Current Waveforms in Spinal Cord Stimulation and Their Impact on the Future of Neuromodulation: A Scoping Review

BACKGROUND

Neuromodulation is a standard and well-accepted treatment for chronic refractory neuropathic pain. There has been progressive innovation in the field over the last decade, particularly in areas of spinal cord stimulation (SCS) and dorsal root ganglion stimulation. Improved outcomes using proprietary waveforms have become customary in the field, leading to an unprecedented expansion of these products and a plethora of options for the management of pain. Although advances in waveform technology have improved our fundamental understanding of neuromodulation, a scoping review describing new energy platforms and their associated clinical effects and outcomes is needed. The authors submit that understanding electrophysiological neuromodulation may be important for clinical decision-making and programming selection for personalized patient care.

OBJECTIVE

This review aims to characterize ways differences in mechanism of action and clinical outcomes of current spinal neuromodulation products may affect contemporary clinical decision-making while outlining a possible path for the future SCS.

STUDY DESIGN

The study is a scoping review of the literature about newer generation SCS waveforms.

MATERIALS AND METHODS

A literature report was performed on PubMed and chapters to include articles on spine neuromodulation mechanism of action and efficacy.

RESULTS

A total of 8469 studies were identified, 75 of which were included for the scoping review after keywords defining recent waveform technology were added.

CONCLUSIONS

Clinical data suggest that neuromodulation remains a promising tool in the treatment of chronic pain. The evidence for SCS for treating chronic pain seems compelling; however, more long-term and comparative data are needed for a comparison of waveforms when it comes to the etiology of pain. In addition, an exploration into combination waveform therapy and waveform cycling may be paramount for future clinical studies and the development of new technologies.

Footwear-Generated Dynamic Biomechanical Manipulation and Perturbation Training for Chronic Nonspecific Low Back Pain

BACKGROUND

Home-based therapy optimizing biomechanics and neuromuscular control is increasingly recognized as a treatment option for chronic nonspecific low back pain (CNSLBP). However, its impact on pain, function, and gait is limited among patients in a metropolitan area.

OBJECTIVE

To evaluate the change of pain, function, and gait parameters with home-based therapy with the use of footwear-generated biomechanical manipulation and perturbation training in a population with CNSLBP in a metropolitan area.

DESIGN

Prospective observational study.

SETTING

Outpatient rehabilitation clinic at an academic teaching hospital.

PARTICIPANTS

One hundred sixteen patients with CNSLBP for more than 6 months.

INTERVENTION

Six months of home-based therapy with a biomechanical device using 4 modular elements attached to a foot-worn platform.

MAIN OUTCOME MEASURES

Instrumental gait analysis (gait velocity, step length, single limb support phase % of gait cycle), Numeric Rating Scale for pain, and Oswestry Disability Questionnaire Index for pain and function.

RESULTS

Only 43 patients (37.1%) completed the study. Among 43 patients, mean gait velocity increased from 86.6 ± 20.7 to 99.7 ± 22.1 cm/s (P < .0001) in 6 months. Mean left step length increased from 51.1 ± 8.4 to 54.8 ± 9.8 cm (P < .0001). Mean right step length increased from 51.0 ± 7.9 to 55.4 ± 9.0 cm (P < .0001). Mean single limb support increased from 36.4 ± 2.8 to 37.2 ± 2.5%, (P = .208) in the right side and from 36.6 ± 3.0 to 37.8 ± 4.4%, (P = .019) in the left side. Median Oswestry Disability Questionnaire Index score improved from 28 (18-44; interquartile range) to 17 (10-35) (P = .045). Mean Numeric Rating Scale for back pain improved from 7.7 ± 1.8 to 3.3 ± 3.1 (P < .0001).

CONCLUSION

At 6 months, patients with CNSLBP undergoing home-based therapy with footwear-generated biomechanical manipulation and perturbation training demonstrated significant improvement of objective gait parameters, pain, and function.

LEVEL OF EVIDENCE

IV.

Confirmation of oxidative stress and fatty acid disturbances in two further Papillon-Lefèvre syndrome families with identification of a new mutation

BACKGROUND

We have previously reported oxidative and fatty acids disturbances in one Papillon-Lefèvre syndrome (PLS) family. This Mendelian condition characterized by palmar plantar keratosis and severe aggressive periodontitis, is caused by mutations in the cathepsin C (CTSC) gene. In this study, we have analysed two further unrelated PLS families to confirm this association.

METHODS

Mutations were identified by direct sequencing of CTSC. Biochemical analyses were performed in probands and their relatives in order to determine plasma levels of vitamin E, CoQ10 , lipid hydroperoxides (HP) and fatty acid patterns.

RESULTS

Pathogenic CTSC mutations were identified in both families including a new mutation (c504C>G). Both probands showed low levels of vitamin E and CoQ10 , and high levels of lipid HP, and also very low levels of docohexaenoic acid.

CONCLUSIONS

The previously reported oxidative and fatty acids disturbances were confirmed as a feature of this condition in two further families. There are low levels of antioxidant markers and high levels of oxidative markers, in addition of low levels of some anti-inflammatory fatty acids in persons suffering PLS and some of their relatives.

Breast mass in a 55-year-old woman

A 55-year-old white woman presented with a one-month history of a palpable breast mass. A mammogram was performed six months prior to her presentation and was read negative. However, the mammogram done two weeks prior to her clinical visit was suspicious for malignancy. Physical examination revealed a 1.5 cm to 2 cm palpable right breast mass. She underwent excision of the mass. Gross examination of the mass revealed a 2.5 cm well defined, ovoid-shaped, firm tan white tumor with a scalloped border, irregular extension into the surrounding tissue, and a granular cut surface. Largest tumor diameter was 2.5 cm. Microscopic examination of the tumor revealed small tumor cells with a solid, alveolar, and classic "single file" arrangement. There is also focal expansion and filling of the acini by similar small cells.

Benign myoepithelioma of the lung: a case report and review of the literature

This report describes a benign myoepithelioma of the lung that occurred in a 60-year-old woman. The patient had experienced hoarseness for 6 weeks, and a computed tomographic scan showed a nodule of approximately 2 cm in diameter at the peripheral portion of her right upper lung. Positron emission tomography showed no uptake of F-18 fluorodeoxyglucose in the nodule. Wedge biopsy of the lesion showed benign spindle cells arranged in a whorled pattern. The cells were positive for both cytokeratin and smooth muscle actin, which corresponded to the presence of tonofilaments and myofilaments that were identified ultrastructurally. The features of the present case of benign myoepithelioma that differ from features of previously reported benign and malignant cases of myoepithelioma in the lung are discussed in the report.