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Bellomo TR, Hsu C, Bolla P, Mohapatra A, Kotler DH. Concurrent Chronic Exertional Compartment Syndrome and Popliteal Artery Entrapment Syndrome. Diagnostics (Basel) 2024; 14:1825. [PMID: 39202313 PMCID: PMC11353322 DOI: 10.3390/diagnostics14161825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 08/19/2024] [Accepted: 08/19/2024] [Indexed: 09/03/2024] Open
Abstract
Exertional leg pain occurs with notable frequency among athletes and poses diagnostic challenges to clinicians due to overlapping symptomatology. In this case report, we delineate the clinical presentation of a young collegiate soccer player who endured two years of progressive bilateral exertional calf pain and ankle weakness during athletic activity. The initial assessment yielded a diagnosis of chronic exertional compartment syndrome (CECS), predicated on the results of compartment testing. However, her clinical presentation was suspicious for concurrent type VI popliteal artery entrapment syndrome (PAES), prompting further radiographic testing of magnetic resonance angiography (MRA). MRA revealed severe arterial spasm with plantarflexion bilaterally, corroborating the additional diagnosis of PEAS. Given the worsening symptoms, the patient underwent open popliteal entrapment release of the right leg. Although CECS and PAES are both known phenomena that are observed in collegiate athletes, their co-occurrence is uncommon owing to their different pathophysiological underpinnings. This case underscores the importance for clinicians to be aware that the successful diagnosis of one condition does not exclude the possibility of a secondary, unrelated pathology. This case also highlights the importance of dynamic imaging modalities, including point-of-care ultrasound, dynamic MRA, and dynamic angiogram.
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Affiliation(s)
- Tiffany R. Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (P.B.); (A.M.)
| | - Connie Hsu
- Division of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (C.H.); (D.H.K.)
| | - Pavan Bolla
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (P.B.); (A.M.)
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (P.B.); (A.M.)
| | - Dana Helice Kotler
- Division of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (C.H.); (D.H.K.)
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Khabbass M, Saleki M, Bretherton B, Baranidharan G. Improvement in Health-Related Quality of Life With Spinal Cord Stimulation in Complex Regional Pain Syndrome: A Single-Center, Retrospective Study. Neuromodulation 2024; 27:1035-1044. [PMID: 38829296 DOI: 10.1016/j.neurom.2024.04.008] [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: 10/31/2023] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) can profoundly affect many aspects of everyday life. Spinal cord stimulation (SCS) is a potential therapeutic option. This retrospective, single-site evaluation explored health-related quality of life (HRQoL) in individuals with CRPS treated with SCS in our Pain Service. MATERIALS AND METHODS All patients aged ≥18 years with fully implanted SCS for CRPS between June 2013 and January 2023 were identified from hospital records. The following data were collected: sex, age, chronic pain diagnosis, CRPS type (I or II), location of CRPS (upper or lower limb), years of CRPS before first SCS implant, SCS system, preimplant and follow-up scores for HRQoL (euroqol 5 dimensions 3 levels [EQ-5D-3L] index score), average pain, worst pain and the influence of pain on aspects of everyday life (all numerical rating scale [NRS]), patient and clinician global impression of change at follow-up, and the occurrence and reasons for revisions and explants. An intention-to-treat approach was used and data statistically analyzed. RESULTS The final cohort comprised 83 patients (46 women), with a median (minimum, maximum) follow-up duration of 29 months (seven, 72). There were statistically and clinically significant improvements in HRQoL, despite relatively low pain response rates. The pain response rate was 34% (reduction of ≥30% in average pain NRS); the pain remission rate was 13% (average pain score ≤3 NRS), and all patients had preimplant EQ-5D-3L index values below the population norm of 0.82. However, 60% of patients reported EQ-5D-3L index scores greater than the published minimally important difference of 0.074, and scores were better at follow-up than at preimplant (p < 0.001); 44% of patients and 41% of clinicians reported improved symptoms at the most recent follow-up. Explants occurred in eight of 83 patients (10%). CONCLUSIONS Patients had meaningful improvements in HRQoL, which is a key outcome in ascertaining the overall outcome of SCS in CRPS. Randomized controlled clinical trials should build on the findings to improve understanding of the benefits and risks of treating CRPS with SCS.
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Affiliation(s)
- Mazen Khabbass
- Pain Management Department, Leeds Teaching Hospitals National Health Service Trust, Leeds, UK
| | - Mohammad Saleki
- Pain Management Department, Leeds Teaching Hospitals National Health Service Trust, Leeds, UK
| | - Beatrice Bretherton
- Pain Management Department, Leeds Teaching Hospitals National Health Service Trust, Leeds, UK; School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Ganesan Baranidharan
- Pain Management Department, Leeds Teaching Hospitals National Health Service Trust, Leeds, UK; School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.
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Limerick G, Christo DK, Tram J, Moheimani R, Manor J, Chakravarthy K, Karri J, Christo PJ. Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. Curr Pain Headache Rep 2023; 27:269-298. [PMID: 37421541 DOI: 10.1007/s11916-023-01130-5] [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] [Accepted: 05/29/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies. RECENT FINDINGS CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.
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Affiliation(s)
- Gerard Limerick
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Dana K Christo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jennifer Tram
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - John Manor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Jay Karri
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
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Provenzano DA, Park N, Edgar D, Bovinet C, Tate J. High-frequency (10 kHz) spinal cord stimulation (SCS) as a salvage therapy for failed traditional SCS: A narrative review of the available evidence. Pain Pract 2023; 23:301-312. [PMID: 36409060 DOI: 10.1111/papr.13184] [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: 12/15/2021] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Traditional spinal cord stimulation (t-SCS) has been used to treat chronic pain for over 50 years. However, up to 30% of patients undergo explant, with the main indication being loss of efficacy (LoE), and few alternative treatment options exist for these patients. Strategies to mitigate LoE commonly include conversion to another type of SCS (termed 'salvage' or 'rescue'). This review summarizes the existing literature concerning the efficacy and safety of 10 kHz SCS as a salvage therapy. METHODS We searched PubMed, the Cochrane Library, ClinicalTrials.gov, and other sources between January 2009 and April 2021. Records were retained if the authors reported clinical outcomes with a minimum of ≥ 3 months of follow-up in patients implanted with a Senza® 10 kHz SCS system in an effort to treat t-SCS LoE. RESULTS Ten articles were eligible for inclusion, reporting 3 prospective studies and 7 retrospective reviews. In the single study that salvaged patients without a repeat trial prior to surgery, 81% of patients were responders (≥ 50% pain relief from baseline), with mean pain relief of 60%. Among repeat-trial studies, the responder rate ranged from 46% to 80%, and mean pain relief from 47% to 68%. No unanticipated therapy-related safety issues were reported among the included articles. CONCLUSION Preliminary data suggest that chronic back and/or leg pain patients with t-SCS LoE can experience improved and durable pain relief after conversion to 10 kHz SCS. However, additional research is needed to define predictors of success and establish whether salvage without a repeat trial is a viable conversion method.
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Affiliation(s)
| | | | | | - Chris Bovinet
- The Spine Center of SE Georgia, Brunswick, Georgia, USA
| | - Jordan Tate
- Southern Pain and Spine, Jasper, Georgia, USA
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Black S, Bretherton B, Baranidharan G, Murray A, Crowther T, Deuchars S, Deuchars J. A Feasibility Study Exploring Measures of Autonomic Function in Patients With Failed Back Surgery Syndrome Undergoing Spinal Cord Stimulation. Neuromodulation 2023; 26:192-205. [PMID: 35088730 DOI: 10.1016/j.neurom.2021.10.016] [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: 05/27/2021] [Revised: 08/20/2021] [Accepted: 09/07/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Failed back surgery syndrome (FBSS) is associated with impaired autonomic tone, characterized by sympathetic prevalence and vagal withdrawal. Although spinal cord stimulation (SCS) alleviates pain in FBSS, there is limited research investigating how SCS affects measures of autonomic function. This was a prospective, open-label, feasibility study exploring measures of autonomic function in patients with FBSS receiving SCS therapy. MATERIALS AND METHODS A total of 14 patients with FBSS were recruited for baseline measurements and underwent a trial of 10-kHz SCS. There were three failed trials, resulting in the remaining 11 participants receiving a fully implanted 10-kHz SCS system. One participant requested an explant, resulting in ten participants completing both baseline and follow-up (three to six months after SCS implant) measurements. Autonomic function was assessed using time- and frequency-domain heart rate variability (HRV), baroreceptor reflex sensitivity (BRS), and muscle sympathetic nerve activity (MSNA) using microneurography. Because this was a feasibility study, most of the analysis was descriptive. However, paired t-tests and Wilcoxon signed-rank tests tested for differences between baseline and follow-up. RESULTS In the whole (N = 14) and final (N = 10) samples, there was between-participant variation in baseline and follow-up measures. This, combined with a small sample, likely contributed to finding no statistically significant differences in any of the measures between baseline and follow-up. However, plotting baseline and follow-up scores for individual participants revealed that those who showed increases in MSNA frequency, square root of the mean of the squared differences between adjacent RR intervals (RMSSD), percentage of the number of RR intervals >50 ms (pRR50), total power, and up BRS between baseline and follow-up had distinct clustering of baseline values compared with those who showed decreases in these measures. CONCLUSIONS Findings from this feasibility study will aid with informing hypotheses for future research. A key aspect that should be considered in future research concerns exploring the role of baseline measures of autonomic function in influencing change in autonomic function with SCS therapy.
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Affiliation(s)
- Sheila Black
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK.
| | - Beatrice Bretherton
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Ganesan Baranidharan
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK; School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Aaron Murray
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Tracey Crowther
- Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Deuchars
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Jim Deuchars
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
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Oliveira MDJ, Matis GK. Spinal cord stimulation as a treatment option for complex regional pain syndrome: a narrative review. Br J Neurosurg 2022:1-5. [PMID: 36548907 DOI: 10.1080/02688697.2022.2159930] [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: 08/19/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
Objectives: This review aims to analyze the last years' experience of applying spinal cord stimulation (SCS) in complex regional pain syndrome (CRPS) patients with persistent or refractory chronic pain. Methods: This is a narrative review which was executed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and was carried out through the following databases: PUBMED and Cochrane Library. Also, a search for trials in the metaRegister of controlled trials (www.clinicaltrials.gov) was performed. Results: SCS provides pain reduction and improves sensory, vasomotor and sudomotor symptoms. It can reduce opioid using, offering better life quality for the patients. Conclusions: SCS found to be an excellent therapeutic alternative for patients with CRPS. It offers immediate pain relief and allows patients to regain functionality and have a better quality of life.
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Affiliation(s)
| | - Georgios K Matis
- Department of Stereotactic and Functional Neurosurgery, University Cologne Hospital, Cologne, Germany
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Kapural L, Calodney A. Retrospective Efficacy and Cost-Containment Assessment of 10 kHz Spinal Cord Stimulation (SCS) in Non-Surgical Refractory Back Pain Patients. J Pain Res 2022; 15:3589-3595. [PMID: 36415659 PMCID: PMC9676005 DOI: 10.2147/jpr.s373873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background Non-surgical refractory back pain (NSRBP) is persistent, severe back pain that is not considered surgically correctable. Published studies have demonstrated clinically important long-term improvement in pain and functional capacity when 10kHz spinal cord stimulation (SCS) is used to treat NSRBP. This study examines if real-world patients in interventional pain practice obtain the same outcomes, and have any reduction in health care utilization (HCU) following 10kHz SCS implant. Methods We conducted a retrospective chart review of 105 patients from two clinical sites who underwent implantation of 10kHz SCS for NSRBP. The three most frequent diagnoses were lumbosacral radiculopathy, degenerative disc disease (DDD)/discogenic back pain and foraminal stenosis. The complete set of patient-level electronic data, including clinical outcomes, HCU, and at least 12 months (12M) follow-up were available in 90 subjects. Results The 90 analyzed patients were 63.9 years old (median 67) with an average of 10.2 years since back pain diagnosis. Reported pain on the Visual Analog Scale (VAS) decreased from 7.78±1.3 cm to 3.4±2.4 cm at 12M after SCS implant (p<0.001). Opioid usage (n = 65) decreased from 57.9±89.9 mg to 34.3±66.4 mg MSO4 equivalents (p = 0.004) at 12M. There were 46 patients on various doses of anticonvulsants, mostly gabapentin. The average dose decreased from 1847.91±973.6 mg at baseline to 1297.9±1184.6 mg at 12M after implant (p = 0.016). HCU was analyzed comparing the 12M before to the 12M after implant. Number of office visits decreased from 10.83±8.0 per year to 8.86±7.64 (p = 0.036), number of procedures to control chronic pain decreased from 2.2±1.9 to 0.6±1.2 (p<0.001). There was no significant change in number of imaging procedures, hospital admissions, or days spent in the hospital. Conclusion 10kHz SCS warrants consideration as a therapeutic option for NSRBP patients and appears to provide a substantial reduction in HCU in the year following implant.
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Affiliation(s)
- Leonardo Kapural
- Carolinas Pain Institute, Winston-Salem, NC, USA
- Correspondence: Leonardo Kapural, Email
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Sweeney J, Sheldon BL, Juneja A, Hadanny A, Foley J, Pilitsis JG, Sukul V. Efficacy of 10 kHz spinal cord stimulation in complex regional pain syndrome: A retrospective analysis. Clin Neurol Neurosurg 2022; 216:107220. [PMID: 35366453 DOI: 10.1016/j.clineuro.2022.107220] [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: 09/22/2021] [Revised: 02/09/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION We examine the clinical efficacy of High Frequency 10 kHz (HF10) spinal cord stimulation (SCS) CRPS patients. MATERIALS AND METHODS This is a retrospective cohort study of SCS-naïve patients with CRPS treated with HF10-SCS after a successful trial. Patients were evaluated at 2 weeks, 6 weeks, 3 months, and 6 months post-operatively. Outcomes included mean numeric pain rating scale (NRS), mean NRS reduction, NRS percentage improvement (PI), patient reported subjective pain PI (Pain PI), and patients reporting > 50% benefit in symptoms. Pre and post-operative NRS were compared by ordinal regression analysis accounting for the patient's response to the SCS trial. RESULTS 20 patients met inclusion criteria. 75% were female. Mean age 51 years. Baseline mean NRS was 6.1 for the cohort (1.7). Post-operatively, mean NRS decreased to 4.5 at 2 weeks (p = 0.077), 3.8 at 6 weeks (p = 0.034), 3.7 at 3 months (p = 0.307), and 4.4 at 6 months (p = 0.832). Mean NRS reduction and NRS PI is reported within. Pain PI was 25% at 2 weeks, 55% at 6 weeks, 54% at 3 months, and 53% at 6 months. Greater than 50% reduction in symptoms was reported in 25% of patients at 2 weeks, 85% at 6 weeks, 87% at 3 months, and 64% at 6 months. CONCLUSIONS HF10 SCS may represent an effective treatment option for reducing objective and subjective symptoms in CRPS that warrants further study.
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Affiliation(s)
- Jared Sweeney
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States.
| | - Breanna L Sheldon
- Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Ankit Juneja
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States
| | - Amir Hadanny
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States
| | - Jeffery Foley
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States; Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Vishad Sukul
- Department of Neurosurgery, Albany Medical College, Albany, NY, United States; Department of Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, United States
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Pain Relief and Safety Outcomes with Cervical 10 kHz Spinal Cord Stimulation: Systematic Literature Review and Meta-analysis. Pain Ther 2021; 10:849-874. [PMID: 34031856 PMCID: PMC8586436 DOI: 10.1007/s40122-021-00269-6] [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: 03/17/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic pain in head, neck, shoulders and upper limbs is debilitating, and patients usually rely on pain medications or surgery to manage their symptoms. However, given the current opioid epidemic, non-pharmacological interventions that reduce pain, such as spinal cord stimulation (SCS), are needed. The purpose of this study was to review the evidence on paresthesia-free 10 kHz SCS therapy for neck and upper extremity pain. METHODS Systematic literature search was performed for studies reporting outcomes for cervical 10 kHz SCS using date limits from May 2008 to November 2020. The study results were analyzed and described qualitatively. Additionally, when feasible, meta-analyses of the outcome data, with 95% confidence intervals (CIs), were conducted using both the fixed-effects (FE) and random-effects (RE) models. RESULTS A total of 15 studies were eligible for inclusion. The proportion of patients who achieved ≥ 50% pain reduction was 83% (95% CI 77-89%) in both the FE and RE models. The proportion of patients who reduced/eliminated their opioid consumption was 39% (95% CI 31-46%) in the FE model and 39% (95% CI 31-48%) in the RE model. Pain or discomfort with the implant, lead migration, and infections were potential risks following cervical SCS. Explant rate was 0.1 (95% CI 0.0-0.2) events per 100 person-months, and no patients in the included studies experienced a neurological complication or paresthesia. CONCLUSION Findings suggest 10 kHz SCS is a promising, safe, minimally invasive alternative for managing chronic upper limb and neck pain.
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Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther 2021; 10:875-892. [PMID: 34165690 PMCID: PMC8586273 DOI: 10.1007/s40122-021-00279-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition often involving hyperalgesia and allodynia of the extremities. CRPS is divided into CRPS-I and CRPS-II. Type I occurs when there is no confirmed nerve injury. Type II is when there is known associated nerve injury. Female gender is a risk factor for developing CRPS. Other risk factors include fibromyalgia and rheumatoid arthritis. Unfortunately, the pathogenesis of CRPS is not yet clarified. Some studies have demonstrated different potential pathways. Neuropathic inflammation, specifically activation of peripheral nociceptors of C-fibers, has been shown to play a critical role in developing CRPS. The autonomic nervous system (ANS) is involved. Depending on whether it is acute or chronic CRPS, norepinephrine levels are either decreased or increased, respectively. Some studies have suggested the importance of genetics in developing CRPS. More consideration is being given to the role of psychological factors. Some association between a history of depression and/or post-traumatic stress disorder (PTSD) and the diagnosis of CRPS has been demonstrated. Treatment modalities available range from physical therapy, pharmacotherapy, and interventional techniques. Physical and occupational therapies include mirror therapy and graded motor imagery. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) has not shown significant improvement. There have been supporting findings in the use of short-course steroids, bisphosphonates, gabapentin, and ketamine. Antioxidant treatment has also shown some promise. Other pharmacotherapies include low-dose naltrexone and Botulinum toxin A (BTX-A). Sympathetic blocks are routinely used, even if their short- and long-term effects are not clear. Finally, spinal cord stimulation (SCS) has been used for decades. In conclusion, CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. Future studies are warranted to better understand this syndrome. This will provide an opportunity for better prevention, diagnosis, and treatment of CRPS.
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Affiliation(s)
- Samantha-Su Taylor
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33130, USA.
| | - Ivan Urits
- grid.492905.3Southcoast Physician Group Pain Medicine, Southcoast Health, North Dartmouth, MA USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA
| | - Antonella Paladini
- grid.158820.60000 0004 1757 2611Department of MESVA, University of L’Aquila, 67100 L’Aquila, Italy
| | - Monica Sri Sadhu
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Clay Gibb
- grid.260024.2Midwestern University Chicago College of Osteopathic Medicine, Chicago, IL USA
| | - Tyler Carlson
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Dariusz Myrcik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Medical University of Silesia, 42-600 Katowice, Bytom Poland
| | | | - Omar Viswanath
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA ,Valley Pain Consultants-Envision Physician Services, Phoenix, AZ USA ,grid.254748.80000 0004 1936 8876Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE USA
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11
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Abraham ME, Gold J, Dondapati A, Sheaffer K, Gendreau JL, Mammis A. High Frequency 10 kHz Spinal Cord Stimulation as a First Line Programming Option for Patients With Chronic Pain: A Retrospective Study and Review of the Current Evidence. Cureus 2021; 13:e17220. [PMID: 34540447 PMCID: PMC8442632 DOI: 10.7759/cureus.17220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Neuromodulation is an evolving and increasingly popular therapy for chronic pain management. Recent data suggest that novel waveforms have demonstrated greater benefit over traditional spinal cord stimulation (SCS). The authors conducted a retrospective review of patients undergoing high-frequency 10 kHz SCS at a single tertiary medical center for the purpose of contributing further evidence to this growing body of data. The literature of high-frequency SCS published to date was also reviewed. Methods A retrospective chart review was performed for patients with chronic pain syndrome, including failed back surgery syndrome and sciatica alone, who underwent high-frequency SCS at 10 kHz. This data was analyzed using R software (R Foundation for Statistical Computing, Vienna, Austria) for statistical analysis. The PubMed database was searched for relevant articles using the search terms "high frequency," "10 kHz," and "spinal cord stimulation." All relevant studies conducted to date were included in this literature review. Results Twenty-one patients had complete follow-up data and were included in this study. Of the 21 patients, 85.7% subjectively reported post-operative pain relief while 71.4% of the total patients reported pain relief by ≥ 50%. There was a statistically significant decrease in mean VAS scores from pre-operative to 12-months post-operative (8.52 vs 4.37, p < 0.001). Additionally, 76.5% of patients subjectively reported improvements in sleep and activities of daily living. Recent studies indicate that high-frequency SCS appears to be a viable option for delivering quality pain relief in patients for chronic regional pain syndrome, failed back surgery syndrome, sciatica, and also pain in the upper cervical region of the spine. Conclusion This article provides evidence both with the authors' own institutional data and from the currently published literature for the efficacy of using high-frequency SCS at 10 kHz as a first-line programming option for patients undergoing SCS.
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Affiliation(s)
| | - Justin Gold
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, USA
| | - Akhil Dondapati
- Department of Neurosurgery, Rutger New Jersey Medical School, Newark, USA
| | - Kristin Sheaffer
- Orthopedic Surgery, Mercer University School of Medicine, Savannah, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, USA
| | - Antonios Mammis
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, USA
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12
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Staats P, Deer T, Ottestad E, Erdek M, Spinner D, Gulati A. Understanding the role of patient preference in the treatment algorithm for chronic low back pain: results from a survey-based study. Pain Manag 2021; 12:371-382. [PMID: 34470473 DOI: 10.2217/pmt-2021-0011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aims: Interventional pain treatments range from injections to established radiofrequency ablation techniques and finally neuromodulation. In addition to safety, efficacy and cost dominance, patient preference for type of treatment is important. Methods: Chronic pain patients (n = 129) completed a preference scale to determine which interventional pain management procedures they would prefer from among radiofrequency ablation, temporary (60-day) peripheral nerve stimulation (PNS), conventional PNS and spinal cord stimulation/dorsal root ganglion stimulation. A second survey (n = 347) specific to assessing the preference for radiofrequency ablation or temporary PNS treatment was completed by patients with low back pain. Results: On the basis of mean rank, temporary PNS percutaneously implanted for up to 60 days was the most preferred treatment compared with the other options presented (p = 0.002). Conclusions: Patient preference should be unbiased and considered as an independent variable for physician discussion in treatment options and future research.
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Affiliation(s)
| | - Timothy Deer
- West Virginia School of Medicine, Morgantown, WV 26506, USA
| | - Einar Ottestad
- Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Michael Erdek
- Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - David Spinner
- Mount Sinai School of Medicine, New York, NY 10029, USA
| | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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13
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Echeverria-Villalobos M, Mitchell J, Fiorda-Diaz J, Weaver T. Effects of Dorsal Column Spinal Cord Stimulation on Neuroinflammation: Revisiting Molecular Mechanisms and Clinical Outcomes on Chronic Lumbar/Leg Pain and Failed Back Surgery Syndrome. J Pain Res 2021; 14:2337-2345. [PMID: 34354373 PMCID: PMC8331196 DOI: 10.2147/jpr.s309872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/26/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE In this narrative review, we reviewed and discussed current literature describing the molecular mechanisms leading to neuroinflammation and its role in the onset and progression of chronic neuropathic lumbar and leg pain in patients with persistent spinal pain syndrome. In addition, we reviewed the proposed mechanisms and impact of spinal cord stimulation (SCS) on neuroinflammation. METHODS A broad search of current literature in PubMed, Embase, Scopus, Cochrane library, Medline/Ovid, and Web of Science was performed using the following terms and their combinations: "biomarkers", "chronic back and leg pain", "cytokines", "neuroinflammation", "spinal cord stimulation (scs)," and "spinal cord modulation". We selected: 1) articles published in the English language between January 2000 and July 2020 2) preclinical and clinical data 3) case reports 4) meta-analysis and systematic reviews and 5) conference abstracts. Manuscripts not disclosing methodology or without full-text availability were excluded. DISCUSSION SCS techniques have gradually evolved since inception to include novel methods such as burst-SCS, high frequency SCS, and differential targeted multiplexed SCS. The incidence of chronic pain after spine surgery is highly variable, with at least one third of patients developing persistent spinal pain syndrome. Novel SCS techniques have been associated with improved clinical and functional outcomes thus increasing patient quality of life. CONCLUSION Currently, health care providers rely on different options and methods for SCS when treating patients with refractory chronic lumbar pain and persistent spinal pain syndrome. Nevertheless, compelling clinical trials remain necessary to elucidate the long-term benefits and mechanisms of neuromodulation of all different types of SCS.
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Affiliation(s)
| | - Justin Mitchell
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Tristan Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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14
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Galan V, Scowcroft J, Chang P, Li S, Staats P, Subbaroyan J, Caraway D. Ten kHz spinal cord stimulation for the treatment of chronic peripheral polyneuropathy: 12-Month results from prospective open-label pilot study. Pain Pract 2021; 21:898-906. [PMID: 34251751 DOI: 10.1111/papr.13059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/24/2021] [Accepted: 07/07/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The goal of this study was to demonstrate that the paresthesia-independent 10 kHz spinal cord stimulation (SCS) can provide long-term pain relief in patients with peripheral polyneuropathy (PPN). Clinically diagnosed subjects with PPN refractory to conventional medical management were enrolled in this prospective, multicenter study between November 2015 and August 2016, after institutional review board approval and patient informed consent were obtained. METHODS Subjects underwent trial stimulation utilizing 2 epidural leads, and if successful, were implanted with a permanent 10 kHz SCS system and followed up for 12 months post-implant. Outcome measures included adverse events, pain, neurological assessments, disability, function, quality of life, pain interference, sleep, satisfaction, and global impression of change. Data are presented as descriptive statistics. Permanent implant population results are reported as mean ± standard error. RESULTS Twenty-one of the 26 trialed subjects had a successful trial and 18 received a permanent implant. All subjects had the leads placed anatomically without the need for paresthesia. Subjects experienced significant and sustained pain relief (at least 65% at all timepoints) whereas physicians noted improvements in neurological function. Significant improvements in disability, function, sleep, sensory, and affective dimensions of pain were reported at all timepoints. All adverse events were resolved without sequelae. CONCLUSION Findings from this study suggest that 10 kHz SCS may provide sustained pain relief and disability improvements in patients suffering from PPN.
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Affiliation(s)
| | | | - Paul Chang
- Georgia Pain Care, Stockbridge, Georgia, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey, USA
| | - Peter Staats
- Premier Pain Centers, Shrewsbury, New Jersey, USA
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15
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Tieppo Francio V, Polston KF, Murphy MT, Hagedorn JM, Sayed D. Management of Chronic and Neuropathic Pain with 10 kHz Spinal Cord Stimulation Technology: Summary of Findings from Preclinical and Clinical Studies. Biomedicines 2021; 9:biomedicines9060644. [PMID: 34200097 PMCID: PMC8229652 DOI: 10.3390/biomedicines9060644] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/12/2021] [Accepted: 06/01/2021] [Indexed: 12/12/2022] Open
Abstract
Since the inception of spinal cord stimulation (SCS) in 1967, the technology has evolved dramatically with important advancements in waveforms and frequencies. One such advancement is Nevro’s Senza® SCS System for HF10, which received Food and Drug and Administration (FDA) approval in 2015. Low-frequency SCS works by activating large-diameter Aβ fibers in the lateral discriminatory pathway (pain location, intensity, quality) at the dorsal column (DC), creating paresthesia-based stimulation at lower-frequencies (30–120 Hz), high-amplitude (3.5–8.5 mA), and longer-duration/pulse-width (100–500 μs). In contrast, high-frequency 10 kHz SCS works with a proposed different mechanism of action that is paresthesia-free with programming at a frequency of 10,000 Hz, low amplitude (1–5 mA), and short-duration/pulse-width (30 μS). This stimulation pattern selectively activates inhibitory interneurons in the dorsal horn (DH) at low stimulation intensities, which do not activate the dorsal column fibers. This ostensibly leads to suppression of hyperexcitable wide dynamic range neurons (WDR), which are sensitized and hyperactive in chronic pain states. It has also been reported to act on the medial pathway (drives attention and pain perception), in addition to the lateral pathways. Other theories include a reversible depolarization blockade, desynchronization of neural signals, membrane integration, glial–neuronal interaction, and induced temporal summation. The body of clinical evidence regarding 10 kHz SCS treatment for chronic back pain and neuropathic pain continues to grow. There is high-quality evidence supporting its use in patients with persistent back and radicular pain, particularly after spinal surgery. High-frequency 10 kHz SCS studies have demonstrated robust statistically and clinically significant superiority in pain control, compared to paresthesia-based SCS, supported by level I clinical evidence. Yet, as the field continues to grow with the technological advancements of multiple waveforms and programming stimulation algorithms, we encourage further research to focus on the ability to modulate pain with precision and efficacy, as the field of neuromodulation continues to adapt to the modern healthcare era.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Keith F Polston
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Micheal T Murphy
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center, Kansas City, KS 66160, USA
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Cordero Tous N, Sánchez Corral C, Ortiz García IM, Jover Vidal A, Gálvez Mateos R, Olivares Granados G. High-frequency spinal cord stimulation as rescue therapy for chronic pain patients with failure of conventional spinal cord stimulation. Eur J Pain 2021; 25:1603-1611. [PMID: 33829605 DOI: 10.1002/ejp.1776] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 04/06/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND This study aims to evaluate the efficacy of 10-kHz high-frequency (HF10) devices as a rescue treatment in patients with failure of conventional spinal cord stimulation (SCS) therapy for chronic pain without the need to change the spinal hardware. METHODS In this real-world prospective study, patients with neuropathic pain treated with conventional tonic SCS in whom the therapy had failed, either during the trial phase or after a period of optimal functioning, were recruited throughout 2 years for HF10-SCS therapy. Data on analgesia, functionality, analgesics use and treatment safety were collected 12 months after treatment. RESULTS Eleven of the 18 (61%) patients included in the study were successfully rescued with HF10-SCS. Of them, 5 out of 12 (45%) were in the trial phase and six out of six (100%) had previously functioning implants. A significant improvement in low-back and limb pain was obtained (p = 0.003 and p = 0.0001, respectively). Treatment success was significantly associated with gender (p = 0.037), weight (p = 0.014), body mass index (BMI) (p = 0.007) and time of rescue (p = 0.015). A linear regression test confirmed a significant association between treatment failure and BMI and gender (p = 0.004). CONCLUSIONS Our results suggest that analgesic rescue with HF10-SCS is an effective therapeutic option for non-responders to conventional SCS, although obesity might be a limiting factor for treatment success. Nevertheless, more comprehensive studies are needed to corroborate our findings. SIGNIFICANCE This study shows that high-frequency stimulation may be useful in patients with failure of conventional tonic stimulation for chronic pain, both in the trial phase and in previously implanted subjects. The novelty of this study lies in the use of the implanted epidural electrodes, which avoids the need for further surgery. The results in terms of pain control and recovery of functionality are satisfactory. In addition, variables such as male gender and high body mass index could be predictors of therapy failure.
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Affiliation(s)
- Nicolas Cordero Tous
- Department of Neurosurgery, Functional Neurosurgery Unit, "Virgen de las Nieves" University Hospital, Granada, Spain
| | - Carlos Sánchez Corral
- Department of Neurosurgery, Functional Neurosurgery Unit, "Virgen de las Nieves" University Hospital, Granada, Spain
| | - Isabel María Ortiz García
- Department of Neurosurgery, Functional Neurosurgery Unit, "Virgen de las Nieves" University Hospital, Granada, Spain
| | - Aarón Jover Vidal
- Department of Neurosurgery, Functional Neurosurgery Unit, "Virgen de las Nieves" University Hospital, Granada, Spain
| | - Rafael Gálvez Mateos
- Department of Anaesthesiology, "Virgen de las Nieves" University Hospital, Granada, Spain
| | - Gonzalo Olivares Granados
- Department of Neurosurgery, Functional Neurosurgery Unit, "Virgen de las Nieves" University Hospital, Granada, Spain
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Kasapovic A, Rommelspacher Y, Walter S, Gathen M, Pflugmacher R. [Minimally invasive implantation technique of a system for spinal cord stimulation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:364-373. [PMID: 33666671 DOI: 10.1007/s00064-021-00700-3] [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: 07/07/2019] [Revised: 01/31/2020] [Accepted: 02/27/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) targets structures of the dorsal column and dorsal horn of the spinal cord with electrical impulses, thereby, modulating pain perception. For chronic pain patients, e.g., in failed back surgery syndrome (FBSS), the aim is to achieve pain relief and enable patients to improve their quality of life. INDICATIONS Failed back surgery syndrome, complex regional pain syndrome (CRPS) type I and II, therapy-refractory ischemic pain, neuropathic pain syndromes (e.g., phantom limb pain). CONTRAINDICATIONS Identification of degenerative alterations as the cause of pain; untreated mental illness. SURGICAL TECHNIQUE A two-stage implantation technique is performed. Initially, after percutaneous implantation of epidural leads a trial period with stimulation by an external pulse generator is evaluated. Following verification of pain relief, a subcutaneous internal pulse generator is implanted. FOLLOW-UP Early mobilization and adjustment of stimulation parameters. RESULTS In all, 19 consecutive patients with FBSS were treated by high frequency SCS (HF-SCS) and included in a prospective prognostic study. In 18 patients, an internal pulse generator (IPG) for HF-SCS was permanently implanted. Therapy success was assessed using the Oswestry Disability Index (ODI), visual analogue pain scale (VAS) and painDetect questionnaire. Neuropathic pain of the legs versus the back (median values: VAS leg 71 mm, VAS back 69 mm) was dominant in the patients at a preoperative mean ODI of 63%. With HF-SCS therapy, a pronounced pain reduction was seen and persisted in the follow-up after 6 months (VAS leg 18 mm, VAS back 24 mm). The ODI showed an improvement to a mean of 24% after 6 months.
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Affiliation(s)
- Adnan Kasapovic
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Yorck Rommelspacher
- Klinik für Orthopädie, Krankenhaus der Augustinerinnen Köln, Jakobstraße 27-31, Köln, 50678, Deutschland
| | - Sebastian Walter
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Martin Gathen
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Robert Pflugmacher
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
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18
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Baranidharan G, Edgar D, Bretherton B, Crowther T, Lalkhen AG, Fritz AK, Vajramani G. Efficacy and Safety of 10 kHz Spinal Cord Stimulation for the Treatment of Chronic Pain: A Systematic Review and Narrative Synthesis of Real-World Retrospective Studies. Biomedicines 2021; 9:180. [PMID: 33670252 PMCID: PMC7918133 DOI: 10.3390/biomedicines9020180] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/27/2021] [Accepted: 02/05/2021] [Indexed: 12/14/2022] Open
Abstract
10 kHz spinal cord stimulation (SCS) is increasingly utilized globally to treat chronic pain syndromes. Real-world evidence complementing randomized controlled trials supporting its use, has accumulated over the last decade. This systematic review aims to summarize the retrospective literature with reference to the efficacy and safety of 10 kHz SCS. We performed a systematic literature search of PubMed between 1 January 2009 and 21 August 2020 for English-language retrospective studies of ≥3 human subjects implanted with a Senza® 10 kHz SCS system and followed-up for ≥3 months. Two independent reviewers screened titles/abstracts of 327 studies and 46 full-text manuscripts. In total, 16 articles were eligible for inclusion; 15 reported effectiveness outcomes and 11 presented safety outcomes. Follow-up duration ranged from 6-34 months. Mean pain relief was >50% in most studies, regardless of follow-up duration. Responder rates ranged from 67-100% at ≤12 months follow-up, and from 46-76% thereafter. 32-71% of patients decreased opioid or nonopioid analgesia intake. Complication incidence rates were consistent with other published SCS literature. Findings suggest 10 kHz SCS provides safe and durable pain relief in pragmatic populations of chronic pain patients. Furthermore, it may decrease opioid requirements, highlighting the key role 10 kHz SCS can play in the medium-term management of chronic pain.
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Affiliation(s)
- Ganesan Baranidharan
- Leeds Teaching Hospitals NHS Trust Leeds, Leeds LS1 3EX, UK; (B.B.); (T.C.)
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds LS2 9JT, UK
| | | | - Beatrice Bretherton
- Leeds Teaching Hospitals NHS Trust Leeds, Leeds LS1 3EX, UK; (B.B.); (T.C.)
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Tracey Crowther
- Leeds Teaching Hospitals NHS Trust Leeds, Leeds LS1 3EX, UK; (B.B.); (T.C.)
| | | | - Ann-Katrin Fritz
- Pain Management Centre, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK;
| | - Girish Vajramani
- Centre for Functional Neurosurgery, University Hospital Southampton NHS Foundation Trust, Hampshire SO16 6YD, UK;
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Canós-Verdecho A, Abejón D, Robledo R, Izquierdo R, Bermejo A, Gallach E, Argente P, Peraita-Costa I, Morales-Suárez-Varela M. Randomized Prospective Study in Patients With Complex Regional Pain Syndrome of the Upper Limb With High-Frequency Spinal Cord Stimulation (10-kHz) and Low-Frequency Spinal Cord Stimulation. Neuromodulation 2021; 24:448-458. [PMID: 33462918 DOI: 10.1111/ner.13358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of this prospective randomized study of cases and controls was to evaluate the efficacy of treatment with low-frequency spinal cord stimulation (LF-SCS) and 10 kHz spinal cord stimulation (10-kHz SCS) in patients diagnosed with complex regional pain syndrome type I (CRPS) with upper limb involvement. MATERIALS AND METHODS Fifty patients were randomized to receive conventional treatment or SCS with a commercially available low-frequency or 10-kHz system. Patients were assessed at 1, 3, 6, and 12 months. The primary endpoint was at 12-months post permanent implantation of the SCS devices. Outcome measures assessed included: Numerical Rating Scale (NRS), 12-Item Short-Format Health Survey (SF-12), Oswestry Disability Index (ODI), Study Sleep Scale medical outcomes (MOS-SS), Douleur Neuropathique 4 questions pain questionnaire (DN4), Patient Global Impression Scale on the impact of treatment improvement (PGI-I), Clinician Global Impression Scale on the impact of improving the patient (CGI-I). RESULTS Forty-one patients were finally included in the analysis, 19 patients in the conventional treatment group, 12 in the LF-SCS group, and 10 in the 10-kHz SCS group. At the primary endpoint, patients treated with LF-SCS presented improvements in the NRS and DN4 outcomes around 2.4 and 1.5 times above the minimal clinically important difference (MCID) thresholds. At the primary endpoint, patients treated with 10-kHz SCS presented improvements in the NRS and DN4 outcomes around 2 and 1.4 times above the MCID thresholds. CONCLUSIONS Patients experienced considerable improvement after SCS. The results show that LF-SCS has very good results when compared with conventional treatment. The results obtained with 10-kHz SCS are encouraging, with the advantages of the absence of paresthesia making it an alternative in the treatment of CRPS.
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Affiliation(s)
- Angeles Canós-Verdecho
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - David Abejón
- Multidisciplinary Pain Management Unit, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Ruth Robledo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rosa Izquierdo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Ara Bermejo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Elisa Gallach
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Psychiatry Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Argente
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Surgical Specialities Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Isabel Peraita-Costa
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine, Universitat de València, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP). The Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - María Morales-Suárez-Varela
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciences, Toxicology and Forensic Medicine, Universitat de València, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP). The Institute of Health Carlos III (ISCIII), Madrid, Spain
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20
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Burgher A, Kosek P, Surrett S, Rosen SM, Bromberg T, Gulve A, Kansal A, Wu P, McRoberts WP, Udeshi A, Esposito M, Gliner BE, Maneshi M, Rotte A, Subbaroyan J. Ten kilohertz SCS for Treatment of Chronic Upper Extremity Pain (UEP): Results from Prospective Observational Study. J Pain Res 2020; 13:2837-2851. [PMID: 33204145 PMCID: PMC7667505 DOI: 10.2147/jpr.s278661] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Chronic upper extremity pain (UEP) has complex etiologies and is often disabling. It has been shown that 10 kHz SCS can provide paresthesia-free and durable pain relief in multiple pain types and improve the quality of life of patients. Objective To gain additional evidence on the safety and effectiveness of 10 kHz SCS for the treatment of chronic UEP. Study Design It was a prospective, multicenter, and observational study. The study was registered on ClinicalTrials.gov prospectively (clinical trial identifier: NCT02703818). Setting Multicenter. Patients Intervention and Main Outcomes A total of 43 subjects with chronic UEP of ≥5 cm (on a 0-10 cm visual analog scale; VAS) underwent a trial of 10 kHz SCS, and subjects with ≥40% pain relief received a permanent implant. All subjects had upper limb pain at baseline, while some had concomitant shoulder or neck pain. Subject outcomes were assessed for 12 months, and the primary outcome was the responder rate (percentage of subjects experiencing ≥50% pain relief from baseline) at three months. Results Thirty-eight subjects successfully completed the trial (88.3% success rate), 33 received permanent implants (five withdrew consent), and 32 had device activation (per protocol population). There were no paresthesias or uncomfortable changes in stimulation related to changes in posture during the study and there were no neurological deficits. Responder rates at 12 months for upper limb, shoulder, and neck pain in per protocol population (N=32) were 78.1%, 85.2%, and 75.0%, respectively. At 12 months, 84.4% of subjects were satisfied or very satisfied with 10 kHz SCS, and 38.7% either reduced or eliminated opioid usage. Conclusion This study further supports the effectiveness of 10 kHz SCS for chronic UEP treatment and documents the safety profile of the therapy. Clinical Trial Identifier NCT02703818.
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Affiliation(s)
| | | | | | | | | | - Ashish Gulve
- The James Cook University Hospital, Middlesbrough, UK
| | - Anu Kansal
- The James Cook University Hospital, Middlesbrough, UK
| | - Paul Wu
- Holy Cross Hospital, Inc., Ft, Lauderdale, FL, USA
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21
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Kapural L, Sayed D, Kim B, Harstroem C, Deering J. Retrospective Assessment of Salvage to 10 kHz Spinal Cord Stimulation (SCS) in Patients Who Failed Traditional SCS Therapy: RESCUE Study. J Pain Res 2020; 13:2861-2867. [PMID: 33204147 PMCID: PMC7667504 DOI: 10.2147/jpr.s281749] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/17/2020] [Indexed: 12/31/2022] Open
Abstract
Background and Objectives A randomized clinical trial demonstrated that 10 kHz SCS (10kHz-SCS) therapy is superior to traditional low-frequency SCS (LF-SCS) at 12- and 24-month clinical follow-ups and led to Food and Drug Administration (FDA) approval of the therapy. The results of the study led our practices to trial 10kHz-SCS in patients who had not maintained pain relief with LF-SCS therapy. Here, we report a large set of data from two clinical sites to assess if 10kHz-SCS is an effective salvage modality when LF-SCS fails. Methods We conducted a retrospective chart review of 120 patients across two clinical sites who had LF-SCS implants and were salvaged with 10kHz-SCS. Results Data were analyzed from 105 patients between 28 and 90 years old (median 60) with chronic pain for 13.6 years. The mean duration of LF-SCS therapy was 4.66±3.9 years. The average Visual Analog Scale (VAS) decreased from 8.30±1.4 (median of 8) cm to 3.32±2.0 (median of 3) cm at 12 months and 3.36±2.0 (median of 3) cm at the most recent clinic visit (p<0.001) following salvage therapy. Pain relief of 50% or more was obtained in 85 out of 105 (81%) patients. Opioid usage decreased from 60.3±77.1 mg to 32.1±44.0 mg MSO4 equivalents (p = 0.001) at 12 months after salvage therapy. Conclusion Eighty-one percent of patient cases reviewed, where LF-SCS had failed, achieved >50% pain relief with 10kHz-SCS, and almost all exhibited some clinical improvement. Therefore, 10kHz-SCS should be considered an appropriate option to rescue failed LF-SCS.
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Affiliation(s)
| | - Dawood Sayed
- Department of Anesthesiology, University of Kansas, Kansas City, KS, USA
| | - Brian Kim
- Department of Anesthesiology, University of Kansas, Kansas City, KS, USA
| | | | - James Deering
- Carolinas Pain Institute, Winston-Salem, NC 27103, USA
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22
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Baranidharan G, Bretherton B, Kay T, Marsh N, Romanis C, Roberts B. BurstDR spinal cord stimulation in the treatment of chronic visceral pain. Pain Manag 2020; 10:319-329. [PMID: 32820670 DOI: 10.2217/pmt-2020-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background:Visceral pain can be disabling for patients and challenging to treat in the clinic. Spinal cord stimulation is a NICE approved treatment for chronic neuropathic pain, presenting potential advantages over conventional therapies for managing chronic visceral pain. Results: A retrospective study revealed that a specific type of spinal cord stimulation, BurstDRTM (Abbott, TX, USA), was effective at improving pain and quality of life in patients with chronic visceral pain. Baseline pain scores significantly correlated with change at follow-up, suggesting it may be possible to identify potential responders from the outset. BurstDR was safe: rates of revision, explantation and complications were low. Conclusion: Clinical trials exploring the long-term effects of BurstDR including a control arm are needed. Findings could have the potential to inform best practice and improve outcomes for individuals with chronic visceral pain.
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Affiliation(s)
- Ganesan Baranidharan
- Department of Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds UK.,School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Beatrice Bretherton
- Department of Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds UK.,School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds UK
| | - Thomas Kay
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Nathan Marsh
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Charlotte Romanis
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Bethan Roberts
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
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23
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Baranidharan G, Bretherton B, Eldabe S, Mehta V, Thomson S, Sharma ML, Vajramani G, Bojanic S, Gulve A, FitzGerald J, Hall S, Firth J. The impact of the COVID-19 pandemic on patients awaiting spinal cord stimulation surgery in the United Kingdom: a multi-centre patient survey. Br J Pain 2020; 15:282-290. [PMID: 34373788 PMCID: PMC7443576 DOI: 10.1177/2049463720948092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction Spinal cord stimulation (SCS) is a recommended treatment for chronic refractory neuropathic pain. During the COVID-19 pandemic, elective procedures have been postponed indefinitely both to provide capacity to deal with the emergency caseload and to avoid exposure of elective patients to COVID-19. This survey aimed to explore the effect of the pandemic on chronic pain in this group and the views of patients towards undergoing SCS treatment when routine services should resume. Methods This was a prospective, multi-centre telephone patient survey that analysed data from 330 patients with chronic pain who were on an SCS waiting list. Questions focussed on severity of pain, effect on mental health, medication consumption and reliance on support networks during the COVID-19 pandemic. Views towards undergoing SCS therapy were also ascertained. Counts and percentages were generated, and chi-square tests of independence explored the impact of COVID-19 risk (very high, high, low) on survey responses. Results Pain, mental health and patient's ability to self-manage pain deteriorated in around 47%, 50% and 38% of patients, respectively. Some patients reported increases in pain medication consumption (37%) and reliance on support network (41%). Patients showed a willingness to attend for COVID-19 testing (92%), self-isolate prior to SCS (94%) and undergo the procedure as soon as possible (76%). Conclusion Our findings suggest that even during the COVID-19 pandemic, there remains a strong clinical need for patients with chronic pain identified as likely SCS responders to be treated quickly. The current prioritisation of new SCS at category 4 (delayed more than 3 months) is challenged judging by this national survey. These patients are awaiting SCS surgery to relieve severe intractable neuropathic pain. A priority at category 3 (delayed up to 3 months) or in some selected cases, at category 2 are the appropriate priority categories.
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Affiliation(s)
- Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Beatrice Bretherton
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Vivek Mehta
- Pain and Anaesthesia Research Centre, St Bartholomew's Hospital, London, UK
| | - Simon Thomson
- Department of Anaesthesiology, Basildon and Thurrock University Hospitals, Basildon, UK
| | - Manohar Lal Sharma
- Department of Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Girish Vajramani
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Stana Bojanic
- Department of Neurosurgery, The John Radcliffe Hospital, Oxford, UK
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - James FitzGerald
- Department of Neurosurgery, The John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Samuel Hall
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Julie Firth
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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24
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Sills S. Treatment of painful polyneuropathies of diabetic and other origins with 10 kHz SCS: a case series. Postgrad Med 2020; 132:352-357. [PMID: 32073352 DOI: 10.1080/00325481.2020.1732065] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Painful diabetic polyneuropathy (PDPN) and painful polyneuropathies of other origins are associated with significant personal and societal burdens with treatments limited to symptomatic management. Treatment options include antidepressants, gamma-aminobutyric acid (GABA) analogs, opioids, and topical analgesics, which are intended to alleviate pain and symptoms of neuropathy, but limited data are available on their efficacy. Paresthesia-based low-frequency spinal cord stimulation (LF-SCS) is considered a last-resort treatment modality for PDPN patients. In a large-scale RCT of neuropathic low back and leg pain, high-frequency SCS at 10 kHz (10 kHz SCS) was shown to provide superior pain relief that is not dependent on paresthesia and a higher responder rate than LF SCS. This retrospective case series includes data from six patients with painful peripheral neuropathies, including PDPN, idiopathic polyneuropathy, and chronic inflammatory demyelinating polyneuropathy, who were candidates for 10 kHz SCS in routine commercial practice. All patients reported a reduction in verbal numerical rating scale (VNRS) pain score at last follow-up (2.7 ± 0.9) compared with baseline (7.0 ± 0.9). Out of five patients with information available at last follow-up, two were completely off their pain medications and two reduced their dose by over 40%. Similarly, at last follow-up, three out of five patients reported sensory improvement in their lower limbs. In conclusion, 10 kHz SCS treatment resulted in significant pain relief in all the patients, decreased reliance on pain medication, and improved lower limb sensory function in the majority of patients.
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Affiliation(s)
- Shawn Sills
- Department of Anesthesiology, Interventional Pain Management, Touchstone Interventional Pain Center , Medford, OR, USA
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25
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Sayed D, Kallewaard JW, Rotte A, Jameson J, Caraway D. Pain relief and improvement in quality of life with 10 kHz SCS therapy: Summary of clinical evidence. CNS Neurosci Ther 2020; 26:403-415. [PMID: 32087613 PMCID: PMC7080433 DOI: 10.1111/cns.13285] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 01/16/2023] Open
Abstract
Objective Chronic pain is a prevalent condition which has a significant effect on the lives of those it impacts. High‐frequency 10 kHz spinal cord stimulation (10 kHz SCS) has been shown to provide paresthesia‐free pain relief for a wide variety of pain indications. This article summarizes the current and emerging data as they relate to the clinical use of the therapy in various pain syndromes. Methods A literature search was conducted using the PubMed electronic database using keywords related to 10 kHz SCS. The database was queried from 2013 to May 2019. Articles reporting clinical studies that included human subjects permanently treated with 10 kHz SCS (Senza® system) were included in the review. Recent and relevant conference proceedings known to the authors were also included. Results The selected literature demonstrated significant evidence for the efficacy of 10 kHz SCS in treating chronic back and leg pain (CBLP), including a randomized, controlled trial as well as prospective and retrospective studies. One‐year follow‐up responder rates (pain relief ≥50%) ranged from 60% to 80%. Other studies and case series showed promising outcomes in specific conditions, including nonsurgical refractory back pain, neuropathic limb pain, complex regional pain syndrome, chronic widespread pain, chronic pelvic pain, and intractable headache. Subgroup analyses also pointed toward the potential of 10 kHz SCS being successful when low‐frequency SCS has failed. The vast majority of these studies reported improved quality of life (QOL) metrics and/or reduced opioid consumption. Conclusions Level I evidence already exists for the efficacy of 10 kHz SCS in treating CBLP, supported by real‐world clinical experience. Other studies demonstrate the potential of the therapy across a range of chronic pain etiologies, although larger confirmatory studies are recommended. Overall, the literature suggests that the therapy is associated with improved QOL as well as reduced opioid consumption.
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Affiliation(s)
- Dawood Sayed
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital Arnhem, Velp, The Netherlands
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26
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Martini ML, Caridi JM, Zeldin L, Neifert SN, Nistal DA, Kim JD, Khelemsky Y, Gal JS. Perioperative Outcomes of Spinal Cord Stimulator Placement in Patients with Complex Regional Pain Syndrome Compared with Patients without Complex Regional Pain Syndrome. World Neurosurg 2020; 137:e106-e117. [PMID: 31954908 DOI: 10.1016/j.wneu.2020.01.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Complex regional pain syndrome (CRPS) is a multifaceted disorder resulting in an abnormal pain response to tissue injury. Among key CRPS features are neurogenic inflammation, maladaptive plasticity, and vasomotor dysfunction, which can result in severe pain and disability. Spinal cord stimulation (SCS) is an efficacious treatment for several chronic pain conditions and may improve pain and life quality in CRPS patients with CRPS. However, little information exists regarding perioperative outcomes of patients with CRPS undergoing surgical implantation of an SCS device. METHODS Patients were included if they underwent an SCS procedure at our institution between 2008 and 2016 for chronic pain. Cases were excluded if the procedure involved stimulator removal or if it was an outpatient procedure. Multivariate regression assessed the effect of CRPS and other clinical variables on perioperative outcomes. RESULTS Eighty-one inpatient SCS implantation cases for chronic pain were included, with 9 patients (11.1%) having a CRPS diagnosis. The CRPS cohort received higher mean quantities of intraoperative opioids and had a lower proportion of patients reporting meaningful pain reduction (16.7%) in the 24-hour postoperative setting compared with patients without CRPS (35.9%), although this was not statistically significant. Multivariate regression modeling suggested that CRPS was a significant predictor of increased odds of extended time to the postanesthesia care unit discharge (P = 0.0406) and higher direct costs of hospitalization (P = 0.0326). CONCLUSIONS Our data suggest that CRPS may pose several unique risks in the perioperative period after inpatient SCS implantation. These findings support the need for future prospective investigations examining risks and outcomes for SCS procedures in this population.
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Affiliation(s)
- Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lawrence Zeldin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dominic A Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jinseong D Kim
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yury Khelemsky
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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27
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Mekhail NA, Argoff CE, Taylor RS, Nasr C, Caraway DL, Gliner BE, Subbaroyan J, Brooks ES. High-frequency spinal cord stimulation at 10 kHz for the treatment of painful diabetic neuropathy: design of a multicenter, randomized controlled trial (SENZA-PDN). Trials 2020; 21:87. [PMID: 31941531 PMCID: PMC6961392 DOI: 10.1186/s13063-019-4007-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 12/17/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Painful diabetic neuropathy (PDN), a debilitating and progressive chronic pain condition that significantly impacts quality of life, is one of the common complications seen with long-standing diabetes mellitus. Neither pharmacological treatments nor low-frequency spinal cord stimulation (SCS) has provided significant and long-term pain relief for patients with PDN. This study aims to document the value of 10-kHz SCS in addition to conventional medical management (CMM) compared with CMM alone in patients with refractory PDN. METHODS In a prospective, multicenter, randomized controlled trial (SENZA-PDN), 216 subjects with PDN will be assigned 1:1 to receive 10-kHz SCS combined with CMM or CMM alone after appropriate institutional review board approvals and followed for 24 months. Key inclusion criteria include (1) symptoms of PDN for at least 12 months, (2) average pain intensity of at least 5 cm-on a 0- to 10-cm visual analog scale (VAS)-in the lower limbs, and (3) an appropriate candidate for SCS. Key exclusion criteria include (1) large or gangrenous ulcers or (2) average pain intensity of at least 3 cm on VAS in the upper limbs or both. Along with pain VAS, neurological assessments, health-related quality of life, sleep quality, and patient satisfaction will be captured. The primary endpoint comparing responder rates (≥50% pain relief) and safety rates between the treatment groups will be assessed at 3 months. Several secondary endpoints will also be reported on. DISCUSSION Enrollment commenced in 2017 and was completed in 2019. This study will help to determine whether 10-kHz SCS improves clinical outcomes and health-related quality of life and is a cost-effective treatment for PDN that is refractory to CMM. TRIAL REGISTRATION ClincalTrials.gov identifier: NCT03228420 (registered 24 July 2017).
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Affiliation(s)
- Nagy A Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, C25, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Charles E Argoff
- Department of Neurology, Albany Medical College, MC 70, 47 New Scotland Avenue, Albany, NY, 12208, USA
| | - Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, Scotland, UK.,College of Medicine and Health, University of Exeter, St. Luke's Campus, Heavitree Road, Exeter EX1 2LU, England, UK
| | - Christian Nasr
- Department of Endocrinology & Metabolism, Cleveland Clinic, F20, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - David L Caraway
- Nevro Corp, 1800 Bridge Parkway, Redwood City, CA, 94065, USA
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