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Koetsier E, Vacchi E, Maino P, Dukanac J, Melli G, van Kuijk SMJ. Dorsal Root Ganglion Stimulation in Chronic Painful Polyneuropathy: A Potential Modulator for Small Nerve Fiber Regeneration. Neuromodulation 2023; 26:1772-1780. [PMID: 36192280 DOI: 10.1016/j.neurom.2022.08.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/02/2022] [Accepted: 08/23/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Neuromodulatory treatments like spinal cord stimulation and dorsal root ganglion stimulation (DRGS) have emerged as effective treatments to relieve pain in painful polyneuropathy. Animal studies have demonstrated that neurostimulation can enhance nerve regeneration. This study aimed to investigate if DRGS may impact intraepidermal nerve fiber regeneration and sensory nerve function. MATERIALS AND METHODS Nine patients with chronic, intractable painful polyneuropathy were recruited. Intraepidermal nerve fiber density (IENFD) quantification in 3 mm punch skin biopsy was performed 1 month before DRGS (placed at the level of the L5 and S1 dorsal root ganglion) and after 12- and 24-month follow-up. Quantitative sensory testing, nerve conduction studies, and a clinical scale score were also performed at the same time points. RESULTS In 7 of 9 patients, DRGS was successful (defined as a reduction of ≥ 50% in daytime and/or night-time pain intensity), allowing a definitive implantable pulse generator implantation. The median baseline IENFD among these 7 patients was 1.6 fibers/mm (first and third quartile: 1.2; 4.3) and increased to 2.6 fibers/mm (2.5; 2.9) and 1.9 fibers/mm (1.6; 2.4) at 1- and 2-years follow-up, respectively. These changes were not statistically significant (p = 1.000 and 0.375). Sensory nerve tests did not show substantial changes. CONCLUSIONS Although not significant, the results of this study showed that in most of the patients with implants, there was a slight increase of the IENFD at the 1- and 2-year follow-up. Larger-scale clinical trials are warranted to explore the possible role of DRGS in reversing the progressive neurodegeneration over time. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02435004; Swiss National Clinical Trials Portal: SNCTP000001376.
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Affiliation(s)
- Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
| | - Elena Vacchi
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Laboratories for Translational Research, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Jasmina Dukanac
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giorgia Melli
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Laboratories for Translational Research, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Sander M J van Kuijk
- Pain Management Center, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
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Raghu ALB, Parker T, Aziz TZ, Green AL, Hadjipavlou G, Rea R, FitzGerald JJ. Invasive Electrical Neuromodulation for the Treatment of Painful Diabetic Neuropathy: Systematic Review and Meta-Analysis. Neuromodulation 2020; 24:13-21. [PMID: 32588933 DOI: 10.1111/ner.13216] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/27/2020] [Accepted: 05/15/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Neuromodulation is a treatment option for people suffering from painful diabetic neuropathy (PDN) unresponsive to conventional pharmacotherapy. We systematically examined the pain outcomes of patients with PDN receiving any type of invasive neuromodulation for treatment of neuropathic pain. MATERIALS AND METHODS MEDLINE and Embase were searched through 10 January 2020, without language restriction. All study types were included. Two reviewers independently screened publications and extracted data. Quantitative meta-analysis was performed with pain scores converted to a standard 100-point scale. Randomized controlled trial (RCT) scores were pooled using the inverse variance method and expressed as mean differences. RESULTS RCTs of tonic spinal cord stimulation (t-SCS) showed greater pain improvement than best medical therapy at six months (intention-to-treat: 38/100, 95% CI: 29-47). By per-protocol analysis, case series of t-SCS and dorsal root ganglion stimulation (DRGS) showed improvement by 56 (95% CI: 39-73) and 55 (22-87), respectively, at 12 months. For t-SCS, the rate of failing a therapeutic stimulation trial was 16%, the risk of infection was 4%, and the rate of lead problems requiring surgery to resolve was 4% per year of follow-up. High-frequency SCS and burst SCS both showed efficacy, with few patients studied. CONCLUSION Efficacious, lasting and safe surgical pain management options are available to diabetic patients suffering from PDN. Tonic-SCS is the established standard of treatment; however, other SCS paradigms and DRGS are emerging as promising treatments offering comparable pain benefits, but with few cases published to date. Randomized controlled trials are ongoing to assess their relative merits.
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Affiliation(s)
- Ashley L B Raghu
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Tariq Parker
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Tipu Z Aziz
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - George Hadjipavlou
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James J FitzGerald
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Zannou AL, Khadka N, Truong DQ, Zhang T, Esteller R, Hershey B, Bikson M. Temperature increases by kilohertz frequency spinal cord stimulation. Brain Stimul 2018; 12:62-72. [PMID: 30482674 DOI: 10.1016/j.brs.2018.10.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Kilohertz frequency spinal cord stimulation (kHz-SCS) deposits significantly more power in tissue compared to SCS at conventional frequencies, reflecting increased duty cycle (pulse compression). We hypothesize kHz-SCS increases local tissue temperature by joule heat, which may influence the clinical outcomes. METHODS To establish the role of tissue heating in KHZ-SCS, a decisive first step is to characterize the range of temperature changes expected during conventional and KHZ-SCS protocols. Fiber optic probes quantified temperature increases around an experimental SCS lead in a bath phantom. These data were used to verify a SCS lead heat-transfer model based on joule heat. Temperature increases were then predicted in a seven-compartment (soft tissue, vertebral bone, fat, intervertebral disc, meninges, spinal cord with nerve roots) geometric human spinal cord model under varied parameterization. RESULTS The experimentally constrained bio-heat model shows SCS waveform power (waveform RMS) determines tissue heating at the spinal cord and surrounding tissues. For example, we predict temperature increased at dorsal spinal cord of 0.18-1.72 °C during 3.5 mA peak 10 KHz stimulation with a 40-10-40 μs biphasic pulse pattern, 0.09-0.22 °C during 3.5 mA 1 KHz 100-100-100 μs stimulation, and less than 0.05 °C during 3.5 mA 50 Hz 200-100-200 μs stimulation. Notably, peak heating of the spinal cord and other tissues increases superlinearly with stimulation power and so are especially sensitive to incremental changes in SCS pulse amplitude or frequency (with associated pulse compression). Further supporting distinct SCS intervention strategies based on heating; the spatial profile of temperature changes is more uniform compared to electric fields, which suggests less sensitivity to lead position. CONCLUSIONS Tissue heating may impact short and long-term outcomes of KHZ-SCS, and even as an adjunct mechanism, suggests distinct strategies for lead position and programming optimization.
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Affiliation(s)
- Adantchede L Zannou
- Department of Biomedical Engineering, The City College of New York, New York, NY, 10031, USA
| | - Niranjan Khadka
- Department of Biomedical Engineering, The City College of New York, New York, NY, 10031, USA
| | - Dennis Q Truong
- Department of Biomedical Engineering, The City College of New York, New York, NY, 10031, USA
| | - Tianhe Zhang
- Boston Scientific Inc., Neuromodulation Research and Advanced Concepts, Valencia, CA, USA
| | - Rosana Esteller
- Boston Scientific Inc., Neuromodulation Research and Advanced Concepts, Valencia, CA, USA
| | - Brad Hershey
- Boston Scientific Inc., Neuromodulation Research and Advanced Concepts, Valencia, CA, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, New York, NY, 10031, USA.
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van Beek M, Hermes D, Honig WM, Linderoth B, van Kuijk SMJ, van Kleef M, Joosten EA. Long-Term Spinal Cord Stimulation Alleviates Mechanical Hypersensitivity and Increases Peripheral Cutaneous Blood Perfusion in Experimental Painful Diabetic Polyneuropathy. Neuromodulation 2018. [PMID: 29522270 PMCID: PMC6099481 DOI: 10.1111/ner.12757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives This study utilizes a model of long‐term spinal cord stimulation (SCS) in experimental painful diabetic polyneuropathy (PDPN) to investigate the behavioral response during and after four weeks of SCS (12 hours/day). Second, we investigated the effect of long‐term SCS on peripheral cutaneous blood perfusion in experimental PDPN. Methods Mechanical sensitivity was assessed in streptozotocin induced diabetic rats (n = 50) with von Frey analysis. Hypersensitive rats (n = 24) were implanted with an internal SCS battery, coupled to an SCS electrode covering spinal levels L2–L5. The effects of four weeks of daily conventional SCS for 12 hours (n = 12) or Sham SCS (n = 12) were evaluated with von Frey assessment, and laser Doppler imaging (LDI). Results Average paw withdrawal thresholds (PWT) increased during long‐term SCS in the SCS group, in contrast to a decrease in the Sham group (Sham vs. SCS; p = 0.029). Twenty‐four hours after long‐term SCS average PWT remained higher in the SCS group. Furthermore, the SCS group showed a higher cutaneous blood perfusion during long‐term SCS compared to the Sham group (Sham vs. SCS; p = 0.048). Forty‐eight hours after long‐term SCS, no differences in skin perfusion were observed. Discussion We demonstrated that long‐term SCS results in decreased baseline mechanical hypersensitivity and results in increased peripheral blood perfusion during stimulation in a rat model of PDPN. Together, these findings indicate that long‐term SCS results in modulation of the physiological circuitry related to the nociceptive system in addition to symptomatic treatment of painful symptoms.
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Affiliation(s)
- Maarten van Beek
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Denise Hermes
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Wiel M Honig
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Bengt Linderoth
- Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, the Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands
| | - Elbert A Joosten
- Department of Anesthesiology and Pain Management, MUMC+, Maastricht, the Netherlands.,Department of Neuroscience, School of Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
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Harkema SJ, Wang S, Angeli CA, Chen Y, Boakye M, Ugiliweneza B, Hirsch GA. Normalization of Blood Pressure With Spinal Cord Epidural Stimulation After Severe Spinal Cord Injury. Front Hum Neurosci 2018; 12:83. [PMID: 29568266 PMCID: PMC5852107 DOI: 10.3389/fnhum.2018.00083] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 02/19/2018] [Indexed: 11/18/2022] Open
Abstract
Chronic low blood pressure and orthostatic hypotension remain challenging clinical issues after severe spinal cord injury (SCI), affecting health, rehabilitation, and quality of life. We previously reported that targeted lumbosacral spinal cord epidural stimulation (scES) could promote stand and step functions and restore voluntary movement in patients with chronic motor complete SCI. This study addresses the effects of targeted scES for cardiovascular function (CV-scES) in individuals with severe SCI who suffer from chronic hypotension. We tested the hypothesis that CV-scES can increase resting blood pressure and attenuate chronic hypotension in individuals with chronic cervical SCI. Four research participants with chronic cervical SCI received an implant of a 16-electrode array on the dura (L1–S1 cord segments, T11–L1 vertebrae). Individual-specific CV-scES configurations (anode and cathode electrode selection, voltage, frequency, and pulse width) were identified to maintain systolic blood pressure within targeted normative ranges without skeletal muscle activity of the lower extremities as assessed by electromyography. These individuals completed five 2-h sessions using CV-scES in an upright, seated position during measurement of blood pressure and heart rate. Noninvasive continuous blood pressure was measured from a finger cuff by plethysmograph technique. For each research participant there were statistically significant increases in mean arterial pressure in response to CV-scES that was maintained within normative ranges. This result was reproducible over the five sessions with concomitant decreases or no changes in heart rate using individual-specific CV-scES that was modulated with modest amplitude changes throughout the session. Our study shows that stimulating dorsal lumbosacral spinal cord can effectively and safely activate mechanisms to elevate blood pressures to normal ranges from a chronic hypotensive state in humans with severe SCI with individual-specific CV-scES.
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Affiliation(s)
- Susan J Harkema
- Frazier Rehab Institute, Louisville, KY, United States.,Department of Neurological Surgery, Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Siqi Wang
- Department of Neurological Surgery, Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Claudia A Angeli
- Frazier Rehab Institute, Louisville, KY, United States.,Department of Neurological Surgery, Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Yangsheng Chen
- Department of Neurological Surgery, Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Maxwell Boakye
- Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, KY, United States
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, KY, United States
| | - Glenn A Hirsch
- Division of Cardiology, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, United States
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6
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Liu JT, Su CH, Chen SY, Liew SJ, Chang CS. Spinal Cord Stimulation Improves the Microvascular Perfusion Insufficiency Caused by Critical Limb Ischemia. Neuromodulation 2018; 21:489-494. [PMID: 29377343 DOI: 10.1111/ner.12753] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/22/2017] [Accepted: 12/06/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE This retrospective case-controlled study intended to identify the benefits and efficacy of spinal cord stimulation (SCS) as a therapeutic strategy for patients with perfusion problems caused by critical limb ischemia (CLI). The outcomes of patients who received SCS were compared with those of patients who did not receive SCS. METHODS This study recruited 78 patients who were diagnosed with perfusion problems over the period of 2003-2011. Lower-limb Thallium-201 (201 Tl) scintigraphy revealed that the patients exhibited a perfusion difference of <0.95. Thirty-seven of the recruited patients received SCS treatment and 41 did not receive SCS treatment. All patients received the same medication: 100 mg aspirin once a day and 500 mg paracetamol thrice a day. The outcomes of walking distance, walking time, and sleeping quality were measured and recorded. Pain intensities were evaluated using the visual analog scale (VAS) scoring system. RESULTS Prior to SCS implantation, patients in the SCS treatment group had worse walking distance (64.86 ± 40.80 vs. 613.70 ± 535.00, p < 0.001), walking time (2.65 ± 1.64 vs. 13.90 ± 11.91, p < 0.001), and sleep quality (1.70 ± 0.78 vs. 3.32 ± 1.17, p < 0.001) than patients in the non-SCS treatment group. At the one-year follow-up, however, patients in the SCS treatment group had significantly better walking distance (1595.00 ± 483.60, p < 0.001), walking time (48.92 ± 14.10, p < 0.001), and sleep quality (4.65 ± 0.92, p < 0.001) than patients in the non-SCS treatment group. Moreover, the VAS score of patients in the SCS treatment group improved one week (8.63 ± 0.54 vs. 4.48 ± 0.59, p < 0.001) and one year after SCS implantation (2.35 ± 0.62, p < 0.001). By contrast, at the one-year follow-up, the walking distance (277.60 ± 374.80, p = 0.002), walking time (9.44 ± 10.73, p = 0.078), sleep quality (2.20 ± 1.10, p < 0.001), and VAS score (7.98 ± 0.43, p = 0.020) of patients in the non-SCS treatment group worsened. Furthermore, lower-limb 201 Tl scintigraphy revealed that microcirculation intensity increased in the lower extremities of patients in the SCS treatment group after SCS implantation relative to that before SCS implantation. Most importantly, 10 of the 41 patients in the non-SCS treatment group required the use of wheelchairs, whereas none of the patients in the SCS treatment group required the use of wheelchairs. CONCLUSION Treatment of CLI patient with SCS improved patient's walking ability, pain severity, and sleep quality. SCS should be considered as an effective treatment toward limb salvage in CLI.
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Affiliation(s)
- Jung-Tung Liu
- Department of Neurosurgery, School of Medicine, Chung-Shan Medical University Hospital, Chung-Shan Medical University, Taichung, Taiwan
| | - Chen-Hsing Su
- Department of Neurosurgery, School of Medicine, Chung-Shan Medical University Hospital, Chung-Shan Medical University, Taichung, Taiwan
| | - Se-Yi Chen
- Department of Neurosurgery, School of Medicine, Chung-Shan Medical University Hospital, Chung-Shan Medical University, Taichung, Taiwan
| | - Sang-Jek Liew
- Department of Neurosurgery, School of Medicine, Chung-Shan Medical University Hospital, Chung-Shan Medical University, Taichung, Taiwan
| | - Cheng-Siu Chang
- Department of Neurosurgery, School of Medicine, Chung-Shan Medical University Hospital, Chung-Shan Medical University, Taichung, Taiwan
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NAAR JAN, JAYE DEBORAH, LINDE CECILIA, NEUŽIL PETR, DOŠKÁŘ PETR, MÁLEK FILIP, BRAUNSCHWEIG FRIEDER, LUND LARSH, MORTENSEN LARS, LINDEROTH BENGT, LIND GÖRAN, BONE DIANNA, SCHOLTE ARTHURJ, KUEFFER FRED, KOEHLER JODI, SHAHGALDI KAMBIZ, LANG OTTO, STÅHLBERG MARCUS. Effects of Spinal Cord Stimulation on Cardiac Sympathetic Nerve Activity in Patients with Heart Failure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:504-513. [DOI: 10.1111/pace.13050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/31/2017] [Accepted: 02/06/2017] [Indexed: 12/18/2022]
Affiliation(s)
- JAN NAAR
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - DEBORAH JAYE
- Cardiac Rhythm and Heart Failure; Medtronic Plc; Minneapolis Minnesota
| | - CECILIA LINDE
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - PETR NEUŽIL
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - PETR DOŠKÁŘ
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - FILIP MÁLEK
- Department of Cardiology; Na Homolce Hospital; Prague Czech Republic
| | - FRIEDER BRAUNSCHWEIG
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - LARS H. LUND
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - LARS MORTENSEN
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - BENGT LINDEROTH
- Department of Clinical Neuroscience, Karolinska Institutet; and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
| | - GÖRAN LIND
- Department of Clinical Neuroscience, Karolinska Institutet; and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
| | - DIANNA BONE
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Department of Clinical Physiology; Karolinska University Hospital; Stockholm Sweden
| | - ARTHUR J. SCHOLTE
- Department of Cardiology; Leiden University Medical Center; Leiden the Netherlands
| | - FRED KUEFFER
- Cardiac Rhythm and Heart Failure; Medtronic Plc; Minneapolis Minnesota
| | - JODI KOEHLER
- Cardiac Rhythm and Heart Failure; Medtronic Plc; Minneapolis Minnesota
| | - KAMBIZ SHAHGALDI
- Department of Clinical Physiology; Sunderby Hospital; Luleå Sweden
| | - OTTO LANG
- Department of Nuclear Medicine; University Hospital Královské Vinohrady; Prague Czech Republic
| | - MARCUS STÅHLBERG
- Department of Medicine, Solna, Karolinska Institutet, and Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
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Tomycz ND. The proposed use of cervical spinal cord stimulation for the treatment and prevention of cognitive decline in dementias and neurodegenerative disorders. Med Hypotheses 2016; 96:83-86. [PMID: 27959284 DOI: 10.1016/j.mehy.2016.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/10/2016] [Indexed: 11/19/2022]
Abstract
Cervical spinal cord stimulation is a well-established treatment for intractable neuropathic upper extremity pain. More than 20years ago it was demonstrated that cervical spinal cord stimulation could engender an increase in cerebral blood flow. Cerebral blood flow has been shown to be decreased in many patients with dementia and in various neurodegenerative disorders such as Alzheimer's disease and Parkinson's disease. Furthermore, there is evidence that reduced cerebral blood flow worsens neurodegenerative disease and may also predict which patients progress from mild cognitive impairment to full blown Alzheimer's disease. Thus, the identification of decreased cerebral blood flow in patients with early cognitive problems may offer clinicians a window of opportunity to intervene and prevent further brain damage. Further evidence that supports augmenting cerebral blood flow as an effective strategy for preventing and treating cognitive brain dysfunction comes from experimental studies with omental transposition. The author proposes cervical spinal cord stimulation as a titratable, programmable extracranial neuromodulation technique to increase cerebral blood flow for the purposes of improving cognitive function and preventing cognitive deterioration in patients with dementias and neurodegenerative disorders.
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Affiliation(s)
- Nestor D Tomycz
- Allegheny General Hospital, Department of Neurological Surgery, United States.
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9
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van Beek M, van Kleef M, Linderoth B, van Kuijk SMJ, Honig WM, Joosten EA. Spinal cord stimulation in experimental chronic painful diabetic polyneuropathy: Delayed effect of High-frequency stimulation. Eur J Pain 2016; 21:795-803. [PMID: 27891705 PMCID: PMC5412908 DOI: 10.1002/ejp.981] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2016] [Indexed: 12/12/2022]
Abstract
Background Spinal cord stimulation (SCS) has been shown to provide pain relief in painful diabetic polyneuropathy (PDPN). As the vasculature system plays a great role in the pathophysiology of PDPN, a potential beneficial side‐effect of SCS is peripheral vasodilation, with high frequency (HF) SCS in particular. We hypothesize that HF‐SCS (500 Hz), compared with conventional (CON) or low frequency (LF)‐SCS will result in increased alleviation of mechanical hypersensitivity in chronic experimental PDPN. Methods Diabetes was induced in 8‐week‐old female Sprague–Dawley rats with an intraperitoneal injection of 65 mg/kg of streptozotocin (n = 44). Rats with a significant decrease in mechanical withdrawal response to von Frey filaments over a period of 20 weeks were implanted with SCS electrodes (n = 18). Rats were assigned to a cross‐over design with a random order of LF‐, CON‐, HF‐ and sham SCS and mechanical withdrawal thresholds were assessed with von Frey testing. Results Compared with sham treatment, the average 50% WT score for 5 Hz was 4.88 g higher during stimulation (p = 0.156), and 1.77 g higher post‐stimulation (p = 0.008). CON‐SCS resulted in 50% WT scores 5.7 g, and 2.51 g higher during (p = 0.064) and after stimulation (p < 0.004), respectively. HF‐SCS started out with an average difference in 50% WT score compared with sham of 1.87 g during stimulation (p = 0.279), and subsequently the steepest rise to a difference of 5.47 g post‐stimulation (p < 0.001). Conclusions We demonstrated a delayed effect of HF‐SCS on mechanical hypersensitivity in chronic PDPN animals compared with LF‐, or CON‐SCS. Significance This study evaluates the effect of SCS frequency (5–500 Hz) on mechanical hypersensitivity in the chronic phase of experimental PDPN. High frequency (500 Hz) – SCS resulted in a delayed effect‐ on pain‐related behavioural outcome in chronic PDPN.
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Affiliation(s)
- M van Beek
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands.,Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands
| | - M van Kleef
- Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands
| | - B Linderoth
- Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands.,Department of Clinical Neuroscience, (Functional Neurosurgery), Karolinska Institutet, Stockholm, Sweden
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC+, Maastricht, The Netherlands
| | - W M Honig
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands
| | - E A Joosten
- Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands.,Pain Management and Research Center, Department of Anesthesiology, MUMC+, Maastricht, The Netherlands
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10
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Liu JT, Chang CS, Su CH, Li CS. Insights Into Microcirculation Underlying Critical Limb Ischemia by Single-Photon Emission Computed Tomography. Medicine (Baltimore) 2015; 94:e1075. [PMID: 26166084 PMCID: PMC4504599 DOI: 10.1097/md.0000000000001075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Perfusion difference is used as a parameter to evaluate microcirculation. This study aims to differentiate lower-limb perfusion insufficiency from neuropathy to prevent possible occurrence of failed back surgery syndrome (FBSS).Patients were retrospectively gathered from 134 FBSS cases diagnosed in the past 7 years. Up to 82 cases that were excluded from neuralgia by radiologic imaging, electrodiagnostic electromyography, and nerve conduction velocity were enrolled in this study. Perfusion difference was evaluated by single-photon emission computed tomography, and pain intensities were recorded via visual analog scale (VAS) score.Lower perfusion at the left leg comprises 51.2% (42 of 82) of the patients. The mean perfusion difference of the 82 patients was 0.86 ± 0.05 (range: 0.75-0.93). Patients with systemic vascular diseases exhibited significantly higher perfusion difference than that of patients without these related diseases (P < 0.05), except for renal insufficiency (P = 0.134). Significant correlation was observed between perfusion difference and VAS score (r = -0.78; P < 0.0001; n = 82).In this study, we presented perfusion difference as a parameter for evaluating microcirculation, which cannot be detected by ultrasonography or angiography.
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Affiliation(s)
- Jung-Tung Liu
- From Department of Neurosurgery, Chung Shan Medical University Hospital, School of Medicine, Chung Shan Medical University, Taichung City, Taiwan (J-TL, C-SC, C-HS, C-SL)
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De Caridi G, Massara M, David A, Giardina M, La Spada M, Stilo F, Spinelli F, Grande R, Butrico L, de Franciscis S, Serra R. Spinal cord stimulation to achieve wound healing in a primary lower limb critical ischaemia referral centre. Int Wound J 2014; 13:220-5. [PMID: 24712687 DOI: 10.1111/iwj.12272] [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: 02/14/2014] [Accepted: 03/10/2014] [Indexed: 12/12/2022] Open
Abstract
Critical lower limb ischaemia is a diffuse pathology that could cause claudication, severe ischaemic pain and tissue loss. The common treatment includes modification of risk factors, pharmacological therapy and endovascular or surgical revascularisation of the lower limb to restore a pulsatile flow distally. Spinal cord stimulator is seen as a valid alternative in patients unsuitable for revascularisation after endovascular or surgical revascularisation failure and as adjuvant therapy in the presence of a functioning bypass in patients with extensive tissue loss and gangrene presenting a slow and difficult wound healing. We report our experience on spinal cord stimulation (SCS) indication and implantation in patients with critical lower limb ischaemia, at a high-volume centre for the treatment of peripheral arterial disease.
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Affiliation(s)
- Giovanni De Caridi
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Mafalda Massara
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Antonio David
- Anesthesiological Sciences Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Massimiliano Giardina
- Anesthesiological Sciences Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Michele La Spada
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Francesco Stilo
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Francesco Spinelli
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Raffaele Grande
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Lucia Butrico
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy.,Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Naoum JJ, Arbid EJ. Spinal cord stimulation for chronic limb ischemia. Methodist Debakey Cardiovasc J 2014; 9:99-102. [PMID: 23805343 DOI: 10.14797/mdcj-9-2-99] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The treatment of chronic limb ischemia involves the restoration of pulsatile blood flow to the distal extremity. Some patients cannot be treated with endovascular means or with open surgery; some may have medical comorbidities that render them unfit for surgery, while others may have persistent ischemia or pain even in the face of previous attempts at reperfusion. In spinal cord stimulation (SCS), a device with electrodes is implanted in the epidural space to stimulate sensory fibers. This activates cell-signaling molecules that in turn cause the release of vasodilatory molecules, a decrease in vascular resistance, and relaxation of smooth muscle cells. SCS also suppresses sympathetic vasoconstriction and pain transmission. When patient selection is based on microcirculatory parameters, SCS therapy can significantly improve pain relief, halt the progression of ulcers, and potentially achieve limb salvage.
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Deogaonkar M, Zibly Z, Slavin KV. Spinal Cord Stimulation for the Treatment of Vascular Pathology. Neurosurg Clin N Am 2014; 25:25-31. [DOI: 10.1016/j.nec.2013.08.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Foreman RD, Linderoth B. Neural mechanisms of spinal cord stimulation. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2013. [PMID: 23206679 DOI: 10.1016/b978-0-12-404706-8.00006-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Neuromodulation, specifically spinal cord stimulation (SCS), relieves pain and improves organ function. This chapter discusses the limited information presently available about the underlying mechanisms that explain the beneficial effects of treating patients with SCS. Where applicable, information is presented about translational research that illustrates the importance of collaboration between clinicians, basic scientists, and engineers. This chapter presents the infant stage of studies that attempt to explain the mechanisms which come into play for treating neuropathic pain, ischemic pain in peripheral vascular disease, and diseases of the visceral organs, specifically the gastrointestinal tract and the heart. The basic science studies will demonstrate how SCS acts on various pain syndromes and diseases via multiple pathways in the central nervous system as well as in somatic structures and visceral organs.
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Affiliation(s)
- Robert D Foreman
- Department of Physiology, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
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Wu M, Thorkilsen MM, Qin C, Farber JP, Linderoth B, Foreman RD. Effects of spinal cord stimulation on peripheral blood circulation in rats with streptozotocin-induced diabetes. Neuromodulation 2012; 10:216-23. [PMID: 22150835 DOI: 10.1111/j.1525-1403.2007.00111.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective. The aim of this study was to investigate the effects of spinal cord stimulation (SCS) on peripheral circulation in rats with streptozotocin (STZ)-induced diabetes. Materials and Methods. Four weeks after streptozotocin or vehicle was injected (i.p.) in male Sprague-Dawley rats, SCS-induced vasodilation was examined. Results. Plasma glucose concentration was significantly higher in diabetic rats than in the control animals. Motor threshold (MT) was significantly higher in diabetic rats than in control rats. SCS-induced vasodilation was attenuated at 90% of the MT, but not at 30% and 60% of MT in diabetic rats when compared to control rats (p < 0.001, N = 13). Furthermore, increasing SCS from 30% to 90% of MT typically produced a progressive increase in blood flow in control rats but not in diabetic rats (p < 0.01, N = 13). Conclusion. This study suggested that SCS-induced vasodilation improves peripheral blood flow, although the pathways were partially impaired in the diabetic condition.
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Affiliation(s)
- Mingyuan Wu
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; Department of Pharmacology and Pharmacotherapy, The Danish University of Pharmaceutical Sciences, Copenhagen, Denmark; and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Effect of cervical spinal cord electrical stimulation on nitric oxide levels in brain and dermal tissues: an evaluation using by real-time nitric oxide measurement. Acta Neurochir (Wien) 2012; 154:1641-6. [PMID: 22454038 DOI: 10.1007/s00701-012-1331-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 03/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Nitric oxide synthesized from L: -arginine via the nitric oxide synthase enzyme family is the main regulatory molecule in many physiological systems. The level of nitric oxide can now be measured in tissues by a direct real-time amperometric method. The effect of electrical stimulation of the upper cervical spine on the arteries that supply the brain and upper extremities has been established by experimental studies, and thus it has begun to be used in clinical practice to increase blood flow in the brain and the peripheral vascular system. The mechanism of this effect is still a subject of research. This is the first report of real-time nitric oxide measurement in living brain and dermal tissue during electrical stimulation of the upper cervical spine. METHODS Using the amperometric method, nitric oxide levels in frontal subcortical and front foot skin were measured before, during and after electrical stimulation of the upper cervical spine in three groups of rabbits that received infusions of saline solution, 7-aminoguanidine or atropine. RESULTS By electrical stimulation, tissue nitric oxide levels increased significantly and remained increased during stimulation in the brain and skin. The nitric oxide levels dropped back to normal value 1 min after stimulation was turned off. CONCLUSION The results we obtained have showed that real-time nitric oxide could also be measured by an amperometric method in living tissues like brain. The effect of stimulation on nitric oxide levels of living tissues disappears immediately when the stimulation is turned off.
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Chen XP, Fu WM, Gu W. Spinal cord stimulation for patients with inoperable chronic critical leg ischemia. World J Emerg Med 2011; 2:262-6. [PMID: 25215020 PMCID: PMC4129719 DOI: 10.5847/wjem.j.1920-8642.2011.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 10/11/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Because of the prevalence of diabetes, the treatment of diabetic foot is still challenging. Even an exactly proved effective and practical method can't be listed except vascular surgery which is not a long-term way for it. Spinal cord stimulation (SCS) is a very promising option in the treatment algorithm of inoperable chronic critical leg ischemia (CLI). DATA SOURCES We searched Pubmed database with key words or terms such as "spinal cord stimulation", "ischemic pain" and "limb ischemia" appeared in the last five years. RESULTS The mechanism of SCS is unclear. Two theories have emerged to interpret the benefits of SCS. Pain relief from SCS can be confirmed by a majority of the studies, while limb salvage and other more ambitious improvements have not come to an agreement. The complications of SCS are not fatal, but most of them are lead migration, lead connection failure, and local infection. CONCLUSIONS SCS is a safe, promising treatment for patients with inoperable CLI. It is effective in pain reduction compared with traditional medical treatment.
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Affiliation(s)
- Xiao-pei Chen
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China (Chen XP, Gu W) Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China (Fu WM)
| | - Wei-min Fu
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China (Chen XP, Gu W) Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China (Fu WM)
| | - Wei Gu
- Department of Endocrinology and Metabolism, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China (Chen XP, Gu W) Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China (Fu WM)
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Kim J, Ho CH, Wang X, Bogie K. The use of sensory electrical stimulation for pressure ulcer prevention. Physiother Theory Pract 2010; 26:528-36. [PMID: 20649492 DOI: 10.3109/09593981003587037] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Pressure ulcer prevention is critically important for many people with reduced mobility. The authors investigated whether sensory (sub-motor-threshold) electrical stimulation (ES) may provide a convenient preventive intervention. A double-blinded, repeated measures study design was used to test the hypothesis that repeated use of sensory surface ES improves tissue health status in individuals with motor paralysis. Six adult males with complete spinal cord injury (SCI) were randomly assigned to treatment or control groups. The treatment group received the ES intervention, whereas the control group received a control sham intervention. Repeated tissue health assessments included transcutaneous oxygen tension (T(c)PO(2)), interface pressure mapping, and gluteal computed tomography (CT) studies. An initial increase in T(c)PO(2) following use of subthreshold ES was observed but was not sustained at follow-up. No statistically significant changes before and after treatment were found in regional T(c)PO(2), gluteal muscle area or pressure distribution. Thus subthreshold ES does not appear to have any sustained effects on tissue health status indicative of reduced pressure ulcer risk for individuals with SCI. This implies that a contractile muscle response is critically important and further that subthreshold ES is unlikely to prevent pressure ulcers. Further studies are needed to find solutions for preventing pressure ulcers in high-risk populations.
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Affiliation(s)
- Jennifer Kim
- Northeastern Ohio Universities College of Medicine, Rootstown, OH 44106, USA
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Gao J, Wu M, Li L, Qin C, Farber JP, Linderoth B, Foreman RD. Effects of spinal cord stimulation with “standard clinical” and higher frequencies on peripheral blood flow in rats. Brain Res 2010; 1313:53-61. [DOI: 10.1016/j.brainres.2009.11.072] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 11/13/2009] [Accepted: 11/24/2009] [Indexed: 11/25/2022]
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Maeda Y, Ikeuchi M, Wacnik P, Sluka KA. Increased c-fos immunoreactivity in the spinal cord and brain following spinal cord stimulation is frequency-dependent. Brain Res 2009; 1259:40-50. [DOI: 10.1016/j.brainres.2008.12.060] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 12/23/2008] [Accepted: 12/24/2008] [Indexed: 10/21/2022]
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Spinal Cord Stimulation for Refractory Angina. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00070-7] [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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de Vos CC, Rajan V, Steenbergen W, van der Aa HE, Buschman HPJ. Effect and safety of spinal cord stimulation for treatment of chronic pain caused by diabetic neuropathy. J Diabetes Complications 2009; 23:40-5. [PMID: 18413161 DOI: 10.1016/j.jdiacomp.2007.08.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Revised: 05/04/2007] [Accepted: 08/09/2007] [Indexed: 10/22/2022]
Abstract
AIM Spinal cord stimulation (SCS) has been shown effective as a therapy for different chronic painful conditions, but the effectiveness of this treatment for pain as a result of peripheral diabetic neuropathy is not well established. The primary objectives of this study were to evaluate the effect and safety of SCS for treatment of pain and the effects on microcirculatory blood flow in the affected areas in patients with refractory peripheral diabetic neuropathy. METHOD The study was designed as a prospective, open-label study. Data were collected during screening, at implant and at regular intervals, after initiation of therapy. Eleven diabetic patients with chronic pain in their lower limbs and no response to conventional treatment were studied. The SCS electrode was implanted in the thoracic epidural space. Neuropathic pain relief was assessed by Visual Analogue Scale (VAS) and microcirculatory skin perfusion was measured with Laser Doppler flowmetry. RESULTS Nine subjects had significant pain relief with the percutaneous electrical stimulator. Average pain score for all nine patients was 77 at baseline and 34 at 6 months after implantation. At the end of the study, eight of nine patients continued to experience significant pain relief and have been able to significantly reduce their pain medication. For six of them, the stimulator was the sole treatment for their neuropathic pain. No significant changes in microcirculatory perfusion were recorded. CONCLUSION Spinal cord stimulation offers an effective and safe therapy for chronic diabetic neuropathic pain.
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Affiliation(s)
- Cecile C de Vos
- Twente Institute for Neuromodulation, Medisch Spectrum Twente, Enschede, The Netherlands.
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Wu M, Linderoth B, Foreman RD. Putative mechanisms behind effects of spinal cord stimulation on vascular diseases: a review of experimental studies. Auton Neurosci 2008; 138:9-23. [PMID: 18083639 PMCID: PMC2291393 DOI: 10.1016/j.autneu.2007.11.001] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 10/29/2007] [Accepted: 11/01/2007] [Indexed: 12/16/2022]
Abstract
Spinal cord stimulation (SCS) is a widely used clinical technique to treat ischemic pain in peripheral, cardiac and cerebral vascular diseases. The use of this treatment advanced rapidly during the late 80's and 90's, particularly in Europe. Although the clinical benefits of SCS are clear and the success rate remains high, the mechanisms are not yet completely understood. SCS at lumbar spinal segments (L2-L3) produces vasodilation in the lower limbs and feet which is mediated by antidromic activation of sensory fibers and decreased sympathetic outflow. SCS at thoracic spinal segments (T1-T2) induces several benefits including pain relief, reduction in both frequency and severity of angina attacks, and reduced short-acting nitrate intake. The benefits to the heart are not likely due to an increase, or redistribution of local blood flow, rather, they are associated with SCS-induced myocardial protection and normalization of the intrinsic cardiac nervous system. At somewhat lower cervical levels (C3-C6), SCS induces increased blood flow in the upper extremities. SCS at the upper cervical spinal segments (C1-C2) increased cerebral blood flow, which is associated with a decrease in sympathetic activity, an increase in vasomotor center activity and a release of neurohumoral factors. This review will summarize the basic science studies that have contributed to our understanding about mechanisms through which SCS produces beneficial effects when used in the treatment of vascular diseases. Furthermore, this review will particularly focus on the antidromic mechanisms of SCS-induced vasodilation in the lower limbs and feet.
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Affiliation(s)
- Mingyuan Wu
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190, United States.
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Wu M, Komori N, Qin C, Farber JP, Linderoth B, Foreman RD. Extracellular signal-regulated kinase (ERK) and protein kinase B (AKT) pathways involved in spinal cord stimulation (SCS)-induced vasodilation. Brain Res 2008; 1207:73-83. [PMID: 18374907 DOI: 10.1016/j.brainres.2007.12.072] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Revised: 12/14/2007] [Accepted: 12/30/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS SCS is used to improve peripheral circulation in selected patients with ischemia of the extremities. However the mechanisms are not fully understood. The present study investigated whether blockade of ERK and AKT activation modulated SCS-induced vasodilation. METHODS A unipolar ball electrode was placed on the left dorsal column at the lumbar 2-3 spinal segments in rats. Cutaneous blood flows from left and right hind foot pads were recorded with laser Doppler flow perfusion monitors. SCS was applied through a ball electrode at 60% or 90% of MT. U0126, an inhibitor of ERK kinase, or LY294002, an inhibitor of PI3K upstream of AKT, was applied to the lumbar 3-5 spinal segments (n=7, each group). RESULTS U0126 (100 nM, 5 microM and 250 microM) significantly attenuated SCS-induced vasodilation at 60% (100 nM: P<0.05; 5 microM and 250 microM: P<0.01, respectively) and 90% of MT (100 nM and 5 microM: P<0.05; 250 microM: P<0.01, respectively). LY294002 at 100 microM also attenuated SCS-induced vasodilation at 60% and 90% of MT (P<0.05). CONCLUSIONS These data suggest that ERK and AKT pathways are involved in SCS-induced vasodilation.
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Affiliation(s)
- Mingyuan Wu
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190, USA
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de Vries J, Anthonio RL, DeJongste MJL, Jessurun GA, Tan ES, de Smet BJGL, van den Heuvel AFM, Staal MJ, Zijlstra F. The effect of electrical neurostimulation on collateral perfusion during acute coronary occlusion. BMC Cardiovasc Disord 2007; 7:18. [PMID: 17597524 PMCID: PMC1925118 DOI: 10.1186/1471-2261-7-18] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 06/27/2007] [Indexed: 11/20/2022] Open
Abstract
Background Electrical neurostimulation can be used to treat patients with refractory angina, it reduces angina and ischemia. Previous data have suggested that electrical neurostimulation may alleviate myocardial ischaemia through increased collateral perfusion. We investigated the effect of electrical neurostimulation on functional collateral perfusion, assessed by distal coronary pressure measurement during acute coronary occlusion. We sought to study the effect of electrical neurostimulation on collateral perfusion. Methods Sixty patients with stable angina and significant coronary artery disease planned for elective percutaneous coronary intervention were split in two groups. In all patients two balloon inflations of 60 seconds were performed, the first for balloon dilatation of the lesion (first episode), the second for stent delivery (second episode). The Pw/Pa ratio (wedge pressure/aortic pressure) was measured during both ischaemic episodes. Group 1 received 5 minutes of active neurostimulation before plus 1 minute during the first episode, group 2 received 5 minutes of active neurostimulation before plus 1 minute during the second episode. Results In group 1 the Pw/Pa ratio decreased by 10 ± 22% from 0.20 ± 0.09 to 0.19 ± 0.09 (p = 0.004) when electrical neurostimulation was deactivated. In group 2 the Pw/Pa ratio increased by 9 ± 15% from 0.22 ± 0.09 to 0.24 ± 0.10 (p = 0.001) when electrical neurostimulation was activated. Conclusion Electrical neurostimulation induces a significant improvement in the Pw/Pa ratio during acute coronary occlusion.
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Affiliation(s)
- Jessica de Vries
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rutger L Anthonio
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Mike JL DeJongste
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Gillian A Jessurun
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Eng-Shiong Tan
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart JGL de Smet
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Ad FM van den Heuvel
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Michiel J Staal
- Dept of Neurosurgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Felix Zijlstra
- Dept of Cardiology, Thoraxcenter, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Wu M, Komori N, Qin C, Farber JP, Linderoth B, Foreman RD. Roles of peripheral terminals of transient receptor potential vanilloid-1 containing sensory fibers in spinal cord stimulation-induced peripheral vasodilation. Brain Res 2007; 1156:80-92. [PMID: 17540346 PMCID: PMC1995562 DOI: 10.1016/j.brainres.2007.04.065] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 04/16/2007] [Accepted: 04/19/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is used to relieve ischemic pain and improve peripheral blood flow in selected patients with peripheral arterial diseases. Our previous studies show that antidromic activation of transient receptor potential vanilloid-1 (TRPV1) containing sensory fibers importantly contributes to SCS-induced vasodilation. OBJECTIVES To determine whether peripheral terminals of TRPV1 containing sensory fibers produces vasodilation that depends upon the release of calcitonin gene-related peptide (CGRP) and nitric oxide (NO) during SCS. METHODS A unipolar ball electrode was placed on the left dorsal column at lumbar spinal cord segments 2-3 in sodium pentobarbital anesthetized, paralyzed and ventilated rats. Cutaneous blood flow from left and right hindpaws was recorded with laser Doppler flow perfusion monitors. SCS was applied through a ball electrode at 30%, 60%, 90% and 300% of motor threshold. Resiniferatoxin (RTX; 2 microg/ml, 100 microl), an ultra potent analog of capsaicin, was injected locally into the left hindpaw to functionally inactivate TRPV-1 containing sensory terminals. In another set of experiments, CGRP(8-37), an antagonist of the CGRP-1 receptor, was injected at 0.06, 0.12 or 0.6 mg/100 microl into the left hindpaw to block CGRP responses; N-omega-nitro-l-arginine methyl ester (L-NAME), a nonselective nitric-oxide synthase (NOS) inhibitor, was injected at 0.02 or 0.2 mg/100 microl into the left hindpaw to block nitric oxide synthesis; (4S)-N-(4-Amino-5[aminoethyl]aminopentyl)-N'-nitroguanidine, TFA, a neuronal NOS inhibitor, was injected at 0.02 or 0.1 mg/100 microl into the left hindpaw to block neuronal nitric oxide synthesis. RESULTS SCS at all intensities produced vasodilation in the left hindpaw, but not in the right. RTX administration attenuated SCS-induced vasodilation at all intensities in the left hindpaw (P<0.05, n=7) compared with responses before RTX. CGRP(8-37) administration attenuated SCS-induced vasodilation in the left hindpaw in a dose dependent manner (linear regression, P<0.05) compared with responses before CGRP(8-37). In addition, L-NAME at a high dose, but not (4S)-N-(4-Amino-5[aminoethyl]aminopentyl)-N'-nitroguanidine, TFA, decreased SCS-induced vasodilation (P<0.05, n=5). CONCLUSION While TRPV1, CGRP and NO are known to be localized in the same nerve terminals, our data indicate that SCS-induced vasodilation depends on CGRP release, but not NO release. NO, released from endothelial cells, may be associated with vascular smooth muscle relaxation and peripheral blood flow increase in response to SCS.
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Affiliation(s)
- Mingyuan Wu
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190
| | - Naoka Komori
- Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190
| | - Chao Qin
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190
| | - Jay P. Farber
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190
| | - Bengt Linderoth
- Department of Clinical neuroscience, Section of Neurosurgery, Karolinska Institute, Stockholm, Sweden
| | - Robert D. Foreman
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73190
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Wu M, Komori N, Qin C, Farber JP, Linderoth B, Foreman RD. Sensory fibers containing vanilloid receptor-1 (VR-1) mediate spinal cord stimulation-induced vasodilation. Brain Res 2006; 1107:177-84. [PMID: 16836986 DOI: 10.1016/j.brainres.2006.05.087] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 05/22/2006] [Accepted: 05/26/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS Spinal cord stimulation (SCS) is used to improve peripheral blood flow in selected populations of patients with ischemia of the extremities. Previous studies show that antidromic activation of sensory fibers is an important mechanism that contributes to SCS-induced vasodilation. However, the characteristics of sensory fibers involved in vasodilation are not fully known. This study investigated the contribution of vanilloid receptor type 1 (VR-1) containing fibers to SCS-induced vasodilation. METHODS A unipolar ball electrode was placed on the left dorsal column at the lumbar 2-3 spinal cord segments (L2-L3) in sodium pentobarbital anesthetized, paralyzed and ventilated rats. Cutaneous blood flows from both ipsilateral (left) and contralateral (right) hind foot pads were recorded with laser Doppler flow perfusion monitors. SCS (50 Hz; 0.2 ms) was applied through the ball electrode at 30%, 60%, 90% and 300% of motor threshold (MT). Resiniferatoxin (RTX), an ultra potent analog of capsaicin and VR-1 receptor agonist, was used to suppress the activities of VR-1 containing sensory fibers. RESULTS SCS at 30%, 60%, 90% and also at 300% of MT significantly increased cutaneous blood flow in the ipsilateral foot pad compared to that in the contralateral side. RTX (2 microg/kg, i.v.) significantly attenuated SCS-induced vasodilation of the ipsilateral side (P<0.05, n=7) compared with responses prior to RTX administration. A pledget of cotton soaked with RTX (2 microg/ml) placed on L2-L3 spinal cord significantly decreased SCS-induced vasodilation of the ipsilateral side at 30%, 60%, 90% and 300% of MT (P<0.05, n=7) compared with responses prior to RTX administration. Additionally, topical application of a pledget of cotton soaked with RTX (2 microg/ml) on the sciatic nerve at the middle level of the thigh or on the tibial nerve at the lower level of the lower hindlimb also decreased SCS-induced vasodilation (n=5). CONCLUSION SCS-induced vasodilation is predominantly mediated via VR-1 containing sensory fibers.
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Affiliation(s)
- Mingyuan Wu
- Department of Physiology, University of Oklahoma Health Sciences Center, PO BOX 26901, Oklahoma City, OK 73190, USA, and Karolinska University Hospital, Stockholm, Sweden.
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Green AL, Wang S, Owen SLF, Xie K, Bittar RG, Stein JF, Paterson DJ, Aziz TZ. Stimulating the human midbrain to reveal the link between pain and blood pressure. Pain 2006; 124:349-359. [PMID: 16781077 DOI: 10.1016/j.pain.2006.05.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Revised: 04/20/2006] [Accepted: 05/02/2006] [Indexed: 10/24/2022]
Abstract
The periaqueductal grey area (PAG) in the midbrain is an important area for both cardiovascular control and modulation of pain. However, the precise relationship between pain and blood pressure is unknown. We prospectively studied 16 patients undergoing deep brain stimulation of the rostral PAG for chronic pain. Pre-operatively, post-operatively, and at 1 year, pain scores were assessed using both visual analogue scores and the McGill Pain Questionnaire. Patients were tested post-operatively to determine whether electrical stimulation of the PAG would modulate blood pressure. We found that the degree of analgesia induced by deep brain stimulation of the rostral PAG in man is related to the magnitude of reduction in arterial blood pressure. We found that this relationship is linear and is related to reduced activity of the sympathetic nervous system. Thus stimulation of the PAG may partly control pain by reducing sympathetic activity as predicted by William James over a century ago.
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Affiliation(s)
- Alexander L Green
- Department of Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford, OX2 6HE, United Kingdom University Laboratory of Physiology, University of Oxford, Parks Road, Oxford, OX1 3PT, United Kingdom
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Linderoth B, Foreman RD. Mechanisms of Spinal Cord Stimulation in Painful Syndromes: Role of Animal Models. PAIN MEDICINE 2006. [DOI: 10.1111/j.1526-4637.2006.00119.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Spinal cord stimulation emerged as a spin-off from the classical gate-control theory, which, however, does not suffice to explain its clinical effects. Whether or not nociceptive forms of pain may be attenuated remains a controversial issue. Previous experimental studies aiming at elucidating the underlying mechanisms were performed on intact, anesthetized animals and were therefore of limited clinical relevance. Not until recent years have some data on the mode of action accumulated providing evidence that gamma-aminobutyric acid (GABA) ergic as well as adenosine-related mechanisms are involved in the pain amelioration. It appears that the effects are exerted mostly via segmental spinal levels, but recent evidence suggests that a supraspinal loop may also be of importance; this issue remains to be resolved. It should be emphasized that most experimental data pertaining to the mode of action are derived from so-called animal models of neuropathic pain. However, caution must be exercised in the translation of such data from bench to bedside, because some behavioral signs interpreted as "pain" in such models may be misleading. We still need animal studies to generate basic data but these findings should also be confirmed in humans.
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Affiliation(s)
- Björn A Meyerson
- Section of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
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