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Hewitt D, Byrne A, Henderson J, Wilford K, Chawla R, Sharma ML, Frank B, Fallon N, Brown C, Stancak A. Pulse Intensity Effects of Burst and Tonic Spinal Cord Stimulation on Neural Responses to Brushing in Patients With Neuropathic Pain. Neuromodulation 2022:S1094-7159(22)01349-6. [DOI: 10.1016/j.neurom.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 12/04/2022]
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Dura JL, Solanes C, De Andres J, Saiz J. Effect of Lead Position and Polarity on Paresthesia Coverage in Spinal Cord Stimulation Therapy: A Computational Study. Neuromodulation 2022; 25:680-692. [DOI: 10.1016/j.neurom.2021.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/25/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
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Provenzano DA, Heller JA, Hanes MC. Current Perspectives on Neurostimulation for the Management of Chronic Low Back Pain: A Narrative Review. J Pain Res 2021; 14:463-479. [PMID: 33628045 PMCID: PMC7899039 DOI: 10.2147/jpr.s249580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/16/2020] [Indexed: 01/29/2023] Open
Abstract
Neurostimulation techniques for the treatment of chronic low back pain (LBP) have been rapidly evolving; however, questions remain as to which modalities provide the most efficacious and durable treatment for intractable axial symptoms. Modalities of spinal cord stimulation, such as traditional low-frequency paresthesia based, high-density or high dose (HD), burst, 10-kHz high-frequency therapy, closed-loop, and differential target multiplexed, have been limitedly studied to determine their efficacy for the treatment of axial LBP. In addition, stimulation methods that target regions other than the spinal cord, such as medial branch nerve stimulation of the multifidus muscles and the dorsal root ganglion may also be viable treatment options. Here, current scientific evidence behind neurostimulation techniques have been reviewed with a focus on the management of chronic axial LBP.
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Affiliation(s)
- David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA, USA.,Western PA Surgery Center, Wexford, PA, USA
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Meuwissen KPV, de Vries LE, Gu JW, Zhang TC, Joosten EAJ. Burst and Tonic Spinal Cord Stimulation Both Activate Spinal GABAergic Mechanisms to Attenuate Pain in a Rat Model of Chronic Neuropathic Pain. Pain Pract 2019; 20:75-87. [PMID: 31424152 PMCID: PMC7004135 DOI: 10.1111/papr.12831] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/28/2019] [Accepted: 08/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Experimental and clinical studies have shown that tonic spinal cord stimulation (SCS) releases gamma-aminobutyric acid (GABA) in the spinal dorsal horn. Recently, it was suggested that burst SCS does not act via spinal GABAergic mechanisms. Therefore, we studied spinal GABA release during burst and tonic SCS, both anatomically and pharmacologically, in a well-established chronic neuropathic pain model. METHODS Animals underwent partial sciatic nerve ligation (PSNL). Quantitative immunohistochemical (IHC) analysis of intracellular GABA levels in the lumbar L4 to L6 dorsal spinal cord was performed after 60 minutes of burst, tonic, or sham SCS in rats that had undergone PSNL (n = 16). In a second pharmacological experiment, the effects of intrathecal administration of the GABAA antagonist bicuculline (5 μg) and the GABAB antagonist phaclofen (5 μg) were assessed. Paw withdrawal thresholds to von Frey filaments of rats that had undergone PSNL (n = 20) were tested during 60 minutes of burst and tonic SCS 30 minutes after intrathecal administration of the drugs. RESULTS Quantitative IHC analysis of GABA immunoreactivity in spinal dorsal horn sections of animals that had received burst SCS (n = 5) showed significantly lower intracellular GABA levels when compared to sham SCS sections (n = 4; P = 0.0201) and tonic SCS sections (n = 7; P = 0.0077). Intrathecal application of the GABAA antagonist bicuculline (5 μg; n = 10) or the GABAB antagonist phaclofen (5 μg; n = 10) resulted in ablation of the analgesic effect for both burst SCS and tonic SCS. CONCLUSIONS In conclusion, our anatomical and pharmacological data demonstrate that, in this well-established chronic neuropathic animal model, the analgesic effects of both burst SCS and tonic SCS are mediated via spinal GABAergic mechanisms.
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Affiliation(s)
- Koen P V Meuwissen
- Department of Anesthesiology and Pain Management, Pain Management and Research Centre, MUMC+, Maastricht, The Netherlands.,School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Luuk E de Vries
- School for Mental Health and Neuroscience (MHeNS), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jianwen Wendy Gu
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Tianhe C Zhang
- Boston Scientific: Neuromodulation, Research and Advanced Concepts Team, Valencia, California, U.S.A
| | - Elbert A J Joosten
- Department of Anesthesiology and Pain Management, Pain Management and Research 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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Caylor J, Reddy R, Yin S, Cui C, Huang M, Huang C, Rao R, Baker DG, Simmons A, Souza D, Narouze S, Vallejo R, Lerman I. Spinal cord stimulation in chronic pain: evidence and theory for mechanisms of action. Bioelectron Med 2019; 5:12. [PMID: 31435499 PMCID: PMC6703564 DOI: 10.1186/s42234-019-0023-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/30/2019] [Indexed: 12/30/2022] Open
Abstract
Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.
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Affiliation(s)
- Jacob Caylor
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Rajiv Reddy
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Sopyda Yin
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Christina Cui
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Mingxiong Huang
- Department of Radiology, University of California San Diego School of Medicine, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
| | - Charles Huang
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Bioengineering, Stanford University, Palo Alto, CA USA
| | - Ramesh Rao
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
| | - Dewleen G. Baker
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Alan Simmons
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, CA USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital. Department of Surgery, Northeast Ohio Medical School (NEOMED), Athens, OH USA
| | - Ricardo Vallejo
- Basic Science Research, Millennium Pain Center, Bloomington, IL USA
- School of Biological Sciences, Illinois State University, Normal, IL USA
- Department of Psychology, Illinois Wesleyan University, Bloomington, IL USA
| | - Imanuel Lerman
- Department of Anesthesiology, Center for Pain Medicine, University of California San Diego School of Medicine, La Jolla, CA USA
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Radiology, VA San Diego Healthcare System, La Jolla, CA USA
- Department of Electrical and Computer Engineering, University of California San Diego, La Jolla, CA USA
- Present Address: VA San Diego, 3350 La Jolla Village Dr, (MC116A), San Diego, CA 92161 USA
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Mourdoukoutas AP, Truong DQ, Adair DK, Simon BJ, Bikson M. High-Resolution Multi-Scale Computational Model for Non-Invasive Cervical Vagus Nerve Stimulation. Neuromodulation 2018; 21:261-268. [PMID: 29076212 PMCID: PMC5895480 DOI: 10.1111/ner.12706] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/26/2017] [Accepted: 08/25/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To develop the first high-resolution, multi-scale model of cervical non-invasive vagus nerve stimulation (nVNS) and to predict vagus fiber type activation, given clinically relevant rheobase thresholds. METHODS An MRI-derived Finite Element Method (FEM) model was developed to accurately simulate key macroscopic (e.g., skin, soft tissue, muscle) and mesoscopic (cervical enlargement, vertebral arch and foramen, cerebral spinal fluid [CSF], nerve sheath) tissue components to predict extracellular potential, electric field (E-Field), and activating function along the vagus nerve. Microscopic scale biophysical models of axons were developed to compare axons of varying size (Aα-, Aβ- and Aδ-, B-, and C-fibers). Rheobase threshold estimates were based on a step function waveform. RESULTS Macro-scale accuracy was found to determine E-Field magnitudes around the vagus nerve, while meso-scale precision determined E-field changes (activating function). Mesoscopic anatomical details that capture vagus nerve passage through a changing tissue environment (e.g., bone to soft tissue) profoundly enhanced predicted axon sensitivity while encapsulation in homogenous tissue (e.g., nerve sheath) dulled axon sensitivity to nVNS. CONCLUSIONS These findings indicate that realistic and precise modeling at both macroscopic and mesoscopic scales are needed for quantitative predictions of vagus nerve activation. Based on this approach, we predict conventional cervical nVNS protocols can activate A- and B- but not C-fibers. Our state-of-the-art implementation across scales is equally valuable for models of spinal cord stimulation, cortex/deep brain stimulation, and other peripheral/cranial nerve models.
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Affiliation(s)
- Antonios P. Mourdoukoutas
- Department of Biomedical Engineering, The City College of New York, City University of New York, New York, NY
| | - Dennis Q. Truong
- Department of Biomedical Engineering, The City College of New York, City University of New York, New York, NY
| | - Devin K. Adair
- Department of Psychology, The Graduate Center, City University of New York, New York, New York
| | | | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, City University of New York, New York, NY
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Provenzano DA, Amirdelfan K, Kapural L, Sitzman BT. Evidence Gaps in the Use of Spinal Cord Stimulation for Treating Chronic Spine Conditions. Spine (Phila Pa 1976) 2017; 42 Suppl 14:S80-92. [PMID: 28368981 DOI: 10.1097/BRS.0000000000002184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A review of literature. OBJECTIVE The aim of this study was to define and explore the current evidence gaps in the use of spinal cord stimulation (SCS) for treating chronic spine conditions. SUMMARY OF BACKGROUND DATA Although over the last 40 years SCS therapy has undergone significant technological advancements, evidence gaps still exist. METHODS A literature review was conducted to define current evidence gaps for the use of SCS. Areas of focus included 1) treatment of cervical spine conditions, 2) treatment of lumbar spine conditions, 3) technological advancement and device selection, 4) appropriate patient selection, 5) the ability to curb pharmacological treatment, and 6) methods to prolong efficacy over time. New SCS strategies using advanced waveforms are explored. RESULTS The efficacy, safety, and cost-effectiveness of traditional SCS for chronic pain conditions are well-established. Evidence gaps do exist. Recently, advancement in waveforms and programming parameters have allowed for paresthesia-reduced/free stimulation that in specific clinical areas may improve clinical outcomes. New waveforms such as 10-kHz high-frequency have resulted in an improvement in back coverage. To date, clinical efficacy data are more prevalent for the treatment of painful conditions originating from the lumbar spine in comparison to the cervical spine. CONCLUSION Evidence gaps still exist that require appropriate study designs with long-term follow-up to better define and improve the use of this therapy for the treatment of chronic spine pain in both the cervical and lumbar regions. LEVEL OF EVIDENCE N/A.
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Miller JP, Eldabe S, Buchser E, Johanek LM, Guan Y, Linderoth B. Parameters of Spinal Cord Stimulation and Their Role in Electrical Charge Delivery: A Review. Neuromodulation 2016; 19:373-84. [DOI: 10.1111/ner.12438] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/07/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Jonathan P. Miller
- Functional and Restorative Neurosurgery Center and Department of Neurological Surgery, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center; Cleveland OH USA
| | - Sam Eldabe
- The James Cook University Hospital; Middlesbrough UK
| | - Eric Buchser
- Anaesthesia and Pain Management Services at the Neuromodulation Centre; Hospital de Morges, Morges; Switzerland
| | - Lisa M. Johanek
- Department of Medical Affairs, Medtronic, PLC; Minneapolis MN USA
| | - Yun Guan
- Department of Anesthesiology/Critical Care Medicine; The Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Bengt Linderoth
- Functional Neurosurgery, Department of Clinical Neuroscience, Karolinska Institutet; Stockholm Sweden
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Tan D, Tyler D, Sweet J, Miller J. Intensity Modulation: A Novel Approach to Percept Control in Spinal Cord Stimulation. Neuromodulation 2015; 19:254-9. [PMID: 26479774 DOI: 10.1111/ner.12358] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/11/2015] [Accepted: 09/01/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) can be effective for neuropathic pain, but clinical benefit is sometimes inadequate or is offset by stimulation-induced side-effects, and response can be inconsistent among patients. Intensity-modulated stimulation (IMS) is an alternative to tonic stimulation (TS) that involves continuous variation of stimulation intensity in a sinusoidal pattern between two different values, sequentially activating distinct axonal populations to produce an effect that resembles natural physiological signals. The purpose of this study is to evaluate the effect of IMS on the clinical effect of SCS. METHODS Seven patients undergoing a percutaneous SCS trial for postlaminectomy syndrome were enrolled. Thresholds for perception, pain relief, and discomfort were measured and used to create patient-specific models of axonal activation and charge delivery for both TS and IMS. All participants underwent three two-min periods of blinded stimulation using TS, IMS, and placebo, and were asked to describe the effect on quality of the sensory percept and pain relief. RESULTS All participants perceived IMS differently from placebo, and five noted significant differences from TS that resulted in a more comfortable sensation. TS was described as electric and tingling, whereas IMS was described as producing a focal area of deep pressure with a sense of motion away from that focus. The anatomic location of coverage was similar between the two forms of stimulation, although one participant reported better lower back coverage with IMS. Computer modeling revealed that, compared with TS, IMS involved 36.4% less charge delivery and produced 78.7% less suprathreshold axonal activation. CONCLUSIONS IMS for SCS is feasible, produces a more comfortable percept than conventional TS, and appears to provide a similar degree of pain relief with significantly lower energy requirements. Further studies are necessary to determine whether this represents an effective alternative to tonic SCS for treatment of neuropathic pain.
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Affiliation(s)
- Daniel Tan
- The Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Dustin Tyler
- The Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Jennifer Sweet
- The Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Jonathan Miller
- The Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
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