1
|
van der Gaag A, Cohen SP, Stojanovic MP, Huygen FJPM, Kallewaard JW. 12. Vascular pain: Ischemic pain in the extremities and Raynaud's syndrome. Pain Pract 2024. [PMID: 39350525 DOI: 10.1111/papr.13421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2024]
Abstract
INTRODUCTION Peripheral artery diseases (PAD) and Raynaud's syndrome are associated with substantial morbidity. PAD, through the restriction of blood flow to the extremities, may lead to critical limb ischemia with symptoms of pain at rest which may eventually progress to severe limb ischemia with gangrene. This serious and painful clinical condition requires extensive medical care, is limb-threatening and, in case of delayed or unsuccessful treatment, is associated with a high mortality rate. In Raynaud's syndrome, the blood supply to certain parts of the body, usually the fingers and toes and less frequently the nose or ears, is restricted because of vasculopathy of the smaller vessels at acral sites. Under certain circumstances, with cold as the most well-known provoking factor, blood flow restriction occurs, leading to demarcated color changes and symptoms such as pain, paresthesia, and numbness. In severe cases of Raynaud syndrome tissue ischemia may lead to necrosis and the need for amputation of the affected area. METHODS In this narrative review, the literature on the diagnosis and interventional pain treatment of PAD and Raynaud's syndrome was updated and summarized. OBJECTIVES This review focused on interventional pain treatment. In PAD, the effects of the intervention on limb salvage, ulcer healing, and ischemic pain were summarized. Additionally, results with respect to skin microcirculation and quality of life were reported if available. In Raynaud's syndrome, we focused on the effect of the intervention on peripheral blood flow metrics and pain intensity during attacks. RESULTS In PAD, prevention and treatment of risk factors are important. Initially, conservative treatment and pharmacological therapy are preferred first-line therapies. However, when disease progression occurs, interventional management may be considered. The literature search yielded conflicting evidence for sympathectomy as a treatment for PAD. Spinal cord stimulation (SCS) as a treatment modality for advanced PAD had high-quality evidence for limb salvage in subgroups of patients but conflicting evidence for other outcome measures such as pain, wound healing, and quality of life. The literature search for interventional pain management in Raynaud's syndrome was limited to only one randomized controlled trial (RCT) studying the effect of thoracic sympathectomy. This study had several limitations and hence the level of evidence for this interventional treatment is very low. No RCTs studying SCS in patients with Raynaud's syndrome were found. CONCLUSIONS In both PAD and Raynaud's syndrome, additional RCTs are needed to substantiate interventional (pain) management and bolster the evidence base for sympathectomy and SCS as treatment options.
Collapse
Affiliation(s)
- Antal van der Gaag
- Anesthesiology and Pain Medicine, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Milan P Stojanovic
- Department of Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Boston, Massachusetts, USA
- VA Bedford Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - Frank J P M Huygen
- Department of Anesthesiology and Pain Management, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Management, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Willem Kallewaard
- Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Elst, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Ali R, Schwalb JM. History and Future of Spinal Cord Stimulation. Neurosurgery 2024; 94:20-28. [PMID: 37681953 DOI: 10.1227/neu.0000000000002654] [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: 03/14/2023] [Accepted: 06/27/2023] [Indexed: 09/09/2023] Open
Abstract
Spinal cord stimulation (SCS) is a surgical treatment for chronic neuropathic pain refractory to medical management. An SCS system comprised one or more leads implanted in the epidural space, typically connected to an implantable pulse generator. This review discusses the history, indications, surgical technique, technological advances, and future directions of SCS.
Collapse
Affiliation(s)
- Rushna Ali
- Department of Neurological Surgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Medical Group, West Bloomfield , Michigan , USA
| |
Collapse
|
3
|
Russo MA, Bhatia A, Hayek S, Doshi T, Eldabe S, Huygen F, Levy RM. Problems With O'Connell et al, "Implanted Spinal Neuromodulation Interventions for Chronic Pain in Adults" (Cochrane Review). Neuromodulation 2023; 26:897-904. [PMID: 37029022 PMCID: PMC10330605 DOI: 10.1016/j.neurom.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/01/2023] [Accepted: 03/05/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Marc A Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia; Genesis Research Services, Broadmeadow, New South Wales, Australia; University of Newcastle, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Tina Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Frank Huygen
- Center of Pain Medicine Erasmus Medical Center, Rotterdam, The Netherlands; Center of Pain Medicine University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert M Levy
- International Neuromodulation Society, Neuromodulation: Technology at the Neural Interface, San Francisco, CA, USA
| |
Collapse
|
4
|
Shanthanna H, Eldabe S, Provenzano DA, Chang Y, Adams D, Kashir I, Goel A, Tian C, Couban RJ, Levit T, Hagedorn JM, Narouze S. Role of patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain: a comprehensive narrative review. Reg Anesth Pain Med 2023; 48:251-272. [PMID: 37001887 DOI: 10.1136/rapm-2022-103820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/22/2022] [Indexed: 04/03/2023]
Abstract
Background/importancePatient selection for spinal cord stimulation (SCS) therapy is crucial and is traditionally performed with clinical selection followed by a screening trial. The factors influencing patient selection and the importance of trialing have not been systematically evaluated.ObjectiveWe report a narrative review conducted to synthesize evidence regarding patient selection and the role of SCS trials.Evidence reviewMedline, EMBASE and Cochrane databases were searched for reports (any design) of SCS in adult patients, from their inception until March 30, 2022. Study selection and data extraction were carried out using DistillerSR. Data were organized into tables and narrative summaries, categorized by study design. Importance of patient variables and trialing was considered by looking at their influence on the long-term therapy success.FindingsAmong 7321 citations, 201 reports consisting of 60 systematic reviews, 36 randomized controlled trials (RCTs), 41 observational studies (OSs), 51 registry-based reports, and 13 case reports on complications during trialing were included. Based on RCTs and OSs, the median trial success rate was 72% and 82%, and therapy success was 65% and 61% at 12 months, respectively. Although several psychological and non-psychological determinants have been investigated, studies do not report a consistent approach to patient selection. Among psychological factors, untreated depression was associated with poor long-term outcomes, but the effect of others was inconsistent. Most RCTs except for chronic angina involved trialing and only one RCT compared patient selection with or without trial. The median (range) trial duration was 10 (0–30) and 7 (0–56) days among RCTs and OSs, respectively.ConclusionsDue to lack of a consistent approach to identify responders for SCS therapy, trialing complements patient selection to exclude patients who do not find the therapy helpful and/or intolerant of the SCS system. However, more rigorous and large studies are necessary to better evaluate its role.
Collapse
Affiliation(s)
| | - Sam Eldabe
- James Cook University Hospital, Middlesbrough, UK
| | | | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Daniel Adams
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Imad Kashir
- University of Waterloo, Waterloo, Ontario, Canada
| | - Akash Goel
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chenchen Tian
- Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Tal Levit
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan M Hagedorn
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| |
Collapse
|
5
|
Medina R, Ho A, Reddy R, Chen J, Castellanos J. Narrative review of current neuromodulation modalities for spinal cord injury. FRONTIERS IN PAIN RESEARCH 2023; 4:1143405. [PMID: 36969918 PMCID: PMC10033643 DOI: 10.3389/fpain.2023.1143405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Neuromodulation is a developing field of medicine that includes a vast array of minimally invasive and non-invasive therapies including transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), vagus nerve stimulation (VNS), peripheral nerve stimulation, and spinal cord stimulation (SCS). Although the current literature surrounding the use of neuromodulation in managing chronic pain is abundant, there is an insufficient amount of evidence specifically regarding neuromodulation in patients with spinal cord injury (SCI). Given the pain and functional deficits that these patients face, that are not amenable to other forms conservative therapy, the purpose of this narrative review is to examine and assess the use of various neuromodulation modalities to manage pain and restore function in the SCI population. Currently, high-frequency spinal cord stimulation (HF-SCS) and burst spinal cord stimulation (B-SCS) have been shown to have the most promising effect in improving pain intensity and frequency. Additionally, dorsal root ganglion stimulation (DRG-S) and TMS have been shown to effectively increase motor responses and improve limb strength. Although these modalities carry the potential to enhance overall functionality and improve a patient's degree of disability, there is a lack of long-term, randomized-controlled trials in the current space. Additional research is warranted to further support the clinical use of these emerging modalities to provide improved pain management, increased level of function, and ultimately an overall better quality of life in the SCI population.
Collapse
Affiliation(s)
- Roi Medina
- Department of Physical Medicine and Rehabilitation, Lake Erie College of Osteopathic Medicine-Bradenton, Bradenton, FL, United States
| | - Alison Ho
- Department of Physical Medicine and Rehabilitation, Baylor University Medical Center, Dallas, TX, United States
| | - Rajiv Reddy
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Jeffrey Chen
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Joel Castellanos
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| |
Collapse
|
6
|
Ito H, Tanei T, Sugawara K, Sando Y, Hori N. Spinal cord stimulation for the treatment of pain and toe ulceration associated with systemic sclerosis: a case report. Fukushima J Med Sci 2022; 68:37-41. [PMID: 35228457 PMCID: PMC9071355 DOI: 10.5387/fms.2021-33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Systemic sclerosis is a complex disease characterized by extensive fibrosis, microvascular alterations, and additional sequelae. Microvascular alterations can cause painful ulcers and necrosis; however, conservative or surgical treatment is often challenging in terms of healing. The study aimed to describe a toe ulcer with systemic sclerosis and its’ successful treatment with spinal cord stimulation. An 83-year-old woman, who was diagnosed with systemic sclerosis over the past decade, was distressed by a non-healing toe ulcer for an extended period of time. The patient underwent spinal cord stimulation treatment with the expectation of pain relief and an improvement in microcirculatory insufficiency. Her pain scales and microcirculation improved, and the toe ulcer healed. Furthermore, the frequency of Raynaud’s symptoms was reduced, and the patient’s pain decreased. There was no recurrence of the ulcer and she no longer needed a cane for walking.
Collapse
Affiliation(s)
- Hiroyuki Ito
- Department of Plastic and Reconstructive Surgery, Komaki City Hospital
| | | | | | - Yu Sando
- Department of Dermatology, Komaki City Hospital
| | - Naohiro Hori
- Department of Plastic and Reconstructive Surgery, Komaki City Hospital
| |
Collapse
|
7
|
Spinal Cord Stimulation and Treatment of Peripheral or Central Neuropathic Pain: Mechanisms and Clinical Application. Neural Plast 2021; 2021:5607898. [PMID: 34721569 PMCID: PMC8553441 DOI: 10.1155/2021/5607898] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/11/2021] [Accepted: 10/05/2021] [Indexed: 12/13/2022] Open
Abstract
Spinal cord stimulation (SCS) as an evidence-based interventional treatment has been used and approved for clinical use in a variety of pathological states including peripheral neuropathic pain; however, until now, it has not been used for the treatment of spinal cord injury- (SCI-) induced central neuropathic pain. This paper reviews the underlying mechanisms of SCS-induced analgesia and its clinical application in the management of peripheral and central neuropathic pain. Evidence from recent research publications indicates that nociceptive processing at peripheral and central sensory systems is thought to be modulated by SCS through (i) inhibition of the ascending nociceptive transmission by the release of analgesic neurotransmitters such as GABA and endocannabinoids at the spinal dorsal horn; (ii) facilitation of the descending inhibition by release of noradrenalin, dopamine, and serotonin acting on their receptors in the spinal cord; and (iii) activation of a variety of supraspinal brain areas related to pain perception and emotion. These insights into the mechanisms have resulted in the clinically approved use of SCS in peripheral neuropathic pain states like Complex Regional Pain Syndrome (CRPS) and Failed Back Surgery Syndrome (FBSS). However, the mechanisms underlying SCS-induced pain relief in central neuropathic pain are only partly understood, and more research is needed before this therapy can be implemented in SCI patients with central neuropathic pain.
Collapse
|
8
|
Asimakidou E, Matis GK. Spinal cord stimulation in the treatment of peripheral vascular disease: a systematic review - revival of a promising therapeutic option? Br J Neurosurg 2021; 36:555-563. [PMID: 33703962 DOI: 10.1080/02688697.2021.1884189] [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] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Peripheral vascular disease (PVD) is caused by a blood circulation disorder of the arteries and Critical Limb Ischemia (CLI) is the advanced state of PVD. For patients with surgically non-reconstructable CLI, Spinal Cord Stimulation (SCS) appears to be an alternative therapeutic option. OBJECTIVE The aim of our study was to investigate the efficacy of SCS in non-reconstructable CLI compared with the conservative treatment and re-appraise the existing literature in light of the recent advances in neuromodulation. METHODS We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, using electronic databases and reference lists for article retrieval. RESULTS A total of 404 records were identified and finally 6 randomised controlled trials (RCTs), a Cochrane review and a meta-analysis were included in our systematic review. The studies assessed the efficacy of tonic SCS in the treatment of patients with non-reconstructable CLI compared with the conservative treatment. There is moderate to high quality evidence suggesting, that tonic SCS has beneficial effects for patients suffering from non-reconstructable CLI in terms of limb salvage, pain relief, clinical improvement and quality of life. The contradictory conclusions of the two meta-analyses regarding the efficacy of SCS for limb salvage at 12 months refer rather to the magnitude of the beneficial effect than to the effect itself. So far, the current literature provides evidence about the traditional tonic SCS but there is a lack of studies investigating the efficacy of new waveforms in the treatment of non-reconstructable CLI. CONCLUSION SCS represents an alternative for PVD patients with non-reconstructable CLI and the existing literature provides encouraging clinical results, that should not be neglected. Instead, they should be re-appraised in light of the recent advances in neuromodulation with the emergence of novel waveform technologies and neuromodulation targets.
Collapse
Affiliation(s)
- Evridiki Asimakidou
- Department of Stereotactic and Functional Neurosurgery, University Cologne Hospital, Cologne, Germany
| | - Georgios K Matis
- Department of Stereotactic and Functional Neurosurgery, University Cologne Hospital, Cologne, Germany
| |
Collapse
|
9
|
Outcomes of Conservative Treatment in Patients with Chronic Limb Threatening Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 62:214-224. [PMID: 33674157 DOI: 10.1016/j.ejvs.2021.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 12/07/2020] [Accepted: 01/07/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Chronic limb threatening ischaemia (CLTI) is the most severe form of peripheral arterial disease. International guidelines recommend arterial revascularisation in patients with CLTI. However, these patients are often fragile elderly people with significant comorbidities, whose vascular anatomy is not always suitable for open or endovascular revascularisation. Recent studies have suggested acceptable outcomes of conservative treatment. A systematic review of the available literature was conducted to obtain best estimates of outcomes of conservative treatment in patients with CLTI. DATA SOURCES MEDLINE, Embase, and Cochrane Central. REVIEW METHODS A systematic review and meta-analysis was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. MEDLINE, Embase, and Cochrane Central were searched from inception until September 2019. All studies reporting on outcomes of conservative treatment for CLTI were considered. Study selection, data extraction, and risk of bias assessment were done by two investigators independently. Risk of bias was evaluated with a modified version of the Cochrane tool for observational studies. Outcomes of interest were all cause mortality, major amputation, and amputation free survival (AFS) after at least 12 months of follow up. A random effects model was used for meta-analyses. RESULTS Twenty-seven publications were included, consisting of 12 observational studies and 15 placebo arms from randomised clinical trials, totalling 1 642 patients. Most studies included patients with non-reconstructable CLTI. Overall study quality was moderate. The pooled 12 month all cause mortality rate in 14 studies comprising 1 003 patients was 18% (95% confidence interval [CI] 13 - 25, I2 = 73%). The pooled major amputation rate from 14 studies comprising 755 patients was 27% (95% CI 20 - 36, I2 = 65%) after one year, and pooled AFS rate after 12 months in 11 studies with 970 patients was 60% (95% CI 52 - 67, I2 = 75%). CONCLUSION Conservative treatment for patients with CLTI may be considered and does not always result in loss of limb or patient demise. The results of this review can be used to inform patients with CLTI about conservative treatment as part of a shared decision making process.
Collapse
|
10
|
Cyrek AE, Henn N, Meinhardt F, Lainka M, Pacha A, Paul A, Koch D. Improving Limb Salvage for Chronic Limb-Threatening Ischemia With Spinal Cord Stimulation: A Retrospective Analysis. Vasc Endovascular Surg 2021; 55:367-373. [PMID: 33550918 PMCID: PMC8041447 DOI: 10.1177/1538574420985765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Chronic limb-threatening ischemia (CLTI) represents the most severe form of peripheral artery disease (PAD). Up to a third of CLTI patients are not eligible to receive first-line treatments such as bypass surgery or endovascular interventions. Epidural spinal cord stimulation (SCS) has been used as a method to improve microcirculatory blood flow and relieve ischemic pain in CTLI patients. The aim of the study was to evaluate limb salvage, ulcer closure, and clinical changes of SCS implanted CTLI patients at 1-year follow-up. Methods: Eligible patients had end-stage lower limb PAD unresponsive to medical therapy and not amenable to surgical reconstruction. Patients were candidates for amputation, but limb loss was not inevitable (Fontaine stage III and IV). Pain intensity and skin temperature in the ischemic area (visual analogue scale), quality of life (WHOQoL-BREF), and ankle/brachial blood pressure index (ABI) were recorded at routine follow-up visits. Data were analyzed retrospectively. Results: 29 patients underwent SCS implantation at one vascular center. The minimum follow-up period was 30 months. Limb survival at 1-year follow-up was 97% (28/29) and 73% (11/15) had complete closure of limb ulcers. Pain intensity, skin temperature, and quality of life progressively improved up to 12 months after implant, with Fontaine stage III patients improving more substantially than Fontaine stage IV patients. SCS therapy did not affect ABI measurement. No complications related to the device or procedure occurred. Conclusions: SCS is a valid alternative in patients unsuitable for revascularization. The quality of results depends on both a strict selection of patients by vascular specialists and the frequency of follow-up controls. The therapy may be more beneficial in patients classified as Fontaine stage III.
Collapse
Affiliation(s)
- Anna E Cyrek
- Division of Vascular and Endovascular Surgery, Department of General, Visceral and Transplantation Surgery, 39081University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nora Henn
- Division of Vascular and Endovascular Surgery, Department of General, Visceral and Transplantation Surgery, 39081University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Fabian Meinhardt
- Division of Vascular and Endovascular Surgery, Department of General, Visceral and Transplantation Surgery, 39081University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Lainka
- Division of Vascular and Endovascular Surgery, Department of General, Visceral and Transplantation Surgery, 39081University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Arkadius Pacha
- Institute of Pharmacology and Toxicology, 9142Ruhr-University Bochum, Bochum, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, 39081University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dietrich Koch
- Division of Vascular and Endovascular Surgery, Department of General, Visceral and Transplantation Surgery, 39081University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
11
|
Claeys LGY, Matamoros R, Ubbink DT. Spinal Cord Stimulation in Critical Limb Ischemia. Acta Chir Belg 2020. [DOI: 10.1080/00015458.2001.12098594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
12
|
McNicol E, Ferguson M, Bungay K, Rowe EL, Eldabe S, Gewandter JS, Hayek SM, Katz N, Kopell BH, Markman J, Rezai A, Taylor RS, Turk DC, Dworkin RH, North RB, Thomson S. Systematic Review of Research Methods and Reporting Quality of Randomized Clinical Trials of Spinal Cord Stimulation for Pain. THE JOURNAL OF PAIN 2020; 22:127-142. [PMID: 32574787 DOI: 10.1016/j.jpain.2020.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 04/21/2020] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
This systematic review assessed design characteristics and reporting quality of published randomized clinical trials of spinal cord stimulation (SCS) for treatment of pain in adults and adolescents. The study protocol was registered with PROSPERO (CRD42018090412). Relevant articles were identified by searching the following databases through December 31, 2018: MEDLINE, Embase, WikiStim, The Cochrane Database of Systematic Reviews, and The Cochrane Central Register of Controlled Trials. Forty-six studies were included. Eighty-seven percent of articles identified a pain-related primary outcome. Secondary outcomes included physical functioning, health-related quality of life, and reductions in opioid use. Nineteen of the 46 studies prespecified adverse events as an outcome, with 4 assessing them as a primary outcome. Eleven studies stated that they blinded participants. Of these, only 5 were assessed as being adequately blinded. The number of participants enrolled was generally low (median 38) and study durations were short (median 12 weeks), particularly in studies of angina. Fifteen studies employed an intention-to-treat analysis, of which only seven specified a method to accommodate missing data. Review of these studies identified deficiencies in both reporting and methodology. The review's findings suggest areas for improving the design of future studies and increasing transparency of reporting. PERSPECTIVE: This article presents a systematic review of research methods and reporting quality of randomized clinical trials of SCS for the treatment of various pain complaints. The review identifies deficiencies in both methodology and reporting, which may inform the design of future studies and improve reporting standards.
Collapse
Affiliation(s)
- Ewan McNicol
- Department of Pharmacy Practice, MCPHS University, Boston, Massachusetts.
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, Illinois
| | | | | | - Sam Eldabe
- University of Exeter, Exeter, UK; Durham University, Durham, UK
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio
| | - Nathaniel Katz
- Analgesic Solutions, Wayland, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
| | - Brian H Kopell
- Departments of Neurosurgery, Neurology, Psychiatry and Neuroscience, The Icahn School of Medicine at Mount Sinai, NY, New York
| | - John Markman
- Translational Pain Research Program, Department of Neurosurgery, University of Rochester, New York
| | - Ali Rezai
- Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, Glasgow, UK; College of Medicine and Health, University of Exeter, Exeter, UK
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | | | - Simon Thomson
- Basildon and Thurrock University Hospitals, Essex, UK
| |
Collapse
|
13
|
Saini HS, Shnoda M, Saini I, Sayre M, Tariq S. The Effects of Spinal Cord Stimulators on End Organ Perfusion: A Literature Review. Cureus 2020; 12:e7253. [PMID: 32292667 PMCID: PMC7152574 DOI: 10.7759/cureus.7253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/12/2020] [Indexed: 12/05/2022] Open
Abstract
Spinal cord stimulators (SCS) have been gaining momentum in the last decade as their role in the management of chronic pain has become more apparent. Our intention was to search, analyze and highlight the effects of spinal cord stimulators on end-organ perfusion. We also looked at vascular diseases of atherosclerotic and nonatherosclerotic nature by examining objective evidence of improved circulation, pain control, limb salvage, and quality of life. We paid specific attention to disease processes such as cerebral hypoperfusion, Chronic-Critical Limb Ischemia, Intractable Angina Pectoris (IAP), Raynaud's syndrome and Thromboangiitis Obliterans. We performed a Medline database search for medical literature relevant to Spinal cord stimulators encompassing the years 1950 to 2019. Search terms included "Spinal cord stimulator," plus one of the following search terms: vasculopathy, stroke, cerebral blood flow, angina pectoris, diabetic ulcers, chronic critical leg ischemia, thromboangiitis obliterans and peripheral vascular disease. We included both clinical and experimental human studies that investigated the effect of SCS's on end-organ perfusion. We also investigated the pathophysiological mechanism of action of SCS's on the vasculature. We found 497 articles of which 43 more relevant and impactful articles investigating the hemodynamic effects of SCS and its possible mechanism were selected. Animal studies were excluded from the literature review as they provided heterogeneity. In addition to reporting literature supporting the use of stimulators for currently FDA approved uses, we also actively looked for potential future uses. Spinal Cord stimulators showed improvement in cerebral blood flow, increased capillary recruitment, and better quality of life in many studies. Patients also had increased exercise capacity and a significant reduction in the use of narcotic drug use and daily anginal attacks in patients suffering from IAP.
Collapse
Affiliation(s)
| | - Mina Shnoda
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Ishveen Saini
- Internal Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Matthew Sayre
- Internal Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | | |
Collapse
|
14
|
Bolton L. Peripheral arterial disease: Scoping review of patient-centred outcomes. Int Wound J 2019; 16:1521-1532. [PMID: 31597226 DOI: 10.1111/iwj.13232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/04/2019] [Accepted: 09/13/2019] [Indexed: 01/13/2023] Open
Abstract
Peripheral arterial disease (PAD) impairs patients' quality of life (QOL), walking and ulcer healing, increasing patient pain, costs, and risks of amputation or mortality. A literature appraisal described PAD treatment capacity to improve validated patient-centred outcomes in controlled clinical studies. The PUBMED database was searched from 1 January 1970 to 21 June 2018, for original and derivative controlled clinical trial references addressing MeSH terms for 'ischemia' AND 'leg ulcer'. Non-ischemic ulcer treatment references were excluded. Frequencies of improved (P < .05) outcomes were reported. Eighty-eight studies on 4153 patients were summarized. Walking, pain or QOL improved mainly for interventions administered before PAD became severe. Amputation incidence, pain and ulcer healing were more frequently reported in those with severe PAD. Independent of PAD severity, patients experienced more likely improved walking, QOL, or pain reduction in response to structured walking interventions or those increasing calf muscle activity. Those with more severe PAD were more likely to report amputation reduction, mainly in response to invasive interventions. Those with PAD experienced more consistently improved patient-centred outcomes if they received multidisciplinary PAD management with supervised walking or calf muscle activity, with more likely amputation risk reduced for those with more severe PAD.
Collapse
Affiliation(s)
- Laura Bolton
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| |
Collapse
|
15
|
Systematic review and meta-analysis of placebo/sham controlled randomised trials of spinal cord stimulation for neuropathic pain. Pain 2019; 161:24-35. [DOI: 10.1097/j.pain.0000000000001689] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Lamer TJ, Moeschler SM, Gazelka HM, Hooten WM, Bendel MA, Murad MH. Spinal Stimulation for the Treatment of Intractable Spine and Limb Pain: A Systematic Review of RCTs and Meta-Analysis. Mayo Clin Proc 2019; 94:1475-1487. [PMID: 31279543 DOI: 10.1016/j.mayocp.2018.12.037] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 12/13/2018] [Accepted: 12/18/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To synthesize the evidence regarding the effect of spinal stimulation (SS) vs medical therapy (MT) and the effect of newer SS technologies vs conventional SS on pain reduction in patients with intractable spine or limb pain. METHODS A comprehensive literature search was conducted by a reference librarian. The literature search encompassed January 1, 1995 - December 31, 2017. Reviewers worked independently to select and appraise trials. Random-effect meta-analysis and frequentist indirect comparison methods were used to compare the three interventions. Results were expressed as odds ratio (OR) or weighted mean difference (WMD) with 95% CIs. RESULTS We identified 12 trials enrolling 980 patients. Compared with MT, SS significantly increased the odds of reducing pain by 50% or more in three trials (OR, 13.01; 95% CI, 4.96-34.17) and significantly reduced pain as measured by visual analogue scale scores in three trials (WMD, 1.43 scale points; 95% CI, 0.16-2.71). Using the common comparator of MT, newer stimulation technology (eg, high-frequency 10 kilohertz spinal stimulation, Burst, dorsal root ganglion) was associated with increased odds of pain relief compared with conventional SS (OR, 2.07; 95% CI, 1.35-3.19). CONCLUSIONS In patients with intractable spine/limb pain, SS was associated with better pain reduction than MT. New stimulation technology was likely associated with better pain reduction than conventional stimulation.
Collapse
Affiliation(s)
- Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Susan M Moeschler
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - W Michael Hooten
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Markus A Bendel
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Preventive, Occupational, and Aerospace Medicine, Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| |
Collapse
|
17
|
Hofmeister M, Memedovich A, Brown S, Saini M, Dowsett LE, Lorenzetti DL, McCarron TL, MacKean G, Clement F. Effectiveness of Neurostimulation Technologies for the Management of Chronic Pain: A Systematic Review. Neuromodulation 2019; 23:150-157. [PMID: 31310417 DOI: 10.1111/ner.13020] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/16/2019] [Accepted: 05/30/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To describe the state of the literature for clinical effectiveness of neurostimulation used for the management of chronic pain. METHODS A systematic review of spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), and supraorbital transcutaneous electrical nerve stimulation in patients with cancer and noncancer chronic pain was conducted. MEDLINE, Embase, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials were searched, using terms like "electrical stimulation therapy" and "pain management." Direction of effect, consistency across studies, and strength of evidence for effects of neurostimulation on chronic pain were narratively synthesized. RESULTS A total of 15 randomized controlled trials (RCTs) examining SCS, 7 RCTs examining PNS/PNFS, and 1 nonrandomized trial examining supraorbital transcutaneous electrical nerve stimulation (TENS) were included. In nine SCS studies, neurostimulation had positive effects on pain. In three studies, neurostimulation did not significantly reduce pain. For PNS/PNFS, five studies found improvements in pain offered by neurostimulation; pain outcomes were not reported in two studies. In the TENS study, neurostimulation reduced headaches per month and medication consumption. Overall, 21 studies were of low or unclear risk of bias, 4 were high risk of bias, and the TENS study was not appropriate for assessment using the Cochrane Risk of Bias tool. CONCLUSIONS A robust body of evidence examining SCS and PNS was identified. Only one study for PNFS and TENS was identified; both reported pain reductions. Generally, neurostimulation improved pain control. Future studies should examine the effectiveness of neurostimulation offered early in the trajectory of chronic pain.
Collapse
Affiliation(s)
- Mark Hofmeister
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada
| | - Ally Memedovich
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada
| | - Sage Brown
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada
| | - Manik Saini
- Research and Innovation Division, British Columbia Ministry of Health, Victoria, British Columbia, Canada
| | - Laura E Dowsett
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,Health Sciences Library, University of Calgary, Calgary, Alberta, Canada
| | - Tamara L McCarron
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada
| | - Gail MacKean
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada
| | - Fiona Clement
- The Department of Community Health Sciences, University of Calgary, Teaching Research and Wellness Building, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Teaching Research and Wellness Building, Calgary, Alberta, Canada
| |
Collapse
|
18
|
Duarte RV, McNicol E, Colloca L, Taylor RS, North RB, Eldabe S. Randomized Placebo-/Sham-Controlled Trials of Spinal Cord Stimulation: A Systematic Review and Methodological Appraisal. Neuromodulation 2019; 23:10-18. [PMID: 31305001 PMCID: PMC7004207 DOI: 10.1111/ner.13018] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/30/2019] [Accepted: 06/04/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The recent availability of paraesthesia/sensation free spinal cord stimulation (SCS) modalities allow the design of clinical trials of SCS using placebo/sham controls and blinding of patients, clinicians, and researchers. The aims of this study were to: 1) systematically review the current evidence base of randomized controlled trials (RCTs) of SCS placebo/sham trials and 2) to undertake a methodological critique of their methods. Based on this critique, we developed a checklist for the design and reporting of future RCTs of SCS. MATERIALS AND METHODS Electronic data bases were searched from inception until January 2019 for RCTs of SCS using a placebo/sham control. RCTs with only an active comparator arm were excluded. The results are presented as a narrative synthesis. RESULTS Searches identified 12 eligible RCTs. SCS modalities included paraesthesia stimulation, subthreshold, burst, and high-frequency SCS and were mainly conducted in patients with failed back surgery syndrome, complex regional pain syndrome, and refractory angina. The quality and transparency of reporting of the methods of placebo stimulation, blinding of patients, clinicians, and researchers varied markedly across studies. CONCLUSIONS To date the methods of placebo/sham control and blinding in RCTs have been poorly reported, leading to concerns about the validity and replicability of the findings. Important aspects that need to be clearly reported in the design of placebo-/sham-controlled RCTs of SCS include the transparent reporting of stimulation programming parameters, patient position during perception threshold measurement, management of the patient handheld programmer, frequency of recharging, and assessment of the fidelity of blinding.
Collapse
Affiliation(s)
- Rui V Duarte
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Ewan McNicol
- Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.,Department of Pain Medicine, Atrius Health, Boston, MA, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, USA.,Department of Anesthesiology and Psychiatry, School of Medicine, University of Maryland, Baltimore, University of Maryland, Baltimore, MD, USA.,Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, USA
| | - Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, Glasgow, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
| | - Richard B North
- Neurosurgery, Anesthesiology and Critical Care Medicine (ret.), Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
19
|
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 767] [Impact Index Per Article: 153.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
Collapse
Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
20
|
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 740] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
Collapse
Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
| |
Collapse
|
21
|
Pollard EM, Lamer TJ, Moeschler SM, Gazelka HM, Hooten WM, Bendel MA, Warner NS, Murad MH. The effect of spinal cord stimulation on pain medication reduction in intractable spine and limb pain: a systematic review of randomized controlled trials and meta-analysis. J Pain Res 2019; 12:1311-1324. [PMID: 31118751 PMCID: PMC6502439 DOI: 10.2147/jpr.s186662] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/27/2019] [Indexed: 12/16/2022] Open
Abstract
Objective: To synthesize the evidence regarding the effect of spinal cord stimulation (SCS) on opioid and pain medication reduction in patients with intractable spine or limb pain. Methods: A comprehensive literature search was conducted to identify RCTs of patients with chronic back and/or limb pain of greater than one year duration. Only comparative studies were included (ie, conventional SCS vs medical therapy, conventional SCS vs high-frequency SCS) and were required to have a minimum follow-up period of 3 months. Random effect meta-an alysis was used to compare the three interventions. Results were expressed as odds ratio (OR) or weighted mean difference (WMD) with 95% confidence intervals (CI). Results: We identified five trials enrolling 489 patients. Three of the trials reported the results as a number of patients who were able to reduce or eliminate opioid consumption in the SCS vs medical therapy group. The odds of reducing opioid consumption were significantly increased in the SCS group compared to medical therapy (OR 8.60, CI {1.93–38.30}). Two of the trials reported the results as mean medication dose reduction as measured by the Medication Quantification Scale (MQS) in the SCS group vs medical therapy group. MQS score significantly decreased in the SCS group and not in the medical group (WMD –1.97, 95% CI {–3.67, –0.27}). One trial reported a number of patients in high-frequency SCS who were able to reduce opioids vs number of patients in conventional SCS group who were able to reduce opioids. Thirty-four percent of the patients in the high-frequency group and 26% of the patients in the conventional SCS group were able to reduce opioid consumption; however, there was not a significant difference between groups (OR 1.43, 95% CI {0.74, 2.78}). This trial also quantified the opioid reduction in morphine equivalent dosage (MED). In the high-frequency SCS group, average MED decreased by 24.8 mg vs average MED decrease of 7.3 mg in the conventional SCS group. Again, the difference between groups did not reach statistical significance (–17.50, CI {–66.27, 31.27}). Conclusions: In patients with intractable spine/limb pain, SCS was associated with increased odds of reducing pain medication consumption. However, results should be treated with caution as available data were limited, and clinical significance of these findings requires further study.
Collapse
Affiliation(s)
- E Morgan Pollard
- Division of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Susan M Moeschler
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - W Michael Hooten
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Markus A Bendel
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nafisseh S Warner
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Preventive, Occupational, and Aerospace Medicine, Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
22
|
Abstract
Spinal cord stimulation (SCS) has been well established as a safe and effective treatment of pain derived from a wide variety of etiologies. Careful patient selection including a rigorous trial period and psychological evaluation are essential. When patients proceed to permanent implantation, various considerations should be made, such as the type of lead, type of anesthesia, and waveform patterns for SCS. This article discusses the common indications for SCS, patient selection criteria, and pertinent outcomes from randomized clinical trials related to common indications treated with SCS. Technical considerations, such as type of implant, anesthesia, and programming, are also discussed.
Collapse
Affiliation(s)
- Andrew K Rock
- Department of Neurosurgery, Albany Medical College, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - Huy Truong
- Department of Neurosurgery, Albany Medical College, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - Yunseo Linda Park
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical College, 43 New Scotland Avenue, Albany, NY 12208, USA; Department of Neuroscience and Experimental Therapeutics, Albany Medical College, 43 New Scotland Avenue, Albany, NY 12208, USA.
| |
Collapse
|
23
|
Spinal Cord Stimulation 50 Years Later: Clinical Outcomes of Spinal Cord Stimulation Based on Randomized Clinical Trials-A Systematic Review. Reg Anesth Pain Med 2019; 43:391-406. [PMID: 29481371 DOI: 10.1097/aap.0000000000000744] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To assess the efficacy of spinal cord stimulation (SCS) for each indication, one must critically assess each specific clinical outcome to identify outcomes that benefit from SCS therapy. To date, a comprehensive review of clinically relevant outcome-specific evidence regarding SCS has not been published. We aimed to assess all randomized controlled trials from the world literature for the purpose of evaluating the clinical outcome-specific efficacy of SCS for the following outcomes: perceived pain relief or change pain score, quality of life, functional status, psychological impact, analgesic medication utilization, patient satisfaction, and health care cost and utilization. Interventions were SCS, without limitation to the type of controls or the type of SCS in the active arms. For each study analyzed, a quality assessment was performed using a validated scale that assesses reporting, external validity, bias, confounding, and power. Each outcome was assessed specific to its indication, and the primary measure of each abovementioned outcome was a summary of the level of evidence. Twenty-one randomized controlled trials were analyzed (7 for trunk and limb pain, inclusive of failed back surgery syndrome; 8 for refractory angina pectoris; 1 for cardiac X syndrome; 3 for critical limb ischemia; 2 for complex regional pain syndrome; and 2 for painful diabetic neuropathy). Evidence assessments for each outcome for each indication were depicted in tabular format. Outcome-specific evidence scores were established for each of the abovementioned indications, providing both physicians and patients with a summary of evidence to assist in choosing the optimal evidence-based intervention. The evidence presented herein has broad applicability as it encompasses a breadth of patient populations, variations of SCS therapy, and comparable controls that, together, reflect comprehensive clinical decision making.
Collapse
|
24
|
Martínez M, Sosa C, Velescu A, Llort C, Elosua R, Clarà A. Predictive factors of a poor outcome following revascularization for critical limb ischemia: implications for practice. INT ANGIOL 2018; 37:370-376. [DOI: 10.23736/s0392-9590.18.03986-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
25
|
Cukiert A, Reis AMD, Almeida ASD, Simões RDS, Buzzini RF, Bernardo WM. Chronic pain treatment with spinal cord neurostimulation. ACTA ACUST UNITED AC 2018; 64:299-306. [PMID: 30133606 DOI: 10.1590/1806-9282.64.04.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.
Collapse
|
26
|
Schulte S, Horsch S. Spinal Cord Stimulation for Peripheral Vascular Disorders. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
27
|
Is Spinal Cord Stimulation Useful and Safe for the Treatment of Chronic Pain of Ischemic Origin? A Review. Clin J Pain 2016; 32:7-13. [DOI: 10.1097/ajp.0000000000000229] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
28
|
Abu Dabrh AM, Steffen MW, Undavalli C, Asi N, Wang Z, Elamin MB, Conte MS, Murad MH. The natural history of untreated severe or critical limb ischemia. J Vasc Surg 2015; 62:1642-51.e3. [DOI: 10.1016/j.jvs.2015.07.065] [Citation(s) in RCA: 193] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/09/2015] [Indexed: 11/26/2022]
|
29
|
Lee S, Abd-Elsayed A. Some Non-FDA Approved Uses for Neuromodulation: A Review of the Evidence. Pain Pract 2015; 16:935-47. [DOI: 10.1111/papr.12405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 07/21/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Samuel Lee
- University of Cincinnati College of Medicine; University of Cincinnati; Cincinnati Ohio U.S.A
| | - Alaa Abd-Elsayed
- Department of Anesthesiology; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin U.S.A
| |
Collapse
|
30
|
Abu Dabrh AM, Steffen MW, Asi N, Undavalli C, Wang Z, Elamin MB, Conte MS, Murad MH. Nonrevascularization-based treatments in patients with severe or critical limb ischemia. J Vasc Surg 2015; 62:1330-9.e13. [DOI: 10.1016/j.jvs.2015.07.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/09/2015] [Indexed: 11/17/2022]
|
31
|
Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Leong M, Levy RM, Abejon D, Buchser E, Burton A, Buvanendran A, Candido K, Caraway D, Cousins M, DeJongste M, Diwan S, Eldabe S, Gatzinsky K, Foreman RD, Hayek S, Kim P, Kinfe T, Kloth D, Kumar K, Rizvi S, Lad SP, Liem L, Linderoth B, Mackey S, McDowell G, McRoberts P, Poree L, Prager J, Raso L, Rauck R, Russo M, Simpson B, Slavin K, Staats P, Stanton-Hicks M, Verrills P, Wellington J, Williams K, North R. The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:515-50; discussion 550. [PMID: 25112889 DOI: 10.1111/ner.12208] [Citation(s) in RCA: 319] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/07/2014] [Accepted: 02/28/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications. METHODS The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar. RESULTS Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medication-related side effects and has enduring effect. Device-related complications are not uncommon; however, the incidence is becoming less frequent as technology progresses and surgical skills improve. Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated. CONCLUSIONS Appropriate neurostimulation is safe and effective in some chronic pain conditions. Technological refinements and clinical evidence will continue to expand its use. The NACC seeks to facilitate the efficacy and safety of neurostimulation.
Collapse
|
32
|
Meier K. Spinal cord stimulation: Background and clinical application. Scand J Pain 2014; 5:175-181. [PMID: 29913713 DOI: 10.1016/j.sjpain.2014.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 03/17/2014] [Indexed: 01/25/2023]
Abstract
Background Spinal cord stimulation (SCS) is a surgical treatment for chronic neuropathic pain refractory to conventional treatment. SCS treatment consists of one or more leads implanted in the epidural space of the spinal canal, connected to an implantable pulse generator (IPG). Each lead carries a number of contacts capable of delivering a weak electrical current to the spinal cord, evoking a feeling of peripheral paresthesia. With correct indication and if implanted by an experienced implanter, success rates generally are in the range of about 50-75%. Common indications include complex regional pain syndrome (CRPS I), angina pectoris, and radicular pain after failed back surgery syndrome, and the treatment is also used to treat stump pain after amputation, and pain due to peripheral nerve injury, peripheral vascular disease, and diabetic neuropathy. Recommended contraindications for the treatment include pregnancy, coagulopathy, severe addiction to psychoactive substances, and lack of ability to cooperate (e.g. due to active psychosis or cognitive impairment). Most common complications to the treatment include lead migration, lead breakage, infection, pain over the implant, and dural puncture. Despite extensive research in the area, the mechanisms of action are still only partially understood. Methods In this topical review the historical background behind the treatment is described and the current theories on the mechanism of action are presented. The implantation procedure is described in detail and illustrated with a series of intraoperative pictures. Finally, indications for SCS are discussed along with some of the controversies surrounding the therapy. Implications The reader is presented with a broad overview of spinal cord stimulation, including the historical and theoretical background, practical implantation technique, and clinical application.
Collapse
Affiliation(s)
- Kaare Meier
- Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
33
|
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.
Collapse
|
34
|
Abstract
Gastric electrostimulation by a pulse generator is an area of intense interest for the treatment of obesity. The concept of a rhythmic electrical current applied to neural or myal tissues has been established for the treatment of major problems in many areas of the body or is being investigated.
Collapse
|
35
|
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]
|
36
|
Mutter UM, Bellut D, Porchet F, Schuknecht B. Spinal magnetic resonance imaging with reduced specific absorption rate in patients harbouring a spinal cord stimulation device - A single-centre prospective study analysing safety, tolerability and image quality. Acta Neurochir (Wien) 2013; 155:2327-32. [PMID: 24078115 DOI: 10.1007/s00701-013-1885-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/12/2013] [Indexed: 01/27/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is an accepted treatment in patients with failed back surgery (FBS), complex regional pain syndrome (CRPS) and persistent radicular pain following surgery. In order to avoid patient hazards or device malfunction manufacturers advise to abstain from magnetic resonance imaging (MRI) in patients with implanted electrodes or pulse generators. METHODS In a prospective study, 13 patients harbouring an implanted Medtronic Spinal Cord Stimulation (SCS) device underwent MRI (1.5 T) of the lumbar (n=13), the cervical (n=2) or the thoracic spine (n=1) following the development of new spinal symptoms. An adapted MRI protocol was used limiting the transmitted energy and specific absorption rate. Tolerability and safety were assessed by means of a standardized patient evaluation form documenting pain on a visual analogue scale (0-10), neurologic deficit, and discomfort during the scan. In addition, overall satisfaction with the examination procedure was rated on a Likert scale (1-5). Image quality was rated independently and blinded to the presence of a SCS device by the radiologist and the surgeon as equivalent, superior or inferior compared to the standard spine MRI examination. RESULTS None of the 13 patients investigated by the modified spinal MRI protocol experienced new neurological deficits, worsening of symptoms or a defect/malfunction of the implant device. Three patients (23.1 %) reported transient warm sensation in the location of the electrode and in one case intermittent slight tingling in the lower extremities. Overall satisfaction with the examination was 1.13 ± 0.34 according to Likert scale (1-5). The image quality was rated - not statistically significant - slightly inferior to standard lumbar spine imaging (0.82 ± 0.54) with a kappa value of 0.68 between the two investigators. MRI examinations detected relevant and new lesions in 9 (69.2 %) patients which affected treatment in 8 (61.5 %) individuals. CONCLUSION Using a protocol with a reduced specific energy absorption rate, spinal MRI examinations in patients with SCS can be considered safe. The current view that neurostimulators are a general contraindication to MR examinations has to be reconsidered in patients with new or progressive spinal symptoms.
Collapse
|
37
|
Claeys LGY. Pain relief and improvement of nutritional skin blood flow under spinal cord stimulation in patients with limb-threatening ischemia. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/156856900750228088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
38
|
Abstract
BACKGROUND Patients suffering from inoperable chronic critical leg ischaemia (NR-CCLI) face amputation of the leg. Spinal cord stimulation (SCS) has been proposed as a helpful treatment in addition to standard conservative treatment. OBJECTIVES To find evidence for an improvement on limb salvage, pain relief, and the clinical situation using SCS compared to conservative treatment alone. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12). SELECTION CRITERIA Controlled studies comparing the addition of SCS with any form of conservative treatment to conservative treatment alone in patients with NR-CCLI. DATA COLLECTION AND ANALYSIS Both authors independently assessed the quality of the studies and extracted data. MAIN RESULTS Six studies comprising nearly 450 patients were included. In general the quality of the studies was good. No study was blinded due to the type of intervention.Limb salvage after 12 months was significantly higher in the SCS group (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.56 to 0.90; risk difference (RD) -0.11, 95% CI -0.20 to -0.02). Significant pain relief occurred in both treatment groups, but was more prominent in the SCS group where the patients required significantly less analgesics. In the SCS group, significantly more patients reached Fontaine stage II than in the conservative group (RR 4.9, 95% CI 2.0 to 11.9; RD 0.33, 95% CI 0.19 to 0.47). Overall, no significantly different effect on ulcer healing was observed with the two treatments.Complications of SCS treatment consisted of implantation problems (9%, 95% CI 4 to 15%) and changes in stimulation requiring re-intervention (15%, 95% CI 10 to 20%). Infections of the lead or pulse generator pocket occurred less frequently (3%, 95% CI 0 to 6%). Overall risk of complications with additional SCS treatment was 17% (95% CI 12 to 22%), indicating a number needed to harm of 6 (95% CI 5 to 8).Average overall costs (one study) at two years were EUR 36,500 (SCS group) and EUR 28,600 (conservative group). The difference (EUR 7900) was significant (P < 0.009). AUTHORS' CONCLUSIONS There is evidence to favour SCS over standard conservative treatment alone to improve limb salvage and clinical situations in patients with NR-CCLI. The benefits of SCS must be considered against the possible harm of relatively mild complications and the costs.
Collapse
Affiliation(s)
- Dirk T Ubbink
- Quality Assurance & Process Innovation, and Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam,
| | | |
Collapse
|
39
|
Yampolsky C, Hem S, Bendersky D. Dorsal column stimulator applications. Surg Neurol Int 2012; 3:S275-89. [PMID: 23230533 PMCID: PMC3514915 DOI: 10.4103/2152-7806.103019] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/04/2012] [Indexed: 11/25/2022] Open
Abstract
Background: Spinal cord stimulation (SCS) has been used to treat neuropathic pain since 1967. Following that, technological progress, among other advances, helped SCS become an effective tool to reduce pain. Methods: This article is a non-systematic review of the mechanism of action, indications, results, programming parameters, complications, and cost-effectiveness of SCS. Results: In spite of the existence of several studies that try to prove the mechanism of action of SCS, it still remains unknown. The mechanism of action of SCS would be based on the antidromic activation of the dorsal column fibers, which activate the inhibitory interneurons within the dorsal horn. At present, the indications of SCS are being revised constantly, while new applications are being proposed and researched worldwide. Failed back surgery syndrome (FBSS) is the most common indication for SCS, whereas, the complex regional pain syndrome (CRPS) is the second one. Also, this technique is useful in patients with refractory angina and critical limb ischemia, in whom surgical or endovascular treatment cannot be performed. Further indications may be phantom limb pain, chronic intractable pain located in the head, face, neck, or upper extremities, spinal lumbar stenosis in patients who are not surgical candidates, and others. Conclusion: Spinal cord stimulation is a useful tool for neuromodulation, if an accurate patient selection is carried out prior, which should include a trial period. Undoubtedly, this proper selection and a better knowledge of its underlying mechanisms of action, will allow this cutting edge technique to be more acceptable among pain physicians.
Collapse
Affiliation(s)
- Claudio Yampolsky
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | |
Collapse
|
40
|
McJunkin TL, Berardoni N, Lynch PJ, Amrani J. An innovative case report detailing the successful treatment of post-thoracotomy syndrome with peripheral nerve field stimulation. Neuromodulation 2012; 13:311-4. [PMID: 21992889 DOI: 10.1111/j.1525-1403.2010.00277.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: 11/29/2022]
Abstract
INTRODUCTION The detrimental effects of post-thoracotomy pain syndrome is experienced worldwide; however, an effective treatment regimen remains elusive. METHODS We report a case of post-thoracotomy pain syndrome effectively treated with peripheral nerve field stimulation (PNfS). RESULTS In the presented case, the patient underwent permanent placement of the PSfS device after a successful trial period. Upon follow-up the patient has reported even better coverage over her painful areas and admits to 80% and higher reductions in her painful symptoms. CONCLUSION Although the data are limited, in the aforesaid case report, post-thoracotomy syndrome was effectively treated with the use of PNfS. This resulted in a significant pain perception reduction, increased quality of life and mobility, as well as decreased usage of oral pain medications. This adds to the accumulating case report and case series data that suggest PNfS is showing great promise as a pain reduction modality. Further, it is minimally invasive, can be trialled prior to implantation, and is reversible. Large prospective studies will be required in the future to further evaluate its efficacy before it can be widely accepted and adopted.
Collapse
|
41
|
Epstein LJ, Palmieri M. Managing chronic pain with spinal cord stimulation. ACTA ACUST UNITED AC 2012; 79:123-32. [PMID: 22238045 DOI: 10.1002/msj.21289] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Since its introduction as a procedure of last resort in a terminally ill patient with intractable cancer-related pain, spinal cord stimulation has been used to effectively treat chronic pain of varied origins. Spinal cord stimulation is commonly used for control of pain secondary to failed back surgery syndrome and complex regional pain syndrome, as well as pain from angina pectoris, peripheral vascular disease, and other causes. By stimulating one or more electrodes implanted in the posterior epidural space, the patient feels paresthesias in their areas of pain, which reduces the level of pain. Pain is reduced without the side effects associated with analgesic medications. Patients have improved quality of life and improved function, with many returning to work. Spinal cord stimulation has been shown to be cost effective as compared with conservative management alone. There is strong evidence for efficacy and cost effectiveness of spinal cord stimulation in the treatment of pain associated with intractable angina, failed back surgery syndrome, and complex regional pain syndrome. In this article, we review the history and pathophysiology of spinal cord stimulation, and the evidence (or lack thereof) for efficacy in common clinical practice.
Collapse
Affiliation(s)
- Lawrence J Epstein
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA.
| | | |
Collapse
|
42
|
Jeon YH. Spinal cord stimulation in pain management: a review. Korean J Pain 2012; 25:143-50. [PMID: 22787543 PMCID: PMC3389317 DOI: 10.3344/kjp.2012.25.3.143] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/08/2012] [Indexed: 11/30/2022] Open
Abstract
Spinal cord stimulation has become a widely used and efficient alternative for the management of refractory chronic pain that is unresponsive to conservative therapies. Technological improvements have been considerable and the current neuromodulation devices are both extremely sophisticated and reliable in obtaining good results for various clinical situations of chronic pain, such as failed back surgery syndrome, complex regional pain syndrome, ischemic and coronary artery disease. This technique is likely to possess a savings in costs compared with alternative therapy strategies despite its high initial cost. Spinal cord stimulation continues to be a valuable tool in the treatment of chronic disabling pain.
Collapse
Affiliation(s)
- Young Hoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu, Korea
| |
Collapse
|
43
|
Logé D, De Coster O, Washburn S. Technological innovation in spinal cord stimulation: use of a newly developed delivery device for introduction of spinal cord stimulation leads. Neuromodulation 2012; 15:392-401. [PMID: 22672129 DOI: 10.1111/j.1525-1403.2012.00461.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The use of multiple cylindrical leads and multicolumn and single column paddle leads in spinal cord stimulation offers many advantages over the use of a single cylindrical lead. Despite these advantages, placement of multiple cylindrical leads or a paddle lead requires a more invasive surgical procedure. Thus, the ideal situation for lead delivery would be percutaneous insertion of a paddle lead or multiple cylindrical leads. This study evaluated the feasibility and safety of percutaneous delivery of S-Series paddle leads using a new delivery device called the Epiducer lead delivery system (all St. Jude Medical Neuromodulation Division, Plano, TX, USA). MATERIALS AND METHODS This uncontrolled, open-label, prospective, two-center study approved by the AZ St. Lucas (Ghent) Ethics Committee evaluated procedural aspects of implantation of an S-Series paddle lead using the Epiducer lead delivery system and any adverse events relating to the device. Efficacy data during the patent's 30-day trial also were collected. RESULTS Data from 34 patients were collected from two investigational sites. There were no adverse events related to the Epiducer lead delivery system. The device was inserted at an angle of either 20°-30° or 30°-40° and was entered into the epidural space at T12/L1 in most patients. The S-Series paddle lead was advanced four vertebral segments in more than 50% of patients. The average (±standard deviation [SD]) time it took to place the Epiducer lead delivery system was 8.7 (±5.0) min. The average (+SD) patient-reported pain relief was 78.8% (+24.1%). CONCLUSIONS This study suggests the safe use of the Epiducer lead delivery system for percutaneous implantation and advancement of the S-Series paddle lead in 34 patients.
Collapse
|
44
|
Benoit E, O'Donnell TF, Kitsios GD, Iafrati MD. Improved amputation-free survival in unreconstructable critical limb ischemia and its implications for clinical trial design and quality measurement. J Vasc Surg 2012; 55:781-9. [DOI: 10.1016/j.jvs.2011.10.089] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 10/04/2011] [Accepted: 10/16/2011] [Indexed: 11/15/2022]
|
45
|
Recommendations for patient selection in spinal cord stimulation. J Clin Neurosci 2011; 18:1295-302. [DOI: 10.1016/j.jocn.2011.02.025] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 02/21/2011] [Accepted: 02/22/2011] [Indexed: 11/18/2022]
|
46
|
Benoit E, O'Donnell TF, Iafrati MD, Asher E, Bandyk DF, Hallett JW, Lumsden AB, Pearl GJ, Roddy SP, Vijayaraghavan K, Patel AN. The role of amputation as an outcome measure in cellular therapy for critical limb ischemia: implications for clinical trial design. J Transl Med 2011; 9:165. [PMID: 21951607 PMCID: PMC3191337 DOI: 10.1186/1479-5876-9-165] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 09/27/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Autologous bone marrow-derived stem cells have been ascribed an important therapeutic role in No-Option Critical limb Ischemia (NO-CLI). One primary endpoint for evaluating NO-CLI therapy is major amputation (AMP), which is usually combined with mortality for AMP-free survival (AFS). Only a trial which is double blinded can eliminate physician and patient bias as to the timing and reason for AMP. We examined factors influencing AMP in a prospective double-blinded pilot RCT (2:1 therapy to control) of 48 patients treated with site of service obtained bone marrow cells (BMAC) as well as a systematic review of the literature. METHODS Cells were injected intramuscularly in the CLI limbs as either BMAC or placebo (peripheral blood). Six month AMP rates were compared between the two arms. Both patient and treating team were blinded of the assignment in follow-up examinations. A search of the literature identified 9 NO-CLI trials, the control arms of which were used to determine 6 month AMP rates and the influence of tissue loss. RESULTS Fifteen amputations occurred during the 6 month period, 86.7% of these during the first 4 months. One amputation occurred in a Rutherford 4 patient. The difference in amputation rate between patients with rest pain (5.6%) and those with tissue loss (46.7%), irrespective of treatment group, was significant (p = 0.0029). In patients with tissue loss, treatment with BMAC demonstrated a lower amputation rate than placebo (39.1% vs. 71.4%, p = 0.1337). The Kaplan-Meier time to amputation was longer in the BMAC group than in the placebo group (p = 0.067). Projecting these results to a pivotal trial, a bootstrap simulation model showed significant difference in AFS between BMAC and placebo with a power of 95% for a sample size of 210 patients. Meta-analysis of the literature confirmed a difference in amputation rate between patients with tissue loss and rest pain. CONCLUSIONS BMAC shows promise in improving AMP-free survival if the trends in this pilot study are validated in a larger pivotal trial. The difference in amp rate between Rutherford 4 & 5 patients suggests that these patients should be stratified in future RCTs.
Collapse
Affiliation(s)
- Eric Benoit
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | | | - Mark D Iafrati
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Enrico Asher
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY 11219, USA
| | - Dennis F Bandyk
- Division of Vascular & Endovascular Surgery, University of Southern Florida, Tampa, FL 33606, USA
| | - John W Hallett
- Heart & Vascular Center, Roper St. Francis Medical Center, Charleston, SC 29401, USA
| | - Alan B Lumsden
- Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, TX 77030, USA
| | - Gregory J Pearl
- Department of Vascular Surgery, Baylor University Medical Center, Dallas, TX 75204, USA
| | | | | | - Amit N Patel
- Division of Surgery, University of Utah, Salt Lake City, UT 84132, USA
| |
Collapse
|
47
|
Colini Baldeschi G, Carlizza A. Spinal Cord Stimulation: Predictive Parameters of Outcome in Patients Suffering From Critical Lower Limb Ischemia. A Preliminary Study. Neuromodulation 2011; 14:530-2; discussion 533. [DOI: 10.1111/j.1525-1403.2011.00378.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
48
|
Abstract
Martorell ulcer is a specific disease entity characterized by multiple small homogeneous, symmetrical lesions, although single lesions are observed as well, most commonly located on the anterolateral aspect of the lower leg. The pain associated to these lesions is disproportionate to their size.Martorell ulcer designates a specific disease entity that occurs predominantly in middle-aged women with poorly controlled hypertension in the form of skin ulcers on the anterolateral aspect of the lower legs. The lesions initially appear as small, painful blisters which may or may not be associated with trauma. The pathophysiology of Martorell ulcer is assumed to be related to hypertension-induced arteriole changes in the dermis. The pain is often disproportionate, and the symptoms are not relieved by rest or elevation.Spinal cord stimulation (SCS) is an accepted evidence-based therapy for the treatment of chronic ischemic pain. Spinal cord stimulation is used as a therapeutic tool in the management of this disease not only for symptomatic pain control but also for accelerating the healing process through its effects on causal mechanisms. The beneficial effects of SCS when used to treat ischemic pain include pain relief, decreased infarction or ulcer size, decreased oxygen requirements, and increased claudication distance. Clinical and basic studies indicate that these beneficial effects are mainly associated with an increase or redistribution of blood flow to the ischemic area and/or normalization of the activity in the nervous system.We present the case of a 71-year-old woman diagnosed with Martorell ulcer in the acute phase of the disease. The patient was treated with SCS to achieve both pain relief and healing of the cutaneous ulcer.
Collapse
|
49
|
Raso L, Deer T. Spinal cord stimulation in the treatment of acute and chronic vasculitis: clinical discussion and synopsis of the literature. Neuromodulation 2011; 14:225-8; discussion 228. [PMID: 21992244 DOI: 10.1111/j.1525-1403.2011.00351.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) has been widely noted as a treatment for ischemic pain secondary to peripheral vascular disease, but evidence in the vasculitis disease state is lacking. In this paper we present two cases that exemplify the potential of SCS in this unique population. MATERIAL AND METHODS Two case studies involving patients with the conditions noted including initial findings, treatment protocol, and results documented throughout the treatment regimen. A comprehensive review of the critical literature also was performed. RESULTS Both patients showed marked improvement with SCS. Pain scores improved dramatically, with a major improvement in disease symptom and quality of life. CONCLUSIONS Based on literature and our results, SCS is an effective and safe therapy for patients with therapeutically refractory vasculitis.
Collapse
Affiliation(s)
- Louis Raso
- Interventional Pain Management Physician, Jupiter, FL, USA
| | | |
Collapse
|
50
|
Devulder J, van Suijlekom H, van Dongen R, Diwan S, Mekhail N, van Kleef M, Huygen F. 25. Ischemic Pain in the Extremities and Raynaud’s Phenomenon. Pain Pract 2011; 11:483-91. [DOI: 10.1111/j.1533-2500.2011.00460.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|