Transgrade Dorsal Root Ganglion Stimulation as a Salvage Technique for Three Different Anatomical Barriers: A Case Series

Extraforaminal Spinal Nerve Stimulation for Neuropathic Pain: Description of the New Approach, Safety, and Long-term Efficacy

BACKGROUND

Managing focal neuropathic pain poses significant challenges. Neuromodulation therapies, particularly dorsal root ganglion stimulation (DRG-S), have shown promise in many cases. However, frequent issues with system durability, necessitating revisions, and the complexity of these revisions due to associated difficulties and the limitations in complex cases with difficult access to the epidural space or foramen have prompted practitioners to seek more durable and long-lasting alternatives. Spinal nerve stimulation through an extraforaminal approach offers a promising solution for patients who have exhausted conventional pain therapies or are unsuitable candidates for DRG-S.

MATERIALS AND METHODS

This is a single-center, retrospective data analysis in 73 patients with neuropathic pain who underwent spinal nerve stimulation (SNS) using our facility's novel extraforaminal approach from January 2019 to December 2024. The collected data included patient-reported outcomes. We also reviewed any adverse events, complications, or procedure-related issues.

RESULTS

Initially, extraforaminal SNS was primarily considered for patients with a history of failed DRG-S. Since 2021, however, this approach has become the primary treatment for focal neuropathic pain at our institution. Of the 73 patients trialed, 75% achieved >50% pain relief, causing permanent implantation in 53 patients. Patient satisfaction remained high, with 38 of 42 patients currently implanted reporting satisfaction in a 2024 follow-up survey. Remarkably, >80% of patients implanted in 2019 and 2020 reported sustained satisfaction five and four years after implantation, respectively. No intraoperative complications or serious adverse events were documented during the trial or after implantation, surgical revisions, or explantation.

CONCLUSION

The extraforaminal SNS approach has shown safety and durability as a treatment for patients with refractory neuropathic pain. With long-term patient satisfaction and a favorable safety profile, it offers a promising alternative to traditional neuromodulation techniques, particularly in complex cases in which DRG-S may be challenging or contraindicated.

The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for Spinal Cord Stimulation Long-Term Outcome Optimization and Salvage Therapy

INTRODUCTION

The International Neuromodulation Society (INS) has recognized a need to establish best practices for optimizing implantable devices and salvage when ideal outcomes are not realized. This group has established the Neurostimulation Appropriateness Consensus Committee (NACC)® to offer guidance on matters needed for both our members and the broader community of those affected by neuromodulation devices.

MATERIALS AND METHODS

The executive committee of the INS nominated faculty for this NACC® publication on the basis of expertise, publications, and career work on the issue. In addition, the faculty was chosen in consideration of diversity and inclusion of different career paths and demographic categories. Once chosen, the faculty was asked to grade current evidence and along with expert opinion create consensus recommendations to address the lapses in information on this topic.

RESULTS

The NACC® group established informative and authoritative recommendations on the salvage and optimization of care for those with indwelling devices. The recommendations are based on evidence and expert opinion and will be expected to evolve as new data are generated for each topic.

CONCLUSIONS

NACC® guidance should be considered for any patient with less-than-optimal outcomes with a stimulation device implanted for treating chronic pain. Consideration should be given to these consensus points to salvage a potentially failed device before explant.

Effectiveness of combined dorsal root ganglion and spinal cord stimulation: a retrospective, single-centre case series for chronic focal neuropathic pain

OBJECTIVE

This case series retrospectively reviewed the outcomes in patients implanted with combined, synchronous dorsal root ganglion stimulation (DRGS) and spinal cord stimulation (SCS) connected to a single implantable pulse generator (IPG) in a tertiary referral neuromodulation centre in the United Kingdom.

METHODS

Twenty-six patients underwent a trial of DRGS+SCS for treating focal neuropathic pain between January 2016 and December 2019, with a follow-up in February 2022. A Transgrade approach was employed for DRGS. Patients were provided with 3 possible stimulation programs: DRGS-only, SCS-only, or DRGS+SCS. Patients were assessed for pain intensity, patients' global impression of change (PGIC), preferred lead(s) and complications.

RESULTS

Twenty patients were successful and went on for full implantation. The most common diagnosis was Complex Regional Pain Syndrome. After an average of 3.1 years follow-up, 1 patient was lost to follow-up, and 2 were non-responders. Of the remaining 17 patients, 16 (94%) continued to report a PGIC of 7. The average pain intensity at Baseline was 8.5 on an NRS scale of 0-10. At the last follow-up, the average NRS reduction overall was 78.9% with no statistical difference between those preferring DRGS+SCS (n = 9), SCS-only (n = 3) and DRGS-only (n = 5). The combination of DRGS+SCS was preferred by 53% at the last follow-up. There were no serious neurological complications.

CONCLUSIONS

This retrospective case series demonstrates the potential effectiveness of combined DRGS+SCS with sustained analgesia observed at an average follow-up of over 3 years. Implanting combined DRGS+SCS may provide programming flexibility and therapeutic alternatives.

Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience

With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion stimulation (DRG-S) has significantly improved the treatment of complex regional pain syndrome (CRPS), and it has broad applicability across a wide range of other conditions. Through funding and organizational leadership by the American Society for Pain and Neuroscience (ASPN), this best practices consensus document has been developed for the selection, implantation, and use of DRG stimulation for the treatment of chronic pain syndromes. This document is composed of a comprehensive narrative literature review that has been performed regarding the role of the DRG in chronic pain and the clinical evidence for DRG-S as a treatment for multiple pain etiologies. Best practice recommendations encompass safety management, implantation techniques, and mitigation of the potential complications reported in the literature. Looking to the future of neuromodulation, DRG-S holds promise as a robust intervention for otherwise intractable pain.