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Eldabe S, Nevitt S, Copley S, Maden M, Goudman L, Hayek S, Mekhail N, Moens M, Rigoard P, Duarte R. Does industry funding and study location impact findings from randomized controlled trials of spinal cord stimulation? A systematic review and meta-analysis. Reg Anesth Pain Med 2024; 49:272-284. [PMID: 37611944 DOI: 10.1136/rapm-2023-104674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/13/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND/IMPORTANCE Concerns have been raised that effects observed in studies of spinal cord stimulation (SCS) funded by industry have not been replicated in non-industry-funded studies and that findings may differ based on geographical location where the study was conducted. OBJECTIVE To investigate the impact of industry funding and geographical location on pain intensity, function, health-related quality of life and adverse events reported in randomized controlled trials (RCTs) of SCS. EVIDENCE REVIEW Systematic review conducted using MEDLINE, CENTRAL, EMBASE and WikiStim databases until September 2022. Parallel-group RCTs evaluating SCS for patients with neuropathic pain were included. Results of studies were combined in random-effects meta-analysis using the generic-inverse variance method. Subgroup meta-analyses were conducted according to funding source and study location. Risk of bias was assessed using Cochrane RoB 2.0 tool. FINDINGS Twenty-nine reports of 17 RCTs (1823 participants) were included. For the comparison of SCS with usual care, test for subgroup differences indicate no significant differences (p=0.48, moderate certainty evidence) in pain intensity score at 6 months for studies with no funding or funding not disclosed (pooled mean difference (MD) -1.96 (95% CI -3.23 to -0.69; 95% prediction interval (PI) not estimable, I2=0%, τ2=0)), industry funding (pooled MD -2.70 (95% CI -4.29 to -1.11; 95% PI -8.75 to 3.35, I2=97%, τ2=2.96) or non-industry funding (MD -3.09 (95% CI -4.47 to -1.72); 95% PI, I2 and τ2 not applicable). Studies with industry funding for the comparison of high-frequency SCS (HF-SCS) with low-frequency SCS (LF-SCS) showed statistically significant advantages for HF-SCS compared to LF-SCS while studies with no funding showed no differences between HF-SCS and LF-SCS (low certainty evidence). CONCLUSION All outcomes of SCS versus usual care were not significantly different between studies funded by industry and those independent from industry. Pain intensity score and change in pain intensity from baseline for comparisons of HF-SCS to LF-SCS seem to be impacted by industry funding.
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Affiliation(s)
- Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Sarah Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sue Copley
- Anaesthesia and Pain Management, James Cook University Hospital, Middlesbrough, UK
| | - Michelle Maden
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Lisa Goudman
- Department of Neurosurgery, UZ Brussel, Brussel, Belgium
| | - Salim Hayek
- Anesthesiology, Case Western Reserve University, Unviersity Hospitals, Cleveland, Ohio, USA
| | | | - Maarten Moens
- Department of Neurosurgery, UZ Brussel, Brussel, Belgium
| | - Phillipe Rigoard
- PRISMATICS Lab, Poitiers, France
- Department of Neurosurgery, Poitiers University Hospital, Poitiers, France
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Mekhail N, Topalsky K, Templeton E, Armanyous S, Prayson N, Olde C, Costandi S. Patient and physician radiation exposure during minimally invasive lumbar decompression: A prospective assessment of X-ray exposure risks. Pain Pract 2024; 24:600-608. [PMID: 38069541 DOI: 10.1111/papr.13329] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 04/09/2024]
Abstract
INTRODUCTION Minimally invasive lumbar decompression (mild®) is becoming a popular procedure for treating lumbar spinal stenosis (LSS) secondary to hypertrophic ligamentum flavum (LF). The mild® procedure is commonly performed under live fluoroscopic guidance and carries a risk of radiation exposure to the patient and healthcare. METHODS One physician performed mild® on 41 patients at the Cleveland Clinic Department of Pain Management from October 2019 to December 2021, while wearing a radiation exposure monitor (Mirion Technologies). Mean fluoroscopy time, mean exposure per case, and mean exposure per unilateral level decompressed were the primary outcomes measured. The secondary outcome was to provide a comparison of radiation exposure during similar fluoroscopically guided procedures. RESULTS Mean patient fluoroscopy exposure time was 2.1 min ±0.9 (range: 1.1-5.6) fluoroscopy time per unilateral level decompressed. The mean patient radiation skin exposure from mild® was 1.1 ± 0.9 mGym2, and the mean total dose was 142.3 ± 108.6 mGy per procedure. On average, the physician was exposed to an average deep tissue exposure of 4.1 ± 3.2 mRem, 2.9 ± 2.2 mRem estimated eye exposure, and 14.7 ± 11.0 mRem shallow tissue exposure per unilateral level decompressed. An individual physician would exceed the annual exposure limit of 5 Rem after approximately 610 mild® procedures per year. CONCLUSIONS This study is an attempt to quantify the radiation exposure to the physician and patient during the mild® procedure. Compared with other fluoroscopically guided pain management procedures, patient and physician radiation exposure during mild® was low.
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Affiliation(s)
- Nagy Mekhail
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Krista Topalsky
- Internal Medicine Department, University Hospital, Cleveland, Ohio, USA
| | - Erin Templeton
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sherif Armanyous
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicholas Prayson
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carl Olde
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shrif Costandi
- Pain Management Department, Cleveland Clinic, Cleveland, Ohio, USA
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Mekhail N, Costandi S, Armanyous S, Templeton E, Acevedo-Moreno LAG, Prayson N. Impact of temperature on the magnitude and duration of relief after lumbar facets medial branch nerves radiofrequency ablation: a randomized double-blinded study. Reg Anesth Pain Med 2024:rapm-2023-104869. [PMID: 38413183 DOI: 10.1136/rapm-2023-104869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/18/2023] [Accepted: 02/02/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION There are numerous studies appraising the variables that may influence the clinical outcomes after lumbar thermal radiofrequency ablation (RFA). Expanding the lesion size may increase the likelihood of capturing the target nerves in the lesion, thereby increasing the technical success rate of RFA. However, our literature search has failed to identify a consensus on the optimal target temperature. A retrospective study demonstrated that there seems to be significant functional improvement associated with the temperature of 90°C compared with 80°C. The authors prospectively studied the subject in a double-blinded randomized fashion. METHODS Patients undergoing RFA for lumbar facetogenic pain were randomized in two cohorts (80°C and 90°C). Physicians and patients were blinded to the temperature used. The primary outcome was self-reported pain scores up to 12 months. Secondary outcomes included: self-reported functional improvement, duration of relief as measured by the time before repeat ablation of the same medial branches nerves, opioids' consumption, and patient satisfaction. RESULTS Both groups reported pain improvement in all follow-up time points. Overall, both groups achieved statistically significant pain reduction (p<0.05). The median time to repeat RFA in the 80°C group was 112 (49-252) days, while it was 217 (198-348) days in the 90°C group (p<0.04). The univariate analysis emphasized that the RFA temperature is a statistically significant factor for pain improvement of more than 50%, OR 2.7 (1.1 to 6.6) p value=0.031. CONCLUSION RFA has been demonstrated as an effective therapeutic modality for lumbar facetogenic back pain. Yet, the several factors involved in determining a favorable outcome of this procedure require further research and optimization. This prospective double-blinded randomized trial demonstrated that RFA at both temperatures (80°C, 90°C) provided significance at all the time periods examined. However, RFA at 90°C was superior to 80°C in regard to the duration of relief.
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Affiliation(s)
- Nagy Mekhail
- Evidence Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Shrif Costandi
- Pain Management Department, Cleveland Clinic, Cleveland, OH, USA
| | - Sherif Armanyous
- Evidence Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Erin Templeton
- Evidence Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Nicholas Prayson
- Pain Management Department, Cleveland Clinic, Cleveland, OH, USA
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Lorio MP, Beall DP, Calodney AK, Lewandrowski KU, Block JE, Mekhail N. Defining the Patient with Lumbar Discogenic Pain: Real-World Implications for Diagnosis and Effective Clinical Management. J Pers Med 2023; 13:jpm13050821. [PMID: 37240991 DOI: 10.3390/jpm13050821] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 04/16/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
There is an enormous body of literature that has identified the intervertebral disc as a potent pain generator. However, with regard to lumbar degenerative disc disease, the specific diagnostic criteria lack clarity and fail to capture the primary components which include axial midline low back pain with or without non-radicular/non-sciatic referred leg pain in a sclerotomal distribution. In fact, there is no specific ICD-10-CM diagnostic code to classify and define discogenic pain as a unique source of pain distinct from other recognized sources of chronic low back pain including facetogenic, neurocompressive including herniation and/or stenosis, sacroiliac, vertebrogenic, and psychogenic. All of these other sources have well-defined ICD-10-CM codes. Corresponding codes for discogenic pain remain absent from the diagnostic coding vernacular. The International Society for the Advancement of Spine Surgery (ISASS) has proposed a modernization of ICD-10-CM codes to specifically define pain associated with lumbar and lumbosacral degenerative disc disease. The proposed codes would also allow the pain to be characterized by location: lumbar region only, leg only, or both. Successful implementation of these codes would benefit both physicians and payers in distinguishing, tracking, and improving algorithms and treatments for discogenic pain associated with intervertebral disc degeneration.
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Affiliation(s)
- Morgan P Lorio
- Advanced Orthopedics, 499 E. Central Pkwy., Ste. 130, Altamonte Springs, FL 32701, USA
| | - Douglas P Beall
- Clinical Radiology of Oklahoma, 1800 S. Renaissance Blvd., Ste. 110, Edmond, OK 73013, USA
| | | | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, 4787 E. Camp Lowell Drive, Tucson, AZ 85712, USA
| | - Jon E Block
- Independent Consultant, 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, USA
| | - Nagy Mekhail
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Mekhail N, Eldabe S, Templeton E, Costandi S, Rosenquist R. Pain Management Interventions for the Treatment of Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Clin J Pain 2023:00002508-990000000-00082. [PMID: 37104694 DOI: 10.1097/ajp.0000000000001116] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Determine the relative effectiveness and safety profiles of percutaneous and minimally invasive interventions for chronic low back pain. METHODS A systematic search was performed for randomized controlled trials (RCTs) published in the past 20 years reporting on radiofrequency (RF) ablation of the basivertebral, disc annulus and facet nerve structures, steroid injection of the disc, facet joint and medial branch, biologic therapies, and multifidus muscle stimulation. Outcomes evaluated included Visual Analog Scale (VAS) pain scores, Oswestry Disability Index (ODI) scores, quality of life (SF-36 and EQ-5D) scores and serious adverse event (SAE) rates. Basivertebral nerve (BVN) ablation was chosen as the subject of comparison to all other therapies using a random-effects meta-analysis. RESULTS Twenty-seven studies were included. BVN ablation was found to provide significant improvements in VAS and ODI scores for 6-, 12- and 24-months follow-up (P≤0.05). Biologic therapy and multifidus muscle stimulation were the only two treatments with both VAS and ODI outcomes not significantly different from BVN ablation at 6-, 12- and 24-months follow-up. All outcomes found to be statistically significant represented inferior results to those of BVN ablation. Insufficient data precluded meaningful comparisons of SF-36 and EQ-5D scores. The SAE rates for all therapies and all reported time points were not significantly different from BVN ablation except for biologic therapy and multifidus muscle stimulation at 6-months follow- up. CONCLUSIONS BVN ablation, biologic therapy and multifidus stimulation all provide significant, durable improvements in both pain and disability compared to other interventions, which provided only short-term pain relief. Studies on BVN ablation reported no SAEs, a significantly better result than for studies of biologic therapy and multifidus stimulation.
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Affiliation(s)
- Nagy Mekhail
- Director, Evidence-Based Pain Management Research Cleveland Clinic, 9500 Euclid Ave/ C25 Cleveland, Ohio, 44195, USA
| | - Sam Eldabe
- Consultant in Pain Medicine, The James Cook University Hospital Marton Road, Middlesbrough TS4 3BW, UK
| | - Erin Templeton
- Research fellow, Evidence-Based Pain Management Research Cleveland Clinic, 9500 Euclid Ave/ C25 Cleveland, Ohio, 44195, USA
| | - Shrif Costandi
- Evidence-Based Pain Management Research Cleveland Clinic, 9500 Euclid Ave/ C25 Cleveland, Ohio, 44195, USA
| | - Richard Rosenquist
- Chairman, Department of Pain Management Cleveland Clinic, 9500 Euclid Ave/ C25 Cleveland, Ohio, 44195, USA
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Mekhail N, Armanyous S, Templeton E, Prayson N, Saweris Y. The Choice of Spinal Cord Stimulation vs Targeted Drug Delivery in the Management of Chronic Pain: Validation of an Outcomes Predictive Formula. Neuromodulation 2023:S1094-7159(23)00136-8. [PMID: 37061895 DOI: 10.1016/j.neurom.2023.02.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/06/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE In 2020, Mekhail et al published a formula that predicted the likelihood of a successful outcome for those who undergo spinal cord stimulation (SCS) for long-term pain management, based on retrospectively collected clinical and demographic data from one major medical center. The aim of this study is to validate such a predictive formula, prospectively, in a cohort of patients from multiple medical practices that are more representative of real-life clinical practice. MATERIALS AND METHODS For the study, 939 patients who underwent successful SCS or targeted drug delivery (TDD) trials at multiple independent medical centers in the USA were enrolled into the Medtronic product surveillance registry data base before they underwent SCS or TDD device implantation, from 2018 to 2020. The registry data were collected prospectively but not specifically for this study. The data examined included demographic information, pain diagnosis, pain scores (visual analog scale [VAS]), Oswestry Disability Index scores, and quality-of-life scores at baseline and six months after implant. Because our goal is to validate the previously published predictive formula, in addition to the outcomes data previously mentioned, we collected the variables necessary for such a task: sex, age, depression, the presence of neuropathic pain, spine-related pain diagnosis, and persistent spinal pain syndrome "post laminectomy syndrome." Spine-related pain diagnosis included subjects with chronic spine pain who never had back surgery and whose pain was not radicular nor neuropathic. RESULTS Of 619 patients with SCS, 138 (22%) achieved ≥ 50% reductions of the baseline VAS at six months. The logistic model predicts SCS success with an area under the receiver operating characteristic curve (AUC) of 80% in the current validation data set. Of 320 patients with TDD, 147 (46%) achieved ≥ 50% reduction of the baseline VAS at six months. The logistic model predicts TDD success with an AUC of 78% in the current validation data set. CONCLUSION The study provides real life validation of the previously published predictive formula(4).
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Affiliation(s)
- Nagy Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Sherif Armanyous
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - Erin Templeton
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas Prayson
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
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Gilligan C, Burnside D, Grant L, Yong RJ, Mullins PM, Schwab F, Mekhail N. ReActiv8 Stimulation Therapy vs. Optimal Medical Management: A Randomized Controlled Trial for the Treatment of Intractable Mechanical Chronic Low Back Pain (RESTORE Trial Protocol). Pain Ther 2023; 12:607-620. [PMID: 36787013 PMCID: PMC10036695 DOI: 10.1007/s40122-023-00475-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 02/15/2023] Open
Abstract
INTRODUCTION Chronic low back pain (CLBP) is the leading cause of years lived with disability globally. The role of restorative neurostimulation in the treatment of patients with refractory mechanical CLBP and multifidus muscle dysfunction has been established in one randomized controlled trial (RCT) and several clinical studies that demonstrated both safety and clinical benefit. This post-market trial provides a direct comparison to optimized medical management to test the hypothesis that the addition of restorative neurostimulation to current care paradigms results in significant improvements in back pain-related disability. METHODS AND ANALYSIS This trial will include people who have reported significant levels of back pain and back pain-related disability with symptoms that have persisted for longer than 6 months prior to enrollment and resulted in pain on most days in the 12 months prior to enrollment. Eligible patients will be randomized to either optimal medical management or optimal medical management plus ReActiv8® restorative neurostimulation therapy. Patient-reported outcomes will be collected at regular intervals out to the 1-year primary endpoint, at which time the patients in the control arm will be offered implantation with the ReActiv8 system. Assessment of each group will continue for an additional year. ETHICS AND DISSEMINATION The RESTORE trial follows the principles of the Declaration of Helsinki. The WCG IRB acts as the Central Institutional Review Board (IRB) for most sites and some sites will receive local IRB approval prior to enrollment of patients. Each IRB assessed the protocol and related documentation. The protocol complies with Good Clinical Practice (GCP). All patients provide written informed consent to participate in the trial. PROTOCOL VERSION Version C, 07 Sep 2022. CLINICALTRIALS gov registration number. NCT04803214 registered March 17, 2021.
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Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
| | | | | | - R Jason Yong
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Peter M Mullins
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Frank Schwab
- Northwell Health Orthopaedic Institute, New York, NY, USA
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Petersen EA, Stauss T, Scowcroft J, Jaasma M, White J, Sills S, Amirdelfan K, Guirguis M, Xu J, Yu C, Nairizi A, Patterson D, Creamer M, Galan V, Bundschu R, Mehta N, Sayed D, Lad NP, DiBenedetto D, Sethi KA, Wu P, Argoff C, Nasr C, Taylor R, Caraway D, Mekhail N. 440 10 kHz Spinal Cord Stimulation (SCS) Provides Significant, Durable Pain Relief for Patients with Painful Diabetic Neuropathy (PDN): 24-Month Results. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_440] [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] [Indexed: 03/18/2023] Open
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Levy RM, Mekhail N, Abd-Elsayed A, Abejón D, Anitescu M, Deer TR, Eldabe S, Goudman L, Kallewaard JW, Moens M, Petersen EA, Pilitsis JG, Pope JE, Poree L, Raslan AM, Russo M, Sayed D, Staats PS, Taylor RS, Thomson S, Verrills P, Duarte RV. Holistic Treatment Response: An International Expert Panel Definition and Criteria for a New Paradigm in the Assessment of Clinical Outcomes of Spinal Cord Stimulation. Neuromodulation 2023:S1094-7159(22)01379-4. [PMID: 36604242 DOI: 10.1016/j.neurom.2022.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [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: 09/17/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Treatment response to spinal cord stimulation (SCS) is focused on the magnitude of effects on pain intensity. However, chronic pain is a multidimensional condition that may affect individuals in different ways and as such it seems reductionist to evaluate treatment response based solely on a unidimensional measure such as pain intensity. AIM The aim of this article is to add to a framework started by IMMPACT for assessing the wider health impact of treatment with SCS for people with chronic pain, a "holistic treatment response". DISCUSSION Several aspects need consideration in the assessment of a holistic treatment response. SCS device data and how it relates to patient outcomes, is essential to improve the understanding of the different types of SCS, improve patient selection, long-term clinical outcomes, and reproducibility of findings. The outcomes to include in the evaluation of a holistic treatment response need to consider clinical relevance for patients and clinicians. Assessment of the holistic response combines two key concepts of patient assessment: (1) patients level of baseline (pre-treatment) unmet need across a range of health domains; (2) demonstration of patient-relevant improvements in these health domains with treatment. The minimal clinical important difference (MCID) is an established approach to reflect changes after a clinical intervention that are meaningful for the patient and can be used to identify treatment response to each individual domain. A holistic treatment response needs to account for MCIDs in all domains of importance for which the patient presents dysfunctional scores pre-treatment. The number of domains included in a holistic treatment response may vary and should be considered on an individual basis. Physiologic confirmation of therapy delivery and utilisation should be included as part of the evaluation of a holistic treatment response and is essential to advance the field of SCS and increase transparency and reproducibility of the findings.
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Affiliation(s)
- Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
| | - Nagy Mekhail
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Abejón
- Multidisciplinary Pain Management Unit, Hospital Universitario Quirónsalud, Madrid, Spain
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders, Brussels, Belgium
| | - Jan W Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, the Netherlands; Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie G Pilitsis
- Department of Clinical Neurosciences, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Lawrence Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia
| | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Rod S Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK; MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Simon Thomson
- Department of Pain Medicine and Neuromodulation, Mid & South Essex University Hospitals, Essex, UK
| | - Paul Verrills
- Metro Pain Group, Melbourne, New South Wales, Australia
| | - Rui V Duarte
- Saluda Medical Pty Ltd, Artarmon, New South Wales, Australia; Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK.
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Copley S, Yassa PE, Batterham AM, Buchser E, Mekhail N, Duarte RV, Eldabe S. A Clinical Evaluation of the Accuracy of an Intrathecal Drug Delivery Device. Neuromodulation 2022:S1094-7159(22)01348-4. [PMID: 36473773 DOI: 10.1016/j.neurom.2022.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/29/2022] [Accepted: 10/25/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Implantable intrathecal drug delivery (ITDD) devices are used to treat severe pain and spasticity refractory to conventional medical management. Although off-label medications and drug admixtures are commonly used in clinical practice and recommended by international guidelines, manufacturers state that this practice can result in device failure. The impact of off-label drugs and drug combinations on pump accuracy has hitherto never been assessed. MATERIALS AND METHODS A multinational, three-center, retrospective review of patient records was undertaken. The inclusion criterion was the presence of an ITDD device implantation in adult patients, with the pump in situ for the expected battery lifespan. Residual drug volumes at each refill, drug mixtures and concentrations, and rate and flow pattern of the pump (simple or flex) were recorded. A normalized flow rate ratio was calculated (actual to theoretical flow rate). The impact of nonapproved drugs, battery life, pump size, and flow program on drug delivery accuracy was assessed. RESULTS Data from 1402 pump refills were collected (73 patients). The overall mean accuracy ratio was 0.995 (95% CI = 0.986-1.004). The ratio for approved drug status was 0.990 vs 0.997 in nonapproved, with a difference of -0.007 (-0.032 to 0.017). At the tenth centile for remaining battery life (14 months), the ratio was 0.983 vs 1.009 for the 90th centile (69 months), with a difference of -0.026 (-0.038 to -0.014). The ratio for flex administration was 0.982 vs 1.006 for simple, with a difference of -0.024 (-0.040 to -0.008). For pump size of 40 mL, the ratio was 0.975 vs 1.010 for 20 mL, with a difference of -0.035 (-0.063 to -0.008). The 95% prediction interval for individual refill ratios was ±0.15. CONCLUSION In a clinical setting, the ITDD pumps retained high levels of accuracy and acceptable precision across their lifespan despite using unapproved drugs or admixtures and under various flow modes and rates.
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Petersen E, Stauss T, Scowcroft J, Brooks E, White J, Sills S, Amirdelfan K, Guirguis M, Xu J, Yu C, Nairizi A, Patterson D, Galan V, Bundschu R, Mehta N, Sayed D, Lad S, Dibenedetto D, Sethi K, Wu P, Argoff C, Nasr C, Taylor R, Caraway D, Mekhail N. O052 / #884 10-KHZ SPINAL CORD STIMULATION IS A DURABLE TREATMENT FOR PAINFUL DIABETIC NEUROPATHY: LONG-TERM MULTICENTER RANDOMIZED CONTROLLED TRIAL RESULTS. Neuromodulation 2022. [DOI: 10.1016/j.neurom.2022.08.090] [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] [Indexed: 11/05/2022]
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Kapural L, Syed Shah N, Fang ZP, Mekhail N. Multicenter, Double-Blinded, Randomized, Active-Sham Controlled Clinical Study Design to Assess the Safety and Effectiveness of a Novel High Frequency Electric Nerve Block System in the Treatment of Post-Amputation Pain (The QUEST Study). J Pain Res 2022; 15:1623-1631. [PMID: 35685299 PMCID: PMC9172922 DOI: 10.2147/jpr.s353674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Chronic pain that follows amputation of a limb is reported as “one of the most severe pains in the human experience,” due to the magnitude of tissue injury and the multiple potential of pain generators at the local peripheral, spinal, and cortical levels. The Altius® System was developed to deliver high-frequency nerve block (HFNB) therapy via a cuff electrode applied to the peripheral nerve(s) and an implantable pulse generator. We report a novel clinical trial design for the first study of an active-implantable medical device in subjects with lower-limb post-amputation pain utilizing a multicenter, double-blinded, randomized, active-sham controlled clinical study protocol called QUEST, which is an ongoing investigational device exemption study to support United States Food and Drug Administration approval. Methods The study enrollment of 180 subjects was completed in September 2021. Subjects were randomized 1:1 to the treatment group or the active-sham control group for the 3-month primary effectiveness and safety endpoints. After month 3, the active-sham control program group crossed over to the treatment program group and all subjects continued to the 12-month study endpoint. Study effectiveness success is determined by a superiority test between responder rates in the treatment and control groups at 3 months. A responder is defined as someone who experiences a 50% or greater reduction in pain scores – after a 30-minute treatment session – for more than 50% of all pain episodes in which the treatment was used. Discussion The QUEST study design employs an active-sham control group to objectively assess the effectiveness of HFNB therapy. Additionally, the electronic diary repeated measures data collection in QUEST is expected to reduce the intra-subject variation typically observed in pain treatment studies. Finally, the longitudinal measurement of health-related quality of life and use of pain medication may, for example, show effectiveness in reducing opioid use over time.
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Affiliation(s)
- Leonardo Kapural
- Carolinas Pain Institute, Winston-Salem, NC, USA
- Correspondence: Leonardo Kapural, Carolinas Pain Institute, 145 Kimel Park Drive, Winston-Salem, NC, 27023, USA, Tel +1 336-765-6181, Email
| | | | | | - Nagy Mekhail
- Evidence-Based Pain Management Research, Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
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Acevedo Moreno LA, Wong YN, Abdelmalak J, Bolash R, Mekhail N. ID:15799 Peripheral Nerve Stimulation for Meralgia Paresthetica: A Case Series. Neuromodulation 2022. [DOI: 10.1016/j.neurom.2022.02.193] [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] [Indexed: 10/18/2022]
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Petersen EA, Stauss T, Scowcroft J, Brooks E, White J, Sills S, Amirdelfan K, Guirguis M, Xu J, Yu C, Nairizi A, Patterson D, Galan V, Bundschu R, Mehta N, Sayed D, Lad NP, DiBenedetto D, Sethi KA, Wu P, Argoff C, Nasr C, Taylor RS, Caraway D, Mekhail N. 123 Long-Term High-Frequency (10 kHz) Spinal Cord Stimulation in Painful Diabetic Neuropathy - A Randomized Controlled Trial. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_123] [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] [Indexed: 11/19/2022] Open
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Mekhail N, Levy RM, Deer TR, Kapural L, Li S, Amirdelfan K, Hunter CW, Rosen SM, Costandi SJ, Falowski SM, Burgher AH, Pope JE, Gilmore CA, Qureshi FA, Staats PS, Scowcroft J, McJunkin T, Carlson J, Kim CK, Yang MI, Stauss T, Pilitsis J, Poree L, Brounstein D, Gilbert S, Gmel GE, Gorman R, Gould I, Hanson E, Karantonis DM, Khurram A, Leitner A, Mugan D, Obradovic M, Ouyang Z, Parker J, Single P, Soliday N. Durability of Clinical and Quality-of-Life Outcomes of Closed-Loop Spinal Cord Stimulation for Chronic Back and Leg Pain: A Secondary Analysis of the Evoke Randomized Clinical Trial. JAMA Neurol 2022; 79:251-260. [PMID: 34998276 PMCID: PMC8742908 DOI: 10.1001/jamaneurol.2021.4998] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance Chronic pain is debilitating and profoundly affects health-related quality of life. Spinal cord stimulation (SCS) is a well-established therapy for chronic pain; however, SCS has been limited by the inability to directly measure the elicited neural response, precluding confirmation of neural activation and continuous therapy. A novel SCS system measures the evoked compound action potentials (ECAPs) to produce a real-time physiological closed-loop control system. Objective To determine whether ECAP-controlled, closed-loop SCS is associated with better outcomes compared with fixed-output, open-loop SCS at 24 months following implant. Design, Setting, and Participants The Evoke study was a double-blind, randomized, controlled, parallel arm clinical trial with 36 months of follow-up. Participants were enrolled from February 2017 to 2018, and the study was conducted at 13 US investigation sites. SCS candidates with chronic, intractable back and leg pain refractory to conservative therapy, who consented, were screened. Key eligibility criteria included overall, back, and leg pain visual analog scale score of 60 mm or more; Oswestry Disability Index score of 41 to 80; stable pain medications; and no previous SCS. Analysis took place from October 2020 to April 2021. Interventions ECAP-controlled, closed-loop SCS was compared with fixed-output, open-loop SCS. Main Outcomes and Measures Reported here are the 24-month outcomes of the trial, which include all randomized patients in the primary and safety analyses. The primary outcome was a reduction of 50% or more in overall back and leg pain assessed at 3 and 12 months (previously published). Results Of 134 randomized patients, 65 (48.5%) were female and the mean (SD) age was 55.2 (10.6) years. At 24 months, significantly more closed-loop than open-loop patients were responders (≥50% reduction) in overall pain (53 of 67 [79.1%] in the closed-loop group; 36 of 67 [53.7%] in the open-loop group; difference, 25.4% [95% CI, 10.0%-40.8%]; P = .001). There was no difference in safety profiles between groups (difference in rate of study-related adverse events: 6.0 [95% CI, -7.8 to 19.7]). Improvements were also observed in health-related quality of life, physical and emotional functioning, and sleep, in parallel with opioid reduction or elimination. Objective neurophysiological measurements substantiated the clinical outcomes and provided evidence of activation of inhibitory pain mechanisms. Conclusions and Relevance ECAP-controlled, closed-loop SCS, which elicited a more consistent neural response, was associated with sustained superior pain relief at 24 months, consistent with the 3- and 12-month outcomes.
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Affiliation(s)
| | - Robert M. Levy
- International Neuromodulation Society, Neuromodulation: Technology at the Neural Interface, San Francisco, California
| | - Timothy R. Deer
- The Spine and Nerve Center of The Virginias, Charleston, West Virginia
| | - Leonardo Kapural
- Carolinas Pain Institute, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Sean Li
- Premier Pain Centers, Shrewsbury, New Jersey
| | | | | | - Steven M. Rosen
- Delaware Valley Pain and Spine Institute, Trevose, Pennsylvania
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lawrence Poree
- University of California at San Francisco, San Francisco
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Mekhail N, Poree L. Response to: A Clinical Feasibility Study of Spinal Evoked Compound Action Potential Estimation Methods. Neuromodulation 2022; 25:155-156. [DOI: 10.1016/j.neurom.2021.10.024] [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: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 11/26/2022]
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Mekhail N, Costandi S, Saweris Y, Armanyous S, Chauhan G. Impact of biological sex on the outcomes of spinal cord stimulation in patients with chronic pain. Pain Pract 2021; 22:432-439. [PMID: 34845813 DOI: 10.1111/papr.13097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/11/2021] [Revised: 10/19/2021] [Accepted: 11/08/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spinal cord stimulation (SCS) continues to gain increasing popularity in the pain management field for the treatment of different painful conditions; however, to-date, the correlation between the SCS effectiveness and biological sex has not been fully established. We aimed to investigate the correlation between the biological sex and SCS outcomes. METHODS Following Institutional Review Board approval, a retrospective cohort study was performed by collecting data for patients treated with SCS at a tertiary academic center between the years 2002 and 2019. Data was assessed with multivariable linear regression to investigate the association between biological sex and pain scores at baseline, 6-, and 12- months following SCS implantation. Propensity score matching (PSM) was performed based on a set of covariates including age, duration of pain, time since implant, BMI, opioid medications use, smoking, depression and history of alcohol, or substance abuse. RESULTS Of the patients treated with SCS implants, 418 patients fit the inclusion and exclusion criteria, out of which the majority were females (272, 65%). The pre-matching data reported a significant difference in history of diabetes and depression and was also significant for greater opioid use in male patients at baseline, 6-, and 12-months post-SCS implant. Propensity score matching (PSM) was performed based on the above mentioned covariant. After matching, no statistical difference was found among the variables, in both groups. Furthermore, after matching no significant differences in the pain scores at baseline, 6-, and 12-months post-SCS implant were observed. CONCLUSION No biological sex-based differences in the analgesic response to SCS therapy was detected at 6- and 12-months post-SCS implant between groups with similar demographics, biomedical, and psychological values.
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Affiliation(s)
- Nagy Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shrif Costandi
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Youssef Saweris
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sherif Armanyous
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gaurav Chauhan
- University of Pittsburgh Medical Center (UPMC) Pain Medicine Program, Pittsburgh, Pennsylvania, USA
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Smuck M, Khalil J, Barrette K, Hirsch JA, Kreiner S, Koreckij T, Garfin S, Mekhail N. Prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 12-month results. Reg Anesth Pain Med 2021; 46:683-693. [PMID: 34031220 PMCID: PMC8311085 DOI: 10.1136/rapm-2020-102259] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/26/2021] [Indexed: 11/25/2022]
Abstract
Introduction Vertebral endplates, innervated by the basivertebral nerve (BVN), are a source of chronic low back pain correlated with Modic changes. A randomized trial comparing BVN ablation to standard care (SC) recently reported results of an interim analysis. Here, we report the results of the full randomized trial, including the 3-month and 6-month between-arm comparisons, 12-month treatment arm results, and 6-month outcomes of BVN ablation in the former SC arm. Methods Prospective, open label, 1:1 randomized controlled trial of BVN ablation versus SC in 23 US sites with follow-up at 6 weeks, 3, 6, 9, and 12 months. SC patients were re-baselined and followed up for 6 months post BVN ablation. The primary endpoint was the between-arm comparison of mean Oswestry Disability Index (ODI) change from baseline. Secondary endpoints were Visual Analog Scale (VAS), Short Form (SF-36), EuroQual Group 5 Dimension 5-Level Quality of Life (EQ-5D-5L), responder rates, and rates of continued opioid use. Results 140 were randomized. Results from BVN ablation (n=66) were superior to SC (n=74) at 3 months for the primary endpoint (mean ODI reduction, difference between arms of −20.3 (CI −25.9 to −14.7 points; p<0.001)), VAS pain improvement (difference of −2.5 cm between arms (CI −3.37 to −1.64, p<0.001)) and quality of life outcomes. At 12 months, basivertebral ablation demonstrated a 25.7±18.5 point reduction in mean ODI (p<0.001), and a 3.8±2.7 cm VAS reduction (p<0.001) from baseline, with 64% demonstrating ≥50% reduction and 29% pain free. Similarly, the former SC patients who elected BVN ablation (92%) demonstrated a 25.9±15.5 point mean ODI reduction (p<0.001) from baseline. The proportion of opioid use did not change in either group (p=0.56). Discussion/Conclusion BVN ablation demonstrates significant improvements in pain and function over SC, with treatment results sustained through 12 months in patients with chronic low back pain of vertebrogenic origin.
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Affiliation(s)
- Matthew Smuck
- Physical Medicine & Rehabilitation Division, Stanford University, Redwood City, California, USA
| | - Jad Khalil
- Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Kevin Barrette
- Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Joshua Adam Hirsch
- Department of Neurointerventional Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott Kreiner
- Neurophysiatry, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Theodore Koreckij
- Orthopaedic Surgery Spine, St Luke's Hospital, Kansas, Missouri, USA
| | - Steven Garfin
- Orthopaedic Surgery, University of California San Diego, La Jolla, California, USA
| | - Nagy Mekhail
- Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Dorsal root ganglion stimulation (DRGS) therapy is a rapidly emerging tool being used by pain physicians in the treatment of chronic pain. Complex regional pain syndrome (CRPS), a debilitating disease whose mechanism is still has yet to be fully elucidated, is a common pathology targeted by DRGS therapy, often better results than traditional spinal cord stimulation. DRGS therapy, however, is not bereft of complications. Lead migration and fracture are two examples in particular that are among the most common of these complications. The authors report an unusual case of lost efficacy due to lead fractures in patients with CRPS treated with DRGS. The case report narrates identification, management and probable mechanism of DRGS lead fracture. The structural instability of DRGS leads can yield distressing symptoms at any point during the therapy, and physicians should be cognisant of the complications of DRGS therapy.
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Affiliation(s)
- Gaurav Chauhan
- Anesthesiology, Chronic Pain Divison, UPMC, Pittsburgh, Pennsylvania, USA
| | - Brandon I Roth
- Pain Management, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nagy Mekhail
- Pain Management, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Mekhail N, Costandi S, Nageeb G, Ekladios C, Saied O. The durability of minimally invasive lumbar decompression procedure in patients with symptomatic lumbar spinal stenosis: Long-term follow-up. Pain Pract 2021; 21:826-835. [PMID: 33942964 PMCID: PMC9291913 DOI: 10.1111/papr.13020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 03/16/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 11/30/2022]
Abstract
Background Minimally invasive lumbar decompression (mild®) has been shown to be safe and effective for the treatment of lumbar spinal stenosis patients with hypertrophic ligamentum flavum as a contributing factor. This study examines the long‐term durability of the mild procedure through 5‐year follow‐up. Pain relief and opioid medications utilization during 12‐month follow‐up were also assessed. Methods All patients diagnosed with lumbar spinal stenosis secondary to ligamentum flavum hypertrophy who underwent mild from 2010 through 2015 at the Cleveland Clinic Department of Pain Management were included in this retrospective longitudinal observational cohort study. The primary outcome measure was the incidence of open lumbar decompression surgery at the same level(s) as the mild intervention during 5‐year follow‐up. Secondary outcome measures were the change in pain levels using the Numeric Rating Scale and opioid medications utilization using Morphine Milligram Equivalent dose per day from baseline to 3, 6, and 12 months post‐mild procedure. Postprocedural complications (minor or major) were also collected. Results Seventy‐five patients received mild during the protocol‐defined time period and were included in the study. Only 9 out of 75 patients required lumbar surgical decompression during the 5‐year follow‐up period. Subjects experienced statistically significant pain relief and reduction of opioid medications utilization at 3, 6, and 12 months compared to baseline. Conclusion Based on our analysis, the mild procedure is durable over 5 years and may allow elderly patients with symptomatic lumbar spinal stenosis to avoid lumbar decompression surgery while providing significant symptomatic relief.
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Affiliation(s)
- Nagy Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - Shrif Costandi
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - George Nageeb
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - Catherine Ekladios
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - Ogena Saied
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
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Deer TR, Grider JS, Lamer TJ, Pope JE, Falowski S, Hunter CW, Provenzano DA, Slavin KV, Russo M, Carayannopoulos A, Shah JM, Harned ME, Hagedorn JM, Bolash RB, Arle JE, Kapural L, Amirdelfan K, Jain S, Liem L, Carlson JD, Malinowski MN, Bendel M, Yang A, Aiyer R, Valimahomed A, Antony A, Craig J, Fishman MA, Al-Kaisy AA, Christelis N, Rosenquist RW, Levy RM, Mekhail N. Corrigendum to: A Systematic Literature Review of Spine Neurostimulation Therapies for the Treatment of Pain. Pain Med 2021; 22:236. [PMID: 32875323 DOI: 10.1093/pm/pnaa209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Petersen EA, Stauss T, Scowcroft J, White J, Sills S, Amirdelfa K, Guirguis M, Xu J, Yu C, Nairizi A, Patterson D, Galan V, Bundschu R, Mehta N, Sayed D, Lad NP, DiBenedetto D, Sethi KA, Wu P, Argoff C, Nasr C, Taylor R, Brooks E, Subbaroyan J, Gliner BE, Caraway D, Mekhail N. 10 kHz Spinal Cord Stimulation for Treatment of Painful Diabetic Neuropathy - A Multicenter Randomized Controlled Trial. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_522] [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] [Indexed: 11/14/2022] Open
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Mekhail N, Saweris Y, Sue Mehanny D, Makarova N, Guirguis M, Costandi S. Diagnosis of Sacroiliac Joint Pain: Predictive Value of Three Diagnostic Clinical Tests. Pain Pract 2020; 21:204-214. [PMID: 32965780 DOI: 10.1111/papr.12950] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 02/18/2020] [Revised: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, there have been no acceptable and accurate diagnostic criteria or standards of care for the management of sacroiliac joint (SIJ) pain. Several studies have yielded different contributions of clinical presentation, history, and physical examination in the diagnosis of SIJ pain. Our goal in this study was to assess the sensitivity and specificity of the diagnostic clinical tests and their predictive value in accurately diagnosing SIJ pain. METHODOLOGY Upon enrolling 200 eligible patients with SIJ pain as their primary diagnosis, they were re-evaluated and their verbal rating scale (VRS) pain scores and demographic data were obtained. Thereafter, three SIJ diagnostic tests were performed: the thigh thrust test, the Patrick test, and a modified version of the Gaenslen test that is referred to as the Mekhail test. Subsequently, the patients were taken to the procedure room to undergo SIJ injection, for which a confirmative result was ≥50% pain relief. The physicians performing the procedure were blinded of the results of the 3 tests performed. Results from the 3 tests were incorporated with the procedure results, from which we drew statistical and medical conclusions determining their predictive value and degree of aid to physicians in diagnosing SIJ pain. RESULTS We found that the cumulative effect of adding simultaneous tests increased the sensitivity of the testing but decreased the specificity, which generates a powerful screening tool. The combination of the Patrick and Mekhail tests demonstrated the best accuracy, with 94% sensitivity, 17% specificity, 81% positive predictive value, and 44% negative predictive value. The Patrick test was better than other tests for differentiating patients with SIJ pain from those with non-SIJ pain. No combination yielded both significant sensitivity and specificity. Generally, the overall predictive value of any of the tests on their own or their combination did not vary significantly from the predictive value of baseline demographics, including pre-injection pain score and pain referral diagram. CONCLUSION In conclusion, our study results were similar to those of previous investigators who found that physical examination plays a limited role in diagnosing SIJ pain. Specifically, we found that the clinical tests and/or their combinations added no significant predictive capacity compared to patients' baseline characteristics in predicting the response to diagnostic SIJ injection, albeit the combination of the Mekhail and Patrick tests yielded high sensitivity (94%), making them viable for consecutive screening, possibly reducing the unnecessary costs of diagnostic SIJ injection procedures.
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Affiliation(s)
- Nagy Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Youssef Saweris
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Diana Sue Mehanny
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Natalya Makarova
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Maged Guirguis
- Pain Management Department, Ochsner Health System, New Orleans, Louisiana, U.S.A
| | - Shrif Costandi
- Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Deer TR, Esposito MF, McRoberts WP, Grider JS, Sayed D, Verrills P, Lamer TJ, Hunter CW, Slavin KV, Shah JM, Hagedorn JM, Simopoulos T, Gonzalez DA, Amirdelfan K, Jain S, Yang A, Aiyer R, Antony A, Azeem N, Levy RM, Mekhail N. A Systematic Literature Review of Peripheral Nerve Stimulation Therapies for the Treatment of Pain. Pain Medicine 2020; 21:1590-1603. [DOI: 10.1093/pm/pnaa030] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
AbstractObjectiveTo conduct a systematic literature review of peripheral nerve stimulation (PNS) for pain.DesignGrade the evidence for PNS.MethodsAn international interdisciplinary work group conducted a literature search for PNS. Abstracts were reviewed to select studies for grading. Inclusion/exclusion criteria included prospective randomized controlled trials (RCTs) with meaningful clinical outcomes that were not part of a larger or previously reported group. Excluded studies were retrospective, had less than two months of follow-up, or existed only as abstracts. Full studies were graded by two independent reviewers using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsPeripheral nerve stimulation was studied in 14 RCTs for a variety of painful conditions (headache, shoulder, pelvic, back, extremity, and trunk pain). Moderate to strong evidence supported the use of PNS to treat pain.ConclusionPeripheral nerve stimulation has moderate/strong evidence. Additional prospective trials could further refine appropriate populations and pain diagnoses.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | | | | | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Jay M Shah
- SamWell Institute for Pain Management, Colonia, New Jersey
| | | | - Tom Simopoulos
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, Arkansas
| | - Ajax Yang
- Mt. Sinai Hospital, New York, New York
| | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry Faculty, Henry Ford Health System, Detroit, Michigan
| | - Ajay Antony
- University of Florida College of Medicine, Jacksonville, Florida
| | - Nomen Azeem
- Florida Spine & Pain Specialists, Bradenton, Florida
| | - Robert M Levy
- Director of Neurosurgical Services, Director of Clinical Research, Anesthesia Pain Care Consultants, Tamarac, Florida
| | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, Ohio, USA
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Deer TR, Hunter CW, Mehta P, Sayed D, Grider JS, Lamer TJ, Pope JE, Falowski S, Provenzano DA, Esposito MF, Slavin KV, Baranidharan G, Russo M, Jassal NS, Mogilner AY, Kapural L, Verrills P, Amirdelfan K, McRoberts WP, Harned ME, Chapman KB, Liem L, Carlson JD, Yang A, Aiyer R, Antony A, Fishman MA, Al-Kaisy AA, Christelis N, Levy RM, Mekhail N. A Systematic Literature Review of Dorsal Root Ganglion Neurostimulation for the Treatment of Pain. Pain Medicine 2020; 21:1581-1589. [DOI: 10.1093/pm/pnaa005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AbstractObjectiveTo conduct a systematic literature review of dorsal root ganglion (DRG) stimulation for pain.DesignGrade the evidence for DRG stimulation.MethodsAn international, interdisciplinary work group conducted a literature search for DRG stimulation. Abstracts were reviewed to select studies for grading. General inclusion criteria were prospective trials (randomized controlled trials and observational studies) that were not part of a larger or previously reported group. Excluded studies were retrospective, too small, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.ResultsDRG stimulation has Level II evidence (moderate) based upon one high-quality pivotal randomized controlled trial and two lower-quality studies.ConclusionsModerate-level evidence supports DRG stimulation for treating chronic focal neuropathic pain and complex regional pain syndrome.
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Affiliation(s)
- Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | | | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Jason E Pope
- Evolve Restorative Center, Santa Rosa, California
| | - Steven Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, Pennsylvania
| | | | | | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, NSW, Australia
| | - Navdeep S Jassal
- Department of Neurology/Pain, University of South Florida, Spine & Pain Institute of Florida, Lakeland, Florida
| | - Alon Y Mogilner
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Leo Kapural
- Carolina Pain Institute at Brookstown, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | | | | | | | - Michael E Harned
- Department of Anesthesiology, University of Kentucky, Lexington, Kentucky
| | | | - Liong Liem
- St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Ajax Yang
- Mt. Sinai Hospital, New York, New York
| | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry Faculty, Henry Ford Health System Detroit, Michigan
| | - Ajay Antony
- University of Florida College of Medicine, Jacksonville, Florida
| | - Michael A Fishman
- Center for Interventional Pain and Spine, Bryn Mawr, Pennsylvania, USA
| | - Adnan A Al-Kaisy
- Pain Management and Neuromodulation Centre at Guy’s and St. Thomas’ NHS Trust, London, UK
| | - Nick Christelis
- Pain Specialists Australia, Monash University, Richmond, Victoria, Australia
| | - Robert M Levy
- Neurosurgical Services and of Clinical Research, Anesthesia Pain Care Consultants, Tamarac, Florida
| | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, Ohio, USA
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Costandi S, Mekhail N, Azer G, Mehanny DS, Hanna D, Salma Y, Bolash R, Saweris Y. Longevity and Utilization Cost of Rechargeable and Non‐Rechargeable Spinal Cord Stimulation Implants: A Comparative Study. Pain Pract 2020; 20:937-945. [DOI: 10.1111/papr.12926] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Shrif Costandi
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
- Anesthesiology Institute Cleveland Clinic Cleveland Ohio U.S.A
| | - Nagy Mekhail
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
- Anesthesiology Institute Cleveland Clinic Cleveland Ohio U.S.A
| | - Gerges Azer
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
- Anesthesiology Institute Cleveland Clinic Cleveland Ohio U.S.A
| | - Diana Sue Mehanny
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
| | - Demiana Hanna
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
| | - Yustina Salma
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
| | - Robert Bolash
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
- Anesthesiology Institute Cleveland Clinic Cleveland Ohio U.S.A
| | - Youssef Saweris
- Evidence‐Based Pain Management Research Cleveland Clinic Cleveland Ohio U.S.A
- Anesthesiology Institute Cleveland Clinic Cleveland Ohio U.S.A
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Deer TR, Sayed D, Pope JE, Chakravarthy KV, Petersen E, Moeschler SM, Abd-Elsayed A, Amirdelfan K, Mekhail N. Emergence From the COVID-19 Pandemic and the Care of Chronic Pain: Guidance for the Interventionalist. Anesth Analg 2020; 131:387-394. [PMID: 32452905 PMCID: PMC7258839 DOI: 10.1213/ane.0000000000005000] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND: The current Coronavirus Disease (COVID-19) pandemic led to a significant disruption in the care of pain from chronic and subacute conditions. The impact of this cessation of pain treatment may have unintended consequences of increased pain, reduced function, increased reliance on opioid medications, and potential increased morbidity, due to the systemic impact of untreated disease burden. This may include decreased mobility, reduction in overall health status, and increase of opioid use with the associated risks. METHODS: The article is the study of the American Society of Pain and Neuroscience (ASPN) COVID-19 task force to evaluate the policies set forth by federal, state, and local agencies to reduce or eliminate elective procedures for those patients with pain from spine, nerve, and joint disease. The impact of these decisions, which were needed to reduce the spread of the pandemic, led to a delay in care for many patients. We hence review an emergence plan to reinitiate this pain-related care. The goal is to outline a path to work with federal, state, and local authorities to combat the spread of the pandemic and minimize the deleterious impact of pain and suffering on our chronic pain patients. RESULTS: The article sets forth a strategy for the interventional pain centers to reemerge from the current pandemic and to set a course for future events. CONCLUSIONS: xxx.
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Affiliation(s)
- Timothy R Deer
- From the Department of Pain Medicine, The Spine and Nerve Center of The Virginias, Charleston, West Virginia.,Department of Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Jason E Pope
- Evolve Restorative Center, Santa Rosa, California
| | - Krishnan V Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, California.,Division of Pain Medicine, Department of Anesthesiology, Veterans Affairs (VA) San Diego Healthcare, San Diego, California
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Nagy Mekhail
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Jonathan M Hagedorn
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Nagy Mekhail
- Division of Pain Medicine, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
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29
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Deer TR, Grider JS, Lamer TJ, Pope JE, Falowski S, Hunter CW, Provenzano DA, Slavin KV, Russo M, Carayannopoulos A, Shah JM, Harned ME, Hagedorn JM, Bolash RB, Arle JE, Kapural L, Amirdelfan K, Jain S, Liem L, Carlson JD, Malinowski MN, Bendel M, Yang A, Aiyer R, Valimahomed A, Antony A, Craig J, Fishman MA, Al-Kaisy AA, Christelis N, Rosenquist RW, Levy RM, Mekhail N. A Systematic Literature Review of Spine Neurostimulation Therapies for the Treatment of Pain. Pain Medicine 2020; 21:1421-1432. [DOI: 10.1093/pm/pnz353] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Abstract
Objective
To conduct a systematic literature review of spinal cord stimulation (SCS) for pain.
Design
Grade the evidence for SCS.
Methods
An international, interdisciplinary work group conducted literature searches, reviewed abstracts, and selected studies for grading. Inclusion/exclusion criteria included randomized controlled trials (RCTs) of patients with intractable pain of greater than one year’s duration. Full studies were graded by two independent reviewers. Excluded studies were retrospective, had small numbers of subjects, or existed only as abstracts. Studies were graded using the modified Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment, the Cochrane Collaborations Risk of Bias assessment, and the US Preventative Services Task Force level-of-evidence criteria.
Results
SCS has Level 1 evidence (strong) for axial back/lumbar radiculopathy or neuralgia (five high-quality RCTs) and complex regional pain syndrome (one high-quality RCT).
Conclusions
High-level evidence supports SCS for treating chronic pain and complex regional pain syndrome. For patients with failed back surgery syndrome, SCS was more effective than reoperation or medical management. New stimulation waveforms and frequencies may provide a greater likelihood of pain relief compared with conventional SCS for patients with axial back pain, with or without radicular pain.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Jason E Pope
- Evolve Restorative Center, Santa Rosa, California
| | - Steven Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, Pennsylvania
| | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, New York
| | | | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, NSW, Australia
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Providence, Rhode Island
- Department of Neurosurgery, Brown Medical School, Providence, Rhode Island
| | - Jay M Shah
- New York Presbyterian Hospital, Memorial Sloan Kettering Cancer Center, Hospital for Special Surgery, New York, New York
| | - Michael E Harned
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Jonathan M Hagedorn
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Robert B Bolash
- Anesthesiology, Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio
| | - Jeff E Arle
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Leo Kapural
- Carolina Pain Institute at Brookstown, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | | | - Sameer Jain
- Pain Treatment Centers of America, Little Rock, Arkansas
| | - Liong Liem
- St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Markus Bendel
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Ajax Yang
- Mt. Sinai Hospital, New York, New York
| | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry Faculty, Henry Ford Health System, Detroit, Michigan
| | - Ali Valimahomed
- Advanced Orthopedics and Sports Medicine Institute, Freehold, New Jersey
| | - Ajay Antony
- University of Florida College of Medicine, Jacksonville, Florida
| | - Justin Craig
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Michael A Fishman
- Center for Interventional Pain and Spine, Bryn Mawr, Pennsylvania, USA
| | - Adnan A Al-Kaisy
- Pain Management and Neuromodulation Centre at Guy’s and St. Thomas’ NHS Trust, London, UK
| | - Nick Christelis
- Pain Specialists Australia, Richmond, Monash University, Victoria, Australia
| | - Richard W Rosenquist
- Anesthesiology, Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, Florida, USA
| | - Nagy Mekhail
- Anesthesiology, Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio
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30
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Mekhail N. Unanswered questions from the Evoke trial – Author's reply. Lancet Neurol 2020; 19:380-381. [DOI: 10.1016/s1474-4422(20)30111-3] [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: 03/03/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
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31
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Mekhail N, Deer TR, Poree L, Staats PS, Burton AW, Connolly AT, Karst E, Mehanny DS, Saweris Y, Levy RM. Cost-Effectiveness of Dorsal Root Ganglion Stimulation or Spinal Cord Stimulation for Complex Regional Pain Syndrome. Neuromodulation 2020; 24:708-718. [PMID: 32153073 DOI: 10.1111/ner.13134] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 07/12/2019] [Revised: 01/20/2020] [Accepted: 01/29/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES ACCURATE, a randomized controlled trial, compared safety and effectiveness of stimulation of the dorsal root ganglion (DRG) vs. conventional spinal cord stimulation (SCS) in complex regional pain syndrome (CRPS-I and II) of the lower extremities. This analysis compares cost-effectiveness of three modalities of treatment for CRPS, namely DRG stimulation, SCS, and comprehensive medical management (CMM). MATERIALS AND METHODS The retrospective cost-utility analysis combined ACCURATE study data with claims data to compare cost-effectiveness between DRG stimulation, SCS, and CMM. Cost-effectiveness was evaluated using a Markov cohort model with ten-year time horizon from the U.S. payer perspective. Incremental cost-effectiveness ratio (ICER) was reported as cost in 2017 U.S. dollars per gain in quality-adjusted life years (QALYs). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were used to define highly cost-effective and cost-effective therapies. RESULTS Both DRG and SCS provided an increase in QALYs (4.96 ± 1.54 and 4.58 ± 1.35 QALYs, respectively) and an increase in costs ($153,992 ± $36,651 and $128,269 ± $27,771, respectively) compared to CMM (3.58 ± 0.91 QALYs, $106,173 ± $27,005) over the ten-year model lifetime. Both DRG stimulation ($34,695 per QALY) and SCS ($22,084 per QALY) were cost-effective compared to CMM. In the base case, ICER for DRG v SCS was $68,095/QALY. CONCLUSIONS DRG and SCS are cost-effective treatments for chronic pain secondary to CRPS-I and II compared to CMM. DRG accrued higher cost due to higher conversion from trial to permanent implant and shorter battery life, but DRG was the most beneficial therapy due to more patients receiving permanent implants and experiencing higher quality of life compared to SCS. New DRG technology has improved battery life, which we expect to make DRG more cost-effective compared to both CMM and SCS in the future.
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Affiliation(s)
- Nagy Mekhail
- Department of Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - Timothy R Deer
- The Center for Pain Relief, Charleston, WA, USA.,West Virginia University, Morganstown, WA, USA
| | - Lawrence Poree
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | - Diana S Mehanny
- Department of Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
| | - Youssef Saweris
- Department of Evidence-Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
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Levy RM, Mekhail N, Kramer J, Poree L, Amirdelfan K, Grigsby E, Staats P, Burton AW, Burgher AH, Scowcroft J, Golovac S, Kapural L, Paicius R, Pope J, Samuel S, McRoberts WP, Schaufele M, Kent AR, Raza A, Deer TR. Therapy Habituation at 12 Months: Spinal Cord Stimulation Versus Dorsal Root Ganglion Stimulation for Complex Regional Pain Syndrome Type I and II. The Journal of Pain 2020; 21:399-408. [DOI: 10.1016/j.jpain.2019.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/03/2019] [Accepted: 08/27/2019] [Indexed: 12/19/2022]
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33
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Mekhail N, Mehanny DS, Armanyous S, Costandi S, Saweris Y, Azer G, Bolash R. Choice of spinal cord stimulation versus targeted drug delivery in the management of chronic pain: a predictive formula for outcomes. Reg Anesth Pain Med 2020:rapm-2019-100859. [PMID: 31932490 DOI: 10.1136/rapm-2019-100859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 07/29/2019] [Revised: 11/21/2019] [Accepted: 11/23/2019] [Indexed: 11/03/2022]
Abstract
Contemporary nonmalignant pain treatment algorithms commence with conservative non-invasive strategies, later progressing from minimally invasive interventions to invasive techniques or implantable devices. The most commonly used implantable devices are spinal cord stimulation (SCS) systems or targeted drug delivery (TDD) devices. Historically, SCS had been considered in advance of TDD, positioning TDD behind SCS failures. Following Institutional Review Board approval, data were extracted from electronic medical records of patients who underwent SCS trial in the Department of Pain Management at Cleveland Clinic from 1994 to 2013. The sample size was analyzed in two cohorts: those who succeeded with SCS and those who failed SCS and consequently proceeded to TDD. Univariate and multivariate analyses were performed and a predictive formula for successful outcomes was created. 945 patients were included in the cohort of which 119 (12.6%) subjects achieved adequate pain relief with TDD after failure of SCS. Gender, age, depression and primary pain diagnosis were significantly different in this subgroup. Males were 52% less likely to experience pain relief with SCS. The odds of SCS success decreased as age increased by 6% per year. Patients with comorbid depression, interestingly, were 63% more likely to succeed with SCS. A logistic model was created to predict SCS success which was used to create a predictive formula. Older male patients diagnosed with spine-related pain were more likely to benefit from TDD than SCS. This observation potentially identifies a subgroup in whom consideration for TDD in advance of SCS failure could prove more efficient and cost effective. These retrospective findings warrant prospective comparative studies to validate this derived predictive formula.
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Affiliation(s)
- Nagy Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Diana S Mehanny
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sherif Armanyous
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Shrif Costandi
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Youssef Saweris
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gerges Azer
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert Bolash
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Mekhail N, Levy RM, Deer TR, Kapural L, Li S, Amirdelfan K, Hunter CW, Rosen SM, Costandi SJ, Falowski SM, Burgher AH, Pope JE, Gilmore CA, Qureshi FA, Staats PS, Scowcroft J, Carlson J, Kim CK, Yang MI, Stauss T, Poree L. Long-term safety and efficacy of closed-loop spinal cord stimulation to treat chronic back and leg pain (Evoke): a double-blind, randomised, controlled trial. Lancet Neurol 2019; 19:123-134. [PMID: 31870766 DOI: 10.1016/s1474-4422(19)30414-4] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/04/2019] [Accepted: 10/18/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Spinal cord stimulation has been an established treatment for chronic back and leg pain for more than 50 years; however, outcomes are variable and unpredictable, and objective evidence of the mechanism of action is needed. A novel spinal cord stimulation system provides the first in vivo, real-time, continuous objective measure of spinal cord activation in response to therapy via recorded evoked compound action potentials (ECAPs) in patients during daily use. These ECAPs are also used to optimise programming and deliver closed-loop spinal cord stimulation by adjusting the stimulation current to maintain activation within patients' therapeutic window. We aimed to examine pain relief and the extent of spinal cord activation with ECAP-controlled closed-loop versus fixed-output, open-loop spinal cord stimulation for the treatment of chronic back and leg pain. METHODS This multicentre, double-blind, parallel-arm, randomised controlled trial was done at 13 specialist clinics, academic centres, and hospitals in the USA. Patients with chronic, intractable pain of the back and legs (Visual Analog Scale [VAS] pain score ≥60 mm; Oswestry Disability Index [ODI] score 41-80) who were refractory to conservative therapy, on stable pain medications, had no previous experience with spinal cord stimulation, and were appropriate candidates for a spinal cord stimulation trial were screened. Eligible patients were randomly assigned (1:1) to receive ECAP-controlled closed-loop spinal cord stimulation (investigational group) or fixed-output, open-loop spinal cord stimulation (control group). The randomisation sequence was computer generated with permuted blocks of size 4 and 6 and stratified by site. Patients, investigators, and site staff were masked to the treatment assignment. The primary outcome was the proportion of patients with a reduction of 50% or more in overall back and leg pain with no increase in pain medications. Non-inferiority (δ=10%) followed by superiority were tested in the intention-to-treat population at 3 months (primary analysis) and 12 months (additional prespecified analysis) after the permanent implant. This study is registered with ClinicalTrials.gov, NCT02924129, and is ongoing. FINDINGS Between Feb 21, 2017, and Feb 20, 2018, 134 patients were enrolled and randomly assigned (67 to each treatment group). The intention-to-treat analysis comprised 125 patients at 3 months (62 in the closed-loop group and 63 in the open-loop group) and 118 patients at 12 months (59 in the closed-loop group and 59 in the open-loop group). The primary outcome was achieved in a greater proportion of patients in the closed-loop group than in the open-loop group at 3 months (51 [82·3%] of 62 patients vs 38 [60·3%] of 63 patients; difference 21·9%, 95% CI 6·6-37·3; p=0·0052) and at 12 months (49 [83·1%] of 59 patients vs 36 [61·0%] of 59 patients; difference 22·0%, 6·3-37·7; p=0·0060). We observed no differences in safety profiles between the two groups. The most frequently reported study-related adverse events in both groups were lead migration (nine [7%] patients), implantable pulse generator pocket pain (five [4%]), and muscle spasm or cramp (three [2%]). INTERPRETATION ECAP-controlled closed-loop stimulation provided significantly greater and more clinically meaningful pain relief up to 12 months than open-loop spinal cord stimulation. Greater spinal cord activation seen in the closed-loop group suggests a mechanistic explanation for the superior results, which aligns with the putative mechanism of action for spinal cord stimulation and warrants further investigation. FUNDING Saluda Medical.
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Affiliation(s)
| | - Robert M Levy
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Timothy R Deer
- The Spine and Nerve Center of The Virginias, Charleston, WV, USA
| | - Leonardo Kapural
- Carolinas Pain Institute and Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Sean Li
- Premier Pain Centers, Shrewsbury, NJ, USA
| | | | - Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Steven M Rosen
- Delaware Valley Pain and Spine Institute, Trevose, PA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Lawrence Poree
- University of California at San Francisco, San Francisco, CA, USA
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35
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Mekhail N, Costandi S, Mehanny DS, Armanyous S, Saied O, Taco‐Vasquez E, Saweris Y. The Impact of Tobacco Smoking on Spinal Cord Stimulation Effectiveness in Complex Regional Pain Syndrome Patients. Neuromodulation 2019; 23:133-139. [DOI: 10.1111/ner.13058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Nagy Mekhail
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Shrif Costandi
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Diana S. Mehanny
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Sherif Armanyous
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Ogena Saied
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Erika Taco‐Vasquez
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
| | - Youssef Saweris
- Evidence‐Based Pain ManagementCleveland Clinic Foundation Cleveland OH USA
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36
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North J, Loudermilk E, Lee A, Sachdeva H, Kaiafas D, Washabaugh E, Sheth S, Scowcroft J, Mekhail N, Lampert B, Yearwood T, Shaw E, Atallah J, McLeod C, Han J, Yu C, Sedrak M, Lucas R, Trobridge A, Hegarty J, Miller N, Chen L, Jain R. Outcomes of a Multicenter, Prospective, Crossover, Randomized Controlled Trial Evaluating Subperception Spinal Cord Stimulation at ≤1.2 kHz in Previously Implanted Subjects. Neuromodulation 2019; 23:102-108. [PMID: 31265205 PMCID: PMC7004055 DOI: 10.1111/ner.13015] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 04/04/2019] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 12/25/2022]
Abstract
Objective The WHISPER randomized controlled trial (RCT) evaluates safety and clinical effectiveness of subperception spinal cord stimulation (SCS) at ≤1.2 kHz in subjects previously implanted with an SCS system for treatment of chronic, neuropathic pain. Methods WHISPER is a prospective, multicenter RCT with a crossover design sponsored by Boston Scientific, Marlborough, MA (http://clinicaltrials.gov: NCT02314000). Eligible subjects were randomized (N = 140) to receive subperception or supraperception for three months and then crossed over to receive the alternative. Upon completion of crossover period, subjects who preferred subperception were followed up to one year. Overall pain, quality‐of‐life, and other outcomes were collected in the study. The primary endpoint was the overall pain responder rate (≥50% improvement from baseline) with no increase in medications. Secondary endpoints consisted of pain scores, physical disability, quality of life, and treatment preference. Results The study met its primary endpoint and demonstrated noninferiority between supraperception and subperception in a prespecified cohort of 70 randomized subjects (Interim Analysis). Thirty‐nine percent of subjects with subperception settings and 29% with supraperception settings had a greater than or equal to 50% reduction in their overall pain scores with no increase in average daily medication at three‐months post‐activation as compared with baseline. Further assessment of all participating study subjects (N = 140) revealed similar results. Subjects were previously implanted 3.8 ± 2 years and had a disability score (Oswestry Disability Index) of 70.2 ± 11.4 at study start. Of the randomized subjects that completed the End of Period 2 Visit, 93 (66%) preferred subperception SCS and their mean overall pain reduced from 7.3 ± 1.1 (N = 89) at baseline to 4.0 ± 2.1 (N = 80) at 12‐months post‐activation. Post hoc analysis also demonstrated that multiple options provide superior outcomes, as supported by a 74% increase in the responder rate when subjects could choose their most effective option (47%) compared with supraperception alone (27%). Discussion Subperception SCS at ≤1.2 kHz is safe and effective in subjects with extreme physical disability and previously implanted for chronic pain. Further, by providing study participants with different waveform options, increased pain relief was achieved.
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Affiliation(s)
- James North
- Carolinas Pain Institute and Center for Clinical Research, Winston-Salem, NC, USA
| | - Eric Loudermilk
- Piedmont Comprehensive Pain Management Group, Greenville, SC, USA
| | - Albert Lee
- Tallahassee Neurological Clinic, Tallahassee, FL, USA
| | | | | | | | | | | | | | | | | | - Erik Shaw
- Shepherd Center, Shepherd Pain Institute, Atlanta, GA, USA
| | | | | | - John Han
- Geisinger Medical Center, Danville, PA, USA
| | - Cong Yu
- Swedish Pain Center, Seattle, WA, USA
| | - Mark Sedrak
- Kaiser Permanente, Redwood City Medical Center, Redwood City, CA, USA
| | | | - Andrew Trobridge
- Indiana University Health Ball Memorial Hospital, Muncie, IN, USA
| | | | | | - Lilly Chen
- Boston Scientific Corporation, Division of Neuromodulation, Valencia, CA, USA
| | - Roshini Jain
- Boston Scientific Corporation, Division of Neuromodulation, Valencia, CA, USA
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Deer T, Kim P, Pope JE, Hayek S, McDowell G, Mekhail N, Diwan S, Saulino M, Moeschler S, Schultz D, Gritsenko K, Prager J, Peterson EA, Staats P, Poree L, Fishman MA, Vallejo R, Calodney A, Slavin K, Leon Cassadala O, Levy R, Buvanendran A, Sitzman BT, Sayed D, Ferrante FM, Kloth D, Gilligan CJ, Kapural L, Kloster DR, Leong M, Rosenow JM, Lamer TJ, Stearns L. Physician Guidance on the Use of Off‐Labeled Drugs in Intrathecal Drug Delivery Systems for Chronic Pain. Neuromodulation 2019; 22:765-768. [DOI: 10.1111/ner.12961] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/04/2019] [Accepted: 03/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of The Virginia Charleston WV USA
| | - Phillip Kim
- Center for Interventional Pain Spine, LLC Bryn Mawr PA USA
| | - Jason E. Pope
- Evolve Restorative CenterCalifornia Society of Interventional Pain Society Santa Rosa CA USA
| | - Salim Hayek
- Department of AnesthesiologyCase Western Reserve University, Division of Pain Medicine, University Hospital of Cleveland Cleveland OH USA
| | | | - Nagy Mekhail
- Evidence‐Based Pain Management Research, Cleveland Clinic Cleveland OH USA
| | | | | | - Susan Moeschler
- Department of Anesthesiology and Perioperative MedicineMayo Clinic Rochester MN USA
| | - David Schultz
- Nura Precision Pain Management, Department of AnesthesiologyUniversity of Minnesota Minneapolis MN USA
| | - Karina Gritsenko
- Regional Anesthesia and Acute Pain Medicine Fellowship, Department of Anesthesiology, Family & Social Medicine, and Physical Medicine & Rehabilitation, Montefiore Medical CenterMontefiore Multidisciplinary Pain Program Bronx MY USA
| | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA, Department of Anesthesiology and Internal Medicine (Pain Medicine)David Geffen School of Medicine at UCLA Los Angeles CA USA
| | - Erika A. Peterson
- Department of NeurosurgeryFunctional and Restorative Neurosurgery, University of Arkansas for Medical Sciences Little Rock AR USA
| | | | - Lawrence Poree
- Department of Anesthesia and Perioperative Carethe North American Neuromodulation Society and the International Neuromodulation Society, UCSF Pain Management Center, University of California at San Francisco San Francisco CA USA
| | | | - Ricardo Vallejo
- Research, Millennium Pain Center, CEO, StimGenics, LLC Bloomington IL USA
| | - Aaron Calodney
- Department of Anesthesiology, Louisiana State University Health Science Center—Shreveport Shreveport LA USA
| | - Konstantin Slavin
- Department of NeurosurgeryUniversity of Illinois at Chicago Chicago IL USA
| | - Oscar Leon Cassadala
- Department of AnesthesiologyThe Jacobs School of Medicine at the University of Buffalo, Division of Pain and Oncology, Roswell Park Cancer Institute Buffalo NY USA
| | - Robert Levy
- International Neuromodulation Society Boca Raton FL USA
| | | | - B. Todd Sitzman
- North American Neuromodulation SocietyAdvanced Pain Therapy Hattiesburg MS USA
| | - Dawood Sayed
- Department of Anesthesiology and Pain MedicineThe University of Kansas Medical Center Kansas City KS USA
| | - F. Michael Ferrante
- UCLA Pain Management Center, Clinical Anesthesiology and MedicineDavid Geffen School of Medicine at UCLA Santa Monica CA USA
| | - David Kloth
- North American Neuromodulation SocietyConnecticut Pain Care Danbury CT USA
| | - Christopher J. Gilligan
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain MedicineBrigham & Women's Hospital Boston MA USA
| | | | | | - Michael Leong
- Department of NeuromodulationStanford Pain Management Center Redwood City CA USA
| | - Joshua M. Rosenow
- Functional Neurosurgery and Epilepsy SurgeryNeurosurgery, Neurology, and Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine Chicago IL USA
| | - Tim J. Lamer
- Department of Anesthesiology and Perioperative Medicine, Division of Pain MedicineMayo Clinic Rochester MN USA
| | - Lisa Stearns
- Center for Pain and Supportive Care Phoenix AZ USA
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Mekhail N, Deer TR, Kramer J, Poree L, Amirdelfan K, Grigsby E, Staats P, Burton AW, Burgher AH, Scowcroft J, Golovac S, Kapural L, Paicius R, Pope J, Samuel S, McRoberts WP, Schaufele M, Kent AR, Raza A, Levy RM. Paresthesia-Free Dorsal Root Ganglion Stimulation: An ACCURATE Study Sub-Analysis. Neuromodulation 2019; 23:185-195. [PMID: 30861286 DOI: 10.1111/ner.12942] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 09/04/2018] [Revised: 01/04/2019] [Accepted: 02/06/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION ACCURATE, a randomized controlled trial comparing dorsal root ganglion (DRG) stimulation to spinal cord stimulation, showed that DRG stimulation is a safe and effective therapy in individuals with lower extremity chronic pain due to complex regional pain syndrome (CRPS) type I or II. Investigators noted that DRG stimulation programming could be adjusted to minimize, or eliminate, the feeling of paresthesia while maintaining adequate pain relief. The present study explores treatment outcomes for DRG subjects who were paresthesia-free vs. those who experienced the sensation of paresthesia, as well as the factors that predicted paresthesia-free analgesia. METHODS A retrospective analysis of therapy outcomes was conducted for 61 subjects in the ACCURATE study who received a permanent DRG neurostimulator. Outcomes of subjects who were paresthesia-free were compared to those who experienced paresthesia-present therapy at 1, 3, 6, 9, and 12-month follow-ups. Predictor variables for the presence or absence of paresthesias with DRG stimulation were also explored. RESULTS The percentage of subjects with paresthesia-free pain relief increased from 16.4% at 1-month to 38.3% at 12-months. Paresthesia-free subjects generally had similar or better outcomes for pain severity, pain interference, quality of life, and mood state as subjects with paresthesia-present stimulation. Factors that increased the odds of a subject feeling paresthesia were higher stimulation amplitudes and frequencies, number of implanted leads, and younger age. CONCLUSIONS Some DRG subjects achieved effective paresthesia-free analgesia in the ACCURATE trial. This supports the observation that paresthesia is not synonymous with pain relief or required for optimal analgesia with DRG stimulation.
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Affiliation(s)
- Nagy Mekhail
- Evidence-based Pain Management Research Department, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jeffery Kramer
- Volta Research and University of Illinois College of Medicine, Chicago, IL, USA
| | - Lawrence Poree
- Department of Anesthesia, University of California, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | | | | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
| | - Samuel Samuel
- Evidence-based Pain Management Research Department, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | - Adil Raza
- Abbott Neuromodulation, Plano, TX, USA
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Levy R, Deer TR, Poree L, Rosen SM, Kapural L, Amirdelfan K, Soliday N, Leitner A, Mekhail N. Multicenter, Randomized, Double-Blind Study Protocol Using Human Spinal Cord Recording Comparing Safety, Efficacy, and Neurophysiological Responses Between Patients Being Treated With Evoked Compound Action Potential-Controlled Closed-Loop Spinal Cord Stimulation or Open-Loop Spinal Cord Stimulation (the Evoke Study). Neuromodulation 2019; 22:317-326. [PMID: 30828946 DOI: 10.1111/ner.12932] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/05/2018] [Accepted: 12/31/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The spinal cord (SC) response to stimulation has yet to be studied in a pivotal clinical study. We report the study design of an ongoing multicenter, randomized, double-blind, controlled, parallel-arm study of an evoked compound action potential (ECAP) controlled closed-loop spinal cord stimulation (SCS) system, which aims to gain U.S. Food and Drug Administration approval. METHODS This study will enroll 134 SCS candidates with chronic trunk and limb pain from up to 20 United States sites. Subjects are randomized 1:1 to receive ECAP-controlled closed-loop or open-loop, conventional SCS. The primary objective is noninferiority of closed-loop stimulation determined by the proportion of subjects with ≥50% reduction in overall trunk and limb pain and no increase in pain medications at the three-month visit. If noninferiority is met, superiority is tested. In addition, measures recommended by IMMPACT (e.g., pain intensity, functional disability, emotional functioning, quality of life, impression of change, and sleep), neurophysiological properties (e.g., SC activation, conduction velocity, chronaxie, and rheobase), and safety are analyzed. DISCUSSION All approved SCS therapies, regardless of the presence or absence of stimulation induced paresthesias, produce fixed-output stimuli; that is, the energy delivered from the electrode array has a defined output irrespective of the neural response of SC fibers. An SCS system has been developed that directly measures the neurophysiologic activation of the SC to stimulation (i.e., ECAP amplitude) and uses this information in a feedback mechanism to produce closed-loop SCS to maintain optimal and stable activation of the SC. This study represents the first randomized, double-blind, pivotal study in the field of neuromodulation to measure SC activation in ECAP-controlled closed-loop versus open-loop stimulation and is expected to yield important information regarding differences in safety, efficacy, and neurophysiological properties. The potential clinical utility of these objective measurements of SC activation and other neurophysiological properties promises to improve outcomes of SCS for chronic pain patients.
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Affiliation(s)
- Robert Levy
- Institute for Neuromodulation, Boca Raton, FL, USA
| | | | - Lawrence Poree
- Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | - Nagy Mekhail
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
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Mekhail N, Mehanny D, Armanyous S, Saweris Y, Costandi S. The impact of obesity on the effectiveness of spinal cord stimulation in chronic spine-related pain patients. Spine J 2019; 19:476-486. [PMID: 30142457 DOI: 10.1016/j.spinee.2018.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Chronic pain and obesity are both on the rise. Spinal cord stimulation has gained increasing popularity in the pain management field for the treatment of spine-related chronic pain, however to-date, the correlation between the spinal cord stimulator effectiveness and increasing body mass index (BMI) has not been fully established. PURPOSE We aimed to investigate the correlation between patients' BMI and the percentage of pain relief as well as opioid utilization in chronic spine-related pain patients treated with spinal cord stimulation. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Patients with chronic spine-related pain who were treated with a spinal cord stimulator. OUTCOME MEASURES Eleven-point numeric rating scale for pain and opioid utilization. METHODS Following Institutional Review Board approval, data from all eligible subjects who had undergone successful spinal cord stimulation (SCS)-trial defined as ≥50% decrease in pain followed by SCS implant were collected and statistically analyzed. Patients were divided into four groups according to BMI. Self-reported pain scores on the 11-point numerical rating scale were collected at baseline, 6 months and 12 months post SCS-implant visits. Opioid utilization, if any, was collected at baseline and 12 months post-SCS implant. RESULTS In all, 181 patients were included. Thirty-three were under and/or normal weight (≤24.9 kg/m2), 72 overweight (25.0-29.9 kg/m2), 63 obese (30.0-39.9 kg/m2), and 13 morbidly obese (≥40.0 kg/m2). The estimated coefficients from multivariable linear regression analysis were -1.91% (95% CI: -2.82% to -0.991%) and -1.48% (95% CI: -2.30% to -0.660%) reduction in pain improvement per unit increase of BMI for 6 months and 12 months scores, respectively. The estimated coefficient of disability status was -15.3% (95% CI: -22.1% to -8.48%). The estimated coefficient for 12 month opioid equivalence was -0.08% (95% CI: -0.14 to -0.021), per` 1 mg unit increase of morphine opioid equivalency. The data showed a statistically significant negative association between increasing BMI and SCS effectiveness at 6 and 12 months post-SCS therapy with a 2% reduction in efficacy for every unit increase of BMI after adjusting for confounding factors and a 20% better response in underweight and/or normal patients over the morbidly obese individuals which was not related to baseline pain score level. The significant difference in pain scores at 6 months (p = .0003) and 12 months (p = .04) post-SCS implant between obese and nonobese patients was not attributable to differences in baseline pain scores. There was no significant change in opioid utilization between baseline and 12 months post-SCS therapy. CONCLUSION A negative association between SCS effectiveness and increasing BMI was found, whereas, no significant difference was noted amongst the various BMI cohorts and the daily opioid consumption.
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Affiliation(s)
- Nagy Mekhail
- Evidence-Based Pain Management, Cleveland Clinic Foundation, 9500 Euclid Avenue-Desk C25, Cleveland, OH 44195, USA.
| | - Diana Mehanny
- Evidence-Based Pain Management, Cleveland Clinic Foundation, 9500 Euclid Avenue-Desk C25, Cleveland, OH 44195, USA
| | - Sherif Armanyous
- Anesthesiology Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Youssef Saweris
- Anesthesiology Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Shrif Costandi
- Evidence-Based Pain Management, Cleveland Clinic Foundation, 9500 Euclid Avenue-Desk C25, Cleveland, OH 44195, USA
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Mekhail N. Where does the balance lie between doing what’s right for our patients and patients’ rights? Spinal cord stimulation in chronic pain smokers. Reg Anesth Pain Med 2019; 44:421-422. [DOI: 10.1136/rapm-2018-100321] [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: 12/22/2018] [Accepted: 12/31/2018] [Indexed: 11/04/2022]
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Deer TR, Levy RM, Kramer J, Poree L, Amirdelfan K, Grigsby E, Staats P, Burgher AH, Scowcroft J, Golovac S, Kapural L, Paicius R, Pope JE, Samuel S, Porter McRoberts W, Schaufele M, Burton AW, Raza A, Agnesi F, Mekhail N. Comparison of Paresthesia Coverage of Patient's Pain: Dorsal Root Ganglion vs. Spinal Cord Stimulation. An ACCURATE Study Sub-Analysis. Neuromodulation 2019; 22:930-936. [PMID: 30624003 DOI: 10.1111/ner.12920] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [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: 09/17/2018] [Revised: 11/14/2018] [Accepted: 11/30/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This was a sub-analysis of the ACCURATE clinical trial that evaluated the accuracy and necessity of targeting paresthesia coverage of painful areas with dorsal root ganglion (DRG) stimulation vs. tonic spinal cord stimulation (SCS). MATERIALS AND METHODS On diagrams of the torso and lower limbs, subjects marked where they felt pain at baseline and paresthesias at three months postimplant. Seventy-five subjects (41 DRG and 34 SCS) with diagrams of sufficient quality were scanned, digitized, and included in this analysis. Subject completed diagrams were digitized and superimposed with a grid of 1398 squares. Quantification of the percentage of bodily areas affected by pain and stimulation induced paresthesias was performed. RESULTS The percent of painful areas covered by paresthesia was significantly lower for DRG subjects than for SCS subjects (13% vs. 28% of the painful regions, p < 0.05), possibly because significantly more DRG subjects felt no paresthesia during stimulation when compared to SCS subjects (13/41 DRG vs. 3/34 SCS) (p < 0.05). The amount of paresthesia produced outside the painful areas (unrequired paresthesia) was significantly lower in DRG subjects than that of SCS subjects. On average, the percent of unrequired paresthesia was only 20% of the subjects' total painful body surface area in the DRG group compared to 210% in the SCS group (p < 0.01). CONCLUSIONS The results of this ACCURATE study sub-analysis show that DRG stimulation produces paresthesias, on average, that are less frequent, less intense, with a smaller footprint on the body and less dependent on positional changes.
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Affiliation(s)
| | | | - Jeffery Kramer
- Volta Research, USA.,University of Illinois, College of Medicine, IL, USA
| | - Lawrence Poree
- University of California at San Francisco, San Francisco, CA, USA
| | | | | | - Peter Staats
- Premier Pain Center, Shrewsbury Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | | | - Adil Raza
- Abbott Neuromodulation, Plano, TX, USA
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Deer TR, Grider JS, Pope JE, Falowski S, Lamer TJ, Calodney A, Provenzano DA, Sayed D, Lee E, Wahezi SE, Kim C, Hunter C, Gupta M, Benyamin R, Chopko B, Demesmin D, Diwan S, Gharibo C, Kapural L, Kloth D, Klagges BD, Harned M, Simopoulos T, McJunkin T, Carlson JD, Rosenquist RW, Lubenow TR, Mekhail N. The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment. Pain Pract 2018; 19:250-274. [PMID: 30369003 DOI: 10.1111/papr.12744] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 06/04/2018] [Revised: 10/11/2018] [Accepted: 10/18/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) can lead to compression of neural elements and manifest as low back and leg pain. LSS has traditionally been treated with a variety of conservative (pain medications, physical therapy, epidural spinal injections) and invasive (surgical decompression) options. Recently, several minimally invasive procedures have expanded the treatment options. METHODS The Lumbar Spinal Stenosis Consensus Group convened to evaluate the peer-reviewed literature as the basis for making minimally invasive spine treatment (MIST) recommendations. Eleven consensus points were clearly defined with evidence strength, recommendation grade, and consensus level using U.S. Preventive Services Task Force criteria. The Consensus Group also created a treatment algorithm. Literature searches yielded 9 studies (2 randomized controlled trials [RCTs]; 7 observational studies, 4 prospective and 3 retrospective) of minimally invasive spine treatments, and 1 RCT for spacers. RESULTS The LSS treatment choice is dependent on the degree of stenosis; spinal or anatomic level; architecture of the stenosis; severity of the symptoms; failed, past, less invasive treatments; previous fusions or other open surgical approaches; and patient comorbidities. There is Level I evidence for percutaneous image-guided lumbar decompression as superior to lumbar epidural steroid injection, and 1 RCT supported spacer use in a noninferiority study comparing 2 spacer products currently available. CONCLUSIONS MISTs should be used in a judicious and algorithmic fashion to treat LSS, based on the evidence of efficacy and safety in the peer-reviewed literature. The MIST Consensus Group recommend that these procedures be used in a multimodal fashion as part of an evidence-based decision algorithm.
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Affiliation(s)
- Timothy R Deer
- Center for Pain Relief, Charleston, West Virginia, U.S.A
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky, U.S.A
| | - Jason E Pope
- Evolve Restorative Clinic, Santa Rosa, California, U.S.A
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, Pennsylvania, U.S.A
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, U.S.A
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Eric Lee
- Summit Pain Alliance, Sonoma, California, U.S.A
| | - Sayed E Wahezi
- Montefiore Medical Center, SUNY-Buffalo, Buffalo, New York, U.S.A
| | - Chong Kim
- Center for Pain Relief, Charleston, West Virginia, U.S.A
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, New York, U.S.A
| | - Mayank Gupta
- Anesthesiology and Pain Medicine, HCA Midwest Health, Overland Park, Kansas, U.S.A
| | - Rasmin Benyamin
- Millennium Pain Center, Bloomington, Illinois, U.S.A.,College of Medicine, University of Illinois, Urbana-Champaign, Illinois, U.S.A
| | | | - Didier Demesmin
- Rutgers Robert Wood Johnson Medical School, Department of Pain Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey, U.S.A
| | - Sudhir Diwan
- Manhattan Spine and Pain Medicine, Lenox Hill Hospital, New York, New York, U.S.A
| | - Christopher Gharibo
- Pain Medicine and Orthopedics, NYU Langone Hospitals Center, New York, New York, U.S.A
| | - Leo Kapural
- Carolina's Pain Institute at Brookstown, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - David Kloth
- Department of Anesthesiology, Danbury Hospital, Danbury, Connecticut, U.S.A
| | - Brian D Klagges
- Anesthesiology and Pain Medicine, Amoskeag Anesthesiology, Manchester, New Hampshire, U.S.A
| | - Michael Harned
- Department of Anesthesiology, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Tom Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | | | | | | | | | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Deer TR, Pope JE, Lamer TJ, Grider JS, Provenzano D, Lubenow TR, FitzGerald JJ, Hunter C, Falowski S, Sayed D, Baranidharan G, Patel NK, Davis T, Green A, Pajuelo A, Epstein LJ, Harned M, Liem L, Christo PJ, Chakravarthy K, Gilmore C, Huygen F, Lee E, Metha P, Nijhuis H, Patterson DG, Petersen E, Pilitsis JG, Rowe JJ, Rupert MP, Skaribas I, Sweet J, Verrills P, Wilson D, Levy RM, Mekhail N. The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation. Neuromodulation 2018; 22:1-35. [PMID: 30246899 DOI: 10.1111/ner.12845] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [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: 02/22/2018] [Revised: 05/03/2018] [Accepted: 05/29/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. METHODS The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. RESULTS The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation. CONCLUSION The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.
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Affiliation(s)
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - James J FitzGerald
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, PA, USA
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nikunj K Patel
- Institute of Clinical Neurosciences, Department of Neurosurgery, Southmead Hospital, University of Bristol, Bristol, UK
| | | | - Alex Green
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | | | - Michael Harned
- Department of Anesthesiology, University of Kentucky, Lexington, KY, USA
| | - Liong Liem
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | | | - Frank Huygen
- Erasmus University Hospital, Rotterdam, The Netherlands
| | - Eric Lee
- Summit Pain Alliance, Santa Rosa, CA, USA
| | | | | | | | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie G Pilitsis
- Neurosurgery and Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | | | | | | | - Jennifer Sweet
- Case Western Reserve University, Stereotactic & Functional Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Derron Wilson
- Goodman Campbell Brain and Spine, Indiana University School of Medicine Department of Neurological Surgery, Indianapolis, IN, USA
| | | | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, OH, USA
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Hunter CW, Sayed D, Lubenow T, Davis T, Carlson J, Rowe J, Justiz R, McJunkin T, Deer T, Mehta P, Falowski S, Kapural L, Pope J, Mekhail N. DRG FOCUS: A Multicenter Study Evaluating Dorsal Root Ganglion Stimulation and Predictors for Trial Success. Neuromodulation 2018; 22:61-79. [PMID: 30085382 DOI: 10.1111/ner.12796] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 02/06/2018] [Revised: 04/02/2018] [Accepted: 04/24/2018] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Dorsal root ganglion stimulation (DRGS) is a powerful tool in the treatment of chronic, neuropathic pain. The premise of DRGS is similar to that of conventional spinal cord stimulation (cSCS), however, there is more variability in how it can be utilized. While it is this variability that likely gives it its versatility, DRGS is not as straightforward to implement as cSCS. The purpose of this study was to assess the efficacy of DRGS on a broad number of diagnoses, determine which dorsal root ganglia were associated with better outcomes for particular body parts/diagnoses, and evaluate what factors/parameters were associated with higher rates of trial success. METHODS This is a physician initiated, multicenter retrospective registry of 217 patients trialed with DRGS. Data were collected via an online questionnaire that assessed specifics regarding the patient's pain, distribution, size, and response to treatment. The data were analyzed to see if there were certain diagnoses and/or parameters that were more or less associated with trial success. RESULTS DRGS was found to be an effective treatment in all diagnoses evaluated within this study, most of which had statistically significant improvements in pain. The most important predictor of trial success was the amount of painful area covered by paresthesias during the programing phase. The number of leads utilized had a direct and indirect impact on trial success. Pain in the distribution of a specific peripheral nerve responded best and there was no statistical difference based on what body part was being treated. CONCLUSION DRGS can be an effective treatment for a variety of neuropathic pain syndromes, in addition to CRPS. It is recommended that a minimum of 2 leads should be utilized per area being treated. In addition, this therapy was shown to be equally efficacious in any body part/region so long as the area being treated is focal and not widespread.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Dawood Sayed
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy Lubenow
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
| | | | | | | | | | | | - Timothy Deer
- The Spine and Nerve Center of The Virginias, Charleston, WV, USA
| | | | - Steven Falowski
- Department of Neurosurgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Leo Kapural
- Department of Anesthesiology
- Wake Forest University, School of Medicine, Carolinas Pain Institute, Winston Salem, NC, USA
| | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
| | - Nagy Mekhail
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
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Bolash RB, Niazi T, Kumari M, Azer G, Mekhail N. Efficacy of a Targeted Drug Delivery on-Demand Bolus Option for Chronic Pain. Pain Pract 2017; 18:305-313. [PMID: 28520273 DOI: 10.1111/papr.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 07/08/2016] [Accepted: 05/10/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Intrathecal targeted drug delivery systems historically required physician office visits for dose adjustment to manage fluctuating pain. A wireless device now enables patients to supplement their basal intrathecal infusion with a programmed on-demand bolus dose. We sought to quantify the change in oral breakthrough opioid need associated with the use of an intrathecal bolus in comparison to those treated with the basal infusion alone. METHODS Demographic, dosage, bolus usage and longevity data were extracted from the historical medical record of 69 patients (18/51 bolus/nonbolus) followed continuously at our center. Medication consumption and Pain Disability Index measures were obtained at baseline and most recent follow-up. RESULTS Among patients with the bolus option, only 2 (11%; confidence interval [CI] 0% to 26%) continued to require oral opiates to manage breakthrough pain compared to 29 (57%; CI 43% to 71%) without the bolus option. The Pain Disability Index score decreased by 19% in patients with the bolus option and by 25% in those with the basal infusion. Total daily intrathecal opioid intake was 34% lower in the group with the bolus device. CONCLUSIONS Utilizing an intrathecal bolus to treat incident pain was a safe way to manage unpredictable breakthrough pain and may represent a cost-saving opportunity by eliminating the need for oral analgesic medications.
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Affiliation(s)
- Robert B Bolash
- Departments of Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Tariq Niazi
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Meera Kumari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Gerges Azer
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Nagy Mekhail
- Departments of Pain Management and Evidence Based Pain Research, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Pope JE, Deer TR, Falowski S, Provenzano D, Hanes M, Hayek SM, Amrani J, Carlson J, Skaribas I, Parchuri K, McRoberts WP, Bolash R, Haider N, Hamza M, Amirdelfan K, Graham S, Hunter C, Lee E, Li S, Yang M, Campos L, Costandi S, Levy R, Mekhail N. Multicenter Retrospective Study of Neurostimulation With Exit of Therapy by Explant. Neuromodulation 2017; 20:543-552. [DOI: 10.1111/ner.12634] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 04/23/2017] [Accepted: 05/20/2017] [Indexed: 12/28/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Maged Hamza
- Midatlantic Spine Specialists; Richmond, VA USA
| | | | - Sean Graham
- Spine Diagnostic and Treatment; Baton Rouge, LA USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management; New York, NY USA
| | - Eric Lee
- Summit Pain Alliance; Santa Rosa CA USA
| | - Sean Li
- Premier Pain Centers, East Brunswick; NJ USA
| | | | | | | | - Robert Levy
- Boca Raton Regional Hospital; Boca Raton FL USA
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Chang Chien GC, Mekhail N. Alternate Intraspinal Targets for Spinal Cord Stimulation: A Systematic Review. Neuromodulation 2017; 20:629-641. [PMID: 28160397 DOI: 10.1111/ner.12568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 10/28/2015] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Conventional dorsal column spinal cord stimulation (SCS) provides less than optimal pain relief for certain pain syndromes and anatomic pain distributions. Practitioners have sought to treat these challenging therapeutic areas with stimulation of alternate intraspinal targets. OBJECTIVE To identify and systematically review the evidence for the value neuromodulating specific neuronal targets within the spinal canal to achieve relief of chronic pain. METHODS A systematic literature search was conducted using PubMed for clinical trials published from 1966 to March 1, 2015 to identify neurostimulation studies that employed non-dorsal column intraspinal stimulation to achieve pain relief. Identified studies on such targeted intraspinal stimulation were reviewed and graded using Evidence Based Interventional Pain Medicine criteria. RESULTS We found a total of 13 articles that satisfied our search criteria on targeted, non-dorsal column intraspinal stimulation for pain. We identified five studies on neurostimulation of the cervicomedullary junction, six studies on neurostimulation of the dorsal root ganglion, two studies on the neurostimulation of the conus medullaris, unfortunately none was found on intraspinal nerve root stimulation. LIMITATIONS The limitations of this review include the relative paucity of well-designed prospective studies on targeted SCS. CONCLUSIONS Clinical use of intraspinal neurostimulation is expanding at a very fast pace. Intraspinal stimulation of non-dorsal column targets may well be the future of neurostimulation as it provides new clinically significant neuromodulation of specific therapeutic targets that are not well or not easily addressed with conventional dorsal column SCS. In addition, they may avoid undesired stimulation induced paraesthesia, particularly in non-painful areas of the body.
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Affiliation(s)
- George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA.,Center for Regenerative Medicine, Southern California University of Health Sciences, Whittier, CA, USA
| | - Nagy Mekhail
- Evidence Based Pain Management Research, Cleveland Clinic, Cleveland, OH, USA
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Deer TR, Provenzano DA, Hanes M, Pope JE, Thomson SJ, Russo MA, McJunkin T, Saulino M, Raso LJ, Lad SP, Narouze S, Falowski SM, Levy RM, Baranidharan G, Golovac S, Demesmin D, Witt WO, Simpson B, Krames E, Mekhail N. The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management. Neuromodulation 2017; 20:31-50. [PMID: 28042909 DOI: 10.1111/ner.12565] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique. METHODS The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations. RESULTS The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices. CONCLUSION Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.
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Affiliation(s)
| | | | | | | | - Simon J Thomson
- Pain Management and Neuromodulation Centre, Basildon & Thurrock University Hospitals, NHS, Trust, UK
| | | | | | | | | | - Shivanand P Lad
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Samer Narouze
- Summa Western Reserve Hospital, Cuyahoga Falls, OH, USA
| | | | | | | | | | - Didier Demesmin
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - William O Witt
- Cardinal Hill Pain Institute (emeritus), Lexington, KY, USA
| | - Brian Simpson
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Elliot Krames
- Pacific Pain Treatment Center (ret.), San Francisco, CA, USA
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Deer TR, Lamer TJ, Pope JE, Falowski SM, Provenzano DA, Slavin K, Golovac S, Arle J, Rosenow JM, Williams K, McRoberts P, Narouze S, Eldabe S, Lad SP, De Andrés JA, Buchser E, Rigoard P, Levy RM, Simpson B, Mekhail N. The Neurostimulation Appropriateness Consensus Committee (NACC) Safety Guidelines for the Reduction of Severe Neurological Injury. Neuromodulation 2017; 20:15-30. [PMID: 28042918 DOI: 10.1111/ner.12564] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [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: 10/16/2016] [Accepted: 11/07/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Neurostimulation involves the implantation of devices to stimulate the brain, spinal cord, or peripheral or cranial nerves for the purpose of modulating the neural activity of the targeted structures to achieve specific therapeutic effects. Surgical placement of neurostimulation devices is associated with risks of neurologic injury, as well as possible sequelae from the local or systemic effects of the intervention. The goal of the Neurostimulation Appropriateness Consensus Committee (NACC) is to improve the safety of neurostimulation. METHODS The International Neuromodulation Society (INS) is dedicated to improving neurostimulation efficacy and patient safety. Over the past two decades the INS has established a process to use best evidence to improve care. This article updates work published by the NACC in 2014. NACC authors were chosen based on nomination to the INS executive board and were selected based on publications, academic acumen, international impact, and diversity. In areas in which evidence was lacking, the NACC used expert opinion to reach consensus. RESULTS The INS has developed recommendations that when properly utilized should improve patient safety and reduce the risk of injury and associated complications with implantable devices. CONCLUSIONS On behalf of INS, the NACC has published recommendations intended to reduce the risk of neurological injuries and complications while implanting stimulators.
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Affiliation(s)
| | | | | | | | | | - Konstantin Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Jeffrey Arle
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joshua M Rosenow
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kayode Williams
- Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Samer Narouze
- Summa Western Reserve Hospital, Cuyahoga Falls, OH, USA
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Shivanand P Lad
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jose A De Andrés
- Valencia School of Medicine, Hospital General Universitario, Valencia, Spain
| | - Eric Buchser
- Anaesthesia and Pain Management Department, EHC Hosptial, Morges, and CHUV University Hospital, Lausanne, Switzerland
| | | | | | - Brian Simpson
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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