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

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Comparison of FDA-Approved Electrical Neuromodulation Techniques for Focal Neuropathic Pain: A Narrative Review of DRG, HF10, and Burst Neuromodulation

January 2018 - Pain Physician ◽

10.36076/ppj.2021.24.e407 ◽

2021 ◽

pp. E407-E423

Keyword(s):

Spinal Cord ◽

Neuropathic Pain ◽

Dorsal Root Ganglion ◽

Spinal Cord Stimulation ◽

High Frequency ◽

Dorsal Root ◽

Case Reports ◽

Case Series ◽

Dorsal Column ◽

Small Sample

BACKGROUND: Evidence suggests that dorsal root ganglion stimulation (DRGS) is a more effective treatment for focal neuropathic pain (FNP) compared with tonic, paresthesia-based dorsal column spinal cord stimulation (SCS). However, new advancements in waveforms for dorsal column SCS have not been thoroughly studied or compared with DRGS for the treatment of FNP. OBJECTIVES: The purpose of this review was to examine the evidence for these novel technologies; to highlight the lack of high-quality evidence for the use of neuromodulation to treat FNP syndromes other than complex regional pain syndrome I or II of the lower extremity; to emphasize the absence of comparison studies between DRGS, burst SCS, and high-frequency SCS; and to underscore that consideration of all neuromodulation systems is more patient-centric than a one-size-fits-all approach. STUDY DESIGN: This is a review article summarizing case reports, case series, retrospective studies, prospective studies, and review articles. SETTING: The University of Miami, Florida. METHODS: A literature search was conducted from February to March 2020 using the PubMed and EMBASE databases and keywords related to DRGS, burst SCS, HF10 (high-frequency of 10 kHz), and FNP syndromes. All English-based literature from 2010 reporting clinical data in human patients were included. RESULTS: Data for the treatment of FNP using burst SCS and HF10 SCS are limited (n = 11 for burst SCS and n = 11 for HF10 SCS). The majority of these studies were small, single-center, nonrandomized, noncontrolled, retrospective case series and case reports with short follow-up duration. To date, there are only 2 randomized controlled trials for burst and HF10 for the treatment of FNP. LIMITATIONS: No studies were available comparing DRGS to HF10 or burst for the treatment of FNP. Data for the treatment of FNP using HF10 and burst stimulation were limited to a small sample size reported in mostly case reports and case series. CONCLUSIONS: FNP is a complex disease, and familiarity with all available systems allows the greatest chance of success. KEY WORDS: Dorsal root ganglion, high frequency, burst, spinal cord stimulation, neuromodulation, focal neuropathic pain

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Conventional and Kilohertz-frequency Spinal Cord Stimulation Produces Intensity- and Frequency-dependent Inhibition of Mechanical Hypersensitivity in a Rat Model of Neuropathic Pain

Anesthesiology ◽

10.1097/aln.0b013e31829bd9e2 ◽

2013 ◽

Vol 119 (2) ◽

pp. 422-432 ◽

Cited By ~ 106

Author(s):

Ronen Shechter ◽

Fei Yang ◽

Qian Xu ◽

Yong-Kwan Cheong ◽

Shao-Qiu He ◽

...

Keyword(s):

Spinal Cord ◽

Neuropathic Pain ◽

Spinal Cord Stimulation ◽

Dynamic Range ◽

Dorsal Column ◽

Dependent Manner ◽

Motor Threshold ◽

Wide Dynamic Range ◽

Mechanical Hypersensitivity ◽

Dorsal Column Stimulation

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.

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Dorsal Root Ganglion Stimulation as a Salvage Treatment for Complex Regional Pain Syndrome Refractory to Dorsal Column Spinal Cord Stimulation: A Case Series

Neuromodulation Technology at the Neural Interface ◽

10.1111/ner.12622 ◽

2017 ◽

Vol 20 (7) ◽

pp. 703-707 ◽

Cited By ~ 14

Author(s):

Ajax Yang ◽

Corey W. Hunter

Keyword(s):

Spinal Cord ◽

Dorsal Root Ganglion ◽

Complex Regional Pain Syndrome ◽

Spinal Cord Stimulation ◽

Dorsal Root ◽

Case Series ◽

Pain Syndrome ◽

Dorsal Column ◽

Salvage Treatment

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Intraoperative electrophysiological monitoring for C1–2 spinal cord stimulation

Journal of Neurosurgery Spine ◽

10.3171/2016.7.spine16103 ◽

2017 ◽

Vol 26 (2) ◽

pp. 183-189 ◽

Cited By ~ 4

Author(s):

Laura M. Muncie ◽

Nathaniel R. Ellens ◽

Emeline Tolod-Kemp ◽

Claudio A. Feler ◽

John S. Winestone

Keyword(s):

Spinal Cord ◽

General Anesthesia ◽

Spinal Cord Stimulation ◽

Case Series ◽

Pain Syndrome ◽

Dorsal Column ◽

Patient Comfort ◽

Retrospective Case ◽

Cervical Stimulation ◽

Endotracheal Anesthesia

OBJECTIVE This study is a retrospective case series involving C1–2 spinal cord stimulation in patients with complex regional pain syndrome (CRPS) under general endotracheal anesthesia. Currently, C1–2 paddle lead placement is an accepted practice, which provides effective cervical stimulation to ameliorate upper-extremity and sometimes lower-extremity symptoms experienced by patients with CRPS. However, this technique must be performed under general endotracheal anesthesia rather than in an awake or semiconscious state due to intraoperative safety concerns and patient comfort. The authors aim to provide additional data to support the following novel technique: the use of somatosensory evoked potential (SSEP) diminution data to assist with proper midline placement of C1–2 leads under general anesthesia. METHODS SSEP median nerve (MN) and posterior tibial nerve (PTN) data were collected from 6 patients undergoing placement of C1–2 leads under general anesthesia. Fluoroscopy was used as an initial guide for proper anatomical midline placement. This was followed by the activation of the spinal cord stimulator and simultaneous collection of primarily MN SSEPs as well as PTN SSEPs for physiological midline placement. Unilateral and bilateral reductions in SSEPs assisted with the correct lateralization of the lead to ensure effective postoperative coverage according to the patient's individual preoperative symptoms. RESULTS Six patients were monitored using SSEPs and repeatable, reliable MN and PTN baseline responses were obtained from all. A reduction in amplitude ranging from 5% to 87% was observed, confirming inhibition of dorsal column conduction, and an average pain relief of 63% at short-term and 64% at long-term follow-up was recorded with 6 of 6 and 5 of 6 patients responding, respectively. CONCLUSIONS Intraoperative SSEP collision study testing appears to be a safe technique to monitor placement of C1–2 paddle leads intraoperatively under general anesthesia.

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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.

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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.

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Successful application of burst spinal cord stimulation for refractory upper limb pain: a case series

Journal of International Medical Research ◽

10.1177/03000605211004035 ◽

2021 ◽

Vol 49 (3) ◽

pp. 030006052110040

Author(s):

Kuen Su Lee ◽

Yoo Kyung Jang ◽

Gene Hyun Park ◽

In Jae Jun ◽

Jae Chul Koh

Keyword(s):

Spinal Cord ◽

Upper Limb ◽

Spinal Cord Stimulation ◽

Therapeutic Potential ◽

Case Series ◽

Limb Amputation ◽

Intractable Pain ◽

Limb Pain ◽

Cord Injury ◽

Upper Limb Pain

Spinal cord stimulation (SCS) has been used to treat sustained pain that is intractable despite various types of treatment. However, conventional tonic waveform SCS has not shown promising outcomes for spinal cord injury (SCI) or postamputation pain. The pain signal mechanisms of burst waveforms are different to those of conventional tonic waveforms, but few reports have presented the therapeutic potential of burst waveforms for the abovementioned indications. This current case report describes two patients with refractory upper limb pain after SCI and upper limb amputation that were treated with burst waveform SCS. While the patients could not obtain sufficient therapeutic effect with conventional tonic waveforms, the burst waveforms provided better pain reduction with less discomfort. However, further studies are necessary to better clarify the mechanisms and efficacy of burst waveform SCS in patients with intractable pain.

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