P.149 Spinal Cord Stimulation for Refractory Angina

Spinal Cord Stimulation for Patients With Refractory Angina and Previous Coronary Surgery

Spinal Cord Stimulation and Evidence-Based Medicine—Cui Bono

Single-Center Experience With High-Density Spinal Cord Stimulation in Patients With Refractory Angina Pectoris

Spinal cord stimulation (SCS) offers new hope for patients with neuropathic pain. SCS "neuromodulates" the transmission and response to "painful" stimuli. The efficacy of SCS has been established in the treatment of a variety of neuropathic pain conditions and more recently in refractory angina pectoris, peripheral vascular disease, and failed back surgery syndrome. Recent publications suggest that visceral pain could be successfully treated with SCS. We report the first successful use of a spinal cord stimulator in the treatment of refractory neuropathic mediastinal, esophageal, and anterior neck pain following esophagogastrectomy.

Background: Spinal cord stimulation is an intervention that has become increasingly popular due to the growing body of literature showing its effectiveness in treating pain and the reversible nature of the treatment with implant removal. It is currently approved by the FDA for chronic pain of the trunk and limbs, intractable low back pain, leg pain, and pain from failed back surgery syndrome. In Europe, it has additional approval for refractory angina pectoris and peripheral limb ischemia. Objective: This narrative review presents the current evidence supporting the use of spinal cord stimulation for the approved indications and also discusses some emerging neuromodulation technologies that may potentially address pain conditions that traditional spinal cord stimulation has difficulty addressing. Study Design: Narrative review. Results: Spinal cord stimulation has been reported to be superior to conservative medical management and reoperation when dealing with pain from failed back surgery syndrome. It has also demonstrated clinical benefit in complex regional pain syndrome, critical limb ischemia, and refractory angina pectoris. Furthermore, several cost analysis studies have demonstrated that spinal cord stimulation is cost effective for these approved conditions. Despite the lack of a comprehensive mechanism, the technology and the complexity in which spinal cord stimulation is being utilized is growing. Newer devices are targeting axial low back pain and foot pain, areas that have been reported to be more difficult to treat with traditional spinal cord stimulation. Percutaneous hybrid paddle leads, peripheral nerve field stimulation, nerve root stimulation, dorsal root ganglion, and high frequency stimulation are actively being refined to address axial low back pain and foot pain. High frequency stimulation is unique in that it provides paresthesia free analgesia by stimulating beyond the physiologic frequency range. The preliminary results have been mixed and a large randomized control trial is underway to evaluate the future of this technology. Other emerging technologies, including dorsal root ganglion stimulation and hybrid leads, also show some promising preliminary results in non-randomized observational trials. Limitation: This review is a primer and not an exhaustive review for the current evidence supporting the use of spinal cord stimulation and precursory discussion of emerging neuromodulation technologies. This review does not address peripheral nerve stimulation and focuses mainly on spinal cord stimulation and touches on peripheral nerve field stimulation. Conclusions: Spinal cord stimulation has demonstrated clinical efficacy in randomized control trials for the approved indications. In addition, several open label observational studies on peripheral nerve field stimulation, hybrid leads, dorsal root ganglion stimulation, and high frequency stimulation show some promising results. However, large randomized control trials demonstrating clear clinical benefit are needed to gain evidence based support for their use. Key words: Spinal cord stimulation, chronic pain; low back pain, high frequency stimulation, peripheral nerve field stimulation, dorsal root ganglion stimulation, failed back surgery syndrome, complex regional pain syndrome, critical limb ischemia, refractory angina pectoris

Background: Spinal cord stimulation (SCS) is an alternative treatment option for refractory angina. Controlled trials demonstrate symptom relief and improvement in functional status. Since patients experience retrosternal prickling during active...

In spite of great progresses in surgical and catheter interventional techniques there is an increasing number of patients with coronary heart disease not suitable for these conventional treatment strategies. A recent review of the Study Group on the treatment of refractory angina pectoris of the European Society of Cardiology (ESC) recommends spinal cord stimulation (SCS) as first-line therapy. SCS is a well-known and often used therapy for refractory angina in other European countries but not in Germany. The present studies show that SCS is an efficient therapy. By reduction of angina symptoms and a consecutive increase of exercise capacity, the patients experience a great improvement in quality of life. In addition, recent data of our own study suggest a significant decrease in myocardial ischemia in patients under SCS. This might be a direct effect of SCS or due to a better collateralization because of the improved exercise capacity. In agreement with the study group of the ESC, we would recommend SCS as first-line therapy for refractory angina pectoris. As a matter of course, conventional treatment strategies should not be replaced by SCS. Hence, a strict evaluation before implanting a SCS device is indispensable.

BackgroundPatients with refractory angina have significant morbidity. This study aimed to compare two of the treatment options, Spinal Cord Stimulation (SCS) and Percutaneous Myocardial Laser Revascularisation (PMR) in terms of clinical outcomes and cost-effectiveness.MethodsEligible patients were randomised to PMR or SCS and followed up for exercise tolerance time (ETT), Canadian Cardiovascular Society (CCS) classification and the quality of life measures SF-36, Seattle Angina Questionnaire and the EuroQoL at 3, 12 and 24 months. Utilities were calculated using the EQ-5D and these and costs were compared between groups. The incremental cost-effectiveness ratio (ICER) per QALY for SCS compared to PMR was also calculated.ResultsAt 24 months post-randomisation, patients that had SCS and PMR had similar ETT (mean difference 0.05, 95% CI -2.08, 2.18, p = 0.96) and there was no difference in CCS classification or quality of life outcomes. The difference in overall mean costs when comparing SCS to PMR was GBP5,520 (95% CI GBP1,966 to GBP8,613; p < 0.01) and the ICER of using SCS was GBP46,000 per QALY.ConclusionOutcomes after SCS did not differ appreciably from those after PMR, with the former procedure being less cost-effective as currently applied. Larger studies could clarify which patients would most benefit from SCS, potentially increasing cost-effectiveness.Trial registrationCurrent Controlled Trials ISRCTN09648950

OBJECTIVETo determine morbidity and mortality characteristics in patients treated with electrical neuromodulation for refractory angina pectoris.DESIGNA retrospective multicentre study of patients treated with spinal cord stimulation between 1987 and 1997;...

Effect of Spinal Cord Stimulation in Patients With Refractory Angina: Evidence From Observational Studies

Spinal Cord Stimulation Has Proven Benefit on Pain and Quality of Life in Patients With Angina Pectoris When Less Invasive Therapies Have Failed

Spinal dorsal column stimulation (DCS) modulates sensory transmission, including pain, at the dorsal horn of the cord. However, the mechanisms of DCS modulatory actions and the effects of anesthetics on these mechanisms remain to be investigated. We studied the effects of isoflurane (1.0% and 2.0%) on conditioned inhibition, the amplitude decrease of the spinal cord potentials (SCPs) after a conditioning volley (DCS), in the ketamine-anesthetized rat by recording the sharp negative (N) and slow positive (P) waves of the SCPs evoked by conditioning dorsal column (DC) and testing segmental stimulations. The N wave is believed to be the synchronized activity of the dorsal horn neurons, and the P wave, primary afferent depolarization (PAD), reflecting presynaptic inhibition. The P potentials evoked by either DC or segmental stimulation were depressed by isoflurane, whereas the N waves remained unchanged, indicating that the pharmacological characteristics of these N and P waves are similar between DC-evoked and segmentally evoked SCPs. The conditioned inhibition of segmental N and P waves by DC stimulation was almost completely suppressed by 2.0% isoflurane. The conditioned inhibition of the segmental N wave was not changed by spinal cord transection, whereas the conditioned inhibition of the segmental P wave was decreased. The results indicate that isoflurane depresses presynaptic inhibition without affecting the synchronized activity of dorsal horn neurons and, most profoundly, depresses the conditioned inhibition by DC stimulation of the dorsal horn neurons and PAD. Further, the results indicate that conditioned inhibition by DC stimulation of PAD receives a facilitatory influence from the supraspinal structures, whereas that of the synchronized activity of the dorsal horn neurons does not. To investigate how anesthetics affect supraspinal modulation of sensory transmission in the spinal cord, the spinal cord potential (SCP) evoked by dorsal cord stimulation (DCS) and segmentally evoked SCP conditioned by DCS were recorded in intact and spinal cord-transected rats during isoflurane anesthesia.

Editorial| April 2023 Modulating the Cardiac Autonomic Nervous System: Stay Close to My Heart or Keep Your Distance? This article has an Audio Podcast Karsten Bartels, M.D., Ph.D., M.B.A.; Karsten Bartels, M.D., Ph.D., M.B.A. 1Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska; Outcomes Research Consortium, Cleveland, Ohio. https://orcid.org/0000-0003-2028-4664 Search for other works by this author on: This Site PubMed Google Scholar Amanda A. Fox, M.D., M.P.H. Amanda A. Fox, M.D., M.P.H. 2Department of Anesthesiology and Pain Management, and McDermott Center for Human Growth and Development/Center for Human Genetics, University of Texas Southwestern Medical Center, Dallas, Texas. Search for other works by this author on: This Site PubMed Google Scholar Author and Article Information This editorial accompanies the article on p. 372. Accepted for publication February 1, 2023. Address correspondence to Dr. Bartels: karbartels@unmc.edu Anesthesiology April 2023, Vol. 138, 348–350. https://doi.org/10.1097/ALN.0000000000004529 Connected Content Article: GABAergic Signaling during Spinal Cord Stimulation Reduces Cardiac Arrhythmias in a Porcine Model Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Karsten Bartels, Amanda A. Fox; Modulating the Cardiac Autonomic Nervous System: Stay Close to My Heart or Keep Your Distance?. Anesthesiology 2023; 138:348–350 doi: https://doi.org/10.1097/ALN.0000000000004529 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsAnesthesiology Search Advanced Search Topics: autonomic nervous system, heart Perioperative cardiac protection research is needed to determine how to prevent and mitigate cardiac injury that can lead to cardiovascular morbidity and mortality. In this month’s issue of Anesthesiology, Howard-Quijano et al.1 report effects of high thoracic spinal cord stimulation on decreasing sympathetic stimulation of the heart and corresponding ventricular arrhythmias. What is particularly meaningful about this paper is that the authors do experiments on Yorkshire pigs in order to define the biology underlying the favorable cardiac effects of high thoracic spinal cord stimulation. In their manuscript, the authors report findings from an elegant sequence of experiments demonstrating specifically that (1) spinal cord stimulation therapy during cardiac ischemia resulted in fewer ventricular arrhythmias, (2) intrathecal γ-aminobutyric acid type A (GABAA) and γ-aminobutyric acid type B (GABAB) receptor blockade eliminated the protective effects of spinal cord stimulation, (3) intrathecal administration of γ-aminobutyric acid (GABA) transaminase... You do not currently have access to this content.

Percutaneous transluminal angioplasty of saphenous vein grafts for medically refractory unstable angina

BackgroundRefractory angina pectoris represents a significant clinical challenge characterized by persistent chest pain despite maximally tolerated medical therapy and optimal revascularization attempts. This study evaluates the efficacy and safety of invasive spinal cord stimulation (SCS) in patients with refractory angina.MethodsTwenty-one patients underwent neurostimulation system implantation between 2022 and 2023 (mean age 62.8 ± 7, 12 males) diagnosed with refractory angina. All patients received both chronic continuous stimulation and on-demand stimulation to alleviate anginal pain episodes. The primary endpoint was changes in the Seattle Angina Questionnaire (SAQ-19) scores. Secondary endpoints included changes in the Short Form Health Survey (SF-36), incidence of major adverse cardiovascular events, device-related complications, and nitrate use.ResultsEighteen patients completed the final follow-up. No statistically significant improvements were observed in any SAQ-19 domains. However, reductions in pain scores (41% vs. 53%, p = 0.007) and improvements in mental health scores (61% vs. 72%, p = 0.021) and physical functionating (36 vs. 52%, p = 0.017) were noted on the SF-36. Device extraction occurred in three cases (14%)—two due to pocket infection and one at the patient's request. Four lead repositioning procedures were performed (19%). Hospitalization rates significantly decreased over the one-year observation period, from 3.8 to 0.5 hospitalizations per patient (p = 0.03). Recurrent acute coronary syndrome was noted in one patient, requiring additional coronary stentings. Notably, although no significant reduction in nitrate therapy was achieved, the treatment regimen prevented any new nitrate prescriptions during the study period.ConclusionSCS did not significantly improve the primary endpoint of disease-specific quality of life (SAQ-19). However, treatment was associated with secondary benefits, including improvements in physical functionating, pain and mental health (SF-36) and a significant reduction in hospitalization rates. Complication rates were significant.