brain stimulation technology is widely used in the clinic to treat brain neurological disorders. However, during treatment, patients may experience side effects such as pain, poor limb coordination, and skin rash. Previous reports have focused on the brilliant chapter on electrical brain stimulation technology and have not paid attention to patients' suffering caused by side effects during treatment. In this study, electrodes were arranged on the medulla oblongata. Pulsed electric fields of different frequencies were used to perform electrical stimulation to study the impact of electric fields on myelinated nerve fibers and reveal the possible microstructural origin of side effects. Transmission electron microscopy was used to analyze and quantify the changes in microstructure. The results illustrated that myelinated nerve fibers underwent atrophy under pulsed electric fields, with the mildest degree of atrophy under high-frequency (400 Hz) electric fields. Myelin sheaths experienced plate separation under pulsed electric fields, and a distinct laminar structure appeared. The microstructure changes may be related to the side effects of clinical electrical stimulation. This study can provide pathological possibilities for exploring the causes of the side effects of electrical stimulation and supply guidance for selecting electrical parameters for clinical electrical stimulation therapy from a distinctive perspective.
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Affiliation(s)
- Hongwei Zhao
- Key Laboratory of CNC Equipment Reliability, Ministry of Education, Jilin University, Changchun, 130025, PR China; School of Mechanical & Aerospace Engineering, Jilin University, Changchun, 130025, PR China; Institute of Structured and Architected Materials, Liaoning Academy of Materials, Shenyang, 110167, PR China; Chongqing Research Institute of Jilin University, Chongqing, 401120, PR China
| | - Yiqiang Li
- Key Laboratory of CNC Equipment Reliability, Ministry of Education, Jilin University, Changchun, 130025, PR China; School of Mechanical & Aerospace Engineering, Jilin University, Changchun, 130025, PR China; Institute of Structured and Architected Materials, Liaoning Academy of Materials, Shenyang, 110167, PR China; Chongqing Research Institute of Jilin University, Chongqing, 401120, PR China
| | - Yibo Zhang
- Key Laboratory of CNC Equipment Reliability, Ministry of Education, Jilin University, Changchun, 130025, PR China; School of Mechanical & Aerospace Engineering, Jilin University, Changchun, 130025, PR China; Institute of Structured and Architected Materials, Liaoning Academy of Materials, Shenyang, 110167, PR China; Chongqing Research Institute of Jilin University, Chongqing, 401120, PR China
| | - Chi Zhang
- Key Laboratory of CNC Equipment Reliability, Ministry of Education, Jilin University, Changchun, 130025, PR China; School of Mechanical & Aerospace Engineering, Jilin University, Changchun, 130025, PR China; Institute of Structured and Architected Materials, Liaoning Academy of Materials, Shenyang, 110167, PR China; Chongqing Research Institute of Jilin University, Chongqing, 401120, PR China.
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Wahezi SE, Caparo MA, Malhotra R, Sundaram L, Batti K, Ejindu P, Veeramachaneni R, Anitescu M, Hunter CW, Naeimi T, Farah F, Kohan L. Current Waveforms in Spinal Cord Stimulation and Their Impact on the Future of Neuromodulation: A Scoping Review. Neuromodulation 2024; 27:47-58. [PMID: 38184341 DOI: 10.1016/j.neurom.2023.11.002] [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: 09/10/2023] [Revised: 10/16/2023] [Accepted: 11/13/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Neuromodulation is a standard and well-accepted treatment for chronic refractory neuropathic pain. There has been progressive innovation in the field over the last decade, particularly in areas of spinal cord stimulation (SCS) and dorsal root ganglion stimulation. Improved outcomes using proprietary waveforms have become customary in the field, leading to an unprecedented expansion of these products and a plethora of options for the management of pain. Although advances in waveform technology have improved our fundamental understanding of neuromodulation, a scoping review describing new energy platforms and their associated clinical effects and outcomes is needed. The authors submit that understanding electrophysiological neuromodulation may be important for clinical decision-making and programming selection for personalized patient care. OBJECTIVE This review aims to characterize ways differences in mechanism of action and clinical outcomes of current spinal neuromodulation products may affect contemporary clinical decision-making while outlining a possible path for the future SCS. STUDY DESIGN The study is a scoping review of the literature about newer generation SCS waveforms. MATERIALS AND METHODS A literature report was performed on PubMed and chapters to include articles on spine neuromodulation mechanism of action and efficacy. RESULTS A total of 8469 studies were identified, 75 of which were included for the scoping review after keywords defining recent waveform technology were added. CONCLUSIONS Clinical data suggest that neuromodulation remains a promising tool in the treatment of chronic pain. The evidence for SCS for treating chronic pain seems compelling; however, more long-term and comparative data are needed for a comparison of waveforms when it comes to the etiology of pain. In addition, an exploration into combination waveform therapy and waveform cycling may be paramount for future clinical studies and the development of new technologies.
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Affiliation(s)
- Sayed E Wahezi
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA.
| | - Moorice A Caparo
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Ria Malhotra
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Lakshman Sundaram
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Kevin Batti
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Prince Ejindu
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | | | - Magdalena Anitescu
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Corey W Hunter
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Tahereh Naeimi
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Fadi Farah
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Lynn Kohan
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
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10
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Hatheway J, Yang M, Fishman M, Verdolin M, McJunkin T, Rosen S, Slee S, Kibler A, Amirdelfan K. Defining the Boundaries of Patient Perception in Spinal Cord Stimulation Programming. Neuromodulation 2024; 27:108-117. [PMID: 38108675 DOI: 10.1016/j.neurom.2023.08.011] [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: 05/04/2022] [Revised: 08/16/2023] [Accepted: 08/26/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES Recent developments in spinal cord stimulation (SCS) programming have initiated new modalities of imperceptible stimulation. However, the boundaries of sensory perception are not well defined. The BEnchtop NEuromodulation Following endIng of Trial study aimed to create a map of perceptual threshold responses across a broad range of SCS parameters and programming to inform subperception therapy design. MATERIALS AND METHODS This multicenter study was conducted at seven US sites. A total of 43 patients with low back and/or leg pain who completed a percutaneous commercial SCS trial were enrolled. Test stimulation was delivered through trial leads for approximately 90 minutes before removal. SCS parameters, including amplitude, frequency, pulse width (PW), electrode configuration, cycling, and multifrequency stimulation were varied during testing. Paresthesia threshold (PT), comfort level (CL), perceptual coverage area, and paresthesia quality (through patient selection of keywords) were collected. Differences were evaluated with analysis of variance followed by post hoc multiple comparisons using t-tests with Bonferroni correction. RESULTS PT was primarily determined by PW and was insensitive to frequency for constant frequency stimulation (range: 20 Hz-10 kHz; F(1284) = 69.58, p < 0.0001). For all tests, CL was approximately 25% higher than PT. The dominant variable that influenced paresthesia quality was frequency. Sensations described as comfortable and tingling were most common for frequencies between 60 Hz and 2.4 kHz; unpleasant sensations were generally more common outside this range. Increasing distance between active electrodes from 7 mm to 14 mm, or cycling the SCS waveform at 1 Hz, decreased PT (p < 0.0001). Finally, PT for a low-frequency stimulus (ie, 60 Hz) was unaffected by mixing with a sub-PT high-frequency stimulus. CONCLUSIONS In contrast to previous work investigating narrower ranges, PW primarily influenced PT, independently of frequency. Paresthesia quality was primarily influenced by pulse frequency. These findings advance our understanding of SCS therapy and may be used to improve future novel neuromodulation paradigms.
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Affiliation(s)
| | | | - Michael Fishman
- Center for Interventional Pain and Spine, Lancaster, PA, USA
| | | | | | - Steven Rosen
- Delaware Valley Pain and Spine Institute, Trevose, PA, USA
| | - Sean Slee
- BIOTRONIK NRO Inc., Lake Oswego, OR, USA
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11
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Heijmans L, Zhang TC, Esteller R, Joosten EA. Ninety-Hz Spinal Cord Stimulation-Induced Analgesia Is Dependent on Active Charge Balance and Is Nonlinearly Related to Amplitude: A Sham-Controlled Behavioral Study in a Rodent Model of Chronic Neuropathic Pain. Neuromodulation 2024; 27:95-107. [PMID: 37978974 DOI: 10.1016/j.neurom.2023.09.005] [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: 06/06/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Ninety-Hz active-recharge spinal cord stimulation (SCS) applied at below sensory-threshold intensity, as used with fast-acting subperception therapy spinal cord stimulation, has been shown clinically to produce significant analgesia, but additional characterization is required to better understand the therapy. This preclinical study investigates the behavioral effect of multiple 90-Hz SCS variants in a rodent model of neuropathic pain, focusing on charge balance and the relationship between 90-Hz efficacy and stimulation intensity. MATERIALS AND METHODS Rats (n = 24) received a unilateral partial sciatic nerve ligation to induce neuropathic pain and were implanted with a quadripolar lead at T13. Mechanical hypersensitivity was assessed before, during, and after 60 minutes of SCS. After a prescreen with 50-Hz SCS 67% motor threshold ([MT], the positive control), rats underwent a randomized-crossover study including sham SCS and several 90-Hz SCS paradigms (at 40% MT or 60% MT, either using active or pseudopassive recharge) (experiment 1, n = 16). A second, identical experiment (experiment 2) was performed to supplement data with 90-Hz SCS at 20% and 80% MT (experiment 2, n = 8). RESULTS Experiment 1: At 40% MT, 90-Hz active-recharge SCS produced a significantly larger recovery to baseline than did 90-Hz pseudopassive SCS at both tested intensities and sham SCS. Experiment 2: Only the 90-Hz SCS active recharge at 40% MT and 50-Hz SCS positive control caused mean recovery to baseline that was statistically better than that of sham SCS. CONCLUSIONS The degree to which 90-Hz SCS reduced mechanical hypersensitivity during stimulation depended on the nature of charge balance, with 90-Hz active-recharge SCS generating better responses than did 90-Hz pseudopassive recharge SCS. In addition, our findings suggest that the amplitude of 90-Hz active-recharge SCS must be carefully configured for efficacy.
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Affiliation(s)
- Lonne Heijmans
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands.
| | - Tianhe C Zhang
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, CA, USA
| | - Rosana Esteller
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, CA, USA
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
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12
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Rigoard P, Ounajim A, Moens M, Goudman L, Roulaud M, Lorgeoux B, Baron S, Nivole K, Many M, Lampert L, David R, Billot M. Should we Oppose or Combine Waveforms for Spinal Cord Stimulation in PSPS-T2 Patients? A Prospective Randomized Crossover Trial (MULTIWAVE Study). THE JOURNAL OF PAIN 2023; 24:2319-2339. [PMID: 37473903 DOI: 10.1016/j.jpain.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/16/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
Refractory persistent spinal pain syndrome after surgery (PSPS-T2) can be successfully addressed by spinal cord stimulation (SCS). While conventional stimulation generates paresthesia, recent systems enable the delivery of paresthesia-free stimulation. Studies have claimed non-inferiority/superiority of selected paresthesia-free stimulation compared with paresthesia-based stimulation, but the comparative efficacy between different waveforms still needs to be determined in a given patient. We designed a randomized controlled 3-month crossover trial to compare pain relief of paresthesia-based stimulation versus high frequency versus burst in 28 PSPS-T2 patients implanted with multiwave SCS systems. Our secondary objectives were to determine the efficacy of these 3 waveforms on pain surface, quality of life, functional capacity, psychological distress, and validated composite multidimensional clinical response index to provide holistic comparisons at 3-, 6-, 9-, and 15-month post-randomization. The preferred stimulation modality was documented during the follow-up periods. No difference between the waveforms was observed in this study (P = .08). SCS led to significant pain relief, quality of life improvement, improvement of multidimensional clinical response index, and of all other clinical outcomes at all follow-up visits. Forty-four percent of the patients chose to keep the paresthesia-based stimulation modality after the 15-month follow-up period. By giving the possibility to switch and/or to combine several waveforms, the overall rate of SCS responders further increased with 25%. In this study, high frequency or burst do not appear superior to paresthesia-based stimulation, wherefore paresthesia-based stimulation should still be considered as a valid option. However, combining paresthesia-based stimulation with paresthesia-free stimulation, through personalized multiwave therapy, might significantly improve SCS responses. PERSPECTIVE: This article assesses clinical SCS efficacy on pain relief, by comparing paresthesia-based stimulation and paresthesia-free stimulation (including high frequency and burst) modalities in patient presenting with PSPS-T2. Switching and/or combining waveforms contribute to increasing the global SCS responders rate.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, Poitiers, France; Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Bertille Lorgeoux
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Sandrine Baron
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Kévin Nivole
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Mathilde Many
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Lucie Lampert
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, Poitiers, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
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13
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Kapural L, Patterson DG, Li S, Hatheway J, Hunter C, Rosen S, Fishman M, Gupta M, Sayed D, Christopher A, Burgher A, McJunkin T, Ross EL, Provenzano D, Amirdelfan K. Multiphase Spinal Cord Stimulation in Participants With Chronic Back or Leg Pain: Results of the BENEFIT-02 Randomized Clinical Trial. Neuromodulation 2023; 26:1400-1411. [PMID: 37589641 DOI: 10.1016/j.neurom.2023.05.006] [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: 03/16/2023] [Revised: 05/05/2023] [Accepted: 05/24/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE This study aimed to assess the safety and effectiveness of a new charge-distributed multiphase stimulation paradigm during an extended spinal cord stimulation (SCS) trial. MATERIALS AND METHODS This prospective, multicenter, randomized, single-blind, feasibility study included participants with chronic low back and/or leg pain and baseline numerical rating scale (NRS) for overall pain intensity ≥6. After a successful commercial SCS trial, participants were randomized to multiphase SCS therapy A (approximately 600-1500 Hz) or B (approximately 300-600 Hz), delivered via an investigational external pulse generator and existing leads during an 11-to-12-day testing period. Primary end points were mean NRS change from baseline to final in-office visit for each multiphase therapy and between therapies. Secondary end points included mean NRS change from end of commercial trial to final study visit and incidence of device-related adverse events (AEs). Additional measures included patient-reported outcomes collected at home through electronic watches and written diaries. Power usage was compared between multiphase and commercial therapies. RESULTS A total of 122 participants initiated a commercial trial; 77 were randomized to a multiphase arm, and 65 completed the study. Reductions in mean NRS scores from baseline to final study visit were significant for multiphase therapy A and B (-4.3 and -4.7, respectively; both p < 0.0001). There was no statistically significant difference in mean NRS reduction or percent pain relief between multiphase therapies. In an additional analysis, 63.9% of participants reported greater pain relief with multiphase than with commercial SCS therapy in the at-home setting. On average, multiphase required less power than did commercial devices. One non-serious device-related AE was reported, and no infections occurred during the extended trial. CONCLUSIONS Multiphase SCS effectively reduced pain in participants with chronic low back and/or leg pain during a trial, with no unanticipated device-related AEs reported. Future studies should evaluate long-term effectiveness of multiphase stimulation. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT03594266.
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Affiliation(s)
| | | | - Sean Li
- Premier Pain Centers, Shrewsbury, NJ, USA
| | | | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Steven Rosen
- Delaware Valley Pain and Spine Institute, Trevose, PA, USA
| | - Michael Fishman
- Center for Interventional Pain and Spine, Lancaster, PA, USA
| | - Mayank Gupta
- Neuroscience Research Center DBA Kansas Pain Management, Overland Park, KS, USA
| | - Dawood Sayed
- The University of Kansas Health System, Kansas City, KS, USA
| | | | | | | | - Edgar L Ross
- Brigham and Women's Hospital, Chestnut Hill, MA, USA
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14
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Russo MA, Volschenk W, Bailey D, Santarelli DM, Holliday E, Barker D, Dizon J, Graham B. A Novel, Paresthesia-Free Spinal Cord Stimulation Waveform for Chronic Neuropathic Low Back Pain: Six-Month Results of a Prospective, Single-Arm, Dose-Response Study. Neuromodulation 2023; 26:1412-1423. [PMID: 37486284 DOI: 10.1016/j.neurom.2023.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/08/2023] [Accepted: 06/18/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES The aim of this prospective, single-blinded, dose-response study was to evaluate the safety and efficacy of a novel, paresthesia-free (subperception) spinal cord stimulation (SCS) waveform designed to target dorsal horn dendrites for the treatment of chronic neuropathic low back pain (LBP). MATERIALS AND METHODS Twenty-seven participants with chronic neuropathic LBP were implanted with a commercial SCS system after a successful trial of SCS therapy. Devices were programmed to deliver the investigative waveform (100 Hz, 1000 μs, T9/T10 bipole) at descending stimulation perception threshold amplitudes (80%, 60%, 40%). Programs were evaluated at six, ten, and 14 weeks, after which participants selected their preferred program, with more follow-up at 26 weeks (primary outcomes). Participants were blinded to the nature of the programming. Pain score (visual analog scale [VAS]), Brief Pain Inventory (BPI), quality of life (EQ-5D-5L), and health status (36-Item Short Form [SF-36]) were measured at baseline and follow-ups. Responder rate, treatment satisfaction, clinician global impression of change, and adverse events (AEs) also were evaluated. RESULTS Mean (± SD) baseline VAS was 72.5 ± 11.2 mm. At 26 weeks (n = 26), mean change from baseline in VAS was -51.7 mm (95% CI, -60.7 to -42.7; p < 0.001), with 76.9% of participants reporting ≥50% VAS reduction, and 46.2% reporting ≥80% VAS reduction. BPI, EQ-5D-5L, and SF-36 scores were all statistically significantly improved at 26 weeks (p < 0.001), and 100% of participants were satisfied with their treatment. There were no unanticipated AEs related to the study intervention, device, or procedures. CONCLUSIONS This novel, paresthesia-free stimulation waveform may be a safe and effective option for patients with chronic neuropathic LBP eligible for SCS therapy and is deliverable by all current commercial SCS systems. CLINICAL TRIAL REGISTRATION This study is registered on anzctr.org.au with identifier ACTRN12618000647235.
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Affiliation(s)
- Marc A Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia; Genesis Research Services, Broadmeadow, New South Wales, Australia; University of Newcastle, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.
| | - Willem Volschenk
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia; Genesis Research Services, Broadmeadow, New South Wales, Australia
| | - Dominic Bailey
- Genesis Research Services, Broadmeadow, New South Wales, Australia
| | | | - Elizabeth Holliday
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Daniel Barker
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Jason Dizon
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Brett Graham
- University of Newcastle, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia
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15
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Kang W, Lee J, Choi W, Kim J, Kim J, Park SM. Fully Implantable Neurostimulation System for Long-Term Behavioral Animal Study. IEEE Trans Neural Syst Rehabil Eng 2023; 31:3711-3721. [PMID: 37708012 DOI: 10.1109/tnsre.2023.3315371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Spinal cord stimulation (SCS) is an emerging therapeutic option for patients with neuropathic pain due to spinal cord injury (SCI). Numerous studies on pain relief effects with SCS have been conducted and demonstrated promising results while the mechanisms of analgesic effect during SCS remain unclear. However, an experimental system that enables large-scale long-term animal studies is still an unmet need for those mechanistic studies. This study proposed a fully wireless neurostimulation system that can efficiently support a long-term animal study for neuropathic pain relief. The developed system consists of an implantable stimulator, an animal cage with an external charging coil, and a wireless communication interface. The proposed device has the feature of remotely controlling stimulation parameters via radio-frequency (RF) communication and wirelessly charging via magnetic induction in freely moving rats. Users can program stimulation parameters such as pulse width, intensity, and duration through an interface on a computer. The stimulator was packaged with biocompatible epoxy to ensure long-term durability under in vivo conditions. Animal experiments using SCI rats were conducted to demonstrate the functionality of the device, including long-term usability and therapeutic effects. The developed system can be tailored to individual user needs with commercially available components, thus providing a cost-effective solution for large-scale long-term animal studies on neuropathic pain relief.
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16
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Levy RM, Mekhail N, Abd-Elsayed A, Abejón D, Anitescu M, Deer TR, Eldabe S, Goudman L, Kallewaard JW, Moens M, Petersen EA, Pilitsis JG, Pope JE, Poree L, Raslan AM, Russo M, Sayed D, Staats PS, Taylor RS, Thomson S, Verrills P, Duarte RV. Holistic Treatment Response: An International Expert Panel Definition and Criteria for a New Paradigm in the Assessment of Clinical Outcomes of Spinal Cord Stimulation. Neuromodulation 2023; 26:1015-1022. [PMID: 36604242 DOI: 10.1016/j.neurom.2022.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Treatment response to spinal cord stimulation (SCS) is focused on the magnitude of effects on pain intensity. However, chronic pain is a multidimensional condition that may affect individuals in different ways and as such it seems reductionist to evaluate treatment response based solely on a unidimensional measure such as pain intensity. AIM The aim of this article is to add to a framework started by IMMPACT for assessing the wider health impact of treatment with SCS for people with chronic pain, a "holistic treatment response". DISCUSSION Several aspects need consideration in the assessment of a holistic treatment response. SCS device data and how it relates to patient outcomes, is essential to improve the understanding of the different types of SCS, improve patient selection, long-term clinical outcomes, and reproducibility of findings. The outcomes to include in the evaluation of a holistic treatment response need to consider clinical relevance for patients and clinicians. Assessment of the holistic response combines two key concepts of patient assessment: (1) patients level of baseline (pre-treatment) unmet need across a range of health domains; (2) demonstration of patient-relevant improvements in these health domains with treatment. The minimal clinical important difference (MCID) is an established approach to reflect changes after a clinical intervention that are meaningful for the patient and can be used to identify treatment response to each individual domain. A holistic treatment response needs to account for MCIDs in all domains of importance for which the patient presents dysfunctional scores pre-treatment. The number of domains included in a holistic treatment response may vary and should be considered on an individual basis. Physiologic confirmation of therapy delivery and utilisation should be included as part of the evaluation of a holistic treatment response and is essential to advance the field of SCS and increase transparency and reproducibility of the findings.
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Affiliation(s)
- Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
| | - Nagy Mekhail
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Abejón
- Multidisciplinary Pain Management Unit, Hospital Universitario Quirónsalud, Madrid, Spain
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders, Brussels, Belgium
| | - Jan W Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, the Netherlands; Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie G Pilitsis
- Department of Clinical Neurosciences, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Lawrence Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia
| | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Rod S Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK; MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Simon Thomson
- Department of Pain Medicine and Neuromodulation, Mid & South Essex University Hospitals, Essex, UK
| | - Paul Verrills
- Metro Pain Group, Melbourne, New South Wales, Australia
| | - Rui V Duarte
- Saluda Medical Pty Ltd, Artarmon, New South Wales, Australia; Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK.
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Wallace MS, North JM, Phillips GM, Calodney AK, Scowcroft JA, Popat-Lewis BU, Lee JM, Washabaugh EP, Paez J, Bolash RB, Noles J, Atallah J, Shah B, Ahadian FM, Trainor DM, Chen L, Jain R. Combination therapy with simultaneous delivery of spinal cord stimulation modalities: COMBO randomized controlled trial. Pain Manag 2023; 13:171-184. [PMID: 36866658 DOI: 10.2217/pmt-2022-0101] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Aim: The Combining Mechanisms for Better Outcomes randomized controlled trial assessed the effectiveness of various spinal cord stimulation (SCS) modalities for chronic pain. Specifically, combination therapy (simultaneous use of customized sub-perception field and paresthesia-based SCS) versus monotherapy (paresthesia-based SCS) was evaluated. Methods: Participants were prospectively enrolled (key inclusion criterion: chronic pain for ≥6 months). Primary end point was the proportion with ≥50% pain reduction without increased opioids at the 3-month follow-up. Patients were followed for 2 years. Results: The primary end point was met (n = 89; p < 0.0001) in 88% of patients in the combination-therapy arm (n = 36/41) and 71% in the monotherapy arm (n = 34/48). Responder rates at 1 and 2 years (with available SCS modalities) were 84% and 85%, respectively. Sustained functional outcomes improvement was observed out to 2 years. Conclusion: SCS-based combination therapy can improve outcomes in patients with chronic pain. Clinical Trial Registration: NCT03689920 (ClinicalTrials.gov), Combining Mechanisms for Better Outcomes (COMBO).
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Affiliation(s)
- Mark S Wallace
- University of California, San Diego, San Diego, CA, 92093, USA
| | - James M North
- Carolinas Pain Institute & the Center for Clinical Research, Winston-Salem, NC, 27103, USA
| | | | | | | | | | - Jennifer M Lee
- Evergreen Health Medical Group, Kirkland, WA, 98034, USA
| | | | - Julio Paez
- South Lake Pain Institute, Clermont, FL, 34711, USA
| | | | - John Noles
- Spine & Pain Specialists, Shreveport, LA, 71105, USA
| | | | - Binit Shah
- Carolinas Pain Center, Huntersville, NC, 28078, USA
| | | | - Drew M Trainor
- The Denver Spine & Pain Institute, Denver, CO, 80033, USA
| | - Lilly Chen
- Boston Scientific Neuromodulation, Valencia, CA, 91355, USA
| | - Roshini Jain
- Boston Scientific Neuromodulation, Valencia, CA, 91355, USA
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18
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Using evoked compound action potentials to quantify differential neural activation with burst and conventional, 40 Hz spinal cord stimulation in ovines. Pain Rep 2022; 7:e1047. [DOI: 10.1097/pr9.0000000000001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/22/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
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19
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Poply K, Haroon A, Ganeshan B, Nikolic S, Sharma S, Ahmad A, Ellamushi H, Parsai A, Mehta V. Dynamic Brain Imaging Response to Spinal Cord Stimulation Differential Frequencies DiFY SCS-PET clinical trial. Neuromodulation 2022:S1094-7159(22)00773-5. [DOI: 10.1016/j.neurom.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 10/14/2022]
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van Roosendaal BKWP, van Heteren EPZ, van Gorp EJ, Bronkhorst EM, Kallewaard JW, Wegener JT, Burger K, Teernstra OPM, Buschman HPJ, Hamm-Faber T, Vissers KCP. Subcutaneous Stimulation as Add-on Therapy to Spinal Cord Stimulation in Patients With Failed Back Surgery Syndrome Significantly Increases the Total Electrical Charge per Second: Aspects on Stimulation Parameters and Energy Requirements of the Implanted Neurostimulators. Neuromodulation 2022; 26:666-675. [PMID: 35279384 DOI: 10.1016/j.neurom.2021.12.005] [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: 08/26/2021] [Revised: 11/14/2021] [Accepted: 11/29/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE In our previous multicenter randomized controlled trial, we demonstrated the clinical effectiveness of peripheral nerve field stimulation (PNFS) as add-on therapy to spinal cord stimulation (SCS) for the treatment of chronic back pain in patients with persistent spinal pain syndrome (PSPS) or failed back surgery syndrome (FBSS). To our knowledge, no previous study has investigated the effect of PNFS as an add-on to SCS on the energy consumption of the implanted neurostimulators. Therefore, in this study, we compared the specific stimulation parameters and energy requirements of a previously unreported group of patients with only SCS with those of a group of patients with SCS and add-on PNFS. We also investigated differences that might explain the need for PNFS in the treatment of chronic low back pain. MATERIALS AND METHODS We analyzed 75 patients with complete sets of stimulation parameters, with 21 patients in the SCS-only group and 54 patients in the SCS + PNFS group. Outcome measures were average visual analog scale score, SCS parameters (voltage, frequency, and pulse width), SCS charge per second, and total charge per second. We analyzed baseline characteristics and differences between and within groups over time. RESULTS Both groups had comparable patient characteristics at baseline and showed a significant decrease in back and leg pain. SCS charge per second did not significantly differ between the groups at baseline or at 12 months. The total charge per second was significantly higher in the active SCS + PNFS group than in the SCS-only group at baseline; in the SCS + PNFS group, this persisted for up to 12 months, and the SCS charge per second and total charge per second increased significantly over time. CONCLUSIONS Our results show that add-on PNFS increases the total charge per second compared with SCS alone, as expected. However, further research is needed because our results do not directly explain why some patients require add-on PNFS to treat low back pain.
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Affiliation(s)
| | - Esther P Z van Heteren
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric-Jan van Gorp
- Department of Anesthesiology, Unit of Pain Medicine, Albert Schweitzer Hospital, Sliedrecht, The Netherlands
| | - Ewald M Bronkhorst
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jessica T Wegener
- Department of Anesthesiology and Pain Medicine, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Katja Burger
- Department of Anesthesiology, Rijnland Hospital, Leiderdorp, The Netherlands
| | - Onno P M Teernstra
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Tanja Hamm-Faber
- Department of Pain Medicine, Albert Schweitzer Hospital, Zwijndrecht, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Chakravarthy K, Reddy R, Al-Kaisy A, Yearwood T, Grider J. A Call to Action Toward Optimizing the Electrical Dose Received by Neural Targets in Spinal Cord Stimulation Therapy for Neuropathic Pain. J Pain Res 2021; 14:2767-2776. [PMID: 34522135 PMCID: PMC8434932 DOI: 10.2147/jpr.s323372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/16/2021] [Indexed: 12/20/2022] Open
Abstract
Spinal cord stimulation has seen unprecedented growth in new technology in the 50 years since the first subdural implant. As we continue to grow our understanding of spinal cord stimulation and relevant mechanisms of action, novel questions arise as to electrical dosing optimization. Programming adjustment — dose titration — is often a process of trial and error that can be time-consuming and frustrating for both patient and clinician. In this report, we review the current preclinical and clinical knowledge base in order to provide insights that may be helpful in developing more rational approaches to spinal cord stimulation dosing. We also provide key conclusions that may help in directing future research into electrical dosing, given the advent of newer waveforms outside traditional programming parameters.
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Affiliation(s)
- 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
| | - Rajiv Reddy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA
| | - Adnan Al-Kaisy
- Pain Management and Neuromodulation Centre at Guy's and St. Thomas' NHS Trust, London, UK
| | - Thomas Yearwood
- Pain Management and Neuromodulation Centre at Guy's and St. Thomas' NHS Trust, London, UK
| | - Jay Grider
- Division of Pain Medicine, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, 40536, USA
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22
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Real-World Outcomes Using a Spinal Cord Stimulation Device Capable of Combination Therapy for Chronic Pain: A European, Multicenter Experience. J Clin Med 2021; 10:jcm10184085. [PMID: 34575196 PMCID: PMC8466217 DOI: 10.3390/jcm10184085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 12/17/2022] Open
Abstract
Given the differing mechanisms thought to underlie therapeutic sub- and supra-perception-based neurostimulative modalities, Spinal Cord Stimulation (SCS) systems designed for combined delivery of these approaches may help improve analgesic outcomes and quality of life, and reduce treatment failures. This multicenter, observational case-series evaluated 188 patients with chronic back and/or leg pain implanted with an SCS device capable of sequential or simultaneous delivery of sub-perception and supra-perception stimulation programming (i.e., combination therapy) at 16 in Europe. Following implantation, patients were provided with an array of advanced supra-perception programs (e.g., paresthesia-based SCS using multiple independent current sources), and a custom set of sub-perception programs optimized with specific waveforms and/or field shapes. A mean overall pain score of 7.9 ± 1.7 (Standard Deviation (SD)) was reported pre-trial (Baseline). Overall pain was reduced by 4.4 ± 2.8 points (NRS) at 3-months (n = 117) and at 12 months post-implant (n = 90), respectively (p < 0.0001). Substantial quality-of-life (EQ-5D-5L) improvement as assessed at last follow-up was also observed (n = 60). These results suggest that an implanted SCS device capable of combination therapy, while also enabled with patient-specific waveform optimization and stimulation field targeting capabilities, can enable highly effective pain relief and improve quality of life in patients suffering with chronic pain.
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