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Yuen J, Klassen BT, Sandroni P, Huston J, Grewal SS, Wharen RE, Lee KH. Implantable Subdural Cortical Stimulation for Chronic Intractable Pain Treatment-The Mayo Experience and Review of Literature. Neuromodulation 2024; 27:200-208. [PMID: 36809871 DOI: 10.1016/j.neurom.2023.01.013] [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: 10/28/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVES Motor cortex stimulation (MCS) is an effective technique in treating chronic intractable pain for some patients. However, most studies are small case series (n < 20). Heterogeneity in technique and patient selection makes it difficult to draw consistent conclusions. In this study, we present one of the largest case series of subdural MCS. MATERIALS AND METHODS Medical records of patients who underwent MCS at our institute between 2007 and 2020 were reviewed. Studies with at least 15 patients were summarized for comparison. RESULTS The study included 46 patients. Mean age was 56.2 ± 12.5 years (SD). Mean follow-up was 57.2 ± 41.9 months. Male-to-female ratio was 13:33. Of the 46 patients, 29 had neuropathic pain in trigeminal nerve territory/anesthesia dolorosa; nine had postsurgical/posttraumatic pain; three had phantom limb pain; two had postherpetic pain, and the rest had pain secondary to stroke, chronic regional pain syndrome, and tumor. The baseline numeric rating pain scale (NRS) was 8.2 ± 1.8 of 10, and the latest follow-up score was 3.5 ± 2.9 (mean improvement of 57.3%). Responders comprised 67% (31/46)(NRS ≥ 40% improvement). Analysis showed no correlation between percentage of improvement and age (p = 0.352) but favored male patients (75.3% vs 48.7%, p = 0.006). Seizures occurred in 47.8% of patients (22/46) at some point but were all self-limiting, with no lasting sequelae. Other complications included subdural/epidural hematoma requiring evacuation (3/46), infection (5/46), and cerebrospinal fluid leak (1/46). These complications resolved with no long-term sequelae after further interventions. CONCLUSION Our study further supports the use of MCS as an effective treatment modality for several chronic intractable pain conditions and provides a benchmark to the current literature.
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Affiliation(s)
- Jason Yuen
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Sanjeet S Grewal
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Robert E Wharen
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
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Aibar-Durán JÁ, Villalba Martínez G, Freixer-Palau B, Araus-Galdós E, Morollón Sanchez-Mateos N, Belvis Nieto R, Revuelta Rizo M, Molet Teixeido J, García Sánchez C, de Quintana Schmidt C, Muñoz Hernandez F, Rodríguez Rodríguez R. Long-Term Results of Cortical Motor Stimulation for Neuropathic Peripheral and Central Pain: Real-World Evidence From Two Independent Centers. Neurosurgery 2024; 94:147-153. [PMID: 37638720 DOI: 10.1227/neu.0000000000002638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/12/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cortical motor stimulation (CMS) is used to modulate neuropathic pain. The literature supports its use; however, short follow-up studies might overestimate its real effect. This study brings real-world evidence from two independent centers about CMS methodology and its long-term outcomes. METHODS Patients with chronic refractory neuropathic pain were implanted with CMS. The International Classification of Headache Disorders 3rd Edition was used to classify craniofacial pain and the Douleur Neuropathique en 4 Questions Scale score to explore its neuropathic nature. Demographics and clinical and surgical data were collected. Pain intensity at 6, 12, and 24 months and last follow-up was registered. Numeric rating scale reduction of ≥50% was considered a good response. The Clinical Global Impression of Change scale was used to report patient satisfaction. RESULTS Twelve males (38.7%) and 19 females (61.3%) with a mean age of 55.8 years (±11.9) were analyzed. Nineteen (61.5%) were diagnosed from painful trigeminal neuropathy (PTN), and seven (22.5%) from central poststroke pain. The mean follow-up was 51 months (±23). At 6 months, 42% (13/31) of the patients were responders, all of them being PTN (13/19; 68.4%). At last follow-up, only 35% (11/31) remained responders (11/19 PTN; 58%). At last follow-up, the global Numeric rating scale reduction was 34% ( P = .0001). The Clinical Global Impression of Change scale punctuated 2.39 (±0.94) after 3 months from the surgery and 2.95 (±1.32) at last follow-up ( P = .0079). Signs of suspicious placebo effect were appreciated in around 40% of the nonresponders. CONCLUSION CMS might show long-term efficacy for neuropathic pain syndromes, with the effect on PTN being more robust in the long term. Multicentric clinical trials are needed to confirm the efficacy of this therapy for this and other conditions.
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Affiliation(s)
- Juan Ángel Aibar-Durán
- Neurosurgery Department, Functional Neurosurgery Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Universitat Pompeu Fabra (UPF), Barcelona , Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona , Spain
| | - Gloria Villalba Martínez
- Neurosurgery Department, Functional Neurosurgery Section, Hospital del Marc-Parc Salut, Universitat Autònoma de Barcelona (AUB) and Universitat Pompeu Fabra (UPF), Barcelona , Spain
| | - Berta Freixer-Palau
- Neurosurgery Department, Functional Neurosurgery Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
| | - Elena Araus-Galdós
- Neurosurgery Department, Neurophysiology Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
| | - Noemi Morollón Sanchez-Mateos
- Neurology Department, Headache-Neuralgia Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Universitat Pompeu Fabra (UPF), Barcelona , Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona , Spain
| | - Robert Belvis Nieto
- Neurology Department, Headache-Neuralgia Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Anesthesiologist Department, Pain Clinic Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona , Spain
| | - Miren Revuelta Rizo
- Anesthesiologist Department, Pain Clinic Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Universitat Pompeu Fabra (UPF), Barcelona , Spain
| | - Joan Molet Teixeido
- Neurosurgery Department, Functional Neurosurgery Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
| | - Carmen García Sánchez
- Neuropsychology Department, Headache-Neuralgia Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Universitat Pompeu Fabra (UPF), Barcelona , Spain
| | - Cristian de Quintana Schmidt
- Neurosurgery Department, Functional Neurosurgery Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona , Spain
| | - Fernando Muñoz Hernandez
- Neurosurgery Department, Functional Neurosurgery Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona , Spain
| | - Rodrigo Rodríguez Rodríguez
- Neurosurgery Department, Functional Neurosurgery Section, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (AUB), Barcelona , Spain
- Universitat Pompeu Fabra (UPF), Barcelona , Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Barcelona , Spain
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Moura-Pacheco TL, Martins-Pereira RC, Medeiros P, Sbragia L, Ramos Andrade Leite-Panissi C, Machado HR, Coimbra NC, de Freitas RL. Effect of electrical and chemical (activation versus inactivation) stimulation of the infralimbic division of the medial prefrontal cortex in rats with chronic neuropathic pain. Exp Brain Res 2023; 241:2591-2604. [PMID: 37725136 DOI: 10.1007/s00221-023-06657-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/20/2023] [Indexed: 09/21/2023]
Abstract
Neuropathic pain (NP) represents a complex disorder with sensory, cognitive, and emotional symptoms. The medial prefrontal cortex (mPFC) takes critical regulatory roles and may change functionally and morphologically during chronic NP. There needs to be a complete understanding of the neurophysiological and psychopharmacological bases of the NP phenomenon. This study aimed to investigate the participation of the infralimbic division (IFL) of the mPFC in chronic NP, as well as the role of the N-methyl-D-aspartic acid receptor (NMDAr) in the elaboration of chronic NP. Male Wistar rats were submitted to the von Frey and acetone tests to assess mechanical and cold allodynia after 21 days of chronic constriction injury (CCI) of the sciatic nerve or Sham-procedure ("false operated"). Electrical neurostimulation of the IFL/mPFC was performed by low-frequency stimuli (20 μA, 100 Hz) applied for 15 s by deep brain stimulation (DBS) device 21 days after CCI. Either cobalt chloride (CoCl2 at 1.0 mM/200 nL), NMDAr agonist (at 0.25, 1.0, and 2.0 nmol/200 nL) or physiological saline (200 nL) was administered into the IFL/mPFC. CoCl2 administration in the IFL cortex did not alter either mechanical or cold allodynia. DBS stimulation of the IFL cortex decreased mechanical allodynia in CCI rats. Chemical stimulation of the IFL cortex by an NMDA agonist (at 2.0 nmol) decreased mechanical allodynia. NMDA at any dose (0.25, 1.0, and 2.0 nmol) reduced the flicking/licking duration in the cold test. These findings suggest that the IFL/mPFC and the NMDAr of the neocortex are involved in attenuating chronic NP in rats.
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Affiliation(s)
- Thais Lohanny Moura-Pacheco
- Multi-User Center of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Laboratory of Neurosciences of Pain and Emotions, Department of Surgery and Anatomy, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Pediatric Surgery Laboratory, Department of Surgery and Anatomy, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | - Renata Cristina Martins-Pereira
- Multi-User Center of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Laboratory of Neurosciences of Pain and Emotions, Department of Surgery and Anatomy, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Protection Laboratory in Childhood, Division of Neurosurgery, Department of Surgery and Anatomy, FMRP-USP, Avenida Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | - Priscila Medeiros
- Multi-User Center of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Laboratory of Neurosciences of Pain and Emotions, Department of Surgery and Anatomy, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Department of General and Specialized Nursing, Ribeirão Preto Nursing School of the University of São Paulo (EERP-USP), Avenida Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | - Lourenço Sbragia
- Pediatric Surgery Laboratory, Department of Surgery and Anatomy, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | - Christie Ramos Andrade Leite-Panissi
- Department of Psychology,, Faculty of Philosophy, Science and Letters of Ribeirão Preto of the University of São Paulo (FFCLRP-USP), Ribeirão Preto, SP, 14040-901, Brazil
| | - Hélio Rubens Machado
- Multi-User Center of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Department of Psychology,, Faculty of Philosophy, Science and Letters of Ribeirão Preto of the University of São Paulo (FFCLRP-USP), Ribeirão Preto, SP, 14040-901, Brazil
| | - Norberto Cysne Coimbra
- Multi-User Center of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
- Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil
| | - Renato Leonardo de Freitas
- Multi-User Center of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil.
- Laboratory of Neurosciences of Pain and Emotions, Department of Surgery and Anatomy, FMRP-USP, Av. Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil.
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Borutta MC, Koehn J, de Oliveira DS, Del Vecchio A, Engelhorn T, Schwab S, Buchfelder M, Kinfe TM. The Impact of Burst Motor Cortex Stimulation on Cardiovascular Autonomic Modulation in Chronic Pain: A Feasibility Study for a New Approach to Objectively Monitor Therapeutic Effects. Pain Ther 2023; 12:1235-1251. [PMID: 37532960 PMCID: PMC10444743 DOI: 10.1007/s40122-023-00541-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023] Open
Abstract
INTRODUCTION Chronic refractory pain of various origin occurs in 30-45% of pain patients, and a considerable proportion remains resistant to pharmacological and behavioral therapies, requiring adjunctive neurostimulation therapies. Chronic pain is known to stimulate sympathetic outflow, yet the impact of burst motor cortex stimulation (burstMCS) on objectifiable autonomic cardiovascular parameters in chronic pain remains largely unknown. METHODS In three patients with chronic pain (2 facial pain/1 post-stroke pain), we compared pain intensity using a visual analog scale (VAS 1-10) and parameters of autonomic cardiovascular modulation at supine rest, during parasympathetic challenge with six cycles per minute of metronomic deep breathing, and during sympathetic challenge (active standing) at baseline and after 4 months of burstMCS compared to age-/gender-matched healthy controls. RESULTS While two out of three patients were responsive after 4 months of adjunctive burstMCS (defined as pain reduction of > 30%), no differences were found in any of the three patients regarding the R-R intervals of adjacent QRS complexes (RRI, 642 vs. 676 ms) and blood pressure (BP, 139/88 vs. 141/90 mmHg). Under resting conditions, parameters of parasympathetic tone [normalized units of high-frequency oscillations of RRI (RRI-HFnu power) 0.24 vs. 0.38, root-mean-square differences of successive RRI (RRI-RMSSD) 7.7 vs. 14.7 ms], total autonomic cardiac modulation [RRI total power 129.3 vs. 406.2 ms2, standard deviation of RRI (RRI-SD) 11.6 vs. 18.5 ms, coefficient of variation of RRI (RRI-CV) 1.9 vs. 3.7%], and baroreceptor reflex sensitivity (BRS, 1.9 vs. 2.3 ms/mmHg) increased, and parameters of sympathetic tone [normalized units of low-frequency oscillations of RRI (RRI-LFnu power) 0.76 vs. 0.62] and sympatho-vagal balance [ratio of RR-LF to RRI-HF power (RRI-LF/HF ratio) 3.4 vs. 1.9] decreased after 4 months of burstMCS. Low-frequency oscillations of systolic blood pressure (SBP-LF power), a parameter of sympathetic cardiovascular modulation, increased slightly (17.6 vs. 20.4 mmHg2). During parasympathetic stimulation, the expiratory-inspiratory ratio (E/I ratio) increased slightly, while upon sympathetic stimulation, the ratio between the shortest RRI around the 15th heartbeat and the longest RRI around the 30th heartbeat after standing up (RRI 30/15 ratio) remained unchanged. CONCLUSION Four months of adjunctive burstMCS was associated with an increase in parameters reflecting both total and parasympathetic autonomic modulation and baroreceptor reflex sensitivity. In contrast, sympathetic tone declined in our three patients, suggesting stimulation-associated improvement not only in subjectively perceived VAS pain scores, but also in objectifiable parameters of autonomic cardiovascular modulation.
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Affiliation(s)
- Matthias C Borutta
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Julia Koehn
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Daniela Souza de Oliveira
- Department of Artificial Intelligence in Biomedical Engineering (AIBE), Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Alessandro Del Vecchio
- Department of Artificial Intelligence in Biomedical Engineering (AIBE), Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas M Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Schwabach Anlage 6, 91054, Erlangen, Germany.
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Impacts of stimulus parameters and configurations on motor cortex direct electrical stimulation using intrinsic optical imaging: a pilot study. Biomed Eng Online 2022; 21:58. [PMID: 36038875 PMCID: PMC9422127 DOI: 10.1186/s12938-022-01026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Abstract
Background Motor cortex stimulation applied as a clinical treatment for neuropathic disorders for decades. With stimulation electrodes placed directly on the cortical surface, this neuromodulation method provides higher spatial resolution than other non-invasive therapies. Yet, the therapeutic effects reported were not in conformity with different syndromes. One of the main issues is that the stimulation parameters are always determined by clinical experience. The lack of understanding about how the stimulation current propagates in the cortex and various stimulation parameters and configurations obstruct the development of this method. Methods In this study, we investigated the effect of different stimulation configurations on cortical responses to motor cortical stimulations using intrinsic optical imaging. Results Our results showed that the cortical activation of electrical stimulation is not only related to the current density but also related to the propagation distance. Besides, stimulation configurations also affect the propagation of the stimulation current. Conclusions All these results provide preliminary experimental evidence for parameter and electrode configuration optimizations.
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Black SR, Janson A, Mahan M, Anderson J, Butson CR. Identification of Deep Brain Stimulation Targets for Neuropathic Pain After Spinal Cord Injury Using Localized Increases in White Matter Fiber Cross Section. Neuromodulation 2022; 25:276-285. [PMID: 35125147 DOI: 10.1111/ner.13399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/12/2021] [Accepted: 03/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The spinal cord injury (SCI) patient population is overwhelmingly affected by neuropathic pain (NP), a secondary condition for which therapeutic options are limited and have a low degree of efficacy. The objective of this study was to identify novel deep brain stimulation (DBS) targets that may theoretically benefit those with NP in the SCI patient population. We hypothesize that localized changes in white matter identified in SCI subjects with NP compared to those without NP could be used to develop an evidence-based approach to DBS target identification. MATERIALS AND METHODS To classify localized neurostructural changes associated with NP in the SCI population, we compared white matter fiber density (FD) and cross section (FC) between SCI subjects with NP (n = 17) and SCI subjects without NP (n = 15) using diffusion-weighted magnetic resonance imaging (MRI). We then identified theoretical target locations for DBS using fiber bundles connected to significantly altered regions of white matter. Finally, we used computational models of DBS to determine if our theoretical target locations could be used to feasibly activate our fiber bundles of interest. RESULTS We identified significant increases in FC in the splenium of the corpus callosum in pain subjects when compared to controls. We then isolated five fiber bundles that were directly connected to the affected region of white matter. Our models were able to predict that our fiber bundles of interest can be feasibly activated with DBS at reasonable stimulation amplitudes and with clinically relevant implantation approaches. CONCLUSIONS Altogether, we identified neuroarchitectural changes associated with NP in the SCI cohort and implemented a novel evidence-driven target selection approach for DBS to guide future research in neuromodulation treatment of NP after SCI.
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Affiliation(s)
- Shana R Black
- Biomedical Engineering, University of Utah, Salt Lake City, UT, USA; Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA
| | - Andrew Janson
- Vanderbilt University Institute of Imaging Science, Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark Mahan
- Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Jeffrey Anderson
- Biomedical Engineering, University of Utah, Salt Lake City, UT, USA; Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Christopher R Butson
- Biomedical Engineering, University of Utah, Salt Lake City, UT, USA; Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA; Neurosurgery, University of Utah, Salt Lake City, UT, USA; Neurology, University of Utah, Salt Lake City, UT, USA; Psychiatry, University of Utah, Salt Lake City, UT, USA.
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Negrini-Ferrari SE, Medeiros P, Malvestio RB, de Oliveira Silva M, Medeiros AC, Coimbra NC, Machado HR, de Freitas RL. The primary motor cortex electrical and chemical stimulation attenuates the chronic neuropathic pain by activation of the periaqueductal grey matter: The role of NMDA receptors. Behav Brain Res 2021; 415:113522. [PMID: 34391797 DOI: 10.1016/j.bbr.2021.113522] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/31/2021] [Accepted: 08/09/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Motor cortex stimulation (MCS) is proper as a non-pharmacological therapy for patients with chronic and neuropathic pain (NP). AIMS This work aims to investigate if the MCS in the primary motor cortex (M1) produces analgesia and how the MCS could interfere in the MCS-induced analgesia. Also, to elucidate if the persistent activation of N-methyl-d-aspartic acid receptor (NMDAr) in the periaqueductal grey matter (PAG) can contribute to central sensitisation of the NP. METHODS Male Wistar rats were submitted to the von Frey test to evaluate the mechanical allodynia after 21 days of chronic constriction injury (CCI) of the sciatic nerve. The MCS was performed with low-frequency (20 μA, 100 Hz) currents during 15 s by a deep brain stimulation (DBS) device. Moreover, the effect of M1-treatment with an NMDAr agonist (at 2, 4, and 8 nmol) was investigated in CCI rats. The PAG dorsomedial column (dmPAG) was pretreated with the NMDAr antagonist LY 235959 (at 8 nmol), followed by MCS. RESULTS The MCS decreased the mechanical allodynia in rats with chronic NP. The M1-treatment with an NMDA agonist at 2 and 8 nmol reduced the mechanical allodynia in CCI rats. In addition, dmPAG-pretreatment with LY 235959 at 8 nmol attenuated the mechanical allodynia evoked by MCS. CONCLUSION The M1 cortex glutamatergic system is involved in the modulation of chronic NP. The analgesic effect of MCS may depend on glutamate signaling recruitting NMDAr located on PAG neurons in rodents with chronic NP.
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Affiliation(s)
- Sylmara Esther Negrini-Ferrari
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Priscila Medeiros
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Rafael Braghetto Malvestio
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Mariana de Oliveira Silva
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Ana Carolina Medeiros
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil
| | - Norberto Cysne Coimbra
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil; Behavioural Neurosciences Institute (INeC), Av. do Café, 2450, Ribeirão Preto, São Paulo, 14050-220, Brazil
| | - Helio Rubens Machado
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Brain Protection Laboratory in Childhood, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Avenida Bandeirantes, 3900, Ribeirão Preto, 14049-900, São Paulo, Brazil
| | - Renato Leonardo de Freitas
- Laboratory of Neurosciences of Pain & Emotions and Multi-User Centre of Neuroelectrophysiology, Department of Surgery and Anatomy, Ribeirão Preto Medical School of the University of São Paulo, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, Brazil; Laboratory of Neuroanatomy and Neuropsychobiology, Department of Pharmacology, Ribeirão Preto Medical School of the University of São Paulo (FMRP-USP), Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-900, Brazil; Biomedical Sciences Institute, Federal University of Alfenas (UNIFAL-MG), Str. Gabriel Monteiro da Silva, 700, Alfenas, 37130-000, Minas Gerais, Brazil; Behavioural Neurosciences Institute (INeC), Av. do Café, 2450, Ribeirão Preto, São Paulo, 14050-220, Brazil.
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di Biase L, Falato E, Caminiti ML, Pecoraro PM, Narducci F, Di Lazzaro V. Focused Ultrasound (FUS) for Chronic Pain Management: Approved and Potential Applications. Neurol Res Int 2021; 2021:8438498. [PMID: 34258062 PMCID: PMC8261174 DOI: 10.1155/2021/8438498] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/19/2021] [Indexed: 02/08/2023] Open
Abstract
Chronic pain is one of the leading causes of disability and disease burden worldwide, accounting for a prevalence between 6.9% and 10% in the general population. Pharmacotherapy alone results ineffective in about 70-60% of patients in terms of a satisfactory degree of pain relief. Focused ultrasound is a promising tool for chronic pain management, being approved for thalamotomy in chronic neuropathic pain and for bone metastases-related pain treatment. FUS is a noninvasive technique for neuromodulation and for tissue ablation that can be applied to several tissues. Transcranial FUS (tFUS) can lead to opposite biological effects, depending on stimulation parameters: from reversible neural activity facilitation or suppression (low-intensity, low-frequency ultrasound, LILFUS) to irreversible tissue ablation (high-intensity focused ultrasounds, HIFU). HIFU is approved for thalamotomy in neuropathic pain at the central nervous system level and for the treatment of facet joint osteoarthritis at the peripheral level. Potential applications include HIFU at the spinal cord level for selected cases of refractory chronic neuropathic pain, knee osteoarthritis, sacroiliac joint disease, intervertebral disc nucleolysis, phantom limb, and ablation of peripheral nerves. FUS at nonablative dosage, LILFUS, has potential reversible and tissue-selective effects. FUS applications at nonablative doses currently are at a research stage. The main potential applications include targeted drug and gene delivery through the Blood-Brain Barrier, assessment of pain thresholds and study of pain, and reversible peripheral nerve conduction block. The aim of the present review is to describe the approved and potential applications of the focused ultrasound technology in the field of chronic pain management.
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Affiliation(s)
- Lazzaro di Biase
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
- Brain Innovations Lab, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Emma Falato
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Maria Letizia Caminiti
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Pasquale Maria Pecoraro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Flavia Narducci
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, Rome 00128, Italy
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Abdallat M, Saryyeva A, Blahak C, Wolf ME, Weigel R, Loher TJ, Runge J, Heissler HE, Kinfe TM, Krauss JK. Centromedian-Parafascicular and Somatosensory Thalamic Deep Brain Stimulation for Treatment of Chronic Neuropathic Pain: A Contemporary Series of 40 Patients. Biomedicines 2021; 9:731. [PMID: 34202202 PMCID: PMC8301341 DOI: 10.3390/biomedicines9070731] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/17/2021] [Accepted: 06/20/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction: The treatment of neuropathic and central pain still remains a major challenge. Thalamic deep brain stimulation (DBS) involving various target structures is a therapeutic option which has received increased re-interest. Beneficial results have been reported in several more recent smaller studies, however, there is a lack of prospective studies on larger series providing long term outcomes. Methods: Forty patients with refractory neuropathic and central pain syndromes underwent stereotactic bifocal implantation of DBS electrodes in the centromedian-parafascicular (CM-Pf) and the ventroposterolateral (VPL) or ventroposteromedial (VPM) nucleus contralateral to the side of pain. Electrodes were externalized for test stimulation for several days. Outcome was assessed with five specific VAS pain scores (maximum, minimum, average pain, pain at presentation, allodynia). Results: The mean age at surgery was 53.5 years, and the mean duration of pain was 8.2 years. During test stimulation significant reductions of all five pain scores was achieved with either CM-Pf or VPL/VPM stimulation. Pacemakers were implanted in 33/40 patients for chronic stimulation for whom a mean follow-up of 62.8 months (range 3-180 months) was available. Of these, 18 patients had a follow-up beyond four years. Hardware related complications requiring secondary surgeries occurred in 11/33 patients. The VAS maximum pain score was improved by ≥50% in 8/18, and by ≥30% in 11/18 on long term follow-up beyond four years, and the VAS average pain score by ≥50% in 10/18, and by ≥30% in 16/18. On a group level, changes in pain scores remained statistically significant over time, however, there was no difference when comparing the efficacy of CM-Pf versus VPL/VPM stimulation. The best results were achieved in patients with facial pain, poststroke/central pain (except thalamic pain), or brachial plexus injury, while patients with thalamic lesions had the least benefit. Conclusion: Thalamic DBS is a useful treatment option in selected patients with severe and medically refractory pain.
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Affiliation(s)
- Mahmoud Abdallat
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Department of Neurosurgery, University of Jordan, Amman 11183, Jordan
| | - Assel Saryyeva
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Christian Blahak
- Department of Neurology, University Hospital Mannheim, 68167 Mannheim, Germany; (C.B.); (M.E.W.)
- Department of Neurology, Ortenau-Klinikum Lahr-Ettenheim, 77933 Lahr Ettenheim, Germany
| | - Marc E. Wolf
- Department of Neurology, University Hospital Mannheim, 68167 Mannheim, Germany; (C.B.); (M.E.W.)
- Department of Neurology, Katharinenhospital, 70174 Stuttgart, Germany
| | - Ralf Weigel
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Department of Neurosurgery, St. Katharinen Krankenhaus, 60389 Frankfurt, Germany
| | | | - Joachim Runge
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Hans E. Heissler
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
| | - Thomas M. Kinfe
- Department of Neurosurgery, Division of Functional Neurosurgery and Stereotaxy, Friedrich-Alexander University, 91054 Erlangen-Nürnberg, Germany;
| | - Joachim K. Krauss
- Department of Neurosurgery, Hannover Medical School, 30625 Hannover, Germany; (M.A.); (R.W.); (J.R.); (H.E.H.); (J.K.K.)
- Center for Systems Neuroscience, 30559 Hannover, Germany
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Lavrov I, Latypov T, Mukhametova E, Lundstrom BN, Sandroni P, Lee K, Klassen B, Stead M. Pre-motor versus motor cerebral cortex neuromodulation for chronic neuropathic pain. Sci Rep 2021; 11:12688. [PMID: 34135363 PMCID: PMC8209192 DOI: 10.1038/s41598-021-91872-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Electrical stimulation of the cerebral cortex (ESCC) has been used to treat intractable neuropathic pain for nearly two decades, however, no standardized approach for this technique has been developed. In order to optimize targeting and validate the effect of ESCC before placing the permanent grid, we introduced initial assessment with trial stimulation, using a temporary grid of subdural electrodes. In this retrospective study we evaluate the role of electrode location on cerebral cortex in control of neuropathic pain and the role of trial stimulation in target-optimization for ESCC. Location of the temporary grid electrodes and location of permanent electrodes were evaluated in correlation with the long-term efficacy of ESCC. The results of this study demonstrate that the long-term effect of subdural pre-motor cortex stimulation is at least the same or higher compare to effect of subdural motor or combined pre-motor and motor cortex stimulation. These results also demonstrate that the initial trial stimulation helps to optimize permanent electrode positions in relation to the optimal functional target that is critical in cases when brain shift is expected. Proposed methodology and novel results open a new direction for development of neuromodulation techniques to control chronic neuropathic pain.
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Affiliation(s)
- Igor Lavrov
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia.
- Skolkovo Institute of Science and Technology, Moscow, Russia.
| | - Timur Latypov
- Division of Brain, Imaging, and Behaviour Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elvira Mukhametova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| | | | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Kendall Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bryan Klassen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Matt Stead
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Seo H, Jun SC. Computational exploration of epidural cortical stimulation using a realistic head model. Comput Biol Med 2021; 135:104290. [PMID: 33775416 DOI: 10.1016/j.compbiomed.2021.104290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/15/2021] [Indexed: 10/21/2022]
Abstract
Motor cortex stimulation, either non-invasively or with implanted electrodes, has been applied worldwide as a treatment for intractable neuropathic pain syndromes. Although computer simulations of non-invasive brain stimulation have been investigated largely to optimize protocols and improve our understanding of underlying mechanisms using a realistic head model, computational studies of invasive cortical stimulation are rare and limited to very simplified cortical models. In this paper, we present an anatomically realistic head model for epidural cortical stimulation that includes the most sophisticated epidural electrodes with an insulating paddle. The head model predicted the stimulus-induced field strengths according to two different stimulation techniques, bipolar and monopolar stimulations. We found that the stimulus-induced field focused on the precentral and postcentral gyri because of the epidural lead's invasiveness. Different stimulation configurations influenced the shape of the field markedly, and complex patterns of inward and outward directions of the radial field were observed in bipolar stimulation compared to those in monopolar stimulation. The spatial distributions of field strength showed that the optimal stimulation varied according to the target areas. In conclusion, we proposed an anatomically realistic head model and a sophisticated epidural lead to simulate epidural cortical stimulation-induced field strengths and identified the importance of such detailed modeling for epidural cortical stimulation because of the current's shunting through the cerebrospinal fluid.
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Affiliation(s)
- Hyeon Seo
- School of Electrical Engineering and Computer Science, Gwangju Institute of Science & Technology, South Korea; Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, South Korea
| | - Sung Chan Jun
- School of Electrical Engineering and Computer Science, Gwangju Institute of Science & Technology, South Korea.
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Nüssel M, Hamperl M, Maslarova A, Chaudhry SR, Köhn J, Stadlbauer A, Buchfelder M, Kinfe T. Burst Motor Cortex Stimulation Evokes Sustained Suppression of Thalamic Stroke Pain: A Narrative Review and Single-Case Overview. Pain Ther 2020; 10:101-114. [PMID: 33325005 PMCID: PMC8119548 DOI: 10.1007/s40122-020-00221-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic refractory central post-stroke pain (CPSP), one of the most disabling consequences of cerebral stroke, occurs in up to 10% of patients with CPSP. Because a considerable proportion of these patients with chronic pain remain resistant to pharmacological and behavioral therapies, adjunctive invasive and non-invasive brain stimulation therapies are needed. We performed a review of human studies applying burst and conventional motor cortex stimulation (burstMCS and cMCS, respectively) for chronic pain states, on the basis of data sources identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, as well as manual searches of the bibliographies of known primary and review articles. Our aim was to review and discuss clinical data on the indications of burstMCS for various chronic pain states originating from central stroke (excluding trigeminal facial pain). In addition, we assessed the efficacy and safety of burst versus cMCS for central post-stroke pain with an extended follow-up of 5 years in a 60-year-old man. According to our review, uncontrolled observational human cohort studies and one RCT using cMCS waveforms have revealed a meaningful clinical response; however, these studies lacked placebo groups and extended observation periods. In our case report, we found that 3 months of adjunctive cMCS reduced pain levels [visual analog scale (VAS) pre: 9/10 versus VAS post 7/10], whereas the pain decreased further under burstMCS (VAS pre: 7/10 versus VAS post: 2/10); the study involved a follow-up of 5 years and the following parameters: burst rate 40 Hz (500 Hz), 1–1.75 mA, 1 ms, bipolar configuration. To date, only limited evidence exists for the efficacy and safety of burst motor cortex stimulation for the treatment of refractory chronic pain. BurstMCS resulted in significantly decreased post-stroke pain observed after 5 years of cMCS. The available literature suggests similar efficacy as that of conventional (tonic) motor cortex stimulation, although the results are preliminary. Mechanistically, the precise mechanism of action is not fully understood. However, burstMCS may interact with the nociceptive thalamic-cingulate and descending spinal pain networks. To determine the potential utility of this treatment, large-scale sham-controlled trials comparing cMCS and burstMCS are highly recommended.
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Affiliation(s)
- Martin Nüssel
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Melanie Hamperl
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Maslarova
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Shafqat R Chaudhry
- College of Pharmaceutical Sciences, Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Julia Köhn
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Stadlbauer
- Institute of Medical Radiology, University Clinic St. Pölten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany.
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Neuromodulation for Medically Refractory Neuropathic Pain: Spinal Cord Stimulation, Deep Brain Stimulation, Motor Cortex Stimulation, and Posterior Insula Stimulation. World Neurosurg 2020; 146:246-260. [PMID: 33217591 DOI: 10.1016/j.wneu.2020.11.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The treatment of neuropathic pain (NP) continues to be controversial as well as an economic health issue and a challenge to health care. Neurosurgery can offer different methods of neuromodulation that may improve patients' condition, including deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS), and posterior insula stimulation (PIS). There is no consensus of opinion as to the final effects of these procedures, which stimulation parameters to select, the correct timing, or how to select the patients who will best benefit from these procedures. OBJECTIVE To review the evidence available regarding these 4 procedures and the management of NP. METHODS We conducted a PubMed, Embase, and Cochrane Library database search from 1990 to 2020. The strategy of the search concentrated on the following keywords: "neuropathic pain," "chronic pain," "deep brain stimulation," "motor cortex stimulation," "spinal cord stimulation," "insula stimulation," and "neuromodulation." Studies that provided data regarding the immediate and long-term effectiveness of the procedure, anatomic stimulation target, percentage of pain control, and cause of the NP were included. RESULTS The most frequent causes of NP were phantom limb pain and central poststroke pain in the MCS group; central poststroke pain, phantom limb pain, and spinal cord injury (SCI) in the DBS group; and complex regional pain syndrome and failed back surgery syndrome in the SCS group. Pain improvement varied between 35% and 80% in the MCS group and 50% and 60% in the DBS group. In the SCS group, successful rates varied between 38% and 89%. CONCLUSIONS This systematic review highlights the literature supporting SCS, DBS, MCS, and PIS methods for the treatment of NP. We found consistent evidence supporting MCS, DBS, and SCS as possible treatments for NP; however, we were not able to define which procedure should be indicated for each cause. Furthermore, we did not find enough evidence to justify the routine use of PIS. We conclude that unanswered points need to be discussed in this controversial field and emphasize that new research must be developed to treat patients with NP, to improve their quality of life.
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Pacheco-Barrios K, Meng X, Fregni F. Neuromodulation Techniques in Phantom Limb Pain: A Systematic Review and Meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2310-2322. [PMID: 32176286 PMCID: PMC7593798 DOI: 10.1093/pm/pnaa039] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effects of neuromodulation techniques in adults with phantom limb pain (PLP). METHODS A systematic search was performed, comprising randomized controlled trials (RCTs) and quasi-experimental (QE) studies that were published from database inception to February 2019 and that measured the effects of neuromodulation in adults with PLP. Hedge's g effect size (ES) and 95% confidence intervals were calculated, and random-effects meta-analyses were performed. RESULTS Fourteen studies (nine RCTs and five QE noncontrolled studies) were included. The meta-analysis of RCTs showed significant effects for i) excitatory primary motor cortex (M1) stimulation in reducing pain after stimulation (ES = -1.36, 95% confidence interval [CI] = -2.26 to -0.45); ii) anodal M1 transcranial direct current stimulation (tDCS) in lowering pain after stimulation (ES = -1.50, 95% CI = -2.05 to 0.95), and one-week follow-up (ES = -1.04, 95% CI = -1.64 to 0.45). The meta-analysis of noncontrolled QE studies demonstrated a high rate of pain reduction after stimulation with transcutaneous electrical nerve stimulation (rate = 67%, 95% CI = 60% to 73%) and at one-year follow-up with deep brain stimulation (rate = 73%, 95% CI = 63% to 82%). CONCLUSIONS The evidence from RCTs suggests that excitatory M1 stimulation-specifically, anodal M1 tDCS-has a significant short-term effect in reducing pain scale scores in PLP. Various neuromodulation techniques appear to have a significant and positive impact on PLP, but due to the limited amount of data, it is not possible to draw more definite conclusions.
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Affiliation(s)
- Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
| | - Xianguo Meng
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Shandong First Medical University & Shandong Academy of Medical Sciences, College of Sport Medicine and Rehabilitation, Jinan, Shandong Province, P.R. China
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
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Franzini A, Messina G, Levi V, D'Ammando A, Cordella R, Moosa S, Prada F, Franzini A. Deep brain stimulation of the posterior limb of the internal capsule in the treatment of central poststroke neuropathic pain of the lower limb: case series with long-term follow-up and literature review. J Neurosurg 2020; 133:830-838. [PMID: 31419792 DOI: 10.3171/2019.5.jns19227] [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: 01/28/2019] [Accepted: 05/08/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Central poststroke neuropathic pain is a debilitating syndrome that is often resistant to medical therapies. Surgical measures include motor cortex stimulation and deep brain stimulation (DBS), which have been used to relieve pain. The aim of this study was to retrospectively assess the safety and long-term efficacy of DBS of the posterior limb of the internal capsule for relieving central poststroke neuropathic pain and associated spasticity affecting the lower limb. METHODS Clinical and surgical data were retrospectively collected and analyzed in all patients who had undergone DBS of the posterior limb of the internal capsule to address central poststroke neuropathic pain refractory to conservative measures. In addition, long-term pain intensity and level of satisfaction gained from stimulation were assessed. Pain was evaluated using the visual analog scale (VAS). Information on gait improvement was obtained from medical records, neurological examination, and interview. RESULTS Four patients have undergone the procedure since 2001. No mortality or morbidity related to the surgery was recorded. In three patients, stimulation of the posterior limb of the internal capsule resulted in long-term pain relief; in a fourth patient, the procedure failed to produce any long-lasting positive effect. Two patients obtained a reduction in spasticity and improved motor capability. Before surgery, the mean VAS score was 9 (range 8-10). In the immediate postoperative period and within 1 week after the DBS system had been turned on, the mean VAS score was significantly lower at a mean of 3 (range 0-6). After a mean follow-up of 5.88 years, the mean VAS score was still reduced at 5.5 (range 3-8). The mean percentage of long-term pain reduction was 38.13%. CONCLUSIONS This series suggests that stimulation of the posterior limb of the internal capsule is safe and effective in treating patients with chronic neuropathic pain affecting the lower limb. The procedure may be a more targeted treatment method than motor cortex stimulation or other neuromodulation techniques in the subset of patients whose pain and spasticity are referred to the lower limbs.
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Affiliation(s)
- Andrea Franzini
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
- 2Department of Neurosurgery, University of Virginia Health System; and
| | - Giuseppe Messina
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
| | - Vincenzo Levi
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
| | - Antonio D'Ammando
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
| | - Roberto Cordella
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
| | - Shayan Moosa
- 2Department of Neurosurgery, University of Virginia Health System; and
| | - Francesco Prada
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
- 2Department of Neurosurgery, University of Virginia Health System; and
- 3Focused Ultrasound Foundation, Charlottesville, Virginia
| | - Angelo Franzini
- 1Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milano, Italy
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Puttaswamy SV, Shi Q, Steele D, Fishlock SJ, Lee C, McLaughlin J. High density nanowire electrodes for intracortical microstimulation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:5657-5660. [PMID: 31947136 DOI: 10.1109/embc.2019.8857305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High-density electrodes with the nano feature size greatly enhance resolution and specificity during intracortical microstimulation. In this viewpoint, we fabricated and developed high-density nanowire (NW) electrodes, ~ 2.45×109 / cm2 that could directly stimulate specific region of the cortex with low current amplitude in the range of 120-180 μA. The proposed nanowire electrodes will help expand the capabilities of microstimulation and extend the range of dysfunctions that can be treated using microstimulation technique.
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Abstract
Phantom limb pain is a chronic neuropathic pain that develops in 45-85% of patients who undergo major amputations of the upper and lower extremities and appears predominantly during two time frames following an amputation: the first month and later about 1 year. Although in most patients the frequency and intensity of pain diminish over time, severe pain persists in about 5-10%. It has been proposed that factors in both the peripheral and central nervous systems play major roles in triggering the development and maintenance of pain associated with extremity amputations. Chronic pain is physically and mentally debilitating, affecting an individual's capacity for self-care, but also diminishing an individual's daily capacity for personal and economic independence. In addition, the pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering from this condition. Although the pain can be reduced by antiepileptic drugs and analgesics, they are frequently ineffective or their side effects preclude their use. The optimal approach for eliminating neuropathic pain and improving individuals' quality of life is the development of novel techniques that permanently prevent the development and maintenance of neuropathic pain, or that eliminate the pain once it has developed. What is still required is understanding when and where an effective novel technique must be applied, such as onto the nerve stump of the transected peripheral axons, dorsal root ganglion neurons, spinal cord, or cortex to induce the desired influences. This review, the second of two in this journal volume, examines the techniques that may be capable of reducing or eliminating chronic neuropathic pain once it has developed. Such an understanding will improve amputees' quality of life by blocking the mechanisms that trigger and/or maintain PLP and chronic neuropathic pain.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, University of Puerto Rico, Medical Science Campus, 201 Blvd. del Valle, San Juan, PR, 00901, Puerto Rico.
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Chronic subdural cortical stimulation for phantom limb pain: report of a series of two cases. Acta Neurochir (Wien) 2019; 161:925-934. [PMID: 30790089 DOI: 10.1007/s00701-019-03828-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
Phantom limb pain is a complex, incompletely understood pain syndrome that is characterized by chronic painful paresthesias in a previous amputated body part. Limited treatment modalities exist that provide meaningful relief, including pharmacological treatments and spinal cord stimulation that are rarely successful for refractory cases. Here, we describe our two-patient cohort with recalcitrant upper extremity phantom limb pain treated with chronic subdural cortical stimulation. The patient with evidence of cortical reorganization and almost 60 years of debilitating phantom limb pain experienced sustained analgesic relief at a follow-up period of 6 months. The second patient became tolerant to the stimulation and his pain returned to baseline at a 1-month follow-up. Our unique case series report adds to the growing body of literature suggesting critical appraisal before widespread implementation of cortical stimulation for phantom limb pain can be considered.
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Corbett M, South E, Harden M, Eldabe S, Pereira E, Sedki I, Hall N, Woolacott N. Brain and spinal stimulation therapies for phantom limb pain: a systematic review. Health Technol Assess 2019; 22:1-94. [PMID: 30407905 DOI: 10.3310/hta22620] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although many treatments exist for phantom limb pain (PLP), the evidence supporting them is limited and there are no guidelines for PLP management. Brain and spinal cord neurostimulation therapies are targeted at patients with chronic PLP but have yet to be systematically reviewed. OBJECTIVE To determine which types of brain and spinal stimulation therapy appear to be the best for treating chronic PLP. DESIGN Systematic reviews of effectiveness and epidemiology studies, and a survey of NHS practice. POPULATION All patients with PLP. INTERVENTIONS Invasive interventions - deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation. Non-invasive interventions - repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). MAIN OUTCOME MEASURES Phantom limb pain and quality of life. DATA SOURCES Twelve databases (including MEDLINE and EMBASE) and clinical trial registries were searched in May 2017, with no date limits applied. REVIEW METHODS Two reviewers screened titles and abstracts and full texts. Data extraction and quality assessments were undertaken by one reviewer and checked by another. A questionnaire was distributed to clinicians via established e-mail lists of two relevant clinical societies. All results were presented narratively with accompanying tables. RESULTS Seven randomised controlled trials (RCTs), 30 non-comparative group studies, 18 case reports and 21 epidemiology studies were included. Results from a good-quality RCT suggested short-term benefits of rTMS in reducing PLP, but not in reducing anxiety or depression. Small randomised trials of tDCS suggested the possibility of modest, short-term reductions in PLP. No RCTs of invasive therapies were identified. Results from small, non-comparative group studies suggested that, although many patients benefited from short-term pain reduction, far fewer maintained their benefits. Most studies had important methodological or reporting limitations and few studies reported quality-of-life data. The evidence on prognostic factors for the development of chronic PLP from the longitudinal studies also had important limitations. The results from these studies suggested that pre-amputation pain and early PLP intensity are good predictors of chronic PLP. Results from the cross-sectional studies suggested that the proportion of patients with severe chronic PLP is between around 30% and 40% of the chronic PLP population, and that around one-quarter of chronic PLP patients find their PLP to be either moderately or severely limiting or bothersome. There were 37 responses to the questionnaire distributed to clinicians. SCS and DRG stimulation are frequently used in the NHS but the prevalence of use of DBS and MCS was low. Most responders considered SCS and DRG stimulation to be at least sometimes effective. Neurosurgeons had mixed views on DBS, but most considered MCS to rarely be effective. Most clinicians thought that a randomised trial design could be successfully used to study neurostimulation therapies. LIMITATION There was a lack of robust research studies. CONCLUSIONS Currently available studies of the efficacy, effectiveness and safety of neurostimulation treatments do not provide robust, reliable results. Therefore, it is uncertain which treatments are best for chronic PLP. FUTURE WORK Randomised crossover trials, randomised N-of-1 trials and prospective registry trials are viable study designs for future research. STUDY REGISTRATION The study is registered as PROSPERO CRD42017065387. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Mark Corbett
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Emily South
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Melissa Harden
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
| | - Sam Eldabe
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Erlick Pereira
- Academic Neurosurgery Unit, St George's, University of London, London, UK
| | - Imad Sedki
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - Neil Hall
- James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination (CRD), University of York, York, UK
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Moysak GI, Rzaev DA, Dzhafarov VM, Slavin KV. [Motor cortex stimulation in deafferentation facial pain]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 82:70-80. [PMID: 30137040 DOI: 10.17116/neiro201882470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To demonstrate the results of treatment of poorly controlled deafferentation facial pain using motor cortex stimulation and to review the relevant literature. MATERIAL AND METHODS The study included 8 patients (3 males and 5 females) with deafferentation facial pain who were implanted with a system of constant motor cortex stimulation at the Illinois University in Chicago in 2004-2016 and Novosibirsk Federal Center of Neurosurgery in 2017. The patients' age ranged from 37 to 81 years (mean age, 57.5 years). Scale-based assessment of the pain severity was performed at admission to hospital, at discharge, and during follow-up. The visual analogue pain scale, Barrow Neurological Institute pain scale (BNIPS), and McLaughlin scale were used. RESULTS Immediately after surgery, a significant improvement in the form of pain reduction by 80-100% occurred in 4 patients. The pain intensity at discharge from the hospital decreased by 55%, on average. During the follow-up period, the efficacy of motor cortex stimulation was assessed (McLaughlin scale) as very good by 3 of the 8 patients, as good by 4 patients, and as unsatisfactory by 1 patient. CONCLUSION Our findings and recent studies have demonstrated that motor cortex stimulation is one of the treatment options for deafferentation facial pain. Even a slight decrease in the intensity of excruciating and debilitating pain (assessed by patients as a good effect) gives grounds for application of the procedure. Further research is needed to define more precise criteria for selecting patients for this treatment and to increase the efficacy of stimulation.
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Affiliation(s)
- G I Moysak
- Federal Center of Neurosurgery, Novosibirsk, Russia; Institute of Medicine and Psychology, Novosibirsk State University, Novosibirsk, Russia
| | - D A Rzaev
- Federal Center of Neurosurgery, Novosibirsk, Russia; Institute of Medicine and Psychology, Novosibirsk State University, Novosibirsk, Russia
| | | | - K V Slavin
- Department of Neurosurgery, University of Illinois, Chicago, USA
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The Current State of Deep Brain Stimulation for Chronic Pain and Its Context in Other Forms of Neuromodulation. Brain Sci 2018; 8:brainsci8080158. [PMID: 30127290 PMCID: PMC6119957 DOI: 10.3390/brainsci8080158] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 12/26/2022] Open
Abstract
Chronic intractable pain is debilitating for those touched, affecting 5% of the population. Deep brain stimulation (DBS) has fallen out of favour as the centrally implantable neurostimulation of choice for chronic pain since the 1970–1980s, with some neurosurgeons favouring motor cortex stimulation as the ‘last chance saloon’. This article reviews the available data and professional opinion of the current state of DBS as a treatment for chronic pain, placing it in the context of other neuromodulation therapies. We suggest DBS, with its newer target, namely anterior cingulate cortex (ACC), should not be blacklisted on the basis of a lack of good quality study data, which often fails to capture the merits of the treatment.
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Microbial nanowires - Electron transport and the role of synthetic analogues. Acta Biomater 2018; 69:1-30. [PMID: 29357319 DOI: 10.1016/j.actbio.2018.01.007] [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: 08/23/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 02/07/2023]
Abstract
Electron transfer is central to cellular life, from photosynthesis to respiration. In the case of anaerobic respiration, some microbes have extracellular appendages that can be utilised to transport electrons over great distances. Two model organisms heavily studied in this arena are Shewanella oneidensis and Geobacter sulfurreducens. There is some debate over how, in particular, the Geobacter sulfurreducens nanowires (formed from pilin nanofilaments) are capable of achieving the impressive feats of natural conductivity that they display. In this article, we outline the mechanisms of electron transfer through delocalised electron transport, quantum tunnelling, and hopping as they pertain to biomaterials. These are described along with existing examples of the different types of conductivity observed in natural systems such as DNA and proteins in order to provide context for understanding the complexities involved in studying the electron transport properties of these unique nanowires. We then introduce some synthetic analogues, made using peptides, which may assist in resolving this debate. Microbial nanowires and the synthetic analogues thereof are of particular interest, not just for biogeochemistry, but also for the exciting potential bioelectronic and clinical applications as covered in the final section of the review. STATEMENT OF SIGNIFICANCE Some microbes have extracellular appendages that transport electrons over vast distances in order to respire, such as the dissimilatory metal-reducing bacteria Geobacter sulfurreducens. There is significant debate over how G. sulfurreducens nanowires are capable of achieving the impressive feats of natural conductivity that they display: This mechanism is a fundamental scientific challenge, with important environmental and technological implications. Through outlining the techniques and outcomes of investigations into the mechanisms of such protein-based nanofibrils, we provide a platform for the general study of the electronic properties of biomaterials. The implications are broad-reaching, with fundamental investigations into electron transfer processes in natural and biomimetic materials underway. From these studies, applications in the medical, energy, and IT industries can be developed utilising bioelectronics.
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Edwards CA, Kouzani A, Lee KH, Ross EK. Neurostimulation Devices for the Treatment of Neurologic Disorders. Mayo Clin Proc 2017; 92:1427-1444. [PMID: 28870357 DOI: 10.1016/j.mayocp.2017.05.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/16/2017] [Accepted: 05/01/2017] [Indexed: 12/01/2022]
Abstract
Rapid advancements in neurostimulation technologies are providing relief to an unprecedented number of patients affected by debilitating neurologic and psychiatric disorders. Neurostimulation therapies include invasive and noninvasive approaches that involve the application of electrical stimulation to drive neural function within a circuit. This review focuses on established invasive electrical stimulation systems used clinically to induce therapeutic neuromodulation of dysfunctional neural circuitry. These implantable neurostimulation systems target specific deep subcortical, cortical, spinal, cranial, and peripheral nerve structures to modulate neuronal activity, providing therapeutic effects for a myriad of neuropsychiatric disorders. Recent advances in neurotechnologies and neuroimaging, along with an increased understanding of neurocircuitry, are factors contributing to the rapid rise in the use of neurostimulation therapies to treat an increasingly wide range of neurologic and psychiatric disorders. Electrical stimulation technologies are evolving after remaining fairly stagnant for the past 30 years, moving toward potential closed-loop therapeutic control systems with the ability to deliver stimulation with higher spatial resolution to provide continuous customized neuromodulation for optimal clinical outcomes. Even so, there is still much to be learned about disease pathogenesis of these neurodegenerative and psychiatric disorders and the latent mechanisms of neurostimulation that provide therapeutic relief. This review provides an overview of the increasingly common stimulation systems, their clinical indications, and enabling technologies.
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Affiliation(s)
- Christine A Edwards
- School of Engineering, Deakin University, Geelong, Victoria, Australia; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Abbas Kouzani
- School of Engineering, Deakin University, Geelong, Victoria, Australia
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | - Erika K Ross
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN; Department of Surgery, Mayo Clinic, Rochester, MN.
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Ward M, Mammis A. Deep Brain Stimulation for the Treatment of Dejerine-Roussy Syndrome. Stereotact Funct Neurosurg 2017; 95:298-306. [PMID: 28848107 DOI: 10.1159/000479526] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 07/11/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND/AIMS Patients who suffer from Dejerine-Roussy syndrome commonly experience severe poststroke hemibody pain which has historically been attributed to thalamic lesions. Despite pharmacological treatment, a significant proportion of the population is resistant to traditional therapy. Deep brain stimulation is often appropriate for the treatment of resistant populations. In this review we aim to summarize the targets that are used to treat Dejerine-Roussy syndrome and provide insight into their clinical efficacy. METHODS In reviewing the literature, we defined stimulation success as achievement of a minimum of 50% pain relief. RESULTS Contemporary targets for deep brain stimulation are the ventral posterior medial/ventral posterior lateral thalamic nuclei, periaqueductal/periventricular gray matter, the ventral striatum/anterior limb of the internal capsule, left centromedian thalamic nuclei, the nucleus ventrocaudalis parvocellularis internis, and the posterior limb of the internal capsule. CONCLUSIONS Due to technological advancements in deep brain stimulation, its therapeutic effects must be reevaluated. Despite a lack of controlled evidence, deep brain stimulation has been effectively used as a therapeutic in clinical pain management. Further clinical investigation is needed to definitively evaluate the therapeutic efficacy of deep brain stimulation in treating the drug-resistant patient population.
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Affiliation(s)
- Max Ward
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
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25
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Ivanishvili Z, Poologaindran A, Honey CR. Cyclization of Motor Cortex Stimulation for Neuropathic Pain: A Prospective, Randomized, Blinded Trial. Neuromodulation 2017; 20:497-503. [PMID: 28524457 DOI: 10.1111/ner.12610] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/10/2017] [Accepted: 04/05/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Programming guidelines for motor cortex stimulation (MCS) in neuropathic pain requires further investigation. After optimizing voltage as a percentage of motor threshold, we evaluated the effect of cyclizing time of stimulation on pain relief for chronic neuropathic pain. METHODS Six patients were enrolled into this trial. In a prospective, randomized, double-blinded manner, patients were programmed to receive stimulation 100, 83.3, 66.7, or 50% of the time in 30-min intervals. Outcomes were assessed after 14 days on each setting with a visual analogue scale (VAS) for pain and the SF36 quality of life questionnaire. RESULTS There was no significant difference (p > 0.05) between the different cyclized settings as measured by the VAS, MGPQ, or SF36 in our cohort. There were two distinct subgroups: responders (n = 4) and nonresponders (n = 2) to cyclization. Responders continued to have pain relief when stimulation was reduced to only 50% of the time (15 min ON/15 min off). Interestingly, this group subjectively preferred the 50% stimulation timing compared to 100%. Nonresponders could not tolerate cyclizing because of increased pain. CONCLUSIONS In this small cohort, cyclization of MCS settings revealed two distinct subgroups: responders and nonresponders. Responders tolerated stimulation in all settings and 50% stimulation (15 min ON/15 min off) was their subjectively preferred setting. Cyclization in responders will prolong battery life and delay the need for INS replacement and may offer improved pain relief. Building from our previous work, we recommend clinicians consider following the Vancouver MCS programming algorithm presented in this manuscript.
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Affiliation(s)
- Zurab Ivanishvili
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - Anujan Poologaindran
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, Canada
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Janice Jimenez-Torres G, Weinstein BL, Walker CR, Christopher Fowler J, Ashford P, Borckardt JJ, Madan A. A study protocol for a single-blind, randomized controlled trial of adjunctive transcranial direct current stimulation (tDCS) for chronic pain among patients receiving specialized, inpatient multimodal pain management. Contemp Clin Trials 2016; 54:36-47. [PMID: 28039022 DOI: 10.1016/j.cct.2016.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/23/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Available treatments for chronic pain (CP) are modestly effective or associated with iatrogenic harm. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that may be an effective, adjunctive treatment to non-opioid therapies. In this randomized control trial (RCT), we compare adjunctive active versus sham tDCS among patients in a multimodal inpatient pain management program. The primary objectives of the RCT are to improve pain tolerance and subjective pain experience. METHODS AND DESIGN Patients admitted to the Pain Management Program at The Menninger Clinic in Houston, Texas are eligible for this trial. Eighty-four participants will be randomized (1:1) into a single-blind, 2×12 (group×time) controlled trial. A battery-powered direct and constant current stimulator (Soterix Medical Inc. 2014) delivers anodal stimulation over the left dorsolateral prefrontal cortex (DLPFC) and cathodal stimulation over the right DLPFC. Active tDCS is applied by supplying a 2mA current for 20min/session over 10 sessions. Participants complete self-report and performance-based assessments on a weekly basis just prior to brain stimulation. Self-report assessments are collected via Chronic Pain Tracker version 3.6, an iPad interfaced application. The performance-based pain tolerance task is completed through the cold presser task. DISCUSSION Interventions with cross-symptomatic therapeutic potential are absolutely essential in the context of CP, in which psychiatric comorbidity is the norm. Modalities that can be used in tandem with evidence-based, non-opioid therapies have the potential to have a synergistic effect, resulting in increased effectiveness of what have been modestly effective treatments to date.
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Affiliation(s)
- G Janice Jimenez-Torres
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Benjamin L Weinstein
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - Cory R Walker
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | - J Christopher Fowler
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
| | | | - Jeffrey J Borckardt
- Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, United States; Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States; Ralph H. Johnson Veterans' Affairs Medical Center, Charleston, SC, United States
| | - Alok Madan
- The Menninger Clinic, Houston, TX, United States; Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States.
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