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De Ridder D, Siddiqi MA, Dauwels J, Serdijn WA, Strydis C. NeuroDots: From Single-Target to Brain-Network Modulation: Why and What Is Needed? Neuromodulation 2024; 27:711-729. [PMID: 38639704 DOI: 10.1016/j.neurom.2024.01.003] [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: 08/07/2023] [Revised: 11/05/2023] [Accepted: 01/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES Current techniques in brain stimulation are still largely based on a phrenologic approach that a single brain target can treat a brain disorder. Nevertheless, meta-analyses of brain implants indicate an overall success rate of 50% improvement in 50% of patients, irrespective of the brain-related disorder. Thus, there is still a large margin for improvement. The goal of this manuscript is to 1) develop a general theoretical framework of brain functioning that is amenable to surgical neuromodulation, and 2) describe the engineering requirements of the next generation of implantable brain stimulators that follow from this theoretic model. MATERIALS AND METHODS A neuroscience and engineering literature review was performed to develop a universal theoretical model of brain functioning and dysfunctioning amenable to surgical neuromodulation. RESULTS Even though a single target can modulate an entire network, research in network science reveals that many brain disorders are the consequence of maladaptive interactions among multiple networks rather than a single network. Consequently, targeting the main connector hubs of those multiple interacting networks involved in a brain disorder is theoretically more beneficial. We, thus, envision next-generation network implants that will rely on distributed, multisite neuromodulation targeting correlated and anticorrelated interacting brain networks, juxtaposing alternative implant configurations, and finally providing solid recommendations for the realization of such implants. In doing so, this study pinpoints the potential shortcomings of other similar efforts in the field, which somehow fall short of the requirements. CONCLUSION The concept of network stimulation holds great promise as a universal approach for treating neurologic and psychiatric disorders.
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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.
| | - Muhammad Ali Siddiqi
- Department of Electrical Engineering, Lahore University of Management Sciences, Lahore, Pakistan; Neuroscience Department, Erasmus Medical Center, Rotterdam, The Netherlands; Quantum and Computer Engineering Department, Delft University of Technology, Delft, The Netherlands
| | - Justin Dauwels
- Microelectronics Department, Delft University of Technology, Delft, The Netherlands
| | - Wouter A Serdijn
- Neuroscience Department, Erasmus Medical Center, Rotterdam, The Netherlands; Section Bioelectronics, Delft University of Technology, Delft, The Netherlands
| | - Christos Strydis
- Neuroscience Department, Erasmus Medical Center, Rotterdam, The Netherlands; Quantum and Computer Engineering Department, Delft University of Technology, Delft, The Netherlands
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Doshi PP, Russo M, Doshi PK. Practice Trends of Neuromodulation Therapies for Pain and Spasticity in India. Neuromodulation 2023; 26:1876-1882. [PMID: 33900661 DOI: 10.1111/ner.13393] [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: 01/19/2021] [Revised: 02/21/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neuromodulation has been successfully used globally to address severe refractory chronic pain for over five decades. Compared to the wide acceptance that it enjoys in United States and Europe, it is fairly underutilized in Asia, including India. OBJECTIVES We conducted the first systematic nationwide survey to provide an overview of neuromodulation in the past 20 years to investigate the practice trends for severe refractory chronic pain and barriers for the uptake of neuromodulation therapies for pain in India. DESIGN A 20-point detailed questionnaire survey was sent out for online completion in August 2020 to practitioners in India involved in interventions for pain. The survey was completed by 112 practitioners (10% return rate). The response data collected were analyzed, tabulated, and presented as percentages. RESULTS The average duration of pain practice in India for the majority of respondents was less than a decade. About 70% of practitioners expressed that they manage severe refractory pain without neuromodulation. This survey confirms that neuromodulation is grossly underutilized for pain, comprising only 10% of total neuromodulation implants performed per annum in India. The most common indications were neuropathic pain (45%) and failed back surgery syndrome (42%). The respondents expressed the main barriers to be related to the cost (85%), lack of awareness (68%), and lack of good training (59%). More than 50% of respondents also expressed difficulty of access to neuromodulation therapies for pain and acceptance by patients. CONCLUSION The younger generation of pain practitioners in India is becoming more aware and convinced about the role of neuromodulation to alleviate severe pain and suffering. An all-round approach combining improved training, awareness at various levels, more flexible options of newer technology and reimbursement approval can positively influence its use. This can be achieved with the collective efforts of physicians, insurers, industry, and focused academic activities of clinical societies.
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Affiliation(s)
- Preeti P Doshi
- Department of Pain Medicine, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India.
| | - Marc Russo
- Department of Pain Medicine, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Paresh K Doshi
- Department of Pain Medicine, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
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Tapia Pérez JH. Spinal cord stimulation: Beyond pain management. Neurologia 2022; 37:586-595. [PMID: 31337556 DOI: 10.1016/j.nrl.2019.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 05/03/2019] [Accepted: 05/20/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The gate control theory of pain was the starting point of the development of spinal cord stimulation (SCS). We describe the indications for the treatment in pain management and other uses not related to pain. DEVELOPMENT There are currently several paradigms for SCS: tonic, burst, and high frequency. The main difference lies in the presence of paraesthesias. SCS is most beneficial for treating neuropathic pain. Patients with failed back surgery syndrome show the best response rates, although a considerable reduction in pain is also observed in patients with complex regional pain syndrome, diabetic neuropathy, radiculopathy, and low back pain without previous surgery. Phantom pain or pain related to cardiovascular or peripheral vascular disease may improve, although there is a lack of robust evidence supporting generalisation of its use. SCS also improves cancer-related pain, although research on this issue is scarce. Non-pain-related indications for SCS are movement disorders, spasticity, and sequelae of spinal cord injury. The main limiting factors for the use of SCS are mechanical complications and the cost of the treatment. CONCLUSION In its 50-year history, SCS has progressed enormously. The perfection of hardware and software may improve its effectiveness and reduce the rate of complications. Indications for SCS could include other diseases, and its use could be expanded, if the costs of the technology are reduced.
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Affiliation(s)
- J H Tapia Pérez
- Department of Spine Surgery, Leopoldina-Krankenhaus der Stadt Schweinfurt, Schweinfurt, Alemania.
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Isagulyan ED, Mikhailova VA, Aslakhanova KS, Slavin KV. Prospects of neuromodulation for chronic pain. BRAIN DISORDERS 2022. [DOI: 10.1016/j.dscb.2021.100027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Cox CJ, Wilkinson MM, Erdek MA. Successful spinal cord stimulation for chronic pancreatitis and post-laminectomy pain. Pain Manag 2021; 12:123-129. [PMID: 34380321 DOI: 10.2217/pmt-2021-0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Approximately one in five adults in the United States experiences chronic pain. Over the last 50 years, spinal cord stimulation has become increasingly recognized as a minimally invasive, efficacious treatment modality for the management of chronic pain. The authors report a case study of a 46-year-old female in the first documented spinal cord stimulation simultaneously targeting intractable neuropathic and visceral pain caused by post-laminectomy syndrome and chronic pancreatitis, respectively. This case study demonstrates near-total relief of the patient's neuropathic low back/leg pain and visceral epigastric pain, showing evidence of potential clinical usefulness for spinal cord stimulation as a treatment option in patients who present with a combination of visceral and somatic pain symptoms.
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Affiliation(s)
- Cody J Cox
- East Tennessee State University Quillen College of Medicine, 178 Maple Ave., Mountain Home, TN 37684, USA
| | - Michael M Wilkinson
- East Tennessee State University Quillen College of Medicine, 178 Maple Ave., Mountain Home, TN 37684, USA
| | - Michael A Erdek
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 550 N. Broadway, Suite 301, Baltimore, MD 21205, USA.,Berman Institute of Bioethics, Johns Hopkins University School of Medicine, 550 N. Broadway, Suite 301, Baltimore, MD 21205, USA
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Tapias Pérez J. Spinal cord stimulation: beyond pain management. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:586-595. [DOI: 10.1016/j.nrleng.2019.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/20/2019] [Indexed: 12/23/2022] Open
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De Ridder D, Maciaczyk J, Vanneste S. The future of neuromodulation: smart neuromodulation. Expert Rev Med Devices 2021; 18:307-317. [PMID: 33764840 DOI: 10.1080/17434440.2021.1909470] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The International Neuromodulation Society defines neuromodulation as the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body.Areas covered: In the near future (<5 years) increasingly complex implantable neuromodulation systems will enter the market. These devices are capable of closed-loop stimulation and the delivery of novel stimulation designs, pushing the need for upgradability. But what about the near-to-far future, meaning 5-10 years from now?Expert opinion: We propose that neuromodulation in the near to far future (5-10 years) will involve integration of adaptive network neuromodulation with predictive artificial intelligence, automatically adjusted by brain and external sensors, and controlled via cloud-based applications. The components will be introduced in a phased approach, culminating in a fully autonomous brain-stimulator-cloud interface. This may, in the long future (>10 years), lead to the brain of the future, a brain with integrated artificial intelligence.
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Affiliation(s)
- Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jarek Maciaczyk
- Stereotactic and Functional Neurosurgery, Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Sven Vanneste
- Lab for Clinical & Integrative Neuroscience, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland
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Nagel SJ, Hsieh J, Machado AG, Frizon LA, Howard MA, Gillies GT, Wilson S. Biomarker Optimization of Spinal Cord Stimulation Therapies. Neuromodulation 2020; 24:3-12. [PMID: 32881257 DOI: 10.1111/ner.13252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We are in the process of designing and testing an intradural stimulation device that will shorten the distance between the location of the electrode array and the targeted neural tissue, thus improving the efficacy of electrical current delivery. Identifying a biomarker that accurately reflects the response to this intervention is highly valued because of the potential to optimize interventional parameters or predict a response before it is clinically measurable. In this report, we summarize the findings pertaining to the study of biomarkers so that we and others will have an up-to-date reference that critically evaluates the current approaches and select one or several for testing during the development of our device. MATERIALS AND METHODS We have conducted a broad survey of the existing literature to catalogue the biomarkers that could be coupled to intradural spinal cord stimulation. We describe in detail some of the most promising biomarkers, existing limitations, and suitability to managing chronic pain. RESULTS Chronic, intractable pain is an all-encompassing condition that is incurable. Many treatments for managing chronic pain are nonspecific in action and intermittently administered; therefore, patients are particularly susceptible to large fluctuations in pain control over the course of a day. The absence of a reliable biomarker challenges assessment of therapeutic efficacy and contributes to either incomplete and inconsistent pain relief or, alternatively, intolerable side effects. Fluctuations in metabolites or inflammatory markers, signals captured during dynamic imaging, and genomics will likely have a role in governing how a device is modulated. CONCLUSIONS Efforts to identify one or more biomarkers are well underway with some preliminary evidence supporting their efficacy. This has far-reaching implications, including improved outcomes, fewer adverse events, harmonization of treatment and individuals, performance gains, and cost savings. We anticipate that novel biomarkers will be used widely to manage chronic pain.
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Affiliation(s)
- Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Hsieh
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Leonardo A Frizon
- Department of Neurosurgery, Hospital Marcelino Champagnat, Curitiba, PR, Brazil
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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De Ridder D, Vanneste S. The Bayesian brain in imbalance: Medial, lateral and descending pathways in tinnitus and pain: A perspective. PROGRESS IN BRAIN RESEARCH 2020; 262:309-334. [PMID: 33931186 DOI: 10.1016/bs.pbr.2020.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Tinnitus and pain share similarities in their anatomy, pathophysiology, clinical picture and treatments. Based on what is known in the pain field, a heuristic model can be proposed for the pathophysiolgy of tinnitus. This heuristic pathophysiological model suggests that pain and tinnitus are the consequence of an imbalance between two pain/tinnitus evoking pathways, i.e., a lateral sensory pathway and a medial affective pathway, both of which are not balanced anymore by a pain/noise inhibitory pathway. Mechanistically, based on the Bayesian brain concept, it can be explained by a switch occuring under influence of the rostral to dorsal anterior cingulate cortex of its prior predictions, i.e., a reference resetting, in which the pain/tinnitus state is considered as the new reference state. This reference resetting is confirmed by the nucleus accumbens as part of the reward system and maintained by connectivity changes between the nucleus accumbens and the pregenual anterior cingulate cortex. As a consequence it can be suggested to treat pain/tinnitus via reconditioning, either surgically or non-surgically. The model can also be used to develop objective measures for tinnitus and pain via supervised machine learning.
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Affiliation(s)
- Dirk De Ridder
- Department of Surgical Sciences, Section of Neurosurgery, 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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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: 45] [Impact Index Per Article: 11.3] [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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11
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Holland MT, Seaman SC, Woodroffe RW, Fredericks DC, Kovach CK, Gibson-Corley KN, Gillies GT, Howard MA. In Vivo Testing of a Prototype Intradural Spinal Cord Stimulator in a Porcine Model. World Neurosurg 2020; 137:e634-e641. [PMID: 32112934 DOI: 10.1016/j.wneu.2020.02.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic midline low back pain is the number one reason for disability in the United States despite the prolific use of medical and surgical interventions. Notwithstanding the widespread use of epidural spinal cord stimulators (SCSs), there remains a large portion of the population with inadequate pain control thought to be because of the limited volume of stimulated neural tissue. Intradural SCSs represent an underexplored alternative strategy with the potential to improve selectivity, power efficiency, and efficacy. We studied and carried out development of an intradural form of an SCS. Herein we present the findings of in vivo testing of a prototype intradural SCS in a porcine model. METHODS Six female juvenile pigs underwent surgical investigation. One control animal underwent a laminectomy only, whereas the 5 other animals had implantation of an intradural SCS prototype. One of the prototypes was fully wired to enable acute stimulation and concurrent electromyographic recordings. All animals underwent terminal surgery 3 months postimplantation, with harvesting of the spinal column. Imaging (microcomputed tomography scan) and histopathologic examinations were subsequently performed. RESULTS All animals survived implantation without evidence of neurologic deficits or infection. Postmortem imaging and histopathologic examination of the spinal column revealed no evidence of spinal cord damage, cerebrospinal fluid fistula formation, abnormal bony overgrowth, or dural defect. Viable dura was present between the intra- and extradural plates of the device. Electromyographic recordings revealed evoked motor units from the stimulator. CONCLUSIONS Chronically implanted intradural device in the porcine model demonstrated safety and feasibility for translation into humans.
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Affiliation(s)
- Marshall T Holland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Scott C Seaman
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Douglas C Fredericks
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Christopher K Kovach
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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Leong SL, De Ridder D, Deer T, Vanneste S. Potential Therapeutic Effect of Low Amplitude Burst Spinal Cord Stimulation on Pain. Neuromodulation 2019; 24:574-580. [PMID: 31854070 DOI: 10.1111/ner.13090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/02/2019] [Accepted: 11/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The SUNBURST Study, a USA-based controlled cross-over trial demonstrated that burst spinal cord stimulation was superior compared to tonic stimulation in suppressing chronic intractable pain. However, when on burst stimulation, participants preferred lower to higher amplitudes. This led to the hypothesis that lower burst amplitudes will correlate with lower pain scores while higher amplitudes will be associated with higher pain scores. OBJECTIVE To investigate correlations between burst amplitude and self-reported pain and different psychosocial measures. MATERIALS AND METHODS One hundred participants in the SUNBURST study were randomized to receive burst or tonic stimulation, each for 12 weeks in a cross-over manner. Complete data of 99 participants were used in this secondary analysis. Pearson correlations were conducted at 6-, 12-, 18-, and 24-weeks postactivation to determine the strength of linear relationships between burst amplitude and (1) the average seven-day daily pain Visual Analogue Scale (VAS), (2) the different domains of the Pain Catastrophizing Scale (PCS), (3) the different domains of the SF-36v2 (Quality Metric Incorporated, Lincoln, RI) Health Survey. In addition, correlations between tonic stimulation amplitude and the above-mentioned outcome measures were examined. RESULTS Significant positive correlations were identified between burst amplitude and total, "worst," and "trunk" pain for VAS; all domains for PCS; and "Role-Physical," "Bodily Pain," and "General Health" for SF-36v2™ after 12-weeks of burst stimulation. CONCLUSIONS In burst spinal cord stimulation, in contrast to tonic stimulation, lower amplitudes are more effective in suppressing pain than high amplitudes.
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Affiliation(s)
- Sook Ling Leong
- Trinity Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | - Dirk De Ridder
- Section of Neurosurgery, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sven Vanneste
- Trinity Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
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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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Abstract
Spinal cord stimulation (SCS) is a neuromodulation therapy used to treat medically refractory chronic pain. In SCS, an implanted pulse generator produces electrical signals that are conveyed through electrode arrays located in the region of the spinal cord. The goal of SCS is to modulate neural signaling through spinal and supraspinal mechanisms to reduce pain. Although available for decades, SCS still enjoys only limited clinical success, limited quality-of-life improvement, and limited long-term efficacy. To improve SCS outcomes, advances in lead design, stimulator features, and waveform paradigms have been recently introduced. While it is an exciting time for the neuromodulation field, empirical SCS advances have surpassed scientific understanding of SCS mechanisms of action. We still do not know why SCS works in some patients but not in others. We also lack information-rich biomarkers of pain and pain relief through which to optimize SCS programming. To optimize both system designs and clinical implementations of SCS, it is critical that we address these scientific and mechanistic knowledge gaps.
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Affiliation(s)
- 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
| | - 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 Neurosurgery, University of Michigan, Ann Arbor, MI, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
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De Groote S, De Jaeger M, Van Schuerbeek P, Sunaert S, Peeters R, Loeckx D, Goudman L, Forget P, De Smedt A, Moens M. Functional magnetic resonance imaging: cerebral function alterations in subthreshold and suprathreshold spinal cord stimulation. J Pain Res 2018; 11:2517-2526. [PMID: 30425564 PMCID: PMC6205143 DOI: 10.2147/jpr.s160890] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background and purpose Failed back surgery syndrome (FBSS) is a common and devastating chronic neuropathic pain disorder. Conventional spinal cord stimulation (SCS) applies electrical suprathreshold pulses to the spinal cord at a frequency of 40-60 Hz and relieves pain in FBSS patients. During the last decade, two major changes have emerged in the techniques of stimulating the spinal cord: paresthesia-free or subthreshold stimulation and administration of higher frequency or higher amounts of energy to the spinal cord. Despite the positive clinical results, the mechanism of action remains unclear. A functional MRI (fMRI) study was conducted to investigate the brain alterations during subthreshold and suprathreshold stimulation at different frequencies. Methods Ten subjects with FBSS, treated with externalized SCS, received randomly four different stimulation frequencies (4 Hz, 60 Hz, 500 Hz, and 1 kHz) during four consecutive days. At every frequency, the patient underwent sub- and suprathreshold stimulation. Cerebral activity was monitored and assessed using fMRI. Results Suprathreshold stimulation is generally accompanied with more activity than sub-threshold SCS. Suprathreshold SCS resulted in increased bilateral activation of the frontal cortex, thalamus, pre- and postcentral gyri, basal ganglia, cingulate gyrus, insula, thalamus, and claustrum. We observed deactivation of the bilateral parahippocampus, amygdala, precuneus, posterior cingulate gyrus, postcentral gyrus, and unilateral superior temporal gyrus. Conclusion Suprathreshold stimulation resulted in greater activity (both activation and deactivation) of the frontal brain regions; the sensory, limbic, and motor cortices; and the diencephalon in comparison with subthreshold stimulation. Each type of frequency at suprathreshold stimulation was characterized by an individual activation pattern.
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Affiliation(s)
- Sander De Groote
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium,
| | - Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium,
| | | | - Stefan Sunaert
- Department of Radiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Ronald Peeters
- Department of Radiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | | | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium, .,Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussel, Belgium
| | - Patrice Forget
- Department Anesthesiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ann De Smedt
- Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium, .,Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium, .,Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium,
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16
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Reddy CG, Miller JW, Abode-Iyamah KO, Safayi S, Wilson S, Dalm BD, Fredericks DC, Gillies GT, Howard MA, Brennan TJ. Ovine model of neuropathic pain for assessing mechanisms of spinal cord stimulation therapy via dorsal horn recordings, von Frey filaments, and gait analysis. J Pain Res 2018; 11:1147-1162. [PMID: 29942150 PMCID: PMC6007193 DOI: 10.2147/jpr.s139843] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background It is becoming increasingly important to understand the mechanisms of spinal cord stimulation (SCS) in alleviating neuropathic pain as novel stimulation paradigms arise. Purpose Additionally, the small anatomic scale of current SCS animal models is a barrier to more translational research. Methods Using chronic constriction injury (CCI) of the common peroneal nerve (CPN) in sheep (ovine), we have created a chronic model of neuropathic pain that avoids motor deficits present in prior large animal models. This large animal model has allowed us to implant clinical grade SCS hardware, which enables both acute and chronic testing using von Frey filament thresholds and gait analysis. Furthermore, the larger anatomic scale of the sheep allows for simultaneous single-unit recordings from the dorsal horn and SCS with minimal electrical artifact. Results Detectable tactile hypersensitivity occurred 21 days after nerve injury, with preliminary indications that chronic SCS may reverse it in the painful limb. Gait analysis revealed no hoof drop in the CCI model. Single neurons were identified and discriminated in the dorsal horn, and their activity was modulated via SCS. Unlike previous large animal models that employed a complete transection of the nerve, no motor deficit was observed in the sheep with CCI. Conclusion To our knowledge, this is the first reported large animal model of chronic neuropathic pain which facilitates the study of both acute and chronic SCS using complementary behavioral and electrophysiologic measures. As demonstrated by our successful establishment of these techniques, an ovine model of neuropathic pain is suitable for testing the mechanisms of SCS.
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Affiliation(s)
- Chandan G Reddy
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - John W Miller
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kingsley O Abode-Iyamah
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Sina Safayi
- Department of Veterinary Clinical Sciences, Iowa State University, Ames, IA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Brian D Dalm
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Douglas C Fredericks
- Department of Orthopedics and Rehabilitation, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Timothy J Brennan
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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17
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Fox KCR, Foster BL, Kucyi A, Daitch AL, Parvizi J. Intracranial Electrophysiology of the Human Default Network. Trends Cogn Sci 2018; 22:307-324. [PMID: 29525387 PMCID: PMC5957519 DOI: 10.1016/j.tics.2018.02.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/01/2018] [Accepted: 02/03/2018] [Indexed: 02/07/2023]
Abstract
The human default network (DN) plays a critical role in internally directed cognition, behavior, and neuropsychiatric disease. Despite much progress with functional neuroimaging, persistent questions still linger concerning the electrophysiological underpinnings, fast temporal dynamics, and causal importance of the DN. Here, we review how direct intracranial recording and stimulation of the DN provides a unique combination of high spatiotemporal resolution and causal information that speaks directly to many of these outstanding questions. Our synthesis highlights the electrophysiological basis of activation, suppression, and connectivity of the DN, each key areas of debate in the literature. Integrating these unique electrophysiological data with extant neuroimaging findings will help lay the foundation for a mechanistic account of DN function in human behavior and cognition.
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Affiliation(s)
- Kieran C R Fox
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA; Stanford Human Intracranial Cognitive Electrophysiology Program (SHICEP), Stanford, CA, USA.
| | - Brett L Foster
- Departments of Neurosurgery and Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Aaron Kucyi
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA; Stanford Human Intracranial Cognitive Electrophysiology Program (SHICEP), Stanford, CA, USA
| | - Amy L Daitch
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA; Stanford Human Intracranial Cognitive Electrophysiology Program (SHICEP), Stanford, CA, USA
| | - Josef Parvizi
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA; Stanford Human Intracranial Cognitive Electrophysiology Program (SHICEP), Stanford, CA, USA; Stanford University School of Medicine, Stanford University, Stanford, CA, USA.
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18
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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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20
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Ahmed S, Yearwood T, De Ridder D, Vanneste S. Burst and high frequency stimulation: underlying mechanism of action. Expert Rev Med Devices 2017; 15:61-70. [PMID: 29249191 DOI: 10.1080/17434440.2018.1418662] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Paresthesia-free spinal cord stimulation (SCS) techniques, such as burst and high-frequency (HF) SCS, have been developed and demonstrated to be successful for treating chronic pain, albeit via different mechanisms of action. The goal of this review is to discuss the mechanisms of action for pain suppression at both the cellular and systems levels for burst and HF SCS. In addition, we also discuss the neuromodulation devices that mimic these paradigms. AREAS COVERED The authors performed a literature review to unravel the mechanisms of action for burst and HF SCS coupled with booklets and user manuals from neuromodulation companies to understand the programmable parameters and operating ranges. Burst SCS modulates the medial pathway to suppress pain. On cellular level, burst SCS is independent on activation of γ-aminobutyric acid (GABA) receptors to inhibit neuronal firing. HF SCS blocks large-diameter fibers from producing action potentials with little influence on smaller fibers, increasing pain suppression as frequency increases. EXPERT COMMENTARY The neuromodulation industry is in a phase of intense innovation characterized by adaptive stimulation to improve patients' experience and experiment with alternative frequencies and novel stimulation targets.
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Affiliation(s)
- Shaheen Ahmed
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
| | | | - Dirk De Ridder
- c Department of Surgical Sciences, Dunedin School of Medicine , University of Otago , Dunedin , New Zealand
| | - Sven Vanneste
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
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21
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Nagel SJ, Reddy CG, Frizon LA, Holland MT, Machado AG, Gillies GT, Howard MA. Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation. Neuromodulation 2017; 21:625-640. [DOI: 10.1111/ner.12693] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/26/2017] [Accepted: 07/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Sean J. Nagel
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - Chandan G. Reddy
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | | | - Marshall T. Holland
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Andre G. Machado
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - George T. Gillies
- Department of Mechanical and Aerospace Engineering; University of Virginia; Charlottesville VA USA
| | - Matthew A. Howard
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
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22
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De Jaeger M, van Hooff RJ, Goudman L, Valenzuela Espinoza A, Brouns R, Puylaert M, Duyvendak W, Moens M. High-Density in Spinal Cord stimulation: Virtual Expert Registry (DISCOVER): Study Protocol for a Prospective Observational Trial. Anesth Pain Med 2017; 7:e13640. [PMID: 29441289 PMCID: PMC5800302 DOI: 10.5812/aapm.13640] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/26/2017] [Accepted: 04/29/2017] [Indexed: 01/21/2023] Open
Abstract
Background Spinal cord stimulation (SCS) is a proven and effective treatment for neuropathic pain
conditions such as failed back surgery syndrome (FBSS). The hypothesis that different
settings for SCS parameters activate unique, pain-relieving mechanisms has boosted the
development of various SCS paradigms. High density spinal cord stimulation (HD-SCS) is
one of those promising, novel stimulation forms characterized by subthreshold
stimulation, delivering more pulses per second and a higher pulse density to the spinal
cord than conventional SCS. Objectives The aim of DISCOVER is to gather evidence about the effectiveness, feasibility, and
(possible) side effects of HD stimulation. Methods The prospective, non-interventional, multi-center, clinical study, DISCOVER, is
currently restricted to Belgium where 19 neuromodulation centers were selected. Patient
recruitment started in October 2016 and is expected to end in October 2017. Subjects
included are (1) patients with insufficient pain relief from conventional SCS or (2)
neurostimulation-naïve patients suited for SCS. Patients will be assessed 1 month, 3
months, and 12 months after conversion to HD-SCS settings. Each patient’s visit will
include: a numerical rating scale (NRS), Oswestry disability index (ODI), Pittsburgh
sleep quality index (PSQI), EQ-5D, a pain map, registration of SCS settings, and a list
of used pain medication. Conclusions Although promising results have been reported, adequate registration of its
effectiveness and (possible) side-effects remains an unmet need. Main results are
expected in 2019.
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Affiliation(s)
- Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel,
Laarbeeklaan 101, 1090 Brussels, Belgium
- Corresponding author: Mats De Jaeger, Vrije
Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium. Tel: +32-2699844,
E-mail:
| | - Robbert-Jan van Hooff
- Department of Radiology, Universitair Ziekenhuis Brussel,
Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel,
Laarbeeklaan 101, 1090 Brussels, Belgium
- Pain in Motion: International Research Group
- Faculty of Physical Education and Physiotherapy, Department of
Physiotherapy, Human Physiology and Anatomy, Vrije Universiteit Brussel (VUB), Laarbeeklaan
103, 1090 Brussels, Belgium
| | - Alexis Valenzuela Espinoza
- Interuniversity Center for Health Economics Research (I-CHER),
Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Raf Brouns
- Department of Neurology, Universitair Ziekenhuis Brussel,
Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Martine Puylaert
- Department of Anesthesiology and Multidisciplinary Pain Center,
Ziekenhuis Oost Limburg (ZOL), Schiepse Bos 6, 3600 Genk, Belgium
| | - Wim Duyvendak
- Department of Neurosurgery, Virga Jessa Hasselt Hospital,
Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel,
Laarbeeklaan 101, 1090 Brussels, Belgium
- Department of Radiology, Universitair Ziekenhuis Brussel,
Laarbeeklaan 101, 1090 Brussels, Belgium
- Center for Neurosciences (C4N), Vrije Universiteit Brussel
(VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
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23
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Nagel SJ, Wilson S, Johnson MD, Machado A, Frizon L, Chardon MK, Reddy CG, Gillies GT, Howard MA. Spinal Cord Stimulation for Spasticity: Historical Approaches, Current Status, and Future Directions. Neuromodulation 2017; 20:307-321. [PMID: 28370802 DOI: 10.1111/ner.12591] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/08/2016] [Accepted: 01/03/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Millions of people worldwide suffer with spasticity related to irreversible damage to the brain or spinal cord. Typical antecedent events include stroke, traumatic brain injury, and spinal cord injury, although insidious onset is also common. Regardless of the cause, the resulting spasticity leads to years of disability and reduced quality of life. Many treatments are available to manage spasticity; yet each is fraught with drawbacks including incomplete response, high cost, limited duration, dose-limiting side effects, and periodic maintenance. Spinal cord stimulation (SCS), a once promising therapy for spasticity, has largely been relegated to permanent experimental status. METHODS In this review, our goal is to document and critique the history and assess the development of SCS as a treatment of lower limb spasticity. By incorporating recent discoveries with the insights gained from the early pioneers in this field, we intend to lay the groundwork needed to propose testable hypotheses for future studies. RESULTS SCS has been tested in over 25 different conditions since a potentially beneficial effect was first reported in 1973. However, the lack of a fully formed understanding of the pathophysiology of spasticity, archaic study methodology, and the early technological limitations of implantable hardware limit the validity of many studies. SCS offers a measure of control for spasticity that cannot be duplicated with other interventions. CONCLUSIONS With improved energy-source miniaturization, tailored control algorithms, novel implant design, and a clearer picture of the pathophysiology of spasticity, we are poised to reintroduce and test SCS in this population.
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Affiliation(s)
- Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Michael D Johnson
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andre Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Leonardo Frizon
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Matthieu K Chardon
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chandan G Reddy
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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24
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De Ridder D, Perera S, Vanneste S. State of the Art: Novel Applications for Cortical Stimulation. Neuromodulation 2017; 20:206-214. [PMID: 28371170 DOI: 10.1111/ner.12593] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/13/2017] [Accepted: 01/30/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Electrical stimulation via implanted electrodes that overlie the cortex of the brain is an upcoming neurosurgical technique that was hindered for a long time by insufficient knowledge of how the brain functions in a dynamic, physiological, and pathological way, as well as by technological limitations of the implantable stimulation devices. METHODS This paper provides an overview of cortex stimulation via implantable devices and introduces future possibilities to improve cortex stimulation. RESULTS Cortex stimulation was initially used preoperatively as a technique to localize functions in the brain and only later evolved into a treatment technique. It was first used for pain, but more recently a multitude of pathologies are being targeted by cortex stimulation. These disorders are being treated by stimulating different cortical areas of the brain. Risks and complications are essentially similar to those related to deep brain stimulation and predominantly include haemorrhage, seizures, infection, and hardware failures. For cortex stimulation to fully mature, further technological development is required to predict its outcomes and improve stimulation designs. This includes the development of network science-based functional connectivity approaches, genetic analyses, development of navigated high definition transcranial alternating current stimulation, and development of pseudorandom stimulation designs for preventing habituation. CONCLUSION In conclusion, cortex stimulation is a nascent but very promising approach to treating a variety of diseases, but requires further technological development for predicting outcomes, such as network science based functional connectivity approaches, genetic analyses, development of navigated transcranial electrical stimulation, and development of pseudorandom stimulation designs for preventing habituation.
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Affiliation(s)
- Dirk De Ridder
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand
| | | | - Sven Vanneste
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand.,The University of Texas at Dallas, Richardson, TX, USA
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