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Gilbert JE, Zhang T, Esteller R, Grill WM. Network model of nociceptive processing in the superficial spinal dorsal horn reveals mechanisms of hyperalgesia, allodynia, and spinal cord stimulation. J Neurophysiol 2023; 130:1103-1117. [PMID: 37727912 DOI: 10.1152/jn.00186.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/21/2023] Open
Abstract
The spinal dorsal horn (DH) processes sensory information and plays a key role in transmitting nociception to supraspinal centers. Loss of DH inhibition during neuropathic pain unmasks a pathway from nonnociceptive Aβ-afferent inputs to superficial dorsal horn (SDH) nociceptive-specific (NS) projection neurons, and this change may contribute to hyperalgesia and allodynia. We developed and validated a computational model of SDH neuronal circuitry that links nonnociceptive Aβ-afferent inputs in lamina II/III to a NS projection neuron in lamina I via a network of excitatory interneurons. The excitatory pathway and the NS projection neuron were in turn gated by inhibitory interneurons with connections based on prior patch-clamp recordings. Changing synaptic weights in the computational model to replicate neuropathic pain states unmasked a low-threshold excitatory pathway to NS neurons similar to experimental recordings. Spinal cord stimulation (SCS) is an effective therapy for neuropathic pain, and accumulating experimental evidence indicates that NS neurons in the SDH also respond to SCS. Accounting for these responses may inform therapeutic improvements, and we quantified responses to SCS in the SDH network model and examined the role of different modes of inhibitory control in modulating NS neuron responses to SCS. We combined the SDH network model with a previously published model of the deep dorsal horn (DDH) and identified optimal stimulation frequencies across different neuropathic pain conditions. Finally, we found that SCS-generated inhibition did not completely suppress model NS activity during simulated pinch inputs, providing an explanation of why SCS does not eliminate acute pain.NEW & NOTEWORTHY Chronic pain is a severe public health problem that reduces the quality of life for those affected and exacts an enormous socio-economic burden worldwide. Spinal cord stimulation (SCS) is an effective treatment for chronic pain, but SCS efficacy has not significantly improved over time, in part because the mechanisms of action remain unclear. Most preclinical studies investigating pain and SCS mechanisms have focused on the responses of deep dorsal horn (DDH) neurons, but neural networks in the superficial dorsal horn (SDH) are also important for processing nociceptive information. This work synthesizes heterogeneous experimental recordings from the SDH into a computational model that replicates experimental responses and that can be used to quantify neuronal responses to SCS under neuropathic pain conditions.
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Affiliation(s)
- John E Gilbert
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States
| | - Tianhe Zhang
- Neuromodulation Research and Advanced Concepts, Boston Scientific Neuromodulation, Valencia, California, United States
| | - Rosana Esteller
- Neuromodulation Research and Advanced Concepts, Boston Scientific Neuromodulation, Valencia, California, United States
| | - Warren M Grill
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States
- Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina, United States
- Department of Neurobiology, Duke University School of Medicine, Durham, North Carolina, United States
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, United States
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Ness TJ, Su X. Parametric Assessment of Spinal Cord Stimulation on Bladder Pain-Like Responses in Rats. Neuromodulation 2022; 25:1134-1140. [PMID: 35088748 DOI: 10.1016/j.neurom.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 08/09/2021] [Accepted: 09/07/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) for the treatment of pelvic visceral pains has been understudied and underused. The goal of the current study was to examine multiple stimulation parameters of SCS to determine optimal settings for the inhibition of responses to urinary bladder distension (UBD) in animal models of bladder pain as a guide for human studies. MATERIALS AND METHODS Adult, female isoflurane/urethane-anesthetized rats underwent a T13/L1 mini-laminectomy sufficient to implant an SCS paddle lead for neuromodulation. Silver wire electrodes were inserted into the external oblique musculature. A 22-gauge angiocatheter was placed transurethrally into the bladder and used to deliver phasic, air UBDs at pressures of 10 to 60 mm Hg and visceromotor (abdominal contractile) electromyographic responses to UBD measured in the presence and absence of SCS. Electromyographic activity was quantified using standard differential amplification and rectification. Parameter settings for SCS included both conventional (10, 50, 100 Hz) and high frequency (1,000, 5,000, and 10,000 Hz) biphasic square wave pulses with 50 to 200 μs durations. To create states of hypersensitivity, pretreatment of adult rats included an intravesical zymosan infusion 24 hours before testing with and without a preceding episode of neonatal bladder inflammation. RESULTS Low frequency (10, 50, and 100 Hz) 200 μs biphasic pulses at submotor thresholds demonstrated inhibition of visceromotor responses (VMRs) to UBD in rats made hypersensitive to UBD by a protocol that included neonatal cystitis. Onset of inhibitory effects occurred within 20 minutes of beginning SCS. Otherwise, SCS at all other parameters studied and in other tested rat models produced either no significant effect or augmentation of VMRs. CONCLUSIONS Demonstration of inhibitory effects of SCS in a clinically relevant model of bladder pain suggests the potential utility of this therapy in patients with painful bladder disorders.
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Affiliation(s)
- Timothy J Ness
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Xin Su
- Global Neuromodulation Research, Medtronic, Fridley, MN, USA
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Sato KL, Sanada LS, Silva MDD, Okubo R, Sluka KA. Transcutaneous electrical nerve stimulation, acupuncture, and spinal cord stimulation on neuropathic, inflammatory and, non-inflammatory pain in rat models. Korean J Pain 2020; 33:121-130. [PMID: 32235012 PMCID: PMC7136295 DOI: 10.3344/kjp.2020.33.2.121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/01/2019] [Accepted: 12/15/2019] [Indexed: 01/05/2023] Open
Abstract
Background Transcutaneous electrical nerve stimulation (TENS), manual acupuncture (MA), and spinal cord stimulation (SCS) are used to treat a variety of pain conditions. These non-pharmacological treatments are often thought to work through similar mechanisms, and thus should have similar effects for different types of pain. However, it is unclear if each of these treatments work equally well on each type of pain condition. The purpose of this study was to compared the effects of TENS, MA, and SCS on neuropathic, inflammatory, and non-inflammatory pain models. Methods TENS 60 Hz, 200 μs, 90% motor threshold (MT), SCS was applied at 60 Hz, an intensity of 90% MT, and a 0.25 ms pulse width. MA was performed by inserting a stainless-steel needle to a depth of about 4-5 mm at the Sanyinjiao (SP6) and Zusanli (ST36) acupoints on a spared nerve injury (SNI), knee joint inflammation (3% carrageenan), and non-inflammatory muscle pain (intramuscular pH 4.0 injections) in rats. Mechanical withdrawal thresholds of the paw, muscle, and/or joint were assessed before and after induction of the pain model, and daily before and after treatment. Results The reduced withdrawal thresholds were significantly reversed by application of either TENS or SCS (P < 0.05). MA, on the other hand, increased the withdrawal threshold in animals with SNI and joint inflammation, but not chronic muscle pain. Conclusions TENS and SCS produce similar effects in neuropathic, inflammatory and non-inflammatory muscle pain models while MA is only effective in inflammatory and neuropathic pain models.
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Affiliation(s)
- Karina Laurenti Sato
- Department of Physical Therapy, Federal University of Sergipe, Sao Cristovao, Brazil
| | - Luciana Sayuri Sanada
- Department of Physical Therapy, Physiotherapy Postgraduate Program, Santa Catarina State University, Florianopolis, Brazil
| | | | - Rodrigo Okubo
- Department of Physical Therapy, Physiotherapy Postgraduate Program, Santa Catarina State University, Florianopolis, Brazil
| | - Kathleen A Sluka
- Department of Physical Therapy and Rehabilitation Science, Pain Research Program, University of Iowa, Iowa City, IA, USA
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Suppression of Superficial Microglial Activation by Spinal Cord Stimulation Attenuates Neuropathic Pain Following Sciatic Nerve Injury in Rats. Int J Mol Sci 2020; 21:ijms21072390. [PMID: 32235682 PMCID: PMC7177766 DOI: 10.3390/ijms21072390] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 12/29/2022] Open
Abstract
We evaluated the mechanisms underlying the spinal cord stimulation (SCS)-induced analgesic effect on neuropathic pain following spared nerve injury (SNI). On day 3 after SNI, SCS was performed for 6 h by using electrodes paraspinally placed on the L4-S1 spinal cord. The effects of SCS and intraperitoneal minocycline administration on plantar mechanical sensitivity, microglial activation, and neuronal excitability in the L4 dorsal horn were assessed on day 3 after SNI. The somatosensory cortical responses to electrical stimulation of the hind paw on day 3 following SNI were examined by using in vivo optical imaging with a voltage-sensitive dye. On day 3 after SNI, plantar mechanical hypersensitivity and enhanced microglial activation were suppressed by minocycline or SCS, and L4 dorsal horn nociceptive neuronal hyperexcitability was suppressed by SCS. In vivo optical imaging also revealed that electrical stimulation of the hind paw-activated areas in the somatosensory cortex was decreased by SCS. The present findings suggest that SCS could suppress plantar SNI-induced neuropathic pain via inhibition of microglial activation in the L4 dorsal horn, which is involved in spinal neuronal hyperexcitability. SCS is likely to be a potential alternative and complementary medicine therapy to alleviate neuropathic pain following nerve injury.
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Prabhala T, Sabourin S, DiMarzio M, Gillogly M, Prusik J, Pilitsis JG. Duloxetine Improves Spinal Cord Stimulation Outcomes for Chronic Pain. Neuromodulation 2018; 22:215-218. [PMID: 30325091 DOI: 10.1111/ner.12872] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/21/2018] [Accepted: 08/30/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) has been shown to be effective in treating chronic pain in patients with varying etiologies. However, the impact of pharmacological treatment on augmenting response to SCS has not been previously studied. METHODS We enrolled 108 patients who had undergone SCS surgery and documented their pain preoperatively and at 12 months postoperatively using the Numeric Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Beck Depression Inventory (BDI), Oswestry Disability Index (ODI), Pain Catastrophizing Scale (PCS), and Global Impression of Change (GIC). Pain outcomes were compared between patients receiving SCS alone and in addition to duloxetine. RESULTS At 1-year follow-up, patients receiving duloxetine and SCS (n = 41) had better pain relief in the affective component of MPQ (p < 0.05) than those receiving SCS alone (n = 71). Patients on duloxetine with SCS also were significantly more willing to receive SCS again (p < 0.01). This willingness appeared to be duloxetine dose dependent (p < 0.05). Patients receiving pregabalin or gabapentin with SCS did not have significantly more pain relief than patients receiving SCS alone. CONCLUSION This study shows the combination therapy to be an effective strategy to provide more holistic pain relief and further improve the quality of life of SCS patients.
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Affiliation(s)
- Tarun Prabhala
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA.,Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Shelby Sabourin
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Marisa DiMarzio
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Michael Gillogly
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Julia Prusik
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA.,Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
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van Beek M, Hermes D, Honig WM, Linderoth B, van Kuijk SMJ, van Kleef M, Joosten EA. Long-Term Spinal Cord Stimulation Alleviates Mechanical Hypersensitivity and Increases Peripheral Cutaneous Blood Perfusion in Experimental Painful Diabetic Polyneuropathy. Neuromodulation 2018. [PMID: 29522270 PMCID: PMC6099481 DOI: 10.1111/ner.12757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives This study utilizes a model of long‐term spinal cord stimulation (SCS) in experimental painful diabetic polyneuropathy (PDPN) to investigate the behavioral response during and after four weeks of SCS (12 hours/day). Second, we investigated the effect of long‐term SCS on peripheral cutaneous blood perfusion in experimental PDPN. Methods Mechanical sensitivity was assessed in streptozotocin induced diabetic rats (n = 50) with von Frey analysis. Hypersensitive rats (n = 24) were implanted with an internal SCS battery, coupled to an SCS electrode covering spinal levels L2–L5. The effects of four weeks of daily conventional SCS for 12 hours (n = 12) or Sham SCS (n = 12) were evaluated with von Frey assessment, and laser Doppler imaging (LDI). Results Average paw withdrawal thresholds (PWT) increased during long‐term SCS in the SCS group, in contrast to a decrease in the Sham group (Sham vs. SCS; p = 0.029). Twenty‐four hours after long‐term SCS average PWT remained higher in the SCS group. Furthermore, the SCS group showed a higher cutaneous blood perfusion during long‐term SCS compared to the Sham group (Sham vs. SCS; p = 0.048). Forty‐eight hours after long‐term SCS, no differences in skin perfusion were observed. Discussion We demonstrated that long‐term SCS results in decreased baseline mechanical hypersensitivity and results in increased peripheral blood perfusion during stimulation in a rat model of PDPN. Together, these findings indicate that long‐term SCS results in modulation of the physiological circuitry related to the nociceptive system in addition to symptomatic treatment of painful symptoms.
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Affiliation(s)
- Maarten van Beek
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Denise Hermes
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Wiel M Honig
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Bengt Linderoth
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, the Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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Chakravarthy K, Richter H, Christo PJ, Williams K, Guan Y. Spinal Cord Stimulation for Treating Chronic Pain: Reviewing Preclinical and Clinical Data on Paresthesia-Free High-Frequency Therapy. Neuromodulation 2017; 21:10-18. [PMID: 29105244 DOI: 10.1111/ner.12721] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/17/2017] [Accepted: 09/22/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traditional spinal cord stimulation (SCS) requires that paresthesia overlaps chronic painful areas. However, the new paradigm high-frequency SCS (HF-SCS) does not rely on paresthesia. STUDY DESIGN A review of preclinical and clinical studies regarding the use of paresthesia-free HF-SCS for various chronic pain states. METHODS We reviewed available literatures on HF-SCS, including Nevro's paresthesia-free ultra high-frequency 10 kHz therapy (HF10-SCS). Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES The primary goal is to describe the present developing conceptions of preclinical mechanisms of HF-SCS and to review clinical efficacy on paresthesia-free HF10-SCS for various chronic pain states. RESULTS HF10-SCS offers a novel pain reduction tool without paresthesia for failed back surgery syndrome and chronic axial back pain. Preclinical findings indicate that potential mechanisms of action for paresthesia-free HF-SCS differ from those of traditional SCS. CONCLUSIONS To fully understand and utilize paresthesia-free HF-SCS, mechanistic study and translational research will be very important, with increasing collaboration between basic science and clinical communities to design better trials and optimize the therapy based on mechanistic findings from effective preclinical models and approaches. Future research in these vital areas may include preclinical and clinical components conducted in parallel to optimize the potential of this technology.
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Affiliation(s)
- Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health System, San Diego, CA, USA
| | - Hira Richter
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kayode Williams
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Henssen DJ, Scheepers N, Kurt E, Arnts I, Steegers M, Vissers K, van Dongen R, Engels Y. Patients’ Expectations on Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Qualitative Exploration. Pain Pract 2017; 18:452-462. [DOI: 10.1111/papr.12617] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 01/20/2023]
Affiliation(s)
- Dylan J.H.A. Henssen
- Department of Anatomy; Donders Institute for Brain, Cognition & Behavior; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Neurosurgery; Radboud University Medical Center; Nijmegen The Netherlands
| | - Nicole Scheepers
- Department of Anesthesiology, Pain and Palliative Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - Erkan Kurt
- Department of Neurosurgery; Radboud University Medical Center; Nijmegen The Netherlands
| | - Inge Arnts
- Department of Anesthesiology, Pain and Palliative Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - Monique Steegers
- Department of Anesthesiology, Pain and Palliative Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - Robert van Dongen
- Department of Anesthesiology, Pain and Palliative Medicine; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Pain Management and Palliative Care; Canisius Wilhelmina Hospital; Nijmegen The Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and Palliative Medicine; Radboud University Medical Center; Nijmegen The Netherlands
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Inoue S, Johanek LM, Sluka KA. Lack of Analgesic Synergy of the Cholecystokinin Receptor Antagonist Proglumide and Spinal Cord Stimulation for the Treatment of Neuropathic Pain in Rats. Neuromodulation 2017; 20:534-542. [PMID: 28393429 DOI: 10.1111/ner.12601] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 01/27/2017] [Accepted: 02/15/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Neuropathic pain is difficult to manage and treat. Spinal cord stimulation (SCS) has become an established procedure for treating chronic neuropathic pain that is refractory to pharmacological therapy. In order to achieve better analgesia, a number of studies have evaluated the effectiveness of combining drug therapy with SCS. Cholecystokinin antagonists, such as proglumide, enhance the analgesic efficacy of endogenous opioids in animal models of pain. We previously reported that both systemic and spinal administration of proglumide enhances analgesia produced by both low- and high-frequency transcutaneous electrical nerve stimulation (TENS). Since SCS produces analgesia through endogenous opioids, we hypothesized that the analgesic effect of SCS would be enhanced through co-administration with proglumide in animals with neuropathic pain. MATERIALS AND METHODS Male Sprague-Dawley rats (n = 40) with spared nerve injury were given proglumide (20 mg/kg, i.p.) or saline prior to treatment with SCS (sham, 4 Hz, and 60 Hz). Mechanical withdrawal thresholds of the paw were measured before and after induction of nerve injury, and after SCS. Physical activity levels were measured after SCS. RESULTS Both proglumide and SCS when given independently significantly increased withdrawal thresholds two weeks after nerve injury. However, there was no additional effect of combining proglumide and SCS on mechanical withdrawal thresholds or activity levels in animals with nerve injury. DISCUSSION AND CONCLUSIONS Proglumide may be a candidate for achieving analgesia for patients with refractory neuropathic pain conditions, but does not enhance analgesia produced by SCS.
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Affiliation(s)
- Shinsuke Inoue
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, the University of Iowa, Iowa City, Iowa, USA
| | - Lisa M Johanek
- Medtronic Neuromodulation, Medtronic, Inc, Minneapolis, Minnesota, USA
| | - Kathleen A Sluka
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, the University of Iowa, Iowa City, Iowa, USA
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Visnjevac O, Costandi S, Patel BA, Azer G, Agarwal P, Bolash R, Mekhail NA. A Comprehensive Outcome-Specific Review of the Use of Spinal Cord Stimulation for Complex Regional Pain Syndrome. Pain Pract 2016; 17:533-545. [PMID: 27739179 DOI: 10.1111/papr.12513] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 06/27/2016] [Accepted: 07/08/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful, debilitating affliction that is often difficult to treat. It has become common international practice to use spinal cord stimulation (SCS) for the treatment of CRPS as other therapies fail to provide adequate relief, quality of life, or improvement in function. This comprehensive outcome-specific systematic review of the use of SCS for CRPS was performed to elucidate the available evidence with focus on clinically relevant patient-specific outcomes. METHODS A systematic review of the literature was conducted to evaluate the effects of SCS on patients with CRPS for the following outcomes and provide summary levels of evidence in regard to each outcome: perceived pain relief, pain score, resolution of CRPS signs, functional status, quality of life, psychological impact, sleep hygiene, analgesic medication utilization, and patient satisfaction with SCS therapy. Search terms included "complex regional pain syndrome," "spinal cord stimulation," and "reflex sympathetic dystrophy," without restriction of language, date, or type of publication, albeit only original data were included in analyses. Of 30 studies selected, seven systematic reviews were excluded, as were four studies reporting combination therapy that included SCS and other therapies (ie, concurrent peripheral nerve stimulation, intrathecal therapy) without clear delineation to the effect of SCS alone on outcomes. A total of 19 manuscripts were evaluated. RESULTS Perceived pain relief, pain score improvement, quality of life, and satisfaction with SCS were all rated 1B+, reflecting positive high-level (randomized controlled trial) evidence favoring SCS use for the treatment of CRPS. Evidence for functional status improvements and psychological effects of SCS was inconclusive, albeit emanating from a randomized controlled trial (evidence level 2B±), and outcomes evidence for both sleep hygiene and resolution of CRPS signs was either nonexistent or of too low quality from which to draw conclusions (evidence level 0). An analgesic sparing effect was observed in nonrandomized reports, reflecting an evidence level of 2C+. CONCLUSIONS Spinal cord stimulation remains a favorable and effective modality for treating CRPS with high-level evidence (1B+) supporting its role in improving CRPS patients' perceived pain relief, pain score, and quality of life. A paucity of evidence for functional improvements, resolution of CRPS signs, sleep hygiene, psychological impact, and analgesic sparing effects mandate further investigation before conclusions can be drawn for these specific outcomes.
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Affiliation(s)
- Ognjen Visnjevac
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Shrif Costandi
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Bimal A Patel
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Girgis Azer
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Priya Agarwal
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Robert Bolash
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Nagy A Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Reddy CG, Dalm BD, Flouty OE, Gillies GT, Howard MA, Brennan TJ. Comparison of Conventional and Kilohertz Frequency Epidural Stimulation in Patients Undergoing Trialing for Spinal Cord Stimulation: Clinical Considerations. World Neurosurg 2016; 88:586-591. [DOI: 10.1016/j.wneu.2015.10.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 10/25/2015] [Accepted: 10/26/2015] [Indexed: 12/29/2022]
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Gong WY, Johanek LM, Sluka KA. A Comparison of the Effects of Burst and Tonic Spinal Cord Stimulation on Hyperalgesia and Physical Activity in an Animal Model of Neuropathic Pain. Anesth Analg 2016; 122:1178-1185. [PMID: 26859873 DOI: 10.1213/ane.0000000000001161] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Parameters of spinal cord stimulation (SCS) play a role in its effectiveness and may impact SCS mechanisms and outcomes. For example, SCS applied in a bursting pattern may result in better pain relief than that for tonic SCS for neuropathic pain. We tested the effectiveness of different SCS pulse frequencies given at 2 different burst frequencies in an animal model of neuropathic pain. METHODS After Sprague-Dawley rats were anesthetized, neuropathic pain was induced using the spared nerve injury model, and an epidural SCS lead was implanted in the upper lumber spinal cord. One of the 8 different SCS parameters was delivered daily for 4 days at 90% motor threshold 2 weeks after nerve injury. Four burst patterns were administered at 4- or 40-Hz frequency with a train of 4 pulses at frequencies of 60, 500, and 1000 Hz. Sham and tonic patterns at 16, 60, and 160 Hz were chosen as controls. Paw withdrawal threshold was assessed before the surgery and 15 minutes before, during, and after SCS daily for 4 days. Physical activity (distance, crossing, rearing, and grooming) was assessed before surgery, before SCS on day 1, and after SCS on day 4. RESULTS Animals showed a decrease in paw withdrawal threshold and physical activity levels 2 weeks after nerve injury. During stimulation, burst SCS with pulse frequencies of 60, 500, or 1000 Hz were more effective for improving paw withdrawal threshold than sham and tonic SCS at 16 Hz. Burst SCS with higher pulse frequencies (500 and 1000 Hz) than 60-Hz SCS and burst SCS with higher pulse frequencies (1000 Hz) than 160-Hz SCS were more effective. In addition, tonic SCS at 160 Hz and burst SCS with higher pulse frequencies (500 and 1000 Hz) significantly increased the distance traveled. Burst SCS at 4 Hz with pulse frequency of 1000 Hz also increased the number of crossings when compared with sham control and tonic SCS at 16 Hz. CONCLUSIONS The current study shows that a variety of SCS pulse frequencies applied with a burst frequency result in greater improvement in hyperalgesia and activity levels than tonic SCS in a neuropathic pain model during stimulation.
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Affiliation(s)
- Wei-Yi Gong
- From the *Department of Pain Management, Xuanwu Hospital, Capital Medical University, Beijing, China; †Department of Physical Therapy and Rehabilitation Science, University of Iowa, Carver College of Medicine, Iowa City, Iowa; and ‡Medtronic Neuromodulation, Medtronic, Inc., Minneapolis, Minnesota
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Electroencephalographic evoked pain response is suppressed by spinal cord stimulation in complex regional pain syndrome: a case report. J Clin Monit Comput 2015; 30:845-848. [DOI: 10.1007/s10877-015-9781-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/22/2015] [Indexed: 11/24/2022]
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Deogaonkar M, Sharma M, Oluigbo C, Nielson DM, Yang X, Vera-Portocarrero L, Molnar GF, Abduljalil A, Sederberg PB, Knopp M, Rezai AR. Spinal Cord Stimulation (SCS) and Functional Magnetic Resonance Imaging (fMRI): Modulation of Cortical Connectivity With Therapeutic SCS. Neuromodulation 2015; 19:142-53. [PMID: 26373920 DOI: 10.1111/ner.12346] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/03/2015] [Accepted: 08/05/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The neurophysiological basis of pain relief due to spinal cord stimulation (SCS) and the related cortical processing of sensory information are not completely understood. The aim of this study was to use resting state functional magnetic resonance imaging (rs-fMRI) to detect changes in cortical networks and cortical processing related to the stimulator-induced pain relief. METHODS Ten patients with complex regional pain syndrome (CRPS) or neuropathic leg pain underwent thoracic epidural spinal cord stimulator implantation. Stimulation parameters associated with "optimal" pain reduction were evaluated prior to imaging studies. Rs-fMRI was obtained on a 3 Tesla, Philips Achieva MRI. Rs-fMRI was performed with stimulator off (300TRs) and stimulator at optimum (Opt, 300 TRs) pain relief settings. Seed-based analysis of the resting state functional connectivity was conducted using seeds in regions established as participating in pain networks or in the default mode network (DMN) in addition to the network analysis. NCUT (normalized cut) parcellation was used to generate 98 cortical and subcortical regions of interest in order to expand our analysis of changes in functional connections to the entire brain. We corrected for multiple comparisons by limiting the false discovery rate to 5%. RESULTS Significant differences in resting state connectivity between SCS off and optimal state were seen between several regions related to pain perception, including the left frontal insula, right primary and secondary somatosensory cortices, as well as in regions involved in the DMN, such as the precuneus. In examining changes in connectivity across the entire brain, we found decreased connection strength between somatosensory and limbic areas and increased connection strength between somatosensory and DMN with optimal SCS resulting in pain relief. This suggests that pain relief from SCS may be reducing negative emotional processing associated with pain, allowing somatosensory areas to become more integrated into default mode activity. CONCLUSION SCS reduces the affective component of pain resulting in optimal pain relief. Study shows a decreased connectivity between somatosensory and limbic areas associated with optimal pain relief due to SCS.
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Affiliation(s)
- Milind Deogaonkar
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Mayur Sharma
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - Dylan M Nielson
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Xiangyu Yang
- Department of Radiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | | | | | - Amir Abduljalil
- Department of Radiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Per B Sederberg
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Michael Knopp
- Department of Radiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ali R Rezai
- Department of Neurosurgery, Center of Neuromodulation, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
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