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Yue JJ, Gilligan CJ, Falowski S, Jameson J, Desai MJ, Moeschler S, Pilitsis J, Heros R, Tavel E, Wahezi S, Funk R, Buchanan P, Christopher A, Weisbein J, Patterson D, Levy R, Antony A, Miller N, Scarfo K, Kreiner S, Wilson D, Lim C, Braun E, Dickerson D, Duncan J, Xu J, Candido K, Mohab I, Michael F, Blomme B, Okaro U, Deer T. Surgical treatment of refractory low back pain using implanted BurstDR spinal cord stimulation (SCS) in a cohort of patients without options for corrective surgery: Findings and results from the DISTINCT study, a prospective randomized multi-center-controlled trial. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 19:100508. [PMID: 39139617 PMCID: PMC11321325 DOI: 10.1016/j.xnsj.2024.100508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/08/2024] [Accepted: 06/11/2024] [Indexed: 08/15/2024]
Abstract
Background Low back pain (LBP) is a highly prevalent, disabling condition affecting millions of people. Patients with an identifiable anatomic pain generator and resulting neuropathic lower extremity symptoms often undergo spine surgery, but many patients lack identifiable and/or surgically corrective pathology. Nonoperative treatment options often fail to provide sustained relief. Spinal cord stimulation (SCS) is sometimes used to treat these patients, but the lack of level 1 evidence limits its widespread use and insurance coverage. The DISTINCT RCT study evaluates the efficacy of passive recharge burst SCS compared to conventional medical treatment (CMM) in alleviating chronic, refractory axial low back pain. Methods This prospective, multicenter, randomized, study with an optional 6-month crossover involved patients who were not candidates for lumbar spine surgery. The primary and secondary endpoints evaluated improvements in low back pain intensity (NRS), back pain-related disability (ODI), pain catastrophizing (PCS), and healthcare utilization. Patients were randomized to SCS therapy or CMM at 30 US study sites. Results The SCS arm reported an 85.3% NRS responder rate (≥ 50% reduction) compared to 6.2% (5/81) in the CMM arm. After the 6M primary endpoint, SCS patients elected to remain on assigned therapy and 66.2% (49/74) of CMM patients chose to trial SCS (crossover). At the 12M follow-up, SCS and crossover patients reported 78.6% and 71.4% NRS responder rates. Secondary outcomes indicated significant improvements in ODI, PCS, and reduced healthcare utilization. Six serious adverse events were reported and resolved without sequelae. Conclusion DISTINCT chronic low back pain patients with no indication for corrective surgery experienced a significant and sustained response to burst SCS therapy for up to 12 months. CMM patients who crossed over to the SCS arm reported profound improvements after 6 months. This data advocates for a timely consideration of SCS therapy in patients unresponsive to conservative therapy.
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Affiliation(s)
- James J. Yue
- Connecticut Orthopaedics, Hamden, CT, United States
| | | | - Steven Falowski
- Center for Interventional Pain and Spine, Lancaster, PA, United States
| | | | - Mehul J. Desai
- International Spine, Pain and Performance Center, Washington, DC, United States
| | | | - Julie Pilitsis
- Florida Atlantic University, Boca Raton, FL, United States
| | | | - Edward Tavel
- Clinical Trials of South Carolina, Charleston, SC, United States
| | - Sayed Wahezi
- Montefiore Montefiore Medical Center, Bronx, NY, United States
| | - Robert Funk
- Indiana Spine Group, Indianapolis, IN United States
| | - Patrick Buchanan
- Spanish Hills Interventional Pain Specialists, Camarillo, CA United States
| | | | | | | | - Robert Levy
- Anesthesia Pain Care Consultants, Tamarac, FL United States
| | - Ajay Antony
- The Orthopaedic Institute, Gainesville, FL United States
| | - Nathan Miller
- Coastal Pain & Spinal Diagnostics Medical Group, Carlsbad, CA United States
| | - Keith Scarfo
- Rhode Island Hospital, Providence, RI United States
| | - Scott Kreiner
- Barrow Brain and Spine—Ahwatukee, Phoenix, AZ United States
| | - Derron Wilson
- Goodman Campbell Brain and Spine, Greenwood, IN United States
| | - Chi Lim
- Carolina Orthopaedic and Neurosurgical Associates, Spartanburg, SC United States
| | - Edward Braun
- Kansas University Medical Center, Kansas City, KS United States
| | | | - Jonathan Duncan
- Burkhart Research Institute for Orthopaedics, San Antonio, TX United States
| | - Jijun Xu
- The Cleveland Clinic Foundation, Cleveland, OH United States
| | - Kenneth Candido
- Chicago Anesthesia Associates, SC, Chicago, IL United States
| | - Ibrahim Mohab
- Banner University Medical Center, Tucson, AZ United States
| | | | | | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV United States
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Falowski SM, Nanivadekar AC. Prospective Six-Month Analysis of Multiarea Burst Spinal Cord Stimulation: Correlating Intraoperative Neuromonitoring With Postoperative Programming and Clinical Outcomes. Neuromodulation 2024; 27:899-907. [PMID: 38520459 DOI: 10.1016/j.neurom.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/20/2024] [Accepted: 02/13/2024] [Indexed: 03/25/2024]
Abstract
INTRODUCTION DeRidder burst spinal cord stimulation (SCS) has shown superior relief from overall pain to traditional tonic neurostimulation therapies and a reduction in back and leg pain. However, nearly 80% of patients have two or more noncontiguous pain areas. This affects the ability to effectively program stimulation and deliver long-term efficacy of the therapy. Multiple DeRidder burst region programming is an option to treat multisite pain by interleaving stimulation at multiple areas along the spinal cord. Previous intraoperative neuromonitoring studies have shown that DeRidder burst stimulation provides broader myotomal coverage at a lower recruitment threshold. The goal of this study is to correlate intraoperative electromyogram (EMG) threshold and postsynaptic excitability with postoperative paresthesia thresholds and optimal burst stimulation programming. MATERIALS AND METHODS Neuromonitoring was performed during permanent implant of SCS leads in ten patients diagnosed with chronic intractable back and/or leg pain. Each patient underwent the surgical placement of a Penta Paddle electrode through laminectomy at the T8-T11 spinal levels. Subdermal electrode needles were placed into lower extremity muscle groups, in addition to the rectus abdominis muscles, for EMG recording. Evoked responses were compared across multiple trials of burst stimulation in which the number of independent burst areas was varied. After intraoperative data collection, all patients were programmed with single- and multiarea DeRidder burst. Intermittent dosing was delivered at 30:90, 120:360, 120:720, and 120:1440 (seconds ON/OFF) intervals. Numerical rating scale (NRS) and Patient Global Impression of Change scores were evaluated at one, two, three, four, and six months after permanent implant. RESULTS The thresholds for EMG recruitment after DeRidder burst differed across all patients owing to anatomical and physiological variations. After a 30-second dose of stimulation, the average decrease in thresholds was 1.25 mA for two-area and 0.9 mA for four-area DeRidder burst. Furthermore, a 30-second dose of multisite DeRidder burst produced a 0.25 mA reduction in the postoperative paresthesia thresholds. Across all patients, the baseline NRS score was 6.5 ± 0.5, and the NRS score after single or multiarea DeRidder burst therapy was 2.87 ± 1.50. Eight of ten patients reported a ≥50% decrease in their pain scores through the six-month follow-up visit. Pain outcomes using intermittent multiarea stimulation with longer OFF times (120:360, 120:720, 120:1440) were comparable to those using single-area DeRidder burst at 30:90 up to six months after implant with patient preference being two-area DeRidder burst. CONCLUSIONS This study aims to evaluate the use of intraoperative neuromonitoring to optimize stimulation programming for multisite pain and correlate it with postoperative programming and efficacy. These results suggest that multisite programming can be used to further customize DeRidder burst stimulation to each individual patient and improve outcomes and quality of life for patients receiving SCS therapy for multisite pain.
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Bonomo R, Bonomo G, Rubiu E, Iess G, Cammarata G, Innocenti N, Restelli F, Falco J, Porto E, Amato A, Zekaj E, Levi V. Integrative approaches in spinal cord stimulation: Neuropathic pain management and motor recovery in spinal cord injury. A narrative review. BRAIN & SPINE 2024; 4:102781. [PMID: 38601775 PMCID: PMC11004705 DOI: 10.1016/j.bas.2024.102781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/08/2024] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Abstract
Introduction Spinal cord stimulation is a widespread treatment of chronic neuropathic pain from different conditions. Several novel and improving technologies have been recently developed to increase the effect of neuromodulation in patients refractory to pharmacological therapy. Research question To explore spinal cord stimulation's mechanisms of action, indications, and management. Material and methods The paper initially explores the mechanism of action of this procedure based on the generation of an electric field between electrodes placed on the posterior dural surface of the spinal cord probably interfering with the transmission of pain stimuli to the brain. Subsequently, the most consolidated criteria for selecting patients for surgery, which constitute a major issue of debate, were defined. Thereafter, the fundamental patterns of stimulation were summarized by exploring the advantages and side effects. Lastly, the most common side effects and the related management were discussed. Results Proper selection of the patient is of paramount importance to achieve the best results from this specific neuromodulation treatment. Regarding the different types of stimulation patterns, no definite evidence-based guidelines exist on the most appropriate approach in relation to the specific type of neuropathic pain. Both burst stimulation and high-frequency stimulation are innovative techniques that reduce the risk of paresthesias compared with conventional stimulation. Discussion and conclusion Novel protocols of stimulation (burst stimulation and high frequency stimulation) may improve the trade-off between therapeutic benefits and potential side effects. Likewise, decreasing the rates of hardware-related complications will be also useful to increase the application of neuromodulation in clinical settings.
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Affiliation(s)
- Roberta Bonomo
- Department of Neurology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- School of Medicine and Surgery, Kore University of Enna, Enna, Italy
| | - Giulio Bonomo
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Emanuele Rubiu
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Guglielmo Iess
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Giacomo Cammarata
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Niccolò Innocenti
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Francesco Restelli
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Jacopo Falco
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Edoardo Porto
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Alessia Amato
- Department of Child Neuropsychiatry, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Edvin Zekaj
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Vincenzo Levi
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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Mironer YE, Hutcheson JK, Haasis JC, Worobel MA, Sakla ES. Epidural Laterality and Pain Relief With Burst Spinal Cord Stimulation. Neuromodulation 2023; 26:1465-1470. [PMID: 36180323 DOI: 10.1016/j.neurom.2022.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/08/2022] [Accepted: 04/24/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Burst spinal cord stimulation (SCS) can achieve excellent clinical reduction of pain, alongside improvements in function, quality of life, and related outcomes. Good outcomes likely depend on good lead placement, thereby enabling recruitment of the relevant neural targets. Several competing approaches exist for lead implantation, such as the use of single vs bilateral leads and leads lateralized vs placed at midline. The objective of this study was to examine the relationship between paresthesia locations and pain relief with burst SCS in a prospective double-blind crossover design. MATERIALS AND METHODS All participants had bilateral back and leg pain, with more intense pain experienced on one side of the body. A trial SCS system was placed, during which brief intraoperative mapping with conventional stimulation was used to characterize paresthesia locations. Two programs for subperception burst SCS treatment were then applied for two days each, in random order: bilateral paresthesia coverage vs unilateral paresthesia coverage contralateral to the side of the body with more intense pain. Pain ratings (visual analog scale [VAS]) and pain reductions (scaling pain relief [SPR]) were reported for each. RESULTS Of the 30 participants who completed the study, 24 (80%) had good pain relief with at least one program. A baseline VAS score of 8.75 was reduced to 5.98 with contralateral stimulation and to 2.88 with bilateral stimulation; with SPR, this equated to 31.25% and 67.50% improvement, respectively. The incremental benefit of bilateral stimulation over contralateral stimulation was statistically significant (p < 0.001). Of the 24 participants, 87.5% preferred bilateral stimulation, whereas 12.5% preferred unilateral stimulation. The six participants who failed the trial had no preference. DISCUSSION When burst stimulation is delivered to spinal targets that can generate paresthesias contralateral to the side of worst pain, suboptimal therapy is achieved. Thus, attention to laterality and pain coverage is critical for successful therapy, and it may be important to carefully consider lead implantation techniques.
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Affiliation(s)
| | | | - John C Haasis
- Carolinas Center for Advanced Management of Pain, Greenville, SC, USA
| | - Michael A Worobel
- Carolinas Center for Advanced Management of Pain, Greenville, SC, USA
| | - Emmanuel S Sakla
- Carolinas Center for Advanced Management of Pain, Greenville, SC, USA
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Falowski SM, Benison AM, Nanivadekar AC. Regional Coverage Differences With Single- and Multi-Area Burst Spinal Cord Stimulation for Treatment of Chronic Pain. Neuromodulation 2023; 26:1471-1477. [PMID: 36870935 DOI: 10.1016/j.neurom.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/10/2023] [Accepted: 01/23/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Burst spinal cord stimulation (SCS) has shown superior relief from overall pain and a reduction in back and leg pain compared with traditional tonic neurostimulation therapies. However, nearly 80% of patients have two or more noncontiguous pain areas. This can provide challenges in effectively programming stimulation and long-term therapy efficacy. Multiarea DeRidder Burst programming is a new option to treat multisite pain by delivering stimulation to multiple areas along the spinal cord. This study aimed to identify the effect of intraburst frequency, multiarea stimulation, and location of DeRidder Burst on the evoked electromyography (EMG) responses. MATERIALS AND METHODS Neuromonitoring was performed during permanent implant of SCS leads in nine patients diagnosed with chronic intractable back and/or leg pain. Each patient underwent the surgical placement of a Penta Paddle electrode via laminectomy at the T8-T10 spinal levels. Subdermal electrode needles were placed into lower extremity muscle groups, in addition to the rectus abdominis muscles, for EMG recording. Evoked responses were compared across multiple trials of burst stimulation in which the number of independent burst areas were varied. RESULTS The thresholds for EMG recruitment with DeRidder Burst differed across patients owing to anatomic and physiological variations. The average threshold to evoke a bilateral EMG response using single site DeRidder Burst was 3.2 mA. Multisite DeRidder Burst stimulation on up to four stimulation programs evoked a bilateral EMG response at a threshold of 2.5 mA (∼23% lower threshold). DeRidder Burst stimulation across four electrode pairs resulted in more proximal recruitment (vastus medialis and tibialis anterior) than did stimulation across two pairs. It also resulted in more focal coverage of areas across multiple sites. CONCLUSIONS Across all patients, multisite DeRidder Burst provided broader myotomal coverage than did traditional DeRidder Burst. Multisite DeRidder Burst stimulation provided focal recruitment and differential control of noncontiguous distal myotomes. Energy requirements were also lower when multisite DeRidder Burst was used.
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Vanneste S, De Ridder D. BurstDR spinal cord stimulation rebalances pain input and pain suppression in the brain in chronic neuropathic pain. Brain Stimul 2023; 16:1186-1195. [PMID: 37541579 DOI: 10.1016/j.brs.2023.07.058] [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: 01/26/2023] [Revised: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVE Chronic pain is processed by at least three well-known pathways, two pain provoking pathways including a medial 'suffering' and lateral 'painfulness' pathway. A third descending pain pathway modulates pain but is predominantly inhibitory. Chronic pain can be seen as an imbalance between the two pain-provoking and the pain inhibitory pathways. If this assumption is correct, then the imbalance between pain input and pain suppression should reverse and normalize in response to successful, i.e., pain reducing burstDR spinal cord stimulation, one of the current treatment options for neuropathic pain. MATERIALS AND METHODS Fifteen patients, who received spinal cord stimulation for failed back surgery were included in this study, using source localized electrical brain activity and connectivity recording via EEG to identify the purported imbalance. RESULTS BurstDR spinal cord stimulation induces a significant change in EEG activity in both the left and right somatosensory cortex (SSC) for both θ and γ oscillations. In the dorsal anterior cingulate cortex (dACC), we observed a significant drop in both α and β oscillations. This reduction is accompanied by a change in pain intensity and suffering. BurstDR spinal cord stimulation is also associated with a reduction in θ at the pregenual anterior cingulate cortex (pgACC). Analyzing effective connectivity indicates that for the θ band, more information is sent from the pgACC to the left and right SSC. For α, increased information is sent from the pgACC to the dACC and both the left and right SSC. This is associated with a reduced θ-γ coupling in the SSC and reduced α-β coupling in dACC. CONCLUSION This study suggests that chronic pain is indeed an imbalance between the ascending and descending pathways in the brain and that burst spinal cord stimulation can normalize this imbalance in the brain.
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Affiliation(s)
- Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.
| | - Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, New Zealand
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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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Smeele SJ, Adhia DB, De Ridder D. Feasibility and Safety of High-Definition Infraslow Pink Noise Stimulation for Treating Chronic Tinnitus—A Randomized Placebo-Controlled Trial. Neuromodulation 2022:S1094-7159(22)01339-3. [DOI: 10.1016/j.neurom.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 12/03/2022]
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Sammak SE, Mualem W, Michalopoulos GD, Romero JM, Ha CT, Hunt CL, Bydon M. Rescue therapy with novel waveform spinal cord stimulation for patients with failed back surgery syndrome refractory to conventional stimulation: a systematic review and meta-analysis. J Neurosurg Spine 2022; 37:670-679. [PMID: 36303477 DOI: 10.3171/2022.4.spine22331] [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: 03/22/2022] [Accepted: 04/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Conventional spinal cord stimulators (SCSs) have demonstrated efficacy in individuals with failed back surgery syndrome (FBSS). However, a subgroup of patients may become refractory to the effects of conventional waveforms over time. The objective of this study was to systematically review and evaluate the current literature on the use of novel waveform spinal cord stimulation for the management of FBSS refractory to conventional SCSs. METHODS A comprehensive electronic search of the literature published in electronic databases, including Ovid MEDLINE and Epub Ahead of Print, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus, was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The outcomes of interest were reduction in back pain and/or leg pain after conversion from conventional to novel SCSs. Risk of bias was assessed with the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria. RESULTS A total of 6 studies with 137 patients with FBSS were identified. Studies were published between 2013 and 2021. The mean ± SD age of the pooled patient sample was 55 ± 10.5 years. All patients who underwent treatment with conventional SCSs were identified. Two studies evaluated the efficacy of high-density spinal cord stimulation, 3 studies evaluated burst spinal cord stimulation, and 1 study assessed multimodal waveforms. The mean difference in back pain scores after conversion from a standard SCS to a novel waveform SCS was 2.55 (95% CI 1.59-4.08), demonstrating a significant reduction in back pain after conversion to novel stimulation. The authors also performed a subgroup analysis to compare burst stimulation to tonic waveforms. In this analysis, the authors found no significant difference in the average reductions in back pain between the 2 groups (p = 0.534).The authors found an I2 statistic equivalent to 98.47% in the meta-regression model used to assess the effect of follow-up duration on study outcome; this value implied that the variability in the data can be attributed to the remaining between-study heterogeneity. The overall certainty was moderate, with a high risk of bias across studies. CONCLUSIONS Rescue therapy with novel waveform spinal cord stimulation is a potential option for pain reduction in patients who become refractory to conventional SCSs. Conversion to novel waveform SCSs may potentially mitigate expenses and complications.
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Affiliation(s)
| | - William Mualem
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
| | | | - Joshua M Romero
- 2Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota; and
| | - Christopher T Ha
- 2Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota; and
| | - Christine L Hunt
- 3Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Jacksonville, Florida
| | - Mohamad Bydon
- 1Department of Neurologic Surgery, Mayo Clinic, Rochester
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Adhia DB, Mani R, Reynolds JN, Hall M, Vanneste S, De Ridder D. High-Definition Transcranial Infraslow Pink-Noise Stimulation Can Influence Functional and Effective Cortical Connectivity in Individuals With Chronic Low Back Pain: A Pilot Randomized Placebo-Controlled Study. Neuromodulation 2022:S1094-7159(22)01225-9. [DOI: 10.1016/j.neurom.2022.08.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/02/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022]
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Mons MR, Edelbroek C, Zuidema X, Bürger K, Elzinga L, de Vries J, van Kuijk S, Joosten EA, Kallewaard JW. Study protocol: Effects of active versus passive recharge burst spinal cord stimulation on pain experience in persistent spinal pain syndrome type 2: a multicentre randomized trial (BURST-RAP study). Trials 2022; 23:749. [PMID: 36064598 PMCID: PMC9446827 DOI: 10.1186/s13063-022-06637-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background Spinal cord stimulation (SCS) has shown to be an effective treatment for patients with persistent spinal pain syndrome type 2 (PSPS Type 2). The method used to deliver electrical charge in SCS is important. One such method is burst stimulation. Within burst stimulation, a recharge pattern is used to prevent buildup of charge in stimulated tissues. Two variations of burst waveforms are currently in use: one that employs active recharge and one that uses passive recharge. It has been suggested that differences exist between active and passive recharge paradigms related to both efficacy of pain relief and their underlying mechanism of action. Active recharge has been shown to activate both the medial spinal pathway, engaging cortical sensorimotor areas involved in location and intensity of pain, and lateral pathway, reaching brain areas involved with cognitive-emotional aspects of pain. Passive recharge has been suggested to act via modulation of thalamic neurons, which fire in a similar electrical pattern, and thereby modulate activity in various cortical areas including those related to motivational and emotional aspects of pain. The objective of this randomized clinical trial is to assess and compare the effect of active versus passive recharge Burst SCS on a wide spectrum of pain in PSPS Type 2 patients. Methods This multicentre randomized clinical trial will take place in 6 Dutch hospitals. PSPS Type 2 patients (n=94) will be randomized into a group receiving either active or passive recharge burst. Following a successful trial period, patients are permanently implanted. Patients complete the Pain Catastrophizing Scale (PCS) (primary outcome at 6 months), Numeric Pain Rating Scale (NRS), Patient Vigilance and Awareness Questionnaire (PVAQ), Hospital Anxiety and Depression Scale (HADS), Quality of Life (EQ-5D), Oswestery Disability Index (ODI), Patient Global Impression of Change (PGIC) and painDETECT questionnaires (secondary outcomes) at baseline, after trial, 1, 3, 6 and 12 months following implantation. Discussion The BURST-RAP trial protocol will shed light on possible clinical differences and effectivity of pain relief, including emotional-motivational aspects between active and passive burst SCS in PSPS Type 2 patients. Trial registration ClinicalTrials.gov registration: NCT05421273. Registered on 16 June 2022. Netherlands Trial Register NL9194. Registered on 23 January 2021.
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Affiliation(s)
- Martijn R Mons
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands. .,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, the Netherlands.
| | - Caro Edelbroek
- Department of Anesthesiology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands
| | - Xander Zuidema
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands.,Department of Anesthesiology, Diakonessen Hospital Utrecht, Utrecht, the Netherlands
| | - Katja Bürger
- Department of Anesthesiology, Alrijne Hospital Leiderdorp, Leiderdorp, the Netherlands
| | - Lars Elzinga
- Department of Anesthesiology, Bravis Hospital Roosendaal, Roosendaal, the Netherlands
| | - Jessica de Vries
- Department of Anesthesiology, Elizabeth TweeSteden Hospital Tilburg, Tilburg, the Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht UMC+, Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, University Pain Clinic Maastricht (UPCM) Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands.,Department of Translational Neuroscience, School for Mental Health and Neuroscience (MHeNS), University of Maastricht, Maastricht, the Netherlands
| | - Jan-Willem Kallewaard
- Department of Anesthesiology, Rijnstate Hospital Arnhem, Arnhem, the Netherlands.,Departement of Anesthesiology, Amsterdam Universitair Medisch Centrum, Amsterdam, the Netherlands
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12
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Endoscopic Lateral Approach for Dorsal Root Ganglion Burst Stimulation: Technical Note and Illustrative Case Series. Neuromodulation 2022; 25:1033-1039. [DOI: 10.1016/j.neurom.2021.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 09/19/2021] [Accepted: 10/11/2021] [Indexed: 11/22/2022]
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13
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Saber M, Schwabe D, Park HJ, Tessmer J, Khan Z, Ding Y, Robinson M, Hogan QH, Pawela CP. Tonic, Burst, and Burst-Cycle Spinal Cord Stimulation Lead to Differential Brain Activation Patterns as Detected by Functional Magnetic Resonance Imaging. Neuromodulation 2022; 25:53-63. [PMID: 35041588 DOI: 10.1111/ner.13460] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The objective of this preclinical study was to examine the responses of the brain to noxious stimulation in the presence and absence of different modes of spinal cord stimulation (SCS) using blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD-fMRI). MATERIALS AND METHODS Sprague-Dawley rats were randomized to groups based on the mode of SCS delivered which included tonic stimulation (n = 27), burst stimulation (n = 30), and burst-cycle stimulation (n = 29). The control (sham) group (n = 28) received no SCS. The SCS electrode was inserted between T10 and T12 spinal levels prior to fMRI session. The experimental protocol for fMRI acquisition consisted of an initial noxious stimulation phase, a treatment phase wherein the SCS was turned on concurrently with noxious stimulation, and a residual effect phase wherein the noxious stimulation alone was turned on. The responses were statistically analyzed through paired t-test and the results were presented as z-scores for the quantitative analysis of the fMRI data. RESULTS The treatment with different SCS modes attenuated the BOLD brain responses to noxious hindlimb stimulation. The tonic, burst, and burst-cycle SCS treatment attenuated BOLD responses in the caudate putamen (CPu), insula (In), and secondary somatosensory cortex (S2). There was little to no corresponding change in sham control in these three regions. The burst and burst-cycle SCS demonstrated greater attenuation of BOLD signals in CPu, In, and S2 compared to tonic stimulation. CONCLUSION The high-resolution fMRI study using a rat model demonstrated the potential of different SCS modes to act on several pain-matrix-related regions of the brain in response to noxious stimulation. The burst and burst-cycle SCS exhibited greater brain activity reduction in response to noxious hindlimb stimulation in the caudate putamen, insula, and secondary somatosensory cortex compared to tonic stimulation.
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Affiliation(s)
- Mohammad Saber
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Schwabe
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - John Tessmer
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zan Khan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yujie Ding
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - Maraika Robinson
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Quinn H Hogan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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14
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Niso G, Tjepkema-Cloostermans MC, Lenders MWPM, de Vos CC. Modulation of the Somatosensory Evoked Potential by Attention and Spinal Cord Stimulation. Front Neurol 2021; 12:694310. [PMID: 34413825 PMCID: PMC8369157 DOI: 10.3389/fneur.2021.694310] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/07/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction: Spinal Cord Stimulation (SCS) is a last-resort treatment for patients with intractable chronic pain in whom pharmacological and other treatments have failed. Conventional tonic SCS is accompanied by tingling sensations. More recent stimulation protocols like burst SCS are not sensed by the patient while providing similar levels of pain relief. It has been previously reported that conventional tonic SCS can attenuate sensory-discriminative processing in several brain areas, but that burst SCS might have additional effects on the medial, motivational-affective pain system. In this explorative study we assessed the influence of attention on the somatosensory evoked brain responses under conventional tonic SCS as well as burst SCS regime. Methods: Twelve chronic pain patients with an implanted SCS device had 2-weeks evaluation periods with three different SCS settings (conventional tonic SCS, burst SCS, and sham SCS). At the end of each period, an electro-encephalography (EEG) measurement was done, at which patients received transcutaneous electrical pulses at the tibial nerve to induce somatosensory evoked potentials (SEP). SEP data was acquired while patients were attending the applied pulses and while they were mind wandering. The effects of attention as well as SCS regimes on the SEP were analyzed by comparing amplitudes of early and late latencies at the vertex as well as brain activity at full cortical maps. Results: Pain relief obtained by the various SCS settings varied largely among patients. Early SEP responses were not significantly affected by attention nor SCS settings (i.e., burst, tonic, and sham). However, late SEP responses (P300) were reduced with tonic and burst SCS: conventional tonic SCS reduced P300 brain activity in the unattended condition, while burst SCS reduced P300 brain activity in both attended and unattended conditions. Conclusion: Burst spinal cord stimulation for the treatment of chronic pain seems to reduce cortical attention that is or can be directed to somatosensory stimuli to a larger extent than conventional spinal cord stimulation treatment. This is a first step in understanding why in selected chronic pain patients burst SCS is more effective than tonic SCS and how neuroimaging could assist in personalizing SCS treatment.
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Affiliation(s)
- Guiomar Niso
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Psychological & Brain Sciences, Indiana University, Bloomington, IN, United States.,ETSI Telecomunicación, Universidad Politécnica de Madrid and Center for Biomedical Research Network CIBER-BBN, Madrid, Spain
| | - Marleen C Tjepkema-Cloostermans
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Clinical Neurophysiology, Institute for Technical Medicine, University of Twente, Enschede, Netherlands
| | - Mathieu W P M Lenders
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Cecile C de Vos
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands.,Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
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15
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De Ridder D, Adhia D, Vanneste S. The anatomy of pain and suffering in the brain and its clinical implications. Neurosci Biobehav Rev 2021; 130:125-146. [PMID: 34411559 DOI: 10.1016/j.neubiorev.2021.08.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 02/08/2023]
Abstract
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Chronic pain, with a prevalence of 20-30 % is the major cause of human suffering worldwide, because effective, specific and safe therapies have yet to be developed. It is unevenly distributed among sexes, with women experiencing more pain and suffering. Chronic pain can be anatomically and phenomenologically dissected into three separable but interacting pathways, a lateral 'painfulness' pathway, a medial 'suffering' pathway and a descending pain inhibitory pathway. One may have pain(fullness) without suffering and suffering without pain(fullness). Pain sensation leads to suffering via a cognitive, emotional and autonomic processing, and is expressed as anger, fear, frustration, anxiety and depression. The medial pathway overlaps with the salience and stress networks, explaining that behavioural relevance or meaning determines the suffering associated with painfulness. Genetic and epigenetic influences trigger chronic neuroinflammatory changes which are involved in transitioning from acute to chronic pain. Based on the concept of the Bayesian brain, pain (and suffering) can be regarded as the consequence of an imbalance between the two ascending and the descending pain inhibitory pathways under control of the reward system. The therapeutic clinical implications of this simple pain model are obvious. After categorizing the working mechanisms of each of the available treatments (pain killers, psychopharmacology, psychotherapy, neuromodulation, psychosurgery, spinal cord stimulation) to 1 or more of the 3 pathways, a rational combination can be proposed of activating the descending pain inhibitory pathway in combination with inhibition of the medial and lateral pathway, so as to rebalance the pain (and suffering) pathways.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Divya Adhia
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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16
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Deer TR, Patterson DG, Baksh J, Pope JE, Mehta P, Raza A, Agnesi F, Chakravarthy KV. Novel Intermittent Dosing Burst Paradigm in Spinal Cord Stimulation. Neuromodulation 2021; 24:566-573. [PMID: 32202044 PMCID: PMC8247280 DOI: 10.1111/ner.13143] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Intermittent dosing (ID), in which periods of stimulation-on are alternated with periods of stimulation-off, is generally employed using 30 sec ON and 90 sec OFF intervals with burst spinal cord stimulation (SCS). The goal of this study was to evaluate the feasibility of using extended stimulation-off periods in patients with chronic intractable pain. MATERIALS AND METHODS This prospective, multicenter, feasibility trial evaluated the clinical efficacy of the following ID stimulation-off times: 90, 120, 150, and 360 sec with burst waveform parameters. After a successful trial (≥50% pain relief) using ID stimulation, subjects were titrated with OFF times beginning with 360 sec. Pain, quality of life, disability, and pain catastrophizing were evaluated at one, three, and six months after permanent implant. RESULTS Fifty subjects completed an SCS trial using ID stimulation settings of 30 sec ON and 90 sec OFF, with 38 (76%) receiving ≥50% pain relief. Pain scores were significantly reduced from baseline at all time points (p < 0.001). Improvements in quality of life, disability, and pain catastrophizing were aligned with pain relief outcomes; 45.8% of the subjects that completed the six-month follow-up visit used an OFF period of 360 seconds. CONCLUSIONS ID burst SCS effectively relieved pain for six months. The largest group of subjects used IDB settings of 30 sec ON and 360 sec OFF. These findings present intriguing implications for the optimal "dose" of electricity in SCS and may offer many advantages such as optimizing the therapeutic window, extending battery life, reducing recharge burden and, potentially, mitigating therapy habituation or tolerance.
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17
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Yoon LJ, Kim DY. Burst spinal cord stimulation for central neuropathic pain: Two case reports. Medicine (Baltimore) 2021; 100:e24628. [PMID: 33578577 PMCID: PMC7886395 DOI: 10.1097/md.0000000000024628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/15/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Central neuropathic pain can result from any type of injury to the central nervous system. Treatment of central neuropathic pain is very challenging. Recently, a novel stimulation paradigm, called burst stimulation, has been presented as an excellent alternative in a group of patients with intractable central neuropathic pain. We report 2 cases where burst spinal cord stimulation (SCS) was applied in patients with neuropathic pain due to spinal cord injury (SCI) or traumatic brain injury. PATIENT CONCERNS A 52-year-old man who underwent posterolateral fusion surgery for a T12 bursting fracture after a fall 11 years prior developed disabling pain in the anterolateral part of his right thigh. His neuropathic pain following SCI was refractory to various treatment modalities. A 65-year-old man had complained of intractable, cold, throbbing, and shooting pain mainly in his left lower limb during rehabilitation since undergoing a craniotomy 9 years prior for multiple brain injuries caused by a motorcycle accident. DIAGNOSIS Both of these 2 cases were diagnosed with central neuropathic pain syndrome caused by SCI or traumatic brain injury. INTERVENTIONS Burst SCS were proposed to alleviate the significant refractory pains that were resistant to various medications and stimulation was delivered to the patient in an alternating pattern between traditional tonic and burst waveforms. CONCLUSION The efficacy of burst SCS in central neuropathic pain is desirable considering the severity of pain in such patients, the refractory nature of their pain, and the paucity of alternative therapeutic options.
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18
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Sankarasubramanian V, Chiravuri S, Mirzakhalili E, Anaya CJ, Scott JR, Brummett CM, Clauw DJ, Patil PG, Harte SE, Lempka SF. Quantitative Sensory Testing of Spinal Cord and Dorsal Root Ganglion Stimulation in Chronic Pain Patients. Neuromodulation 2021; 24:672-684. [PMID: 33471409 DOI: 10.1111/ner.13329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/17/2020] [Accepted: 11/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND/OBJECTIVES The physiological mechanisms underlying the pain-modulatory effects of clinical neurostimulation therapies, such as spinal cord stimulation (SCS) and dorsal root ganglion stimulation (DRGS), are only partially understood. In this pilot prospective study, we used patient-reported outcomes (PROs) and quantitative sensory testing (QST) to investigate the physiological effects and possible mechanisms of action of SCS and DRGS therapies. MATERIALS AND METHODS We tested 16 chronic pain patients selected for SCS and DRGS therapy, before and after treatment. PROs included pain intensity, pain-related symptoms (e.g., pain interference, pain coping, sleep interference) and disability, and general health status. QST included assessments of vibration detection theshold (VDT), pressure pain threshold (PPT) and tolerance (PPToL), temporal summation (TS), and conditioned pain modulation (CPM), at the most painful site. RESULTS Following treatment, all participants reported significant improvements in PROs (e.g., reduced pain intensity [p < 0.001], pain-related functional impairment [or pain interference] and disability [p = 0.001 for both]; better pain coping [p = 0.03], sleep [p = 0.002]), and overall health [p = 0.005]). QST showed a significant treatment-induced increase in PPT (p = 0.002) and PPToL (p = 0.011), and a significant reduction in TS (p = 0.033) at the most painful site, but showed no effects on VDT and CPM. We detected possible associations between a few QST measures and a few PROs. Notably, higher TS was associated with increased pain interference scores at pre-treatment (r = 0.772, p = 0.009), and a reduction in TS was associated with the reduction in pain interference (r = 0.669, p = 0.034) and pain disability (r = 0.690, p = 0.027) scores with treatment. CONCLUSIONS Our preliminary findings suggest significant clinical and therapeutic benefits associated with SCS and DRGS therapies, and the possible ability of these therapies to modulate pain processing within the central nervous system. Replication of our pilot findings in future, larger studies is necessary to characterize the physiological mechanisms of SCS and DRGS therapies.
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Affiliation(s)
- Vishwanath Sankarasubramanian
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Srinivas Chiravuri
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Ehsan Mirzakhalili
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Carlos J Anaya
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - John Ryan Scott
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Daniel J Clauw
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Steven E Harte
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
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19
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Shimizu T, Maruo T, Miura S, Kimoto Y, Ushio Y, Goto S, Kishima H. Burst Spinal Cord Stimulation for the Treatment of Cervical Dystonia with Intractable Pain: A Pilot Study. Brain Sci 2020; 10:brainsci10110827. [PMID: 33171779 PMCID: PMC7694959 DOI: 10.3390/brainsci10110827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/31/2020] [Accepted: 11/03/2020] [Indexed: 12/02/2022] Open
Abstract
Pain is the most common and disabling non-motor symptom in patients with cervical dystonia. Here, we report four patients with painful cervical dystonia in whom burst spinal cord stimulation (SCS) in the cervical region produced sustained and significant improvements in both dystonic pain and motor symptoms. Further studies need to be performed to investigate the clinical efficacy of burst SCS for patients with cervical dystonia.
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Affiliation(s)
- Takeshi Shimizu
- Department of Neurosurgery, Parkinson’s Disease Research Center, KKR Otemae Hospital, Osaka 540-0008, Japan; (T.S.); (Y.U.)
- Department of Neurosurgery, Kansai Rosai Hospital, Hyogo 660-8511, Japan
| | - Tomoyuki Maruo
- Department of Neurosurgery, Parkinson’s Disease Research Center, KKR Otemae Hospital, Osaka 540-0008, Japan; (T.S.); (Y.U.)
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (S.M.); (Y.K.); (H.K.)
- Correspondence: ; Tel.: +81-6-6942-0484
| | - Shimpei Miura
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (S.M.); (Y.K.); (H.K.)
| | - Yuki Kimoto
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (S.M.); (Y.K.); (H.K.)
| | - Yukitaka Ushio
- Department of Neurosurgery, Parkinson’s Disease Research Center, KKR Otemae Hospital, Osaka 540-0008, Japan; (T.S.); (Y.U.)
| | - Satoshi Goto
- Department of Neurodegenerative Disorders Research, Institute of Biomedical Sciences, Graduate School of Medical Sciences, Tokushima University, Tokushima 770-8503, Japan;
| | - Haruhiko Kishima
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan; (S.M.); (Y.K.); (H.K.)
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20
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Rigoard P, Billot M, Ingrand P, Durand-Zaleski I, Roulaud M, Peruzzi P, Dam Hieu P, Voirin J, Raoul S, Page P, Djian MC, Fontaine D, Lantéri-Minet M, Blond S, Buisset N, Cuny E, Cadenne M, Caire F, Ranoux D, Mertens P, Naous H, Simon E, Emery E, Béraud G, Debiais F, Durand G, Serrie A, Diallo B, Bulsei J, Ounajim A, Nivole K, Duranton S, Naiditch N, Monlezun O, Bataille B. How Should we Use Multicolumn Spinal Cord Stimulation to Optimize Back Pain Spatial Neural Targeting? A Prospective, Multicenter, Randomized, Double-Blind, Controlled Trial (ESTIMET Study). Neuromodulation 2020; 24:86-101. [PMID: 32865344 DOI: 10.1111/ner.13251] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent studies have highlighted multicolumn spinal cord stimulation (SCS) efficacy, hypothesizing that optimized spatial neural targeting provided by new-generation SCS lead design or its multicolumn programming abilities could represent an opportunity to better address chronic back pain (BP). OBJECTIVE To compare multicolumn vs. monocolumn programming on clinical outcomes of refractory postoperative chronic BP patients implanted with SCS using multicolumn surgical lead. MATERIALS AND METHODS Twelve centers included 115 patients in a multicenter, randomized, double-blind, controlled trial. After randomization, leads were programmed using only one or several columns. The primary outcome was change in BP visual analogic scale (VAS) at six months. All patients were then programmed using the full potential of the lead up until 12-months follow-up. RESULTS At six months, there was no significant difference in clinical outcomes whether the SCS was programmed using a mono or a multicolumn program. At 12 months, in all patients having been receiving multicolumn SCS for at least six months (n = 97), VAS decreases were significant for global pain (45.1%), leg pain (55.8%), and BP (41.5%) compared with baseline (p < 0.0001). CONCLUSION The ESTIMET study confirms the significant benefit experienced on chronic BP by patients implanted with multicolumn SCS, independently from multicolumn lead programming. These good clinical outcomes might result from the specific architecture of the multicolumn lead, giving the opportunity to select initially the best column on a multicolumn grid and to optimize neural targeting with low-energy requirements. However, involving more columns than one does not appear necessary, once initial spatial targeting of the "sweet spot" has been achieved. Our findings suggest that this spatial concept could also be transposed to cylindrical leads, which have drastically improved their capability to shape the electrical field, and might be combined with temporal resolution using SCS new modalities.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research In Spine/neurostimulation Management and Thoracic Innovation in Cardiac Surgery), Poitiers University Hospital, Poitiers, France.,Department of Neurosurgery, Spine & Neurostimulation Unit, Poitiers University Hospital, Poitiers, France.,UPR 3346, CNRS, P' Institute, Futuroscope, Faculty of Sciences, Poitiers, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research In Spine/neurostimulation Management and Thoracic Innovation in Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Pierre Ingrand
- Faculty of Medicine and Pharmacy, Poitiers University Hospital, Poitiers, France
| | | | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research In Spine/neurostimulation Management and Thoracic Innovation in Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Philippe Peruzzi
- Department of Neurosurgery, Reims University Hospital, Reims, France
| | - Phong Dam Hieu
- Department of Neurosurgery, Brest University Hospital, Brest, France
| | - Jimmy Voirin
- Department of Neurosurgery, Colmar Hospital, Colmar, France
| | - Sylvie Raoul
- Department of Neurosurgery, Nantes University Hospital, Nantes, France
| | - Philippe Page
- Department of Neurosurgery, Spine & Neurostimulation Unit, Poitiers University Hospital, Poitiers, France
| | | | - Denys Fontaine
- Centre Hospitalier Universitaire de Nice, Department of Neurosurgery, Université Côte d'Azur, Nice, France.,FHU InovPain, Côte Azur University, Nice, France
| | - Michel Lantéri-Minet
- FHU InovPain, Côte Azur University, Nice, France.,Pain Evaluation and Treatment Centre, Nice University Hospital, Nice, France.,INSERM U1107, Neuro-Dol, Trigeminal Pain and Migraine, Auvergne University, Clermont-Ferrand, France
| | - Serge Blond
- Department of Neurosurgery, Lille University Hospital, Lille, France
| | - Nadia Buisset
- Department of Neurosurgery, Lille University Hospital, Lille, France
| | - Emmanuel Cuny
- Department of Neurosurgery, Bordeaux University Hospital, Bordeaux, France
| | - Myriam Cadenne
- Pain Evaluation and Treatment Centre, Bordeaux University Hospital, Bordeaux, France
| | - François Caire
- Department of Neurosurgery, Limoges University Hospital, Limoges, France
| | - Danièle Ranoux
- Pain Evaluation and Treatment Centre, Limoges University Hospital, Limoges, France
| | - Patrick Mertens
- Department of Neurosurgery, Lyon University Hospital, Lyon, France
| | - Hussein Naous
- Department of Neurosurgery, Lyon University Hospital, Lyon, France
| | - Emile Simon
- Department of Neurosurgery, Lyon University Hospital, Lyon, France
| | - Evelyne Emery
- Department of Neurosurgery, Caen University Hospital, Caen, France
| | - Guillaume Béraud
- Internal Medicine/Infectious and Tropical Diseases Department, Poitiers University Hospital, Poitiers, France
| | - Françoise Debiais
- Department of Rheumatology, Poitiers University Hospital, Poitiers, France
| | - Géraldine Durand
- Department of Rheumatology, Poitiers University Hospital, Poitiers, France
| | - Alain Serrie
- Pain Evaluation and Treatment Centre, Lariboisière Hospital, Paris, France
| | - Bakari Diallo
- Pain Evaluation and Treatment Centre, Poitiers University Hospital, Poitiers, France
| | - Julie Bulsei
- Clinical Research Unit in Economics, Hôtel Dieu, Paris, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research In Spine/neurostimulation Management and Thoracic Innovation in Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Kevin Nivole
- PRISMATICS Lab (Predictive Research In Spine/neurostimulation Management and Thoracic Innovation in Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Sophie Duranton
- Vigilance Department, Clinical Research Direction, Poitiers University Hospital, Poitiers, France
| | - Nicolas Naiditch
- PRISMATICS Lab (Predictive Research In Spine/neurostimulation Management and Thoracic Innovation in Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Olivier Monlezun
- PRISMATICS Lab (Predictive Research In Spine/neurostimulation Management and Thoracic Innovation in Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Benoit Bataille
- Department of Neurosurgery, Spine & Neurostimulation Unit, Poitiers University Hospital, Poitiers, France
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21
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Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. Burst Spinal Cord Stimulation: A Clinical Review. PAIN MEDICINE 2020; 20:S31-S40. [PMID: 31152175 PMCID: PMC6544556 DOI: 10.1093/pm/pnz003] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective Clinical review on outcomes using burst spinal cord stimulation (SCS) in the treatment of chronic, intractable pain. Design Narrative clinical literature review conducted utilizing a priori search terms including key words for burst spinal cord stimulation. Synthesis and reporting of data from publications including an overview of comparative SCS outcomes. Results Burst SCS demonstrated greater pain relief over tonic stimulation in multiple studies, which included blinded, sham-controlled, randomized trials. Additionally, burst stimulation impacts multiple dimensions of pain, including somatic pain as well as emotional and psychological elements. Patient preference is weighted toward burst over tonic due to increased pain relief, a lack of paresthesias, and impression of change in condition. Conclusion Burst SCS has been shown to be both statistically and clinically superior to tonic stimulation and may provide additional benefits through different mechanisms of action. Further high-quality controlled studies are warranted to not only elucidate the basic mechanisms of burst SCS but also address how this unique stimulation signature/pattern may more adequately handle the multiple affective dimensions of pain in varying patient populations.
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Affiliation(s)
- Terje Kirketeig
- Multidisciplinary Pain Clinic, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Carsten Schultheis
- Departement für Interventionelle Schmerzmedizin, Krankenhaus Neuwerk "Maria von den Aposteln" Muskulo-Skeletales Zentrum Mönchengladbach, Germany
| | - Xander Zuidema
- Department of Anesthesiology and Pain Management, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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Fishman MA, Antony A, Esposito M, Deer T, Levy R. The Evolution of Neuromodulation in the Treatment of Chronic Pain: Forward-Looking Perspectives. PAIN MEDICINE 2020; 20:S58-S68. [PMID: 31152176 PMCID: PMC6600066 DOI: 10.1093/pm/pnz074] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The field of neuromodulation is continually evolving, with the past decade showing significant advancement in the therapeutic efficacy of neuromodulation procedures. The continued evolution of neuromodulation technology brings with it the promise of addressing the needs of both patients and physicians, as current technology improves and clinical applications expand. Design This review highlights the current state of the art of neuromodulation for treating chronic pain, describes key areas of development including stimulation patterns and neural targets, expanding indications and applications, feedback-controlled systems, noninvasive approaches, and biomarkers for neuromodulation and technology miniaturization. Results and Conclusions The field of neuromodulation is undergoing a renaissance of technology development with potential for profoundly improving the care of chronic pain patients. New and emerging targets like the dorsal root ganglion, as well as high-frequency and patterned stimulation methodologies such as burst stimulation, are paving the way for better clinical outcomes. As we look forward to the future, neural sensing, novel target-specific stimulation patterns, and approaches combining neuromodulation therapies are likely to significantly impact how neuromodulation is used. Moreover, select biomarkers may influence and guide the use of neuromodulation and help objectively demonstrate efficacy and outcomes.
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Affiliation(s)
| | | | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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De Ridder D, Vancamp T, Falowski SM, Vanneste S. All bursts are equal, but some are more equal (to burst firing): burstDR stimulation versus Boston burst stimulation. Expert Rev Med Devices 2020; 17:289-295. [PMID: 32129099 DOI: 10.1080/17434440.2020.1736560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Since the introduction of burst spinal cord stimulation for neuropathic pain, several companies have developed their own version of burst stimulation, which is confusing the marketplace and clinicians of what burst stimulation truly is, the value and utilization of the therapy.Areas covered: We review those two burst stimulation designs and notice important differences. The original burstDRTM stimulation tries to mimic physiologic burst firing, which involves closely spaced high frequency sodium spikes nested on a calcium mediated plateau. This is realized by generating a train of 5 monophasic spikes of increasing amplitude with passive charge balance after the last spike, in contrast to the other burst designs which involve a version of cycling 4-5 spikes each being individually actively charge balanced spikes.Expert opinion: Based on the neurobiology of burst firing as well as abductive reasoning we like to clarify that burstDRTM is a true physiologic burst stimulation, and that other versions being called burst stimulation are essentially clustered tonic stimulation. This differentiating terminology will prevent confusion for healthcare providers, regulators, and the marketplace of what burst stimulation is.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | | | | | - Sven Vanneste
- Global Brain Health Institute, Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland.,Lab for Clinical and Integrative Neuroscience, School for Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, USA
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Abejón D, Vancamp T, Monzón EM. A Cost-Consequence Analysis Examining the Differences Between Non-Rechargeable and Rechargeable Systems. Anesth Pain Med 2020; 10:e100308. [PMID: 32337173 PMCID: PMC7158244 DOI: 10.5812/aapm.100308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 02/05/2020] [Indexed: 11/18/2022] Open
Abstract
Background Spinal cord stimulation (SCS) is an effective treatment option to relieve chronic intractable pain, and failed back surgery syndrome (FBSS) is a key indication. Objectives The objective of the current study was to analyze the cost consequences of using non-rechargeable (NR)-SCS and rechargeable (R)-SCS. Methods Real data taken from a review of 86 patients were used to simulate costs and review which patients might have benefitted more from R-SCS. Calculations were made to see what is the impact from a monetary point of view. Results On average, NR-SCS devices lasted for 58 months (M). Only 14 patients were not eligible to receive an R-SCS implant. We found that using R-SCS batteries would save up to €56.322 on average over a patient’s life expectancy, which means a saving of 43% compared to using NR-SCS systems. In our analysis, we found that if R-SCS implants were used instead of NR-SCS batteries, a saving of €5,735,334.23 over patients’ life expectancy would be made, which represented a 63% saving to the public health system. We found that R-SCS was cost-beneficial from second year compared to NR-SCS, saving up to 70% when patients are implanted for 9 years. Conclusions This cost-consequences analysis suggests that R-SCS implants are more cost-beneficial than NR-SCS systems in well-selected patient candidates for this type of treatment.
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Affiliation(s)
- David Abejón
- Pain Unit, Hospital Universitario Quiron Salud, Madrid, Spain
| | | | - Eva M. Monzón
- Pain Unit, Hospital Universitario Quiron Salud, Madrid, Spain
- Corresponding Author: Pain Unit, Hospital Universitario Quiron Salud, Madrid, Spain. Tel: +34-667750949,
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25
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Quindlen-Hotek JC, Kent AR, De Anda P, Kartha S, Benison AM, Winkelstein BA. Changes in Neuronal Activity in the Anterior Cingulate Cortex and Primary Somatosensory Cortex With Nonlinear Burst and Tonic Spinal Cord Stimulation. Neuromodulation 2020; 23:594-604. [PMID: 32027444 DOI: 10.1111/ner.13116] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/20/2019] [Accepted: 01/02/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although nonlinear burst and tonic SCS are believed to treat neuropathic pain via distinct pain pathways, the effectiveness of these modalities on brain activity in vivo has not been investigated. This study compared neuronal firing patterns in the brain after nonlinear burst and tonic SCS in a rat model of painful radiculopathy. METHODS Neuronal activity was recorded in the ACC or S1 before and after nonlinear burst or tonic SCS on day 7 following painful cervical nerve root compression (NRC) or sham surgery. The amplitude of nonlinear burst SCS was set at 60% and 90% motor threshold to investigate the effect of lower amplitude SCS on brain activity. Neuronal activity was recorded during and immediately following light brush and noxious pinch of the paw. Change in neuron firing was measured as the percent change in spikes post-SCS relative to pre-SCS baseline. RESULTS ACC activity decreases during brush after 60% nonlinear burst compared to tonic (p < 0.05) after NRC and compared to 90% nonlinear burst (p < 0.04) and pre-SCS baseline (p < 0.03) after sham. ACC neuron activity decreases (p < 0.01) during pinch after 60% and 90% nonlinear burst compared to tonic for NRC. The 60% of nonlinear burst decreases (p < 0.02) ACC firing during pinch in both groups compared to baseline. In NRC S1 neurons, tonic SCS decreases (p < 0.01) firing from baseline during light brush; 60% nonlinear burst decreases (p < 0.01) firing from baseline during brush and pinch. CONCLUSIONS Nonlinear burst SCS reduces firing in the ACC from a painful stimulus; a lower amplitude nonlinear burst appears to have the greatest effect. Tonic and nonlinear burst SCS may have comparable effects in S1.
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Affiliation(s)
| | | | - Patrisia De Anda
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Sonia Kartha
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Beth A Winkelstein
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.,Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
In addition to basic image-guided injections, there are many advanced procedures to address the challenges of spine pain. Patients with debilitating symptoms are offered relief, a shorter recovery period, and fewer potential complications. Pain arises from numerous sites along the spine, presenting as spine pain or radiculopathy. This article is an overview of advanced techniques in this rapidly progressing field, including neuromodulation, radiofrequency thermocoagulation, discography, intradiscal thermocoagulation, and percutaneous image-guided lumbar decompression; and it highlights etiologic factors and their relationship to therapeutic technique and clinical evidence.
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28
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Pope JE, Schu S, Sayed D, Raslan AM, Baranidharan G, Heros RD, Blomme B, Capobianco RA, Deer TR. Anatomic Lead Placement Without Paresthesia Mapping Provides Effective and Predictable Therapy During the Trial Evaluation Period: Results From the Prospective, Multicenter, Randomized, DELIVERY Study. Neuromodulation 2019; 23:109-117. [DOI: 10.1111/ner.13019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/15/2019] [Accepted: 06/06/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Jason E. Pope
- Evolve Restorative Center, California Society of Interventional Pain Society Santa Rosa CA USA
| | | | - Dawood Sayed
- Department of Anesthesiology and Pain MedicineThe University of Kansas Medical Center Kansas City KS USA
| | - Ahmed M. Raslan
- Department of Neurological SurgeryOregon Health & Science University Portland Oregon
| | | | | | - Bram Blomme
- Abbott (formerly St. Jude Medical), Neuromodulation division Brussels Belgium
| | - Robyn A. Capobianco
- Abbott (formerly St. Jude Medical), Neuromodulation division Brussels Belgium
| | - Timothy R. Deer
- The Spine and Nerve Center of the Virginias Charleston WV USA
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29
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Sokal P, Harat M, Malukiewicz A, Kiec M, Świtońska M, Jabłońska R. Effectiveness of tonic and burst motor cortex stimulation in chronic neuropathic pain. J Pain Res 2019; 12:1863-1869. [PMID: 31354335 PMCID: PMC6580141 DOI: 10.2147/jpr.s195867] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 04/08/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Motor cortex stimulation (MCS) is an intracranial, invasive method for treatment of chronic pain. Main indications for MCS are central post stroke pain, neuropathic facial pain, phantom limb pain and brachial plexus or spinal cord injury pain. Spinal cord stimulation (SCS) with burst waveform has been proved to be more effective than tonic mode in chronic pain. Necessity to replace depleted batteries of motor cortex tonic stimulators gave us an opportunity of applying burst stimulation. The objective of the pilot study was to evaluate the effects of burst stimulation applied on motor cortex in patients with chronic pain syndromes as well as comparison to tonic mode. Materials and methods: We have evaluated 6 patients (females N=3, males N=3) belonging to the group of 14 cases (females N=5, males N=9) who had undergone surgical procedure of MCS in years 2005-2017. Selected for the study were 6 patients with thalamic pain N=3, with facial pain N=3 (anaesthesia dolorosa and neuropathic trigeminal neuralgia). The patients were subjected to both modes of stimulation then they chose which one was better in relieving pain: tonic or burst. Pain intensity was assessed with the visual analogue scale (VAS) before the replacement of implanted pulse generator (IPG) and after the stimulation with tonic and burst modes. Results: In the study, 5 out of 6 patients with MCS found burst mode more effective than tonic mode. Baseline VAS score in patients that had at least 3 months depleted battery of tonic IPG was 95 mm. After implantation of a new IPG mean VAS score on tonic stimulation was 72 mm, on burst 53 mm. Conclusions: The most preferred option of MCS in selected group of patients was burst stimulation. This study has shown, that the burst stimulation of cerebral cortex is a promising modality when tonic stimulation is not sufficient in refractory, neuropathic pain.
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Affiliation(s)
- Paweł Sokal
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Marek Harat
- Division of Preventive Medicine and Healthy Policy, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Agnieszka Malukiewicz
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michał Kiec
- Department of Neurosurgery, The 10th Military Clinical Hospital, Bydgoszcz, Poland
| | - Milena Świtońska
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Renata Jabłońska
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital nr 2, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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30
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Chakravarthy K, Fishman MA, Zuidema X, Hunter CW, Levy R. Mechanism of Action in Burst Spinal Cord Stimulation: Review and Recent Advances. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:S13-S22. [PMID: 31152180 PMCID: PMC6544550 DOI: 10.1093/pm/pnz073] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This is a comprehensive, structured review synthesizing and summarizing the current experimental data and knowledge about the mechanisms of action (MOA) underlying spinal cord stimulation with the burst waveform (as defined by De Ridder) in chronic pain treatment. METHODS Multiple database queries and article back-searches were conducted to identify the relevant literature and experimental findings for results integration and interpretation. Data from recent peer-reviewed conference presentations were also included for completeness and to ensure that the most up-to-date scientific information was incorporated. Both human and animal data were targeted in the search to provide a translational approach in understanding the clinical relevance of the basic science findings. RESULTS/CONCLUSIONS Burst spinal cord stimulation likely provides pain relief via multiple mechanisms at the level of both the spinal cord and the brain. The specific waveforms and temporal patterns of stimulation both play a role in the responses observed. Differential modulation of neurons in the dorsal horn and dorsal column nuclei are the spinal underpinnings of paresthesia-free analgesia. The burst stimulation pattern also produces different patterns of activation within the brain when compared with tonic stimulation. The latter may have implications for not only the somatic components of chronic pain but also the lateral and affective pathway dimensions as well.
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Affiliation(s)
| | | | - Xander Zuidema
- Department of Anesthesiology and Pain Management, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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31
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Sankarasubramanian V, Harte SE, Chiravuri S, Harris RE, Brummett CM, Patil PG, Clauw DJ, Lempka SF. Objective Measures to Characterize the Physiological Effects of Spinal Cord Stimulation in Neuropathic Pain: A Literature Review. Neuromodulation 2018; 22:127-148. [PMID: 30246905 DOI: 10.1111/ner.12804] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The physiological mechanisms behind the therapeutic effects of spinal cord stimulation (SCS) are only partially understood. Our aim was to perform a literature review of studies that used objective measures to characterize mechanisms of action of SCS in neuropathic pain patients. MATERIALS AND METHODS We searched the PubMed data base to identify clinical studies that used objective measures to assess the effects of SCS in neuropathic pain. We extracted the study factors (e.g., type of measure, diagnoses, painful area[s], and SCS parameters) and outcomes from the included studies. RESULTS We included 67 studies. Of these, 24 studies used neurophysiological measures, 14 studies used functional neuroimaging techniques, three studies used a combination of neurophysiological and functional neuroimaging techniques, 14 studies used quantitative sensory testing, and 12 studies used proteomic, vascular, and/or pedometric measures. Our findings suggest that SCS largely inhibits somatosensory processing and/or spinal nociceptive activity. Our findings also suggest that SCS modulates activity across specific regions of the central nervous system that play a prominent role in the sensory and emotional functions of pain. CONCLUSIONS SCS appears to modulate pain via spinal and/or supraspinal mechanisms of action (e.g., pain gating, descending pain inhibition). However, to better understand the mechanisms of action of SCS, we believe that it is necessary to carry out systematic, controlled, and well-powered studies using objective patient measures. To optimize the clinical effectiveness of SCS for neuropathic pain, we also believe that it is necessary to develop and implement patient-specific approaches.
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Affiliation(s)
| | - Steven E Harte
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Srinivas Chiravuri
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Richard E Harris
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Daniel J Clauw
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
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32
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Sdrulla AD, Guan Y, Raja SN. Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms. Pain Pract 2018. [PMID: 29526043 DOI: 10.1111/papr.12692] [Citation(s) in RCA: 197] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Spinal cord stimulation (SCS) is a minimally invasive therapy used for the treatment of chronic neuropathic pain. SCS is a safe and effective alternative to medications such as opioids, and multiple randomized controlled studies have demonstrated efficacy for difficult-to-treat neuropathic conditions such as failed back surgery syndrome. Conventional SCS is believed mediate pain relief via activation of dorsal column Aβ fibers, resulting in variable effects on sensory and pain thresholds, and measurable alterations in higher order cortical processing. Although potentiation of inhibition, as suggested by Wall and Melzack's gate control theory, continues to be the leading explanatory model, other segmental and supraspinal mechanisms have been described. Novel, non-standard, stimulation waveforms such as high-frequency and burst have been shown in some studies to be clinically superior to conventional SCS, however their mechanisms of action remain to be determined. Additional studies are needed, both mechanistic and clinical, to better understand optimal stimulation strategies for different neuropathic conditions, improve patient selection and optimize efficacy.
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Affiliation(s)
- Andrei D Sdrulla
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A.,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
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33
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Schu S, Vancamp T. Clinical Aspects of Burst Stimulation for Pain Control. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00052-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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36
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Deer TR, Campos LW, Pope JE. Evaluation of Abbott’s BurstDR stimulation device for the treatment of chronic pain. Expert Rev Med Devices 2017; 14:417-422. [DOI: 10.1080/17434440.2017.1330147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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37
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De Ridder D, Perera S, Vanneste S. Are 10 kHz Stimulation and Burst Stimulation Fundamentally the Same? Neuromodulation 2017; 20:650-653. [PMID: 28544432 DOI: 10.1111/ner.12614] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/28/2017] [Accepted: 03/30/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is routinely used for intractable pain syndromes. For SCS to be efficacious the painful area needs to be covered by SCS induced paresthesia symptoms. Recently, novel stimulation designs have been developed for spinal cord stimulation (SCS) that are superior to classical spinal cord stimulation and exert their effects without the mandatory paresthesia. Two such stimulation designs are burst stimulation and 10 kHz stimulation. OBJECTIVE Whereas the mechanism of action of burst SCS has been partly elucidated, in that it modulates the medial pain pathway in contrast to tonic stimulation, the mechanism of action of 10 kHz SCS is still enigmatic. The goal of this paper is to provide a perspective or informed opinion on the differences and similarities between burst SCS and 10 kHz stimulation by using a literature search on the two stimulation designs. DISCUSSION/CONCLUSION Human clinical data, simulation studies, quantitative sensory testing, cellular investigations, and comparative animal and human studies all point in the same direction, namely that 10 kHz and burst SCS might both modulate the medial pain pathway, and could be fundamentally similar neurostimulation designs.
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Affiliation(s)
- Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand
| | - Sanjaya Perera
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand
| | - Sven Vanneste
- Laboratory for Clinical & Integrative Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, TX, USA
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Muhammad S, Roeske S, Chaudhry SR, Kinfe TM. Burst or High-Frequency (10 kHz) Spinal Cord Stimulation in Failed Back Surgery Syndrome Patients With Predominant Back Pain: One Year Comparative Data. Neuromodulation 2017; 20:661-667. [PMID: 28544182 DOI: 10.1111/ner.12611] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/05/2017] [Accepted: 03/30/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Burst and 10 kHz spinal cord stimulation (SCS) demonstrated improvement for failed back surgery syndrome (FBSS) with predominant, refractory back pain. Here, we report the long-term follow-up of a previously published study comparing the safety and efficacy of burst vs. 10 kHz SCS for predominant back pain (70% of global pain) of FBSS patients. METHODS This comparative, observational study extended the follow-up period up to 20 months evaluating both SCS modalities. Pain intensity (visual analog scale [VASB , VASL ]), functional capacity (Pittsburgh Sleep Quality Index [PSQI]; depression (Beck Depression Inventory [BDI]), stimulation parameters and hardware and/or stimulation associated adverse events were recorded and analyzed over time. RESULTS Overall VASB (t1,12 = 66.76, p < 0.001) and VASL (t1,12 = 4.763, p < 0.049; p < 0.001) declined over time. Burst significantly decreased VASB by 87.5% (±17.7) (mean 8 ± 0.76 to 1 ± 1.41; t1 =12.3, p < 0.001), and 10 kHz significant decreased VASB by 54.9% (±44) (mean 8 ± 0.63 to 3.5 ± 3.27; t1 =3.09, p = 0.027). No significant differences for between SCS types were revealed (t1 =1.75, p = 0.13). VASL was significantly suppressed for burst (burst: 3.6 ± 1.59 to 1.5 ± 1.06; t1 = 3.32, p = 0.013). A significant effect of time was found for functional outcome with no significant differences between SCS types (PSQI: t1,12 = 8.8, p = 0.012; and BDI: t1 = 53.3, p < 0.001). No stimulation/hardware-related complications occurred. DISCUSSION Long-term data of this comparative study suggests that burst responsiveness was superior to 10 kHz in our small-scale cohort, thus a larger, randomized-controlled comparative study design is highly recommended.
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Affiliation(s)
- Sajjad Muhammad
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Sandra Roeske
- DZNE, German Center for Neurodegenerative Diseases, Bonn, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Shafqat Rasul Chaudhry
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Thomas Mehari Kinfe
- Department of Neurosurgery, Division of Functional Neurosurgery, Stereotaxy and Neuromodulation, Bonn, Germany
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Kinfe TM, Muhammad S, Link C, Roeske S, Chaudhry SR, Yearwood TL. Burst Spinal Cord Stimulation Increases Peripheral Antineuroinflammatory Interleukin 10 Levels in Failed Back Surgery Syndrome Patients With Predominant Back Pain. Neuromodulation 2017; 20:322-330. [PMID: 28194840 DOI: 10.1111/ner.12586] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/14/2016] [Accepted: 01/03/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Burst spinal cord stimulation (SCS) has been reported to reduce back pain and improve functional capacity in Failed Back Surgery Syndrome (FBSS). However, its mechanism of action is not completely understood. Systemic circulating cytokines have been associated with the development of chronic back pain. METHODS This prospective, feasibility study enrolled 12 refractory FBSS patients with predominant back pain (70% of overall pain) suitable for Burst SCS. Back and leg pain intensity (back pain [VASB ]/leg pain [VASL ]), functional capacity (sleep quality [PSQI]), depressive symptoms (BDI), body weight, stimulation parameters, and plasma levels of pro-inflammatory (Il-1b; TNF; HMGB1)/anti-inflammatory (Il-10) cytokines were collected at baseline and after three months of Burst SCS and compared to healthy controls. RESULTS Pain intensity (pre VASB : 8.25 ± 0.75 vs. post 1.42 ± 1.24) and functional capacity (PSQI: pre 7.92 ± 3.92 vs. post 3.42 ± 1.24; BDI: pre 20.83 ± 3.56 vs. post 10.92 ± 0.75) significantly improved compared to baseline. Pro-inflammatory HMGB1 remained unchanged (preburst: 3.35 ± 3.25 vs. postburst: 3.78 ± 3.83 ng/mL; p = 0.27; W = -30) versus the HC group (2.53 ± 2.6 ng/mL; p = 0.47; U = 59), while anti-inflammatory IL-10 levels were significantly elevated after burst SCS as compared to baseline (preburst 12.54 ± 22.95 vs. postburst 43.16 ± 74.71 pg/mL; p = 0.03; W = -48) and HC group (HC: 7.03 ± 11.6 vs. postburst 43.16 ± 74.71 pg/mL; p = 0.03; W = -48; p = 0.04). Baseline preburst IL-10 values and preburst VASB significantly correlated (Spearman correlation r = -0.66; p = 0.05; 95 CI -0.86 to -0.24), while correlation was not significant between postburst IL-10 values and postburst VASB (Spearman correlation r = -0.49; p = 0.18; 95 CI -0.83 to -0.15). Postburst IL-10 values correlated significantly with postburst PSQI scores (Spearman correlation r = -0.66; p = 0.05; 95 CI -0.86 to -0.24), while no correlation was found between preburst and postburst changes related to the BDI. CONCLUSIONS Burst SCS increased systemic circulating anti-inflammatory IL-10, improved FBSS back pain and back pain associated co-morbidities like disrupted sleep architecture and depressive symptoms in FBSS patients. Thus, suggesting a possible relationship between burst SCS and burst-evoked modulation of peripheral anti-inflammatory cytokine IL-10 in chronic back pain.
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Affiliation(s)
- Thomas M Kinfe
- Department of Neurosurgery, Rheinische Friedrich Wilhelms - University Hospital, Bonn, Germany.,Division of Functional Neurosurgery and Neuromodulation, Rheinische Friedrich Wilhelms - University Hospital, Bonn, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Rheinische Friedrich Wilhelms - University Hospital, Bonn, Germany
| | - Carolina Link
- Department of Anesthesiology, Rheinische Friedrich Wilhelms - University Hospital, Bonn, Germany
| | - Sandra Roeske
- DZNE, German Center for Neurodegenerative Diseases, Bonn, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Shafqat R Chaudhry
- Department of Neurosurgery, Rheinische Friedrich Wilhelms - University Hospital, Bonn, Germany
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De Ridder D, Vanneste S. Visions on the future of medical devices in spinal cord stimulation: what medical device is needed? Expert Rev Med Devices 2016; 13:233-42. [DOI: 10.1586/17434440.2016.1136560] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Kinfe TM, Pintea B, Link C, Roeske S, Güresir E, Güresir Á, Vatter H. High Frequency (10 kHz) or Burst Spinal Cord Stimulation in Failed Back Surgery Syndrome Patients With Predominant Back Pain: Preliminary Data From a Prospective Observational Study. Neuromodulation 2016; 19:268-75. [DOI: 10.1111/ner.12379] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 09/28/2015] [Accepted: 10/23/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Thomas M. Kinfe
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
- Department of Neurosurgery, Division of Functional Neurosurgery and Neuromodulation, Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
| | - Bogdan Pintea
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
| | - Carolina Link
- Department of Anesthesiology, Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
| | - Sandra Roeske
- DZNE, German Center for Neurodegenerative Diseases; Bonn Germany
- Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
| | - Ági Güresir
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital; Bonn Germany
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De Ridder D, Vanneste S. Burst and Tonic Spinal Cord Stimulation: Different and Common Brain Mechanisms. Neuromodulation 2015; 19:47-59. [DOI: 10.1111/ner.12368] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/05/2015] [Accepted: 09/24/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Sven Vanneste
- Lab for Clinical & Integrative Neuroscience; School of Behavioral and Brain Sciences; The University of Texas at Dallas; Dallas TX USA
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Evans MC, Clark VW, Manning PJ, De Ridder D, Reynolds JN. Optimizing Deep Brain Stimulation of the Nucleus Accumbens in a Reward Preference Rat Model. Neuromodulation 2015; 18:531-40; discussion 540-1. [DOI: 10.1111/ner.12339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/01/2015] [Accepted: 06/29/2015] [Indexed: 12/28/2022]
Affiliation(s)
- Maggie C. Evans
- Department of Anatomy; Brain Health Research Centre; School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Vincent W. Clark
- Department of Anatomy; Brain Health Research Centre; School of Medical Sciences; University of Otago; Dunedin New Zealand
- Department of Surgical Sciences; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Patrick J. Manning
- Department of Medicine; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Dirk De Ridder
- Department of Surgical Sciences; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - John N.J. Reynolds
- Department of Anatomy; Brain Health Research Centre; School of Medical Sciences; University of Otago; Dunedin New Zealand
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