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Hussain N, Schatman ME, Abd-Elsayed A. Knowledge Dissemination in Pain Medicine: Searching for Signal Within the Noise. J Pain Res 2022; 15:1563-1565. [PMID: 35651881 PMCID: PMC9150757 DOI: 10.2147/jpr.s372196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/24/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Nasir Hussain
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard, Boston, MA, USA
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
- School of Social Work, North Carolina State University, Raleigh, NC, USA
- Correspondence: Michael E Schatman, Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA, Email
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Medicine, University of Wisconsin-Madison, Madison, WI, USA
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2
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Vuka I, Marciuš T, Kovačić D, Šarolić A, Puljak L, Sapunar D. Implantable, Programmable, and Wireless Device for Electrical Stimulation of the Dorsal Root Ganglion in Freely-Moving Rats: A Proof of Concept Study. J Pain Res 2021; 14:3759-3772. [PMID: 34916842 PMCID: PMC8668248 DOI: 10.2147/jpr.s332438] [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: 08/03/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This was a proof of concept study, based on systematic reviews of the efficacy and safety of the dorsal root ganglion (DRG) stimulation. The main objective was to develop an implantable, programmable, and wireless device for electrical stimulation of DRG and a methodology that can be used in translational research, especially to understand the mechanism of neuromodulation and to test new treatment modalities in animal models of pain. Methods We developed and tested a stimulator that uses a battery-powered microelectronic circuit, to generate constant current square biphasic or monophasic pulsed waveform of variable amplitudes and duration. It is controlled by software and an external controller that allows radio frequency communication with the stimulator. The stimulator was implanted in Sprague–Dawley (SD) rats. The lead was positioned at the L5 DRG level, while the stimulator was placed in the skin pocket at the ipsilateral side. Forty-five animals were used and divided into six groups: spinal nerve ligation (SNL), chronic compression injury of the DRG (CCD), SNL + active DRG stimulation, intact control group, group with the implanted sham stimulator, and sham lead. Behavioral testing was performed on the day preceding surgery and three times postoperatively (1st, 3rd, and 7th day). Results In animals with SNL, neurostimulation reduced pain-related behavior, tested with pinprick hyperalgesia, pinprick withdrawal test, and cold test, while the leads per se did not cause DRG compression. The rats well tolerated the stimulator. It did not hinder animal movement, and it enabled the animals to be housed under regular conditions. Conclusion A proof-of-concept experiment with our stimulator verified the usability of the device. The stimulator enables a wide range of research applications from adjusting stimulation parameters for different pain conditions, studying new stimulation methods with different frequencies and waveforms to obtain knowledge about analgesic mechanisms of DRG stimulation.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Damir Kovačić
- Laboratory for Biophysics and Medical Neuroelectronics, University of Split Faculty of Science, Split, Croatia
| | - Antonio Šarolić
- Laboratory for Applied Electromagnetics (EMLab), FESB, University of Split, Split, Croatia
| | - Livia Puljak
- Centre for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
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3
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Chapman KB, Kallewaard JW. Response to "the Effectiveness of Dorsal Root Ganglion Neurostimulation for the Treatment of Chronic Pelvic Pain and Chronic Neuropathic Pain of the Lower Extremity: A Comprehensive Review of the Published Data". PAIN MEDICINE 2021; 22:2771-2772. [PMID: 33904571 DOI: 10.1093/pm/pnab146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Kenneth B Chapman
- The Spine & Pain Institute of New York, New York, New York, USA.,Department of Anesthesiology, NYU Langone Medical Center, New York, New York, USA.,The Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
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4
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Kretzschmar M, Reining M. Dorsal root ganglion stimulation for treatment of central poststroke pain in the lower extremity after medullary infarction. Pain 2021; 162:2682-2685. [PMID: 34354016 DOI: 10.1097/j.pain.0000000000002439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT We report a case of relief in central poststroke pain of the lower extremity by stimulation of the dorsal root ganglion (DRG). Central poststroke pain is a poorly understood and even more poorly managed condition that can greatly impact the quality of life. To the best of our knowledge, this investigation is the first to describe the successful treatment of previously intractable chronic pain caused by stroke using DRG stimulation. Noting the anatomical structures and the physiological function, the efficacy of DRG stimulation in central poststroke pain could be explained in a neurophysiological manner. This clinical observation successfully builds on the existing understanding around the pathophysiology of central pain and offers the possibility of nondrug therapy for the treatment of this often refractory chronic pain syndrome.
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Affiliation(s)
- Michael Kretzschmar
- SRH Wald-Klinikum Gera, Clinic of Pain Medicine and Palliative Care, Gera, Germany
- SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Germany
| | - Marco Reining
- SRH Wald-Klinikum Gera, Clinic of Pain Medicine and Palliative Care, Gera, Germany
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5
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Vuka I, Marciuš T, Došenović S, Ferhatović Hamzić L, Vučić K, Sapunar D, Puljak L. Efficacy and Safety of Pulsed Radiofrequency as a Method of Dorsal Root Ganglia Stimulation in Patients with Neuropathic Pain: A Systematic Review. PAIN MEDICINE 2021; 21:3320-3343. [PMID: 32488240 DOI: 10.1093/pm/pnaa141] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Pulsed radiofrequency (PRF) is a nonablative pain treatment that uses radiofrequency current in short high-voltage bursts, resulting in interruption of nociceptive afferent pathways. We conducted a systematic review with the aim to create a synthesis of evidence about the efficacy and safety of PRF applied to the dorsal root ganglion (DRG) for the treatment of neuropathic pain. METHODS We searched MEDLINE, CINAHL, Embase, and PsycINFO through January 8, 2019, as well as ClinicalTrials.gov and the clinical trial register of the World Health Organization. All study designs were eligible. We assessed risk of bias using the Cochrane tool for randomized controlled trials and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I). We assessed level of evidence using the Oxford tool and quality of evidence with GRADE. RESULTS We included 28 studies with participants suffering from lumbosacral, cervical, or thoracic radicular pain, post-herpetic neuralgia, neuropathicbone pain in cancer patients, or carpal tunnel syndrome. Only five studies were randomized controlled trials (RCTs), while others were of nonrandomized designs, predominantly before and after comparisons. A total of 991 participants were included, with a median number (range) of 31 (1-101) participants. Only 204 participants were included in the RCTs, with a median number (range) of 38 (23-62) participants. The overall quality of evidence was low, as the majority of the included studies were rated as evidence level 4 or 5. The quality of evidence was very low. CONCLUSIONS Evidence about the efficacy and safety of PRF of the DRG for the treatment of neuropathic pain is based mainly on results from very small studies with low evidence quality. Current research results about the benefits of PRF of the DRG for the treatment of neuropathic pain should be considered preliminary and confirmed in high-quality RCTs with sufficient numbers of participants.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Svjetlana Došenović
- Department of Anaesthesiology, Reanimatology and Intensive Care, University Hospital Split, Split, Croatia
| | - Lejla Ferhatović Hamzić
- Department of Proteomics, Centre for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Katarina Vučić
- Department for Safety and Efficacy Assessment of Medicinal Products, Agency for Medicinal Products and Medical Devices, Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia.,Centre for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
| | - Livia Puljak
- Centre for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
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Franken G, Douven P, Debets J, Joosten EAJ. Conventional Dorsal Root Ganglion Stimulation in an Experimental Model of Painful Diabetic Peripheral Neuropathy: A Quantitative Immunocytochemical Analysis of Intracellular γ-Aminobutyric Acid in Dorsal Root Ganglion Neurons. Neuromodulation 2021; 24:639-645. [PMID: 33942947 PMCID: PMC8360133 DOI: 10.1111/ner.13398] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/26/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Abstract
Background and Objective The sensory cell somata in the DRG contain all equipment necessary for extensive GABAergic signaling and are able to release GABA upon depolarization. With this study, we hypothesize that pain relief induced by conventional dorsal root ganglion stimulation (Con‐DRGS) in animals with experimental painful diabetic peripheral neuropathy is related to the release of GABA from DRG neurons. With use of quantitative immunocytochemistry, we hypothesize DRGS to result in a decreased intensity of intracellular GABA‐immunostaining in DRG somata. Materials and Methods Female Sprague‐Dawley rats (n = 31) were injected with streptozotocin (STZ) in order to induce Diabetes Mellitus. Animals that developed neuropathic pain after four weeks (Von Frey) were implanted with a unilateral DRGS device at L4 (n = 14). Animals were then stimulated for 30 min with Con‐DRGS (20 Hz, pulse width = 0.2 msec, amplitude = 67% of motor threshold, n = 8) or Sham‐DRGS (n = 6), while pain behavior (von Frey) was measured. DRGs were then collected and immunostained for GABA, and a relation to size of sensory cell soma diameter (small: 12–26 μm, assumed to be C‐fiber related sensory neurons; medium: 26–40 μm, assumed to be Aδ related sensory neurons; and large: 40–54 μm, assumed to be Aβ related sensory neurons) was made. Results DRGS treated animals showed significant reductions in STZ‐induced mechanical hypersensitivity. No significant differences in GABA immunostaining intensity per sensory neuron cell soma type (small‐, medium‐, or large‐sized) were noted in DRGs of stimulated (Con‐DRGS) animals versus Sham animals. No differences in GABA immunostaining intensity per sensory cell soma type in ipsi‐ as compared to contralateral DRGs were observed. Conclusion Con‐DRGS does not affect the average intracellular GABA immunofluorescence staining intensity in DRG sensory neurons of those animals which showed significant pain reduction. Similarly, no soma size related changes in intracellular GABA immunofluorescence were observed following Con‐DRGS.
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Affiliation(s)
- Glenn Franken
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Perla Douven
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Urology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Jacques Debets
- School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Muroidean Facility, School of Cardiovascular Diseases (CARIM), Maastricht, The Netherlands
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Berger AA, Liu Y, Possoit H, Rogers AC, Moore W, Gress K, Cornett EM, Kaye AD, Imani F, Sadegi K, Varrassi G, Viswanath O, Urits I. Dorsal Root Ganglion (DRG) and Chronic Pain. Anesth Pain Med 2021; 11:e113020. [PMID: 34336621 PMCID: PMC8314073 DOI: 10.5812/aapm.113020] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 12/12/2022] Open
Abstract
Context Chronic neuropathic pain is a common condition, and up to 11.9% of the population have been reported to suffer from uncontrolled neuropathic pain. Chronic pain leads to significant morbidity, lowered quality of life, and loss of workdays, and thus carries a significant price tag in healthcare costs and lost productivity. dorsal root ganglia (DRG) stimulation has been recently increasingly reported and shows promising results in the alleviation of chronic pain. This paper reviews the background of DRG stimulation, anatomical, and clinical consideration and reviews the clinical evidence to support its use. Evidence Acquisition The DRG span the length of the spinal cord and house the neurons responsible for sensation from the periphery. They may become irritated by direct compression or local inflammation. Glial cells in the DRG respond to nerve injury, producing inflammatory markers and contribute to the development of chronic pain, even after the resolution of the original insult. While the underlying mechanism is still being explored, recent studies explored the efficacy of DRG stimulation and neuromodulation for chronic pain treatment. Results Several reported cases and a small number of randomized trials were published in recent years, describing different methods of DRG stimulation and neuromodulation with promising results. Though evidence quality is mostly low, these results provide evidence to support the utilization of this technique. Conclusions Chronic neuropathic pain is a common condition and carries significant morbidity and impact on the quality of life. Recent evidence supports the use of DRG neuromodulation as an effective technique to control chronic pain. Though studies are still emerging, the evidence appears to support this technique. Further studies, including large randomized trials evaluating DRG modulation versus other interventional and non-interventional techniques, are needed to further elucidate the efficacy of this method. These studies are also likely to inform the patient selection and the course of treatment.
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Affiliation(s)
- Amnon A. Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
- Corresponding Author: Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Yao Liu
- Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - HarLee Possoit
- LSU Health Shreveport, School of Medicine, Shreveport, LA, USA
| | - Anna C. Rogers
- LSU Health Shreveport, School of Medicine, Shreveport, LA, USA
| | - Warner Moore
- LSU Health Shreveport, School of Medicine, Shreveport, LA, USA
| | - Kyle Gress
- Georgetown University School of Medicine, Washington, DC, USA
| | - Elyse M. Cornett
- LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Alan David Kaye
- LSU Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Kambiz Sadegi
- Department of Anesthesiology, Zabol University of Medical Sciences, Zabol, Iran
- Corresponding Author: Department of Anesthesiology, Zabol University of Medical Sciences, Zabol, Iran.
| | | | - Omar Viswanath
- Georgetown University School of Medicine, Washington, DC, USA
- University of Arizona College of Medicine - Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
- Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA
- Valley Anesthesiology and Pain Consultants – Envision Physician Services, Phoenix, AZ, USA
| | - Ivan Urits
- Georgetown University School of Medicine, Washington, DC, USA
- Southcoast Health, Southcoast Health Physicians Group Pain Medicine, Wareham, MA, USA
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8
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Hagedorn JM, McArdle I, D'Souza RS, Yadav A, Engle AM, Deer TR. Effect of Patient Characteristics on Clinical Outcomes More Than 12 Months Following Dorsal Root Ganglion Stimulation Implantation: A Retrospective Review. Neuromodulation 2021; 24:695-699. [PMID: 33508161 DOI: 10.1111/ner.13326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Dorsal root ganglion (DRG) stimulation is an effective treatment option for lower extremity complex regional pain syndrome and other focal pain conditions. However, the patient characteristics that may predict long-term outcomes have not been defined. MATERIALS AND METHODS This was a retrospective observational study that included 93 patients who were implanted with a DRG stimulator at a single private practice institution. A variety of demographic data was collected. Follow-up results were reviewed from multiple time points more than 12 months. Patients were classified as either "responder" or "nonresponder" status using two different thresholds, "greater than or equal to 50% pain relief" and "greater than or equal to 80% pain relief." RESULTS A history of prior chronic opioid use was associated with significantly lower rates of responder status based on both a 50% pain relief threshold and 80% pain relief threshold at the one week to one month, three months, and 12-months visits. CONCLUSIONS This single-center retrospective study found patients prescribed chronic opioids at the time of DRG stimulator implantation had a higher likelihood of less than 50% pain relief and 80% pain relief at one month, three months, and 12 months follow-up visits.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ian McArdle
- West Virginia University School of Medicine, Charleston, WV, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Abhishek Yadav
- Department of Anesthesiology, Brown University, Providence, RI, USA
| | - Alyson M Engle
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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9
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Stelter B, Karri J, Marathe A, Abd-Elsayed A. Dorsal Root Ganglion Stimulation for the Treatment of Non-Complex Regional Pain Syndrome Related Chronic Pain Syndromes: A Systematic Review. Neuromodulation 2021; 24:622-633. [PMID: 33501749 DOI: 10.1111/ner.13361] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/08/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND While the majority of indications and approvals for dorsal root ganglion stimulation (DRGS) are for the refractory management of complex regional pain syndrome (CRPS), emerging evidence has suggested that DRGS may be favorably used for a plethora of other chronic pain phenomena. Consequently, we aimed to characterize the use and efficacy of DRGS for these non-CRPS-related chronic pain syndromes. MATERIALS AND METHODS A systematic review of clinical studies demonstrating the use of DRGS for non-CRPS-related chronic pain syndromes. The literature search was performed using PubMed, Cochrane Library, and CINAHL plus across August and September 2020. RESULTS A total of 28 reports comprising 354 total patients were included in the analysis. Of the chronic pain syndromes presented, axial low back pain, chronic pelvic and groin pain, other peripheral neuropathies, and studies with multiple concomitant pain syndromes, a majority demonstrated >50% mean pain reduction at the time of last follow-up following DRGS. Physical function, quality of life (QOL), and lesser pain medication usage also were repeatedly reported to be significantly improved. CONCLUSIONS DRGS continues to lack supportive evidence from well designed, high level studies and recommendations from consensus committee experts. However, we present repeated and consistent evidence from lower level studies showing success with the use of DRGS for various non-CRPS chronic pain syndromes in reducing pain along with increasing function and QOL from one week to three years. Due to such low-level, high bias evidence, we strongly encourage the continuation of high-level studies in order to provide a stronger foundation for the use of DRGS in non-CRPS chronic pain patients. However, it may be reasonable and appropriate to evaluate patients for DRGS candidacy on a case-by-case basis particularly if they manifest focal pain syndromes refractory to noninterventional measures and may not be ideal candidates for other forms of neuromodulation.
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Affiliation(s)
- Bradly Stelter
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Anuj Marathe
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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10
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Urits I, Li N, Berger AA, Walker P, Wesp B, Zamarripa AM, An D, Cornett EM, Abd-Elsayed A, Kaye AD. Treatment and Management of Loin Pain Hematuria Syndrome. Curr Pain Headache Rep 2021; 25:6. [PMID: 33495883 DOI: 10.1007/s11916-020-00925-0] [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] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available. RECENT FINDINGS LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.,Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Nathan Li
- Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Amnon A Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Paul Walker
- Weill Cornell Medical College, New York, NY, USA
| | - Brendan Wesp
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alec M Zamarripa
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Daniel An
- Georgetown University School of Medicine, Washington, DC, USA
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
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11
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Hagedorn JM, Demian PS, Scarfo KA, Engle AM, Deer TR. Proclaim™ DRG Neurostimulator System for the management of chronic, intractable pain. Pain Manag 2020; 10:225-233. [DOI: 10.2217/pmt-2020-0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic pain is consistently listed as one of the most costly and disabling health problems worldwide. In an effort to treat these suffering individuals, significant amounts of time and energy have been devoted to discover safe and effective pain relieving treatments. Dorsal root ganglion stimulation is the newest treatment modality to be created for chronic intractable pain. In this manuscript, we review the history and development, published research and safety profile of the Proclaim™ DRG Neurostimulator System (Abbott, TX, USA). At last, we offer our outlook on future developments with dorsal root ganglion stimulation.
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Affiliation(s)
- Jonathan M Hagedorn
- Department of Anesthesiology & Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Pavli S Demian
- The Pain Management Center, 2271 NJ-33 #103, Hamilton Township, NJ 08690, USA
| | - Keith-Austin Scarfo
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, 593 Eddy Street, George 1st Floor, Providence, RI 02903, USA
| | - Alyson M Engle
- Department of Anesthesiology, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Suite 402, Pittsburgh, PA 15213, USA
| | - Timothy R Deer
- The Spine & Nerve Center of The Virginias, 400 Court Street, Suite 100, Charleston, WV 25301, USA
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12
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Kretzschmar M, Reining M, Schwarz MA. Three-Year Outcomes After Dorsal Root Ganglion Stimulation in the Treatment of Neuropathic Pain After Peripheral Nerve Injury of Upper and Lower Extremities. Neuromodulation 2020; 24:700-707. [PMID: 32573868 DOI: 10.1111/ner.13222] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/30/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Traumatic peripheral nerve injuries (PNI) often result in severe neuropathic pain which typically becomes chronic, is recalcitrant to common analgesics, and is associated with sleep disturbances, anxiety, and depression. Pharmacological treatments proven to be effective against neuropathic pain are not well tolerated due to side effects. Neuromodulative interventions such as peripheral nerve or spinal cord stimulation have generated mixed results and may be limited by reduced somatotopic specificity. Dorsal root ganglion (DRG) stimulation may be more effective in this etiology. MATERIALS AND METHODS Twenty-seven patients were trialed with a DRG neurostimulation system for PNI; trial success (defined as ≥50% pain relief) was 85%, and 23 patients received a permanent stimulator. However, 36-month outcome data was only available for 21 patients. Pain, quality of life, mental and physical function, and opioid usage were assessed at baseline and at 3-, 6-, 12-, 18-, 24-, and 36 months post-permanent implant. Implant-related complications were also documented. RESULTS Compared to baseline, we observed a significant pain relief (p < 0.001) at 3 (58%), 12 (66%), 18 (69%), 24 (71%), and 36 months (73%) in 21 patients (52.5 ± 14.2 years; 12 female), respectively. Mental and physical function showed immediate and sustained improvements. Participants reported improvements in quality of life. Opioid dosage reduced significantly (p < 0.001) at 3 (30%), 12 (93%), 18 (98%), 24 (99%), and 36 months (99%), and 20 of 21 patients were completely opioid-free after 36 months. There were five lead migrations and two electrode fractures (corrected by surgical intervention) and one wound infection (conservatively managed). CONCLUSIONS DRG neuromodulation appears to be a safe, effective, and durable option for treating neuropathic pain caused by PNI. The treatment allows cessation of often ineffective pharmacotherapy (including opioid misuse) and significantly improves quality of life.
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Affiliation(s)
- Michael Kretzschmar
- SRH Wald-Klinikum Gera, Department of Pain Medicine and Palliative Care, Gera, Strasse des Friedens 122, D-07548, Germany.,SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Neue Strasse 30-32, D-07548, Germany
| | - Marco Reining
- SRH Wald-Klinikum Gera, Department of Pain Medicine and Palliative Care, Gera, Strasse des Friedens 122, D-07548, Germany
| | - Marcus A Schwarz
- SRH Hochschule für Gesundheit (University of Applied Health Sciences) Campus Gera, Gera, Neue Strasse 30-32, D-07548, Germany
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Vuka I, Došenović S, Marciuš T, Ferhatović Hamzić L, Vučić K, Sapunar D, Puljak L. Efficacy and safety of pulsed radiofrequency as a method of dorsal root ganglia stimulation for treatment of non-neuropathic pain: a systematic review. BMC Anesthesiol 2020; 20:105. [PMID: 32366286 PMCID: PMC7199300 DOI: 10.1186/s12871-020-01023-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/26/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND We systematically reviewed the evidence on the efficacy and safety of dorsal root ganglion (DRG) targeted pulsed radiofrequency (PRF) versus any comparator for treatment of non-neuropathic pain. METHODS We searched MEDLINE, CINAHL, Embase, PsycINFO, clinicaltrials.gov and WHO clinical trial register until January 8, 2019. All study designs were eligible. Two authors independently conducted literature screening. Primary outcomes were pain intensity and serious adverse events (SAEs). Secondary outcomes were any other pain-related outcome and any other safety outcome that was reported. We assessed the risk of bias using the Cochrane tool and Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I). We conducted narrative evidence synthesis and assessed the conclusiveness of included studies regarding efficacy and safety. RESULTS We included 17 studies with 599 participants, which analyzed various pain syndromes. Two studies were randomized controlled trials; both included participants with low back pain (LBP). Non-randomized studies included patients with the following indications: LBP, postsurgical pain, pain associated with herpes zoster, cervicogenic headache, complex regional pain syndrome type 1, intractable vertebral metastatic pain, chronic scrotal and inguinal pain, occipital radiating pain in rheumatoid arthritis and chronic migraine. In these studies, the PRF was usually initiated after other treatments have failed. Eleven studies had positive conclusive statements (11/17) about efficacy; the remaining had positive inconclusive statements. Only three studies provided conclusiveness of evidence statements regarding safety - two indicated that the evidence was positive conclusive, and one positive inconclusive. The risk of bias was predominantly unclear in randomized and serious in non-randomized studies. CONCLUSION Poor quality and few participants characterize evidence about benefits and harms of DRG PRF in patients with non-neuropathic pain. Results from available studies should only be considered preliminary. Not all studies have reported data regarding the safety of the intervention, but those that did, indicate that the intervention is relatively safe. As the procedure is non-destructive and early results are promising, further comparative studies about PRF in non-neuropathic pain syndromes would be welcomed.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, Šoltanska 2, 21000, Split, Croatia
| | - Svjetlana Došenović
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Split, Spinčićeva 1, 21000, Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, Šoltanska 2, 21000, Split, Croatia
| | - Lejla Ferhatović Hamzić
- Center for Translational and Clinical Research, Department of Proteomics, University of Zagreb School of Medicine, Šalata 3, 10000, Zagreb, Croatia
| | - Katarina Vučić
- Department for Safety and Efficacy Assessment of Medicinal Products, Agency for Medicinal Products and Medical Devices, Ksaverska cesta 4, 10000, Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Šoltanska 2, 21000, Split, Croatia
- Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Ilica 242, 10000, Zagreb, Croatia
| | - Livia Puljak
- Center for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Ilica 242, 10000, Zagreb, Croatia.
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