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Schwarm FP, Rehman R, Nagl J, Gött H, Uhl E, Kolodziej MA. Does lumbar spinal decompression or fusion surgery influence outcome parameters in patients with intrathecal morphine treatment for persistent spinal pain syndrome type 2 (PSPS-T2). Scand J Pain 2023; 23:677-686. [PMID: 37667441 DOI: 10.1515/sjpain-2023-0042] [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: 03/28/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVES Intrathecal morphine pump (ITMP) infusion therapy is efficient in managing chronic pain refractory to standard treatment. This study evaluates pain relief and improvement of quality of life in chronic pain patients after intrathecal morphine pump implantation for treatment of persistent pain after lumbar spinal fusion surgery and lumbar spinal decompression alone. METHODS Forty three chronic pain patients that received an ITMP at our department between 2009 and 2019 were retrospectively analyzed divided into 2 cohorts (lumbar spinal fusion surgery and lumbar spinal decompression alone). Pain intensity was evaluated using the numeric rating scale (NRS), quality of life was assessed by EQ-5D-3L, mental health was assessed by Beck Depression Inventory (BDI-V), and Pain Catastrophizing Scale (PCS). Morphine dosage was assessed over time. Data was collected preoperatively, 6 and 24 months postoperatively. Statistical analysis was performed using Friedman's analysis of variance to evaluate the development of NRS, PCS, BDI and EQ-5D-3L over time and Mann-Whitney-U-test for the differences between these parameters in the different cohorts. A two-sided p-value <0.05 was considered statistically significant. RESULTS Median age was 64 years (IQR25-75 56-71 years). NRS, EQ-5D-3L, BDI-V, and PCS showed a significant overall improvement after 6 and 24 months compared to baseline data (p<0.001). No statistically significant differences between patients with lumbar spinal fusion surgery and lumbar spinal decompression alone were seen. Furthermore, no statistically significant differences for age and gender were seen. The initially administered median morphine dosage was significantly higher in the fusion group (3.0 mg/day; IQR25-75 1.5-4.2 mg/day) compared to the decompression-alone group (1.5 mg/day; IQR25-75 1.0-2.6 mg/day); (p=0.027). CONCLUSIONS This retrospective study showed that ITMP have a major long-term impact on pain relief, improve the quality of life, psychological distress, as well as pain catastrophizing in patients with chronic pain following lumbar spinal surgery independent of the previous surgical procedure. After ITMP implantation initial median morphine dosage seems to be significantly higher after spinal fusion compared to decompressive surgery alone.
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Affiliation(s)
| | - Raza Rehman
- Department of Neurosurgery Hospital Darmstadt, Darmstadt, Germany
| | - Jasmin Nagl
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Hanna Gött
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
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Abstract
BACKGROUND Spinal cord stimulation (SCS) is a surgical intervention used to treat persistent low back pain. SCS is thought to modulate pain by sending electrical signals via implanted electrodes into the spinal cord. The long term benefits and harms of SCS for people with low back pain are uncertain. OBJECTIVES To assess the effects, including benefits and harms, of SCS for people with low back pain. SEARCH METHODS On 10 June 2022, we searched CENTRAL, MEDLINE, Embase, and one other database for published trials. We also searched three clinical trials registers for ongoing trials. SELECTION CRITERIA We included all randomised controlled trials and cross-over trials comparing SCS with placebo or no treatment for low back pain. The primary comparison was SCS versus placebo, at the longest time point measured in the trials. Major outcomes were mean low back pain intensity, function, health-related quality of life, global assessment of efficacy, withdrawals due to adverse events, adverse events, and serious adverse events. Our primary time point was long-term follow-up (≥ 12 months). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 studies with 699 participants: 55% of participants were female; mean age ranged from 47 to 59 years; and all participants had chronic low back pain with mean duration of symptoms ranging from five to 12 years. Ten cross-over trials compared SCS with placebo. Three parallel-group trials assessed the addition of SCS to medical management. Most studies were at risk of performance and detection bias from inadequate blinding and selective reporting bias. The placebo-controlled trials had other important biases, including lack of accounting for period and carryover effects. Two of the three parallel trials assessing SCS as an addition to medical management were at risk of attrition bias, and all three had substantial cross-over to the SCS group for time points beyond six months. In the parallel-group trials, we considered the lack of placebo control to be an important source of bias. None of our included studies evaluated the impact of SCS on mean low back pain intensity in the long term (≥ 12 months). The studies most often assessed outcomes in the immediate term (less than one month). At six months, the only available evidence was from a single cross-over trial (50 participants). There was moderate-certainty evidence that SCS probably does not improve back or leg pain, function, or quality of life compared with placebo. Pain was 61 points (on a 0- to 100-point scale, 0 = no pain) at six months with placebo, and 4 points better (8.2 points better to 0.2 points worse) with SCS. Function was 35.4 points (on a 0- to 100-point scale, 0 = no disability or best function) at six months with placebo, and 1.3 points better (3.9 points better to 1.3 points worse) with SCS. Health-related quality of life was 0.44 points out of 1 (0 to 1 index, 0 = worst quality of life) at six months with placebo, and 0.04 points better (0.16 points better to 0.08 points worse) with SCS. In that same study, nine participants (18%) experienced adverse events and four (8%) required revision surgery. Serious adverse events with SCS included infections, neurological damage, and lead migration requiring repeated surgery. We could not provide effect estimates of the relative risks as events were not reported for the placebo period. In parallel trials assessing SCS as an addition to medical management, it is uncertain whether, in the medium or long term, SCS can reduce low back pain, leg pain, or health-related quality of life, or if it increases the number of people reporting a 50% improvement or better, because the certainty of the evidence was very low. Low-certainty evidence suggests that adding SCS to medical management may slightly improve function and slightly reduce opioid use. In the medium term, mean function (0- to 100-point scale; lower is better) was 16.2 points better with the addition of SCS to medical management compared with medical management alone (95% confidence interval (CI) 19.4 points better to 13.0 points better; I2 = 95%; 3 studies, 430 participants; low-certainty evidence). The number of participants reporting opioid medicine use was 15% lower with the addition of SCS to medical management (95% CI 27% lower to 0% lower; I2 = 0%; 2 studies, 290 participants; low-certainty evidence). Adverse events with SCS were poorly reported but included infection and lead migration. One study found that, at 24 months, 13 of 42 people (31%) receiving SCS required revision surgery. It is uncertain to what extent the addition of SCS to medical management increases the risk of withdrawals due to adverse events, adverse events, or serious adverse events, because the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Data in this review do not support the use of SCS to manage low back pain outside a clinical trial. Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention.
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Affiliation(s)
- Adrian C Traeger
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Stephen E Gilbert
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Tapia Pérez JH. Spinal cord stimulation: Beyond pain management. Neurologia 2022; 37:586-595. [PMID: 31337556 DOI: 10.1016/j.nrl.2019.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 05/03/2019] [Accepted: 05/20/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The gate control theory of pain was the starting point of the development of spinal cord stimulation (SCS). We describe the indications for the treatment in pain management and other uses not related to pain. DEVELOPMENT There are currently several paradigms for SCS: tonic, burst, and high frequency. The main difference lies in the presence of paraesthesias. SCS is most beneficial for treating neuropathic pain. Patients with failed back surgery syndrome show the best response rates, although a considerable reduction in pain is also observed in patients with complex regional pain syndrome, diabetic neuropathy, radiculopathy, and low back pain without previous surgery. Phantom pain or pain related to cardiovascular or peripheral vascular disease may improve, although there is a lack of robust evidence supporting generalisation of its use. SCS also improves cancer-related pain, although research on this issue is scarce. Non-pain-related indications for SCS are movement disorders, spasticity, and sequelae of spinal cord injury. The main limiting factors for the use of SCS are mechanical complications and the cost of the treatment. CONCLUSION In its 50-year history, SCS has progressed enormously. The perfection of hardware and software may improve its effectiveness and reduce the rate of complications. Indications for SCS could include other diseases, and its use could be expanded, if the costs of the technology are reduced.
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Affiliation(s)
- J H Tapia Pérez
- Department of Spine Surgery, Leopoldina-Krankenhaus der Stadt Schweinfurt, Schweinfurt, Alemania.
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O'Connell NE, Ferraro MC, Gibson W, Rice AS, Vase L, Coyle D, Eccleston C. Implanted spinal neuromodulation interventions for chronic pain in adults. Cochrane Database Syst Rev 2021; 12:CD013756. [PMID: 34854473 PMCID: PMC8638262 DOI: 10.1002/14651858.cd013756.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Implanted spinal neuromodulation (SNMD) techniques are used in the treatment of refractory chronic pain. They involve the implantation of electrodes around the spinal cord (spinal cord stimulation (SCS)) or dorsal root ganglion (dorsal root ganglion stimulation (DRGS)), and a pulse generator unit under the skin. Electrical stimulation is then used with the aim of reducing pain intensity. OBJECTIVES To evaluate the efficacy, effectiveness, adverse events, and cost-effectiveness of implanted spinal neuromodulation interventions for people with chronic pain. SEARCH METHODS We searched CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science (ISI), Health Technology Assessments, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry from inception to September 2021 without language restrictions, searched the reference lists of included studies and contacted experts in the field. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing SNMD interventions with placebo (sham) stimulation, no treatment or usual care; or comparing SNMD interventions + another treatment versus that treatment alone. We included participants ≥ 18 years old with non-cancer and non-ischaemic pain of longer than three months duration. Primary outcomes were pain intensity and adverse events. Secondary outcomes were disability, analgesic medication use, health-related quality of life (HRQoL) and health economic outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently screened database searches to determine inclusion, extracted data and evaluated risk of bias for prespecified results using the Risk of Bias 2.0 tool. Outcomes were evaluated at short- (≤ one month), medium- four to eight months) and long-term (≥12 months). Where possible we conducted meta-analyses. We used the GRADE system to assess the certainty of evidence. MAIN RESULTS We included 15 unique published studies that randomised 908 participants, and 20 unique ongoing studies. All studies evaluated SCS. We found no eligible published studies of DRGS and no studies comparing SCS with no treatment or usual care. We rated all results evaluated as being at high risk of bias overall. For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as low or very low, downgraded due to limitations of studies, imprecision and in some cases, inconsistency. Active stimulation versus placebo SCS versus placebo (sham) Results were only available at short-term follow-up for this comparison. Pain intensity Six studies (N = 164) demonstrated a small effect in favour of SCS at short-term follow-up (0 to 100 scale, higher scores = worse pain, mean difference (MD) -8.73, 95% confidence interval (CI) -15.67 to -1.78, very low certainty). The point estimate falls below our predetermined threshold for a clinically important effect (≥10 points). No studies reported the proportion of participants experiencing 30% or 50% pain relief for this comparison. Adverse events (AEs) The quality and inconsistency of adverse event reporting in these studies precluded formal analysis. Active stimulation + other intervention versus other intervention alone SCS + other intervention versus other intervention alone (open-label studies) Pain intensity Mean difference Three studies (N = 303) demonstrated a potentially clinically important mean difference in favour of SCS of -37.41 at short term (95% CI -46.39 to -28.42, very low certainty), and medium-term follow-up (5 studies, 635 participants, MD -31.22 95% CI -47.34 to -15.10 low-certainty), and no clear evidence for an effect of SCS at long-term follow-up (1 study, 44 participants, MD -7 (95% CI -24.76 to 10.76, very low-certainty). Proportion of participants reporting ≥50% pain relief We found an effect in favour of SCS at short-term (2 studies, N = 249, RR 15.90, 95% CI 6.70 to 37.74, I2 0% ; risk difference (RD) 0.65 (95% CI 0.57 to 0.74, very low certainty), medium term (5 studies, N = 597, RR 7.08, 95 %CI 3.40 to 14.71, I2 = 43%; RD 0.43, 95% CI 0.14 to 0.73, low-certainty evidence), and long term (1 study, N = 87, RR 15.15, 95% CI 2.11 to 108.91 ; RD 0.35, 95% CI 0.2 to 0.49, very low certainty) follow-up. Adverse events (AEs) Device related No studies specifically reported device-related adverse events at short-term follow-up. At medium-term follow-up, the incidence of lead failure/displacement (3 studies N = 330) ranged from 0.9 to 14% (RD 0.04, 95% CI -0.04 to 0.11, I2 64%, very low certainty). The incidence of infection (4 studies, N = 548) ranged from 3 to 7% (RD 0.04, 95%CI 0.01, 0.07, I2 0%, very low certainty). The incidence of reoperation/reimplantation (4 studies, N =5 48) ranged from 2% to 31% (RD 0.11, 95% CI 0.02 to 0.21, I2 86%, very low certainty). One study (N = 44) reported a 55% incidence of lead failure/displacement (RD 0.55, 95% CI 0.35, 0 to 75, very low certainty), and a 94% incidence of reoperation/reimplantation (RD 0.94, 95% CI 0.80 to 1.07, very low certainty) at five-year follow-up. No studies provided data on infection rates at long-term follow-up. We found reports of some serious adverse events as a result of the intervention. These included autonomic neuropathy, prolonged hospitalisation, prolonged monoparesis, pulmonary oedema, wound infection, device extrusion and one death resulting from subdural haematoma. Other No studies reported the incidence of other adverse events at short-term follow-up. We found no clear evidence of a difference in otherAEs at medium-term (2 studies, N = 278, RD -0.05, 95% CI -0.16 to 0.06, I2 0%) or long term (1 study, N = 100, RD -0.17, 95% CI -0.37 to 0.02) follow-up. Very limited evidence suggested that SCS increases healthcare costs. It was not clear whether SCS was cost-effective. AUTHORS' CONCLUSIONS We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to conventional medical management or physical therapy. SCS is associated with complications including infection, electrode lead failure/migration and a need for reoperation/re-implantation. The level of certainty regarding the size of those risks is very low. SNMD may lead to serious adverse events, including death. We found no evidence to support or refute the use of DRGS for chronic pain.
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Affiliation(s)
- Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - William Gibson
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Andrew Sc Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Doug Coyle
- Epidemiology and Community Medicine, Ottawa Health Research Institute, Ottawa, Canada
- Health Economics Research Group, Institute of Environment, Health and Societies, Department of Clinical Sciences, Brunel University London, Uxbridge, UK
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Tapias Pérez J. Spinal cord stimulation: beyond pain management. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:586-595. [DOI: 10.1016/j.nrleng.2019.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/20/2019] [Indexed: 12/23/2022] Open
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Ranjan M, Kumar P, Konrad P, Rezai AR. Finding Optimal Neuromodulation for Chronic Pain: Waves, Bursts, and Beyond. Neurol India 2020; 68:S218-S223. [PMID: 33318354 DOI: 10.4103/0028-3886.302465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Spinal cord stimulation (SCS) has emerged as state-of-the-art evidence-based treatment for chronic intractable pain related to spinal and peripheral nerve disorders. Traditionally delivered as steady-state, paraesthesia-producing electrical stimulation, newer technology has augmented the SCS option and outcome in the last decade. Objective To present an overview of the traditional and newer SCS waveforms. Materials and Methods We present a short literature review of SCS waveforms in reference to newer waveforms and describing paraesthesia-free, high frequency, and burst stimulation methods as well as advances in waveform paradigms and programming modalities. Pertinent literature was reviewed, especially in the context of evolution in the waveforms of SCS and stimulation parameters. Results Conventional tonic SCS remains one of the most utilized and clinically validated SCS waveforms. Newer waveforms such as burst stimulation, high-frequency stimulation, and the sub-perception SCS have emerged in the last decades with favorable results with no or minimal paraesthesia, including in cases otherwise intractable to conventional tonic SCS. The recent evolution and experience of closed-loop SCS is promising and appealing. The experience and validation of the newer SCS waveforms, however, remain limited but optimistic. Conclusions Advances in SCS device technology and waveforms have improved patient outcomes, leading to its increased utilization of SCS for chronic pain. These improvements and the development of closed-loop SCS have been increasingly promising development and foster a clinical translation of improved pain relief as the years of research and clinical study beyond conventional SCS waveform come to fruition.
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Affiliation(s)
- Manish Ranjan
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
| | - Pranab Kumar
- Department of Anaesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto
| | - Peter Konrad
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
| | - Ali R Rezai
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University
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Sclafani J, Leong M, Desai MJ, Mehta N, Sayed D, Singh JR. Conventional versus High-Frequency Neuromodulation in the Treatment of Low Back Pain Following Spine Surgery. PM R 2020; 11:1346-1353. [PMID: 31648418 DOI: 10.1002/pmrj.12270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022]
Affiliation(s)
| | - Michael Leong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Mehul J Desai
- International Spine, Pain & Performance Center, George Washington University, Washington, DC
| | - Neel Mehta
- Departmet of Anesthestiology, Division of Pain Medicine, Weill Cornell Medicine, New York, NY
| | - Dawood Sayed
- Department of Anesthesiology, Medical Director of Spine Center, University of Kansas, Kansas City, KS
| | - Jaspal R Singh
- Department of Rehabilitation Medicine, Weill Cornell Center for Comprehensive Spine Care, Weill Cornell Medicine, New York, NY
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Remacle T, Mauviel S, Renwart HJ, Ghassempour K, Belle F, Lückers O, Bex V, Remacle JM, Bonhomme V. Long-Term Multicolumn-Lead Spinal Cord Stimulation Efficacy in Patients with Failed Back Surgery Syndrome: A Six-Year Prospective Follow-up Study. World Neurosurg 2020; 142:e245-e252. [PMID: 32599205 DOI: 10.1016/j.wneu.2020.06.181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The use of multicolumn-lead spinal cord stimulation (SCS) to control back pain (BP) and leg pain (LP) in patients with failed back surgery syndrome (FBSS) in the short term and mid-term has been well documented. Our study investigated whether SCS remained efficient after 72 months. METHODS In an observational, single-center study, we assessed SCS efficacy in 62 patients with FBSS patients. BP, LP, and magnitude of daily activity limitation (DAL) were graded using a 0-10 visual analog scale (VAS) preoperatively and at 2, 6, 12, 24, 36, and 72 months after SCS implantation. Sleep quality, use of medications, and complications were also recorded. RESULTS Of the 62 patients, 15 with complete follow-up data available were still using their SCS device at 72 months (SCS+). For these patients, the VAS scores for BP, LP, and DAL had changed from a median of 9 (interquartile range [IQR], 8.5-10), 7 (IQR, 6-8), and 8 (IQR, 8-9) preoperatively to a median of 4 (IQR, 3-4.5), 3 (IQR, 1.5-3.5), and 3 (IQR, 2-4) at 72 months. Their quality of sleep and analgesic medication consumption had also improved. In a subset of patients no longer using the SCS device after 72 months (SCS-), the VAS scores for BP, LP, and DAL, quality of sleep, and medication consumption were comparable to those for the SCS+ group. The SCS- group was less satisfied with the technique and were less professionally active than were the SCS+ group. CONCLUSIONS The SCS device provides sustained beneficial effects on BP, LP, DAL, sleep, and medication consumption in patients with FBSS still using it at 72 months postoperatively. Further studies are needed to identify the factors of adherence to the technique and the chances of success compared with the natural evolution of FBSS.
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Affiliation(s)
- Thibault Remacle
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium; Department of Neurosurgery, University Hospital Center Liege, Liege, Belgium.
| | - Stephane Mauviel
- Department of Algology, Regional Hospital Center Citadelle, Liege, Belgium
| | - Henri-Jean Renwart
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Keyvan Ghassempour
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Frederic Belle
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Olivier Lückers
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Vincent Bex
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Jean-Michel Remacle
- Department of Neurosurgery, Regional Hospital Center Citadelle, Liege, Belgium
| | - Vincent Bonhomme
- Department of Algology, Regional Hospital Center Citadelle, Liege, Belgium; University Department of Anesthesia and Intensive Care Medicine, Regional Hospital Center Citadelle, Liege, Belgium; Department of Anesthesia and Intensive Care Medicine, University Hospital Center Liege, Liege, Belgium; Anesthesia and Intensive Care Laboratory, GIGA-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
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Sun L, Fleetwood-Walker S, Mitchell R, Joosten EA, Cheung CW. Prolonged Analgesia by Spinal Cord Stimulation Following a Spinal Injury Associated With Activation of Adult Neural Progenitors. Pain Pract 2020; 20:859-877. [PMID: 32474998 DOI: 10.1111/papr.12921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 01/29/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Responses of spinal progenitors to spinal cord stimulation (SCS) following spinal cord injury (SCI) in rats were assessed to reveal their potential contribution to SCS-induced analgesia. METHODS Spinal epidural electrodes were implanted in rats at T12 rostral to a quadrant dorsal horn injury at T13. Further groups additionally received either a microlesion to the dorsolateral funiculus (DLF) or gabapentin (10 mg/kg). SCS was performed at 25 Hz for 10 minutes on day 4 (early SCS) and at 10 Hz for 10 minutes on day 8 (late SCS) after injury. Paw withdrawal threshold (PWT) was measured before injury, 30 minutes before or after SCS, and before cull on day 14, followed by immunostaining assessment. RESULTS Paw withdrawal thresholds in uninjured animals (51.0 ± 4.0 g) were markedly reduced after SCI (17.3 ± 2.2 g). This was significantly increased by early SCS (38.5 ± 5.2 g, P < 0.01) and further enhanced by late SCS (50.9 ± 1.9 g, P < 0.01) over 6 days. Numbers of neural progenitors expressing nestin, Sox2, and doublecortin (DCX) in the spinal dorsal horn were increased 6 days after SCS by 6-fold, 2-fold, and 2.5-fold, respectively (P < 0.05 to 0.01). The elevated PWT evoked by SCS was abolished by DLF microlesions (48.9 ± 2.6 g vs. 19.0 ± 3.9 g, P < 0.01) and the number of nestin-positive cells was reduced to the level without SCS (P < 0.05). Gabapentin enhanced late SCS-induced analgesia from 37.0 ± 3.9 g to 54.0 ± 0.8 g (P < 0.01) and increased gamma-aminobutyric acid (GABA)-ergic neuronal marker vesicular GABA transporter-positive newborn cells 2-fold (P < 0.01). CONCLUSIONS Spinal progenitor cells appear to be activated by SCS via descending pathways, which may be enhanced by gabapentin and potentially contributes to relief of SCI-induced neuropathic pain.
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Affiliation(s)
- Liting Sun
- Brain and Spinal Cord Innovation Research Center, The First Rehabilitation Hospital of Shanghai, Tongji University School of Medicine, Shanghai, China
| | - Sue Fleetwood-Walker
- Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Edinburgh, UK
| | - Rory Mitchell
- Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Edinburgh, UK
| | - Elbert A Joosten
- Department of Anesthesiology/Pain Management, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Chi Wai Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, University of Hong Kong, HKSAR, China
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Multicolumn spinal cord stimulation for predominant back pain in failed back surgery syndrome patients: a multicenter randomized controlled trial. Pain 2020; 160:1410-1420. [PMID: 30720582 PMCID: PMC6553955 DOI: 10.1097/j.pain.0000000000001510] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite optimal medical management (OMM), low back pain (LBP) can be disabling, particularly after spinal surgery. Spinal cord stimulation (SCS) is effective in reducing neuropathic leg pain; however, evidence is limited for LBP. This prospective, open-label, parallel-group trial randomized (1:1) failed back surgery syndrome (FBSS) patients with predominant LBP to SCS plus OMM (SCS group) or OMM alone (OMM group) at 28 sites in Europe and the Americas. If trial stimulation was successful, a multicolumn SCS system was implanted. Outcomes were assessed at baseline (before randomization) and at 1, 3, 6, and 12 months after randomization. Patients could change treatment groups at 6 months. The primary outcome was the proportion of patients with ≥50% reduction in LBP (responder) at 6 months. Secondary outcomes included change in pain intensity, functional disability, and health-related quality of life (HRQoL). The results are posted at ClinicalTrials.gov under registration number NCT01697358. In the intent-to-treat analysis, there were more responders in the SCS group than in the OMM group (13.6%, 15/110 vs 4.6%, 5/108, difference 9% with 95% confidence interval 0.6%-17.5%, P = 0.036) at 6 months. The SCS group improved in all secondary outcomes compared with the OMM group. The OMM group only improved in HRQoL. In the SCS group, 17.6% (18/102) experienced SCS-related adverse events through 6 months, with 11.8% (12/102) requiring surgical reintervention. Adding multicolumn SCS to OMM improved pain relief, HRQoL, and function in a traditionally difficult-to-treat population of failed back surgery syndrome patients with predominant LBP. Improvements were sustained at 12 and 24 months.
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Use Stereoscopic Model in Interventional and Surgical Procedures. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1205:11-24. [PMID: 31894567 DOI: 10.1007/978-3-030-31904-5_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The 3-dimensional (3D) stereoscopic modeling software allows anatomists to create high-resolution 3D models from computed tomography (CT) images. In this paper, we used high resolution CT images from a cadaver and a patient to develop clinically relevant anatomic models that can be used to teach surgical trainees different surgical procedures and approaches. The model facilitates visualization, manipulation, and interaction. It can be presented in stereoscopic 3D in a virtual environment, either in a classroom setting or immediately preceding a surgical procedure.
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Duy PQ, Anderson WS. Two Surgeries Do Not Always Make a Right: Spinal Cord Stimulation for Failed Back Surgery Syndrome. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2018; 91:323-331. [PMID: 30258319 PMCID: PMC6153614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Failed back surgery syndrome (FBBS) is characterized by chronic pain that persists following spine surgery. In this review, we discuss the use of spinal cord stimulation (SCS) for FBBS treatment and how the clinical use of SCS may be influenced by private manufacturers. While SCS therapy can be promising for the appropriate patient, there remain knowledge gaps in understanding the full potential of SCS technology for delivering optimal therapeutic benefit. We caution that the use of SCS without a complete understanding of the technology may create exploitative situations that private manufacturers can capitalize on while subjecting patients to potentially unnecessary health and financial burdens.
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Affiliation(s)
- Phan Q. Duy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD,Medical Scientist Training Program, Yale University School of Medicine, New Haven, CT,To whom all correspondence should be addressed: Phan Q. Duy, Current address: 367 Cedar Street, Room 316 ESH, New Haven, CT, 06510;
| | - William S. Anderson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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The Current State of Deep Brain Stimulation for Chronic Pain and Its Context in Other Forms of Neuromodulation. Brain Sci 2018; 8:brainsci8080158. [PMID: 30127290 PMCID: PMC6119957 DOI: 10.3390/brainsci8080158] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 12/26/2022] Open
Abstract
Chronic intractable pain is debilitating for those touched, affecting 5% of the population. Deep brain stimulation (DBS) has fallen out of favour as the centrally implantable neurostimulation of choice for chronic pain since the 1970–1980s, with some neurosurgeons favouring motor cortex stimulation as the ‘last chance saloon’. This article reviews the available data and professional opinion of the current state of DBS as a treatment for chronic pain, placing it in the context of other neuromodulation therapies. We suggest DBS, with its newer target, namely anterior cingulate cortex (ACC), should not be blacklisted on the basis of a lack of good quality study data, which often fails to capture the merits of the treatment.
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The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:31-45. [PMID: 30078053 DOI: 10.1007/s00586-018-5711-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/29/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. METHODS Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1-3 and 7-9). RESULTS Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. CONCLUSIONS Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. These slides can be retrieved under Electronic Supplementary Material.
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Sdrulla AD, Guan Y, Raja SN. Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms. Pain Pract 2018. [PMID: 29526043 DOI: 10.1111/papr.12692] [Citation(s) in RCA: 188] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Spinal cord stimulation (SCS) is a minimally invasive therapy used for the treatment of chronic neuropathic pain. SCS is a safe and effective alternative to medications such as opioids, and multiple randomized controlled studies have demonstrated efficacy for difficult-to-treat neuropathic conditions such as failed back surgery syndrome. Conventional SCS is believed mediate pain relief via activation of dorsal column Aβ fibers, resulting in variable effects on sensory and pain thresholds, and measurable alterations in higher order cortical processing. Although potentiation of inhibition, as suggested by Wall and Melzack's gate control theory, continues to be the leading explanatory model, other segmental and supraspinal mechanisms have been described. Novel, non-standard, stimulation waveforms such as high-frequency and burst have been shown in some studies to be clinically superior to conventional SCS, however their mechanisms of action remain to be determined. Additional studies are needed, both mechanistic and clinical, to better understand optimal stimulation strategies for different neuropathic conditions, improve patient selection and optimize efficacy.
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Affiliation(s)
- Andrei D Sdrulla
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Yun Guan
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A.,Department of Neurological Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, U.S.A
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16
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Spinal Cord Stimulation for the Treatment of Low Back Pain. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00050-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Shamji MF, De Vos C, Sharan A. The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain. Neurosurgery 2017; 80:S108-S113. [PMID: 28350939 DOI: 10.1093/neuros/nyw047] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 09/30/2016] [Indexed: 01/09/2023] Open
Abstract
Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. These procedures can be done with acceptably low morbidity and provide a cost-effective solution for those patients in whom medical therapies have failed. Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.
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Affiliation(s)
- Mohammed F Shamji
- Division of Neurosurgery, Toronto West-ern Hospital, Toronto, Canada.,Depart-ment of Surgery, University of Toronto, Toronto, Canada.,Institute of Biomate-rials and Biomedical Engineering, Uni-versity of Toronto, Toronto, Canada.,Krembil Research Institute, Toronto, Canada.,Techna Research Institute, Toronto, Canada
| | - Cecile De Vos
- Medisch Spectrum Twente hospital, Enschede, Netherlands
| | - Ashwini Sharan
- Division of Neurosurgery, Thomas Jefferson University, Philadephia, PA
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Minimum Clinically Important Difference and Substantial Clinical Benefit in Pain, Functional, and Quality of Life Scales in Failed Back Surgery Syndrome Patients. Spine (Phila Pa 1976) 2017; 42:E474-E481. [PMID: 27792107 DOI: 10.1097/brs.0000000000001950] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN .: Prospective observational 1-year study. OBJECTIVE .: To determine minimum clinically important difference (MCID) and substantial clinical benefit (SCB) of outcome measures in failed back surgery syndrome (FBSS) patients, as these metrics enable assessment of whether and when an intervention produces clinically meaningful effects in a patient. SUMMARY OF BACKGROUND DATA .: Several methods have been devised to quantify clinically important difference, but MCID and SCB for FBSS patients has yet to be determined. METHODS .: Patients with persisting/recurrent low back pain (LBP) and/or leg pain after lumbar surgery who completed 16 weeks of treatment (n = 105) at two hospitals in Korea from November 2011 to September 2014 were analyzed. Global perceived effect was used to determine receiver operating characteristic curves in visual analogue scale (VAS), Oswestry disability index (ODI), and short form-36 (SF-36) in an anchor-based approach. RESULTS .: MCIDs for ODI, LBP and leg pain VAS, physical component summary, mental health component summary (MCS), and overall health scores of SF-36 were 9.0, 22.5, 27.5, 10.2, 4.0, and 8.9, and SCBs were 15.0, 32.5, 37.0, 19.7, 19.3, and 21.1, respectively. MCID and SCB area under the curve was ≥0.8, and ≥0.7, respectively. CONCLUSION .: LBP and leg pain VAS, ODI, and physical component summary of SF-36 may be used to measure responsiveness in FBSS patients. LEVEL OF EVIDENCE 3.
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Lee J, Shin JS, Lee YJ, Kim MR, Choi A, Lee JH, Shin KM, Shin BC, Cho JH, Ha IH. Long-Term Course of Failed Back Surgery Syndrome (FBSS) Patients Receiving Integrative Korean Medicine Treatment: A 1 Year Prospective Observational Multicenter Study. PLoS One 2017; 12:e0170972. [PMID: 28129399 PMCID: PMC5271391 DOI: 10.1371/journal.pone.0170972] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 12/28/2016] [Indexed: 11/18/2022] Open
Abstract
Background With increase of spine surgeries, failed back surgery syndrome (FBSS) prevalence is also rising. While complementary and alternative medicine (CAM) is commonly used for low back pain (LBP), there are no studies reporting use of integrative Korean medicine in FBSS patients. Methods Patients with pain continuing after back surgery or recurring within 1 year and visual analogue scale (VAS) of LBP or leg pain of ≥6 (total n = 120) were recruited at 2 hospital sites from November 2011 to September 2014. Weekly sessions of integrative Korean medicine treatment were conducted for 16 weeks (herbal medicine, acupuncture/electroacupuncture, pharmacopuncture/bee venom pharmacopuncture, and Chuna manual therapy) with additional follow-ups at 24 weeks and 1 year. Outcome measures included VAS of LBP and leg pain (primary outcome), Oswestry Disability Index (ODI), Short-Form 36 (SF-36), medical use, and patient global impression of change (PGIC). Results VAS of LBP and leg pain improved at 6 months (LBP from 6.1±2.0 at baseline to 2.9±2.3; and leg pain from 5.4±2.6 to 2.4±2.5, respectively). Eighty patients (66.7%) showed improvement of 50% or more in main pain of LBP or leg pain from baseline. Disability and quality of life also improved at 6 months (ODI from 41.3±12.3 at baseline to 23.6±13.6; and SF-36 from 42.8±14.5 to 62.7±16.8). At 1 year follow-up, conventional medical management use decreased, improvement in pain and disability was maintained, and 79.2% reported improvement of PGIC. Conclusions Despite limitations as an observational study, integrative Korean medicine treatment showed positive results in pain, function, and quality of life of FBSS patients.
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Affiliation(s)
- Jinho Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Joon-Shik Shin
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Yoon Jae Lee
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Me-riong Kim
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Areum Choi
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Jun-Hwan Lee
- Clinical Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
- University of Science & Technology (UST), Korean Medicine Life Science, Campus of Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - Kyung-Min Shin
- Clinical Research Division, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea
| | - Byung-Cheul Shin
- Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Jae-Heung Cho
- Department of Korean Rehabilitation Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
- * E-mail:
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Spinal Cord Stimulation in Failed Back Surgery Syndrome: Review of Clinical Use, Quality of Life and Cost-Effectiveness. Asian Spine J 2016; 10:1195-1204. [PMID: 27994797 PMCID: PMC5165011 DOI: 10.4184/asj.2016.10.6.1195] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/15/2016] [Indexed: 01/15/2023] Open
Abstract
Failed back surgery syndrome (FBSS) is complex and recurrent chronic pain after spinal surgery. Several important patient and surgery related risk factors play roles in development of FBSS. Inadequate selection of the candidates for the spinal surgeries is one of the most crucial causes. The guidelines suggest that conservative management featuring pharmacologic approaches and rehabilitation should be introduced first. For therapy-refractory FBSS, spinal cord stimulation (SCS) is recommended in selected patients. Treatment efficacy for FBSS has increased over the years with the majority of patients experiencing pain relief and reduced medicinal load. Improved quality of life can also be achieved using SCS. Cost-effectiveness of SCS still remains unclear. However evidence for SCS role in FBSS is controversial, SCS can be beneficial for carefully classified patients.
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Abstract
The treatment of failed back surgery syndrome (FBSS) can be equally challenging to surgeons, pain specialists, and primary care providers alike. The onset of FBSS occurs when surgery fails to treat the patient's lumbar spinal pain. Minimizing the likelihood of FBSS is dependent on determining a clear etiology of the patient's pain, recognizing those who are at high risk, and exhausting conservative measures before deciding to go into a revision surgery. The workup of FBSS includes a thorough history and physical examination, diagnostic imaging, and procedures. After determining the cause of FBSS, a multidisciplinary approach is preferred. This includes pharmacologic management of pain, physical therapy, and behavioral modification and may include therapeutic procedures such as injections, radiofrequency ablation, lysis of adhesions, spinal cord stimulation, and even reoperations.
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Affiliation(s)
- Zafeer Baber
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael A Erdek
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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22
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Abstract
Unfortunately, 10-40 % of patients still experience pain after spinal surgery. There are many reasons for the patients' complaints. If no identifiable cause, such as a recurrent disc herniation, is visible, this is referred to as failed back surgery syndrome. However, this definition includes a variety of possible underlying causes of the pain, which result in just as many different therapeutic approaches. In addition to pharmacological, behavioral and physical therapy, also neuromodulation techniques can be offered; the best known method is spinal cord stimulation (SCS). The following article describes evidence-based studies with regard to the beneficial treatment of failed back surgery syndrome with conventional tonic SCS and new developments in spinal cord stimulation addressing the treatment of chronic refractory back pain.
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Affiliation(s)
- V Tronnier
- Universitätsklinikum Schleswig-Holstein, Klinik für Neurochirurgie Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland.
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Liu L, Skinner MA, McDonough SM, Taylor KGM, Baxter GD. Does the dose of Traditional Chinese Medicine acupuncture in addition to usual care affect outcomes for adults with chronic low back pain? Protocol for a randomized controlled feasibility study. PHYSICAL THERAPY REVIEWS 2016. [DOI: 10.1080/10833196.2015.1107365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Orita S, Shiga Y, Fujimoto K, Sainoh T, Kubota G, Inage K, Sato J, Yamauchi K, Aoki Y, Nakamura J, Matsuura Y, Suzuki T, Takahashi K, Ohtori S. Modified and systematically-designed installation procedure for spinal cord stimulation in the decubitus position under local anesthesia: a introductory technical case report. Int J Clin Exp Med 2015; 8:12356-12364. [PMID: 26550145 PMCID: PMC4612830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 08/06/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) is sometimes preferable in some refractory chronic lower back pain (LBP) pathologies. SCS involves an insertion of electrode leads into the epidural space in the prone position under local anesthesia, followed by neurostimulator implantation under local/general anesthesia. These continuous procedures can cause transient post-operative LBP exacerbation and to make temporary pockets that will store redundant leads in it with some risk of subcutaneous irritation and infection in addition to making extra incisions. We introduce a modified simpler method for SCS implantation, systematically designed to be performed only under local anesthesia in a decubitus, non-prone position. MATERIALS AND METHODS An 81-year-old patient with FBSS was treated. A physician was able to insert SCS leads with ease while the patient was in a decubitus position. The patient was comfortable, under totally local anesthesia, and the procedure produced no extra subcutaneous pockets. RESULT The patient felt almost no LBP and reported no pain exacerbation during the operation. The SCS installation provided the patient with great improvement in both her lower back (NRS from 8 to 0-1) and leg (from 7 to 2) pain with a great improvement in her daily life activities. No adverse events were observed during the perioperative period. CONCLUSION The modified SCS insertion method enabled us to achieve both intraoperative pain relief and complete SCS implantation in a minimally invasive manner.
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Affiliation(s)
- Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Kazuki Fujimoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Takeshi Sainoh
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Go Kubota
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Jun Sato
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Kazuyo Yamauchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, East Chiba Medical CenterChiba, Japan
| | - Junichi Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Yusuke Matsuura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Takane Suzuki
- Department of Bioenvironmental Medicine, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Kazuhisa Takahashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba UniversityChiba, Japan
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Gilligan CJ, Borsook D. The Promise of Effective Pain Treatment Outcomes: Rallying Academic Centers to Lead the Charge. PAIN MEDICINE 2015. [PMID: 26219090 DOI: 10.1111/pme.12772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Christopher J Gilligan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - David Borsook
- Department of Anesthesia, Center for Pain and the Brain, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Pereira P, Severo M, Monteiro P, Silva PA, Rebelo V, Castro-Lopes JM, Vaz R. Results of Lumbar Endoscopic Adhesiolysis Using a Radiofrequency Catheter in Patients with Postoperative Fibrosis and Persistent or Recurrent Symptoms After Discectomy. Pain Pract 2014; 16:67-79. [DOI: 10.1111/papr.12266] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 10/10/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Paulo Pereira
- Department of Neurosurgery; São João Hospital Center; Porto Portugal
- Department of Clinical Neurosciences and Mental Health; Faculty of Medicine; University of Porto; Porto Portugal
- Unit of Neurosciences; Hospital CUF-Porto; Porto Portugal
| | - Milton Severo
- Institute of Public Health; University of Porto; Porto Portugal
- Department of Clinical Epidemiology, Predictive Medicine and Public Health; Faculty of Medicine, University of Porto; Porto Portugal
| | - Pedro Monteiro
- Department of Neurosurgery; São João Hospital Center; Porto Portugal
- Department of Clinical Neurosciences and Mental Health; Faculty of Medicine; University of Porto; Porto Portugal
| | - Pedro Alberto Silva
- Department of Neurosurgery; São João Hospital Center; Porto Portugal
- Department of Clinical Neurosciences and Mental Health; Faculty of Medicine; University of Porto; Porto Portugal
| | - Virgínia Rebelo
- Department of Psychiatry and Mental Health; São João Hospital Center; Porto Portugal
| | | | - Rui Vaz
- Department of Neurosurgery; São João Hospital Center; Porto Portugal
- Department of Clinical Neurosciences and Mental Health; Faculty of Medicine; University of Porto; Porto Portugal
- Unit of Neurosciences; Hospital CUF-Porto; Porto Portugal
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Abstract
With continuous progress and rapid technological advancement of neuromodulation it is conceivable that within next decade or so, our approach to the electrical stimulation of the spinal cord used in treatment of chronic pain will change radically. The currently used spinal cord stimulation (SCS), with its procedural invasiveness, bulky devices, simplistic stimulation paradigms, and frustrating decline in effectiveness over time will be replaced by much more refined and individually tailored modality. Better understanding of underlying mechanism of action will allow us to use SCS in a more rational way, selecting patient-specific targets and techniques that properly fit each patient with chronic pain based on pain characteristics, distribution, and cause. Based on the information available today, this article will summarize emerging applications of SCS in the treatment of pain and theorize on further developments that may be introduced in the foreseeable future. An overview of clinical and technological innovations will serve as a basis for better understanding of SCS landscape for the next several years.
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Affiliation(s)
- Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, 912 South Wood Street (MC 799), Chicago, IL, 60612, USA,
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