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Fatima K, Javed SO, Saleem A, Marsia S, Zafar R, Noorani K, Kumar S, Ali SM, Ismail I, Hashim I, Ganatra FA. Long-term efficacy of spinal cord stimulation for chronic primary neuropathic pain in the contemporary era: a systematic review and meta-analysis. J Neurosurg Sci 2024; 68:128-139. [PMID: 36943763 DOI: 10.23736/s0390-5616.23.05930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) is a modern neuromodulation technique extensively proven to be an effective modality for treatment of chronic neuropathic pain. It has been mainly studied for complex regional pain syndrome (CRPS) and failed back surgery syndrome (FBSS) and recent data almost uniformly establishes its statistically significant positive therapeutic results. It has also been compared with other available treatment modalities across various studies. However, long term data on maintenance of its efficacious potential remains less explored. Few studies have reported data on long follow-up times (>= 12 months) and have compared its efficacy with other treatment options for chronic pain, respectively. Our study pools and analyzes the available data and compares SCS with other treatment options. It also analyzes the efficacy of SCS in long term management of patients with chronic pain. EVIDENCE ACQUISITION We reviewed all the data available on MEDLINE, Embase and Cochrane CENTRAL using a search strategy designed to fit our pre-set inclusion and exclusion criteria. Both single-arm and double-arm studies were included. The primary outcome was defined as decrease of visual analogue scale (VAS) by >50% at 6, 12 and/or 24 months after SCS. EVIDENCE SYNTHESIS According to the pooled data of double-arm studies, SCS has unanimously proven its superiority over other treatment options at 6 months follow-up; however it fails to prove statistically significant difference in results at longer treatment intervals. Dorsal root ganglion stimulation, a relatively recent technique with the same underlying physiologic mechanisms as SCS, showed far more promising results than SCS. Single-arm studies show around 70% patients experiencing greater than 50% reduction in their VAS scores at 6 and 12 months. CONCLUSIONS SCS is a viable option for management of chronic neuropathic pain secondary to FBSS and CRPS. However, data available for its long term efficacy remains scarce and show no further statistically significant results.
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Affiliation(s)
- Kaneez Fatima
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed O Javed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Aqsa Saleem
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Shayan Marsia
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ramsha Zafar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Komal Noorani
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Sahlish Kumar
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan -
| | - Sara M Ali
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Iqra Ismail
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Insiya Hashim
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Fatima A Ganatra
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Shanthanna H, Eldabe S, Provenzano DA, Chang Y, Adams D, Kashir I, Goel A, Tian C, Couban RJ, Levit T, Hagedorn JM, Narouze S. Role of patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain: a comprehensive narrative review. Reg Anesth Pain Med 2023; 48:251-272. [PMID: 37001887 DOI: 10.1136/rapm-2022-103820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/22/2022] [Indexed: 04/03/2023]
Abstract
Background/importancePatient selection for spinal cord stimulation (SCS) therapy is crucial and is traditionally performed with clinical selection followed by a screening trial. The factors influencing patient selection and the importance of trialing have not been systematically evaluated.ObjectiveWe report a narrative review conducted to synthesize evidence regarding patient selection and the role of SCS trials.Evidence reviewMedline, EMBASE and Cochrane databases were searched for reports (any design) of SCS in adult patients, from their inception until March 30, 2022. Study selection and data extraction were carried out using DistillerSR. Data were organized into tables and narrative summaries, categorized by study design. Importance of patient variables and trialing was considered by looking at their influence on the long-term therapy success.FindingsAmong 7321 citations, 201 reports consisting of 60 systematic reviews, 36 randomized controlled trials (RCTs), 41 observational studies (OSs), 51 registry-based reports, and 13 case reports on complications during trialing were included. Based on RCTs and OSs, the median trial success rate was 72% and 82%, and therapy success was 65% and 61% at 12 months, respectively. Although several psychological and non-psychological determinants have been investigated, studies do not report a consistent approach to patient selection. Among psychological factors, untreated depression was associated with poor long-term outcomes, but the effect of others was inconsistent. Most RCTs except for chronic angina involved trialing and only one RCT compared patient selection with or without trial. The median (range) trial duration was 10 (0–30) and 7 (0–56) days among RCTs and OSs, respectively.ConclusionsDue to lack of a consistent approach to identify responders for SCS therapy, trialing complements patient selection to exclude patients who do not find the therapy helpful and/or intolerant of the SCS system. However, more rigorous and large studies are necessary to better evaluate its role.
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Affiliation(s)
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | | | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Adams
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Imad Kashir
- University of Waterloo, Waterloo, Ontario, Canada
| | - Akash Goel
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chenchen Tian
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Tal Levit
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan M Hagedorn
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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Deer TR, Falowski SM, Moore GA, Hutcheson JK, Peña I, Candido K, Cornidez EG, zu Fraunberg VU, Blomme B, Capobianco RA. Passive Recharge Burst Spinal Cord Stimulation Provides Sustainable Improvements in Pain and Psychosocial Function: 2-year Results From the TRIUMPH Study. Spine (Phila Pa 1976) 2022; 47:548-556. [PMID: 34812195 PMCID: PMC8912964 DOI: 10.1097/brs.0000000000004283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/26/2021] [Accepted: 10/26/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, international, multicenter, single-arm, post-market study. OBJECTIVE The aim of this study was to assess long-term safety and effectiveness of spinal cord stimulation using a passive recharge burst stimulation design for chronic intractable pain in the trunk and/or limbs. Herein we present 24-month outcomes from the TRIUMPH study (NCT03082261). SUMMARY OF BACKGROUND DATA Passive recharge burst spinal cord stimulation (B-SCS) uniquely mimics neuronal burst firing patterns in the nervous system and has been shown to modulate the affective and attentional components of pain processing. METHODS After a successful trial period, subjects received a permanent SCS implant and returned for follow-up at 6, 12, 18, and 24 months. RESULTS Significant improvements in physical, mental, and emotional functioning observed after 6 months of treatment were maintained at 2 years. Pain catastrophizing scale (PCS) scores dropped below the population norm. Health-related quality of life on EQ-5D improved across all domains and the mean index score was within one standard deviation of norm. Pain reduction (on NRS) was statistically significant (P < 0.001) at all timepoints. Patient reported pain relief, a stated percentage of improvement in pain, was consistent at all timepoints at 60%. Patients reported significant improvements across all measures including activity levels and impact of pain on daily life. At 24 months, 84% of subjects were satisfied and 90% would recommend the procedure. Subjects decreased their chronic pain medication intake for all categories; 38% reduced psychotropic and muscle relaxants, 46% reduced analgesic, anti-convulsant and NSAIDs, and 48% reduced opioid medication. Adverse events occurred at low rates without unanticipated events. CONCLUSION Early positive results with B-SCS were maintained long term. Evidence across multiple assessment tools show that B-SCS can alleviate pain intensity, psychological distress, and improve physical function and health-related quality of life.Level of Evidence: 3.
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Affiliation(s)
| | | | | | | | - Isaac Peña
- Hospital Universitario Virgen del Rocío, Seville, Spain
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Lee KS, Jang YK, Park GH, Jun IJ, Koh JC. Successful application of burst spinal cord stimulation for refractory upper limb pain: a case series. J Int Med Res 2021; 49:3000605211004035. [PMID: 33788644 PMCID: PMC8020113 DOI: 10.1177/03000605211004035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Spinal cord stimulation (SCS) has been used to treat sustained pain that is
intractable despite various types of treatment. However, conventional tonic
waveform SCS has not shown promising outcomes for spinal cord injury (SCI) or
postamputation pain. The pain signal mechanisms of burst waveforms are different
to those of conventional tonic waveforms, but few reports have presented the
therapeutic potential of burst waveforms for the abovementioned indications.
This current case report describes two patients with refractory upper limb pain
after SCI and upper limb amputation that were treated with burst waveform SCS.
While the patients could not obtain sufficient therapeutic effect with
conventional tonic waveforms, the burst waveforms provided better pain reduction
with less discomfort. However, further studies are necessary to better clarify
the mechanisms and efficacy of burst waveform SCS in patients with intractable
pain.
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Affiliation(s)
- Kuen Su Lee
- Department of Anaesthesiology and Pain Medicine, Eulji University Uijeongbu Eulji Medical Centre, Uijeongbu, Republic of Korea
| | - Yoo Kyung Jang
- Department of Anaesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Gene Hyun Park
- Department of Anaesthesiology and Pain Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - In Jae Jun
- Department of Anaesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jae Chul Koh
- Department of Anaesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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Hyun DM, Park CH, Kim Y, Choi SS. Successful electrode insertion for spinal cord stimulation after balloon adhesiolysis in a patient with epidural adhesion - A case report. Anesth Pain Med (Seoul) 2021; 16:191-195. [PMID: 33940768 PMCID: PMC8107254 DOI: 10.17085/apm.20084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 02/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background Spinal cord stimulation (SCS) can be successfully performed using highly developed implantation techniques. However, anatomical barriers, such as epidural adhesion, may impede placing the electrode for SCS in an adequate position. Case A 60-year-old female who had SCS with an electrode at the T9-10 level removed because she had a wound infection at the back incision site. After the wound infection was completely resolved, we tried to re-insert the SCS electrode. However, it was difficult to advance it up to the T11 level due to epidural adhesion. We performed a combined epidural adhesiolysis using balloon decompression with an inflatable balloon catheter. After that, the SCS lead was successfully placed up to the T11 level, and implantation of SCS was performed. Conclusions When a patient has epidural adhesion, an epidural adhesiolysis with an inflatable balloon catheter may help the insertion of the SCS electrode in the epidural space.
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Affiliation(s)
- Dong-Min Hyun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan-Hye Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yujin Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Verrills P, Salmon J, Russo M, Gliner B, Barnard A, Caraway D. 10 kHz spinal cord stimulation for chronic upper limb and neck pain: Australian experience. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2786-2794. [PMID: 32607784 DOI: 10.1007/s00586-020-06480-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 05/03/2020] [Accepted: 05/26/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Intractable upper limb and neck pain has traditionally been a challenging pain condition to treat, with conventional spinal cord stimulation (SCS) often inducing positional variation in paraesthesia and/or inadequate coverage of axial neck pain. The purpose of this Australian multi-centre prospective, clinical trial was to assess the safety and effectiveness of paraesthesia-independent 10 kHz SCS for the treatment of upper limb and neck pain. METHODS Subjects with chronic, intractable neck and/or upper limb pain of ≥ 5 cm (on a 0-10-cm visual analogue scale) were enrolled (ACTRN12614000153617) following human research ethics committee approval. Subjects were implanted with two epidural leads spanning C2-C6 vertebral bodies. Subjects with successful trial stimulation were implanted with a Senza® system (Nevro Corp., Redwood City, CA, USA) and included in the safety and effectiveness evaluation at 3 months post-implant (primary endpoint assessment, PEA) and followed to 12 months. RESULTS Overall, 31/38 (82.6%) subjects reported a successful 10 kHz SCS trial and proceeded to a permanent implant. Twenty-three of 30 subjects (76.7%) met the PEA. Subjects reported a reduction in neck pain and upper limb pain from baseline at the PEA (8.1 ± 0.2 cm vs. 2.9 ± 0.5 cm, 7.3 ± 0.3 cm vs. 2.5 ± 0.5 cm, respectively, p ≤ 0.0001). Disability, as measured by pain disability index score, decreased from 42.6 ± 2.6 at baseline to 22.7 ± 3.2 at PEA. Results were maintained 12 months post-implant. No neurological deficits, nor reports of paraesthesia, were observed. CONCLUSIONS Stable, long-term results demonstrated that 10 kHz SCS is a promising therapy option for intractable chronic upper limb and neck pain.
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Affiliation(s)
| | | | - Marc Russo
- Genesis Research Services, Broadmeadow, NSW, Australia
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7
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Remacle T, Mauviel S, Renwart HJ, Ghassempour K, Belle F, Lückers O, Bex V, Remacle JM, Bonhomme V. Long-Term Multicolumn-Lead Spinal Cord Stimulation Efficacy in Patients with Failed Back Surgery Syndrome: A Six-Year Prospective Follow-up Study. World Neurosurg 2020; 142:e245-e252. [PMID: 32599205 DOI: 10.1016/j.wneu.2020.06.181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The use of multicolumn-lead spinal cord stimulation (SCS) to control back pain (BP) and leg pain (LP) in patients with failed back surgery syndrome (FBSS) in the short term and mid-term has been well documented. Our study investigated whether SCS remained efficient after 72 months. METHODS In an observational, single-center study, we assessed SCS efficacy in 62 patients with FBSS patients. BP, LP, and magnitude of daily activity limitation (DAL) were graded using a 0-10 visual analog scale (VAS) preoperatively and at 2, 6, 12, 24, 36, and 72 months after SCS implantation. Sleep quality, use of medications, and complications were also recorded. RESULTS Of the 62 patients, 15 with complete follow-up data available were still using their SCS device at 72 months (SCS+). For these patients, the VAS scores for BP, LP, and DAL had changed from a median of 9 (interquartile range [IQR], 8.5-10), 7 (IQR, 6-8), and 8 (IQR, 8-9) preoperatively to a median of 4 (IQR, 3-4.5), 3 (IQR, 1.5-3.5), and 3 (IQR, 2-4) at 72 months. Their quality of sleep and analgesic medication consumption had also improved. In a subset of patients no longer using the SCS device after 72 months (SCS-), the VAS scores for BP, LP, and DAL, quality of sleep, and medication consumption were comparable to those for the SCS+ group. The SCS- group was less satisfied with the technique and were less professionally active than were the SCS+ group. CONCLUSIONS The SCS device provides sustained beneficial effects on BP, LP, DAL, sleep, and medication consumption in patients with FBSS still using it at 72 months postoperatively. Further studies are needed to identify the factors of adherence to the technique and the chances of success compared with the natural evolution of FBSS.
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Affiliation(s)
- Thibault Remacle
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium; Department of Neurosurgery, University Hospital Center Liege, Liege, Belgium.
| | - Stephane Mauviel
- Department of Algology, Regional Hospital Center Citadelle, Liege, Belgium
| | - Henri-Jean Renwart
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Keyvan Ghassempour
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Frederic Belle
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Olivier Lückers
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Vincent Bex
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Jean-Michel Remacle
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Vincent Bonhomme
- Department of Algology, Regional Hospital Center Citadelle, Liege, Belgium; University Department of Anesthesia and Intensive Care Medicine, Regional Hospital Center Citadelle, Liege, Belgium; Department of Anesthesia and Intensive Care Medicine, University Hospital Center Liege, Liege, Belgium; Anesthesia and Intensive Care Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
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Sayed D, Salmon J, Khan TW, Sack AM, Braun T, Barnard A, Rotte A. Retrospective Analysis of Real-World Outcomes of 10 kHz SCS in Patients with Upper Limb and Neck Pain. J Pain Res 2020; 13:1441-1448. [PMID: 32606910 PMCID: PMC7304671 DOI: 10.2147/jpr.s257071] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/29/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients living with chronic upper limb and neck (ULN) pain are reliant on often ineffective therapies as they face limited options for effective long-term treatment. OBJECTIVE Prospective clinical studies have demonstrated that high-frequency spinal cord stimulation at 10 kHz (10 kHz SCS) is effective in treating chronic pain in multiple etiologies including ULN pain. This study aimed at validating the findings from clinical studies on ULN in a real-world cohort. STUDY DESIGN A retrospective, observational review. SETTING A multicenter review between April 2016 and August 2019. PATIENTS AND METHODS Anonymized data were extracted from a real-world database of 47 consecutive patients aged ≥18 years of age with chronic upper limb and/or neck pain who were trialed and permanently implanted with 10 kHz SCS. Patient-reported pain relief, quality of life, function, sleep and medication use were extracted from anonymised patient records where available. Responder rates, defined as the proportion of patients with at least 50% pain relief at the end of trial and the last visit after implantation, were calculated. RESULTS All patients reported successful response (≥50% pain relief) at the end of trial and >75% patients continued to respond to the therapy at the last follow-up period. Majority (72%) of patients reported improvement in function, about half of the patients (53%) reported improvement in sleep and one-third of the patients (36%) reported reducing their medication at last follow-up. CONCLUSION 10 kHz SCS provides durable pain relief to patients with chronic upper limb and neck pain.
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Affiliation(s)
- Dawood Sayed
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - John Salmon
- PainCare Perth, Parkland House, Cottesloe, Western Australia, Australia
| | - Talal W Khan
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Andrew M Sack
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Ted Braun
- University of Kansas School of Medicine, Kansas City, KS, USA
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Piedade GS, Vesper J, Slotty PJ. Synergetic efficacy of simultaneous DRG- and traditional spinal cord stimulation. Acta Neurochir (Wien) 2020; 162:257-260. [PMID: 31863300 DOI: 10.1007/s00701-019-04166-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dorsal root ganglion stimulation has established its role in chronic pain states and is commonly used as an alternative treatment to traditional spinal cord stimulation. Due to its approach, DRG stimulation is preferably used in pain conditions affecting a small area or a distinct nerve root. In selected patients, a combination of both techniques might be useful. METHODS We report a series of five patients with chronic pain treated with DRG stimulation and traditional spinal cord stimulation from 2011 to 2018. Pain was reported on the VAS scale at the baseline, before and 12 months after the second procedure. RESULTS All patients suffered from back and lower limb pain, four with a FBSS syndrome, one with CRPS. In all but one patient, SCS was implanted first and complemented with a DRG in the course (4-90 months between procedures). An additional stimulation system was implanted because the previous stimulation failed to reach the pain area or because the patient had an altered perception of other pain component after stimulation. All but one patient had a consistent and satisfying therapeutic effect with both systems activated. CONCLUSION The combination of dorsal root ganglion and traditional spinal cord stimulation is surgically and technically feasible. In selected patients, the combination of both methods offers an option to alleviate pain states not sufficiently or not efficiently treated with one method alone. The introduction of IPGs combining SCS and DRG stimulation paradigms might be useful to increase acceptance of this option.
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Affiliation(s)
- G S Piedade
- Department of Neurosurgery, Heinrich-Heine-Universität Düsseldorf, Moorenstraße. 5, 40225, Düsseldorf, Germany
| | - J Vesper
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Moorenstraße. 5, 40225, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Neurosurgery, Heinrich-Heine-Universität Düsseldorf, Moorenstraße. 5, 40225, Düsseldorf, Germany.
- Department of Functional Neurosurgery and Stereotaxy, Heinrich-Heine-Universität Düsseldorf, Moorenstraße. 5, 40225, Düsseldorf, Germany.
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10
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van Gorp EJJAA, Adang EMM, Gültuna I, Hamm-Faber TE, Bürger K, Kallewaard JW, Schapendonk JWCL, Vonhögen L, Bronkhorst E, Teernstra OP, Vissers KCP. Cost-Effectiveness Analysis of Peripheral Nerve Field Stimulation as Add-On Therapy to Spinal Cord Stimulation in the Treatment of Chronic Low Back Pain in Failed Back Surgery Syndrome Patients. Neuromodulation 2019; 23:639-645. [PMID: 31423686 DOI: 10.1111/ner.13032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/30/2019] [Accepted: 06/26/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Presently, there is only limited evidence about the cost-effectiveness of peripheral nerve field stimulation (PNFS) and no evidence to date on the cost-effectiveness of PNFS as an add-on therapy to spinal cord stimulation (SCS). In a multicenter randomized controlled trial, PNFS as add-on therapy to SCS demonstrated clinical effectiveness in treating chronic low back pain in failed back surgery syndrome (FBSS) patients. We report here the cost-effectiveness of PNFS as additional therapy. MATERIALS AND METHODS Cost-effectiveness analysis was performed from a health-care perspective using the general principles of cost-utility analysis, using empirical data from our multicenter randomized controlled trial on the effectiveness of hybrid SCS + PNFS on low back pain in FBSS patients, who were back pain non-responders to initial SCS-therapy, over a time-horizon of three months. Outcome measures were costs and quality-adjusted life-years (QALYs). Cost and QALYs were integrated using the net monetary benefit (NMB). Differences in costs, effects, and NMB were analyzed using multilevel regression. Uncertainty surrounding the NMB was presented by cost-effectiveness acceptability curves. RESULTS A total of 52 patients implanted with both SCS and PNFS, randomly assigned to a group with PNFS either activated or inactive, completed the controlled part of the study. With mean total costs for the SCS + active PNFS group of €1813.86 (SD €109.78) versus €1103.64 (SD €123.43) for the SCS + inactive PNFS group at three months, we found an incremental cost-utility ratio of €25.311 per QALY gained and a probability being cost-effective of more than 80% given a willingness to pay for a QALY of about €40.000. CONCLUSIONS From a Dutch national health-care context, when the willingness to pay threshold is up to 60.000 Euros per QALY, PNFS as an add-on therapy to SCS for the treatment of low back pain in FBSS patients has a high probability of being cost-effective.
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Affiliation(s)
- Eric-Jan J A A van Gorp
- Albert Schweitzer Hospital, Department of Anesthesiology, Unit of Pain Medicine, Sliedrecht, The Netherlands
| | - Eddy M M Adang
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ismail Gültuna
- Albert Schweitzer Hospital, Department of Anesthesiology, Unit of Pain Medicine, Sliedrecht, The Netherlands
| | - Tanja E Hamm-Faber
- Albert Schweitzer Hospital, Department of Anesthesiology, Unit of Pain Medicine, Sliedrecht, The Netherlands
| | - Katja Bürger
- Rijnland Hospital, Department of Anesthesiology, Leiderdorp, The Netherlands
| | | | | | - Leon Vonhögen
- Sint Maartenskliniek, Department of Anesthesiology, Nijmegen, The Netherlands
| | - Ewald Bronkhorst
- Radboud University Medical Centre, Department of Cariology and Preventive Dentistry, Nijmegen, The Netherlands
| | - Onno P Teernstra
- Atrium Medical Centre, Department of Neurosurgery, Heerlen, The Netherlands.,Maastricht University Medical Centre, Department of Neurosurgery, Maastricht, The Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain Medicine and Palliative Care, Radboud University Medical Centre, The Netherlands
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10 kHz SCS therapy for chronic pain, effects on opioid usage: Post hoc analysis of data from two prospective studies. Sci Rep 2019; 9:11441. [PMID: 31391503 PMCID: PMC6686020 DOI: 10.1038/s41598-019-47792-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/24/2019] [Indexed: 12/29/2022] Open
Abstract
Chronic pain, including chronic low back and leg pain are prominent causes of disability worldwide. While patient management aims to reduce pain and improve daily function, prescription of opioids remains widespread despite significant adverse effects. This study pooled data from two large prospective trials on 10 kHz spinal cord stimulation (10 kHz SCS) in subjects with chronic low back pain and/or leg pain and performed post hoc analysis on changes in opioid dosage 12 months post 10 kHz SCS treatment. Patient-reported back and leg pain using the visual analog scale (VAS) and opioid dose (milligrams morphine equivalent/day, MME/day) were compared at 12 months post-10 kHz SCS therapy to baseline. Results showed that in the combined dataset, 39.3% of subjects were taking >90 MME dose of opioids at baseline compared to 23.0% at 12 months post-10 kHz SCS therapy (p = 0.007). The average dose of opioids in >90 MME group was significantly reduced by 46% following 10 kHz SCS therapy (p < 0.001), which was paralleled by significant pain relief (P < 0.001). In conclusion, current analysis demonstrates the benefits of 10 kHz SCS therapy and offers an evidence-based, non-pharmaceutical alternative to opioid therapy and/or an adjunctive therapy to facilitate opioid dose reduction whilst delivering significant pain relief. Healthcare providers involved in management of chronic non-cancer pain can include reduction or elimination of opioid use as part of treatment plan when contemplating 10 kHz SCS.
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Harrison C, Epton S, Bojanic S, Green AL, FitzGerald JJ. The Efficacy and Safety of Dorsal Root Ganglion Stimulation as a Treatment for Neuropathic Pain: A Literature Review. Neuromodulation 2017; 21:225-233. [PMID: 28960653 DOI: 10.1111/ner.12685] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/26/2017] [Accepted: 07/28/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Dorsal root ganglion stimulation (DRGS) received its first regulatory approval (CE marking in Europe) in late 2011, and so its use is now almost six years old. Several thousand patients have already been treated, and a landmark trial in lower limb complex regional pain syndrome (CRPS) and causalgia has recently been published. METHODS In this review we have summarized the literature to date on the use of DRGS in the treatment of neuropathic pain. RESULTS The results so far are encouraging, with reports of successful use in treating a wide range of indications including postsurgical pain, CRPS, and phantom pain. Treatment of failed back surgery syndrome (FBSS) appears less successful. The therapy is still young, and long term results are not yet available. There is now good randomized clinical trial (RCT) evidence that DRGS provides superior pain relief to spinal cord stimulation for CRPS and causalgia of the lower limb, and produces stimulation that is more posturally stable, with more precise paraesthesia coverage. However evidence of this quality for other indications and pain locations is lacking. CONCLUSION There is now Class A RCT evidence that DRGS provides superior pain relief to SCS for CRPS and causalgia of the lower limb. In the coming years we hope that randomized controlled trials will be performed on an indication-by-indication basis, which, together with the publication of longer term follow-up data, will provide a more complete understanding of the role of DRGS in the treatment of neuropathic pain syndromes.
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Affiliation(s)
- Conrad Harrison
- John Radcliffe Hospital, University of Oxford Medical Sciences Office, Oxford, UK
| | - Sarah Epton
- Vascular Research Department, St George's Hospital, London, UK
| | - Stana Bojanic
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - Alexander L Green
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - James J FitzGerald
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Goebel A, Lewis S, Phillip R, Sharma M. Dorsal Root Ganglion Stimulation for Complex Regional Pain Syndrome (CRPS) Recurrence after Amputation for CRPS, and Failure of Conventional Spinal Cord Stimulation. Pain Pract 2017; 18:104-108. [DOI: 10.1111/papr.12582] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 02/28/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Andreas Goebel
- Walton Centre NHS Foundation Trust; Liverpool U.K
- Pain Research Institute; University of Liverpool; Liverpool U.K
| | - Sarah Lewis
- Defense Medical Rehabilitation Centre Headley Court; Epson Surrey U.K
| | - Rhodri Phillip
- Defense Medical Rehabilitation Centre Headley Court; Epson Surrey U.K
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Han JL, Murphy KR, Hussaini SMQ, Yang S, Parente B, Xie J, Pagadala P, Lad SP. Explantation Rates and Healthcare Resource Utilization in Spinal Cord Stimulation. Neuromodulation 2017; 20:331-339. [PMID: 28205332 DOI: 10.1111/ner.12567] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/08/2016] [Accepted: 11/14/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Certain patients ultimately undergo explantation of their spinal cord stimulation (SCS) devices. Understanding the predictors and rates of SCS explantation has important implications for healthcare resource utilization (HCRU) and pain management. The present study identifies explant predictors and discerns differences in HCRU for at-risk populations. METHODS We designed a large, retrospective analysis using the Truven MarketScan Database. We included all adult patients who underwent a SCS trial from 2007 to 2012. Patients were grouped into cohorts that remained explant-free or underwent explantation over a three-year period, and multivariate models evaluated differences in healthcare resource utilization. RESULTS A total of 8727 unique instances of trial implants between 2007 and 2012 were identified. Overall, 805 (9.2%) patients underwent device explantation. One year prior to SCS implantation, the explant cohort had significantly higher median baseline costs ($42,140.3 explant vs. $27,821.7 in non-explant groups; p < 0.0001), total number of pain encounters (180 vs. 103 p < 0.0001), and associated costs ($15,446.9 vs. $9,227.9; p < 0.0001). The explant cohort demonstrated increased use of procedures (19.0 vs. 9.0; p < 0.0001) compared to non-explanted patients. For each month after initial SCS implantation, explanted patients had a slower decrease in total costs (4% vs. 6% in non-explant; p < 0.01). At the month of explant, explant patients were expected to have incurred 2.65 times the total cost compared to the non-explant cohort (CR 2.65, 95% CI [1.83, 3.84]; p < 0.001). Medium volume providers had lower rates of explantation at one-year and three-years compared to low volume providers (p = 0.042). Increased age and Charlson index were independent predictors of explantation during the same periods. CONCLUSIONS In this nationwide analysis, we identified that SCS device explantation is correlated with patients who have higher baseline costs, higher total cost post-SCS implantation, and increased use of procedures to control pain. The higher rates of explantation at three-years postimplant among low volume providers suggest that variations in provider experience and approach also contributes to differences in explantation rates.
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Affiliation(s)
- Jing L Han
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Kelly R Murphy
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | - Siyun Yang
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jichun Xie
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Promila Pagadala
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Murphy KR, Han JL, Hussaini SMQ, Yang S, Parente B, Xie J, Lad SP. The Volume-Outcome Effect: Impact on Trial-to-Permanent Conversion Rates in Spinal Cord Stimulation. Neuromodulation 2016; 20:256-262. [PMID: 27696607 DOI: 10.1111/ner.12526] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/08/2016] [Accepted: 08/16/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Conversion rates from trial leads to permanent spinal cord stimulation (SCS) systems have important implications for healthcare resource utilization (HCRU) and pain management. We hypothesized that there is a volume-outcome effect, with chronic pain patients who visit high volume SCS implanters will have higher trial-to-permanent conversion rates. MATERIALS AND METHODS We designed a large, retrospective analysis using the Truven MarketScan database analyzing adult SCS patients with provider information available, with or without IPG implantation from the years 2007 to 2012 was designed. Patients were divided into three provider-based groups: high (>25), medium (9-24), and low (3-8) volume providers. Univariate and multivariate models identified factors associated with successful conversion. RESULTS A total of 17,850 unique trial implants were performed by 3028 providers. Of 13,879 patients with baseline data available, 8981 (64.7%) progressed to permanent SCS. Higher volume providers were associated with slightly higher conversion rates (65.9% vs. 63.3% low volume, p = 0.029), explant rates (9.2% vs. 7.7% medium volume, p = 0.026), younger age (52.0 ± 13.4 years vs. 53.0 ± 13.4 years, p = 0.0026), Medicare/Medicaid (47.8% vs. 35.0% low volume, p < 0.0001), Southern region (53.5% vs. 38.9% low volume, p < 0.0001), and higher Charlson comorbidity scores (1.0 [SD = 1.4], p = 0.0002). Multivariate regression results showed female gender (1.13 [95% CI: 1.05-1.22], p < 0.001) and high volume providers associated with higher odds of successful trial conversion (1.12 [95% CI: 1.02-1.22], p = 0.014). CONCLUSIONS In this nationwide analysis, high volume providers achieved higher trial-to-permanent SCS conversion rates than lower volume providers. The study has implications for both training requirements and referral patterns to delineate minimum implant experience necessary for provider proficiency. Future studies may be useful to understand HCRU differences.
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Affiliation(s)
- Kelly Ryan Murphy
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jing L Han
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | - Siyun Yang
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jichun Xie
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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De Ridder D, Plazier M, Menovsky T, Kamerling N, Vanneste S. C2 Subcutaneous Stimulation for Failed Back Surgery Syndrome: A Case Report. Neuromodulation 2013; 16:610-3. [DOI: 10.1111/j.1525-1403.2012.00518.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 07/30/2012] [Accepted: 08/30/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Dirk De Ridder
- Brai2n, TRI & Department of Neurosurgery; University Hospital Antwerp; Edegem Belgium
- Department of Surgical Sciences, Dunedin School of Medicine; University of Otago; New Zealand
| | - Mark Plazier
- Brai2n, TRI & Department of Neurosurgery; University Hospital Antwerp; Edegem Belgium
| | - Tomas Menovsky
- Brai2n, TRI & Department of Neurosurgery; University Hospital Antwerp; Edegem Belgium
| | - Niels Kamerling
- Brai2n, TRI & Department of Neurosurgery; University Hospital Antwerp; Edegem Belgium
| | - Sven Vanneste
- Brai2n, TRI & Department of Neurosurgery; University Hospital Antwerp; Edegem Belgium
- Department of Translational Neuroscience, Faculty of Medicine; University of Antwerp; Edegem Belgium
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Williams KA, Gonzalez-Fernandez M, Hamzehzadeh S, Wilkinson I, Erdek MA, Plunkett A, Griffith S, Crooks M, Larkin T, Cohen SP. A multi-center analysis evaluating factors associated with spinal cord stimulation outcome in chronic pain patients. PAIN MEDICINE 2011; 12:1142-53. [PMID: 21749636 DOI: 10.1111/j.1526-4637.2011.01184.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In addition to its conventional use as a treatment for refractory neuropathic extremity pain, spinal cord stimulation (SCS) has recently emerged as a possible treatment for visceral and arthritic pain. But concurrent with the expansion of possible conditions amenable to SCS, other studies have questioned the long-term efficacy of SCS for traditional indications. These disparate findings argue strongly for the refinement of selection criteria. The purpose of this study is to identify correlates of outcome for SCS. METHODS Data were retrospectively collected on 244 patients who underwent a SCS trial at two academic medical centers. Success was predefined as ≥50% pain relief sustained for ≥6 months. Variables analyzed for their association with outcome included demographics, location of pain, diagnosis, presence of coexisting diseases, pain descriptors, opioid and adjuvant medication use, duration and pain relief during trial, and complications. RESULTS The presence of allodynia and/or hyperalgesia correlated with both a positive SCS trial (P = 0.01) and long-term implantation outcome (P = 0.05). History of substance abuse was associated with a negative permanent SCS outcome (P = 0.05) but bore no relationship to trial results. The variable most strongly associated with an SCS outcome was experiencing <50% pain relief during the trial, which strongly presaged a negative result (P < 0.001). CONCLUSIONS Although weak associations with outcome were noted for several clinical variables, none was strongly associated with trial and permanent implantation results. The strongest predictor of a negative SCS outcome was obtaining <50% pain relief during the trial period.
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Affiliation(s)
- Kayode A Williams
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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Balzer JR, Tomycz ND, Crammond DJ, Habeych M, Thirumala PD, Urgo L, Moossy JJ. Localization of cervical and cervicomedullary stimulation leads for pain treatment using median nerve somatosensory evoked potential collision testing. J Neurosurg 2011; 114:200-5. [DOI: 10.3171/2010.5.jns091640] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Spinal cord stimulation (SCS) is being currently used to treat medically refractory pain syndromes involving the face, trunk, and extremities. Unlike thoracic SCS surgery, during which patients can be awakened from conscious sedation to confirm good lead placement, safe placement of paddle leads in the cervical spine has required general anesthesia. Using intraoperative neurophysiological monitoring, which is routinely performed during these cases at the authors' institution, the authors developed an electrophysiological technique to intraoperatively lateralize lead placement in the cervical epidural space.
Methods
Data from 44 patients undergoing median and tibial nerve somatosensory evoked potential (SSEP) monitoring during cervical laminectomy or hemilaminectomy for placement or replacement of dorsal column stimulators were retrospectively reviewed. Paddle leads were positioned laterally or just off midline and parallel to the axis of the cervical spinal cord to effectively treat what was most commonly a predominant unilateral pain syndrome. During SSEP recording, the spinal cord stimulator was activated at 1.0 V and increased in increments of 1.0 V to a maximum of 6.0 V. A unilateral reduction or abolishment of SSEP amplitude was regarded as an indicator of lateralized placement of the stimulator. A bilateral diminutive effect on SSEPs was interpreted as a midline or near midline lead placement.
Results
Epidural stimulation abolished or significantly reduced SSEP amplitudes in all patients undergoing placement for a unilateral pain syndrome. In 15 patients, electrodes were repositioned intraoperatively to achieve the most robust SSEP amplitude reduction or abolishment using the lowest epidural stimulation intensity. In all cases in which a significant unilateral reduction in SSEP was observed, the patient reported postoperative sensory alterations in target locations predicted by intraoperative SSEP changes. Placement of cervical spinal cord stimulators for bilateral pain syndromes often resulted in bilateral but asymmetrical SSEP changes. In no cases were significant SSEP changes, other than those induced using the device to directly stimulate the dorsal surface of the spinal cord, observed. No case of new postoperative neurological deficit was observed.
Conclusions
Somatosensory evoked potentials can be used safely and successfully for predicting the lateralization of cervical spinal cord stimulator placement. Moreover, they can also intraoperatively alert the surgical team to inadvertent displacement of a lead during anchoring. Further studies are needed to determine whether apart from assisting with proper lateralization, SSEP collision testing may help to optimize electrode positioning and improve pain control outcomes.
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North RB, Shipley J, Taylor RS, Eldabe S. Questions about Turner et al. Spinal cord stimulation for failed back surgery syndrome: Outcomes in a worker's compensation setting. Pain 2010; 151:550-551. [DOI: 10.1016/j.pain.2010.08.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 07/07/2010] [Accepted: 08/20/2010] [Indexed: 11/15/2022]
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Jeon IC, Kim MS, Kim SH. Median Nerve Stimulation in a Patient with Complex Regional Pain Syndrome Type II. J Korean Neurosurg Soc 2009; 46:273-6. [PMID: 19844632 DOI: 10.3340/jkns.2009.46.3.273] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 03/09/2009] [Accepted: 08/17/2009] [Indexed: 11/27/2022] Open
Abstract
A 54-year-old man experienced injury to the second finger of his left hand due to damage from a paintball gun shot 8 years prior, and the metacarpo-phalangeal joint was amputated. He gradually developed mechanical allodynia and burning pain, and there were trophic changes of the thenar muscle and he reported coldness on his left hand and forearm. A neuroma was found on the left second common digital nerve and was removed, but his symptoms continued despite various conservative treatments including a morphine infusion pump on his left arm. We therefore attempted median nerve stimulation to treat the chronic pain. The procedure was performed in two stages. The first procedure involved exposure of the median nerve on the mid-humerus level and placing of the electrode. The trial stimulation lasted for 7 days and the patient's symptoms improved. The second procedure involved implantation of a pulse generator on the left subclavian area. The mechanical allodynia and pain relief score, based on the visual analogue scale, decreased from 9 before surgery to 4 after surgery. The patient's activity improved markedly, but trophic changes and vasomotor symptom recovered only moderately. In conclusion, median nerve stimulation can improve chronic pain from complex regional pain syndrome type II.
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Affiliation(s)
- Ik-Chan Jeon
- Department of Neurosurgery, College of Medicine, Yeungnam University, Daegu, Korea
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