Evoked compound action potentials during spinal cord stimulation: effects of posture and pulse width on signal features and neural activation within the spinal cord

Objective.Evoked compound action potential (ECAP) recordings have emerged as a quantitative measure of the neural response during spinal cord stimulation (SCS) to treat pain. However, utilization of ECAP recordings to optimize stimulation efficacy requires an understanding of the factors influencing these recordings and their relationship to the underlying neural activation.Approach.We acquired a library of ECAP recordings from 56 patients over a wide assortment of postures and stimulation parameters, and then processed these signals to quantify several aspects of these recordings (e.g., ECAP threshold (ET), amplitude, latency, growth rate). We compared our experimental findings against a computational model that examined the effect of variable distances between the spinal cord and the SCS electrodes.Main results.Postural shifts strongly influenced the experimental ECAP recordings, with a 65.7% lower ET and 178.5% higher growth rate when supine versus seated. The computational model exhibited similar trends, with a 71.9% lower ET and 231.5% higher growth rate for a 2.0 mm cerebrospinal fluid (CSF) layer (representing a supine posture) versus a 4.4 mm CSF layer (representing a prone posture). Furthermore, the computational model demonstrated that constant ECAP amplitudes may not equate to a constant degree of neural activation.Significance.These results demonstrate large variability across all ECAP metrics and the inability of a constant ECAP amplitude to provide constant neural activation. These results are critical to improve the delivery, efficacy, and robustness of clinical SCS technologies utilizing these ECAP recordings to provide closed-loop stimulation.

The Prevalence of Elevated Impedances and Magnetic Resonance Imaging Ineligibility Following Implantation of 10 kHz Spinal Cord Stimulation Devices: A Retrospective Review

OBJECTIVES

Spinal cord stimulation (SCS) is increasingly utilized in the treatment of multiple chronic pain conditions. However, patients will continue to experience other medical issues and the potential for future magnetic resonance imaging (MRI) needs must not be overlooked. SCS devices have device-specific MRI conditional labeling and if impedances are elevated the patient may not be able to obtain an MRI. With 10 kHz SCS devices specifically, an impedance value above 10,000 ohms (Ω) is MRI ineligible. The primary objective of this article was to report the incidence of elevated impedances with a multilumen lead design per electrode, per lead, and to describe the total number of MRI ineligible patients due to elevated impedances using 10 kHz SCS cutoff values. The secondary objective was to determine whether certain patient demographics or surgery characteristics put patients at increased risk of elevated impedances.

MATERIALS AND METHODS

We performed a retrospective review of 327 patients who were implanted with a 10 kHz SCS device between January 2015 and November 2020. Regression models were fitted to determine associations between MRI ineligibility status with clinical characteristics including age, sex, BMI, lead location, implantable pulse generator (IPG) location, and time since implant.

RESULTS

We found elevated impedances with subsequent MRI ineligibility in 13 patients (4.0%). Regression analysis did not identify any associations with MRI ineligibility and patient risk factors including age, sex, body mass index, lead location, IPG location, and follow-up time since implant.

CONCLUSION

We found the prevalence of elevated impedances above 10,000 Ω to be 4% of implanted patients. This information is important for patients and physicians alike and should be considered when device selection is occurring in the pre-operative visits.

Ontogeny of cation-Cl- cotransporter expression in rat neocortex

Neuronal precursors and immature cortical neurons actively accumulate Cl- and as a consequence depolarize in response to GABAA receptor activation. With maturity, intracellular Cl- decreases resulting in a shift towards GABAA inhibition. These observations suggest that changes in expression of cation-Cl- cotransporters may have a significant role in the ontogeny of neuronal Cl- homeostasis. Using ribonuclease protection analysis and in situ hybridization we examined the developmental expression of all presently known members of the cation-Cl- cotransporter gene family in rat brain. Of the inwardly directed cotransporters, NKCC-1, NKCC-2, and NCC-1, only NKCC-1 was detected at significant levels in brain. NKCC-1 was expressed in neurons, appearing first in cortical plate but not in ventricular or subventricular zone. Expression levels peaked by the third postnatal week and were maintained into adulthood. The outwardly directed cotransporters, KCC-1 and KCC-2, demonstrated significantly different levels and time courses of expression. KCC-1 was expressed prenatally at very low levels which increased little over the course of development. In contrast, KCC-2 expression appeared perinatally and increased dramatically after the first week of postnatal life. Differential changes in expression of this gene family occurred during periods of critical shifts in chloride homeostasis and GABA response suggestive of a role in these processes. Furthermore the absence of expression of known inwardly directed cotransporters in Cl- accumulating neuroepithelia and lack of evidence for glial expression suggests that as yet unidentified members of this gene family may be involved in chloride homeostasis in immature neuronal precursors and neuroglia.

The effects of levonantradol hydrochloride on tumor growth and therapy

The effects of levonantradol on tumor growth, both directly and in combination with the cytotoxic agent cyclophosphamide, were determined. Levonantradol hydrochloride administered alone had no effect on the progression of either murine sarcoma 180J or leukemia L-1210. Likewise, the increased survival obtained in both tumor systems with cyclophosphamide was not altered by concurrent administration of levonantradol hydrochloride. Levonantradol did not affect the incidence or extent of artificial melanotic lung metastases, nor did it modify lymphoreticular cell stimulation. These data support the use of levonantradol in conjunction with chemotherapy in cancer patients.

Chemical carcinogenesis in vitro: an improved method for chemical transformation in Rauscher leukemia virus-infected rat embryo cells

In vitro assay for carcinogenesis, using mammalian cells, provide opportunity for rapid and inexpensive means, compared to in vivo assays, for studying carcinogenesis and for identifying potential carcinogens. These assays must, however, be shown to be reproducible, reliable and able to detect a variety of known carcinogens before they can be recommended for general use. We have, independently, reproduced a transformation assay which utilizes murine leukemia virus-infected rat embryo cells as targets. In the process a new culture, designated 2FR4(50), was generated to replace the F1706 line, of Freeman, which is no longer available. Through careful control of the assay parameters a readily reproducible test has been developed. In 2-4 culture passages after chemical treatment, morphologically transformed foci of cells are observed while no such foci are found in noncarcinogen treated or control cultures. Over 75 compounds have been tested in this assay; 20 of these are detailed here as representative of the chemically diverse types of carcinogens detected.

Two-stage carcinogenesis in vitro: transformation of 3-methylcholanthrene-initiated Rauscher murine leukemia virus-infected rat embryo cells by diverse tumor promoters

A modified in vitro transformation assay demonstrated potential for use in the identification and study of tumor promoters. Rauscher murine leukemia virus-infected F344 rat embryo cells were transformable by various chemical carcinogens when they were administered at appropriate doses. Cells treated with subeffective doses of 3-methylcholanthrene did not transform. However, when these cells were regularly treated with 12-O-tetradecanoylphorbol 13-acetate, sodium phenobarbital, limonene, oleic acid, lauric acid, or saccharin, transformation was observed. Thus several dhemically diverse in vivo tumor promoters behaved as promoters in this in vitro system. This assay appeared to be useful for in vitro efforts to identify promoters and may be of value in studies on the mechanisms of action of these cocarcinogens.

Delayed cutaneous hypersensitivity to oxazolone in mice with tumors

A murine model of immune responsiveness had been adapted to study anergic conditions associated with neoplasia. Marked anergy observed in mice bearing L1210 leukemia and P-388 lymphoma is contrasted to the minimal immune depression associated with B-16 melanotic melanoma and Sarcoma 180J. The ability of N,N-bis(2-chloroethyl)-N-nitrosourea chemotherapy to reduce tumor burden without prolonged suppression of delayed cutaneous hypersensitivity is compared to the profound suppression of the cutaneous response observed with Adriamycin cytoreductive therapy. The applications of our model are discussed in relation to tumor-associated anergy, new approaches to the evaluation of pharmaceuticals, and studies of combined chemoimmunotherapy regimens.