34. Mechanism of therapeutic benefit with dorsal column stimulation using a computational model of the spinal cord

Abstract Background: Spinal cord stimulation (SCS) is a useful neuromodulatory technique for treatment of certain neuropathic pain conditions. However, the optimal stimulation parameters remain unclear. Methods: In rats after L5 spinal nerve ligation, the authors compared the inhibitory effects on mechanical hypersensitivity from bipolar SCS of different intensities (20, 40, and 80% motor threshold) and frequencies (50, 1 kHz, and 10 kHz). The authors then compared the effects of 1 and 50 Hz dorsal column stimulation at high- and low-stimulus intensities on conduction properties of afferent Aα/β-fibers and spinal wide-dynamic–range neuronal excitability. Results: Three consecutive daily SCS at different frequencies progressively inhibited mechanical hypersensitivity in an intensity-dependent manner. At 80% motor threshold, the ipsilateral paw withdrawal threshold (% preinjury) increased significantly from pre-SCS measures, beginning with the first day of SCS at the frequencies of 1 kHz (50.2 ± 5.7% from 23.9 ± 2.6%, n = 19, mean ± SEM) and 10 kHz (50.8 ± 4.4% from 27.9 ± 2.3%, n = 17), whereas it was significantly increased beginning on the second day in the 50 Hz group (38.9 ± 4.6% from 23.8 ± 2.1%, n = 17). At high intensity, both 1 and 50 Hz dorsal column stimulation reduced Aα/β-compound action potential size recorded at the sciatic nerve, but only 1 kHz stimulation was partially effective at the lower intensity. The number of actions potentials in C-fiber component of wide-dynamic–range neuronal response to windup-inducing stimulation was significantly decreased after 50 Hz (147.4 ± 23.6 from 228.1 ± 39.0, n = 13), but not 1 kHz (n = 15), dorsal column stimulation. Conclusions: Kilohertz SCS attenuated mechanical hypersensitivity in a time course and amplitude that differed from conventional 50 Hz SCS, and may involve different peripheral and spinal segmental mechanisms.

Download Full-text

Supraspinal interactions resulting from experimental dorsal column stimulation

Journal of Neurosurgery ◽

10.3171/jns.1975.42.3.0296 ◽

1975 ◽

Vol 42 (3) ◽

pp. 296-300 ◽

Cited By ~ 36

Author(s):

Heinrich Bantli ◽

James R. Bloedel ◽

Phudhiphorn Thienprasit

Keyword(s):

Spinal Cord ◽

Mechanism Of Action ◽

Rhesus Monkeys ◽

Conduction Block ◽

Dorsal Column ◽

Content Type ◽

Spinal Cord Dorsal ◽

Ascending Pathways ◽

Dorsal Column Stimulation ◽

Fine Print

✓ Experiments were performed on rhesus monkeys to examine the hypothesis that stimulation with dorsal column electrodes of the type implanted clinically could alter the responses evoked in supraspinal nuclei through pathways in the ventral quadrant of the spinal cord. Dorsal column stimulation did produce changes in responses evoked in supraspinal nuclei; this effect could not be ascribed to a conduction block in ascending pathways. These results suggest that the mechanism of action of the dorsal column stimulator need not be dependent on interactions in the dorsal horn.

Download Full-text

Considerations for the Use of Dorsal Column Stimulation for Lumbosacral Radiation Neuritis of the Nerve Root in the Spine Tumor Patient (A Case Series)

Pain Management Case Reports ◽

10.36076/pmcr.2017/1/195 ◽

2017 ◽

pp. 195-204

Author(s):

Amitabh Gulati

Keyword(s):

Spinal Cord ◽

Spinal Cord Stimulation ◽

Case Series ◽

Dorsal Column ◽

Spine Tumor ◽

Tumor Patient ◽

Post Procedure ◽

Radiation Induced ◽

Mri Conditional ◽

Dorsal Column Stimulation

Background: Radiation therapy (RT) has become a mainstay in the treatment of various malignancies. Unfortunately, a potential side effect of this modality is radiation-induced neuritis. The time-course is varied and the emergence of pain syndromes can be delayed by several years after the completion of treatment. Risk factors include the total radiation dose, fractionation schedule, and radiation field size. Spinal cord stimulation (SCS) may have an important role in attenuating the symptoms of radiation-induced neuritis. Objectives: We aim to characterize a case series of oncologic patients who underwent SCS to treat iatrogenic radiation neuritis of the lumbosacral nerve roots. Study Design: This is a retrospective review of 4 cases of patients who were eligible for either intrathecal drug delivery or SCS (magnetic resonance imaging [MRI] conditional devices for spine surveillance), of which each patient elected to have a SCS trial and possible permanent implantation. Setting: The data were collected at a major cancer center in the US. Methods: In this case series, we present 4 patients with radiation-induced neuropathy. For each patient, we describe the use of SCS, which uses electric impulse generation, in an effort to treat the patient’s symptoms. To assess for efficacy, we compare pre- and post-procedure numerical rating scale (NRS) pain scores and post-procedure pain medication requirements. Results: Each patient had marked improvement in their pain (> 50%) during the trial lead placement and proceeded to the permanent implant. In subsequent months and years, the patients decreased their opioid utilization and reported an improvement in their overall pain. Limitations: This case series is a small sample size of heterogeneous malignancies with radiation treatment to the spine. Conclusions: Radiation-induced neuritis remains a severe and limiting outcome that some patients must live with after RT. Survivors of malignancy have often found this pathology to severely impact their quality of life, and it is difficult to treat. We have described the utilization of spinal cord neuromodulation as an effective treatment modality in the spine tumor patient population. Further research is needed to maximize the benefit and ensure appropriate case selection in the future. Key words: Radiation neuritis, radiation neuropathy, oncologic lumbar radiculopathy, spinal cord stimulation, neuromodulation, dorsal column stimulation, spinal tumor pain, MRI conditional spinal cord stimulation

Download Full-text

Mechanism of Dorsal Column Stimulation to Treat Neuropathic but not Nociceptive Pain: Analysis With a Computational Model

Neuromodulation Technology at the Neural Interface ◽

10.1111/ner.12178 ◽

2014 ◽

Vol 17 (7) ◽

pp. 642-655 ◽

Cited By ~ 16

Author(s):

Jeffrey E. Arle ◽

Kristen W. Carlson ◽

Longzhi Mei ◽

Nicolae Iftimia ◽

Jay L. Shils

Keyword(s):

Computational Model ◽

Dorsal Column ◽

Nociceptive Pain ◽

Dorsal Column Stimulation ◽

Pain Analysis

Download Full-text

The use of high-dose cervical spinal cord stimulation in the treatment of chronic upper extremity and neck pain

Surgical Neurology International ◽

10.25259/sni-249-2019 ◽

2019 ◽

Vol 10 ◽

pp. 109

Author(s):

Trey A. Baird ◽

Chris S. Karas

Keyword(s):

Spinal Cord ◽

Chronic Pain ◽

Upper Extremity ◽

Spinal Cord Stimulation ◽

Cervical Spinal Cord ◽

Dorsal Column ◽

High Dose ◽

Before And After ◽

Stage Process ◽

Dorsal Column Stimulation

Background: Dorsal column spinal cord stimulation is used for the treatment of chronic neuropathic pain of the axial spine and extremities. Recently, high-dose (HD) thoracic dorsal column stimulation for paresthesias has been successful. This study evaluates the utility of HD stimulation in the cervical spine for managing upper neck and upper extremity pain and paresthesias. Methods: Three patients suffering from cervical and upper extremity chronic pain were assessed. Each underwent a two-stage process that included a trial period, followed by permanent stimulator implantation. Therapy included the latest HD stimulation settings including a pulse width of 90 μs, a frequency setting of 1000 Hz, and an amplitude range of 1.5 amps–2.0 amps. Pain relief was measured utilizing relative percent pain improvement as self-reported by each patient before and after surgery. Results: After permanent implantation, (range 15–21 months), all three patients continued to experience persistent pain and paresthesia relief (70%–90%). Conclusions: In three patients, HD cervical spinal cord stimulation successfully controlled upper extremity chronic pain/paresthesias.

Download Full-text

Dorsal Column Stimulation Treats Pain from Chemotherapy-induced, Small Fiber Neuropathy

Pain Management Case Reports ◽

10.36076/pmcr.2017/1/57 ◽

2017 ◽

pp. 57-61

Author(s):

David Dickerson

Keyword(s):

Spinal Cord ◽

Dorsal Column ◽

Nerve Fibers ◽

Small Fiber Neuropathy ◽

Autonomic Nerve ◽

Vitamin Deficiencies ◽

Small Fiber ◽

Analgesic Regimen ◽

Number Of Patients ◽

Dorsal Column Stimulation

Small fiber neuropathy (SFN) is a disorder of small afferent nerve fibers that can result in debilitating pain and functional limitations. There are many etiologies including, but not limited to, diabetes, vitamin deficiencies, infections, and exposure to neurotoxic drugs such as chemotherapeutics. The constellation of signs and symptoms overlap with other disease states leading to potential misdiagnosis. New tests including histologic studies of skin biopsies and autonomic nerve tests have emerged in the last 20 years improving differentiation between these disease processes and SFN. Multiple chemotherapeutic medications have been implicated in causing SFN, including vincristine which was the causative agent in this case report. The exact incidence of chemotherapy-induced peripheral neurotoxicity (CIPN) is currently unknown, but according to some publications it has been reported to be as high as 40% in patients that have been treated with chemotherapy. As the number of cancer survivors continues to grow, the number of patients with painful SFN will potentially increase. Devising an effective analgesic regimen for patients with painful SFN can be difficult, and often requires the pain physician to employ multiple pharmacologic and non-pharmacologic therapies. Treatments include analgesics from several drug classes: antidepressants, opioids, and anticonvulsants. Often times however, more advanced interventional techniques must be employed as effective pain control may be limited by medication side effects or inadequate return of function. While dorsal column stimulation was approved for a limited number of applications, a number of new applications are reported in the literature. In this paper, we present a case of vincristineinduced SFN successfully treated with neuromodulation via spinal cord stimulator. Key words: Vincristine, vinblastine, chemotherapy- induced neuropathy, chronic pain, spinal cord stimulation, dorsal column stimulation, neuromodulation, small fiber neuropathy, neuropathic pain

Download Full-text

Pain reduction in amputees by long-term spinal cord stimulation

Journal of Neurosurgery ◽

10.3171/jns.1980.52.3.0346 ◽

1980 ◽

Vol 52 (3) ◽

pp. 346-350 ◽

Cited By ~ 108

Author(s):

Jörg-Ulrich Krainick ◽

Uwe Thoden ◽

Traugott Riechert

Keyword(s):

Spinal Cord ◽

Spinal Cord Stimulation ◽

Pain Reduction ◽

Dorsal Column ◽

Content Type ◽

Follow Up Study ◽

Dorsal Column Stimulation ◽

Fine Print

✓ This follow-up study analyzes the results of dorsal column stimulation instituted between 1972 and 1974 for the relief of pain in 84 patients, including 64 amputees. Good results decreased from 52.4% after 2 years of stimulation to 39% after 5 years. Special therapeutic problems in amputees are discussed.

Download Full-text

Synaptic responses of substantia gelatinosa neurones to dorsal column stimulation in rat spinal cord in vitro.

The Journal of Physiology ◽

10.1113/jphysiol.1994.sp020232 ◽

1994 ◽

Vol 478 (1) ◽

pp. 87-99 ◽

Cited By ~ 45

Author(s):

H Baba ◽

M Yoshimura ◽

S Nishi ◽

K Shimoji

Keyword(s):

Spinal Cord ◽

Dorsal Column ◽

Substantia Gelatinosa ◽

Rat Spinal Cord ◽

Dorsal Column Stimulation ◽

Synaptic Responses

Download Full-text

Effect of dorsal-column stimulation on gelatinosa and marginal neurons of cat spinal cord

Journal of Neurosurgery ◽

10.3171/jns.1989.70.2.0257 ◽

1989 ◽

Vol 70 (2) ◽

pp. 257-265 ◽

Cited By ~ 59

Author(s):

David Dubuisson

Keyword(s):

Spinal Cord ◽

Dorsal Horn ◽

Synaptic Input ◽

Time Course ◽

Dorsal Column ◽

Substantia Gelatinosa ◽

Spinothalamic Tract ◽

Nociceptive Responses ◽

Excitatory Synaptic Input ◽

Dorsal Column Stimulation

✓ Single neuronal units with physiological characteristics of superficial dorsal-horn neurons were recorded extracellularly in laminae 1, 2, and 3 of cat spinal cord. When focal electrical stimulation was applied to the ipsilateral dorsal column, most of the units were excited transsynaptically at various latencies consistent with an effect mediated by large myelinated axons. Units recorded in laminae 2 and 3 had earlier latencies of activation than units in lamina 1. Units with cutaneous receptive fields only for noxious stimuli were activated at significantly longer latencies than units responsive to innocuous stimuli. The time course of these effects was consistent with the concept that many cells in laminae 1 to 3 receive direct excitatory synaptic input from collaterals of dorsal-column fibers, and some lamina 1 cells receive excitatory synaptic input from lamina 2 neurons. Previous reports have emphasized the inhibitory action of dorsal-column stimulation on nociceptive responses of cells in laminae 4 and 5 of the dorsal-horn, particularly those of the spinocervical tract in cats and the spinothalamic tract in primates. The present study suggests that some of this inhibition might be sustained by a network of interneurons in or near the substantia gelatinosa and marginal layer. The therapeutic efficiency of dorsal-column stimulation for pain relief in humans may depend in part on the activation of neurons in the superficial layers of the dorsal horn.

Download Full-text

Quick Reference: Chapter 1: The Musculoskeletal System: The Hand and Upper Extremity

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2000.sepoct03 ◽

2000 ◽

Vol 5 (5) ◽

pp. 4-5

Keyword(s):

Dorsal Column ◽

Persistent Pain ◽

Illness Behavior ◽

Abnormal Illness Behavior ◽

Organ Systems ◽

Spinal Cord Dorsal ◽

Objective Basis ◽

Dorsal Column Stimulation ◽

Underlying Pathology

Abstract Spinal cord (dorsal column) stimulation (SCS) and intraspinal opioids (ISO) are treatments for patients in whom abnormal illness behavior is absent but who have an objective basis for severe, persistent pain that has not been adequately relieved by other interventions. Usually, physicians prescribe these treatments in cancer pain or noncancer-related neuropathic pain settings. A survey of academic centers showed that 87% of responding centers use SCS and 84% use ISO. These treatments are performed frequently in nonacademic settings, so evaluators likely will encounter patients who were treated with SCS and ISO. Does SCS or ISO change the impairment associated with the underlying conditions for which these treatments are performed? Although the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) does not specifically address this question, the answer follows directly from the principles on which the AMA Guides impairment rating methodology is based. Specifically, “the impairment percents shown in the chapters that consider the various organ systems make allowance for the pain that may accompany the impairing condition.” Thus, impairment is neither increased due to persistent pain nor is it decreased in the absence of pain. In summary, in the absence of complications, the evaluator should rate the underlying pathology or injury without making an adjustment in the impairment for SCS or ISO.

Download Full-text