1
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Huang Y, Sadeghzadeh S, Li AHY, Schonfeld E, Ramayya AG, Buch VP. Rates and Predictors of Pain Reduction With Intracranial Stimulation for Intractable Pain Disorders. Neurosurgery 2024:00006123-990000000-01186. [PMID: 38836613 DOI: 10.1227/neu.0000000000003006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/01/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intracranial modulation paradigms, namely deep brain stimulation (DBS) and motor cortex stimulation (MCS), have been used to treat intractable pain disorders. However, treatment efficacy remains heterogeneous, and factors associated with pain reduction are not completely understood. METHODS We performed an individual patient review of pain outcomes (visual analog scale, quality-of-life measures, complications, pulse generator implant rate, cessation of stimulation) after implantation of DBS or MCS devices. We evaluated 663 patients from 36 study groups and stratified outcomes by pain etiology and implantation targets. RESULTS Included studies comprised primarily retrospective cohort studies. MCS patients had a similar externalized trial success rate compared with DBS patients (86% vs 81%; P = .16), whereas patients with peripheral pain had a higher trial success rate compared with patients with central pain (88% vs 79%; P = .004). Complication rates were similar for MCS and DBS patients (12% vs 15%; P = .79). Patients with peripheral pain had lower likelihood of device cessation compared with those with central pain (5.7% vs 10%; P = .03). Of all implanted patients, mean pain reduction at last follow-up was 45.8% (95% CI: 40.3-51.2) with a 31.2% (95% CI: 12.4-50.1) improvement in quality of life. No difference was seen between MCS patients (43.8%; 95% CI: 36.7-58.2) and DBS patients (48.6%; 95% CI: 39.2-58) or central (41.5%; 95% CI: 34.8-48.2) and peripheral (46.7%; 95% CI: 38.9-54.5) etiologies. Multivariate analysis identified the anterior cingulate cortex target to be associated with worse pain reduction, while postherpetic neuralgia was a positive prognostic factor. CONCLUSION Both DBS and MCS have similar efficacy and complication rates in the treatment of intractable pain. Patients with central pain disorders tended to have lower trial success and higher rates of device cessation. Additional prognostic factors include anterior cingulate cortex targeting and postherpetic neuralgia diagnosis. These findings underscore intracranial neurostimulation as an important modality for treatment of intractable pain disorders.
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Affiliation(s)
- Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alice Huai-Yu Li
- Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ethan Schonfeld
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ashwin G Ramayya
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vivek P Buch
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
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2
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da Cunha PHM, de Andrade DC. The deep and the deeper: Spinal cord and deep brain stimulation for neuropathic pain. Presse Med 2024; 53:104231. [PMID: 38636785 DOI: 10.1016/j.lpm.2024.104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Neuropathic pain occurs in people experiencing lesion or disease affecting the somatosensorial system. It is present in 7 % of the general population and may not fully respond to first- and second-line treatments in up to 40 % of cases. Neuromodulation approaches are often proposed for those not tolerating or not responding to usual pharmacological management. These approaches can be delivered surgically (invasively) or non-invasively. Invasive neuromodulation techniques were the first to be employed in neuropathic pain. Among them is spinal cord stimulation (SCS), which consists of the implantation of epidural electrodes over the spinal cord. It is recommended in some guidelines for peripheral neuropathic pain. While recent studies have called into question its efficacy, others have provided promising data, driven by advances in techniques, battery capabilities, programming algorithms and software developments. Deep brain stimulation (DBS) is another well-stablished neuromodulation therapy routinely used for movement disorders; however, its role in pain management remains limited to specific research centers. This is not only due to variable results in the literature contesting its efficacy, but also because several different brain targets have been explored in small trials, compromising comparisons between these studies. Structures such as the periaqueductal grey, posterior thalamus, anterior cingulate cortex, ventral striatum/anterior limb of the internal capsule and the insula are the main targets described to date in literature. SCS and DBS present diverse rationales for use, mechanistic backgrounds, and varying levels of support from experimental studies. The present review aims to present their methodological details, main mechanisms of action for analgesia and their place in the current body of evidence in the management of patients with neuropathic pain, as well their particularities, effectiveness, safety and limitations.
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Affiliation(s)
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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3
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Shaheen N, Shaheen A, Elgendy A, Bezchlibnyk YB, Zesiewicz T, Dalm B, Jain J, Green AL, Aziz TZ, Flouty O. Deep brain stimulation for chronic pain: a systematic review and meta-analysis. Front Hum Neurosci 2023; 17:1297894. [PMID: 38098761 PMCID: PMC10719838 DOI: 10.3389/fnhum.2023.1297894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/30/2023] [Indexed: 12/17/2023] Open
Abstract
Background Deep brain stimulation (DBS) has shown promise in effectively treating chronic pain. This study aimed to assess the efficacy of DBS in this context. Methods We conducted a systematic literature search using PubMed, Scopus, and Web of Science, following the PRISMA guidelines. A well-constructed search strategy was utilized. Our literature search identified two groups of subjects: one group underwent DBS specifically for chronic pain treatment (DBS-P), while the second group received DBS for other indications (DBS-O), such as Parkinson's disease or dystonia, with pain perception investigated as a secondary outcome in this population. Meta-analysis was performed using R version 4.2.3 software. Heterogeneity was assessed using the tau^2 and I^2 indices, and Cochran's Q-test was conducted. Results The analysis included 966 patients in 43 original research studies with chronic pain who underwent DBS (340 for DBS-P and 625 for DBS-O). Subgroup analysis revealed that DBS-P exhibited a significant effect on chronic pain relief, with a standardized mean difference (SMD) of 1.65 and a 95% confidence interval (CI) of [1.31; 2.00]. Significant heterogeneity was observed among the studies, with an I^2 value of 85.8%. However, no significant difference was found between DBS-P and DBS-O subgroups. Subgroup analyses based on study design, age, pain diseases, and brain targets demonstrated varying levels of evidence for the effectiveness of DBS across different subgroups. Additionally, meta-regression analyses showed no significant relationship between age or pain duration and DBS effectiveness for chronic pain. Conclusion These findings significantly contribute to the expanding body of knowledge regarding the utility of DBS in the management of chronic pain. The study underscores the importance of conducting further research to enhance treatment outcomes and elucidate patient-specific factors that are associated with treatment response. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=428442, identifier CRD42023428442.
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Affiliation(s)
- Nour Shaheen
- Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | | | - Yarema B. Bezchlibnyk
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
| | - Theresa Zesiewicz
- Department of Neurology, University of South Florida, Tampa, FL, United States
| | - Brian Dalm
- Department of Neurosurgery, The Ohio State University, Columbus, OH, United States
| | - Jennifer Jain
- Department of Neurology, University of South Florida, Tampa, FL, United States
| | - Alexander L. Green
- Oxford Functional Neurosurgery, Department of Neurosurgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Tipu Z. Aziz
- Oxford Functional Neurosurgery, Department of Neurosurgery, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Oliver Flouty
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
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4
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Shin DH, Son S, Kim EY. Low-Energy Transcranial Navigation-Guided Focused Ultrasound for Neuropathic Pain: An Exploratory Study. Brain Sci 2023; 13:1433. [PMID: 37891801 PMCID: PMC10605299 DOI: 10.3390/brainsci13101433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Neuromodulation using high-energy focused ultrasound (FUS) has recently been developed for various neurological disorders, including tremors, epilepsy, and neuropathic pain. We investigated the safety and efficacy of low-energy FUS for patients with chronic neuropathic pain. We conducted a prospective single-arm trial with 3-month follow-up using new transcranial, navigation-guided, focused ultrasound (tcNgFUS) technology to stimulate the anterior cingulate cortex. Eleven patients underwent FUS with a frequency of 250 kHz and spatial-peak temporal-average intensity of 0.72 W/cm2. A clinical survey based on the visual analog scale of pain and a brief pain inventory (BPI) was performed during the study period. The average age was 60.55 ± 13.18 years-old with a male-to-female ratio of 6:5. The median current pain decreased from 10.0 to 7.0 (p = 0.021), median average pain decreased from 8.5 to 6.0 (p = 0.027), and median maximum pain decreased from 10.0 to 8.0 (p = 0.008) at 4 weeks after treatment. Additionally, the sum of daily life interference based on BPI was improved from 59.00 ± 11.66 to 51.91 ± 9.18 (p = 0.021). There were no side effects such as burns, headaches, or seizures, and no significant changes in follow-up brain magnetic resonance imaging. Low-energy tcNgFUS could be a safe and noninvasive neuromodulation technique for the treatment of chronic neuropathic pain.
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Affiliation(s)
- Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
| | - Seong Son
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
| | - Eun Young Kim
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon 21565, Republic of Korea;
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5
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Motzkin JC, Kanungo I, D’Esposito M, Shirvalkar P. Network targets for therapeutic brain stimulation: towards personalized therapy for pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1156108. [PMID: 37363755 PMCID: PMC10286871 DOI: 10.3389/fpain.2023.1156108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Precision neuromodulation of central brain circuits is a promising emerging therapeutic modality for a variety of neuropsychiatric disorders. Reliably identifying in whom, where, and in what context to provide brain stimulation for optimal pain relief are fundamental challenges limiting the widespread implementation of central neuromodulation treatments for chronic pain. Current approaches to brain stimulation target empirically derived regions of interest to the disorder or targets with strong connections to these regions. However, complex, multidimensional experiences like chronic pain are more closely linked to patterns of coordinated activity across distributed large-scale functional networks. Recent advances in precision network neuroscience indicate that these networks are highly variable in their neuroanatomical organization across individuals. Here we review accumulating evidence that variable central representations of pain will likely pose a major barrier to implementation of population-derived analgesic brain stimulation targets. We propose network-level estimates as a more valid, robust, and reliable way to stratify personalized candidate regions. Finally, we review key background, methods, and implications for developing network topology-informed brain stimulation targets for chronic pain.
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Affiliation(s)
- Julian C. Motzkin
- Departments of Neurology and Anesthesia and Perioperative Care (Pain Management), University of California, San Francisco, San Francisco, CA, United States
| | - Ishan Kanungo
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Mark D’Esposito
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
| | - Prasad Shirvalkar
- Departments of Neurology and Anesthesia and Perioperative Care (Pain Management), University of California, San Francisco, San Francisco, CA, United States
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
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6
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Caragher SP, Khouri KS, Raasveld FV, Winograd JM, Valerio IL, Gfrerer L, Eberlin KR. The Peripheral Nerve Surgeon's Role in the Management of Neuropathic Pain. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5005. [PMID: 37360238 PMCID: PMC10287132 DOI: 10.1097/gox.0000000000005005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/29/2023] [Indexed: 06/28/2023]
Abstract
Neuropathic pain (NP) underlies significant morbidity and disability worldwide. Although pharmacologic and functional therapies attempt to address this issue, they remain incompletely effective for many patients. Peripheral nerve surgeons have a range of techniques for intervening on NP. The aim of this review is to enable practitioners to identify patients with NP who might benefit from surgical intervention. The workup for NP includes patient history and specific physical examination maneuvers, as well as imaging and diagnostic nerve blocks. Once diagnosed, there is a range of options surgeons can utilize based on specific causes of NP. These techniques include nerve decompression, nerve reconstruction, nerve ablative techniques, and implantable nerve-modulating devices. In addition, there is an emerging role for preoperative involvement of peripheral nerve surgeons for cases known to carry a high risk of inducing postoperative NP. Lastly, we describe the ongoing work that will enable surgeons to expand their armamentarium to better serve patients with NP.
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Affiliation(s)
| | - Kimberly S. Khouri
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Floris V. Raasveld
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan M. Winograd
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Ian L. Valerio
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
| | - Lisa Gfrerer
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, N.Y
| | - Kyle R. Eberlin
- From the Harvard Medical School, Boston, Mass
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hosptial, Boston, Mass
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7
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Saway BF, Webb T, Weber A, Triano M, Barley J, Spampinato M, Rowland N. Functional MRI-Guided Motor Cortex and Deep Brain Stimulation for Intractable Facial Pain: A Novel, Personalized Approach in 1 Patient. Oper Neurosurg (Hagerstown) 2023; 24:103-110. [PMID: 36251418 DOI: 10.1227/ons.0000000000000440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/29/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Facial neuropathic pain syndromes such as trigeminal neuralgia are debilitating disorders commonly managed by medications, vascular decompression, and/or ablative procedures. In trigeminal neuralgia cases unresponsive to these interventions, trigeminal deafferentation pain syndrome (TDPS) can emerge and remain refractory to any further attempts at these conventional therapies. Deep brain stimulation (DBS) and motor cortex stimulation are 2 neuromodulatory treatments that have demonstrated efficacy in small case series of TDPS yet remain largely underutilized. In addition, functional MRI (fMRI) is a tool that can help localize central processing of evoked stimuli such as mechanically triggered facial pain. In this study, we present a case report and operative technique in a patient with TDPS who underwent fMRI to guide the operative management and placement of dual targets in the sensory thalamus and motor cortex. OBJECTIVE To evaluate the safety, efficacy, and outcome of a novel surgical approach for TDPS in a single patient. METHODS The fMRI and operative technique of unilateral DBS targeting the ventroposteromedial nucleus of the thalamus and facial motor cortex stimulator placement through a single burr hole is illustrated as well as the patient's clinical outcome. RESULTS In less than 1 year, the patient had near complete resolution of his facial pain with no postoperative complications. CONCLUSION We present the first published case of successful treatment of TDPS using simultaneous DBS of the ventroposteromedial and motor cortex stimulation. fMRI can be used as an effective imaging modality to guide neuromodulation in this complex disorder.
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Affiliation(s)
- Brian Fabian Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Timothy Webb
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aimee Weber
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Matthew Triano
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica Barley
- Department of Clinical Neurophysiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Maria Spampinato
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nathan Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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8
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Raghu ALB, Martin SC, Parker T, Aziz TZ, Green AL. Connectivity-based thalamus parcellation and surgical targeting of somatosensory subnuclei. J Neurosurg 2022; 137:209-216. [PMID: 34798607 DOI: 10.3171/2021.7.jns211140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The anatomy of the posterolateral thalamus varies substantially between individuals, presenting a challenge for surgical targeting. Patient-specific, connectivity-based parcellation of the thalamus may effectively approximate the ventrocaudal nucleus (Vc). This remains to be robustly validated or assessed as a method to guide surgical targeting. The authors assessed the validity of connectivity-based parcellation for targeting the Vc and its potential for improving clinical outcomes of pain surgery. METHODS A cohort of 19 patients with regional, chronic neuropathic pain underwent preoperative structural and diffusion MRI, then progressed to deep brain stimulation targeting the Vc based on traditional atlas coordinates. Surgical thalami were retrospectively segmented and then parcellated based on tractography estimates of thalamocortical connectivity. The location of each patient's electrode array was analyzed with respect to their primary somatosensory cortex (S1) parcel and compared across patients with reference to the thalamic homunculus. RESULTS Ten patients achieved long-term pain relief. Sixty-one percent of an average array (interquartile range 42%-74%) was located in the S1 parcel. In patients who achieved long-term benefit from surgery, array location in the individually generated S1 parcels was medial for face pain, centromedial for arm pain, and centrolateral for leg pain. Patients who did not benefit from surgery did not follow this pattern. Standard stereotactic coordinates of electrode locations diverged from this pattern. CONCLUSIONS Connectivity-based parcellation of the thalamus appears to be a reliable method for segmenting the Vc. Identifying the Vc in this way, and targeting mediolaterally as appropriate for the region of pain, merits exploration in an effort to increase the yield of successful surgical procedures.
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Affiliation(s)
- Ashley L B Raghu
- 1Oxford Functional Neurosurgery, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; and
| | - Sean C Martin
- 1Oxford Functional Neurosurgery, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; and
- 2Department of Neurosurgery, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford, United Kingdom
| | - Tariq Parker
- 1Oxford Functional Neurosurgery, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; and
| | - Tipu Z Aziz
- 1Oxford Functional Neurosurgery, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; and
- 2Department of Neurosurgery, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford, United Kingdom
| | - Alexander L Green
- 1Oxford Functional Neurosurgery, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; and
- 2Department of Neurosurgery, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford, United Kingdom
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9
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Deep Brain Stimulation for Chronic Pain. Neurosurg Clin N Am 2022; 33:311-321. [DOI: 10.1016/j.nec.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Mongardi L, Visani J, Mantovani G, Vitali C, Ricciardi L, Giordano F, Cavallo MA, Lofrese G, D'andrea M, Roblot P, De Bonis P, Scerrati A. Long term results of Dorsal Root Entry Zone (DREZ) lesions for the treatment of intractable pain: A systematic review of the literature on 1242 cases. Clin Neurol Neurosurg 2021; 210:107004. [PMID: 34739884 DOI: 10.1016/j.clineuro.2021.107004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Different Dorsal root entry zone (DREZ) lesion techniques have been reported as effective treatment for intractable painful conditions, though with contradictory results. Overall, good results were reported especially in specific conditions, such as pain due to brachial plexus avulsion, spinal cord injuries and oncological pain management. However, data on long term results in different clinical conditions are still missing. OBJECTIVE This study aims to systematically review the pertinent literature to evaluate indications, clinical outcomes, and complications of DREZ lesion (DREZotomy), in chronic pain management. METHODS A systematic literature review was conducted according to the PRISMA statement. Papers on DREZotomy for chronic pain in cancer, brachial plexus avulsion, spinal cord injury, post herpetic neuralgia, and phantom limb pain were considered for eligibility. For each category we further identified two sub-group according to the length of follow up: medium term and long term follow up (more than 3 years) respectively. RESULTS 46 papers, and 1242 patients, were included in the present investigation. When considering long term results DREZotomy provided favorable clinical outcomes in brachial plexus avulsion and spinal cord injury, in 60.8% and 55.8% of the cases respectively. Conversely, the success rate was 35.3% in phantom limb pain and 28.2% in post herpetic neuralgia. A poor clinical outcome was reported in over than 25% of the patients suffering from phantom limb pain, post herpetic neuralgia and spinal cord injury. The mean complications rate was 23.58%. While BPA and SCI patients presented stable improvement over time, good outcomes among PHN and PLP groups dropped by - 46.2%; and - 14.7% at long term follow up respectively. CONCLUSION DREZotomy seems to be an effective treatment for chronic pain conditions, especially for brachial plexus avulsion, spinal cord injury and intractable cancer/post-radiation pain. According to the low level of evidence of the pertinent literature, further studies are strongly recommended, to better define potential benefits and limitations of this technique.
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Affiliation(s)
- Lorenzo Mongardi
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy.
| | - Jacopo Visani
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Giorgio Mantovani
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Costanza Vitali
- Department of Morphology, Surgery and Experimental Medicine, Section of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Luca Ricciardi
- UO di Neurochirurgia, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, LE, Italy
| | - Flavio Giordano
- Department of Neurosurgery, Children's Hospital A. Meyer, University of Florence, Florence, Italy
| | - Michele Alessandro Cavallo
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy
| | | | | | - Paul Roblot
- Department of Neurosurgery, University Hospital of Bordeaux, Bordeaux, France
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy; Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy
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11
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Parker T, Raghu A, Huang Y, Gillies MJ, FitzGerald JJ, Aziz T, Green AL. Paired Acute Invasive/Non-invasive Stimulation (PAINS) study: A phase I/II randomized, sham-controlled crossover trial in chronic neuropathic pain. Brain Stimul 2021; 14:1576-1585. [PMID: 34673258 DOI: 10.1016/j.brs.2021.10.384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 10/09/2021] [Accepted: 10/18/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Dorsal root ganglion (DRG) stimulation, an invasive method of neuromodulation, and transcranial direct current stimulation (tDCS), a non-invasive method of altering cortical excitability, have both proven effective in relieving chronic pain. OBJECTIVE We employed a randomized, sham-controlled crossover study design to investigate whether single-session tDCS would have an additive therapeutic effect alongside DRG stimulation (DRGS) in the treatment of chronic pain. METHODS Sixteen neuropathic pain patients who were previously implanted with DRG stimulators were recruited. Baseline pain scores were established with DRGS-OFF. Pain scores were then recorded with DRGS-ON, after paired sham tDCS stimulation, and after paired active anodal tDCS (a-tDCS) stimulation. For active tDCS, patients were randomized to 'MEG (magnetoencephalography) localized' tDCS or contralateral motor cortex (M1) tDCS for 30 min. EEG recordings and evaluations of tDCS adverse effects were also collected. RESULTS All participants reported the interventions to be tolerable with no significant adverse effects during the session. Paired DRGS/active tDCS resulted in a significant reduction in pain scores compared to paired DRGS-ON/sham tDCS or DRGS alone. There was no difference in the additive effect of M1 vs. MEG-localized tDCS. Significant augmentation of beta activity was observed between DRGS-OFF and DRGS-ON conditions, as well as between paired DRGS-ON/sham tDCS and paired DRGS-ON/active tDCS. CONCLUSION Our results indicate that a single session of tDCS alongside DRGS is safe and can significantly reduce pain acutely in neuropathic pain patients. Paired invasive/non-invasive neuromodulation is a promising new treatment strategy for pain management and should be evaluated further to assess long-term benefits.
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Affiliation(s)
- Tariq Parker
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; Neurosurgery Department, Massachusetts General Hospital, Boston, MA, USA.
| | - Ashley Raghu
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Yongzhi Huang
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, 300072, China
| | - Martin J Gillies
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - James J FitzGerald
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Tipu Aziz
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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12
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Abdallat M, Saryyeva A, Blahak C, Wolf ME, Weigel R, Loher TJ, Runge J, Heissler HE, Kinfe TM, Krauss JK. Centromedian-Parafascicular and Somatosensory Thalamic Deep Brain Stimulation for Treatment of Chronic Neuropathic Pain: A Contemporary Series of 40 Patients. Biomedicines 2021; 9:731. [PMID: 34202202 PMCID: PMC8301341 DOI: 10.3390/biomedicines9070731] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/17/2021] [Accepted: 06/20/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction: The treatment of neuropathic and central pain still remains a major challenge. Thalamic deep brain stimulation (DBS) involving various target structures is a therapeutic option which has received increased re-interest. Beneficial results have been reported in several more recent smaller studies, however, there is a lack of prospective studies on larger series providing long term outcomes. Methods: Forty patients with refractory neuropathic and central pain syndromes underwent stereotactic bifocal implantation of DBS electrodes in the centromedian-parafascicular (CM-Pf) and the ventroposterolateral (VPL) or ventroposteromedial (VPM) nucleus contralateral to the side of pain. Electrodes were externalized for test stimulation for several days. Outcome was assessed with five specific VAS pain scores (maximum, minimum, average pain, pain at presentation, allodynia). Results: The mean age at surgery was 53.5 years, and the mean duration of pain was 8.2 years. During test stimulation significant reductions of all five pain scores was achieved with either CM-Pf or VPL/VPM stimulation. Pacemakers were implanted in 33/40 patients for chronic stimulation for whom a mean follow-up of 62.8 months (range 3-180 months) was available. Of these, 18 patients had a follow-up beyond four years. Hardware related complications requiring secondary surgeries occurred in 11/33 patients. The VAS maximum pain score was improved by ≥50% in 8/18, and by ≥30% in 11/18 on long term follow-up beyond four years, and the VAS average pain score by ≥50% in 10/18, and by ≥30% in 16/18. On a group level, changes in pain scores remained statistically significant over time, however, there was no difference when comparing the efficacy of CM-Pf versus VPL/VPM stimulation. The best results were achieved in patients with facial pain, poststroke/central pain (except thalamic pain), or brachial plexus injury, while patients with thalamic lesions had the least benefit. Conclusion: Thalamic DBS is a useful treatment option in selected patients with severe and medically refractory pain.
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Affiliation(s)
- Mahmoud Abdallat
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Department of Neurosurgery, University of Jordan, Amman 11183, Jordan
| | - Assel Saryyeva
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Christian Blahak
- Department of Neurology, University Hospital Mannheim, 68167 Mannheim, Germany; (C.B.); (M.E.W.)
- Department of Neurology, Ortenau-Klinikum Lahr-Ettenheim, 77933 Lahr Ettenheim, Germany
| | - Marc E. Wolf
- Department of Neurology, University Hospital Mannheim, 68167 Mannheim, Germany; (C.B.); (M.E.W.)
- Department of Neurology, Katharinenhospital, 70174 Stuttgart, Germany
| | - Ralf Weigel
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Department of Neurosurgery, St. Katharinen Krankenhaus, 60389 Frankfurt, Germany
| | | | - Joachim Runge
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Hans E. Heissler
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Thomas M. Kinfe
- Department of Neurosurgery, Division of Functional Neurosurgery and Stereotaxy, Friedrich-Alexander University, 91054 Erlangen-Nürnberg, Germany;
| | - Joachim K. Krauss
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Center for Systems Neuroscience, 30559 Hannover, Germany
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13
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Abreu V, Vaz R, Chamadoira C, Rebelo V, Reis C, Costa F, Martins J, Gillies MJ, Aziz TZ, Pereira EAC. Thalamic deep brain stimulation for post-traumatic neuropathic limb pain: Efficacy at five years' follow-up and effective volume of activated brain tissue. Neurochirurgie 2021; 68:52-60. [PMID: 34166646 DOI: 10.1016/j.neuchi.2021.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 04/24/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
Chronic neuropathic pain affects 7%-10% of the population. Deep brain stimulation (DBS) has shown variable but promising results in its treatment. This study prospectively assessed the long-term effectiveness of DBS in a series of patients with chronic neuropathic pain, correlating clinical results with neuroimaging. Sixteen patients received 5 years' post-surgical follow-up in a single center. Six had phantom limb pain after amputation and 10 had deafferentation pain after traumatic brachial plexus injury. Patient-reported outcome measures were completed before and after surgery, using VAS, UWNPS, BPI and SF-36 scores. Neuroimaging evaluated electrode location and effective volumes of activated tissue (VAT). Two subgroups were created based on the percentage of VAT superimposed upon the ventroposterolateral thalamic nucleus (eVAT), and clinical outcomes were compared. Analgesic effect was assessed at 5 years and compared to preoperative pain, with an improvement on VAS of 76.4% (p=0.0001), on UW-NPS of 35.2% (p=0.3582), on BPI of 65.1% (p=0.0505) and on SF-36 of 5% (p=0.7406). Eight patients with higher eVAT showed improvement on VAS of 67.5% (p=0.0017) while the remaining patients, with lower eVAT, improved by 50.6% (p=0.03607). DBS remained effective in improving chronic neuropathic pain after 5 years. While VPL-targeting contributes to success, analgesia is also obtained by stimulating surrounding posterior ventrobasal thalamic structures and related spinothalamocortical tracts.
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Affiliation(s)
- V Abreu
- Department of Neuroradiology. Centro Hospitalar Universitário do Porto, Porto, Portugal; Faculdade de Medicina da Universidade do Porto, Portugal.
| | - R Vaz
- Faculdade de Medicina da Universidade do Porto, Portugal; Department of Neurosurgery. Centro Hospitalar Universitário São João, Porto, Portugal; Neurociences Unity Hospital Cuf, Porto, Portugal
| | - C Chamadoira
- Department of Neurosurgery. Centro Hospitalar Universitário São João, Porto, Portugal
| | - V Rebelo
- Pain Unit. Centro Hospitalar Universitário São João, Porto, Portugal
| | - C Reis
- Department of Neuroradiology. Centro Hospitalar Universitário São João, Porto, Portugal
| | - F Costa
- Department of Neuroradiology. Centro Hospitalar Universitário São João, Porto, Portugal
| | | | - M J Gillies
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
| | - T Z Aziz
- Faculdade de Medicina da Universidade do Porto, Portugal; Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
| | - E A C Pereira
- Faculdade de Medicina da Universidade do Porto, Portugal; Neurosciences Research Centre, Institute of Molecular and Clinical Neurosciences, St. George's, University of London, London, United Kingdom
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14
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Gebreyohanes AMH, Ahmed AI, Choi D. Dorsal Root Entry Zone Lesioning for Brachial Plexus Avulsion: A Comprehensive Literature Review. Oper Neurosurg (Hagerstown) 2021; 20:324-333. [PMID: 33469654 DOI: 10.1093/ons/opaa447] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/23/2020] [Indexed: 11/14/2022] Open
Abstract
Dorsal root entry zone (DREZ) lesioning is a neurosurgical procedure that aims to relieve severe neuropathic pain in patients with brachial plexus avulsion by selectively destroying nociceptive neural structures in the posterior cervical spinal cord. Since the introduction of the procedure over 4 decades ago, the DREZ lesioning technique has undergone numerous modifications, with a variety of center- and surgeon-dependent technical differences and patient outcomes. We have reviewed the literature to discuss reported methods of DREZ lesioning and outcomes.
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Affiliation(s)
- Axumawi Mike Hailu Gebreyohanes
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom.,University College London (UCL) Medical School, London, United Kingdom
| | - Aminul Islam Ahmed
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - David Choi
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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15
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Deer TR, Falowski S, Arle JE, Vesper J, Pilitsis J, Slavin KV, Hancu M, Grider JS, Mogilner AY. A Systematic Literature Review of Brain Neurostimulation Therapies for the Treatment of Pain. PAIN MEDICINE 2021; 21:1415-1420. [PMID: 32034418 DOI: 10.1093/pm/pnz371] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To conduct a systematic literature review of brain neurostimulation for pain. DESIGN Grade the evidence for deep brain neurostimulation (DBS). METHODS An international, interdisciplinary work group conducted a literature search for brain stimulation. Abstracts were reviewed to select studies for grading. Randomized controlled trials (RCTs) meeting inclusion/exclusion criteria were graded by two independent reviewers. General inclusion criteria were prospective trials (RCTs and observational) that were not part of a larger or previously reported group. Excluded studies were retrospective or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the United States Preventative Services Task Force level-of-evidence criteria. RESULTS Two high-quality RCTs and three observational trials supported DBS, resulting in Level II (moderate) evidence. CONCLUSION Moderate evidence supports DBS to treat chronic pain. Additional Level I RCTs are needed to further the strength of the evidence in this important area of medicine, but the current evidence suggests that DBS should be considered as an option in treating complex pain cases.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Steven Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, Pennsylvania
| | - Jeff E Arle
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich Heine University, Dusseldorf, Germany
| | - Julie Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Maria Hancu
- Department of Neurosurgery, Albany Medical College, Albany, New York
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Alon Y Mogilner
- Department Neurosurgery, NYU Langone Medical Center, New York, New York, USA
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16
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Comparison of Different In Vivo Animal Models of Brachial Plexus Avulsion and Its Application in Pain Study. Neural Plast 2020; 2020:8875915. [PMID: 33273909 PMCID: PMC7676973 DOI: 10.1155/2020/8875915] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 01/11/2023] Open
Abstract
Brachial plexus injuries (BPIs) are high-energy trauma that can result in serious functional problems in the affected upper extremities, and brachial plexus avulsion (BPA) could be considered the most severe type of them. The booming occurrence rate of BPA brings up devastating impact on patients' life. Complications of muscle atrophy, neuropathic pain, and denervation-associated psychological disorders are major challenges in the treatment of BPA. Animal models of BPA are good vehicles for this kind of research. Full understanding of the current in vivo BPA models, which could be classified into anterior approach avulsion, posterior approach avulsion, and closed approach avulsion groups, could help researchers select the appropriate type of models for their studies. Each group of the BPA model has its distinct merits and demerits. An ideal BPA model that can inherit the advantages and make up for the disadvantages is still required for further exploration.
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17
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Pacheco-Barrios K, Meng X, Fregni F. Neuromodulation Techniques in Phantom Limb Pain: A Systematic Review and Meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2310-2322. [PMID: 32176286 PMCID: PMC7593798 DOI: 10.1093/pm/pnaa039] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effects of neuromodulation techniques in adults with phantom limb pain (PLP). METHODS A systematic search was performed, comprising randomized controlled trials (RCTs) and quasi-experimental (QE) studies that were published from database inception to February 2019 and that measured the effects of neuromodulation in adults with PLP. Hedge's g effect size (ES) and 95% confidence intervals were calculated, and random-effects meta-analyses were performed. RESULTS Fourteen studies (nine RCTs and five QE noncontrolled studies) were included. The meta-analysis of RCTs showed significant effects for i) excitatory primary motor cortex (M1) stimulation in reducing pain after stimulation (ES = -1.36, 95% confidence interval [CI] = -2.26 to -0.45); ii) anodal M1 transcranial direct current stimulation (tDCS) in lowering pain after stimulation (ES = -1.50, 95% CI = -2.05 to 0.95), and one-week follow-up (ES = -1.04, 95% CI = -1.64 to 0.45). The meta-analysis of noncontrolled QE studies demonstrated a high rate of pain reduction after stimulation with transcutaneous electrical nerve stimulation (rate = 67%, 95% CI = 60% to 73%) and at one-year follow-up with deep brain stimulation (rate = 73%, 95% CI = 63% to 82%). CONCLUSIONS The evidence from RCTs suggests that excitatory M1 stimulation-specifically, anodal M1 tDCS-has a significant short-term effect in reducing pain scale scores in PLP. Various neuromodulation techniques appear to have a significant and positive impact on PLP, but due to the limited amount of data, it is not possible to draw more definite conclusions.
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Affiliation(s)
- Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
| | - Xianguo Meng
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Shandong First Medical University & Shandong Academy of Medical Sciences, College of Sport Medicine and Rehabilitation, Jinan, Shandong Province, P.R. China
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
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18
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Mostofi A, Rezaei Haddad A, Bourlogiannis F, Pereira EAC. Stereotactic radiofrequency ventral posterolateral thalamotomy for cancer pain. NEUROSURGICAL FOCUS: VIDEO 2020; 3:V17. [PMID: 36285260 PMCID: PMC9542380 DOI: 10.3171/2020.7.focvid2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/02/2020] [Indexed: 11/08/2022]
Abstract
Palliative neuroablative procedures are often performed for medication-refractory cancer pain. A 57-year-old female with lung carcinoma and metastases to the brachial plexus and cervical spine with severe neuropathic pain affecting the right upper limb was referred to the authors’ functional neurosurgery service. This video shows her treatment with an awake stereotactic radiofrequency thalamotomy targeting the left ventral posterolateral nucleus. Postoperatively, she experienced immediate and complete resolution of the pain. Palliative radiofrequency thalamotomy can be a viable and effective procedure for somatotopically distributed regional cancer pain. The video can be found here: https://youtu.be/jykYWXTP3c4
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Affiliation(s)
- Abteen Mostofi
- Neurosciences Research Centre, St. George’s, University of London; and
- St. George’s University Hospital, London, United Kingdom
| | - Ali Rezaei Haddad
- Neurosciences Research Centre, St. George’s, University of London; and
- St. George’s University Hospital, London, United Kingdom
| | | | - Erlick A. C. Pereira
- Neurosciences Research Centre, St. George’s, University of London; and
- St. George’s University Hospital, London, United Kingdom
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19
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Frizon LA, Yamamoto EA, Nagel SJ, Simonson MT, Hogue O, Machado AG. Deep Brain Stimulation for Pain in the Modern Era: A Systematic Review. Neurosurgery 2020; 86:191-202. [PMID: 30799493 DOI: 10.1093/neuros/nyy552] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 01/25/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) has been considered for patients with intractable pain syndromes since the 1950s. Although there is substantial experience reported in the literature, the indications are contested, especially in the United States where it remains off-label. Historically, the sensory-discriminative pain pathways were targeted. More recently, modulation of the affective sphere of pain has emerged as a plausible alternative. OBJECTIVE To systematically review the literature from studies that used contemporary DBS technology. Our aim is to summarize the current evidence of this therapy. METHODS A systematic search was conducted in the MEDLINE, EMBASE, and Cochrane libraries through July 2017 to review all studies using the current DBS technology primarily for pain treatment. Study characteristics including patient demographics, surgical technique, outcomes, and complications were collected. RESULTS Twenty-two articles were included in this review. In total, 228 patients were implanted with a definitive DBS system for pain. The most common targets used were periaqueductal/periventricular gray matter region, ventral posterior lateral/posterior medial thalamus, or both. Poststroke pain, phantom limb pain, and brachial plexus injury were the most common specific indications for DBS. Outcomes varied between studies and across chronic pain diagnoses. Two different groups of investigators targeting the affective sphere of pain have demonstrated improvements in quality of life measures without significant reductions in pain scores. CONCLUSION DBS outcomes for chronic pain are heterogeneous thus far. Future studies may focus on specific pain diagnosis rather than multiple syndromes and consider randomized placebo-controlled designs. DBS targeting the affective sphere of pain seems promising and deserves further investigation.
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Affiliation(s)
- Leonardo A Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Erin A Yamamoto
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Olivia Hogue
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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20
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Hou AL, Zheng MX, Hua XY, Huo BB, Shen J, Xu JG. Electroacupuncture-Related Metabolic Brain Connectivity in Neuropathic Pain due to Brachial Plexus Avulsion Injury in Rats. Front Neural Circuits 2020; 14:35. [PMID: 32625066 PMCID: PMC7313422 DOI: 10.3389/fncir.2020.00035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022] Open
Abstract
Objective: The present study aimed to investigate the analgesic effect of electroacupuncture (EA) in neuropathic pain due to brachial plexus avulsion injury (BPAI) and related changes in the metabolic brain connectivity. Methods: Neuropathic pain model due to BPAI was established in adult female Sprague-Dawley rats. EA stimulations (2/15 Hz, 30 min/day, 5-day intervention followed by 2-day rest in each session) were applied to the fifth-seventh cervical "Jiaji" acupoints on the noninjured side from 1st to 12th weeks following BPAI (EA group, n = 8). Three control groups included sham EA (nonelectrical acupuncture applied to 3 mm lateral to the real "Jiaji" acupoints), BPAI-only, and normal rats (no particular intervention; eight rats in each group). Thermal withdrawal latency (TWL) of the noninjured forepaw was regularly tested to evaluate the threshold of thermalgesia. Small animal [fluorine-18]-fluoro-2-deoxy-D-glucose (18F-FDG) PET/CT scans of brain were conducted at the end of 4th, 12th, and 16th weeks to explore metabolic alterations of brain. Results: In the EA group, the TWL of the noninjured forepaw significantly decreased following BPAI and then increased following EA stimulation, compared with sham EA (P < 0.001). The metabolic brain connectivity among somatosensory cortex (SC), motor cortex (MC), caudate putamen (Cpu), and dorsolateral thalamus (DLT) in bilateral hemispheres decreased throughout the 16 weeks' observation in the BPAI-only group, compared with the normal rats (P < 0.05). In the EA group, the strength of connectivity among the above regions were found to be increased at the end of 4th week following BPAI modeling, decreased at 12th week, and then increased again at 16th week (P < 0.05). The changes in metabolic connectivity were uncharacteristic and dispersed in the sham EA group. Conclusion: The study revealed long-term and extensive changes of metabolic brain connectivity in EA-treated BPAI-induced neuropathic pain rats. Bilateral sensorimotor and pain-related brain regions were mainly involved in this process. It indicated that modulation of brain metabolic connectivity might be an important mechanism of analgesic effect in EA stimulation for the treatment of neuropathic pain.
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Affiliation(s)
- Ao-Lin Hou
- Shanghai Eighth People Hospital, Shanghai, China
| | - Mou-Xiong Zheng
- Department of Traumatology and Orthopedics, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xu-Yun Hua
- Department of Traumatology and Orthopedics, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bei-Bei Huo
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jun Shen
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Department of Orthopedics, Guanghua Hospital of Integrative Chinese and Western Medicine, Shanghai, China
| | - Jian-Guang Xu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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21
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Huo BB, Zheng MX, Hua XY, Shen J, Wu JJ, Xu JG. Brain Metabolism in Rats with Neuropathic Pain Induced by Brachial Plexus Avulsion Injury and Treated via Electroacupuncture. J Pain Res 2020; 13:585-595. [PMID: 32273747 PMCID: PMC7106655 DOI: 10.2147/jpr.s232030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/19/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Brain organisation is involved in the mechanism of neuropathic pain. Acupuncture is a common clinical practise in traditional Chinese medicine for the treatment of chronic pain. This study explored electroacupuncture's effects on brain metabolism following brachial plexus avulsion injury (BPAI)-induced pain. METHODS A total of 32 female rats were randomised into a normal group, model group, sham electroacupuncture group, and electroacupuncture group. A pain model was included via right BPAI. The electroacupuncture intervention at cervical "Jiaji" points (C5-7) was performed for 11 weeks. The mechanical withdrawal threshold of the non-injured (left) forepaw was measured at the baseline and on days 3, 7, 14, 21, 28, 56, 84, and 112 subsequent to BPAI. Positron emission tomography (PET) was applied to explore metabolic changes on days 28, 84, and 112. RESULTS After electroacupuncture, the mechanical withdrawal threshold of the left forepaws was significantly elevated and the effect persisted until 4 weeks after the intervention ceased (p<0.05 or p<0.001). In the sensorimotor-related brain regions, standardised uptake values in the bilateral somatosensory and motor cortices were observed in the electroacupuncture group. Metabolism particularly increased in the right somatosensory cortex. Metabolism changes also occurred in the pain-related brain regions and emotion- and cognition-related brain regions. CONCLUSION The present study demonstrated the beneficial effects of electroacupuncture for relieving BPAI-induced neuropathic pain in rats. Electroacupuncture intervention might inhibit maladaptive plasticity in brain areas governing multidimensional functions, especially in sensorimotor- and cognition-related cortices.
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Affiliation(s)
- Bei-Bei Huo
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Mou-Xiong Zheng
- Department of Traumatology and Orthopedics, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Xu-Yun Hua
- Department of Traumatology and Orthopedics, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Jun Shen
- Department of Orthopedic, Guanghua Hospital of Integrative Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Jia-Jia Wu
- Department of Rehabilitation Medicine, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Jian-Guang Xu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
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22
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Abstract
Deep brain stimulation is the most advanced and effective neuromodulation therapy for Parkinson disease, essential tremor, and generalized dystonia. This article discusses how imaging improves surgical techniques and outcomes and widens possibilities in translational neuroscience in Parkinson disease, essential tremor, generalized dystonia, and epilepsy. In movement disorders diffusion tensor imaging allows anatomic segment of cortical areas and different functional subregions within deep-seated targets to understand the side effects of stimulation and gain more data to describe the therapeutic mechanism of action. The introduction of visualization of white matter tracks increases the safety of neurosurgical techniques in functional neurosurgery and neuro-oncology.
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Affiliation(s)
- Lorand Eross
- Department of Functional Neurosurgery, Center of Neuromodulation, National Institute of Clinical Neurosciences, Amerikai út 57, Budapest 1145, Hungary.
| | - Jonathan Riley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University Buffalo Medical, 955 Main Street, Buffalo, NY 14203, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University Buffalo, 955 Main Street, Buffalo, NY 14203, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University Buffalo, 955 Main Street, Buffalo, NY 14203, USA
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23
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Ben-Haim S, Mirzadeh Z, Rosenberg WS. Deep brain stimulation for intractable neuropathic facial pain. Neurosurg Focus 2019; 45:E15. [PMID: 30064325 DOI: 10.3171/2018.5.focus18160] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is a well-established, evidence-based therapy with FDA approval for Parkinson's disease and essential tremor. Despite the early successful use of DBS to target the sensory thalamus for intractable facial pain, subsequent studies pursuing various chronic pain syndromes reported variable efficacy, keeping DBS for pain as an investigational and "off-label" use. The authors report promising results for a contemporary series of patients with intractable facial pain who were treated with DBS. METHODS Pain outcomes for 7 consecutive patients with unilateral, intractable facial pain undergoing DBS of the ventral posteromedial nucleus of the thalamus (VPM) and the periaqueductal gray (PAG) were retrospectively reviewed. Pain was assessed preoperatively and at multiple postoperative time points using the visual analog scale (VAS), the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2), and the Pain Disability Index (PDI). RESULTS VAS scores significantly decreased from a mean ± SD of 9.0 ± 1.3 preoperatively to 2.6 ± 1.5 at 1 year postoperatively (p = 0.001). PDI scores decreased from a mean total of 48.5 to 28.5 (p = 0.01). SF-MPQ-2 scores decreased from a mean of 4.6 to 2.4 (p = 0.03). Notably, several patients did not experience maximum improvement until 6-9 months postoperatively, correlating with repeated programming adjustments. CONCLUSIONS DBS of the VPM and PAG is a potential therapeutic option for patients suffering from severe, intractable facial pain refractory to other interventions. Improved efficacy may be observed over time with close follow-up and active DBS programming adjustments.
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Affiliation(s)
- Sharona Ben-Haim
- 1Department of Neurosurgery, University of California, San Diego, California
| | - Zaman Mirzadeh
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
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24
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Abstract
Phantom limb pain is a chronic neuropathic pain that develops in 45-85% of patients who undergo major amputations of the upper and lower extremities and appears predominantly during two time frames following an amputation: the first month and later about 1 year. Although in most patients the frequency and intensity of pain diminish over time, severe pain persists in about 5-10%. It has been proposed that factors in both the peripheral and central nervous systems play major roles in triggering the development and maintenance of pain associated with extremity amputations. Chronic pain is physically and mentally debilitating, affecting an individual's capacity for self-care, but also diminishing an individual's daily capacity for personal and economic independence. In addition, the pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering from this condition. Although the pain can be reduced by antiepileptic drugs and analgesics, they are frequently ineffective or their side effects preclude their use. The optimal approach for eliminating neuropathic pain and improving individuals' quality of life is the development of novel techniques that permanently prevent the development and maintenance of neuropathic pain, or that eliminate the pain once it has developed. What is still required is understanding when and where an effective novel technique must be applied, such as onto the nerve stump of the transected peripheral axons, dorsal root ganglion neurons, spinal cord, or cortex to induce the desired influences. This review, the second of two in this journal volume, examines the techniques that may be capable of reducing or eliminating chronic neuropathic pain once it has developed. Such an understanding will improve amputees' quality of life by blocking the mechanisms that trigger and/or maintain PLP and chronic neuropathic pain.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, University of Puerto Rico, Medical Science Campus, 201 Blvd. del Valle, San Juan, PR, 00901, Puerto Rico.
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25
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Corbett M, South E, Harden M, Eldabe S, Pereira E, Sedki I, Hall N, Woolacott N. Brain and spinal stimulation therapies for phantom limb pain: a systematic review. Health Technol Assess 2019; 22:1-94. [PMID: 30407905 DOI: 10.3310/hta22620] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although many treatments exist for phantom limb pain (PLP), the evidence supporting them is limited and there are no guidelines for PLP management. Brain and spinal cord neurostimulation therapies are targeted at patients with chronic PLP but have yet to be systematically reviewed. OBJECTIVE To determine which types of brain and spinal stimulation therapy appear to be the best for treating chronic PLP. DESIGN Systematic reviews of effectiveness and epidemiology studies, and a survey of NHS practice. POPULATION All patients with PLP. INTERVENTIONS Invasive interventions - deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation. Non-invasive interventions - repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). MAIN OUTCOME MEASURES Phantom limb pain and quality of life. DATA SOURCES Twelve databases (including MEDLINE and EMBASE) and clinical trial registries were searched in May 2017, with no date limits applied. REVIEW METHODS Two reviewers screened titles and abstracts and full texts. Data extraction and quality assessments were undertaken by one reviewer and checked by another. A questionnaire was distributed to clinicians via established e-mail lists of two relevant clinical societies. All results were presented narratively with accompanying tables. RESULTS Seven randomised controlled trials (RCTs), 30 non-comparative group studies, 18 case reports and 21 epidemiology studies were included. Results from a good-quality RCT suggested short-term benefits of rTMS in reducing PLP, but not in reducing anxiety or depression. Small randomised trials of tDCS suggested the possibility of modest, short-term reductions in PLP. No RCTs of invasive therapies were identified. Results from small, non-comparative group studies suggested that, although many patients benefited from short-term pain reduction, far fewer maintained their benefits. Most studies had important methodological or reporting limitations and few studies reported quality-of-life data. The evidence on prognostic factors for the development of chronic PLP from the longitudinal studies also had important limitations. The results from these studies suggested that pre-amputation pain and early PLP intensity are good predictors of chronic PLP. Results from the cross-sectional studies suggested that the proportion of patients with severe chronic PLP is between around 30% and 40% of the chronic PLP population, and that around one-quarter of chronic PLP patients find their PLP to be either moderately or severely limiting or bothersome. There were 37 responses to the questionnaire distributed to clinicians. SCS and DRG stimulation are frequently used in the NHS but the prevalence of use of DBS and MCS was low. Most responders considered SCS and DRG stimulation to be at least sometimes effective. Neurosurgeons had mixed views on DBS, but most considered MCS to rarely be effective. Most clinicians thought that a randomised trial design could be successfully used to study neurostimulation therapies. LIMITATION There was a lack of robust research studies. CONCLUSIONS Currently available studies of the efficacy, effectiveness and safety of neurostimulation treatments do not provide robust, reliable results. Therefore, it is uncertain which treatments are best for chronic PLP. FUTURE WORK Randomised crossover trials, randomised N-of-1 trials and prospective registry trials are viable study designs for future research. STUDY REGISTRATION The study is registered as PROSPERO CRD42017065387. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Mark Corbett
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Emily South
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Melissa Harden
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Sam Eldabe
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Erlick Pereira
- Academic Neurosurgery Unit, St George's, University of London, London, UK
| | - Imad Sedki
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Neil Hall
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
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Shen J, Huo BB, Hua XY, Zheng MX, Lu YC, Wu JJ, Shan CL, Xu JG. Cerebral 18F-FDG metabolism alteration in a neuropathic pain model following brachial plexus avulsion: A PET/CT study in rats. Brain Res 2019; 1712:132-138. [PMID: 30738025 DOI: 10.1016/j.brainres.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 12/14/2022]
Abstract
The present study aimed to investigate cerebral metabolic changes in a neuropathic pain model following deafferentation. A total of 24 Sprague-Dawley rats were included for modeling of right brachial plexus avulsion (BPA) through the posterior approach. As nerve injury would cause central sensitization and facilitate pain sensitivity in other parts of the body, thermal withdrawal latency (TWL) of the intact forepaw was assessed to investigate the level of pain perception following BPA-induced neuropathic pain. [Fluorine-18]-fluoro-2-deoxy-d-glucose (18F-FDG) positron emission tomography (PET) was applied to the brain before and after brachial plexus avulsion to explore metabolic changes in neuropathic pain following deafferentation. The TWL of the left (intact) forepaw was significantly lower after BPA than that of baseline (p < 0.001). Using TWL as a covariate, standardized uptake values (SUVs) of 18F-FDG significantly increased in the ipsilateral dorsolateral thalamus and contralateral anterodorsal hippocampus after BPA. Conversely, SUVs in multiple brain regions decreased, including the contralateral somatosensory cortex, ipsilateral cingulate cortex, and ipsilateral temporal association cortex. The Pearson correlation analysis showed that the SUVs of the contralateral anterodorsal hippocampus and ipsilateral dorsolateral thalamus were negatively related to the TWL of the intact forepaw, whereas the SUVs in the contralateral somatosensory cortex and ipsilateral cingulate cortex were positively related to it (p < 0.05). These findings indicate that upregulation of metabolism in the anterodorsal hippocampus and dorsolateral thalamus and downregulation metabolism in the contralateral somatosensory cortex and ipsilateral cingulate cortex could be a unique pattern of metabolic changes for neuropathic pain following brachial plexus avulsion.
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Affiliation(s)
- Jun Shen
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bei-Bei Huo
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xu-Yun Hua
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Trauma and Orthopedics, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mou-Xiong Zheng
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Trauma and Orthopedics, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ye-Chen Lu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jia-Jia Wu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chun-Lei Shan
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Rehabilitation Medicine, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jian-Guang Xu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China; Department of Rehabilitation Medicine, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
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27
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Long-Term Results of Deep Brain Stimulation of the Anterior Cingulate Cortex for Neuropathic Pain. World Neurosurg 2017; 106:625-637. [PMID: 28710048 DOI: 10.1016/j.wneu.2017.06.173] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the anterior cingulate cortex (ACC) is a recent technique that has shown some promising short-term results in patients with chronic refractory neuropathic pain. Three years after the first case series, we assessed its efficacy on a larger cohort, with longer follow-up. METHODS Twenty-four patients (19 males; average age, 49.1 years) with neuropathic pain underwent bilateral ACC DBS. Patient-reported outcome measures were collected before and after surgery, using the Numerical Rating Scale (NRS), Short-Form 36 quality of life (SF-36), McGill Pain Questionnaire (MPQ), and EuroQol 5-domain quality of life (EQ-5D) questionnaire. RESULTS Twenty-two patients after a trial week were fully internalized and 12 had a mean follow-up of 38.9 months. Six months after surgery the mean NRS score decreased from 8.0 to 4.27 (P = 0.004). There was a significant improvement in the MPQ (mean, -36%; P = 0.021) and EQ-5D score significantly decreased (mean, -21%; P = 0.036). The physical functioning domain of SF-36 was significantly improved (mean, +54.2%; P = 0.01). Furthermore, in 83% of these patients, at 6 months, NRS score was improved by 60% (P < 0.001) and MPQ decreased by 47% (P < 0.01). After 1 year, NRS score decreased by 43% (P < 0.01), EQ-5D was significantly reduced (mean, -30.8; P = 0.05) and significant improvements were also observed for different domains of the SF-36. At longer follow-ups, efficacy was sustained up to 42 months in some patients, with an NRS score as low as 3. CONCLUSIONS Follow-up results confirm that ACC DBS alleviates chronic neuropathic pain refractory to pharmacotherapy and improves quality of life in many patients.
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28
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Abreu V, Vaz R, Rebelo V, Rosas MJ, Chamadoira C, Gillies MJ, Aziz TZ, Pereira EAC. Thalamic Deep Brain Stimulation for Neuropathic Pain: Efficacy at Three Years' Follow-Up. Neuromodulation 2017. [PMID: 28631870 DOI: 10.1111/ner.12620] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECT Chronic neuropathic pain is estimated to affect 3-4.5% of the worldwide population, posing a serious burden to society. Deep Brain Stimulation (DBS) is already established for movement disorders and also used to treat some "off-label" conditions. However, DBS for the treatment of chronic, drug refractory, neuropathic pain, has shown variable outcomes with few studies performed in the last decade. Thus, this procedure has consensus approval in parts of Europe but not the USA. This study prospectively evaluated the efficacy at three years of DBS for neuropathic pain. METHODS Sixteen consecutive patients received 36 months post-surgical follow-up in a single-center. Six had phantom limb pain after amputation and ten deafferentation pain after brachial plexus injury, all due to traumas. To evaluate the efficacy of DBS, patient-reported outcome measures were collated before and after surgery, using a visual analog scale (VAS) score, University of Washington Neuropathic Pain Score (UWNPS), Brief Pain Inventory (BPI), and 36-Item Short-Form Health Survey (SF-36). RESULTS Contralateral, ventroposterolateral sensory thalamic DBS was performed in sixteen patients with chronic neuropathic pain over 29 months. A postoperative trial of externalized DBS failed in one patient with brachial plexus injury. Fifteen patients proceeded to implantation but one patient with phantom limb pain after amputation was lost for follow-up after 12 months. No surgical complications or stimulation side effects were noted. After 36 months, mean pain relief was sustained, and the median (and interquartile range) of the improvement of VAS score was 52.8% (45.4%) (p = 0.00021), UWNPS was 30.7% (49.2%) (p = 0.0590), BPI was 55.0% (32.0%) (p = 0.00737), and SF-36 was 16.3% (30.3%) (p = 0.4754). CONCLUSIONS DBS demonstrated efficacy at three years for chronic neuropathic pain after traumatic amputation and brachial plexus injury, with benefits sustained across all pain outcomes measures and slightly greater improvement in phantom limb pain.
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Affiliation(s)
- Vasco Abreu
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rui Vaz
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Departmento de Neurocirugia, Hospital de São João, Porto, Portugal.,Center for Neurosciences CUF Porto, Porto, Portugal
| | - Virgínia Rebelo
- Departamento de Psicologia, Hospital São João, Porto, Portugal
| | - Maria José Rosas
- Center for Neurosciences CUF Porto, Porto, Portugal.,Departamento de Neurologia, Hospital São João, Porto, Portugal
| | - Clara Chamadoira
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,Departmento de Neurocirugia, Hospital de São João, Porto, Portugal
| | - Martin J Gillies
- Department of Neurosurgery and Nuffield Department of Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Tipu Z Aziz
- Departmento de Neurocirugia, Hospital de São João, Porto, Portugal.,Department of Neurosurgery and Nuffield Department of Surgery, Oxford University Hospitals, Oxford, United Kingdom
| | - Erlick A C Pereira
- Departmento de Neurocirugia, Hospital de São João, Porto, Portugal.,Academic Neurosurgery Unit, St. George's, University of London, London, United Kingdom
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29
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Roy HA, Green AL, Aziz TZ. State of the Art: Novel Applications for Deep Brain Stimulation. Neuromodulation 2017; 21:126-134. [DOI: 10.1111/ner.12604] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/19/2017] [Accepted: 03/11/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Holly A. Roy
- Nuffield Department of Surgical Sciences; Oxford University; Oxford UK
- Neurosurgery Department; Oxford University Hospitals; Oxford UK
| | - Alexander L. Green
- Nuffield Department of Surgical Sciences; Oxford University; Oxford UK
- Neurosurgery Department; Oxford University Hospitals; Oxford UK
| | - Tipu Z. Aziz
- Nuffield Department of Surgical Sciences; Oxford University; Oxford UK
- Neurosurgery Department; Oxford University Hospitals; Oxford UK
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30
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Kim JH, Shin SH, Lee YR, Lee HS, Chon JY, Sung CH, Hong SJ, Lee JY, Moon HS. Ultrasound-guided peripheral nerve stimulation for neuropathic pain after brachial plexus injury: two case reports. J Anesth 2017; 31:453-457. [PMID: 28190124 DOI: 10.1007/s00540-017-2315-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/21/2017] [Indexed: 11/26/2022]
Abstract
Brachial plexus injury (BPI) often causes severe neuropathic pain that becomes chronic and difficult to treat pharmacologically or surgically. Here, we describe two cases of successful treatment of BPI with peripheral nerve stimulation (PNS). Both patients had experienced severe neuropathic pain after incomplete BPI for a long time (32 and 17 years) and did not response to medication, radiofrequency neuroablation, or spinal cord stimulation. After PNS using ultrasound, their pain was relieved by more than 50% over the course of 1 year. Both patients were satisfied with their improved sleep and quality of life. We conclude that PNS could be an alternative therapeutic modality for neuropathic pain after BPI as it provides direct nerve stimulation, has few complications, and is easy to perform.
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Affiliation(s)
- Jung Hyun Kim
- Gotbareun Intervention Pain Management Center, Seoul, Republic of Korea
| | - Sang Ho Shin
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea
| | - Young Rong Lee
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea
| | - Hyo Seon Lee
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea
| | - Jin Young Chon
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea
| | - Choon Ho Sung
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea
| | - Sung Jin Hong
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea
| | - Ji Young Lee
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea
| | - Ho Sik Moon
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 10, 63-ro, Yeoungdeungpo-gu, Seoul, 07345, Republic of Korea.
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31
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Hollingworth M, Sims-Williams HP, Pickering AE, Barua N, Patel NK. Single Electrode Deep Brain Stimulation with Dual Targeting at Dual Frequency for the Treatment of Chronic Pain: A Case Series and Review of the Literature. Brain Sci 2017; 7:brainsci7010009. [PMID: 28098766 PMCID: PMC5297298 DOI: 10.3390/brainsci7010009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/04/2017] [Accepted: 01/09/2017] [Indexed: 01/02/2023] Open
Abstract
Deep Brain Stimulation (DBS) has been used to target many deep brain structures for the treatment of chronic pain. The periaqueductal grey and periventricular grey (PAG/PVG) is an effective target but results are variable, sometimes short-lived or subject to tolerance. The centromedian intra-laminar parafascicular complex (CMPf) modulates medial pain pathways and CMPf DBS may address the affective aspects of pain perception. Stimulation of multiple deep brain targets may offer a strategy to optimize management of patients with complex pain symptomatology. However, previous attempts to stimulate multiple targets requires multiple trajectories and considerable expense. Using a single electrode to stimulate multiple targets would help overcome these challenges. A pre-requisite of such a technique is the ability to use different stimulation parameters at different contacts simultaneously on the same electrode. We describe a novel technique in 3 patients with chronic pain syndromes for whom conventional medical and/or neuromodulation therapy had failed using a single electrode technique to stimulate PVG/PAG and CMPf at dual frequencies.
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Affiliation(s)
- Milo Hollingworth
- Department of Neurosurgery, North Bristol Trust, Bristol BS10 5NB, UK.
| | | | - Anthony E Pickering
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol BS8 1TD, UK.
| | - Neil Barua
- Department of Neurosurgery, North Bristol Trust, Bristol BS10 5NB, UK.
| | - Nikunj K Patel
- Department of Neurosurgery, North Bristol Trust, Bristol BS10 5NB, UK.
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32
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Russo JF, Sheth SA. Deep brain stimulation of the dorsal anterior cingulate cortex for the treatment of chronic neuropathic pain. Neurosurg Focus 2016; 38:E11. [PMID: 26030699 DOI: 10.3171/2015.3.focus1543] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic neuropathic pain is estimated to affect 3%-4.5% of the worldwide population. It is associated with significant loss of productive time, withdrawal from the workforce, development of mood disorders such as depression and anxiety, and disruption of family and social life. Current medical therapeutics often fail to adequately treat chronic neuropathic pain. Deep brain stimulation (DBS) targeting subcortical structures such as the periaqueductal gray, the ventral posterior lateral and medial thalamic nuclei, and the internal capsule has been investigated for the relief of refractory neuropathic pain over the past 3 decades. Recent work has identified the dorsal anterior cingulate cortex (dACC) as a new potential neuromodulation target given its central role in cognitive and affective processing. In this review, the authors briefly discuss the history of DBS for chronic neuropathic pain in the United States and present evidence supporting dACC DBS for this indication. They review existent literature on dACC DBS and summarize important findings from imaging and neurophysiological studies supporting a central role for the dACC in the processing of chronic neuropathic pain. The available neurophysiological and empirical clinical evidence suggests that dACC DBS is a viable therapeutic option for the treatment of chronic neuropathic pain and warrants further investigation.
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Affiliation(s)
- Jennifer F Russo
- 1Columbia University College of Physicians and Surgeons and.,2Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Sameer A Sheth
- 2Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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33
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Hentall ID, Luca CC, Widerstrom-Noga E, Vitores A, Fisher LD, Martinez-Arizala A, Jagid JR. The midbrain central gray best suppresses chronic pain with electrical stimulation at very low pulse rates in two human cases. Brain Res 2015; 1632:119-26. [PMID: 26711853 DOI: 10.1016/j.brainres.2015.12.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/23/2015] [Accepted: 12/14/2015] [Indexed: 01/08/2023]
Abstract
Deep brain stimulation in the midbrain׳s central gray can relieve neuropathic pain in man, but for unclear reasons sometimes fails intraoperatively or in early weeks. Here we describe continuous bilateral stimulation in the central gray of two subjects with longstanding, severe neuropathic pain from spinal cord injury. Stimulation parameters were recursively adjusted over many weeks to optimize analgesia while minimizing adverse effects. In early weeks, adjustments were made in periodic office visits; subjects later selected ad libitum at home among several blinded choices while rating pain twice daily. Both subjects received significantly better pain relief when stimulus pulse rates were low. The best relief occurred with 2 Hz cycled on for 1s and off for 2s. After inferior parameters were set, pain typically climbed slowly over 1-2 days; superior parameters led to both slow and fast improvements. Over many weeks of stimulation at low pulse rates, both subjects experienced significantly less interference from pain with sleep. One subject, with major pain relief, also showed less interference with social/recreational ability and mood; the other subject, despite minor pain relief, experienced a significantly positive global impression of change. Oscillopsia, the only observed complication of stimulation, disappeared at low mean pulse rates (≤ 3/s). These subjects׳ responses are not likely to be unique even if they are uncommon. Thus daily or more frequent pain assessment, combined with slower periodic adjustment of stimulation parameters that incorporate mean pulse rates about one per second, will likely improve success with this treatment.
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Affiliation(s)
- Ian D Hentall
- The Miami Project to Cure Paralysis and Department of Neurological Surgery, Miller School of Medicine, University of Miami, R-48, Miami, FL 33136, USA.
| | - Corneliu C Luca
- The Miami Project to Cure Paralysis and Department of Neurological Surgery, Miller School of Medicine, University of Miami, R-48, Miami, FL 33136, USA
| | - Eva Widerstrom-Noga
- The Miami Project to Cure Paralysis and Department of Neurological Surgery, Miller School of Medicine, University of Miami, R-48, Miami, FL 33136, USA
| | - Alberto Vitores
- The Miami Project to Cure Paralysis and Department of Neurological Surgery, Miller School of Medicine, University of Miami, R-48, Miami, FL 33136, USA
| | - Letitia D Fisher
- The Miami Project to Cure Paralysis and Department of Neurological Surgery, Miller School of Medicine, University of Miami, R-48, Miami, FL 33136, USA
| | - Alberto Martinez-Arizala
- The Miami Project to Cure Paralysis and Department of Neurological Surgery, Miller School of Medicine, University of Miami, R-48, Miami, FL 33136, USA; Department of Veterans Affairs Medical Center, Miami, FL 33101, USA
| | - Jonathan R Jagid
- The Miami Project to Cure Paralysis and Department of Neurological Surgery, Miller School of Medicine, University of Miami, R-48, Miami, FL 33136, USA
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34
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Ko AL, Ozpinar A, Raskin JS, Magill ST, Raslan AM, Burchiel KJ. Correlation of preoperative MRI with the long-term outcomes of dorsal root entry zone lesioning for brachial plexus avulsion pain. J Neurosurg 2015; 124:1470-8. [PMID: 26406799 DOI: 10.3171/2015.2.jns142572] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Lesioning of the dorsal root entry zone (DREZotomy) is an effective treatment for brachial plexus avulsion (BPA) pain. The role of preoperative assessment with MRI has been shown to be unreliable for determining affected levels; however, it may have a role in predicting pain outcomes. Here, DREZotomy outcomes are reviewed and preoperative MRI is examined as a possible prognostic factor. METHODS A retrospective review was performed of an institutional database of patients who had undergone brachial plexus DREZ procedures since 1995. Preoperative MRI was examined to assess damage to the DREZ or dorsal horn, as evidenced by avulsion of the DREZ or T2 hyperintensity within the spinal cord. Phone interviews were conducted to assess the long-term pain outcomes. RESULTS Between 1995 and 2012, 27 patients were found to have undergone cervical DREZ procedures for BPA. Of these, 15 had preoperative MR images of the cervical spine available for review. The outcomes were graded from 1 to 4 as poor (no significant relief), good (more than 50% pain relief), excellent (more than 75% pain relief), or pain free, respectively. Overall, DREZotomy was found to be a safe, efficacious, and durable procedure for relief of pain due to BPA. The initial success rate was 73%, which declined to 66% at a median follow-up time of 62.5 months. Damage to the DREZ or dorsal horn was significantly correlated with poorer outcomes (p = 0.02). The average outcomes in patients without MRI evidence of DREZ or dorsal horn damage was significantly higher than in patients with such damage (3.67 vs 1.75, t-test; p = 0.001). A longer duration of pain prior to operation was also a significant predictor of treatment success (p = 0.004). CONCLUSIONS Overall, the DREZotomy procedure has a 66% chance of achieving meaningful pain relief on long-term follow-up. Successful pain relief is associated with the lack of damage to the DREZ and dorsal horn on preoperative MRI.
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Affiliation(s)
- Andrew L Ko
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Alp Ozpinar
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Stephen T Magill
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
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Eldabe S, Burger K, Moser H, Klase D, Schu S, Wahlstedt A, Vanderick B, Francois E, Kramer J, Subbaroyan J. Dorsal Root Ganglion (DRG) Stimulation in the Treatment of Phantom Limb Pain (PLP). Neuromodulation 2015; 18:610-6; discussion 616-7. [PMID: 26268453 DOI: 10.1111/ner.12338] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/27/2015] [Accepted: 06/25/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Phantom limb pain (PLP) is a neuropathic condition in which pain is perceived as arising from an amputated limb. PLP is distinct from, although associated with, pain in the residual limb and nonpainful phantom sensations of the missing limb. Its treatment is extremely challenging; pharmaceutical options, while commonly employed, may be insufficient or intolerable. Neuromodulatory interventions such as spinal cord stimulation have generated mixed results and may be limited by poor somatotopic specificity. It was theorized that dorsal root ganglion (DRG) neuromodulation may be more effective. MATERIALS AND METHODS Patients trialed a DRG neurostimulation system for their PLP and were subsequently implanted if results were positive. Retrospective chart review was completed, including pain ratings on a 100-mm visual analogue scale (VAS) and patient-reported outcomes. RESULTS Across eight patients, the average baseline pain rating was 85.5 mm. At follow-up (mean of 14.4 months), pain was rated at 43.5 mm. Subjective ratings of quality of life and functional capacity improved. Some patients reduced or eliminated pain medications. Patients reported precise concordance of the paresthesia with painful regions, including in their phantom limbs; in one case, stimulation eliminated PLP as well as nonpainful phantom sensations. Three patients experienced a diminution of pain relief, despite good initial outcomes. CONCLUSIONS DRG neuromodulation may be an effective tool in treating this pain etiology. Clinical outcomes in this report support recent converging evidence suggesting that the DRG may be the site of PLP generation and/or maintenance. Further research is warranted to elucidate mechanisms and optimal treatment pathways.
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Affiliation(s)
- Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Katja Burger
- Rijnland Ziekenhuis, Leiderdorp, The Netherlands
| | | | | | - Stefan Schu
- University of Dusseldorf, Dusseldorf, Germany
| | | | | | - Eric Francois
- Clinique et Maternité Sainte-Elisabeth, Namur, Belgium
| | - Jeffery Kramer
- Spinal Modulation, Inc., Menlo Park, CA, USA.,College of Medicine, University of Illinois, Peoria, IL, USA
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Boccard SGJ, Pereira EAC, Aziz TZ. Deep brain stimulation for chronic pain. J Clin Neurosci 2015; 22:1537-43. [PMID: 26122383 DOI: 10.1016/j.jocn.2015.04.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/11/2015] [Indexed: 11/29/2022]
Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention popularised in movement disorders such as Parkinson's disease, and also reported to improve symptoms of epilepsy, Tourette's syndrome, obsessive compulsive disorders and cluster headache. Since the 1950s, DBS has been used as a treatment to relieve intractable pain of several aetiologies including post stroke pain, phantom limb pain, facial pain and brachial plexus avulsion. Several patient series have shown benefits in stimulating various brain areas, including the sensory thalamus (ventral posterior lateral and medial), the periaqueductal and periventricular grey, or, more recently, the anterior cingulate cortex. However, this technique remains "off label" in the USA as it does not have Federal Drug Administration approval. Consequently, only a small number of surgeons report DBS for pain using current technology and techniques and few regions approve it. Randomised, blinded and controlled clinical trials that may use novel trial methodologies are desirable to evaluate the efficacy of DBS in patients who are refractory to other therapies. New imaging techniques, including tractography, may help optimise electrode placement and clinical outcome.
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Affiliation(s)
- Sandra G J Boccard
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
| | - Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Tipu Z Aziz
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
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Keifer OP, Riley JP, Boulis NM. Deep brain stimulation for chronic pain: intracranial targets, clinical outcomes, and trial design considerations. Neurosurg Clin N Am 2015; 25:671-92. [PMID: 25240656 DOI: 10.1016/j.nec.2014.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
For over half a century, neurosurgeons have attempted to treat pain from a diversity of causes using acute and chronic intracranial stimulation. Targets of stimulation have included the sensory thalamus, periventricular and periaqueductal gray, the septum, the internal capsule, the motor cortex, posterior hypothalamus, and more recently, the anterior cingulate cortex. The current work focuses on presenting and evaluating the evidence for the efficacy of these targets in a historical context while also highlighting the major challenges to having a double-blind placebo-controlled clinical trial. Considerations for pain research in general and use of intracranial targets specifically are included.
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Affiliation(s)
- Orion Paul Keifer
- MD/PhD Program, School of Medicine, Emory University, Suite 375-B, 1648 Pierce Drive, Atlanta, GA 30322, USA
| | - Jonathan P Riley
- Department of Neurosurgery, Emory University, 1365-B Clifton Road Northeast, Suite 2200, Atlanta, GA 30322, USA
| | - Nicholas M Boulis
- Department of Neurosurgery, Emory University, 1365-B Clifton Road Northeast, Suite 2200, Atlanta, GA 30322, USA.
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Pereira EAC, Boccard SG, Aziz TZ. Deep brain stimulation for pain: distinguishing dorsolateral somesthetic and ventromedial affective targets. Neurosurgery 2015; 61 Suppl 1:175-81. [PMID: 25032548 DOI: 10.1227/neu.0000000000000397] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Erlick A C Pereira
- *Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, United Kingdom; ‡Department of Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Portugal
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Abstract
Deep brain stimulation (DBS) and motor cortex stimulation (MCS) are established surgical modalities that have been successfully used over the last several decades for treatment of numerous chronic pain disorders. Most often, these approaches are reserved for severe, disabling, and medically refractory syndromes after less invasive approaches have been tried and have failed. Although the exact mechanism of action for DBS and MCS remains unknown, it appears that these central neuromodulation processes have multifactorial effects on central pain processing and descending pain inhibition. Clinical studies and laboratory reports have shed some light on stimulation details and optimal parameters, as well as the choice of stimulation targets, best surgical indications, and expected long-term outcomes. Based on the worldwide published experience, it appears that additional data is needed to obtain regulatory approval for both MCS and DBS for the treatment of pain. Following approval, further clinical research will shape the ability to initiate, implement, and update comprehensive patient and procedure selection paradigms.
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Shankar H, Hansen J, Thomas K. Phantom pain in a patient with brachial plexus avulsion injury. PAIN MEDICINE 2014; 16:777-81. [PMID: 25529640 DOI: 10.1111/pme.12635] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Phantom limb pain is a painful sensation perceived in the absent limb following surgical or traumatic amputation. Phantom limb sensations, which are nonpainful, occur in nearly all amputees. Deafferentation can also produce similar symptoms. Here we report the presence of phantom pain in a deafferented limb. DESIGN Case report. SETTING Hospital-based outpatient clinic. PATIENT A 65-year-old man was referred to the pain clinic for management of upper extremity pain secondary to brachial plexus avulsion (BPA) following a motor vehicle accident. Initially he noticed a feeling of growing and shrinking of his arm. Following this, the pain started gradually from his elbow extending to his fingertips covering all dermatomes. He described the pain as continuous, severe, and sharp. He also described the arm as being separate from his existing insensate arm and felt as though the fist was closed with the thumb pointing out. On physical examination, he had no sensation to fine touch or pressure below the elbow. There were no consistent areas of allodynia. He had diffuse muscle wasting in all the muscle groups of his left upper extremity, besides winging of the scapula. Electrodiagnostic studies showed a left brachial plexopathy consistent with multilevel nerve root avulsion sparing the dorsal rami. CONCLUSION This is a report of phantom limb sensations and phantom pain following BPA in an intact but flaccid and insensate limb.
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Affiliation(s)
- Hariharan Shankar
- Department of Anesthesiology, Clement Zablocki VA Medical Center, Milwaukee, Wisconsin, USA; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Pereira EA, Moore T, Moir L, Aziz TZ. Long-term motor cortex stimulation for phantom limb pain. Br J Neurosurg 2014; 29:272-4. [DOI: 10.3109/02688697.2014.971708] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention the efficacy, safety, and utility of which are established in the treatment of Parkinson's disease. For the treatment of chronic, neuropathic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated with current standards of neuroimaging and stimulator technology over the last decade . We summarize the history, science, selection, assessment, surgery, programming, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and latterly rostral anterior cingulate cortex (Cg24) in 113 patients treated at 2 centers (John Radcliffe, Oxford, UK, and Hospital de São João, Porto, Portugal) over 13 years. Several experienced centers continue DBS for chronic pain, with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS under general anesthesia considered for whole or hemibody pain, or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, OX3 9DU, UK,
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Parmar VK, Gee L, Smith H, Pilitsis JG. Supraspinal stimulation for treatment of refractory pain. Clin Neurol Neurosurg 2014; 123:155-63. [PMID: 24956545 DOI: 10.1016/j.clineuro.2014.05.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 05/21/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
Abstract
Refractory pain syndromes often have far reaching effects and are quite a challenge for primary care providers and specialists alike to treat. With the help of site-specific neuromodulation and appropriate patient selection these difficult to treat pain syndromes may be managed. In this article, we focus on supraspinal stimulation (SSS) for treatment of intractable pain and discuss off-label uses of deep brain stimulation (DBS) and motor cortex stimulation (MCS) in context to emerging indications in neuromodulation. Consideration for neuromodulatory treatment begins with rigorous patient selection based on exhaustive conservative management, elimination of secondary gains, and a proper psychology evaluation. Trial stimulation prior to DBS is nearly always performed while trial stimulation prior to MCS surgery is symptom dependent. Overall, a review of the literature demonstrates that DBS should be considered for refractory conditions including nociceptive/neuropathic pain, phantom limb pain, and chronic cluster headache (CCH). MCS should be considered primarily for trigeminal neuropathic pain (TNP) and central pain. DBS outcome studies for post-stroke pain as well as MCS studies for complex regional pain syndrome (CRPS) show more modest results and are also discussed in detail.
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Affiliation(s)
- V K Parmar
- Division of Neurosurgery, Albany Medical College, Albany, NY 12208, USA
| | - L Gee
- Division of Neurosurgery, Albany Medical College, Albany, NY 12208, USA
| | - H Smith
- Department of Anesthesia, Albany Medical College, Albany, NY 12208, USA
| | - J G Pilitsis
- Division of Neurosurgery, Albany Medical College, Albany, NY 12208, USA; Center for Neuropharmacology and Neuroscience, Albany Medical College, Albany NY 12208, USA.
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Boccard SG, Fitzgerald JJ, Pereira EA, Moir L, Van Hartevelt TJ, Kringelbach ML, Green AL, Aziz TZ. Targeting the Affective Component of Chronic Pain. Neurosurgery 2014; 74:628-35; discussion 635-7. [DOI: 10.1227/neu.0000000000000321] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
Deep brain stimulation (DBS) has shown considerable promise for relieving nociceptive and neuropathic symptoms of refractory chronic pain. Nevertheless, for some patients, standard DBS for pain remains poorly efficacious. Pain is a multidimensional experience with an affective component: the unpleasantness. The anterior cingulate cortex (ACC) is a structure involved in this affective component, and targeting it may relieve patients' pain.
OBJECTIVE:
To describe the first case series of ACC DBS to relieve the affective component of chronic neuropathic pain.
METHODS:
Sixteen patients (13 male and 3 female patients) with neuropathic pain underwent bilateral ACC DBS. The mean age at surgery was 48.7 years (range, 33-63 years). Patient-reported outcome measures were collected before and after surgery using a Visual Analog Scale, SF-36 quality of life survey, McGill Pain Questionnaire, and EQ-5D (EQ-5D and EQ-5D Health State) questionnaires.
RESULTS:
Fifteen patients (93.3%) transitioned from externalized to fully internalized systems. Eleven patients had data to be analyzed with a mean follow-up of 13.2 months. Post-surgery, the Visual Analog Scale score dropped below 4 for 5 of the patients, with 1 patient free of pain. Highly significant improvement on the EQ-5D was observed (mean, +20.3%; range, +0%-+83%; P = .008). Moreover, statistically significant improvements were observed for the physical functioning and bodily pain domains of the SF-36 quality-of-life survey: mean, +64.7% (range, −8.9%-+276%; P = .015) and mean +39.0% (range, −33.8%-+159%; P = .050), respectively.
CONCLUSION:
Affective ACC DBS can relieve chronic neuropathic pain refractory to pharmacotherapy and restore quality of life.
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Affiliation(s)
- Sandra G.J. Boccard
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery
| | - James J. Fitzgerald
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery
| | - Erlick A.C. Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery
| | - Liz Moir
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery
| | | | | | - Alexander L. Green
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery
| | - Tipu Z. Aziz
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery
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Roy HA, Aziz TZ. Deep brain stimulation and multiple sclerosis: Therapeutic applications. Mult Scler Relat Disord 2014; 3:431-9. [PMID: 25877053 DOI: 10.1016/j.msard.2014.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 02/11/2014] [Indexed: 11/28/2022]
Abstract
Deep brain stimulation is a neurosurgical technique that can be used to alleviate symptoms in a growing number of neurological conditions through modulating activity within brain networks. Certain applications of deep brain stimulation are relevant for the management of symptoms in multiple sclerosis. In this paper we discuss existing treatment options for tremor, facial pain and urinary dysfunction in multiple sclerosis and discuss evidence to support the potential use of deep brain stimulation for these symptoms.
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Affiliation(s)
- Holly A Roy
- Nuffield Department of Surgical Science, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Tipu Z Aziz
- Nuffield Department of Surgical Science, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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