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Chitneni A, Jain E, Sahni S, Mavrocordatos P, Abd-Elsayed A. Spinal Cord Stimulation Waveforms for the Treatment of Chronic Pain. Curr Pain Headache Rep 2024; 28:595-605. [PMID: 38607547 DOI: 10.1007/s11916-024-01247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Since the advent of spinal cord stimulation (SCS), advances in technology have allowed for improvement and treatment of various conditions, especially chronic pain. Additionally, as the system has developed, the ability to provide different stimulation waveforms for patients to treat different conditions has improved. The purpose and objective of the paper is to discuss basics of waveforms and present the most up-to-date literature and research studies on the different types of waveforms that currently exist. During our literature search, we came across over sixty articles that discuss the various waveforms we intend to evaluate. RECENT FINDINGS There are several publications on several waveforms used in clinical practice, but to our knowledge, this is the only educational document teaching on waveforms which provides essential knowledge. There is a gap of knowledge related to understanding wave forms and how they work.
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Affiliation(s)
- Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USA
| | - Esha Jain
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, B6/319 CSC53792-3272, USA.
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Patel J, Deschler E, Galang E. Spinal cord stimulation for the symptomatic treatment of rigidity and painful spasm in a case of stiff person syndrome. Pain Pract 2024; 24:798-804. [PMID: 38185725 DOI: 10.1111/papr.13340] [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: 01/09/2024]
Abstract
BACKGROUND Stiff person syndrome (SPS) is a rare neuroimmunological disorder characterized by rigidity and painful spasm primarily affecting the truncal and paraspinal musculature due to autoimmune-mediated neuronal hyperexcitability. Spinal cord stimulation (SCS) is an approved therapy for managing painful neuropathic conditions, including diabetic peripheral neuropathy and refractory angina pectoris. We describe the novel use of SCS for the treatment of spasm and rigidity in a 49-year-old man with seropositive stiff person syndrome (SPS). The patient was treated with intravenous immunoglobulin (IVIG) and oral medications over a 13-month period with minimal improvement, prompting consideration of SCS. To our knowledge, this is the first report of the successful use of SCS in SPS with the demonstration of multifaceted clinical improvement. METHODS Following a successful temporary SCS trial, permanent implantation was performed. Spasm/stiffness (Distribution of Stiffness Index; Heightened Sensitivity Scale; Penn Spasm Frequency Scale, PSFS), disability (Oswestry Disability Index, ODI; Pain Disability Index, PDI), depression (Patient Health Questionnaire-9, PHQ-9), sleep (Pittsburgh Sleep Quality Index, PSQI), fatigue (Fatigue Severity Scale, FSS), pain (Numerical Pain Rating Scale, NPRS), quality of life (EuroQoL 5 Dimension 5 Level, EQ-5D-5L), and medication usage were assessed at baseline, 6-month, and 10-month postimplantation. RESULTS ODI, PHQ-9, FSS, NPRS, PSQI, and EQ-5D-5L scores showed a notable change from baseline and surpassed the defined minimal clinically important difference (MCID) at 6-month and 10-month follow-up. Oral medication dosages were reduced. CONCLUSIONS The novel use of SCS therapy in seropositive SPS resulted in functional improvement and attenuation of symptoms. We present possible mechanisms by which SCS may produce clinical response in patients with SPS and aim to demonstrate proof-of-concept for a future comprehensive pilot study evaluating SCS-mediated response in SPS.
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Affiliation(s)
- Janus Patel
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Emily Deschler
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Enrique Galang
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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De Andres J. Neurostimulation in the patient with chronic pain: forecasting the future with data from the present - data-driven analysis or just dreams? Reg Anesth Pain Med 2024; 49:155-162. [PMID: 36396299 DOI: 10.1136/rapm-2022-103962] [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: 08/02/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022]
Abstract
Chronic pain involves a structured and individualized development of neurophysiological and biological responses. The final expression in each patient correlates with diverse expressions of mediators and activations of different transmission and modulation pathways, as well as alterations in the structure and function of the brain, all of which develop according to the pain phenotype. Still today, the selection process for the ideal candidate for spinal cord stimulation (SCS) is based on results from test and functional variables analysis as well as pain evaluation. In addition to the difficulties in the initial selection of patients and the predictive analysis of the test phase, which undoubtedly impact on the results in the middle and long term, the rate of explants is one of the most important concerns, in the analysis of suitability of implanted candidates. A potential for useful integration of genome analysis and lymphocyte expression in the daily practice of neurostimulation, for pain management is presented. Structural and functional quantitative information provided by imaging biomarkers will allow establishing a clinical decision support system that improve the effectiveness of the SCS implantation, optimizing human, economic and psychological resources. A correct programming of the neurostimulator, as well as other factors associated with the choice of leads and their position in the epidural space, are the critical factors for the effectiveness of the therapy. Using a model of SCS based on mathematical methods and computational simulation, the effect of different factors of influence on clinical practice studied, as several configurations of electrodes, position of these, and programming of polarities, in order to draw conclusions of clinical utility in neuroestimulation therapy.
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Affiliation(s)
- Jose De Andres
- Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, Consorci Hospital General Universitari de València, Valencia, Spain
- Anesthesia Unit. Surgical Specialties Department, Universidad de Valencia Facultad de Medicina y Odontología, Valencia, Spain
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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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Shlobin NA, Wu C. Current Neurostimulation Therapies for Chronic Pain Conditions. Curr Pain Headache Rep 2023; 27:719-728. [PMID: 37728863 DOI: 10.1007/s11916-023-01168-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation treatment options have become more commonly used for chronic pain conditions refractory to these options. In this review, we characterize current neurostimulation therapies for chronic pain conditions and provide an analysis of their effectiveness and clinical adoption. This manuscript will inform clinicians of treatment options for chronic pain. RECENT FINDINGS Non-invasive neurostimulation includes transcranial direct current stimulation and repetitive transcranial magnetic stimulation, while more invasive options include spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), dorsal root ganglion stimulation, motor cortex stimulation, and deep brain stimulation. Developments in transcranial direct current stimulation, repetitive transcranial magnetic stimulation, spinal cord stimulation, and peripheral nerve stimulation render these modalities most promising for the alleviating chronic pain. Neurostimulation for chronic pain involves non-invasive and invasive modalities with varying efficacy. Well-designed randomized controlled trials are required to delineate the outcomes of neurostimulatory modalities more precisely.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Floor 2, Philadelphia, PA, 19107, USA.
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Kirkpatrick K, Shah JD, Shah K. Neuromodulation for Adjunctive Treatment in Postmastectomy Pain Syndrome. Cureus 2023; 15:e47827. [PMID: 38021503 PMCID: PMC10676758 DOI: 10.7759/cureus.47827] [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] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Postmastectomy pain syndrome (PMPS) affects nearly half of patients who undergo mastectomy to treat breast cancer. As the survival rate of breast cancer increases with advancements in treatment, the incidence of PMPS is also increasing. Patients with PMPS can experience unrelenting, chronic pain refractory to traditional management with oral pharmacotherapy in conjunction with nonpharmacologic treatment (physical therapy, transcutaneous electrical nerve stimulation (TENS)). Neuromodulation is an emerging treatment modality for numerous chronic pain conditions. This case report highlights the tremendous success of spinal cord stimulator placement for a patient with PMPS.
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Affiliation(s)
| | - Jay D Shah
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Krishna Shah
- Anesthesiology, Baylor College of Medicine, Houston, USA
- Anesthesiology and Interventional Pain, Baylor College of Medicine, Houston, USA
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Paladini A, Vallejo R, Guerrero M, Pasqualucci A, Peppin JF, Pergolizzi J, Varrassi G. Answering Big Questions in Pain Medicine. Cureus 2023; 15:e43561. [PMID: 37719539 PMCID: PMC10502917 DOI: 10.7759/cureus.43561] [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: 07/17/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
The future of pain medicine is marked by many questions. What can other nations around the world learn from the opioid crisis that is still affecting the United States? The American opioid experience was mischaracterized and wrongly described, and its causes were misdiagnosed from the outset, leading to its mismanagement and the abandonment of many chronic pain patients to their suffering. There are a few new drugs in the analgesic armamentarium. What new targets do we have in pain medicine? There are many breakthroughs, discoveries, and potential new targets that could add to our analgesic prescribing choices. These include sigma receptors, d-amino acid oxidase, endoplasmic reticulum stress receptors, histone deacetylase, and others. Neuromodulation had been used with varying degrees of success for years, but with a simplistic approach based on the gate theory of pain. Despite our familiarity with neuromodulation and spinal cord stimulators, neuromodulation research indicates that the activation of glial cells may activate the immune system and enhance analgesia. Neuromodulation studies have concentrated on how electricity affects neuronal activity rather than how electrical activity could reduce pain. There are still more frontiers in our battle against pain and some promising avenues for treatments. This narrative review will try to summarize what can be done from the perspective of recent technological and pharmacological developments.
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Affiliation(s)
- Antonella Paladini
- Department of Life, Health & Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | - Ricardo Vallejo
- Department of Research, Millennium Pain Center, Bloomington, USA
| | - Marixa Guerrero
- Department of Pain Medicine/ Pain Management, Clínica del Country, Bogota, COL
| | - Alberto Pasqualucci
- Department of Anesthesia and Critical Care, University of Perugia, Perugia, ITA
| | - John F Peppin
- Department of Osteopathic Medicine, Marian University, Indianapolis, USA
| | - Joseph Pergolizzi
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Nema Research, Naples, USA
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Peacock J, Provenzano D, Fishman M, Amirdelfan K, Bromberg T, Schmidt T, White T, Grewal P, Justiz R, Calodney A, El-Naggar A, Shah B, Esposito M, Gatzinsky K, Kallewaard JW, Cain C, Cleland A, LaRue M, Riillo F, Theis E. 6-month Prospective Study Outcomes of a DTM™ SCS Therapy Derivative. Neuromodulation 2023. [DOI: 10.1016/j.neurom.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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9
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Tilley DM, Vallejo R, Vetri F, Platt DC, Cedeño DL. Regulation of Expression of Extracellular Matrix Proteins by Differential Target Multiplexed Spinal Cord Stimulation (SCS) and Traditional Low-Rate SCS in a Rat Nerve Injury Model. BIOLOGY 2023; 12:biology12040537. [PMID: 37106738 PMCID: PMC10135794 DOI: 10.3390/biology12040537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/15/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023]
Abstract
There is limited research on the association between the extracellular matrix (ECM) and chronic neuropathic pain. The objective of this study was twofold. Firstly, we aimed to assess changes in expression levels and the phosphorylation of ECM-related proteins due to the spared nerve injury (SNI) model of neuropathic pain. Secondly, two modalities of spinal cord stimulation (SCS) were compared for their ability to reverse the changes induced by the pain model back toward normal, non-injury levels. We identified 186 proteins as ECM-related and as having significant changes in protein expression among at least one of the four experimental groups. Of the two SCS treatments, the differential target multiplexed programming (DTMP) approach reversed expression levels of 83% of proteins affected by the pain model back to levels seen in uninjured animals, whereas a low-rate (LR-SCS) approach reversed 67%. There were 93 ECM-related proteins identified in the phosphoproteomic dataset, having a combined 883 phosphorylated isoforms. DTMP back-regulated 76% of phosphoproteins affected by the pain model back toward levels found in uninjured animals, whereas LR-SCS back-regulated 58%. This study expands our knowledge of ECM-related proteins responding to a neuropathic pain model as well as providing a better perspective on the mechanism of action of SCS therapy.
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Affiliation(s)
- Dana M. Tilley
- Research and Development, SGX Medical, Bloomington, IL 61704, USA
| | - Ricardo Vallejo
- Research and Development, SGX Medical, Bloomington, IL 61704, USA
- Neuroscience Program, Illinois Wesleyan University, Bloomington, IL 61701, USA
| | - Francesco Vetri
- Pain Management, National Spine and Pain Centers, Bloomington, IL 61704, USA
| | - David C. Platt
- Research and Development, SGX Medical, Bloomington, IL 61704, USA
- Neuroscience Program, Illinois Wesleyan University, Bloomington, IL 61701, USA
| | - David L. Cedeño
- Research and Development, SGX Medical, Bloomington, IL 61704, USA
- Neuroscience Program, Illinois Wesleyan University, Bloomington, IL 61701, USA
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10
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Miękisiak G. Editorial for the Special Issue “Chronic Neuropathic Pain Therapy and Anaesthesia”. Medicina (B Aires) 2023; 59:medicina59040674. [PMID: 37109632 PMCID: PMC10145259 DOI: 10.3390/medicina59040674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Chronic neuropathic pain (CNP), a complex and debilitating condition arising from damage or dysfunction of the somatosensory nervous system, affects millions of people worldwide [...]
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Medina R, Ho A, Reddy R, Chen J, Castellanos J. Narrative review of current neuromodulation modalities for spinal cord injury. FRONTIERS IN PAIN RESEARCH 2023; 4:1143405. [PMID: 36969918 PMCID: PMC10033643 DOI: 10.3389/fpain.2023.1143405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Neuromodulation is a developing field of medicine that includes a vast array of minimally invasive and non-invasive therapies including transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), vagus nerve stimulation (VNS), peripheral nerve stimulation, and spinal cord stimulation (SCS). Although the current literature surrounding the use of neuromodulation in managing chronic pain is abundant, there is an insufficient amount of evidence specifically regarding neuromodulation in patients with spinal cord injury (SCI). Given the pain and functional deficits that these patients face, that are not amenable to other forms conservative therapy, the purpose of this narrative review is to examine and assess the use of various neuromodulation modalities to manage pain and restore function in the SCI population. Currently, high-frequency spinal cord stimulation (HF-SCS) and burst spinal cord stimulation (B-SCS) have been shown to have the most promising effect in improving pain intensity and frequency. Additionally, dorsal root ganglion stimulation (DRG-S) and TMS have been shown to effectively increase motor responses and improve limb strength. Although these modalities carry the potential to enhance overall functionality and improve a patient's degree of disability, there is a lack of long-term, randomized-controlled trials in the current space. Additional research is warranted to further support the clinical use of these emerging modalities to provide improved pain management, increased level of function, and ultimately an overall better quality of life in the SCI population.
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Affiliation(s)
- Roi Medina
- Department of Physical Medicine and Rehabilitation, Lake Erie College of Osteopathic Medicine-Bradenton, Bradenton, FL, United States
- Correspondence: Roi Medina
| | - Alison Ho
- Department of Physical Medicine and Rehabilitation, Baylor University Medical Center, Dallas, TX, United States
| | - Rajiv Reddy
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Jeffrey Chen
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Joel Castellanos
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
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Dorrian RM, Berryman CF, Lauto A, Leonard AV. Electrical stimulation for the treatment of spinal cord injuries: A review of the cellular and molecular mechanisms that drive functional improvements. Front Cell Neurosci 2023; 17:1095259. [PMID: 36816852 PMCID: PMC9936196 DOI: 10.3389/fncel.2023.1095259] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Spinal cord injury (SCI) is a devastating condition that causes severe loss of motor, sensory and autonomic functions. Additionally, many individuals experience chronic neuropathic pain that is often refractory to interventions. While treatment options to improve outcomes for individuals with SCI remain limited, significant research efforts in the field of electrical stimulation have made promising advancements. Epidural electrical stimulation, peripheral nerve stimulation, and functional electrical stimulation have shown promising improvements for individuals with SCI, ranging from complete weight-bearing locomotion to the recovery of sexual function. Despite this, there is a paucity of mechanistic understanding, limiting our ability to optimize stimulation devices and parameters, or utilize combinatorial treatments to maximize efficacy. This review provides a background into SCI pathophysiology and electrical stimulation methods, before exploring cellular and molecular mechanisms suggested in the literature. We highlight several key mechanisms that contribute to functional improvements from electrical stimulation, identify gaps in current knowledge and highlight potential research avenues for future studies.
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Affiliation(s)
- Ryan M. Dorrian
- Spinal Cord Injury Research Group, School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia,*Correspondence: Ryan M. Dorrian,
| | | | - Antonio Lauto
- School of Science, Western Sydney University, Penrith, NSW, Australia
| | - Anna V. Leonard
- Spinal Cord Injury Research Group, School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia
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Lam CM, Latif U, Sack A, Govindan S, Sanderson M, Vu DT, Smith G, Sayed D, Khan T. Advances in Spinal Cord Stimulation. Bioengineering (Basel) 2023; 10:185. [PMID: 36829678 PMCID: PMC9951889 DOI: 10.3390/bioengineering10020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/17/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Neuromodulation, specifically spinal cord stimulation (SCS), has become a staple of chronic pain management for various conditions including failed back syndrome, chronic regional pain syndrome, refractory radiculopathy, and chronic post operative pain. Since its conceptualization, it has undergone several advances to increase safety and convenience for patients and implanting physicians. Current research and efforts are aimed towards novel programming modalities and modifications of existing hardware. Here we review the recent advances and future directions in spinal cord stimulation including a brief review of the history of SCS, SCS waveforms, new materials for SCS electrodes (including artificial skins, new materials, and injectable electrodes), closed loop systems, and neurorestorative devices.
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Affiliation(s)
- Christopher M. Lam
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Usman Latif
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Andrew Sack
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Susheel Govindan
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Miles Sanderson
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Dan T. Vu
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Gabriella Smith
- School of Medicine, University of Kansas, Kansas City, KS 66160, USA
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | - Talal Khan
- Department of Anesthesiology and Pain Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
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Successful use of differential target multiplexed spinal cord stimulation for chronic postsurgical abdominal pain. Pain Rep 2023; 8:e1059. [PMID: 36699989 PMCID: PMC9857349 DOI: 10.1097/pr9.0000000000001059] [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: 05/24/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Recent advances in stimulation techniques have improved the efficacy and expanded the applicability of spinal cord stimulation (SCS). Among these techniques, there are no reports on the efficacy of differential target multiplexed (DTM) SCS for chronic postsurgical pain (CPSP) after abdominal surgery. Therefore, we present the successful use of DTM SCS for CPSP after distal pancreatectomy. Methods A 49-year-old man with hypertension and severe chronic low back pain presented with neuropathic CPSP involving the left abdomen in the area of a laparotomy incision. His pain was refractory to conservative treatment and was rated 10 on a numerical rating scale (NRS). He underwent permanent implantation of a pulse generator after a 14-day trial stimulation. Results Chronic postsurgical pain was well controlled (NRS 1-2) at a 3-month follow-up with DTM SCS. Conclusion Differential target multiplexed SCS can be a new treatment option for neuropathic CPSP that is resistant to conservative treatment. It is important to further examine the characteristics of CPSP and identify appropriate candidates for the successful use of DTM SCS.
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Cedeño DL, Vallejo R, Kelley CA, Platt DC, Litvak LM, Straka M, Dinsmoor DA. Spinal Evoked Compound Action Potentials in Rats With Clinically Relevant Stimulation Modalities. Neuromodulation 2023; 26:68-77. [PMID: 35961888 DOI: 10.1016/j.neurom.2022.06.006] [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] [Received: 02/15/2022] [Revised: 06/07/2022] [Accepted: 06/29/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Rats are commonly used for translational pain and spinal cord stimulation (SCS) research. Although many SCS parameters are configured identically between rats and humans, stimulation amplitudes in rats are often programmed relative to visual motor threshold (vMT). Alternatively, amplitudes may be programmed relative to evoked compound action potential (ECAP) thresholds (ECAPTs), a sensed measure of neural activation. The objective of this study was to characterize ECAPTs, evoked compound muscle action potential thresholds (ECMAPTs), and vMTs with clinically relevant SCS modalities. MATERIALS AND METHODS We implanted ten anesthetized rats with two quadripolar epidural SCS leads: one for stimulating in the lumbar spine, and another for sensing ECAPs in the thoracic spine. We then delivered two SCS paradigms to the rats. The first used 50-Hz SCS with 50-, 100-, 150-, and 200-μs pulse widths (PWs), whereas the second used a 50-Hz, 150-μs PW low-rate program (LRP) multiplexed to a 1200-Hz, 50-μs PW high-rate program (HRP). We increased SCS amplitudes up to the vMT in the first paradigm, and in the second, we increased HRP amplitudes up to the HRP ECAPT with a fixed amplitude (70% of the vMT) LRP. For each test case, we captured ECAPTs, ECMAPTs, and vMTs from each rat. RESULTS vMTs were 3.0 ± 0.7 times greater than ECAPTs, with vMTs marginally (3.0 ± 3.6%) greater than ECMAPTs (mean ± SD) across all PWs with the first paradigm. With the second paradigm, we noted a negligible increase (3.6 ± 6.2%) on the LRP ECAP as HRP amplitudes were increased. CONCLUSIONS Our results demonstrate reasonable levels of neural activation in anesthetized rats with SCS amplitudes appropriately programmed relative to vMT or ECMAPT when using clinically relevant SCS modalities. Furthermore, we demonstrate the feasibility of ECAP recording in rats with multiplexed HRP SCS.
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de Geus TJ, Franken G, Joosten EA. Conventional, high frequency and differential targeted multiplexed spinal cord stimulation in experimental painful diabetic peripheral neuropathy: Pain behavior and role of the central inflammatory balance. Mol Pain 2023; 19:17448069231193368. [PMID: 37488684 PMCID: PMC10504849 DOI: 10.1177/17448069231193368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
Spinal cord stimulation (SCS) is a last resort treatment for pain relief in painful diabetic peripheral neuropathy (PDPN) patients. However, the effectivity of SCS in PDPN is limited. New SCS paradigms such as high frequency (HF) and differential target multiplexed (DTM) might improve responder rates and efficacy of SCS-induced analgesia in PDPN patients, and are suggested to modulate the inflammatory balance and glial response in the spinal dorsal horn. The aim of this study was to research the effects of Con-, HF- and DTM-SCS on pain behavior and the spinal inflammatory balance in an animal model of PDPN. Streptozotocin-induced PDPN animals were stimulated for 48 hours with either Con-SCS (50Hz), HF-SCS (1200Hz) or DTM-SCS (combination of Con- and HF-SCS). Mechanical hypersensitivity was assessed using Von Frey (VF) test and the motivational aspects of pain were assessed using the mechanical conflict avoidance system (MCAS). The inflammatory balance and glial response were analyzed in the dorsal spinal cord based on RNA expression of pro- and anti-inflammatory cytokines (Tnf-α, Il-1ß, Il-4, Il-10), a microglia marker (Itgam), an astrocyte marker (Gfap), a T-cell marker (Cd3d), microglia proliferation markers (Irf8, Adgre1) and P2X4, p13-MAPK, BDNF signaling markers (P2x4, Mapk14, Bdnf). The results show that Con-, HF-, and DTM-SCS significantly decreased hypersensitivity after 48 hours of stimulation compared to Sham-SCS in PDPN animals, but at the same time did not affect escape latency in the MCAS. At the molecular level, Con-SCS resulted in a significant increase in spinal pro-inflammatory cytokine Tnf-α after 48 hours compared to DTM-SCS and Sham-SCS. In summary, Con-SCS showed a shift of the inflammatory balance towards a pro-inflammatory state whilst HF- and DTM-SCS shifted the balance towards an anti-inflammatory state. These findings suggest that the underlying mechanism of Con-SCS induced pain relief in PDPN differs from that induced by HF- and DTM-SCS.
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Affiliation(s)
- Thomas J. de Geus
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Glenn Franken
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Elbert A Joosten
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
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de Geus TJ, Franken G, Joosten EAJ. Spinal Cord Stimulation Paradigms and Pain Relief: A Preclinical Systematic Review on Modulation of the Central Inflammatory Response in Neuropathic Pain. Neuromodulation 2023; 26:25-34. [PMID: 35931643 DOI: 10.1016/j.neurom.2022.04.049] [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: 01/05/2022] [Revised: 03/11/2022] [Accepted: 04/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) is a last-resort treatment for patients with chronic neuropathic pain. The mechanism underlying SCS and pain relief is not yet fully understood. Because the inflammatory balance between pro- and anti-inflammatory molecules in the spinal nociceptive network is pivotal in the development and maintenance of neuropathic pain, the working mechanism of SCS is suggested to be related to the modulation of this balance. The aim of this systematic review is to summarize and understand the effects of different SCS paradigms on the central inflammatory balance in the spinal cord. MATERIALS AND METHODS A systematic literature search was conducted using MEDLINE, Embase, and PubMed. All articles studying the effects of SCS on inflammatory or glial markers in neuropathic pain models were included. A quality assessment was performed on predetermined entities of bias. RESULTS A total of 11 articles were eligible for this systematic review. In general, induction of neuropathic pain in rats results in a proinflammatory state and at the same time an increased activity/expression of microglial and astroglial cells in the spinal cord dorsal horn. Conventional SCS seems to further enhance this proinflammatory state and increase the messenger RNA expression of microglial markers, but it also results in a decrease in microglial protein marker levels. High-frequency and especially differential targeted multiplexed SCS can not only restore the balance between pro- and anti-inflammatory molecules but also minimize the overexpression/activation of glial cells. Quality assessment and risk of bias analysis of the studies included make it clear that the results of these preclinical studies must be interpreted with caution. CONCLUSIONS In summary, the preclinical findings tend to indicate that there is a distinct SCS paradigm-related effect in the modulation of the central inflammatory balance of the spinal dorsal horn.
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Affiliation(s)
- Thomas J de Geus
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands.
| | - Glenn Franken
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
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18
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Gill JS, Kohan LR, Hasoon J, Urits I, Viswanath O, Cai VL, Yazdi C, Aner MM, Kaye AD, Simopoulos TT. A Survey on the Choice of Spinal Cord Stimulation Parameters and Implantable Pulse Generators and on Reasons for Explantation. Orthop Rev (Pavia) 2022; 14:39648. [PMID: 36381501 PMCID: PMC9662606 DOI: 10.52965/001c.39648] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVE Spinal Cord Stimulation (SCS) is a vital treatment for chronic intractable pain. In the last few years, the field has undergone dramatic changes in new waveform and frequency introduction as well as device miniaturization. It is important to understand contemporary practice patterns regarding these parameters. METHODS We surveyed the active membership of Spine Intervention Society (SIS), and American Society of Regional Anesthesia (ASRA) on their practices regarding various aspects of Spinal Cord Stimulation therapy. Here we report on SCS waveform usage, battery types, and causes of explant in this cohort of providers. RESULTS There was similar degree of usage of tonic, burst, and 10 kHz usage at 71.5%, 74.1% and 61.7% respectively. Dorsal root ganglion stimulation was used by 32.6% and other modes of stimulation by 13.5%. Rechargeable systems were often or always used by 67.2% whereas 10% never used a rechargeable system. Most common cause of explant was loss of effectiveness, reported by 53.7%. CONCLUSION There has been significant adoption of new waveforms in daily practice of spinal cord stimulation therapy and there is robust mixed usage of new waveforms and frequencies. Rechargeable systems are the most commonly used but primary cell is also used in significant numbers. Loss of efficacy remains the most common cause of explant for the majority of practitioners. This survey establishes practice patterns of SCS usage regarding these important variables against which future changes can be gauged.
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Affiliation(s)
- Jatinder S Gill
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Lynn R Kohan
- University of Virginia Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Charlottesville, VA
| | - Jamal Hasoon
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
- UTHealth McGovern Medical School, Department of Anesthesia and Pain Medicine, Houston, TX
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA
- Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ
- Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
- University of Arizona College of Medicine Phoenix, Department of Anesthesiology, Phoenix, AZ
| | - Viet L Cai
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Cyrus Yazdi
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
| | - Musa M Aner
- Dartmouth-Hitchcock Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Dartmouth Medical School, Lebanon, NH
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA
| | - Thomas T Simopoulos
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA
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Tilley DM, Vallejo R, Vetri F, Platt DC, Cedeno DL. Activation of Neuroinflammation via mTOR Pathway is Disparately Regulated by Differential Target Multiplexed and Traditional Low-Rate Spinal Cord Stimulation in a Neuropathic Pain Model. J Pain Res 2022; 15:2857-2866. [PMID: 36156899 PMCID: PMC9507284 DOI: 10.2147/jpr.s378490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Spinal cord stimulation (SCS) has been used for decades to treat neuropathic pain conditions with limited understanding of its mechanisms of action. The mTOR pathway is a well-known co-factor in chronic pain and has not been previously linked to SCS therapy. Proteomic and phosphorylation analyses allow capturing a broad view of tissue response to an injury model and subsequent therapies such as SCS. Here, we evaluated the effect of differential target multiplexed SCS programming (DTMP) and traditional low-rate spinal cord stimulation (LR-SCS) on the mTOR pathway using proteomic and phosphoproteomic analyses. Methods The spared nerve injury (SNI) model of neuropathic pain in animals was established followed by continuous treatment with either DTMP or LR-SCS for 48 hours. Control groups included sham-stimulated (No-SCS) and uninjured animals (No-SNI). Proteins were extracted from spinal cord tissue removed post-stimulation and subjected to liquid chromatography/tandem mass spectrometry to assess changes in protein expression and states of phosphorylation. Bioinformatics tools and literature were used to identify mTOR-related proteins in the various groups. Results Over 7000 proteins were identified and filtered to find 1451 and 705 proteins significantly affected by DTMP and LR-SCS (p < 0.05), respectively, relative to No-SCS. Literature and bioinformatic tools yielded 192 mTOR-related proteins that were cross-referenced to the list of DTMP and LR-SCS affected proteins. Of these proteins, 49 were found in the proteomic dataset. Eight of these proteins showed a significant response to the pain model, 25 were significantly modulated by DTMP, and 8 by LR-SCS. Phosphoproteomic analyses yielded 119 mTOR-related phosphoproteins affected by the injury model with a 66% reversal following DTMP versus a 58% reversal by LR-SCS. Conclusion Proteomic and phosphoproteomic analyses support the hypothesis that DTMP, and to a lesser extent LR-SCS, reverse injury induced changes of the mTOR pathway while treating neuropathic pain.
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Affiliation(s)
- Dana M Tilley
- Research and Development, SGX Medical, Bloomington, IL, USA
| | - Ricardo Vallejo
- Research and Development, SGX Medical, Bloomington, IL, USA.,Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
| | - Francesco Vetri
- Research Department, National Spine and Pain Centers, Bloomington, IL, USA
| | - David C Platt
- Research and Development, SGX Medical, Bloomington, IL, USA.,Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
| | - David L Cedeno
- Research and Development, SGX Medical, Bloomington, IL, USA.,Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
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20
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Su PYP, Zhang L, He L, Zhao N, Guan Z. The Role of Neuro-Immune Interactions in Chronic Pain: Implications for Clinical Practice. J Pain Res 2022; 15:2223-2248. [PMID: 35957964 PMCID: PMC9359791 DOI: 10.2147/jpr.s246883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/19/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Po-Yi Paul Su
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Lingyi Zhang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
- Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People’s Republic of China
| | - Liangliang He
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
- Department of Pain Management, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Na Zhao
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Zhonghui Guan
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
- Correspondence: Zhonghui Guan, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA, Tel +415.885.7246, Fax +415.885.7575, Email
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21
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Strand N, J M, Tieppo Francio V, M M, Turkiewicz M, El Helou A, M M, S C, N S, J P, C W. Advances in Pain Medicine: a Review of New Technologies. Curr Pain Headache Rep 2022; 26:605-616. [PMID: 35904729 PMCID: PMC9334973 DOI: 10.1007/s11916-022-01062-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
Purpose of Review This narrative review highlights the interventional musculoskeletal techniques that have evolved in recent years. Recent Findings The recent progress in pain medicine technologies presented here represents the ideal treatment of the pain patient which is to provide personalized care. Advances in pain physiology research and pain management technologies support each other concurrently. Summary As new technologies give rise to new perspectives and understanding of pain, new research inspires the development of new technologies
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Affiliation(s)
- Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA. .,NorthShore University HealthSystem, Evanston, IL, USA. .,University of Chicago Medicine, Chicago, IL, USA.
| | - Maloney J
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), 3901 Rainbow Blvd. MS1046, Kansas City, KS, 66160, USA
| | - Murphy M
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), 3901 Rainbow Blvd. MS1046, Kansas City, KS, 66160, USA
| | | | - Antonios El Helou
- Department of Neurosurgery, The Moncton Hospital, Moncton, NB, Canada
| | - Maita M
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Covington S
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Singh N
- OrthoAlabama Spine and Sports, Birmingham, AL, USA
| | - Peck J
- Performing Arts Medicine Department, Shenandoah University, Winchester, VA, USA
| | - Wie C
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
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22
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Karri J, Doan J, Vangeison C, Catalanotto M, Nagpal AS, Li S. Emerging Evidence for Intrathecal Management of Neuropathic Pain Following Spinal Cord Injury. FRONTIERS IN PAIN RESEARCH 2022; 3:933422. [PMID: 35965596 PMCID: PMC9371595 DOI: 10.3389/fpain.2022.933422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
A high prevalence of patients with spinal cord injury (SCI) suffer from chronic neuropathic pain. Unfortunately, the precise pathophysiological mechanisms underlying this phenomenon have yet to be clearly elucidated and targeted treatments are largely lacking. As an unfortunate consequence, neuropathic pain in the population with SCI is refractory to standard of care treatments and represents a significant contributor to morbidity and suffering. In recent years, advances from SCI-specific animal studies and translational models have furthered our understanding of the neuronal excitability, glial dysregulation, and chronic inflammation processes that facilitate neuropathic pain. These developments have served advantageously to facilitate exploration into the use of neuromodulation as a treatment modality. The use of intrathecal drug delivery (IDD), with novel pharmacotherapies, to treat chronic neuropathic pain has gained particular attention in both pre-clinical and clinical contexts. In this evidence-based narrative review, we provide a comprehensive exploration into the emerging evidence for the pathogenesis of neuropathic pain following SCI, the evidence basis for IDD as a therapeutic strategy, and novel pharmacologics across impactful animal and clinical studies.
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Affiliation(s)
- Jay Karri
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Jay Karri
| | - James Doan
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- Veterans Affairs Boston Healthcare System—West Roxbury Division, Spinal Cord Injury Service, Boston, MA, United States
| | - Christian Vangeison
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Marissa Catalanotto
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Ameet S. Nagpal
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas HSC at Houston, Houston, TX, United States
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23
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Involvement of Opioid Peptides in the Analgesic Effect of Spinal Cord Stimulation in a Rat Model of Neuropathic Pain. Neurosci Bull 2022; 38:403-416. [PMID: 35397112 PMCID: PMC9068858 DOI: 10.1007/s12264-022-00844-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/19/2022] [Indexed: 10/18/2022] Open
Abstract
Spinal cord stimulation (SCS)-induced analgesia was characterized, and its underlying mechanisms were examined in a spared nerve injury model of neuropathic pain in rats. The analgesic effect of SCS with moderate mechanical hypersensitivity was increased with increasing stimulation intensity between the 20% and 80% motor thresholds. Various frequencies (2, 15, 50, 100, 10000 Hz, and 2/100 Hz dense-dispersed) of SCS were similarly effective. SCS-induced analgesia was maintained without tolerance within 24 h of continuous stimulation. SCS at 2 Hz significantly increased methionine enkephalin content in the cerebrospinal fluid. The analgesic effect of 2 Hz was abolished by μ or κ opioid receptor antagonist. The effect of 100 Hz was prevented by a κ antagonist, and that of 10 kHz was blocked by any of the μ, δ, or κ receptor antagonists, suggesting that the analgesic effect of SCS at different frequencies is mediated by different endorphins and opioid receptors.
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Cedeño DL, Tilley DM, Vetri F, Platt DC, Vallejo R. Proteomic and Phosphoproteomic Changes of MAPK-Related Inflammatory Response in an Animal Model of Neuropathic Pain by Differential Target Multiplexed SCS and Low-Rate SCS. J Pain Res 2022; 15:895-907. [PMID: 35392631 PMCID: PMC8983055 DOI: 10.2147/jpr.s348738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/24/2022] [Indexed: 12/30/2022] Open
Abstract
Introduction Neuropathic pain initiates an interplay of pathways, involving MAP kinases and NFκB-signaling, leading to expression of immune response factors and activation and inactivation of proteins via phosphorylation. Neuropathic pain models demonstrated that spinal cord stimulation (SCS) may provide analgesia by modulating gene and protein expression in neuroinflammatory processes. A differential target multiplexed programming (DTMP) approach was more effective than conventional SCS treatments at modulating these. This work investigated the effect of DTMP and low rate SCS (LR-SCS) on proteins associated with MAP kinases and NFκB-signaling relevant to neuroinflammation. Methods Animals subjected to the spared nerve injury model (SNI) of neuropathic pain were treated continuously (48h) with either DTMP or LR-SCS. No-SNI and No-SCS groups were included as controls. Proteomics and phosphoproteomics of stimulated spinal cord tissues were performed via liquid chromatography/tandem mass spectrometry. Proteins were identified from mass spectra using bioinformatics. Expression levels and fold changes (No-SCS/No-SNI and SCS/No-SCS) were obtained from spectral intensities. Results Analyses identified 7192 proteins, with 1451 and 705 significantly changed by DTMP and LR-SCS, respectively. Eighty-one proteins, including MAP kinases, facilitating NFκB-signaling as part of inflammatory processes were identified. The pain model significantly increased expression levels of complement pathway-related proteins (LBP, NRG1, APP, CFH, C3, C5), which were significantly reversed by DTMP. Expression levels of other complement pathway-related proteins (HMGB1, S100A8, S100A9, CRP, C4) were decreased by DTMP, although not significantly affected by SNI. Other proteins (ORM1, APOE, NG2, CNTF) involved in NFκB-signaling were increased by SNI and decreased by DTMP. Expression levels of phosphorylated protein kinases involved in NFκB-signaling (including MAP kinases, PKC, MARK1) were affected by the pain model and reverse modulated by DTMP. LR-SCS modulated inflammatory-related proteins although to a lesser extent than DTMP. Conclusion Proteomic analyses support the profound effect of the DTMP approach on neuroinflammation via MAP kinases and NFκB-mediated signaling to alleviate neuropathic pain.
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Affiliation(s)
- David L Cedeño
- Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
- Research and Development, SGX Medical, Bloomington, IL, USA
| | - Dana M Tilley
- Research and Development, SGX Medical, Bloomington, IL, USA
| | - Francesco Vetri
- Research Department, National Spine and Pain Centers, Bloomington, IL, USA
| | - David C Platt
- Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
- Research and Development, SGX Medical, Bloomington, IL, USA
| | - Ricardo Vallejo
- Neuroscience, Illinois Wesleyan University, Bloomington, IL, USA
- Research and Development, SGX Medical, Bloomington, IL, USA
- Research Department, National Spine and Pain Centers, Bloomington, IL, USA
- Correspondence: Ricardo Vallejo; David L Cedeño, Email ;
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25
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D'Souza RS, Olatoye OO, Butler CS, Barman RA, Ashmore ZM, Hagedorn JM. Adverse Events Associated With 10-kHz Dorsal Column Spinal Cord Stimulation: A 5-Year Analysis of the Manufacturer and User Facility Device Experience (MAUDE) Database. Clin J Pain 2022; 38:320-327. [PMID: 35132023 DOI: 10.1097/ajp.0000000000001026] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND High-frequency (10-kHz) spinal cord stimulation (SCS) continues to be an emerging therapy in chronic pain management. The same complications that plagued earlier SCS systems may affect newer stimulation technologies, although there is limited data on the type of complications and surgical management of these complications. OBJECTIVE The aim of this study was to systematically examine real-world complications associated with 10-kHz SCS reported on the Manufacturer and User Facility Device Experience (MAUDE) database. MATERIALS AND METHODS The MAUDE database was queried for entries reported between January 1, 2016 and December 31, 2020. Entries were classified into procedural complications, device-related complications, patient complaints, surgically managed complications, serious adverse events, and/or other complications. Primary outcomes included type and frequency of complications, and surgical management of complications. RESULTS A total of 1651 entries were analyzed. Most entries were categorized as procedural complications (72.6%), followed by serious adverse events (10.5%), device-related complications (10.5%), and patient complaints (9.9%). Most complications were managed surgically with explant (50.9%) rather than revision (5.0%) or incision/drainage (6.6%). Of procedural complications, the most common entries included non-neuraxial infection (52.9%), new neurological symptoms (14.7%), and dural puncture (9.5%). Of device-related complications, the most common entries included lead damage (41.6%), erosion (18.5%), and difficult insertion (11.5%). CONCLUSION This retrospective 5-year analysis of complications from10-kHz SCS provides a real-world assessment of safety data unique for this stimulation modality. This analysis may help inform future clinical decisions, lead to device enhancement and optimization, and improve mitigation of risks to provide safe and efficacious use of 10-kHz SCS.
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Affiliation(s)
- Ryan S D'Souza
- Division of Pain Medicine Department of Anesthesiology and Perioperative Medicine
| | - Oludare O Olatoye
- Division of Pain Medicine Department of Anesthesiology and Perioperative Medicine
| | - Casey S Butler
- Division of Pain Medicine Department of Anesthesiology and Perioperative Medicine
| | - Ross A Barman
- Departments of Anesthesiology and Perioperative Medicine
| | - Zachary M Ashmore
- Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Rochester, MN
| | - Jonathan M Hagedorn
- Division of Pain Medicine Department of Anesthesiology and Perioperative Medicine
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Graham RD, Sankarasubramanian V, Lempka SF. Dorsal Root Ganglion Stimulation for Chronic Pain: Hypothesized Mechanisms of Action. THE JOURNAL OF PAIN 2022; 23:196-211. [PMID: 34425252 PMCID: PMC8943693 DOI: 10.1016/j.jpain.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/28/2021] [Accepted: 07/20/2021] [Indexed: 02/03/2023]
Abstract
Dorsal root ganglion stimulation (DRGS) is a neuromodulation therapy for chronic pain that is refractory to conventional medical management. Currently, the mechanisms of action of DRGS-induced pain relief are unknown, precluding both our understanding of why DRGS fails to provide pain relief to some patients and the design of neurostimulation technologies that directly target these mechanisms to maximize pain relief in all patients. Due to the heterogeneity of sensory neurons in the dorsal root ganglion (DRG), the analgesic mechanisms could be attributed to the modulation of one or many cell types within the DRG and the numerous brain regions that process sensory information. Here, we summarize the leading hypotheses of the mechanisms of DRGS-induced analgesia, and propose areas of future study that will be vital to improving the clinical implementation of DRGS. PERSPECTIVE: This article synthesizes the evidence supporting the current hypotheses of the mechanisms of action of DRGS for chronic pain and suggests avenues for future interdisciplinary research which will be critical to fully elucidate the analgesic mechanisms of the therapy.
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Affiliation(s)
- Robert D. Graham
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Vishwanath Sankarasubramanian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States
| | - Scott F. Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, United States,Biointerfaces Institute, University of Michigan, Ann Arbor, MI 48109, United States,Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109, United States,Corresponding author: Scott F. Lempka, PhD, Department of Biomedical Engineering, University of Michigan, 2800 Plymouth Road, NCRC 14-184, Ann Arbor, MI 48109-2800,
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27
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Tilley DM, Cedeño DL, Vetri F, Platt DC, Vallejo R. Differential target multiplexed spinal cord stimulation programming modulates proteins involved in ion regulation in an animal model of neuropathic pain. Mol Pain 2022; 18:17448069211060181. [PMID: 35048719 PMCID: PMC8785327 DOI: 10.1177/17448069211060181] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The effect of spinal cord stimulation (SCS) using differential target multiplexed programming (DTMP) on proteins involved in the regulation of ion transport in spinal cord (SC) tissue of an animal model of neuropathic pain was evaluated in comparison to low rate (LR) SCS. Rats subjected to the spared nerve injury model (SNI) and implanted with a SCS lead were assigned to DTMP or LR and stimulated for 48 h. A No-SCS group received no stimulation, and a Sham group received no SNI or stimulation. Proteins in the dorsal ipsilateral quadrant of the stimulated SC were identified and quantified using mass spectrometry. Proteins significantly modulated by DTMP or LR relative to No-SCS were identified. Bioinformatic tools were used to identify proteins related to ion transport regulation. DTMP modulated a larger number of proteins than LR. More than 40 proteins significantly involved in the regulation of chloride (Cl-), potassium (K+), sodium (Na+), or calcium (Ca2+) ions were identified. SNI affected proteins that promote the increase of intracellular Ca2+, Na+, and K+ and decrease of intracellular Cl-. DTMP modulated proteins involved in glial response to neural injury that affect Ca2+ signaling. DTMP decreased levels of proteins related to Ca2+ transport that may result in the reduction of intracellular Ca2+. Presynaptic proteins involved in GABA vesicle formation and release were upregulated by DTMP. DTMP also upregulated postsynaptic proteins involved with elevated intracellular Cl-, while modulating proteins, expressed by astrocytes, that regulate postsynaptic Cl- inhibition. DTMP downregulated K+ regulatory proteins affected by SNI that affect neuronal depolarization, and upregulated proteins that are associated with a decrease of intracellular neuronal K+ and astrocyte uptake of extracellular K+. DTMP treatment modulated the expression of proteins with the potential to facilitate a reversal of dysregulation of ion transport and signaling associated with a model of neuropathic pain.
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Affiliation(s)
| | - David L Cedeño
- SGX Medical LLC, Bloomington, IL, USA.,Department of Psychology, 1770Illinois Wesleyan University, Bloomington, IL, USA
| | | | - David C Platt
- SGX Medical LLC, Bloomington, IL, USA.,Department of Psychology, 1770Illinois Wesleyan University, Bloomington, IL, USA
| | - Ricardo Vallejo
- SGX Medical LLC, Bloomington, IL, USA.,Department of Psychology, 1770Illinois Wesleyan University, Bloomington, IL, USA.,National Spine and Pain Centers, Bloomington, IL, USA
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Lubejko ST, Graham RD, Livrizzi G, Schaefer R, Banghart MR, Creed MC. The role of endogenous opioid neuropeptides in neurostimulation-driven analgesia. Front Syst Neurosci 2022; 16:1044686. [PMID: 36591324 PMCID: PMC9794630 DOI: 10.3389/fnsys.2022.1044686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Due to the prevalence of chronic pain worldwide, there is an urgent need to improve pain management strategies. While opioid drugs have long been used to treat chronic pain, their use is severely limited by adverse effects and abuse liability. Neurostimulation techniques have emerged as a promising option for chronic pain that is refractory to other treatments. While different neurostimulation strategies have been applied to many neural structures implicated in pain processing, there is variability in efficacy between patients, underscoring the need to optimize neurostimulation techniques for use in pain management. This optimization requires a deeper understanding of the mechanisms underlying neurostimulation-induced pain relief. Here, we discuss the most commonly used neurostimulation techniques for treating chronic pain. We present evidence that neurostimulation-induced analgesia is in part driven by the release of endogenous opioids and that this endogenous opioid release is a common endpoint between different methods of neurostimulation. Finally, we introduce technological and clinical innovations that are being explored to optimize neurostimulation techniques for the treatment of pain, including multidisciplinary efforts between neuroscience research and clinical treatment that may refine the efficacy of neurostimulation based on its underlying mechanisms.
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Affiliation(s)
- Susan T. Lubejko
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Robert D. Graham
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Giulia Livrizzi
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Robert Schaefer
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Matthew R. Banghart
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
- *Correspondence: Matthew R. Banghart,
| | - Meaghan C. Creed
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Neuroscience, Washington University in St. Louis, St. Louis, MO, United States
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
- Meaghan C. Creed,
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Malinowski MN, Chopra PR, Tieppo Francio V, Budwany R, Deer TR. A narrative review and future considerations of spinal cord stimulation, dorsal root ganglion stimulation and peripheral nerve stimulation. Curr Opin Anaesthesiol 2021; 34:774-780. [PMID: 34608057 DOI: 10.1097/aco.0000000000001072] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW In recent years, neuromodulation has experienced a renaissance. Novel waveforms and anatomic targets show potential improvements in therapy that may signify substantial benefits. New innovations in peripheral nerve stimulation and dorsal root ganglion stimulation have shown prospective evidence and sustainability of results. Sub-perception physiologic bursting, high-frequency stimulation and feedback loop mechanisms provide significant benefits over traditional tonic spinal cords stimulation (SCS) in peer reviewed investigations. We reviewed the themes associated with novel technology in the context of historical stalwart publications. RECENT FINDINGS New innovations have led to better nerve targeting, improvements in disease-based treatment, and opioid alternatives for those in chronic pain. In addition, new neural targets from both structural and cellular perspectives have changed the field of Neurostimulation. SUMMARY For many years, tonic SCS was representative of neuromodulation, but as this review examines, the progression of the field in the past decade has reshaped patient options.
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Affiliation(s)
- Mark N Malinowski
- OhioHealth Grant Medical Center, Ohio University Heritage COM, Columbus, Ohio
| | | | - Vinicius Tieppo Francio
- The University of Kansas Medical Center, Department of Rehabilitative Medicine, Kansas City, Kansas
| | - Ryan Budwany
- Center for Integrative Pain Management, West Virginia University School of Medicine, Morgantown
| | - Timothy Ray Deer
- The Spine and Nerve Center of The Virginias
- Anesthesiology and Pain Medicine, WVU School of Medicine
- American Society of Pain and Neuroscience, Charleston, West Virginia, USA
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30
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Torlakcik H, Sarica C, Bayer P, Yamamoto K, Iorio-Morin C, Hodaie M, Kalia SK, Neimat JS, Hernesniemi J, Bhatia A, Nelson BJ, Pané S, Lozano AM, Zemmar A. Magnetically Guided Catheters, Micro- and Nanorobots for Spinal Cord Stimulation. Front Neurorobot 2021; 15:749024. [PMID: 34744678 PMCID: PMC8565609 DOI: 10.3389/fnbot.2021.749024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022] Open
Abstract
Spinal cord stimulation (SCS) is an established treatment for refractory pain syndromes and has recently been applied to improve locomotion. Several technical challenges are faced by surgeons during SCS lead implantation, particularly in the confined dorsal epidural spaces in patients with spinal degenerative disease, scarring and while targeting challenging structures such as the dorsal root ganglion. Magnetic navigation systems (MNS) represent a novel technology that uses externally placed magnets to precisely steer tethered and untethered devices. This innovation offers several benefits for SCS electrode placement, including enhanced navigation control during tip placement, and the ability to position and reposition the lead in an outpatient setting. Here, we describe the challenges of SCS implant surgery and how MNS can be used to overcome these hurdles. In addition to tethered electrode steering, we discuss the navigation of untethered micro- and nanorobots for wireless and remote neuromodulation. The use of these small-scale devices can potentially change the current standard of practice by omitting the need for electrode and pulse generator implantation or replacement. Open questions include whether small-scale robots can generate an electrical field sufficient to activate neuronal tissue, as well as testing precise navigation, placement, anchoring, and biodegradation of micro- and nanorobots in the in vivo environment.
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Affiliation(s)
- Harun Torlakcik
- Department of Neurosurgery, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China.,Multi-Scale Robotics Laboratory, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Can Sarica
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Patrick Bayer
- Faculty of Medicine, Ludwig Maximilians University Munich, Munich, Germany
| | - Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Joseph S Neimat
- Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, KY, United States
| | - Juha Hernesniemi
- Department of Neurosurgery, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Bradley J Nelson
- Multi-Scale Robotics Laboratory, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Salvador Pané
- Multi-Scale Robotics Laboratory, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ajmal Zemmar
- Department of Neurosurgery, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, KY, United States
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31
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Wang J, Wu XC, Zhang MM, Ren JH, Sun Y, Liu JZ, Wu XQ, He SY, Li YQ, Zhang JB. Spinal cord stimulation reduces cardiac pain through microglial deactivation in rats with chronic myocardial ischemia. Mol Med Rep 2021; 24:835. [PMID: 34608504 PMCID: PMC8503748 DOI: 10.3892/mmr.2021.12475] [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: 07/15/2021] [Accepted: 09/07/2021] [Indexed: 01/14/2023] Open
Abstract
Angina pectoris is cardiac pain that is a common clinical symptom often resulting from myocardial ischemia. Spinal cord stimulation (SCS) is effective in treating refractory angina pectoris, but its underlying mechanisms have not been fully elucidated. The spinal dorsal horn is the first region of the central nervous system that receives nociceptive information; it is also the target of SCS. In the spinal cord, glial (astrocytes and microglia) activation is involved in the initiation and persistence of chronic pain. Thus, the present study investigated the possible cardiac pain-relieving effects of SCS on spinal dorsal horn glia in chronic myocardial ischemia (CMI). CMI was established by left anterior descending artery ligation surgery, which induced significant spontaneous/ongoing cardiac pain behaviors, as measured using the open field test in rats. SCS effectively improved such behaviors as shown by open field and conditioned place preference tests in CMI model rats. SCS suppressed CMI-induced spinal dorsal horn microglial activation, with downregulation of ionized calcium-binding adaptor protein-1 expression. Moreover, SCS inhibited CMI-induced spinal expression of phosphorylated-p38 MAPK, which was specifically colocalized with the spinal dorsal horn microglia rather than astrocytes and neurons. Furthermore, SCS could depress spinal neuroinflammation by suppressing CMI-induced IL-1β and TNF-α release. Intrathecal administration of minocycline, a microglial inhibitor, alleviated the cardiac pain behaviors in CMI model rats. In addition, the injection of fractalkine (microglia-activating factor) partially reversed the SCS-produced analgesic effects on CMI-induced cardiac pain. These results indicated that the therapeutic mechanism of SCS on CMI may occur partially through the inhibition of spinal microglial p38 MAPK pathway activation. The present study identified a novel mechanism underlying the SCS-produced analgesic effects on chronic cardiac pain.
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Affiliation(s)
- Jian Wang
- Department of Cardiothoracic Surgery, General Hospital of Western Theater Command, Chengdu, Sichuan 610083, P.R. China
| | - Xiao-Chen Wu
- Department of Cardiothoracic Surgery, General Hospital of Western Theater Command, Chengdu, Sichuan 610083, P.R. China
| | - Ming-Ming Zhang
- Department of Anatomy and K.K. Leung Brain Research Centre, Air Force Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Jia-Hao Ren
- Department of Anatomy and K.K. Leung Brain Research Centre, Air Force Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yi Sun
- Department of Anatomy and K.K. Leung Brain Research Centre, Air Force Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Jing-Zhen Liu
- Department of Cardiothoracic Surgery, General Hospital of Western Theater Command, Chengdu, Sichuan 610083, P.R. China
| | - Xi-Qiang Wu
- Department of Cardiothoracic Surgery, General Hospital of Western Theater Command, Chengdu, Sichuan 610083, P.R. China
| | - Si-Yi He
- Department of Cardiothoracic Surgery, General Hospital of Western Theater Command, Chengdu, Sichuan 610083, P.R. China
| | - Yun-Qing Li
- Department of Anatomy and K.K. Leung Brain Research Centre, Air Force Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Jin-Bao Zhang
- Department of Cardiothoracic Surgery, General Hospital of Western Theater Command, Chengdu, Sichuan 610083, P.R. China
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Howard-Quijano K, Yamaguchi T, Gao F, Kuwabara Y, Puig S, Lundquist E, Salavatian S, Taylor B, Mahajan A. Spinal Cord Stimulation Reduces Ventricular Arrhythmias by Attenuating Reactive Gliosis and Activation of Spinal Interneurons. JACC Clin Electrophysiol 2021; 7:1211-1225. [PMID: 34454884 DOI: 10.1016/j.jacep.2021.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study investigated spinal cord neuronal and glial cell activation during cardiac ischemia-reperfusion (IR)-triggered ventricular arrhythmias and neuromodulation therapy by spinal cord stimulation (SCS). BACKGROUND Myocardial ischemia induces changes in cardiospinal neural networks leading to sudden cardiac death. Neuromodulation with SCS decreases cardiac sympathoexcitation; however, the molecular mechanisms remain unknown. METHODS Yorkshire pigs (n = 16) were randomized to Control, IR, or IR+SCS groups. A 4-pole SCS lead was placed in the T1-T4 epidural space with stimulation for 30 minutes before IR (50 Hz, 0.4-ms duration, 90% motor threshold). Cardiac electrophysiological mapping and Ventricular Arrhythmia Score (VAS) were recorded. Immunohistochemistry of thoracic spinal sections was used to map and identify Fos-positive neuronal and glial cell types during IR with and without SCS. RESULTS IR increased cardiac sympathoexcitation and arrhythmias (VAS = 6.2 ± 0.9) that were attenuated in IR + SCS (VAS = 2.8 ± 0.5; P = 0.017). IR increased spinal cellular Fos expression (#Fos+ cells Control = 23 ± 2 vs IR = 88 ± 5; P < 0.0001) in T1-T4, with the greatest increase localized to T3, and the greatest %Fos+ cells being microglia and astrocytes. Fos expression was attenuated by IR + SCS (62 ± 4; P < 0.01), primarily though a reduction in Fos+ microglia and astrocytes, as SCS also led to increase in Fos+ neurons in deep dorsal laminae. CONCLUSIONS In a porcine model, cardiac IR was associated with astrocyte and microglial cell activation. Our results suggest that preemptive thoracic SCS decreased IR-induced cardiac sympathoexcitation and ventricular arrhythmias through attenuation of reactive gliosis and activation of inhibitory interneurons in the dorsal horn of spinal cord.
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Affiliation(s)
- Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tomoki Yamaguchi
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Fei Gao
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Stephanie Puig
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eevanna Lundquist
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradley Taylor
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Fishman M, Cordner H, Justiz R, Provenzano D, Merrell C, Shah B, Naranjo J, Kim P, Calodney A, Carlson J, Bundschu R, Sanapati M, Mangal V, Vallejo R. Twelve-Month results from multicenter, open-label, randomized controlled clinical trial comparing differential target multiplexed spinal cord stimulation and traditional spinal cord stimulation in subjects with chronic intractable back pain and leg pain. Pain Pract 2021; 21:912-923. [PMID: 34363307 PMCID: PMC9290817 DOI: 10.1111/papr.13066] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/18/2022]
Abstract
Background Spinal cord stimulation (SCS) is a well‐established treatment for chronic intractable pain of the trunk and/or limbs; however, low back pain (LBP) is difficult to treat using traditional SCS. Differential Target Multiplexed spinal cord stimulation (DTM SCS) is an advanced approach inspired from animal studies demonstrating improved pain‐related behavior and pain‐relevant biological processes. Objective The purpose of this study was to compare the effectiveness of DTM SCS and traditional SCS in treating chronic LBP and leg pain (LP). Methods This prospective, postmarket randomized controlled trial compared DTM SCS to traditional SCS in patients with chronic LBP and LP. Primary end point was LBP responder rate (percentage of subjects with ≥ 50% relief) at 3 months. Noninferiority and superiority were assessed. Other outcomes included mean change in back and leg pain, responder rates, disability, global health, satisfaction, and safety profile throughout the 12‐month follow‐up. Results One hundred twenty‐eight subjects were randomized across 12 centers (67 DTM SCS and 61 traditional SCS). Of the 94 patients implanted, 46 subjects in each group completed the 3‐month assessment. LBP responder rate of 80.1% with DTM SCS was superior to 51.2% with traditional SCS (p = 0.0010). Mean LBP reduction (5.36 cm) with DTM SCS was greater than reduction (3.37 cm) with traditional SCS (p < 0.0001). These results were sustained at 6 months and 12 months. Safety profiles were similar between treatment groups. Conclusion Superiority of DTM SCS compared with traditional SCS for chronic LBP was demonstrated. Clinical improvements provided by DTM SCS were sustained over 12 months and are expected to significantly impact the management of chronic LBP.
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Affiliation(s)
- Michael Fishman
- Center for Interventional Pain and Spine, Exton, Pennsylvania, USA
| | - Harold Cordner
- Florida Pain Management Associates, Sebastian, Florida, USA
| | - Rafael Justiz
- Oklahoma Pain Physicians, Oklahoma City, Oklahoma, USA
| | - David Provenzano
- Pain Diagnostics and Interventional Care, LLC, Sewickly, Pennsylvania, USA
| | | | - Binit Shah
- Carolinas Research Institute, PLLC, Huntersville, North Carolina, USA
| | - Julian Naranjo
- South Florida Clinical Research, South Miami, Florida, USA
| | - Philip Kim
- Center for Interventional Pain and Spine, Exton, Pennsylvania, USA
| | | | | | | | | | - Vipul Mangal
- National Spine and Pain Center, Oxon Hill, Maryland, USA
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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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35
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Cedeño DL, Smith WJ, Kelley CA, Vallejo R. Spinal cord stimulation using differential target multiplexed programming modulates neural cell-specific transcriptomes in an animal model of neuropathic pain. Mol Pain 2021; 16:1744806920964360. [PMID: 33050770 PMCID: PMC7710394 DOI: 10.1177/1744806920964360] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Spinal cord stimulation is a proven effective therapy for treating chronic
neuropathic pain. Previous work in our laboratory demonstrated that spinal cord
stimulation based on a differential target multiplexed programming approach
provided significant relief of pain-like behavior in rodents subjected to the
spared nerve injury model of neuropathic pain. The relief was significantly
better than obtained using high rate and low rate programming. Furthermore,
transcriptomics-based results implied that differential target multiplexed
programming modulates neuronal–glial interactions that have been perturbed by
the pain process. Although differential target multiplexed programming was
developed to differentially target neurons and glial cells, our previous work
did not address this. This work presents transcriptomes, specific to each of the
main neural cell populations (neurons, microglia, astrocytes, and
oligodendrocytes), obtained from spinal cord subjected to continuous spinal cord
stimulation treatment with differential target multiplexed programming, high
rate programming, or low rate programming compared with no spinal cord
stimulation treatment, using the spared nerve injury model. To assess the effect
of each spinal cord stimulation treatment on these cell-specific transcriptomes,
gene expression levels were compared with that of healthy animals, naïve to
injury and interventional procedures. Pearson correlations and cell population
analysis indicate that differential target multiplexed programming yielded
strong and significant correlations to expression levels found in the healthy
animals across every evaluated cell-specific transcriptome. In contrast, high
rate programming only yielded a strong correlation for the microglia-specific
transcriptome, while low rate programming did not yield strong correlations with
any cell types. This work provides evidence that differential target multiplexed
programming distinctively targeted and modulated the expression of cell-specific
genes in the direction of the healthy state thus supporting its previously
established action on regulating neuronal–glial interaction processes in a pain
model.
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Affiliation(s)
- David L Cedeño
- Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - William J Smith
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Courtney A Kelley
- Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Ricardo Vallejo
- Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,National Spine and Pain Centers, Bloomington, IL, USA
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Cedeño DL, Kelley CA, Chakravarthy K, Vallejo R. Modulation of Glia-Mediated Processes by Spinal Cord Stimulation in Animal Models of Neuropathic Pain. FRONTIERS IN PAIN RESEARCH 2021; 2:702906. [PMID: 35295479 PMCID: PMC8915735 DOI: 10.3389/fpain.2021.702906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/31/2021] [Indexed: 12/23/2022] Open
Abstract
Glial cells play an essential role in maintaining the proper functioning of the nervous system. They are more abundant than neurons in most neural tissues and provide metabolic and catabolic regulation, maintaining the homeostatic balance at the synapse. Chronic pain is generated and sustained by the disruption of glia-mediated processes in the central nervous system resulting in unbalanced neuron–glial interactions. Animal models of neuropathic pain have been used to demonstrate that changes in immune and neuroinflammatory processes occur in the course of pain chronification. Spinal cord stimulation (SCS) is an electrical neuromodulation therapy proven safe and effective for treating intractable chronic pain. Traditional SCS therapies were developed based on the gate control theory of pain and rely on stimulating large Aβ neurons to induce paresthesia in the painful dermatome intended to mask nociceptive input carried out by small sensory neurons. A paradigm shift was introduced with SCS treatments that do not require paresthesia to provide effective pain relief. Efforts to understand the mechanism of action of SCS have considered the role of glial cells and the effect of electrical parameters on neuron–glial interactions. Recent work has provided evidence that SCS affects expression levels of glia-related genes and proteins. This inspired the development of a differential target multiplexed programming (DTMP) approach using electrical signals that can rebalance neuroglial interactions by targeting neurons and glial cells differentially. Our group pioneered the utilization of transcriptomic and proteomic analyses to identify the mechanism of action by which SCS works, emphasizing the DTMP approach. This is an account of evidence demonstrating the effect of SCS on glia-mediated processes using neuropathic pain models, emphasizing studies that rely on the evaluation of large sets of genes and proteins. We show that SCS using a DTMP approach strongly affects the expression of neuron and glia-specific transcriptomes while modulating them toward expression levels of healthy animals. The ability of DTMP to modulate key genes and proteins involved in glia-mediated processes affected by pain toward levels found in uninjured animals demonstrates a shift in the neuron–glial environment promoting analgesia.
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Affiliation(s)
- David L. Cedeño
- Research and Development, Lumbrera LLC, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
- *Correspondence: David L. Cedeño
| | - Courtney A. Kelley
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
| | - Krishnan Chakravarthy
- Deparment of Anesthesiology and Pain Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Ricardo Vallejo
- Research and Development, Lumbrera LLC, Bloomington, IL, United States
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL, United States
- Research Department, National Spine and Pain Center, Bloomington, IL, United States
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Tao X, Luo X, Zhang T, Hershey B, Esteller R, Ji RR. Spinal Cord Stimulation Attenuates Mechanical Allodynia and Increases Central Resolvin D1 Levels in Rats With Spared Nerve Injury. Front Physiol 2021; 12:687046. [PMID: 34248674 PMCID: PMC8267572 DOI: 10.3389/fphys.2021.687046] [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: 03/28/2021] [Accepted: 05/12/2021] [Indexed: 12/31/2022] Open
Abstract
Mounting evidence from animal models of inflammatory and neuropathic pain suggests that inflammation regulates the resolution of pain by producing specialized pro-resolving mediators (SPMs), such as resolvin D1 (RvD1). However, it remains unclear how SPMs are induced in the central nervous system and whether these mechanisms can be reconciled with outcomes of neuromodulation therapies for pain, such as spinal cord stimulation. Here, we show that in a male rat model of neuropathic pain produced by spared nerve injury (SNI), 1 kHz spinal cord stimulation (1 kHz SCS) alone was sufficient to reduce mechanical allodynia and increase RvD1 in the cerebrospinal fluid (CSF). SNI resulted in robust and persistent mechanical allodynia and cold allodynia. Spinal cord electrode implantation was conducted at the T11-T13 vertebral level 1 week after SNI. The spinal locations of the implanted electrodes were validated by X-Ray radiography. 1 kHz SCS was applied for 6 h at 0.1 ms pulse-width, and this stimulation alone was sufficient to effectively reduce nerve injury-induced mechanical allodynia during stimulation without affecting SNI-induced cold allodynia. SCS alone significantly reduced interleukin-1β levels in both serum and CSF samples. Strikingly, SCS significantly increased RvD1 levels in the CSF but not serum. Finally, intrathecal injection of RvD1 (100 and 500 ng, i.t.) 4 weeks after nerve injury reduced SNI-induced mechanical allodynia in a dose-dependent manner. Our findings suggest that 1 kHz SCS may alleviate neuropathic pain via reduction of IL-1β and via production and/or release of RvD1 to control SNI-induced neuroinflammation.
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Affiliation(s)
- Xueshu Tao
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States.,Department of Pain Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xin Luo
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Tianhe Zhang
- Boston Scientific Neuromodulation Research and Advanced Concepts, Valencia, CA, United States
| | - Brad Hershey
- Boston Scientific Neuromodulation Research and Advanced Concepts, Valencia, CA, United States
| | - Rosana Esteller
- Boston Scientific Neuromodulation Research and Advanced Concepts, Valencia, CA, United States
| | - Ru-Rong Ji
- Center for Translational Pain Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States.,Department of Cell Biology, Duke University Medical Center, Durham, NC, United States.,Department of Neurobiology, Duke University Medical Center, Durham, NC, United States
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Deer TR, Eldabe S, Falowski SM, Huntoon MA, Staats PS, Cassar IR, Crosby ND, Boggs JW. Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. J Pain Res 2021; 14:721-736. [PMID: 33737830 PMCID: PMC7966353 DOI: 10.2147/jpr.s297091] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is an effective tool for the treatment of chronic pain, although its efficacy and utilization have previously been significantly limited by technology. In recent years, purpose-built percutaneous PNS devices have been developed to overcome the limitations of conventional permanently implanted neurostimulation devices. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period, outcomes that have not previously been observed with conventional permanently implanted neurostimulation devices. This narrative review summarizes mechanistic processes that contribute to chronic pain, and the potential mechanisms by which selective large diameter afferent fiber activation may reverse these changes to induce a prolonged reduction in pain. The interplay of these mechanisms, supported by data in chronic pain states that have been effectively treated with percutaneous PNS, will also be discussed in support of a new theory of pain management in neuromodulation: Peripherally Induced Reconditioning of the Central Nervous System (CNS).
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Affiliation(s)
- 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
| | - Steven M Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Marc A Huntoon
- Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Asimakidou E, Matis GK. Spinal cord stimulation in the treatment of peripheral vascular disease: a systematic review - revival of a promising therapeutic option? Br J Neurosurg 2021; 36:555-563. [PMID: 33703962 DOI: 10.1080/02688697.2021.1884189] [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] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Peripheral vascular disease (PVD) is caused by a blood circulation disorder of the arteries and Critical Limb Ischemia (CLI) is the advanced state of PVD. For patients with surgically non-reconstructable CLI, Spinal Cord Stimulation (SCS) appears to be an alternative therapeutic option. OBJECTIVE The aim of our study was to investigate the efficacy of SCS in non-reconstructable CLI compared with the conservative treatment and re-appraise the existing literature in light of the recent advances in neuromodulation. METHODS We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, using electronic databases and reference lists for article retrieval. RESULTS A total of 404 records were identified and finally 6 randomised controlled trials (RCTs), a Cochrane review and a meta-analysis were included in our systematic review. The studies assessed the efficacy of tonic SCS in the treatment of patients with non-reconstructable CLI compared with the conservative treatment. There is moderate to high quality evidence suggesting, that tonic SCS has beneficial effects for patients suffering from non-reconstructable CLI in terms of limb salvage, pain relief, clinical improvement and quality of life. The contradictory conclusions of the two meta-analyses regarding the efficacy of SCS for limb salvage at 12 months refer rather to the magnitude of the beneficial effect than to the effect itself. So far, the current literature provides evidence about the traditional tonic SCS but there is a lack of studies investigating the efficacy of new waveforms in the treatment of non-reconstructable CLI. CONCLUSION SCS represents an alternative for PVD patients with non-reconstructable CLI and the existing literature provides encouraging clinical results, that should not be neglected. Instead, they should be re-appraised in light of the recent advances in neuromodulation with the emergence of novel waveform technologies and neuromodulation targets.
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Affiliation(s)
- Evridiki Asimakidou
- Department of Stereotactic and Functional Neurosurgery, University Cologne Hospital, Cologne, Germany
| | - Georgios K Matis
- Department of Stereotactic and Functional Neurosurgery, University Cologne Hospital, Cologne, Germany
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Smith WJ, Cedeño DL, Thomas SM, Kelley CA, Vetri F, Vallejo R. Modulation of microglial activation states by spinal cord stimulation in an animal model of neuropathic pain: Comparing high rate, low rate, and differential target multiplexed programming. Mol Pain 2021; 17:1744806921999013. [PMID: 33626981 PMCID: PMC7925954 DOI: 10.1177/1744806921999013] [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] [Indexed: 12/12/2022] Open
Abstract
While numerous studies and patient experiences have demonstrated the efficacy of spinal cord stimulation as a treatment for chronic neuropathic pain, the exact mechanism underlying this therapy is still uncertain. Recent studies highlighting the importance of microglial cells in chronic pain and characterizing microglial activation transcriptomes have created a focus on microglia in pain research. Our group has investigated the modulation of gene expression in neurons and glial cells after spinal cord stimulation (SCS), specifically focusing on transcriptomic changes induced by varying SCS stimulation parameters. Previous work showed that, in rodents subjected to the spared nerve injury (SNI) model of neuropathic pain, a differential target multiplexed programming (DTMP) approach provided significantly better relief of pain-like behavior compared to high rate (HRP) and low rate programming (LRP). While these studies demonstrated the importance of transcriptomic changes in SCS mechanism of action, they did not specifically address the role of SCS in microglial activation. The data presented herein utilizes microglia-specific activation transcriptomes to further understand how an SNI model of chronic pain and subsequent continuous SCS treatment with either DTMP, HRP, or LRP affects microglial activation. Genes for each activation transcriptome were identified within our dataset and gene expression levels were compared with that of healthy animals, naïve to injury and interventional procedures. Pearson correlations indicated that DTMP yields the highest significant correlations to expression levels found in the healthy animals across all microglial activation transcriptomes. In contrast, HRP or LRP yielded weak or very weak correlations for these transcriptomes. This work demonstrates that chronic pain and subsequent SCS treatments can modulate microglial activation transcriptomes, supporting previous research on microglia in chronic pain. Furthermore, this study provides evidence that DTMP is more effective than HRP and LRP at modulating microglial transcriptomes, offering potential insight into the therapeutic efficacy of DTMP.
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Affiliation(s)
- William J Smith
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - David L Cedeño
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Samuel M Thomas
- College of Osteopathic Medicine, Des Moines University, Des Moines, IA, USA
| | - Courtney A Kelley
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | | | - Ricardo Vallejo
- Research and Development, Lumbrera LLC, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,National Spine and Pain Centers, Bloomington, IL, USA
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Provenzano DA, Heller JA, Hanes MC. Current Perspectives on Neurostimulation for the Management of Chronic Low Back Pain: A Narrative Review. J Pain Res 2021; 14:463-479. [PMID: 33628045 PMCID: PMC7899039 DOI: 10.2147/jpr.s249580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/16/2020] [Indexed: 01/29/2023] Open
Abstract
Neurostimulation techniques for the treatment of chronic low back pain (LBP) have been rapidly evolving; however, questions remain as to which modalities provide the most efficacious and durable treatment for intractable axial symptoms. Modalities of spinal cord stimulation, such as traditional low-frequency paresthesia based, high-density or high dose (HD), burst, 10-kHz high-frequency therapy, closed-loop, and differential target multiplexed, have been limitedly studied to determine their efficacy for the treatment of axial LBP. In addition, stimulation methods that target regions other than the spinal cord, such as medial branch nerve stimulation of the multifidus muscles and the dorsal root ganglion may also be viable treatment options. Here, current scientific evidence behind neurostimulation techniques have been reviewed with a focus on the management of chronic axial LBP.
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Affiliation(s)
- David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA, USA.,Western PA Surgery Center, Wexford, PA, USA
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Chakravarthy K, Bink H, Dinsmoor D. Sensing Evoked Compound Action Potentials from the Spinal Cord: Novel Preclinical and Clinical Considerations for the Pain Management Researcher and Clinician. J Pain Res 2020; 13:3269-3279. [PMID: 33328760 PMCID: PMC7733896 DOI: 10.2147/jpr.s289098] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/25/2020] [Indexed: 01/16/2023] Open
Abstract
Purpose Spinal cord stimulation (SCS) is a drug-free treatment for chronic neuropathic pain. Recent SCS technology can record evoked compound action potentials (ECAPs) in the spinal cord during therapy and utilize features of the sensed ECAP to optimize the SCS. The purpose of this work is to characterize the relevant parameters that govern the integrity and morphology of acquired ECAPs, and the implications for pain management clinicians and researchers working with ECAPs. Materials and Methods Eight-contact percutaneous SCS leads were implanted into sheep, and a prototype ECAP-sensing system was used to record spinal cord activity across a range of electrode configurations, pulse widths, and stimulus amplitudes. Similar iterative testing was then completed in human subjects who were undergoing trials of commercial SCS systems. Results Longer pulse width stimulation results in a progressive increase in ECAP latency, a neurophysiologic effect that enables ECAP sensing with longer pulses despite more encroachment by stimulation artifact. ECAPs may manifest a polyphasic morphology—an effect not seen in all subjects studied—with longer pulse width stimulation; these later phases may be used to assess ECAP amplitude when earlier features are effaced by artifact. Triphasic stimulation limits artifact from spinal cord ECAPs at the expense of potentially higher activation thresholds. If applied, alternating polarity stimulation must account for the ECAP latency differences resulting from alternating sites of neural activation. Conclusion Together, this information can allow the ECAP to be readily distinguished from the stimulation artifact, although movement may continue to be a confounder; caution is inculcated for ECAP signal processing techniques that rely on the stability of the artifact to avoid clinically misleading results. The promise of closed-loop, ECAP-servoed neuromodulation relies on accurate and proper sensing of the ECAP, while clearly elucidating the clinically relevant trade-offs and design choices made to enable these novel features.
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Affiliation(s)
- Krishnan Chakravarthy
- Anesthesiology and Pain Management, University of California San Diego, San Diego, CA, USA
| | - Hank Bink
- Neuromodulation, Medtronic Plc, Minneapolis, MN, USA
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Shu B, He SQ, Guan Y. Spinal Cord Stimulation Enhances Microglial Activation in the Spinal Cord of Nerve-Injured Rats. Neurosci Bull 2020; 36:1441-1453. [PMID: 32889636 DOI: 10.1007/s12264-020-00568-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Microglia can modulate spinal nociceptive transmission. Yet, their role in spinal cord stimulation (SCS)-induced pain inhibition is unclear. Here, we examined how SCS affects microglial activation in the lumbar cord of rats with chronic constriction injury (CCI) of the sciatic nerve. Male rats received conventional SCS (50 Hz, 80% motor threshold, 180 min, 2 sessions/day) or sham stimulation on days 18-20 post-CCI. SCS transiently attenuated the mechanical hypersensitivity in the ipsilateral hind paw and increased OX-42 immunoreactivity in the bilateral dorsal horns. SCS also upregulated the mRNAs of M1-like markers, but not M2-like markers. Inducible NOS protein expression was increased, but brain-derived neurotrophic factor was decreased after SCS. Intrathecal minocycline (1 μg-100 μg), which inhibits microglial activation, dose-dependently attenuated the mechanical hypersensitivity. Pretreatment with low-dose minocycline (1 μg, 30 min) prolonged the SCS-induced pain inhibition. These findings suggest that conventional SCS may paradoxically increase spinal M1-like microglial activity and thereby compromise its own ability to inhibit pain.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shao-Qiu He
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA. .,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
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Fishman MA, Calodney A, Kim P, Slezak J, Benyamin R, Rehman A, Soto E, Yang T, Hacobian A, Griffith L, Yu C, Vallejo R. Prospective, Multicenter Feasibility Study to Evaluate Differential Target Multiplexed Spinal Cord Stimulation Programming in Subjects With Chronic Intractable Back Pain With or Without Leg Pain. Pain Pract 2020; 20:761-768. [DOI: 10.1111/papr.12908] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/26/2020] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Philip Kim
- Center for Interventional Pain and Spine Exton PennsylvaniaU.S.A
| | - Jan Slezak
- Interventional Spine Medicine Barrington New HampshireU.S.A
| | | | - Atiq Rehman
- Decatur Memorial Hospital Decatur IllinoisU.S.A
| | - Eliezer Soto
- Millennium Pain Center—Libertyville Libertyville IllinoisU.S.A
| | - Thomas Yang
- Swedish Medical Center Seattle Washington U.S.A
| | | | | | - Cong Yu
- Swedish Medical Center Seattle Washington U.S.A
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