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Guzzi G, Della Torre A, Bruni A, Lavano A, Bosco V, Garofalo E, La Torre D, Longhini F. Anatomo-physiological basis and applied techniques of electrical neuromodulation in chronic pain. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:29. [PMID: 38698460 PMCID: PMC11064427 DOI: 10.1186/s44158-024-00167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
Chronic pain, a complex and debilitating condition, poses a significant challenge to both patients and healthcare providers worldwide. Conventional pharmacological interventions often prove inadequate in delivering satisfactory relief while carrying the risks of addiction and adverse reactions. In recent years, electric neuromodulation emerged as a promising alternative in chronic pain management. This method entails the precise administration of electrical stimulation to specific nerves or regions within the central nervous system to regulate pain signals. Through mechanisms that include the alteration of neural activity and the release of endogenous pain-relieving substances, electric neuromodulation can effectively alleviate pain and improve patients' quality of life. Several modalities of electric neuromodulation, with a different grade of invasiveness, provide tailored strategies to tackle various forms and origins of chronic pain. Through an exploration of the anatomical and physiological pathways of chronic pain, encompassing neurotransmitter involvement, this narrative review offers insights into electrical therapies' mechanisms of action, clinical utility, and future perspectives in chronic pain management.
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Affiliation(s)
- Giusy Guzzi
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Attilio Della Torre
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Angelo Lavano
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Vincenzo Bosco
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Domenico La Torre
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy.
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Sivanesan E, North RB, Russo MA, Levy RM, Linderoth B, Hayek SM, Eldabe S, Lempka SF. A Definition of Neuromodulation and Classification of Implantable Electrical Modulation for Chronic Pain. Neuromodulation 2024; 27:1-12. [PMID: 37952135 DOI: 10.1016/j.neurom.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/24/2023] [Accepted: 10/09/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES Neuromodulation therapies use a variety of treatment modalities (eg, electrical stimulation) to treat chronic pain. These therapies have experienced rapid growth that has coincided with escalating confusion regarding the nomenclature surrounding these neuromodulation technologies. Furthermore, studies are often published without a complete description of the effective stimulation dose, making it impossible to replicate the findings. To improve clinical care and facilitate dissemination among the public, payors, research groups, and regulatory bodies, there is a clear need for a standardization of terms. APPROACH We formed an international group of authors comprising basic scientists, anesthesiologists, neurosurgeons, and engineers with expertise in neuromodulation. Because the field of neuromodulation is extensive, we chose to focus on creating a taxonomy and standardized definitions for implantable electrical modulation of chronic pain. RESULTS We first present a consensus definition of neuromodulation. We then describe a classification scheme based on the 1) intended use (the site of modulation and its indications) and 2) physical properties (waveforms and dose) of a neuromodulation therapy. CONCLUSIONS This framework will help guide future high-quality studies of implantable neuromodulatory treatments and improve reporting of their findings. Standardization with this classification scheme and clear definitions will help physicians, researchers, payors, and patients better understand the applications of implantable electrical modulation for pain and guide informed treatment decisions.
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Affiliation(s)
- Eellan Sivanesan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Richard B North
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Marc A Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Salim M Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
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Mangnus TJP, Dirckx M, Huygen FJPM. Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy. J Pain Res 2023; 16:4379-4391. [PMID: 38162406 PMCID: PMC10757771 DOI: 10.2147/jpr.s432209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP-nociceptive, neuropathic, and nociplastic pain-will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.
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Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Hu Y, Feng Z, Zheng L, Ye X. Interactions between cathodic- and anodic-pulses during high-frequency stimulations with the monophasic-pulses alternating in polarity at axons-experiment and simulation studies. J Neural Eng 2023; 20:056021. [PMID: 37703869 DOI: 10.1088/1741-2552/acf959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 09/13/2023] [Indexed: 09/15/2023]
Abstract
Background. Electrical neuromodulation therapies commonly utilize high-frequency stimulations (HFS) of biphasic-pulses to treat neurological disorders. The biphasic pulse consists of a leading cathodic-phase to activate neurons and a lagging anodic-phase to balance electrical charges. Because both monophasic cathodic- and anodic-pulses can depolarize neuronal membranes, splitting biphasic-pulses into alternate cathodic- and anodic-pulses could be a feasible strategy to improve stimulation efficiency.Objective. We speculated that neurons in the volume initially activated by both polarity pulses could change to be activated only by anodic-pulses during sustained HFS of alternate monophasic-pulses. To verify the hypothesis, we investigated the interactions of the monophasic pulses during HFS and revealed possible underlying mechanisms.Approach. Different types of pulse stimulations were applied at the alvear fibers (i.e. the axons of CA1 pyramidal neurons) to antidromically activate the neuronal cell bodies in the hippocampal CA1 region of anesthetized ratsin-vivo. Sequences of antidromic HFS (A-HFS) were applied with alternate monophasic-pulses or biphasic-pulses. The pulse frequency in the A-HFS sequences was 50 or 100 Hz. The A-HFS duration was 120 s. The amplitude of antidromically-evoked population spike was measured to evaluate the neuronal firing induced by each pulse. A computational model of axon was used to explore the possible mechanisms of neuronal modulations. The changes of model variables during sustained A-HFS were analyzed.Main results. In rat experiments, with a same pulse intensity, the activation volume of a cathodic-pulse was greater than that of an anodic-pulse. In paired-pulse tests, a preceding cathodic-pulse was able to prevent a following anodic-pulse from activating neurons due to refractory period. This indicated that the activation volume of a cathodic-pulse covered that of an anodic-pulse. However, during sustained A-HFS of alternate monophasic-pulses, the anodic-pulses were able to prevail over the cathodic-pulses in activating neurons in the overlapped activation volume. Model simulation results show the mechanisms of the activation failures of cathodic-pulses. They include the excessive membrane depolarization caused by an accumulation of potassium ions, the obstacle of hyperpolarization in the conduction pathway and the interactions from anodic-pulses.Significance. The study firstly showed the domination of anodic-pulses over cathodic-pulses in their competitions to activate neurons during sustained HFS. The finding provides new clues for designing HFS paradigms to improve the efficiency of neuromodulation therapies.
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Affiliation(s)
- Yifan Hu
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Zhouyan Feng
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Lvpiao Zheng
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Xiangyu Ye
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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Papadopoulos DV, Suk MS, Andreychik D, Nikolaou V, Haak M. Rates and Causes of Reoperations Following Spinal Cord Stimulation Within a 2-12 year Period. Global Spine J 2023:21925682231194466. [PMID: 37542526 DOI: 10.1177/21925682231194466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2023] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE Spinal cord stimulation has been mainly used for the management of postsurgical persistent neuropathic. The purpose of the study was to evaluate the rate and causes for reoperation following spinal cord stimulation, and to identify risk factors for reoperation. METHODS A retrospective study was conducted including patients who underwent surgical implantation of spinal cord stimulators within a 10-year period. The medical records of the included patients were reviewed for reoperations, demographics and certain clinical parameters. Demographics and clinical parameters were compared between patients with and without reoperations, and between patients with and without surgical site infections. RESULTS Overall, 1014 index procedures and 175 reoperations were performed within the study period. At least 1 reoperation was performed in 97 (9.5%) cases. The most common cause for revision was lead migration or lead misplacement (n = 31, 3.0%). In 31 (3.1%) cases the stimulator was removed due to no pain relief. Surgical site infection that required reoperation developed in 30 cases (2.9%). Younger age was associated with a need for reoperation (Odds Ratio [OR]: .97,95% Confidence Interval [CI]:0.95-.99, P = .005), while higher Body Mass index and diabetes were associated with development of infection (OR: 1.05, 95% CI: 1.00-1.11, P = .036 and OR: 2.42, 95% CI: 1.05-5.47, P = .033 respectively). CONCLUSIONS The results of this study indicate that certain measures could improve the overall reoperation rate after spinal cord stimulation, such as accurate positioning of the spinal cord stimulators and design of smaller generators. Moreover, preoperative optimization of patients could result in lower complication rate, lower reoperations rate, and subsequently better clinical outcomes.
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Affiliation(s)
- Dimitrios V Papadopoulos
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Madeline S Suk
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - David Andreychik
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Vasileios Nikolaou
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Michael Haak
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA, USA
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Attal N, Bouhassira D, Colvin L. Advances and challenges in neuropathic pain: a narrative review and future directions. Br J Anaesth 2023; 131:79-92. [PMID: 37210279 DOI: 10.1016/j.bja.2023.04.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/20/2023] [Accepted: 04/05/2023] [Indexed: 05/22/2023] Open
Abstract
Over the past few decades, substantial advances have been made in neuropathic pain clinical research. An updated definition and classification have been agreed. Validated questionnaires have improved the detection and assessment of acute and chronic neuropathic pain; and newer neuropathic pain syndromes associated with COVID-19 have been described. The management of neuropathic pain has moved from empirical to evidence-based medicine. However, appropriately targeting current medications and the successful clinical development of drugs acting on new targets remain challenging. Innovative approaches to improving therapeutic strategies are required. These mainly encompass rational combination therapy, drug repurposing, non-pharmacological approaches (such as neurostimulation techniques), and personalised therapeutic management. This narrative review reports historical and current perspectives regarding the definitions, classification, assessment, and management of neuropathic pain and explores potential avenues for future research.
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Affiliation(s)
- Nadine Attal
- Inserm U987, UVSQ-Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France.
| | - Didier Bouhassira
- Inserm U987, UVSQ-Paris-Saclay University, Ambroise Pare Hospital, Boulogne-Billancourt, France
| | - Lesley Colvin
- University of Dundee, Ninewells Medical School, Ninewells Hospital, Dundee, UK
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Howard-Quijano K, Kuwabara Y, Yamaguchi T, Roman K, Salavatian S, Taylor B, Mahajan A. GABAergic Signaling during Spinal Cord Stimulation Reduces Cardiac Arrhythmias in a Porcine Model. Anesthesiology 2023; 138:372-387. [PMID: 36724342 PMCID: PMC9998372 DOI: 10.1097/aln.0000000000004516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Neuraxial modulation, including spinal cord stimulation, reduces cardiac sympathoexcitation and ventricular arrhythmogenesis. There is an incomplete understanding of the molecular mechanisms through which spinal cord stimulation modulates cardiospinal neural pathways. The authors hypothesize that spinal cord stimulation reduces myocardial ischemia-reperfusion-induced sympathetic excitation and ventricular arrhythmias through γ-aminobutyric acid (GABA)-mediated pathways in the thoracic spinal cord. METHODS Yorkshire pigs were randomized to control (n = 11), ischemia-reperfusion (n = 16), ischemia-reperfusion plus spinal cord stimulation (n = 17), ischemia-reperfusion plus spinal cord stimulation plus γ-aminobutyric acid type A (GABAA) or γ-aminobutyric acid type B (GABAB) receptor antagonist (GABAA, n = 8; GABAB, n = 8), and ischemia-reperfusion plus GABA transaminase inhibitor (GABAculine, n = 8). A four-pole spinal cord stimulation lead was placed epidurally (T1 to T4). GABA modulating pharmacologic agents were administered intrathecally. Spinal cord stimulation at 50 Hz was applied 30 min before ischemia. A 56-electrode epicardial mesh was used for high-resolution electrophysiologic recordings, including activation recovery intervals and ventricular arrhythmia scores. Immunohistochemistry and Western blots were performed to measure GABA receptor expression in the thoracic spinal cord. RESULTS Cardiac ischemia led to myocardial sympathoexcitation with reduction in activation recovery interval (mean ± SD, -42 ± 11%), which was attenuated by spinal cord stimulation (-21 ± 17%, P = 0.001). GABAA and GABAB receptor antagonists abolished spinal cord stimulation attenuation of sympathoexcitation (GABAA, -9.7 ± 9.7%, P = 0.043 vs. ischemia-reperfusion plus spinal cord stimulation; GABAB, -13 ± 14%, P = 0.012 vs. ischemia-reperfusion plus spinal cord stimulation), while GABAculine alone caused a therapeutic effect similar to spinal cord stimulation (-4.1 ± 3.7%, P = 0.038 vs. ischemia-reperfusion). The ventricular arrhythmia score supported these findings. Spinal cord stimulation during ischemia-reperfusion increased GABAA receptor expression with no change in GABAB receptor expression. CONCLUSIONS Thoracic spinal cord stimulation reduces ischemia-reperfusion-induced sympathoexcitation and ventricular arrhythmias through activation of GABA signaling pathways. These data support the hypothesis that spinal cord stimulation-induced release of GABA activates inhibitory interneurons to decrease primary afferent signaling from superficial dorsal horn to sympathetic output neurons in the intermediolateral nucleus. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. A-1305 Scaife Hall, 3550 Terrace Street Pittsburgh, PA 15261, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center. 200 Lothrop St, Pittsburgh, PA 15213, United States
| | - Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. A-1305 Scaife Hall, 3550 Terrace Street Pittsburgh, PA 15261, United States
| | - Tomoki Yamaguchi
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. A-1305 Scaife Hall, 3550 Terrace Street Pittsburgh, PA 15261, United States
| | - Kenny Roman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. A-1305 Scaife Hall, 3550 Terrace Street Pittsburgh, PA 15261, United States
| | - Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. A-1305 Scaife Hall, 3550 Terrace Street Pittsburgh, PA 15261, United States
| | - Bradley Taylor
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. A-1305 Scaife Hall, 3550 Terrace Street Pittsburgh, PA 15261, United States
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh. A-1305 Scaife Hall, 3550 Terrace Street Pittsburgh, PA 15261, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center. 200 Lothrop St, Pittsburgh, PA 15213, United States
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Liu C, Liu DQ, Tian YK, Mei W, Tian XB, Xu AJ, Zhou YQ. The Emerging Role of Quercetin in the Treatment of Chronic Pain. Curr Neuropharmacol 2022; 20:2346-2353. [PMID: 35959909 PMCID: PMC9890298 DOI: 10.2174/1570159x20666220812122437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/11/2022] [Accepted: 06/13/2022] [Indexed: 12/29/2022] Open
Abstract
Despite much research efforts being devoted to designing alternative pharmacological interventions, chronic pain remains to be an unresolved clinical problem. Quercetin, a compound that belongs to the flavonoids family, is abundantly found in fruits and vegetables. Emerging evidence indicates that quercetin possesses anti-nociceptive effects in different rodent models of chronic pain, including inflammatory pain, neuropathic pain and cancer pain. In this review, we summarize the mechanisms underlying the analgesic effect of quercetin in preclinical studies. These studies showed that quercetin exerts potent analgesic effects against chronic pain via suppressing neuroinflammation and oxidative stress as well as modulation of synaptic plasticity, GABAergic system, and opioidergic system. Considering that the safety of quercetin is well established, it has great potential for clinical use in pain treatment.
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Affiliation(s)
- Cheng Liu
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Dai-Qiang Liu
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yu-Ke Tian
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wei Mei
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xue-Bi Tian
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ai-Jun Xu
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ya-Qun Zhou
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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Spinal Cord Stimulation in Chronic Low Back Pain Syndrome: Mechanisms of Modulation, Technical Features and Clinical Application. Healthcare (Basel) 2022; 10:healthcare10101953. [PMID: 36292400 PMCID: PMC9601444 DOI: 10.3390/healthcare10101953] [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: 09/14/2022] [Revised: 09/29/2022] [Accepted: 10/04/2022] [Indexed: 11/04/2022] Open
Abstract
Chronic low-back pain (CLBP) is a common disease with several negative consequences on the quality of life, work and activity ability and increased costs to the health-care system. When pharmacological, psychological, physical and occupational therapies or surgery fail to reduce CLBP, patients may be a candidate for Spinal Cord Stimulation (SCS). SCS consists of the transcutaneous or surgical implantation of different types of electrodes in the epidural space; electrodes are then connected to an Implanted Pulse Generator (IPG) that generates stimulating currents. Through spinal and supraspinal mechanisms based on the “gate control theory for pain transmission”, SCS reduces symptoms of CLBP in the almost totality of well-selected patients and its effect lasts up to eight years in around 75% of patients. However, the evidence in favor of SCS still remains weak, mainly due to poor trial methodology and design. This narrative review is mainly addressed to those professionals that may encounter patients with CLBP failing conventional treatments. For this reason, we report the mechanisms of pain relief during SCS, the technical features and some clinical considerations about the application of SCS in patients with CLBP.
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Liu YJ, Li YL, Fang ZH, Liao HL, Zhang YY, Lin J, Liu F, Shen JF. NMDARs mediate peripheral and central sensitization contributing to chronic orofacial pain. Front Cell Neurosci 2022; 16:999509. [PMID: 36238833 PMCID: PMC9553029 DOI: 10.3389/fncel.2022.999509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
Peripheral and central sensitizations of the trigeminal nervous system are the main mechanisms to promote the development and maintenance of chronic orofacial pain characterized by allodynia, hyperalgesia, and ectopic pain after trigeminal nerve injury or inflammation. Although the pathomechanisms of chronic orofacial pain are complex and not well known, sufficient clinical and preclinical evidence supports the contribution of the N-methyl-D-aspartate receptors (NMDARs, a subclass of ionotropic glutamate receptors) to the trigeminal nociceptive signal processing pathway under various pathological conditions. NMDARs not only have been implicated as a potential mediator of pain-related neuroplasticity in the peripheral nervous system (PNS) but also mediate excitatory synaptic transmission and synaptic plasticity in the central nervous system (CNS). In this review, we focus on the pivotal roles and mechanisms of NMDARs in the trigeminal nervous system under orofacial neuropathic and inflammatory pain. In particular, we summarize the types, components, and distribution of NMDARs in the trigeminal nervous system. Besides, we discuss the regulatory roles of neuron-nonneuronal cell/neuron-neuron communication mediated by NMDARs in the peripheral mechanisms of chronic orofacial pain following neuropathic injury and inflammation. Furthermore, we review the functional roles and mechanisms of NMDARs in the ascending and descending circuits under orofacial neuropathic and inflammatory pain conditions, which contribute to the central sensitization. These findings are not only relevant to understanding the underlying mechanisms, but also shed new light on the targeted therapy of chronic orofacial pain.
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Affiliation(s)
- Ya-Jing Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yue-Ling Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Zhong-Han Fang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hong-Lin Liao
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yan-Yan Zhang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jiu Lin
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Fei Liu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- *Correspondence: Jie-Fei Shen Fei Liu
| | - Jie-Fei Shen
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, National Center for Stomatology, West China School of Stomatology, Sichuan University, Chengdu, China
- Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- *Correspondence: Jie-Fei Shen Fei Liu
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Pirondini E, Carranza E, Balaguer JM, Sorensen E, Weber DJ, Krakauer JW, Capogrosso M. Poststroke arm and hand paresis: should we target the cervical spinal cord? Trends Neurosci 2022; 45:568-578. [PMID: 35659414 DOI: 10.1016/j.tins.2022.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/18/2022] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
Despite advances in understanding of corticospinal motor control and stroke pathophysiology, current rehabilitation therapies for poststroke upper limb paresis have limited efficacy at the level of impairment. To address this problem, we make the conceptual case for a new treatment approach. We first summarize current understanding of motor control deficits in the arm and hand after stroke and their shared physiological mechanisms with spinal cord injury (SCI). We then review studies of spinal cord stimulation (SCS) for recovery of locomotion after SCI, which provide convincing evidence for enhancement of residual corticospinal function. By extrapolation, we argue for using cervical SCS to restore upper limb motor control after stroke.
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Affiliation(s)
- Elvira Pirondini
- Rehab and Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Erick Carranza
- Rehab and Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josep-Maria Balaguer
- Rehab and Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Erynn Sorensen
- Rehab and Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Douglas J Weber
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA; Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA, USA
| | - John W Krakauer
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA; The Santa Fe Institute, Santa Fe, CA, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA; Department of Neuroscience, Johns Hopkins University, Baltimore, MD, USA.
| | - Marco Capogrosso
- Rehab and Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA; Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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12
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Spinal Cord Stimulation to Treat Unresponsive Cancer Pain: A Possible Solution in Palliative Oncological Therapy. Life (Basel) 2022; 12:life12040554. [PMID: 35455045 PMCID: PMC9025741 DOI: 10.3390/life12040554] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/03/2022] [Accepted: 04/04/2022] [Indexed: 12/03/2022] Open
Abstract
(1) Background: Treatment of cancer-related pain is still challenging, and it can be managed by both medical and interventional therapies. Spinal Cord Stimulation (SCS) is a minimally invasive technique, and its use is rapidly increasing in the treatment of chronic pain. (2) Materials and Methods: Our study aims to perform a review of the pertinent literature about current evidences in cancer pain treatment by Spinal Cord Stimulation. Moreover, we created a database based on case reports or case series (18 studies) in the literature. We analyzed a clinical group of oncological patients affected by intractable pain undergoing SCS implantation, focusing on outcome. (3) Results: The analysis of the 18 included studies in our series has shown a reduction in painful symptoms in 48 out of 56 treated patients (87.51%); also 53 out of 56 patients (96.64%) have shown an improvement in their Quality of Life (QoL). (4) Conclusions: Spinal Cord Stimulation can be considered an efficient method in the treatment of cancer-related pain. However, literature regarding SCS for the treatment of cancer-related pain is largely represented by case reports and small case series, with no effective population studies or Randomized Controlled Trials demonstrating the efficacy and the level of evidence. Further prospective studies are needed.
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13
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Rahman MA, Tharu NS, Gustin SM, Zheng YP, Alam M. Trans-Spinal Electrical Stimulation Therapy for Functional Rehabilitation after Spinal Cord Injury: Review. J Clin Med 2022; 11:jcm11061550. [PMID: 35329875 PMCID: PMC8954138 DOI: 10.3390/jcm11061550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023] Open
Abstract
Spinal cord injury (SCI) is one of the most debilitating injuries in the world. Complications after SCI, such as respiratory issues, bowel/bladder incontinency, pressure ulcers, autonomic dysreflexia, spasticity, pain, etc., lead to immense suffering, a remarkable reduction in life expectancy, and even premature death. Traditional rehabilitations for people with SCI are often insignificant or ineffective due to the severity and complexity of the injury. However, the recent development of noninvasive electrical neuromodulation treatments to the spinal cord have shed a ray of hope for these individuals to regain some of their lost functions, a reduction in secondary complications, and an improvement in their life quality. For this review, 250 articles were screened and about 150 were included to summarize the two most promising noninvasive spinal cord electrical stimulation methods of SCI rehabilitation treatment, namely, trans-spinal direct current stimulation (tsDCS) and trans-spinal pulsed current stimulation (tsPCS). Both treatments have demonstrated good success in not only improving the sensorimotor function, but also autonomic functions. Due to the noninvasive nature and lower costs of these treatments, in the coming years, we expect these treatments to be integrated into regular rehabilitation therapies worldwide.
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Affiliation(s)
- Md. Akhlasur Rahman
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
- Centre for the Rehabilitation of the Paralysed (CRP), Savar Union 1343, Bangladesh
| | - Niraj Singh Tharu
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
| | - Sylvia M. Gustin
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia;
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW 2031, Australia
| | - Yong-Ping Zheng
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
| | - Monzurul Alam
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia;
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW 2031, Australia
- Correspondence: ; Tel.: +852-6213-5054
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14
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Lubejko ST, Graham RD, Livrizzi G, Schaefer R, Banghart MR, Creed MC. The role of endogenous opioid neuropeptides in neurostimulation-driven analgesia. Front Syst Neurosci 2022; 16:1044686. [PMID: 36591324 PMCID: PMC9794630 DOI: 10.3389/fnsys.2022.1044686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Due to the prevalence of chronic pain worldwide, there is an urgent need to improve pain management strategies. While opioid drugs have long been used to treat chronic pain, their use is severely limited by adverse effects and abuse liability. Neurostimulation techniques have emerged as a promising option for chronic pain that is refractory to other treatments. While different neurostimulation strategies have been applied to many neural structures implicated in pain processing, there is variability in efficacy between patients, underscoring the need to optimize neurostimulation techniques for use in pain management. This optimization requires a deeper understanding of the mechanisms underlying neurostimulation-induced pain relief. Here, we discuss the most commonly used neurostimulation techniques for treating chronic pain. We present evidence that neurostimulation-induced analgesia is in part driven by the release of endogenous opioids and that this endogenous opioid release is a common endpoint between different methods of neurostimulation. Finally, we introduce technological and clinical innovations that are being explored to optimize neurostimulation techniques for the treatment of pain, including multidisciplinary efforts between neuroscience research and clinical treatment that may refine the efficacy of neurostimulation based on its underlying mechanisms.
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Affiliation(s)
- Susan T. Lubejko
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Robert D. Graham
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Giulia Livrizzi
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Robert Schaefer
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Matthew R. Banghart
- Department of Neurobiology, School of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
- *Correspondence: Matthew R. Banghart,
| | - Meaghan C. Creed
- Department of Anesthesiology, Pain Center, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Neuroscience, Washington University in St. Louis, St. Louis, MO, United States
- Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
- Meaghan C. Creed,
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15
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Budwany RR, Navalgund YA, Abd-Elsayed A. Translation research in pain medicine. PERIOPERATIVE NEUROSCIENCE 2022:203-213. [DOI: 10.1016/b978-0-323-91003-3.00001-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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16
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Aryal V, Poudel S, Zulfiqar F, Shrestha T, Singh A, Shah SA, Soomro U, Choudhari J, Quinonez J, Ruxmohan S, Amra A, Albert T, Kemmerlin J, Stein J. Updates on the Role of Spinal Cord Stimulation in the Management of Non-Surgical Chronic Lower Back Pain. Cureus 2021; 13:e18928. [PMID: 34812312 PMCID: PMC8603867 DOI: 10.7759/cureus.18928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/26/2022] Open
Abstract
Studies have shown that spinal cord stimulation (SCS) therapy is effective in the management of chronic low back pain. It plays a role by minimizing the intensity of chronic pain, improving the quality of life index, reducing the intake of narcotic analgesics, and increasing the functional improvement in the working environment. However, spinal cord stimulation therapy is not universal because of the complications in the procedure itself, the invasive nature of the treatment, and cost-effectiveness. Therefore, the proper selection of the patients is necessary to get the maximum benefit from the treatment. The study's main objective is to determine the role of spinal cord stimulation in treating non-surgical patients with chronic low back pain. The article will review the mechanism, outcomes, efficacy, predisposing factors in the success and failure of the treatment and indications, contraindications, and selection of patients undergoing spinal cord stimulation therapy. A manual search of the literature was done using databases like Google Scholar and PubMed using the keywords: spinal cord, stimulation, chronic, and low back pain. A total of 37 articles were included in the study after considering the inclusion and exclusion criteria. Spinal cord stimulation therapy effectively treats refractory lower back pain, considering the technology and mechanism of action. The authors conclude that spinal cord stimulation therapy can be used to manage chronic low back pain, other neuropathic pain, and ischemic pain when other standard treatment methods have failed and the pain persisted for more than six months.
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Affiliation(s)
- Vinayak Aryal
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA.,Pathology and Laboratory Medicine, Nepal Cancer Hospital and Research Center, Lalitpur, NPL
| | - Sujan Poudel
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Fizza Zulfiqar
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Thakur Shrestha
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Annie Singh
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Shahtaj A Shah
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Umar Soomro
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Jinal Choudhari
- Division of Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - Jonathan Quinonez
- Department of Neurology/Osteopathic Neuromuscular Medicine, Larkin Community Hospital, South Miami, USA
| | - Samir Ruxmohan
- Department of Neurology, Larkin Community Hospital, South Miami, USA
| | - Amean Amra
- Osteopathic Neuromuscular Medicine/Family Medicine, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
| | - Trevine Albert
- Division of Interventional Pain, Larkin Community Hospital, South Miami, USA
| | - Jesse Kemmerlin
- Osteopathic Neuromuscular Medicine/Family Medicine, Larkin Community Hospital Palm Springs Campus, Hialeah, USA
| | - Joel Stein
- Division of Pain Management, Larkin Community Hospital, South Miami, USA
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17
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da Silva Fiorin F, de Araújo E Silva M, Rodrigues AC. Electrical stimulation in animal models of epilepsy: A review on cellular and electrophysiological aspects. Life Sci 2021; 285:119972. [PMID: 34560081 DOI: 10.1016/j.lfs.2021.119972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/02/2021] [Accepted: 09/17/2021] [Indexed: 01/24/2023]
Abstract
Epilepsy is a debilitating condition, primarily refractory individuals, leading to the search for new efficient therapies. Electrical stimulation is an important method used for years to treat several neurological disorders. Currently, electrical stimulation is used to reduce epileptic crisis in patients and shows promising results. Even though the use of electricity to treat neurological disorders has grown worldwide, there are still many caveats that must be clarified, such as action mechanisms and more efficient stimulation treatment parameters. Thus, this review aimed to explore the comprehension of the main stimulation methods in animal models of epilepsy using rodents to develop new experimental protocols and therapeutic approaches.
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Affiliation(s)
- Fernando da Silva Fiorin
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil.
| | - Mariane de Araújo E Silva
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil
| | - Abner Cardoso Rodrigues
- Graduate Program in Neuroengineering, Edmond and Lily Safra International Institute of Neuroscience, Santos Dumont Institute, Brazil
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18
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Niso G, Tjepkema-Cloostermans MC, Lenders MWPM, de Vos CC. Modulation of the Somatosensory Evoked Potential by Attention and Spinal Cord Stimulation. Front Neurol 2021; 12:694310. [PMID: 34413825 PMCID: PMC8369157 DOI: 10.3389/fneur.2021.694310] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/07/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction: Spinal Cord Stimulation (SCS) is a last-resort treatment for patients with intractable chronic pain in whom pharmacological and other treatments have failed. Conventional tonic SCS is accompanied by tingling sensations. More recent stimulation protocols like burst SCS are not sensed by the patient while providing similar levels of pain relief. It has been previously reported that conventional tonic SCS can attenuate sensory-discriminative processing in several brain areas, but that burst SCS might have additional effects on the medial, motivational-affective pain system. In this explorative study we assessed the influence of attention on the somatosensory evoked brain responses under conventional tonic SCS as well as burst SCS regime. Methods: Twelve chronic pain patients with an implanted SCS device had 2-weeks evaluation periods with three different SCS settings (conventional tonic SCS, burst SCS, and sham SCS). At the end of each period, an electro-encephalography (EEG) measurement was done, at which patients received transcutaneous electrical pulses at the tibial nerve to induce somatosensory evoked potentials (SEP). SEP data was acquired while patients were attending the applied pulses and while they were mind wandering. The effects of attention as well as SCS regimes on the SEP were analyzed by comparing amplitudes of early and late latencies at the vertex as well as brain activity at full cortical maps. Results: Pain relief obtained by the various SCS settings varied largely among patients. Early SEP responses were not significantly affected by attention nor SCS settings (i.e., burst, tonic, and sham). However, late SEP responses (P300) were reduced with tonic and burst SCS: conventional tonic SCS reduced P300 brain activity in the unattended condition, while burst SCS reduced P300 brain activity in both attended and unattended conditions. Conclusion: Burst spinal cord stimulation for the treatment of chronic pain seems to reduce cortical attention that is or can be directed to somatosensory stimuli to a larger extent than conventional spinal cord stimulation treatment. This is a first step in understanding why in selected chronic pain patients burst SCS is more effective than tonic SCS and how neuroimaging could assist in personalizing SCS treatment.
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Affiliation(s)
- Guiomar Niso
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Psychological & Brain Sciences, Indiana University, Bloomington, IN, United States.,ETSI Telecomunicación, Universidad Politécnica de Madrid and Center for Biomedical Research Network CIBER-BBN, Madrid, Spain
| | - Marleen C Tjepkema-Cloostermans
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Clinical Neurophysiology, Institute for Technical Medicine, University of Twente, Enschede, Netherlands
| | - Mathieu W P M Lenders
- Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Cecile C de Vos
- McConnell Brain Imaging Centre, Montreal Neurological Institute, McGill University, Montreal, QC, Canada.,Department of Neurology and Neurosurgery, Medisch Spectrum Twente, Enschede, Netherlands.,Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
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19
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Knotkova H, Hamani C, Sivanesan E, Le Beuffe MFE, Moon JY, Cohen SP, Huntoon MA. Neuromodulation for chronic pain. Lancet 2021; 397:2111-2124. [PMID: 34062145 DOI: 10.1016/s0140-6736(21)00794-7] [Citation(s) in RCA: 160] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/24/2021] [Accepted: 03/31/2021] [Indexed: 12/23/2022]
Abstract
Neuromodulation is an expanding area of pain medicine that incorporates an array of non-invasive, minimally invasive, and surgical electrical therapies. In this Series paper, we focus on spinal cord stimulation (SCS) therapies discussed within the framework of other invasive, minimally invasive, and non-invasive neuromodulation therapies. These therapies include deep brain and motor cortex stimulation, peripheral nerve stimulation, and the non-invasive treatments of repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and transcutaneous electrical nerve stimulation. SCS methods with electrical variables that differ from traditional SCS have been approved. Although methods devoid of paraesthesias (eg, high frequency) should theoretically allow for placebo-controlled trials, few have been done. There is low-to-moderate quality evidence that SCS is superior to reoperation or conventional medical management for failed back surgery syndrome, and conflicting evidence as to the superiority of traditional SCS over sham stimulation or between different SCS modalities. Peripheral nerve stimulation technologies have also undergone rapid development and become less invasive, including many that are placed percutaneously. There is low-to-moderate quality evidence that peripheral nerve stimulation is effective for neuropathic pain in an extremity, low quality evidence that it is effective for back pain with or without leg pain, and conflicting evidence that it can prevent migraines. In the USA and many areas in Europe, deep brain and motor cortex stimulation are not approved for chronic pain, but are used off-label for refractory cases. Overall, there is mixed evidence supporting brain stimulation, with most sham-controlled trials yielding negative findings. Regarding non-invasive modalities, there is moderate quality evidence that repetitive transcranial magnetic stimulation does not provide meaningful benefit for chronic pain in general, but conflicting evidence regarding pain relief for neuropathic pain and headaches. For transcranial direct current stimulation, there is low-quality evidence supporting its benefit for chronic pain, but conflicting evidence regarding a small treatment effect for neuropathic pain and headaches. For transcutaneous electrical nerve stimulation, there is low-quality evidence that it is superior to sham or no treatment for neuropathic pain, but conflicting evidence for non-neuropathic pain. Future research should focus on better evaluating the short-term and long-term effectiveness of all neuromodulation modalities and whether they decrease health-care use, and on refining selection criteria and treatment variables.
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Affiliation(s)
- Helena Knotkova
- MJHS Institute for Innovation in Palliative Care, New York, NY, USA; Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Harquail Centre for Neuromodulation, University of Toronto, Toronto, ON, Canada
| | - Eellan Sivanesan
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Jee Youn Moon
- Department of Anesthesiology, Seoul National University, Seoul, South Korea
| | - Steven P Cohen
- Department of Neurology, Department of Physical Medicine & Rehabilitation, and Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Department of Physical Medicine & Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Marc A Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
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20
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High-dose spinal cord stimulation for patients with failed back surgery syndrome: a multicenter effectiveness and prediction study. Pain 2021; 162:582-590. [PMID: 32910099 DOI: 10.1097/j.pain.0000000000002035] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022]
Abstract
ABSTRACT The use of high-dose spinal cord stimulation (HD-SCS) has increased drastically during the past few years, with positive results. However, there remains a deficit of real-world data of the effectiveness of HD-SCS. Therefore, the primary aim was to evaluate the effectiveness of HD-SCS in patients with failed back surgery syndrome (FBSS). The second aim was to develop a prediction model for a holistic responder. One hundred ninety-four patients were recruited to a multicenter real-world registry. Self-reporting outcome variables were evaluated at baseline (before SCS) and at 1, 3, and 12 months of HD-SCS implant. Outcome measures were the mean pain intensity over time, sleep quality, disability, health-related quality of life, and medication use. Besides the effectiveness, logistic regression and decision tree analysis were performed to define a holistic responder (pain intensity reduction, medication reduction, Oswestry disability index reduction, and EQ5D improvement) after 12 months of HD-SCS. Of 185 FBSS patients who underwent a baseline visit, 75.13% had a successful HD trial. At 12 months, 92 patients were still receiving HD-SCS. Both low back and leg pain significantly decreased at 12 months. All outcome measures revealed a significant time-dependent effect from baseline to 12 months. Holistic responders could be predicted with a sensitivity and specificity of 90%. Clinically significant and sustained pain relief over a period of 12 months was achieved with HD-SCS in patients with FBSS. In addition, HD-SCS also achieved an improvement in sleep quality, functionality, and a decrease in pain medication.
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21
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Fan W, Sdrulla AD. Differential modulation of excitatory and inhibitory populations of superficial dorsal horn neurons in lumbar spinal cord by Aβ-fiber electrical stimulation. Pain 2021; 161:1650-1660. [PMID: 32068665 DOI: 10.1097/j.pain.0000000000001836] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Activation of Aβ-fibers is fundamental to numerous analgesic therapies, yet its effects on dorsal horn neuronal activity remain unclear. We used multiphoton microscopy of the genetically encoded calcium indicator GCaMP6s to characterize the effects of Aβ-fiber electrical stimulation (Aβ-ES) on neural activity. Specifically, we quantified somatic responses evoked by C-fiber intensity stimulation before and after a 10-minute train of dorsal root Aβ-ES in superficial dorsal horn (SDH) neurons, in mouse lumbar spinal cord. Aβ-ES did not alter C-fiber-evoked activity when GCaMP6s was virally expressed in all neurons, in an intact lumbar spinal cord preparation. However, when we restricted the expression of GCaMP6s to excitatory or inhibitory populations, we observed that Aβ-ES modestly potentiated evoked activity of excitatory neurons and depressed that of inhibitory neurons. Aβ-ES had no significant effects in a slice preparation in either SDH population. A larger proportion of SDH neurons was activated by Aβ-ES when delivered at a root rostral or caudal to the segment where the imaging and C-fiber intensity stimulation occurred. Aβ-ES effects on excitatory and inhibitory populations depended on the root used. Our findings suggest that Aβ-ES differentially modulates lumbar spinal cord SDH populations in a cell type- and input-specific manner. Furthermore, they underscore the importance of the Aβ-ES delivery site, suggesting that Aβ stimulation at a segment adjacent to where the pain is may improve analgesic efficacy.
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Affiliation(s)
- Wei Fan
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, United States
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22
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Parker T, Huang Y, Raghu ALB, FitzGerald J, Aziz TZ, Green AL. Supraspinal Effects of Dorsal Root Ganglion Stimulation in Chronic Pain Patients. Neuromodulation 2021; 24:646-654. [PMID: 33974317 DOI: 10.1111/ner.13408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Dorsal root ganglion stimulation (DRGS) has become a popular neuromodulatory treatment for neuropathic pain. We used magnetoencephalography (MEG) to investigate potential biomarkers of pain and pain relief, based on the differences in power spectral density (PSD) during varying degrees of pain and how these oscillations change during DRGS-mediated pain relief. MATERIALS AND METHODS Thirteen chronic pain patients with implanted dorsal root ganglion stimulators were included in the MEG analysis. MEG Recordings were performed at rest while the stimulator was turned ON or OFF. Numerical rating scale (NRS) scores were also recorded before and after DRGS was turned OFF and ON. Power spectral and source localization analyses were then performed on preprocessed MEG recordings. RESULTS With DRGS-OFF, patients in severe pain had significantly increased cortical theta (4-7 Hz) power and decreased cortical alpha (7-13 Hz) power compared to patients reporting less pain. This shift in power toward lower frequencies was contrasted by a shift toward the higher frequency power spectrum (low beta 13-20 Hz activity) during DRGS-mediated pain relief. A significant correlation was found between the increase in low beta activity and the degree of reported pain relief. CONCLUSION Our results demonstrate increased low-frequency power spectral activity in chronic pain patients in the absence of stimulation which shifts toward higher frequency power spectrum activity in response to therapeutic DRGS. These cortical changes in response to DRGS provide support for the use of neuroimaging in the search for potential biomarkers of pain.
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Affiliation(s)
- Tariq Parker
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Yongzhi Huang
- Academy of Medical Engineering and Translational Medicine, Tianjin University, Tianjin, China
| | - Ashley L B Raghu
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - James FitzGerald
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Tipu Z Aziz
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alexander L Green
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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23
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Vallejo R, Kelley CA, Gupta A, Smith WJ, Vallejo A, Cedeño DL. Modulation of neuroglial interactions using differential target multiplexed spinal cord stimulation in an animal model of neuropathic pain. Mol Pain 2021; 16:1744806920918057. [PMID: 32290778 PMCID: PMC7160773 DOI: 10.1177/1744806920918057] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The development and maintenance of chronic neuropathic pain involves distorted
neuroglial interactions, which result in prolonged perturbations of immune and
inflammatory response, as well as disrupted synapses and cellular interactions.
Spinal cord stimulation (SCS) has proven effective and safe for more than
40 years, but comprehensive understanding of its mode of action remains elusive.
Previous work in our laboratory provided evidence that conventional SCS
parameters modulate biological processes associated with neuropathic pain in
animals. This inspired the development of differential target multiplexed
programming (DTMP) in which multiple electrical signals are used for modulating
glial cells and neurons in order to rebalance their interactions. This work
compares DTMP with both low rate and high rate programming using an animal model
of neuropathic pain. The spared nerve injury model was implemented in 48 rats
equally randomized into four experimental groups: No-SCS, DTMP, low rate, and
high rate. Naive animals (N = 7) served as a reference control. SCS was applied
continuously for 48 h and pain-related behavior assessed before and after SCS.
RNA from the spinal cord exposed to SCS was sequenced to determine changes in
gene expression as a result of injury (No-SCS vs. naïve) and as a result of SCS
(SCS vs. No-SCS). Bioinformatics tools (Weighted Gene Co-expression Network
Analysis and Gene Ontology Enrichment Analysis) were used to evaluate the
significance of the results. All three therapies significantly reduced
mechanical hypersensitivity, although DTMP provided statistically better results
overall. DTMP also reduced thermal hypersensitivity significantly.
RNA-sequencing corroborated the complex effects of nerve injury on the
transcriptome. In addition, DTMP provided significantly more effective
modulation of genes associated with pain-related processes in returning their
expression toward levels observed in naïve, noninjured animals. DTMP provides a
more effective way of modulating the expression of genes involved in
pain-relevant biological processes associated with neuroglial interactions.
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Affiliation(s)
- Ricardo Vallejo
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Courtney A Kelley
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
| | - Ashim Gupta
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA.,Department of Research, South Texas Orthopaedic Research Institute, Laredo, TX, USA
| | - William J Smith
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Alejandro Vallejo
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA
| | - David L Cedeño
- Department of Basic Science, Millennium Pain Center, Bloomington, IL, USA.,Department of Psychology, Illinois Wesleyan University, Bloomington, IL, USA
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Fisher AS, Lanigan MT, Upton N, Lione LA. Preclinical Neuropathic Pain Assessment; the Importance of Translatability and Bidirectional Research. Front Pharmacol 2021; 11:614990. [PMID: 33628181 PMCID: PMC7897667 DOI: 10.3389/fphar.2020.614990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/10/2020] [Indexed: 02/04/2023] Open
Abstract
For patients suffering with chronic neuropathic pain the need for suitable novel therapies is imperative. Over recent years a contributing factor for the lack of development of new analgesics for neuropathic pain has been the mismatch of primary neuropathic pain assessment endpoints in preclinical vs. clinical trials. Despite continuous forward translation failures across diverse mechanisms, reflexive quantitative sensory testing remains the primary assessment endpoint for neuropathic pain and analgesia in animals. Restricting preclinical evaluation of pain and analgesia to exclusively reflexive outcomes is over simplified and can be argued not clinically relevant due to the continued lack of forward translation and failures in the clinic. The key to developing new analgesic treatments for neuropathic pain therefore lies in the development of clinically relevant endpoints that can translate preclinical animal results to human clinical trials. In this review we discuss this mismatch of primary neuropathic pain assessment endpoints, together with clinical and preclinical evidence that supports how bidirectional research is helping to validate new clinically relevant neuropathic pain assessment endpoints. Ethological behavioral endpoints such as burrowing and facial grimacing and objective measures such as electroencephalography provide improved translatability potential together with currently used quantitative sensory testing endpoints. By tailoring objective and subjective measures of neuropathic pain the translatability of new medicines for patients suffering with neuropathic pain will hopefully be improved.
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Affiliation(s)
- Amy S Fisher
- Transpharmation Ltd., The London Bioscience Innovation Centre, London, United Kingdom
| | - Michael T Lanigan
- Transpharmation Ltd., The London Bioscience Innovation Centre, London, United Kingdom.,School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Neil Upton
- Transpharmation Ltd., The London Bioscience Innovation Centre, London, United Kingdom
| | - Lisa A Lione
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
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Multicentre, clinical trial of burst spinal cord stimulation for neck and upper limb pain NU-BURST: a trial protocol. Neurol Sci 2021; 42:3285-3296. [PMID: 33387056 DOI: 10.1007/s10072-020-04907-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain and most frequently utilised for Failed Back Surgery Syndrome (FBSS). BurstDR™ also known as DeRidder Burst-SCS, a novel waveform, has demonstrated superiority to conventional tonic stimulation of the thoracic spine in FBSS. There are case reports of an improvement in multidimensional pain outcomes using DeRidder Burst-SCS in the cervical spine for chronic neck and cervical radicular pain. The safety and efficacy of cervical DeRidder Burst-SCS stimulation still however remain undetermined. METHODS/DESIGN This is a prospective, multicentre feasibility trial evaluating the safety and therapeutic efficacy of DeRidder Burst-SCS stimulation for the treatment of chronic intractable neck pain with or without radiation to the arm, shoulder, and upper back. After baseline evaluation, subjects will undergo an SCS trial using the Abbott Invisible Trial system according to standard clinical procedures. During the trial phase, SCS leads will be implanted in the cervical epidural space. At the end of the SCS trial, subjects experiencing at least 50% pain relief will be considered for permanent implant. Pain intensity, medication usage, and other multidimensional pain outcomes will be collected. The timing of these will be at baseline, end of the SCS trial and at 3-, 6-, and 12-month visits. Incidence of adverse events will be collected throughout the study duration. DISCUSSION The results of this feasibility study will validate the efficacy and safety of DeRidder Burst-SCS stimulation in the cervical spine. The results obtained in this study will potentially be used to generate a level 1 evidence-based study with formal statistical hypotheses testing. TRIAL REGISTRATION www.clinicaltrials.gov Identifier: NCT03159169.
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Xu W, Zhang C, Sun B, Li D. Sustainable Effects of 8-Year Intermittent Spinal Cord Stimulation in a Patient with Thalamic Post-Stroke Pain. World Neurosurg 2020; 143:223-227. [DOI: 10.1016/j.wneu.2020.07.195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
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Kumar S, Khoury A, Searcy S. A Case Report on Spinal Cord Stimulation in an Atrophic Spinal Cord: What Exactly Are We Stimulating? Pain Pract 2020; 21:348-352. [PMID: 33010095 DOI: 10.1111/papr.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/25/2020] [Accepted: 09/11/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We present a patient with paraplegia secondary to anterior spinal cord infarct below T6, with subsequent development of chronic low-back and bilateral lower-extremity neuropathic pain with an atrophic cord. In this patient with reduced spinal cord mass and modified neuroanatomy, spinal cord stimulation was surprisingly very effective. OBJECTIVES The primary objective of this report is to describe a case in which a patient benefited from spinal cord stimulator therapy in a way that is not explained by the traditionally accepted mechanism of action. METHODS A spinal cord stimulator was implanted with two 16-contact leads placed in series starting at the top of T6. RESULTS He reported complete resolution of low-back pain and about 50% resolution of bilateral lower-extremity pain. CONCLUSION Traditionally accepted mechanisms of action of dorsal column stimulation and suppression of wide-dynamic-range neurons are unlikely to explain the relief obtained in our patient with an atrophic spinal cord. No single consensus has been reached on the primary mechanism through which spinal cord stimulation renders its therapeutic effects. Spinal cord stimulator therapy is promising, and the future direction of its study is discussed.
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Affiliation(s)
- Sanjeev Kumar
- Department of Anesthesiology/Pain Medicine, University of Florida, Gainesville, Florida, U.S.A
| | - Andrew Khoury
- Department of Anesthesiology/Pain Medicine, University of Florida, Gainesville, Florida, U.S.A
| | - Sam Searcy
- Department of Anesthesiology/Pain Medicine, University of Florida, Gainesville, Florida, U.S.A
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28
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Shu B, He SQ, Guan Y. Spinal Cord Stimulation Enhances Microglial Activation in the Spinal Cord of Nerve-Injured Rats. Neurosci Bull 2020; 36:1441-1453. [PMID: 32889636 DOI: 10.1007/s12264-020-00568-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/23/2020] [Indexed: 12/14/2022] Open
Abstract
Microglia can modulate spinal nociceptive transmission. Yet, their role in spinal cord stimulation (SCS)-induced pain inhibition is unclear. Here, we examined how SCS affects microglial activation in the lumbar cord of rats with chronic constriction injury (CCI) of the sciatic nerve. Male rats received conventional SCS (50 Hz, 80% motor threshold, 180 min, 2 sessions/day) or sham stimulation on days 18-20 post-CCI. SCS transiently attenuated the mechanical hypersensitivity in the ipsilateral hind paw and increased OX-42 immunoreactivity in the bilateral dorsal horns. SCS also upregulated the mRNAs of M1-like markers, but not M2-like markers. Inducible NOS protein expression was increased, but brain-derived neurotrophic factor was decreased after SCS. Intrathecal minocycline (1 μg-100 μg), which inhibits microglial activation, dose-dependently attenuated the mechanical hypersensitivity. Pretreatment with low-dose minocycline (1 μg, 30 min) prolonged the SCS-induced pain inhibition. These findings suggest that conventional SCS may paradoxically increase spinal M1-like microglial activity and thereby compromise its own ability to inhibit pain.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.,Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shao-Qiu He
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA. .,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA.
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29
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De Groote S, Goudman L, Van Schuerbeek P, Peeters R, Sunaert S, Linderoth B, De Andrés J, Rigoard P, De Jaeger M, Moens M. Effects of spinal cord stimulation on voxel-based brain morphometry in patients with failed back surgery syndrome. Clin Neurophysiol 2020; 131:2578-2587. [PMID: 32927213 DOI: 10.1016/j.clinph.2020.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/30/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Despite the clinical effectiveness of Spinal Cord Stimulation (SCS), potential structural brain modifications have not been explored. Our aim was to identify structural volumetric changes during subsensory SCS, in patients with Failed Back Surgery Syndrome (FBSS). METHODS In this cohort study, twenty-two FBSS patients underwent a magnetic resonance imaging protocol before SCS and 3 months after SCS. Clinical parameters were correlated with volumetric changes, calculated with voxel-based morphometry. RESULTS After 3 months, a significant volume decrease was found in the inferior frontal gyrus, precuneus, cerebellar posterior lobe and middle temporal gyrus. Significant increases were found in the inferior temporal gyrus, precentral gyrus and the middle frontal gyrus after SCS. Additionally, significant increases in volume of superior frontal and parietal white matter and a significant decrease in volume of white matter underlying the premotor/middle frontal gyrus were revealed after SCS. A significant correlation was highlighted between white matter volume underlying premotor/middle frontal gyrus and leg pain relief. CONCLUSIONS This study revealed for the first time that SCS is able to induce volumetric changes in gray and white matter, suggesting the reversibility of brain alterations after chronic pain treatment. SIGNIFICANCE Volumetric brain alterations are observable after 3 months of subsensory SCS in FBSS patients.
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Affiliation(s)
- Sander De Groote
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.; Pain in Motion International Research Group, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Peter Van Schuerbeek
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Ronald Peeters
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ Herestraat 49-bus 7003 54, 3000 Leuven, Belgium
| | - Stefan Sunaert
- Department of Radiology, Universitair Ziekenhuis Leuven, UZ Herestraat 49-bus 7003 54, 3000 Leuven, Belgium
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jose De Andrés
- Surgical Specialties Department Valencia University Medical School, and Department of Anesthesiology Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | - Philippe Rigoard
- Department of Neurosurgery, Poitiers University Hospital, Poitiers, France; Institut Pprime UPR 3346, CNRS, University of Poitiers, Poitiers, ISAE-ENSMA, France; PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.; Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Laarbeeklaan 103, 1090 Brussels, Belgium.
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30
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Gray CM, Adaralegbe AO, Kumar S. A Case Report of High Cervical Spinal Cord Stimulation for Chronic Otalgia and Tinnitus. A A Pract 2020; 14:e01261. [DOI: 10.1213/xaa.0000000000001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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31
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De Groote S, Goudman L, Linderoth B, Buyck F, Rigoard P, De Jaeger M, Van Schuerbeek P, Peeters R, Sunaert S, Moens M. A Regions of Interest Voxel-Based Morphometry Study of the Human Brain During High-Frequency Spinal Cord Stimulation in Patients With Failed Back Surgery Syndrome. Pain Pract 2020; 20:878-888. [PMID: 32470180 DOI: 10.1111/papr.12922] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/14/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The effectiveness of spinal cord stimulation (SCS) as pain-relieving treatment for failed back surgery syndrome (FBSS) has already been demonstrated. However, potential structural and functional brain alterations resulting from subsensory SCS are less clear. The aim of this study was to test structural volumetric changes in a priori chosen regions of interest related to chronic pain after 1 month and 3 months of high-frequency SCS in patients with FBSS. METHODS Eleven patients with FBSS who were scheduled for SCS device implantation were included in this study. All patients underwent a magnetic resonance imaging protocol before SCS device implantation 1 and 3 months after high-frequency SCS. Pain intensity, pain catastrophizing, and sleep quality were also measured. Regions-of-interest voxel-based morphometry was used to explore grey matter volumetric changes over time. Additionally, volumetric changes were correlated with changes in pain intensity, catastrophizing, and sleep quality. RESULTS Significant decreases were found in volume in the left and right hippocampus over time. More specifically, a significant difference was revealed between volumes before SCS implantation and after 3 months of SCS. Repeated-measures correlations revealed a significant positive correlation between volumetric changes in the left hippocampus and changes in back pain score over time and between volumetric changes in the right hippocampus and changes in back pain score over time. CONCLUSION In patients with FBSS, high-frequency SCS influences structural brain regions over time. The volume of the hippocampus was decreased bilaterally after 3 months of high-frequency SCS with a positive correlation with back pain intensity.
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Affiliation(s)
- Sander De Groote
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,Pain in Motion International Research Group, Vrije Universiteit Brussel, Jette, Belgium
| | - Bengt Linderoth
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Félix Buyck
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - Philippe Rigoard
- Spine & Neuromodulation Functional Unit, Poitiers University Hospital, Poitiers, France.,Institut Prime UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Poitiers, France.,PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Mats De Jaeger
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium
| | | | - Ronald Peeters
- Department of Radiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Stefan Sunaert
- Department of Radiology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium.,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium.,Department of Radiology, Universitair Ziekenhuis Brussel, Jette, Belgium
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Sun L, Fleetwood-Walker S, Mitchell R, Joosten EA, Cheung CW. Prolonged Analgesia by Spinal Cord Stimulation Following a Spinal Injury Associated With Activation of Adult Neural Progenitors. Pain Pract 2020; 20:859-877. [PMID: 32474998 DOI: 10.1111/papr.12921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 01/29/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Responses of spinal progenitors to spinal cord stimulation (SCS) following spinal cord injury (SCI) in rats were assessed to reveal their potential contribution to SCS-induced analgesia. METHODS Spinal epidural electrodes were implanted in rats at T12 rostral to a quadrant dorsal horn injury at T13. Further groups additionally received either a microlesion to the dorsolateral funiculus (DLF) or gabapentin (10 mg/kg). SCS was performed at 25 Hz for 10 minutes on day 4 (early SCS) and at 10 Hz for 10 minutes on day 8 (late SCS) after injury. Paw withdrawal threshold (PWT) was measured before injury, 30 minutes before or after SCS, and before cull on day 14, followed by immunostaining assessment. RESULTS Paw withdrawal thresholds in uninjured animals (51.0 ± 4.0 g) were markedly reduced after SCI (17.3 ± 2.2 g). This was significantly increased by early SCS (38.5 ± 5.2 g, P < 0.01) and further enhanced by late SCS (50.9 ± 1.9 g, P < 0.01) over 6 days. Numbers of neural progenitors expressing nestin, Sox2, and doublecortin (DCX) in the spinal dorsal horn were increased 6 days after SCS by 6-fold, 2-fold, and 2.5-fold, respectively (P < 0.05 to 0.01). The elevated PWT evoked by SCS was abolished by DLF microlesions (48.9 ± 2.6 g vs. 19.0 ± 3.9 g, P < 0.01) and the number of nestin-positive cells was reduced to the level without SCS (P < 0.05). Gabapentin enhanced late SCS-induced analgesia from 37.0 ± 3.9 g to 54.0 ± 0.8 g (P < 0.01) and increased gamma-aminobutyric acid (GABA)-ergic neuronal marker vesicular GABA transporter-positive newborn cells 2-fold (P < 0.01). CONCLUSIONS Spinal progenitor cells appear to be activated by SCS via descending pathways, which may be enhanced by gabapentin and potentially contributes to relief of SCI-induced neuropathic pain.
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Affiliation(s)
- Liting Sun
- Brain and Spinal Cord Innovation Research Center, The First Rehabilitation Hospital of Shanghai, Tongji University School of Medicine, Shanghai, China
| | - Sue Fleetwood-Walker
- Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Edinburgh, UK
| | - Rory Mitchell
- Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Edinburgh, UK
| | - Elbert A Joosten
- Department of Anesthesiology/Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Chi Wai Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, University of Hong Kong, HKSAR, China
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33
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Sawicki CM, Humeidan ML, Sheridan JF. Neuroimmune Interactions in Pain and Stress: An Interdisciplinary Approach. Neuroscientist 2020; 27:113-128. [PMID: 32441204 DOI: 10.1177/1073858420914747] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Mounting evidence indicates that disruptions in bidirectional communication pathways between the central nervous system (CNS) and peripheral immune system underlie the etiology of pathologic pain conditions. The purpose of this review is to focus on the cross-talk between these two systems in mediating nociceptive circuitry under various conditions, including nervous system disorders. Elevated and prolonged proinflammatory signaling in the CNS is argued to play a role in psychiatric illnesses and chronic pain states. Here we review current research on the dynamic interplay between altered nociceptive mechanisms, both peripheral and central, and physiological and behavioral changes associated with CNS disorders.
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Affiliation(s)
- Caroline M Sawicki
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA
| | - Michelle L Humeidan
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.,Institute for Behavioral Medicine Research, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - John F Sheridan
- Division of Biosciences, College of Dentistry, The Ohio State University, Columbus, OH, USA.,Institute for Behavioral Medicine Research, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.,Department of Neuroscience, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.,Center for Brain and Spinal Cord Repair, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
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34
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Telkes L, Hancu M, Paniccioli S, Grey R, Briotte M, McCarthy K, Raviv N, Pilitsis JG. Differences in EEG patterns between tonic and high frequency spinal cord stimulation in chronic pain patients. Clin Neurophysiol 2020; 131:1731-1740. [PMID: 32504934 DOI: 10.1016/j.clinph.2020.03.040] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/20/2020] [Accepted: 03/22/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the differences in neural patterns between spinal cord stimulation (SCS) waveforms (60-Hz tonic vs 10-KHz high frequency stimulation, HFS) and their correlation to stimulation-induced pain relief. METHODS We recorded 10-channel electroencephalogram (EEG) in response to stimulation ON and OFF in 9 chronic pain patients (4 women, 5 men) during SCS surgery and examined the intraoperative spatio-spectral EEG features. RESULTS We discovered stronger relative alpha power in the somatosensory region and higher trend in alpha/theta peak power ratio in frontal cortex with HFS. We also observed a shift in peak frequency from theta to alpha rhythms in HFS as compared to baseline and tonic stimulation, where slower theta activity was maintained. Further, a positive correlation was found between changes in Oswestry disability index (ODI) scores (from preoperative to postoperative) and HFS-induced alpha/theta peak power ratio in frontal and somatosensory regions. CONCLUSIONS Altogether, our findings suggest that dynamic spectral interactions in theta-alpha band and their spatial distributions might be the first intraoperative neural signatures of pain relief induced by HFS in chronic pain. SIGNIFICANCE Examining electrophysiological changes intraoperatively has a potential to elucidate response to SCS therapy prior to device selection, reducing the healthcare expenditures associated with failed implants.
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Affiliation(s)
- Llknur Telkes
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, NY, USA
| | - Maria Hancu
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, NY, USA
| | | | | | | | | | - Nataly Raviv
- Department of Neurosurgery, Albany Medical Center, NY, USA
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, NY, USA; Department of Neurosurgery, Albany Medical Center, NY, USA.
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35
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Lai Y, Pan Y, Wang L, Zhang C, Sun B, Li D. Spinal Cord Stimulation with Surgical Lead Improves Pain and Gait in Parkinson's Disease after a Dislocation of Percutaneous Lead: A Case Report. Stereotact Funct Neurosurg 2020; 98:104-109. [PMID: 32097953 DOI: 10.1159/000505707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 12/31/2019] [Indexed: 11/19/2022]
Abstract
Spinal cord stimulation (SCS) is receiving increasing interests for treating pain and gait disorders in patients with Parkinson's disease (PD). In an SCS study, it is hard to apply a double-blind approach, especially at low frequencies, as the stimulation normally induces paresthesia which can be perceived by the patient. We herein demonstrate a case treated with SCS in which a blinding design was accomplished by an accidental dislocation of a stimulation lead. A 73-year-old man with PD was admitted to our hospital because of relapsed low back pain. This was due to the dislocation of a previously implanted SCS lead, which caused a decrease in its effectiveness in alleviating pain (from 81 to 43% measured by King's Parkinson's Disease Pain Scale) and improving gait (from 35 to 28% measured by the timed up and go test). A second SCS surgery using a paddle lead solved this problem, with improvements in pain and gait rebounded to 81 and 45%. In this case, the paresthesia induced by SCS (using either a paddle lead or percutaneous leads) was below the threshold of perception when the patient was sitting and standing, and a dislocation of one previously implanted percutaneous lead did not cause evident changes in his sensation of paresthesia. At last follow-up, the patient's quality of life had improved by 40% as measured by the 8-item Parkinson's Disease questionnaire (PDQ-8). This study could serve partly as a proof that low-frequency SCS is effective in improving pain as well as gait problems in PD patients, which was unlikely a result of a placebo effect.
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Affiliation(s)
- Yijie Lai
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yixin Pan
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Linbin Wang
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chencheng Zhang
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bomin Sun
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dianyou Li
- Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,
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Dombovy-Johnson ML, Hagedorn JM, Wilson RE, Canzanello NC, Pingree MJ, Watson JC. Spinal Cord Stimulation for Neuropathic Pain Treatment in Brachial Plexus Avulsions: A Literature Review and Report of Two Cases. Neuromodulation 2020; 23:704-712. [PMID: 32069374 DOI: 10.1111/ner.13128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/18/2020] [Accepted: 02/03/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND At least 50% of individuals who suffer a brachial plexus avulsion (BPA) will develop chronic pain, frequently more debilitating than their functional limitations. Similar to other neuropathic pain states, BPA pain is often refractory to pharmacological agents. Despite spinal cord stimulation (SCS) first being used for BPA in 1974, there have been no published literature reviews examining the current evidence of SCS for the treatment of neuropathic pain following BPA. In addition to a clinical review of the literature for this indication, we also share our experience with high-frequency SCS (HF-SCS) for BPA-related pain. METHODS MEDLINE and EMBASE databases were searched. All published articles including at least one BPA individual treated with SCS for pain treatment were included. RESULTS The initial search identified 288 articles, of which 13 met inclusion criteria for a total of 41 patients. These patients were primarily male and underwent SCS with reported improved pain scores. CASE REPORTS HF-SCS leads were percutaneously placed in two male patients who suffered BPA from traumatic injuries. At follow-ups of 13 and eight months, respectively, both patients continued to report an improvement in their pain. CONCLUSIONS Despite published reports showing benefit for pain control in patients with BPA, the overall low quality, retrospective evidence included in this review highlights the need for a rigorous prospective study to further address this indication.
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Affiliation(s)
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rachel E Wilson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | | | - Matthew J Pingree
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - James C Watson
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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Ghorbanzadeh S, Alimadadi H, Zargar N, Dianat O. Effect of vibratory stimulation on pain during local anesthesia injections: a clinical trial. Restor Dent Endod 2019; 44:e40. [PMID: 31799168 PMCID: PMC6875536 DOI: 10.5395/rde.2019.44.e40] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/24/2019] [Accepted: 08/16/2019] [Indexed: 11/11/2022] Open
Abstract
Objectives This study aimed to assess the effect of DentalVibe on the level of pain experienced during anesthetic injections using 2 different techniques. Materials and Methods This randomized crossover clinical trial evaluated 60 patients who required 2-session endodontic treatment. Labial infiltration (LI) anesthesia was administered in the anterior maxilla of 30 patients, while inferior alveolar nerve block (IANB) was performed in the remaining 30 patients. 1.8 mL of 2% lidocaine was injected at a rate of 1 mL/min using a 27-gauge needle. DentalVibe was randomly assigned to either the first or second injection session. A visual analog scale was used to determine participants' pain level during needle insertion and the anesthetic injection. The paired t-test was applied to assess the efficacy of DentalVibe for pain reduction. Results In LI anesthesia, the pain level was 12.0 ± 15.5 and 38.1 ± 21.0 during needle insertion and 19.1 ± 16.1 and 48.9 ± 24.6 during the anesthetic injection using DentalVibe and the conventional method, respectively. In IANB, the pain level was 14.1 ± 15.9 and 35.1 ± 20.8 during needle insertion and 17.3 ± 14.2 and 39.5 ± 20.8 during the anesthetic injection using DentalVibe and the conventional method, respectively. DentalVibe significantly decreased the level of pain experienced during needle insertion and the anesthetic injection in anterior LI and mandibular IANB anesthesia. Conclusions The results suggest that DentalVibe can be used to reduce the level of pain experienced by adult patients during needle insertion and anesthetic injection.
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Affiliation(s)
- Sajedeh Ghorbanzadeh
- Department of Endodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hoda Alimadadi
- Department of Endodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nazanin Zargar
- Department of Endodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Dianat
- Division of Endodontics, University of Maryland School of Dentistry, Baltimore, MD, USA
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Spinal cord stimulation prevents paclitaxel-induced mechanical and cold hypersensitivity and modulates spinal gene expression in rats. Pain Rep 2019; 4:e785. [PMID: 31875188 PMCID: PMC6882571 DOI: 10.1097/pr9.0000000000000785] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 01/28/2023] Open
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Paclitaxel-induced peripheral neuropathy (PIPN) is a common dose-limiting side effect of this cancer treatment drug. Spinal cord stimulation (SCS) has demonstrated efficacy for attenuating some neuropathic pain conditions. Objective: We aim to examine the inhibitory effect of SCS on the development of PIPN pain and changes of gene expression in the spinal cord in male rats after SCS. Methods: We examined whether traditional SCS (50 Hz, 6–8 h/session daily for 14 consecutive days) administered during paclitaxel treatment (1.5 mg/kg, i.p.) attenuates PIPN-related pain behavior. After SCS treatment, we performed RNA-seq of the lumbar spinal cord to examine which genes are differentially expressed after PIPN with and without SCS. Results: Compared to rats treated with paclitaxel alone (n = 7) or sham SCS (n = 6), SCS treatment (n = 11) significantly inhibited the development of paclitaxel-induced mechanical and cold hypersensitivity, without altering open-field exploratory behavior. RNA-seq showed that SCS induced upregulation of 836 genes and downregulation of 230 genes in the spinal cord of paclitaxel-treated rats (n = 3) as compared to sham SCS (n = 5). Spinal cord stimulation upregulated immune responses in paclitaxel-treated rats, including transcription of astrocyte- and microglial-related genes, but repressed transcription of multiple gene networks associated with synapse transmission, neuron projection development, γ-aminobutyric acid reuptake, and neuronal plasticity. Conclusion: Our findings suggest that traditional SCS may attenuate the development of pain-related behaviors in PIPN rats, possibly by causing aggregate inhibition of synaptic plasticity through upregulation and downregulation of gene networks in the spinal cord.
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Chakravarthy K, Fishman MA, Zuidema X, Hunter CW, Levy R. Mechanism of Action in Burst Spinal Cord Stimulation: Review and Recent Advances. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:S13-S22. [PMID: 31152180 PMCID: PMC6544550 DOI: 10.1093/pm/pnz073] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This is a comprehensive, structured review synthesizing and summarizing the current experimental data and knowledge about the mechanisms of action (MOA) underlying spinal cord stimulation with the burst waveform (as defined by De Ridder) in chronic pain treatment. METHODS Multiple database queries and article back-searches were conducted to identify the relevant literature and experimental findings for results integration and interpretation. Data from recent peer-reviewed conference presentations were also included for completeness and to ensure that the most up-to-date scientific information was incorporated. Both human and animal data were targeted in the search to provide a translational approach in understanding the clinical relevance of the basic science findings. RESULTS/CONCLUSIONS Burst spinal cord stimulation likely provides pain relief via multiple mechanisms at the level of both the spinal cord and the brain. The specific waveforms and temporal patterns of stimulation both play a role in the responses observed. Differential modulation of neurons in the dorsal horn and dorsal column nuclei are the spinal underpinnings of paresthesia-free analgesia. The burst stimulation pattern also produces different patterns of activation within the brain when compared with tonic stimulation. The latter may have implications for not only the somatic components of chronic pain but also the lateral and affective pathway dimensions as well.
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Affiliation(s)
| | | | - Xander Zuidema
- Department of Anesthesiology and Pain Management, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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Li H, Dong X, Cheng W, Jin M, Zheng D. Neuroprotective mechanism involved in spinal cord stimulation postconditioning. J Thorac Cardiovasc Surg 2019; 159:813-824.e1. [PMID: 31030961 DOI: 10.1016/j.jtcvs.2019.03.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 02/25/2019] [Accepted: 03/13/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Delayed paraplegia developed postoperatively after thoracoabdominal aneurysm surgery is primarily associated with spinal cord ischemia/reperfusion injury. Our previous study suggested that spinal cord stimulation postconditioning protected the spinal cord from ischemia/reperfusion injury through microglia inhibition. In this study, we further investigated whether α7 nicotinic acetylcholine receptors were involved in the neuroprotective mechanism of spinal cord stimulation. METHODS Rabbits were randomly assigned to sham, control, 2 Hz, α-bungarotoxin, and 2 Hz-α-bungarotoxin groups (n = 24/group). Transient spinal cord ischemia was performed on all rabbits except rabbits in the sham group. Rabbits in the control group received no further intervention, rabbits in the 2 Hz group were given 2 Hz spinal cord stimulation, rabbits in the α-bungarotoxin group received prescribed intrathecal α-bungarotoxin (α-bungarotoxin, a specific α7 nicotinic acetylcholine receptor antagonist) injections, and rabbits in the 2 Hz-α-bungarotoxin group received both α-bungarotoxin injections and 2 Hz spinal cord stimulation. Hind-limb neurologic function was assessed, and spinal cord histologic examination, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling staining, and microglia staining were performed at 8 hours, 1 day, 3 days, and 7 days of reperfusion. RESULTS Rabbits in the 2 Hz group had significantly better neurologic functions, more α-motor neurons, and lower terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-positive neuron rates and microglia area/anterior horn area ratios (microglia area ratios) than the control group. The neurologic functions of the α-bungarotoxin group were significantly worse than those of the control group, whereas other results were not significantly different from the control group. The results of the 2 Hz-α-bungarotoxin group were insignificant to the control group except for the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling-positive neuron rates, which were significantly lower than in the control group. CONCLUSIONS The neuroprotective effects of spinal cord stimulation postconditioning against spinal cord ischemia/reperfusion injury were partially mediated by activating α7 nicotinic acetylcholine receptors.
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Affiliation(s)
- Huixian Li
- Department of Cardiac Surgery, The First Hospital of Tsinghua University, Beijing, China
| | - Xiuhua Dong
- Department of Anesthesiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Weiping Cheng
- Department of Anesthesiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China.
| | - Mu Jin
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
| | - Deqiang Zheng
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.
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