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da Cunha PHM, de Andrade DC. The deep and the deeper: Spinal cord and deep brain stimulation for neuropathic pain. Presse Med 2024; 53:104231. [PMID: 38636785 DOI: 10.1016/j.lpm.2024.104231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/04/2024] [Indexed: 04/20/2024] Open
Abstract
Neuropathic pain occurs in people experiencing lesion or disease affecting the somatosensorial system. It is present in 7 % of the general population and may not fully respond to first- and second-line treatments in up to 40 % of cases. Neuromodulation approaches are often proposed for those not tolerating or not responding to usual pharmacological management. These approaches can be delivered surgically (invasively) or non-invasively. Invasive neuromodulation techniques were the first to be employed in neuropathic pain. Among them is spinal cord stimulation (SCS), which consists of the implantation of epidural electrodes over the spinal cord. It is recommended in some guidelines for peripheral neuropathic pain. While recent studies have called into question its efficacy, others have provided promising data, driven by advances in techniques, battery capabilities, programming algorithms and software developments. Deep brain stimulation (DBS) is another well-stablished neuromodulation therapy routinely used for movement disorders; however, its role in pain management remains limited to specific research centers. This is not only due to variable results in the literature contesting its efficacy, but also because several different brain targets have been explored in small trials, compromising comparisons between these studies. Structures such as the periaqueductal grey, posterior thalamus, anterior cingulate cortex, ventral striatum/anterior limb of the internal capsule and the insula are the main targets described to date in literature. SCS and DBS present diverse rationales for use, mechanistic backgrounds, and varying levels of support from experimental studies. The present review aims to present their methodological details, main mechanisms of action for analgesia and their place in the current body of evidence in the management of patients with neuropathic pain, as well their particularities, effectiveness, safety and limitations.
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Affiliation(s)
| | - Daniel Ciampi de Andrade
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
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Patron M, Neset M, Mielkozorova M, Bisson DG, Vigouroux M, Cata JP, Ingelmo PM, Ouellet JA, Haglund L, Komarova SV. Markers of Tissue Deterioration and Pain on Earth and in Space. J Pain Res 2024; 17:1683-1692. [PMID: 38742243 PMCID: PMC11089065 DOI: 10.2147/jpr.s450180] [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: 11/16/2023] [Accepted: 04/25/2024] [Indexed: 05/16/2024] Open
Abstract
Purpose Pain is an understudied physiological effect of spaceflight. Changes in inflammatory and tissue degradation markers are often associated with painful conditions. Our aim was to evaluate the changes in markers associated with tissue deterioration after a short-term spaceflight. Patients and Methods Plasma levels of markers for systemic inflammation and tissue degeneration markers were assessed in two astronauts before and within 24 h after the 17-day Axiom Space AX-1 mission. Results After the spaceflight, C-reactive protein (CRP) was reduced in both astronauts, while INFγ, GM-CSF, TNFα, BDNF, and all measured interleukins were consistently increased. Chemokines demonstrated variable changes, with consistent positive changes in CCL3, 4, 8, 22 and CXCL8, 9, 10, and consistent negative change in CCL8. Markers associated with tissue degradation and bone turnover demonstrated consistent increases in MMP1, MMP13, NTX and OPG, and consistent decreases in MMP3 and MMP9. Conclusion Spaceflight induced changes in the markers of systemic inflammation, tissue deterioration, and bone resorption in two astronauts after a short, 17-day, which were often consistent with those observed in painful conditions on Earth. However, some differences, such as a consistent decrease in CRP, were noted. All records for the effect of space travel on human health are critical for improving our understanding of the effect of this unique environment on humans.
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Affiliation(s)
- Madalina Patron
- Shriners Hospital for Children, Montreal, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Canada
| | - Mattias Neset
- Shriners Hospital for Children, Montreal, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Canada
| | - Mariia Mielkozorova
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Canada
| | - Daniel G Bisson
- Shriners Hospital for Children, Montreal, Canada
- Orthopaedic Research Laboratory, Department of Surgery, McGill University, Montreal, Canada
| | - Marie Vigouroux
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, Montreal, QC, Canada
| | - Juan Pablo Cata
- Department of Anesthesia and Perioperative Medicine, The University of Texas – MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Pablo M Ingelmo
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, Montreal, QC, Canada
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, Canada
- Research Institute, McGill University Health Center, Montreal, Canada
| | - Jean A Ouellet
- Shriners Hospital for Children, Montreal, Canada
- Orthopaedic Research Laboratory, Department of Surgery, McGill University, Montreal, Canada
| | - Lisbet Haglund
- Shriners Hospital for Children, Montreal, Canada
- Orthopaedic Research Laboratory, Department of Surgery, McGill University, Montreal, Canada
| | - Svetlana V Komarova
- Shriners Hospital for Children, Montreal, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Canada
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Chitneni A, Jain E, Sahni S, Mavrocordatos P, Abd-Elsayed A. Spinal Cord Stimulation Waveforms for the Treatment of Chronic Pain. Curr Pain Headache Rep 2024:10.1007/s11916-024-01247-1. [PMID: 38607547 DOI: 10.1007/s11916-024-01247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE OF REVIEW Since the advent of spinal cord stimulation (SCS), advances in technology have allowed for improvement and treatment of various conditions, especially chronic pain. Additionally, as the system has developed, the ability to provide different stimulation waveforms for patients to treat different conditions has improved. The purpose and objective of the paper is to discuss basics of waveforms and present the most up-to-date literature and research studies on the different types of waveforms that currently exist. During our literature search, we came across over sixty articles that discuss the various waveforms we intend to evaluate. RECENT FINDINGS There are several publications on several waveforms used in clinical practice, but to our knowledge, this is the only educational document teaching on waveforms which provides essential knowledge. There is a gap of knowledge related to understanding wave forms and how they work.
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Affiliation(s)
- Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USA
| | - Esha Jain
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, Madison, WI, B6/319 CSC53792-3272, USA.
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Kobayashi R, Taketomi A, Hara E, Mera H, Oe K. Temporary Spinal Cord Stimulation for Herpes Zoster With Myelitis: A Case Series. Cureus 2024; 16:e55979. [PMID: 38606211 PMCID: PMC11006553 DOI: 10.7759/cureus.55979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction: Preventing the development of postherpetic neuralgia (PHN), the most prevalent and severe complication of herpes zoster (HZ), is vital. Recently, it has been suggested that using temporary spinal cord stimulation (tSCS) for 10-14 days can improve HZ-associated pain (ZAP) and prevent PHN. However, myelitis complicates HZ. Permanent SCS has been successful in treating neuropathic pain induced by postoperative transverse myelitis of the spine that has not responded to traditional multidisciplinary treatment. However, it is unknown whether tSCS can reduce ZAP complicated with myelitis. Methodology: Between January 2020 and April 2022, all patients with HZ who visited our pain clinic with spinal cord edema and who underwent tSCS were enrolled in this study; their medical records were retrospectively examined. Pain intensity was assessed at baseline (before initiating interventional procedures), just before tSCS, after tSCS removal, and one and three months after tSCS. Results: Twelve patients were enrolled. The mean Numerical Rating Scale (NRS) was 7.9 ± 1.6 at baseline (before interventional procedures), 6.8 ± 2.2 before tSCS (after interventional procedures), and 3.5 ± 2.4 after tSCS. Compared with before tSCS, the mean NRS decreased to 3.3 ± 2.3 after tSCS (P = 0.0004). The mean NRS changes with interventional procedures before and after tSCS were -1.2 ± 2.2 (P = 0.0945) and 3.3 ± 2.3 (P = 0.0004), respectively; the change after tSCS was significantly higher (between-group difference: -2.1 ± 3.7; P = 0.0324). Conclusions: Temporary SCS alleviated pain in cases of shingles with myelitis refractory to interventional therapy. Even in cases with myelitis, tSCS for ZAP remains an effective way to prevent PHN.
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Affiliation(s)
- Reon Kobayashi
- Anesthesiology, Showa University School of Medicine, Tokyo, JPN
| | - Asae Taketomi
- Anesthesiology, Showa University School of Medicine, Tokyo, JPN
| | - Eiko Hara
- Anesthesiology, Showa University School of Medicine, Tokyo, JPN
| | - Hitoshi Mera
- Anesthesiology, Showa University School of Medicine, Tokyo, JPN
| | - Katsunori Oe
- Anesthesiology, Showa University School of Medicine, Tokyo, JPN
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Wahezi SE, Caparo MA, Malhotra R, Sundaram L, Batti K, Ejindu P, Veeramachaneni R, Anitescu M, Hunter CW, Naeimi T, Farah F, Kohan L. Current Waveforms in Spinal Cord Stimulation and Their Impact on the Future of Neuromodulation: A Scoping Review. Neuromodulation 2024; 27:47-58. [PMID: 38184341 DOI: 10.1016/j.neurom.2023.11.002] [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: 09/10/2023] [Revised: 10/16/2023] [Accepted: 11/13/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Neuromodulation is a standard and well-accepted treatment for chronic refractory neuropathic pain. There has been progressive innovation in the field over the last decade, particularly in areas of spinal cord stimulation (SCS) and dorsal root ganglion stimulation. Improved outcomes using proprietary waveforms have become customary in the field, leading to an unprecedented expansion of these products and a plethora of options for the management of pain. Although advances in waveform technology have improved our fundamental understanding of neuromodulation, a scoping review describing new energy platforms and their associated clinical effects and outcomes is needed. The authors submit that understanding electrophysiological neuromodulation may be important for clinical decision-making and programming selection for personalized patient care. OBJECTIVE This review aims to characterize ways differences in mechanism of action and clinical outcomes of current spinal neuromodulation products may affect contemporary clinical decision-making while outlining a possible path for the future SCS. STUDY DESIGN The study is a scoping review of the literature about newer generation SCS waveforms. MATERIALS AND METHODS A literature report was performed on PubMed and chapters to include articles on spine neuromodulation mechanism of action and efficacy. RESULTS A total of 8469 studies were identified, 75 of which were included for the scoping review after keywords defining recent waveform technology were added. CONCLUSIONS Clinical data suggest that neuromodulation remains a promising tool in the treatment of chronic pain. The evidence for SCS for treating chronic pain seems compelling; however, more long-term and comparative data are needed for a comparison of waveforms when it comes to the etiology of pain. In addition, an exploration into combination waveform therapy and waveform cycling may be paramount for future clinical studies and the development of new technologies.
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Affiliation(s)
- Sayed E Wahezi
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA.
| | - Moorice A Caparo
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Ria Malhotra
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Lakshman Sundaram
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Kevin Batti
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Prince Ejindu
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | | | - Magdalena Anitescu
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Corey W Hunter
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Tahereh Naeimi
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Fadi Farah
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
| | - Lynn Kohan
- Multidisciplinary Pain Program, Montefiore Medical Center, Bronx, New York, USA
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Puk O, Jabłońska M, Sokal P. Immunomodulatory and endocrine effects of deep brain stimulation and spinal cord stimulation - A systematic review. Biomed Pharmacother 2023; 168:115732. [PMID: 37862972 DOI: 10.1016/j.biopha.2023.115732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023] Open
Abstract
INTRODUCTION Deep Brain Stimulation (DBS) and Spinal Cord Stimulation (SCS) represent burgeoning treatments for diverse neurological disorders. This systematic review aims to consolidate findings on the immunological and endocrine effects of DBS and SCS, shedding light on the intricate mechanisms of neuromodulation. MATERIALS AND METHODS This systematic review, aligned with PRISMA protocols, synthesizes findings from 33 references-20 on DBS and 13 on SCS-to unravel the immunological and endocrine impacts of neuromodulation. RESULTS DBS interventions exhibited divergent effects on cytokines, with an increase in hepcidin levels and a variable impact on the IL-6/IL-10 ratio. While some studies reported elevated IL-6, animal studies consistently demonstrated a reduction in IL-1β and IL-6, with no significant changes in TNF-α and an increase in IL-10. Noteworthy hormonal changes included decreased corticosterone and ACTH concentrations and increased oxytocin levels following DBS of the hypothalamus. SCS mirrored similar effects on interleukins, indicating a reduction in IL-6 and IL-1β and an increase in IL-10 levels. Additionally, SCS led to reduced VEGF levels and elevated expression of neurotrophic factors such as BDNF and GDNF, particularly under burst stimulation. CONCLUSIONS Both DBS and SCS exert anti-inflammatory effects, manifesting as a decrease in pro-inflammatory cytokines alongside the stimulation of anti-inflammatory cytokine synthesis. These findings, observed in both animal and human models, imply that neurostimulation may modify the trajectory of neurological diseases by modulating local immune responses in an immunomodulatory and endocrine manner. This comprehensive exploration sets the stage for future research endeavors in this evolving domain.
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Affiliation(s)
- Oskar Puk
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - Magdalena Jabłońska
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Paweł Sokal
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
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Dorrian RM, Berryman CF, Lauto A, Leonard AV. Electrical stimulation for the treatment of spinal cord injuries: A review of the cellular and molecular mechanisms that drive functional improvements. Front Cell Neurosci 2023; 17:1095259. [PMID: 36816852 PMCID: PMC9936196 DOI: 10.3389/fncel.2023.1095259] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Spinal cord injury (SCI) is a devastating condition that causes severe loss of motor, sensory and autonomic functions. Additionally, many individuals experience chronic neuropathic pain that is often refractory to interventions. While treatment options to improve outcomes for individuals with SCI remain limited, significant research efforts in the field of electrical stimulation have made promising advancements. Epidural electrical stimulation, peripheral nerve stimulation, and functional electrical stimulation have shown promising improvements for individuals with SCI, ranging from complete weight-bearing locomotion to the recovery of sexual function. Despite this, there is a paucity of mechanistic understanding, limiting our ability to optimize stimulation devices and parameters, or utilize combinatorial treatments to maximize efficacy. This review provides a background into SCI pathophysiology and electrical stimulation methods, before exploring cellular and molecular mechanisms suggested in the literature. We highlight several key mechanisms that contribute to functional improvements from electrical stimulation, identify gaps in current knowledge and highlight potential research avenues for future studies.
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Affiliation(s)
- Ryan M. Dorrian
- Spinal Cord Injury Research Group, School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia,*Correspondence: Ryan M. Dorrian,
| | | | - Antonio Lauto
- School of Science, Western Sydney University, Penrith, NSW, Australia
| | - Anna V. Leonard
- Spinal Cord Injury Research Group, School of Biomedicine, The University of Adelaide, Adelaide, SA, Australia
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8
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Desai MJ, Salmon J, Verrills P, Mitchell B, Du Toit N, Bates D, Vajramani G, Williams A, Love-Jones S, Patel N, Nikolic S, Mehta V, Ahmad A, Yu J, Christellis N, Harkin S, Baranidharan G, Levy R, Staats P, Malinowski MN, Makous J, Sullivan N, Kottalgi S, Hartley M, Mishra LN. A Novel Pulsed Stimulation Pattern in Spinal Cord Stimulation: Clinical Results and Postulated Mechanisms of Action in the Treatment of Chronic Low Back and Leg Pain. Neuromodulation 2023; 26:182-191. [PMID: 36503999 DOI: 10.1016/j.neurom.2022.10.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 10/23/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this article is to discuss the possible mechanisms of action (MOAs) and results of a pilot study of a novel, anatomically placed, and paresthesia-independent, neurostimulation waveform for the management of chronic intractable pain. MATERIALS AND METHODS A novel, multilayered pulsed stimulation pattern (PSP) that comprises three temporal layers, a Pulse Pattern layer, Train layer, and Dosage layer, was developed for the treatment of chronic intractable pain. During preliminary development, the utility was evaluated of anatomical PSP (aPSP) in human subjects with chronic intractable pain of the leg(s) and/or low back, compared with that of traditional spinal cord stimulation (T-SCS) and physiological PSP. The scientific theory and testing presented in this article provide the preliminary justification for the potential MOAs by which PSP may operate. RESULTS During the pilot study, aPSP (n = 31) yielded a greater decrease in both back and leg pain than did T-SCS (back: -60% vs -46%; legs: -63% vs -43%). In addition, aPSP yielded higher responder rates for both back and leg pain than did T-SCS (61% vs 48% and 78% vs 50%, respectively). DISCUSSION The novel, multilayered approach of PSP may provide multimechanistic therapeutic relief through preferential fiber activation in the dorsal column, optimization of the neural onset response, and use of both the medial and lateral pathway through the thalamic nuclei. The results of the pilot study presented here suggest a robust responder rate, with several subjects (five subjects with back pain and three subjects with leg pain) achieving complete relief from PSP during the acute follow-up period. These clinical findings suggest PSP may provide a multimechanistic, anatomical, and clinically effective management for intractable chronic pain. Because of the limited sample size of clinical data, further testing and long-term clinical assessments are warranted to confirm these preliminary findings.
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Affiliation(s)
- Mehul J Desai
- International Spine, Pain & Performance Center, Washington, DC, USA; School of Medicine and Health Sciences, George Washington University, Washington, DC, USA.
| | - John Salmon
- Department of Pain Management, Pain Care Perth and Western Australia, Perth, Western Australia, Australia
| | - Paul Verrills
- Department of Pain Management, Metro Pain, Melbourne, Victoria, Australia
| | - Bruce Mitchell
- Department of Pain Management, Metro Pain, Melbourne, Victoria, Australia
| | - Neels Du Toit
- Department of Pain Management, Metro Pain, Melbourne, Victoria, Australia
| | - Dan Bates
- Department of Pain Management, Metro Pain, Melbourne, Victoria, Australia
| | - Girish Vajramani
- Department of Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Adam Williams
- Department of Neurosurgery, University of Bristol, Bristol, UK
| | - Sarah Love-Jones
- Department of Pain Management, North Bristol National Health Service Trust, Bristol, UK
| | - Nikunj Patel
- Department of Neurosurgery, North Bristol National Health Service Trust, Bristol, UK
| | - Serge Nikolic
- Department of Pain Management, St Bartholomew's Hospital, London, UK
| | - Vivek Mehta
- Department of Pain Management, St Bartholomew's Hospital, London, UK
| | - Alia Ahmad
- Department of Pain Management, St Bartholomew's Hospital, London, UK
| | - James Yu
- Department of Pain Management, Sydney Spine and Pain, Sydney, New South Wales, Australia
| | - Nick Christellis
- Department of Pain Management, Pain Specialists Australia, Richmond, New South Wales, Australia
| | - Sam Harkin
- Department of Pain Management, Pain Specialists Australia, Richmond, New South Wales, Australia
| | - Ganesan Baranidharan
- Department of Pain Management, Leeds Teaching Hospital National Health Service Trust, Leeds, UK
| | - Robert Levy
- Department of Neurosurgery, Institute for Neuromodulation, Boca Raton, FL, USA
| | - Peter Staats
- Department of Pain Management, Premier Pain Centers, Shrewsbury, NJ, USA
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Novel Spinal Cord Stimulation Waveforms for Treating Back and Leg Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Neuromodulation 2022:S1094-7159(22)01364-2. [DOI: 10.1016/j.neurom.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 12/14/2022]
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10
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Alizadeh R, Sharifzadeh SR. Pathogenesis, etiology and treatment of failed back surgery syndrome. Neurochirurgie 2021; 68:426-431. [PMID: 34543614 DOI: 10.1016/j.neuchi.2021.09.005] [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: 12/11/2020] [Revised: 06/22/2021] [Accepted: 09/04/2021] [Indexed: 12/19/2022]
Abstract
Failed back surgery syndrome (FBSS) is associated with persistent lower back pain after and despite one or more surgical interventions. A number of factors underlie and maintain FBSS and successful management of pain chiefly depends on identifying them. Pharmacological, surgical, and non-surgical therapeutic measures are taken to treat the pain. Spinal cord stimulation and nerve stimulation have been widely practiced in this regard and enhanced pain reduction and patient satisfaction. In hernia and recurrent disc degeneration and sagittal imbalance, discectomy and/or fusion are indicated. The present review focuses on FBSS and its underlying components and on available treatment options.
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Affiliation(s)
- R Alizadeh
- Department of Anesthesiology and Intensive Care, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - S R Sharifzadeh
- Department of Orthopedic Surgery, School of Medicine, AJA University of Medical Science, Tehran, Iran.
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11
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Echeverria-Villalobos M, Mitchell J, Fiorda-Diaz J, Weaver T. Effects of Dorsal Column Spinal Cord Stimulation on Neuroinflammation: Revisiting Molecular Mechanisms and Clinical Outcomes on Chronic Lumbar/Leg Pain and Failed Back Surgery Syndrome. J Pain Res 2021; 14:2337-2345. [PMID: 34354373 PMCID: PMC8331196 DOI: 10.2147/jpr.s309872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/26/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE In this narrative review, we reviewed and discussed current literature describing the molecular mechanisms leading to neuroinflammation and its role in the onset and progression of chronic neuropathic lumbar and leg pain in patients with persistent spinal pain syndrome. In addition, we reviewed the proposed mechanisms and impact of spinal cord stimulation (SCS) on neuroinflammation. METHODS A broad search of current literature in PubMed, Embase, Scopus, Cochrane library, Medline/Ovid, and Web of Science was performed using the following terms and their combinations: "biomarkers", "chronic back and leg pain", "cytokines", "neuroinflammation", "spinal cord stimulation (scs)," and "spinal cord modulation". We selected: 1) articles published in the English language between January 2000 and July 2020 2) preclinical and clinical data 3) case reports 4) meta-analysis and systematic reviews and 5) conference abstracts. Manuscripts not disclosing methodology or without full-text availability were excluded. DISCUSSION SCS techniques have gradually evolved since inception to include novel methods such as burst-SCS, high frequency SCS, and differential targeted multiplexed SCS. The incidence of chronic pain after spine surgery is highly variable, with at least one third of patients developing persistent spinal pain syndrome. Novel SCS techniques have been associated with improved clinical and functional outcomes thus increasing patient quality of life. CONCLUSION Currently, health care providers rely on different options and methods for SCS when treating patients with refractory chronic lumbar pain and persistent spinal pain syndrome. Nevertheless, compelling clinical trials remain necessary to elucidate the long-term benefits and mechanisms of neuromodulation of all different types of SCS.
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Affiliation(s)
| | - Justin Mitchell
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Tristan Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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12
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Hellman A, Clum A, Maietta T, Srikanthan A, Patel V, Panse D, Zimmerman O, Neubauer P, Nalwalk J, Williams E, Ghoshal G, Burdette C, Pilitsis JG. Effects of external low intensity focused ultrasound on inflammatory markers in neuropathic pain. Neurosci Lett 2021; 757:135977. [PMID: 34023413 DOI: 10.1016/j.neulet.2021.135977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/18/2021] [Accepted: 05/18/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Changes in inflammatory cytokine levels contribute to the induction and maintenance of neuropathic pain. We have shown that external low intensity focused ultrasound (liFUS) reduces allodynia in a common peroneal nerve injury (CPNI). Here, we investigate an underlying mechanism of action for this treatment and measure the effect of liFUS on inflammatory markers. METHODS Male rats were divided into four groups: CPNI/liFUS, CPNI/shamliFUS, shamCPNI/liFUS, and shamCPNI/shamliFUS. Mechanical nociceptive thresholds were measured using Von Frey filaments (VFF) to confirm the absence/presence of allodynia at baseline, after CPNI, and after liFUS. Commercial microarray and ELISA assays were used to assess cytokine expression in the treated L5 dorsal root ganglion (DRG) and dorsal horn (DH) tissue 24 and 72 h after liFUS. RESULTS VFF thresholds were significantly reduced following CPNI in both groups that received the injury (p < 0.001). After liFUS, only the CPNI/liFUS cohort showed a significant increase in mechanical thresholds (p < 0.001). CPNI significantly increased TNFa, IL6, CNTF, IL1b (p < 0.05 for all) levels in the DRG and DH, compared to baseline, consistent with previous work in sciatic nerve injury. LiFUS in CPNI rats resulted in a decrease in these cytokines in DRG 72 h post-therapy (TNFa, IL6, CNTF and IL1b, p < 0.001). In the DH, IL1b, CNTF, and TNFa (p < 0.05 for all) decreased 72 h after liFUS. CONCLUSION We have demonstrated that liFUS modifies inflammatory cytokines in both DRG and DH in CPNI rats. These data provide evidence that liFUS, reverses the allodynic phenotype, in part, by altering inflammatory cytokine pathways.
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Affiliation(s)
- Abigail Hellman
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Alicia Clum
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Teresa Maietta
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Adithya Srikanthan
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Vraj Patel
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Drishti Panse
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | - Olivia Zimmerman
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | | | - Julia Nalwalk
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States
| | | | | | | | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical Center, Albany, NY, United States; Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, United States.
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13
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Conger A, Sperry BP, Cheney CW, Burnham TM, Mahan MA, Onofrei LV, Cushman DM, Wagner GE, Shipman H, Teramoto M, McCormick ZL. The Effectiveness of Spinal Cord Stimulation for the Treatment of Axial Low Back Pain: A Systematic Review with Narrative Synthesis. PAIN MEDICINE 2021; 21:2699-2712. [PMID: 32472130 DOI: 10.1093/pm/pnaa142] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Determine the effectiveness of spinal cord stimulation (SCS) for the treatment of axial low back pain (LBP) with or without leg pain. DESIGN Systematic review. SUBJECTS Persons aged ≥18 with axial LBP with or without accompanying leg pain. INTERVENTION Traditional low-frequency, burst, or high-frequency SCS. COMPARISON Sham, active standard of care treatment, or none. OUTCOMES The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement measured six or more months after treatment intervention. METHODS Publications in PubMed, MEDLINE, and Cochrane databases were reviewed through September 19, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Cochrane Risk of Bias Tool and GRADE system were used to assess individual study characteristics and overall quality. RESULTS Query identified 262 publications; 17 were suitable for inclusion. For high-frequency SCS, the only level 1 study showed that 79% (95% confidence interval = 70-87%) of patients reported ≥50% pain improvement. For low-frequency SCS, the only level 1 study reported no categorical data for axial LBP-specific outcomes; axial LBP improved by a mean 14 mm on the visual analog scale at six months. Meta-analysis was not performed due to study heterogeneity. CONCLUSIONS According to GRADE, there is low-quality evidence that high-frequency SCS compared with low-frequency SCS is effective in patients with axial LBP with concomitant leg pain. There is very low-quality evidence for low-frequency SCS for the treatment of axial LBP in patients with concomitant leg pain. There is insufficient evidence addressing the effectiveness of burst SCS to apply a GRADE rating.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Beau P Sperry
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cole W Cheney
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Taylor M Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mark A Mahan
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ligia V Onofrei
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Daniel M Cushman
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Graham E Wagner
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Hank Shipman
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
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Prasad Md A, Chakravarthy Md K. Review of complex regional pain syndrome and the role of the neuroimmune axis. Mol Pain 2021; 17:17448069211006617. [PMID: 33788654 PMCID: PMC8020088 DOI: 10.1177/17448069211006617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Complex regional pain syndrome (CRPS) is a progressive and painful disease of
the extremities that is characterized by continuous pain inconsistent with
the initial trauma. CRPS is caused by a multi-mechanism process that
involves both the peripheral and central nervous system, with a prominent
role of inflammation in CRPS pathophysiology. This review examines what is
currently known about the CRPS inflammatory and pain mechanisms, as well as
the possible impact of neurostimulation therapies on the neuroimmune axis of
CRPS. Study design A narrative review of preclinical and clinical studies provided an overview
of the pain and inflammatory mechanisms in CRPS and addressed the effect of
neurostimulation on immunomodulation. Methods A systematic literature search was conducted based on the PRISMA guidelines
between September 2015 to September 2020. Data sources included relevant
literature identified through searches of PubMed, Embase and the Cochrane
Database of Systematic Reviews. Results Sixteen preclinical and eight clinical studies were reviewed. Preclinical
studies identified different mechanisms of pain development in the acute and
chronic CRPS phases. Several preclinical and clinical studies investigating
inflammatory mechanisms, autoimmunity, and genetic profiles in CRPS,
supported a role of neuroinflammation in the pathophysiology of CRPS. The
immunomodulatory effects of neurostimulation therapy is still unclear,
despite clinical improvement in the CRPS patients. Conclusions Increasing evidence supports a role for inflammation and neuroinflammation in
CRPS pathophysiology. Preliminary neurostimulation findings, together with
the role of (neuro)inflammation in CRPS, seems to provide a compelling
rationale for its use in CRPS pain treatment. The possible immunomodulatory
effects of neurostimulation opens new therapeutic possibilities, however
further research is needed to gain a better understanding of the working
mechanisms.
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Affiliation(s)
- Amrita Prasad Md
- Axxon Pain, Brisbane Private Hospital, 259 Wickham Terrace, Brisbane, Queensland 4000, Australia
| | - Krishnan Chakravarthy Md
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA.,Department of Anesthesiology and Pain Medicine, VA San Diego Health Care, San Diego, CA, USA
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15
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Sokal P, Świtońska M, Kierońska S, Rudaś M, Harat M. The Impact of Electrical Stimulation of the Brain and Spinal Cord on Iron and Calcium-Phosphate Metabolism. Brain Sci 2021; 11:156. [PMID: 33503960 PMCID: PMC7912219 DOI: 10.3390/brainsci11020156] [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: 12/12/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Deep-brain stimulation (DBS) electrically modulates the subcortical brain regions. Under conditions of monopolar cerebral stimulation, electrical current flows between electrode's contacts and an implantable pulse generator, placed in the subclavicular area. Spinal cord stimulation (SCS) delivers an electrical current to the spinal cord. Epidural electrical stimulation is associated with the leakage of current, which can cause a generalized reaction. The aim of our study was to investigate whether the electrical stimulation of the cerebrum and spinal cord could have generalized effects on biochemical parameters. MATERIALS AND METHODS A total of 25 patients with Parkinson's disease (PD, n = 21) and dystonia (n = 4), who underwent DBS implantation, and 12 patients with chronic pain, who had SCS, received electrical stimulation. The blood levels of selected biochemical parameters were measured before and after overnight stimulation. RESULTS After DBS, the mean ± interquartile range (IQR) values for iron (off 15.6 ± 13.53 µmol/L; on: 7.65 ± 10.8 µmol/L; p < 0.001), transferrin (off: 2.42 ± 0.88 g/L; on: 1.99 ± 0.59 g/L; p < 0.001), transferrin saturation (off: 23.20 ± 14.50%; on: 10.70 ± 11.35%; p = 0.001), phosphate (off: 1.04 ± 0.2 mmol/L; on: 0.83 ± 0.2 mmol/L; p = 0.007), and total calcium (off: 2.39 ± 0.29 mmol/L; on: 2.27 ± 0.19 mmol/L; p = 0.016) were significantly reduced, whereas ferritin (off: 112.00 ± 89.00 ng/mL; on: 150.00 ± 89.00 ng/mL; p = 0.003) and C-reactive protein (off: 0.90 ± 19.39 mg/L; on: 60.35 ± 35.91 mg/L; p = 0.002) were significantly increased. Among patients with SCS, significant differences were observed for ferritin (off: 35 ± 63 ng/mL; on: 56 ± 62 ng/mL; p = 0.013), transferrin (off: 2.70 ± 0.74 g/L; on: 2.49 ± 0.69 g/L; p = 0.048), and C-reactive protein (off: 31.00 ± 36.40 mg/L; on: 36.60 ± 62.030 mg/L; p = 0.018) before and after electrical stimulation. No significant changes in the examined parameters were observed among patients after thalamotomy and pallidotomy. CONCLUSIONS Leaking electric current delivered to the subcortical nuclei of the brain and the dorsal column of the spinal cord exposes the rest of the body to a negative charge. The generalized reaction is associated with an inflammatory response and altered iron and calcium-phosphate metabolism. Alterations in iron metabolism due to electrical stimulation may impact the course of PD. Future research should investigate the influence of electric current and electromagnetic field induced by neurostimulators on human metabolism.
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Affiliation(s)
- Paweł Sokal
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital No 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (M.Ś.); (S.K.); (M.R.)
- Faculty of Health Science, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Jagielonska 13–15 Street, 85-067 Bydgoszcz, Poland;
| | - Milena Świtońska
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital No 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (M.Ś.); (S.K.); (M.R.)
- Faculty of Health Science, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Jagielonska 13–15 Street, 85-067 Bydgoszcz, Poland;
| | - Sara Kierońska
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital No 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (M.Ś.); (S.K.); (M.R.)
| | - Marcin Rudaś
- Department of Neurosurgery and Neurology, Jan Biziel University Hospital No 2, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (M.Ś.); (S.K.); (M.R.)
| | - Marek Harat
- Faculty of Health Science, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Jagielonska 13–15 Street, 85-067 Bydgoszcz, Poland;
- Department of Neurosurgery, The 10th Military Research Hospital, Powstanców Warszawy 5 Street, 85-081 Bydgoszcz, Poland
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16
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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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17
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Nagel SJ, Hsieh J, Machado AG, Frizon LA, Howard MA, Gillies GT, Wilson S. Biomarker Optimization of Spinal Cord Stimulation Therapies. Neuromodulation 2020; 24:3-12. [PMID: 32881257 DOI: 10.1111/ner.13252] [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: 03/02/2020] [Revised: 06/18/2020] [Accepted: 06/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We are in the process of designing and testing an intradural stimulation device that will shorten the distance between the location of the electrode array and the targeted neural tissue, thus improving the efficacy of electrical current delivery. Identifying a biomarker that accurately reflects the response to this intervention is highly valued because of the potential to optimize interventional parameters or predict a response before it is clinically measurable. In this report, we summarize the findings pertaining to the study of biomarkers so that we and others will have an up-to-date reference that critically evaluates the current approaches and select one or several for testing during the development of our device. MATERIALS AND METHODS We have conducted a broad survey of the existing literature to catalogue the biomarkers that could be coupled to intradural spinal cord stimulation. We describe in detail some of the most promising biomarkers, existing limitations, and suitability to managing chronic pain. RESULTS Chronic, intractable pain is an all-encompassing condition that is incurable. Many treatments for managing chronic pain are nonspecific in action and intermittently administered; therefore, patients are particularly susceptible to large fluctuations in pain control over the course of a day. The absence of a reliable biomarker challenges assessment of therapeutic efficacy and contributes to either incomplete and inconsistent pain relief or, alternatively, intolerable side effects. Fluctuations in metabolites or inflammatory markers, signals captured during dynamic imaging, and genomics will likely have a role in governing how a device is modulated. CONCLUSIONS Efforts to identify one or more biomarkers are well underway with some preliminary evidence supporting their efficacy. This has far-reaching implications, including improved outcomes, fewer adverse events, harmonization of treatment and individuals, performance gains, and cost savings. We anticipate that novel biomarkers will be used widely to manage chronic pain.
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Affiliation(s)
- Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Hsieh
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Leonardo A Frizon
- Department of Neurosurgery, Hospital Marcelino Champagnat, Curitiba, PR, Brazil
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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18
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Baranidharan G, Bretherton B, Kay T, Marsh N, Romanis C, Roberts B. BurstDR spinal cord stimulation in the treatment of chronic visceral pain. Pain Manag 2020; 10:319-329. [PMID: 32820670 DOI: 10.2217/pmt-2020-0014] [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] [Indexed: 12/26/2022] Open
Abstract
Background:Visceral pain can be disabling for patients and challenging to treat in the clinic. Spinal cord stimulation is a NICE approved treatment for chronic neuropathic pain, presenting potential advantages over conventional therapies for managing chronic visceral pain. Results: A retrospective study revealed that a specific type of spinal cord stimulation, BurstDRTM (Abbott, TX, USA), was effective at improving pain and quality of life in patients with chronic visceral pain. Baseline pain scores significantly correlated with change at follow-up, suggesting it may be possible to identify potential responders from the outset. BurstDR was safe: rates of revision, explantation and complications were low. Conclusion: Clinical trials exploring the long-term effects of BurstDR including a control arm are needed. Findings could have the potential to inform best practice and improve outcomes for individuals with chronic visceral pain.
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Affiliation(s)
- Ganesan Baranidharan
- Department of Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds UK.,School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Beatrice Bretherton
- Department of Pain Management, Leeds Teaching Hospitals NHS Trust, Leeds UK.,School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds UK
| | - Thomas Kay
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Nathan Marsh
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Charlotte Romanis
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
| | - Bethan Roberts
- School of Medicine, Faculty of Medicine & Health, University of Leeds, Leeds UK
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19
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Royds J, Conroy MJ, Dunne MR, Cassidy H, Matallanas D, Lysaght J, McCrory C. Examination and characterisation of burst spinal cord stimulation on cerebrospinal fluid cellular and protein constituents in patient responders with chronic neuropathic pain - A Pilot Study. J Neuroimmunol 2020; 344:577249. [PMID: 32361148 DOI: 10.1016/j.jneuroim.2020.577249] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/11/2020] [Accepted: 04/21/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Patients with neuropathic pain have altered proteomic and neuropeptide constituents in cerebrospinal fluid (CSF) compared to controls. Tonic spinal cord stimulation (SCS) has demonstrated differential expression of neuropeptides in CSF before and after treatment suggesting potential mechanisms of action. Burst-SCS is an evidence-based paraesthesia free waveform utilised for neuropathic pain with a potentially different mechanistic action to tonic SCS. This study examines the dynamic biological changes of CSF at a cellular and proteome level after Burst-SCS. METHODS Patients with neuropathic pain selected for SCS had CSF sampled prior to implant of SCS and following 8 weeks of continuous Burst-SCS. Baseline and 8-week pain scores with demographics were recorded. T cell frequencies were analysed by flow cytometry, proteome analysis was performed using mass spectrometry and secreted cytokines, chemokines and neurotrophins were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS 4 patients (2 females, 2 males) with a mean age of 51 years (+/-SEM 2.74, SD 5.48) achieved a reduction in pain of >50% following 8 weeks of Burst-SCS. Analysis of the CSF proteome indicated a significant alteration in protein expression most related to synapse assembly and immune regulators. There was significantly lower expression of the proteins: growth hormone A1 (PRL), somatostatin (SST), nucleobindin-2 (NUCB2), Calbindin (CALB1), acyl-CoA binding protein (DBI), proSAAS (PCSK1N), endothelin-3 (END3) and cholecystokinin (CCK) after Burst-SCS. The concentrations of secreted chemokines and cytokines and the frequencies of T cells were not significantly changed following Burst-SCS. CONCLUSION This study characterised the alteration in the CSF proteome in response to burst SCS in vivo. Functional analysis indicated that the alterations in the CSF proteome is predominately linked to synapse assembly and immune effectors. Individual protein analysis also suggests potential supraspinal mechanisms.
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Affiliation(s)
- Jonathan Royds
- Department of Pain Medicine, St. James Hospital, Dublin and School of Medicine, Trinity College Dublin, Ireland.
| | - Melissa J Conroy
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital and Trinity College Dublin, Dublin 8, Ireland
| | - Margaret R Dunne
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital and Trinity College Dublin, Dublin 8, Ireland
| | - Hilary Cassidy
- Systems Biology Ireland, School of Medicine, University College Dublin, Dublin 4, Ireland
| | - David Matallanas
- Systems Biology Ireland, School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Joanne Lysaght
- Department of Surgery, Trinity Translational Medicine Institute, St. James's Hospital and Trinity College Dublin, Dublin 8, Ireland
| | - Connail McCrory
- Department of Pain Medicine, St. James Hospital, Dublin and School of Medicine, Trinity College Dublin, Ireland
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20
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Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. Burst Spinal Cord Stimulation: A Clinical Review. PAIN MEDICINE 2020; 20:S31-S40. [PMID: 31152175 PMCID: PMC6544556 DOI: 10.1093/pm/pnz003] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective Clinical review on outcomes using burst spinal cord stimulation (SCS) in the treatment of chronic, intractable pain. Design Narrative clinical literature review conducted utilizing a priori search terms including key words for burst spinal cord stimulation. Synthesis and reporting of data from publications including an overview of comparative SCS outcomes. Results Burst SCS demonstrated greater pain relief over tonic stimulation in multiple studies, which included blinded, sham-controlled, randomized trials. Additionally, burst stimulation impacts multiple dimensions of pain, including somatic pain as well as emotional and psychological elements. Patient preference is weighted toward burst over tonic due to increased pain relief, a lack of paresthesias, and impression of change in condition. Conclusion Burst SCS has been shown to be both statistically and clinically superior to tonic stimulation and may provide additional benefits through different mechanisms of action. Further high-quality controlled studies are warranted to not only elucidate the basic mechanisms of burst SCS but also address how this unique stimulation signature/pattern may more adequately handle the multiple affective dimensions of pain in varying patient populations.
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Affiliation(s)
- Terje Kirketeig
- Multidisciplinary Pain Clinic, Uppsala University Hospital, Uppsala, Sweden; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Carsten Schultheis
- Departement für Interventionelle Schmerzmedizin, Krankenhaus Neuwerk "Maria von den Aposteln" Muskulo-Skeletales Zentrum Mönchengladbach, Germany
| | - 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
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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21
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Fishman MA, Antony A, Esposito M, Deer T, Levy R. The Evolution of Neuromodulation in the Treatment of Chronic Pain: Forward-Looking Perspectives. PAIN MEDICINE 2020; 20:S58-S68. [PMID: 31152176 PMCID: PMC6600066 DOI: 10.1093/pm/pnz074] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The field of neuromodulation is continually evolving, with the past decade showing significant advancement in the therapeutic efficacy of neuromodulation procedures. The continued evolution of neuromodulation technology brings with it the promise of addressing the needs of both patients and physicians, as current technology improves and clinical applications expand. Design This review highlights the current state of the art of neuromodulation for treating chronic pain, describes key areas of development including stimulation patterns and neural targets, expanding indications and applications, feedback-controlled systems, noninvasive approaches, and biomarkers for neuromodulation and technology miniaturization. Results and Conclusions The field of neuromodulation is undergoing a renaissance of technology development with potential for profoundly improving the care of chronic pain patients. New and emerging targets like the dorsal root ganglion, as well as high-frequency and patterned stimulation methodologies such as burst stimulation, are paving the way for better clinical outcomes. As we look forward to the future, neural sensing, novel target-specific stimulation patterns, and approaches combining neuromodulation therapies are likely to significantly impact how neuromodulation is used. Moreover, select biomarkers may influence and guide the use of neuromodulation and help objectively demonstrate efficacy and outcomes.
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Affiliation(s)
| | | | | | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Robert Levy
- Institute for Neuromodulation, Boca Raton, Florida, USA
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22
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Chakravarthy K, Malayil R, Kirketeig T, Deer T. Burst Spinal Cord Stimulation: A Systematic Review and Pooled Analysis of Real-World Evidence and Outcomes Data. PAIN MEDICINE 2020; 20:S47-S57. [PMID: 31152177 PMCID: PMC6544549 DOI: 10.1093/pm/pnz046] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective This review provides a comprehensive assessment of the effectiveness of burst spinal cord stimulation (SCS). Ratings of pain intensity (visual analog scale or numeric rating scale) and patient-reported outcomes (PROs) on functional/psychometric domains such as depression (Beck Depression Index), catastrophizing (Pain Catastrophizing Scale), surveillance (Pain Vigilance and Attention Questionnaire), and others are addressed. Design Articles were identified and selected from the literature according to prospective, replicable methods. Effectiveness data—pain scores and PRO ratings—were weighted by study sample sizes and pooled. The effects of burst SCS were compared against values at baseline and with tonic SCS. For PROs, published population norms were used for comparison. Results Fifteen articles, with a combined sample size of 427, were included. Follow-up ranged from a few hours to two years. A variety of prospective designs were employed, including crossover studies, single-arm cohorts, and a randomized controlled trial, as well as retrospective case reports. The weighted pooled mean pain rating across articles at baseline was 76.7 (±27.4). With tonic SCS, this was reduced to 49.2 (±12.9), and with burst SCS it was further reduced to 36.7 (±11.6), a 12.5-point difference between tonic and burst values. Psychometric analyses of PROs noted preferential improvement with burst SCS. In addition, 65% of subjects stated a preference for burst SCS. Conclusions In pooled analyses that incorporated all available published evidence, the improvement over baseline for burst SCS was shown to have a clinically important incremental benefit over tonic SCS. In addition, burst SCS may support resolution of the emotional or cognitive aspects of pain that are mediated by medial thalamo-cortical pathways. This study highlights the value in considering the entire knowledge base in therapeutic assessments as well as adopting a consistent set of outcome variables within neuromodulation. Burst SCS is a valuable intervention, providing both analgesia and psychometric benefits that warrant further thoughtful applications.
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Affiliation(s)
| | - Rudy Malayil
- St. Mary's Pain Relief Specialists, Huntington, West Virginia
| | - Terje Kirketeig
- Multidisciplinary Pain Clinic, Uppsala University Hospital, Uppsala, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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23
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De Andrés J, Navarrete-Rueda F, Fabregat G, García-Gutiérrez MS, Monsalve-Dolz V, Harutyunyan A, Mínguez-Martí A, Rodriguez-Lopez R, Manzanares J. Differences in Gene Expression of Endogenous Opioid Peptide Precursor, Cannabinoid 1 and 2 Receptors and Interleukin Beta in Peripheral Blood Mononuclear Cells of Patients With Refractory Failed Back Surgery Syndrome Treated With Spinal Cord Stimulation: Markers of Therapeutic Outcomes? Neuromodulation 2020; 24:49-60. [PMID: 32027775 DOI: 10.1111/ner.13111] [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: 09/03/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The use of spinal cord stimulation for patients with failed back surgery syndrome (FBSS) is very common. In order to better understand the mechanisms of action of spinal cord stimulation (SCS), our aim was to determine potential changes in relative gene and protein expression in the peripheral blood mononuclear cells (PBMCs) of patients as potential biomarkers of disease outcomes and potential new targets for therapy. METHODS Twenty-four patients with diagnosis of FBSS refractory to conservative therapy for at least six months were included in the study. Clinical evaluation in this study included validated questionnaires. Blood samples (10 mL) were collected five times from baseline until two months after implant of the leads. Proenkephalin (PENK), cannabinoid receptors CB1 and CB2, and interleukin 1β (IL 1β) were analyzed. Each patient served as his/her own control by comparing the samples collected at different time points against the baseline sample collected at T0. RESULTS A total of 16 patients met all relevant criteria during the whole study and were assessed. Only PENK showed significant changes over time (Friedman p = 0.000). A positive correlation was observed between changes in visual analog scale (VAS) scores and PENK and a negative correlation between changes in PENK and Short Form-12 (SF-12) mental component score (MCS) scores, as well as between changes in IL 1β and Pain Detect Questionnaire (PD-Q) scores. As PENK changes increased, so did pain (VAS). As changes in PENK increased, SF-12 MCS health worsened. As changes in IL 1β increased, PD-Q values decreased. No severe adverse events occurred. CONCLUSIONS Previously unknown effects of SCS on levels of PBMCs biomarkers are demonstrated. The findings of our research suggest a potential for useful integration of genome analysis and lymphocyte expression in the daily practice of neurostimulation for pain management and represent a novel road map in the light of the important questions that remain unanswered.
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Affiliation(s)
- Jose De Andrés
- Anesthesia Unit-Surgical specialties department. Valencia University Medical School. Department of Anesthesiology, Critical Care and Pain Management. General University Hospital, Valencia, Spain
| | | | - Gustavo Fabregat
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | | | - Vincente Monsalve-Dolz
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | - Anushik Harutyunyan
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | - Ana Mínguez-Martí
- Multidisciplinary Pain Management Division, Department of Anesthesia, General University Hospital, Valencia, Spain
| | | | - Jorge Manzanares
- Institute of Neurosciences, Miguel Hernández University, CSIC, Alicante, Spain
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Leptin and Associated Mediators of Immunometabolic Signaling: Novel Molecular Outcome Measures for Neurostimulation to Treat Chronic Pain. Int J Mol Sci 2019; 20:ijms20194737. [PMID: 31554241 PMCID: PMC6802360 DOI: 10.3390/ijms20194737] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/15/2019] [Accepted: 09/19/2019] [Indexed: 12/13/2022] Open
Abstract
Chronic pain is a devastating condition affecting the physical, psychological, and socioeconomic status of the patient. Inflammation and immunometabolism play roles in the pathophysiology of chronic pain disorders. Electrical neuromodulation approaches have shown a meaningful success in otherwise drug-resistant chronic pain conditions, including failed back surgery, neuropathic pain, and migraine. A literature review (PubMed, MEDLINE/OVID, SCOPUS, and manual searches of the bibliographies of known primary and review articles) was performed using the following search terms: chronic pain disorders, systemic inflammation, immunometabolism, prediction, biomarkers, metabolic disorders, and neuromodulation for chronic pain. Experimental studies indicate a relationship between the development and maintenance of chronic pain conditions and a deteriorated immunometabolic state mediated by circulating cytokines, chemokines, and cellular components. A few uncontrolled in-human studies found increased levels of pro-inflammatory cytokines known to drive metabolic disorders in chronic pain patients undergoing neurostimulation therapies. In this narrative review, we summarize the current knowledge and possible relationships of available neurostimulation therapies for chronic pain with mediators of central and peripheral neuroinflammation and immunometabolism on a molecular level. However, to address the needs for predictive factors and biomarkers, large-scale databank driven clinical trials are needed to determine the clinical value of molecular profiling.
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Kent AR, Weisshaar CL, Venkatesan L, Winkelstein BA. Burst & High-Frequency Spinal Cord Stimulation Differentially Effect Spinal Neuronal Activity After Radiculopathy. Ann Biomed Eng 2019; 48:112-120. [DOI: 10.1007/s10439-019-02336-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/30/2019] [Indexed: 01/21/2023]
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Caylor J, Reddy R, Yin S, Cui C, Huang M, Huang C, Rao R, Baker DG, Simmons A, Souza D, Narouze S, Vallejo R, Lerman I. Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectron Med 2019; 5:12. [PMID: 31435499 PMCID: PMC6703564 DOI: 10.1186/s42234-019-0023-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/30/2019] [Indexed: 12/30/2022] Open
Abstract
Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.
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Affiliation(s)
- Jacob Caylor
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Rajiv Reddy
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Sopyda Yin
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Christina Cui
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Mingxiong Huang
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
| | - Charles Huang
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Bioengineering, Stanford University, Palo Alto, CA USA
| | - Ramesh Rao
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
| | - Dewleen G. Baker
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Alan Simmons
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Ricardo Vallejo
- Basic Science Research, Millennium Pain Center, Bloomington, IL USA
- School of Biological Sciences, Illinois State University, Normal, IL USA
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL USA
| | - Imanuel Lerman
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
- Present Address: VA San Diego, 3350 La Jolla Village Dr, (MC116A), San Diego, CA 92161 USA
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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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The Elevated Serum Level of IFN- γ in Patients with Failed Back Surgery Syndrome Remains Unchanged after Spinal Cord Stimulation. DISEASE MARKERS 2019; 2019:2606808. [PMID: 30755780 PMCID: PMC6348905 DOI: 10.1155/2019/2606808] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/08/2018] [Accepted: 11/25/2018] [Indexed: 01/10/2023]
Abstract
Objectives We investigated the influence of spinal cord stimulation (SCS) on IFN-γ, IL-1β, IL-6, TNF-α, IL-10, and TGF-β serum levels in failed back surgery syndrome (FBSS) patients. The study will try to give new insights into the mechanism of SCS action and the role of IFN-γ and other cytokines in neuropathic pain (NP) development. Materials and Methods Clinical and biochemical assessment was conducted in four groups of patients: group 0 consisted of 24 FBSS patients qualified to SCS therapy, group 1 included 17 patients who were one month after implantation, group 2 featured 12 patients who were 3 months after the implantation, and group C (the control group) with no NP. Clinical status was assessed with the use of Numeric Rating Scale (NRS), the Pain Rating Index of McGill Pain Questionnaire (SF-MPQ), the Oswestry Disability Index (ODI), and Beck Depression Inventory (BDI). The plasma concentrations of IFN-γ were ascertained by an immunoenzymatic method. Results We found a significant difference between the patients before SCS and controls' serum level of IFN-γ. Similarly, a significantly higher level of TNF-α and significantly lower level of IL-10 in FBSS patients than controls were observed. The significant differences were not observed between SCS patients 3 months after the procedure and controls' serum level of IFN-γ and other cytokines. We noticed a positive correlation between IFN-γ concentration with NRS back value before SCS and positive correlation between IFN-γ concentration after SCS with NRS leg value before SCS. Higher IFN-γ concentrations accompanied higher NRS values. Levels of TGF-β and IL-10 may correlate with physical ability and depressive behavior. Conclusions SCS did not influence serum cytokine levels significantly. Serum concentration of IFN-γ may be recognized as an occasional pain factor because of its significantly higher level in FBSS patients versus controls and higher IFN-γ value accompanying higher pain intensity.
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Chakravarthy KV, Xing F, Bruno K, Kent AR, Raza A, Hurlemann R, Kinfe TM. A Review of Spinal and Peripheral Neuromodulation and Neuroinflammation: Lessons Learned Thus Far and Future Prospects of Biotype Development. Neuromodulation 2018; 22:235-243. [DOI: 10.1111/ner.12859] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/18/2018] [Accepted: 08/15/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Krishnan V. Chakravarthy
- Department of Anesthesiology and Pain MedicineUniversity of California San Diego Health Sciences San Diego CA USA
- VA San Diego Healthcare System San Diego CA USA
| | - Fang Xing
- Department of Anesthesiology and Pain MedicineBrigham and Women's Hospital Boston MA USA
| | - Kelly Bruno
- Department of Anesthesiology and Pain MedicineUniversity of California San Diego Health Sciences San Diego CA USA
- VA San Diego Healthcare System San Diego CA USA
| | | | - Adil Raza
- Neuromodulation Division, Abbott Plano TX USA
| | - Rene Hurlemann
- Department of Psychiatry, Division of Medical Psychology (NEMO Neuromodulation of Emotions)Rheinische Friedrich Wilhelms‐University Hospital Bonn Germany
| | - Thomas M. Kinfe
- Department of Psychiatry, Division of Medical Psychology (NEMO Neuromodulation of Emotions)Rheinische Friedrich Wilhelms‐University Hospital Bonn Germany
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Sankarasubramanian V, Harte SE, Chiravuri S, Harris RE, Brummett CM, Patil PG, Clauw DJ, Lempka SF. Objective Measures to Characterize the Physiological Effects of Spinal Cord Stimulation in Neuropathic Pain: A Literature Review. Neuromodulation 2018; 22:127-148. [PMID: 30246905 DOI: 10.1111/ner.12804] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The physiological mechanisms behind the therapeutic effects of spinal cord stimulation (SCS) are only partially understood. Our aim was to perform a literature review of studies that used objective measures to characterize mechanisms of action of SCS in neuropathic pain patients. MATERIALS AND METHODS We searched the PubMed data base to identify clinical studies that used objective measures to assess the effects of SCS in neuropathic pain. We extracted the study factors (e.g., type of measure, diagnoses, painful area[s], and SCS parameters) and outcomes from the included studies. RESULTS We included 67 studies. Of these, 24 studies used neurophysiological measures, 14 studies used functional neuroimaging techniques, three studies used a combination of neurophysiological and functional neuroimaging techniques, 14 studies used quantitative sensory testing, and 12 studies used proteomic, vascular, and/or pedometric measures. Our findings suggest that SCS largely inhibits somatosensory processing and/or spinal nociceptive activity. Our findings also suggest that SCS modulates activity across specific regions of the central nervous system that play a prominent role in the sensory and emotional functions of pain. CONCLUSIONS SCS appears to modulate pain via spinal and/or supraspinal mechanisms of action (e.g., pain gating, descending pain inhibition). However, to better understand the mechanisms of action of SCS, we believe that it is necessary to carry out systematic, controlled, and well-powered studies using objective patient measures. To optimize the clinical effectiveness of SCS for neuropathic pain, we also believe that it is necessary to develop and implement patient-specific approaches.
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Affiliation(s)
| | - Steven E Harte
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Srinivas Chiravuri
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Richard E Harris
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Daniel J Clauw
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - 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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Xu J, Liu A, Cheng J. New advancements in spinal cord stimulation for chronic pain management. Curr Opin Anaesthesiol 2018; 30:710-717. [PMID: 28938297 DOI: 10.1097/aco.0000000000000531] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To update the recent development of spinal cord stimulation (SCS) technology in the management of chronic pain. RECENT FINDINGS Efficacy of SCS therapy has been significantly improved by the recent development of high frequency (HF-10 kHz) stimulation, burst stimulation, and dorsal root ganglion (DRG) stimulation. A few latest SCS modalities are in clinical trial. New approaches to guide lead placement and advances in surgical lead are introduced. SUMMARY HF-10 SCS is free of paresthesia and associated with significantly better coverage of axial lower back pain. Burst stimulation invokes minimal paresthesia and provides better coverage of low back pain. DRG stimulation results in better outcomes in patients with complex regional pain syndrome. It requires less energy and delivers consistent stimulation regardless of postural variations. Clinical trials with new SCS modalities, such as Stimwaves, are under way to make SCS wireless. Intraoperative neuromonitoring and paresthesia atlas may be used to guide lead placement. Multicolumn surgical paddle leads enable a combination of independent current control with up to 32 contacts for better programming and better coverage.
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Affiliation(s)
- Jijun Xu
- aDepartment of Pain Management bDepartment of Immunology, Cleveland Clinic, Cleveland, Ohio, USA cDepartment of Neurosurgery, First Affiliated Hospital of PLA General Hospital, Beijing, China dDepartment of Neurosciences, Cleveland Clinic, Cleveland, Ohio, USA
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Dorsal root ganglia pulsed radiofrequency treatment alters the spinal immune environment. Brain Behav Immun 2018; 70:6-7. [PMID: 29574259 DOI: 10.1016/j.bbi.2018.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 03/18/2018] [Indexed: 11/22/2022] Open
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Chakravarthy K, Kent AR, Raza A, Xing F, Kinfe TM. Burst Spinal Cord Stimulation: Review of Preclinical Studies and Comments on Clinical Outcomes. Neuromodulation 2018; 21:431-439. [PMID: 29431275 DOI: 10.1111/ner.12756] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/01/2017] [Accepted: 12/06/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Burst spinal cord stimulation (SCS) technology uses a novel waveform that consists of closely packed high-frequency electrical impulses followed by a quiescent period. Within the growing field of neuromodulation, burst stimulation is unique in that it mimics the natural burst firing of the nervous system, in particular the thalamo-cingulate rhythmicity, resulting in modulation of the affective and attentional components of pain processing (e.g., medial thalamic pathways). STUDY DESIGN A review of preclinical and clinical studies regarding burst SCS for various chronic pain states. METHODS Available literature was reviewed on burst stimulation technology. Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, SCOPUS, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES The primary outcome measure was to understand the mechanisms of action with regards to burst stimulation and to review clinical data on the indications of burst SCS for various chronic pain states. RESULTS We present both mechanisms of action and review uses of burst stimulation for various pain states. CONCLUSIONS Burst stimulation offers a novel pain reduction tool with the absence of uncomfortable paresthesia for failed back surgery syndrome, diabetic neuropathic pain, and anesthesia dolorosa. Preclinical models have emphasized that the potential mechanisms for burst therapy could be related to neural coding algorithms that mimic the natural nervous system firing patterns, resulting in effects on both the medial and lateral pain pathways. Other mechanisms include frequency dependent opioid release, modulation of the pain gate, and activation of electrical and chemical synapses.
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Affiliation(s)
- Krishnan Chakravarthy
- Department of Anesthesiology and Pain Medicine, University of California San Diego Health Sciences, San Diego, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | | | - Adil Raza
- Abbott, Neuromodulation Division, Plano, TX, USA
| | - Fang Xing
- Department of Anesthesiology and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas M Kinfe
- Division of Functional Neurosurgery, Stereotaxy and Neuromodulation, Rheinische Friedrich Wilhelms, University Hospital, Bonn, Germany
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Ahmed S, Yearwood T, De Ridder D, Vanneste S. Burst and high frequency stimulation: underlying mechanism of action. Expert Rev Med Devices 2017; 15:61-70. [PMID: 29249191 DOI: 10.1080/17434440.2018.1418662] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Paresthesia-free spinal cord stimulation (SCS) techniques, such as burst and high-frequency (HF) SCS, have been developed and demonstrated to be successful for treating chronic pain, albeit via different mechanisms of action. The goal of this review is to discuss the mechanisms of action for pain suppression at both the cellular and systems levels for burst and HF SCS. In addition, we also discuss the neuromodulation devices that mimic these paradigms. AREAS COVERED The authors performed a literature review to unravel the mechanisms of action for burst and HF SCS coupled with booklets and user manuals from neuromodulation companies to understand the programmable parameters and operating ranges. Burst SCS modulates the medial pathway to suppress pain. On cellular level, burst SCS is independent on activation of γ-aminobutyric acid (GABA) receptors to inhibit neuronal firing. HF SCS blocks large-diameter fibers from producing action potentials with little influence on smaller fibers, increasing pain suppression as frequency increases. EXPERT COMMENTARY The neuromodulation industry is in a phase of intense innovation characterized by adaptive stimulation to improve patients' experience and experiment with alternative frequencies and novel stimulation targets.
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Affiliation(s)
- Shaheen Ahmed
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
| | | | - Dirk De Ridder
- c Department of Surgical Sciences, Dunedin School of Medicine , University of Otago , Dunedin , New Zealand
| | - Sven Vanneste
- a Lab for Clinical and Integrative Neuroscience, School of Behavioral and Brain Sciences , The University of Texas at Dallas , Dallas , TX , USA
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Kriek N, Schreurs MW, Groeneweg JG, Dik WA, Tjiang GC, Gültuna I, Stronks DL, Huygen FJ. Spinal Cord Stimulation in Patients With Complex Regional Pain Syndrome: A Possible Target for Immunomodulation? Neuromodulation 2017; 21:77-86. [DOI: 10.1111/ner.12704] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/10/2017] [Accepted: 07/25/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Nadia Kriek
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Marco W.J. Schreurs
- Department of Immunology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - J. George Groeneweg
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Wim A. Dik
- Department of Immunology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Gilbert C.H. Tjiang
- Department of Anaesthesiology, Pain Management and Intensive Care; Amphia Hospital; Oosterhout The Netherlands
| | - Ismail Gültuna
- Pain Treatment Center; Albert Schweitzer Hospital; Sliedrecht The Netherlands
| | - Dirk L. Stronks
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Frank J.P.M. Huygen
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
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Muhammad S, Chaudhry SR, Yearwood TL, Krauss JK, Kinfe TM. Changes of Metabolic Disorders Associated Peripheral Cytokine/Adipokine Traffic in Non-Obese Chronic Back Patients Responsive to Burst Spinal Cord Stimulation. Neuromodulation 2017; 21:31-37. [PMID: 29064604 DOI: 10.1111/ner.12708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 08/12/2017] [Accepted: 09/09/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES In our previous study, anti-inflammatory IL-10 serum levels were significantly elevated after burst spinal cord stimulation (SCS) in back pain patients and correlated with pain intensity. This current study extended cytokine analysis including metabolic-associated adipokine/cytokine serum assessment in chronic back pain patients with co-existing metabolic disorders such as diabetes, hypertension, and cardiovascular diseases. METHODS At baseline and after three months of burst SCS treatment, leptin (LP), adiponectin (AN), and ghrelin (GH) were recorded in non-/pre-obese chronic back pain patients with co-existing metabolic disorders and compared to age-/gender-matched healthy controls (HC). RESULTS Mean BMI was 22 ± 0.81 kg/m2 in 12 (five male/seven female) participants with diabetes in 6/12 (50%), hypertension in 9 (75%), and CVD in five patients (42%). Pre- and post-SCS LP levels were significantly higher compared to healthy controls: pre-SCS, 30567 (12,996-58,821) vs. HC, 7952 (4932-12,583) pg/mL, p = 0.029; post-SCS, 18,890 (7140-44,719) vs. HC, 7952 (4932-12,583) pg/mL, p = 0.035. Pre- and post-SCS changes of GH (p = 0.18) and AN (p = 0.8) did not differ significantly. GH serum levels correlated with AN (Spearman r = 0.5; p = 0.012; 95 CI 0.11 to -0.76) and AN levels were significantly correlated with higher age (Pearson correlation r = 0.8; p = 0.002; 95 CI 0.41-0.94) at baseline. CONCLUSIONS This study determined serum changes of metabolic-associated cytokines/adipokines in non-obese chronic back pain patients responsive to burst SCS suggesting that neuroinflammation assessment may consider pain-associated mood, cognition, sleep, and metabolic state.
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Affiliation(s)
- Sajjad Muhammad
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Shafqat R Chaudhry
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | | | - Joachim K Krauss
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany.,Department of Neurosurgery, Medical School, Hannover, Germany
| | - Thomas M Kinfe
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany.,Division of Functional Neurosurgery and Neuromodulation, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
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Muhammad S, Roeske S, Chaudhry SR, Kinfe TM. Burst or High-Frequency (10 kHz) Spinal Cord Stimulation in Failed Back Surgery Syndrome Patients With Predominant Back Pain: One Year Comparative Data. Neuromodulation 2017; 20:661-667. [PMID: 28544182 DOI: 10.1111/ner.12611] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/05/2017] [Accepted: 03/30/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Burst and 10 kHz spinal cord stimulation (SCS) demonstrated improvement for failed back surgery syndrome (FBSS) with predominant, refractory back pain. Here, we report the long-term follow-up of a previously published study comparing the safety and efficacy of burst vs. 10 kHz SCS for predominant back pain (70% of global pain) of FBSS patients. METHODS This comparative, observational study extended the follow-up period up to 20 months evaluating both SCS modalities. Pain intensity (visual analog scale [VASB , VASL ]), functional capacity (Pittsburgh Sleep Quality Index [PSQI]; depression (Beck Depression Inventory [BDI]), stimulation parameters and hardware and/or stimulation associated adverse events were recorded and analyzed over time. RESULTS Overall VASB (t1,12 = 66.76, p < 0.001) and VASL (t1,12 = 4.763, p < 0.049; p < 0.001) declined over time. Burst significantly decreased VASB by 87.5% (±17.7) (mean 8 ± 0.76 to 1 ± 1.41; t1 =12.3, p < 0.001), and 10 kHz significant decreased VASB by 54.9% (±44) (mean 8 ± 0.63 to 3.5 ± 3.27; t1 =3.09, p = 0.027). No significant differences for between SCS types were revealed (t1 =1.75, p = 0.13). VASL was significantly suppressed for burst (burst: 3.6 ± 1.59 to 1.5 ± 1.06; t1 = 3.32, p = 0.013). A significant effect of time was found for functional outcome with no significant differences between SCS types (PSQI: t1,12 = 8.8, p = 0.012; and BDI: t1 = 53.3, p < 0.001). No stimulation/hardware-related complications occurred. DISCUSSION Long-term data of this comparative study suggests that burst responsiveness was superior to 10 kHz in our small-scale cohort, thus a larger, randomized-controlled comparative study design is highly recommended.
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Affiliation(s)
- Sajjad Muhammad
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Sandra Roeske
- DZNE, German Center for Neurodegenerative Diseases, Bonn, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Shafqat Rasul Chaudhry
- Department of Neurosurgery, Rheinische Friedrich Wilhelms University Hospital, Bonn, Germany
| | - Thomas Mehari Kinfe
- Department of Neurosurgery, Division of Functional Neurosurgery, Stereotaxy and Neuromodulation, Bonn, Germany
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