Percutaneous Cervical Spinal Cord Stimulation

Spinal cord stimulation has been increasing in influence as an option to regulate pain, especially in the chronic pain patient population. However, even with the numerous changes made to this technology since its inception, it is still prone to various complications such as hardware issues, neurological injury/epidural hematoma, infections, and other biological concerns. The purpose of this article is to thoroughly review and evaluate literature pertaining to the complications associated with percutaneous spinal cord stimulation. Lead migration is generally the most common complication of percutaneous spinal cord stimulation; however, recent utilization of various anchoring techniques has been discussed and experienced clinical success in decreasing the prevalence of lead migration and lead fractures. With newer high-frequency systems gaining traction to improve pain management and decrease complications as compared to traditional systems, rechargeable implantable pulse generators have been the preferred power source. However, recent findings may suggest that these rechargeable implantable pulse generators do not significantly increase battery life as much as was proposed. Intraoperative neuromonitoring has seen success in mitigating neurological injury postoperatively and may see more usage in the future through more testing. Though the occurrence of infection and biological complications, including dural puncture and skin erosion, has been less frequent over time, they should still be treated in accordance with established protocols. While many complications can arise following percutaneous spinal cord stimulator implantation, the procedure is less invasive than open implantation and has seen largely positive patient feedback. Hardware complications, the more common issues that can occur, rarely indicate a serious risk and can generally be remedied through reoperation. However, less common cases such as neurological injury, infections, and biological complications require prompt diagnosis to improve the condition of the patient and prevent significant damage.

Chapter 3 - Percutaneous spinal cord stimulation trial for cervical lead placement

ID: 222252 Incidence and Predictors of Inadvertent Dural Puncture Following Percutaneous Spinal Cord Stimulation

Despite increasing number of coronary interventions over recent years, there is still a considerable number of patients suffering from chronic refractory angina pectoris. The volume of no option patients is not exactly known, but has been suggested to be 30 per million inhabitants per year; other estimates are 2.5–5% of coronary angiography procedures.1,2 The group of no option patients includes those who have angina despite optimal medical therapy; they may not have been offered PCI or CABG because of severe diffuse coronary artery disease, or they who continue to experience severe angina after CABG, PCI, or both. A considerable number of therapeutic strategies have been investigated to treat severe chronic angina, such as transcutaneous electric nerve stimulation (TENS), left stellate ganglion blockade (LSGB), endoscopic thoracoscopic symathectomy (ETS), thoracic epidural anaesthesia (TEDA), external balloon counter pulsation (EECP), stem cell therapy, and finally myocardial laser revascularization by surgical (TMR) or percutaneous (PMR) technique or spinal cord stimulation (SCS).1 These interventions have been suggested to have primary effect on pain; there is no valid evidence that any of these procedures reduces any clinical major cardiac endpoints. Only a few of these options have undergone the test of randomized studies, so the impact of a placebo effect on pain is largely not known. When trying to orientate in the jungle of mechanical or implant options to decide on how to advice patients, it may be helpful to look at the natural course of chronic refractory angina. We know that this group of patients often are in agony with severe coronary artery disease. It is therefore natural to first look at the data on mortality with drug therapy only. The suggestion of a mortality over 1-year of up to 17%2 is often quoted, however, there is other evidence suggesting that … *Corresponding author. Tel: +47 55972172; fax: +47 55975150. E-mail address : jan.nordrehaug{at}helse-bergen.no

Lead and Pulse Generator Migration After Spinal Cord Stimulation Implantation: Insights From an Analysis of 7322 Patients

Spinal cord stimulation is a safe, effective, and reversible method for the management of chronic neuropathic pain. Spinal cord stimulation was found to be superior to traditional conservative management in recent clinical trials. The superiority of this therapeutic strategy is in part due to the many benefits, such as decreased use of prescription pain medications, cost-effectiveness, and improvement in patient quality of life. With appropriate patient consent for photography during the operation per hospital policy, the technical description for percutaneous placement of a spinal cord stimulator was documented at the authors home institution. The percutaneous technique allows for decreased operative times and thus reduced anesthesia, as well as decreased post-operative pain due to less tissue and muscle dissection. Additionally, the percutaneous leads have a smaller footprint in the epidural space, allowing more patients with mild spinal canal stenosis to receive this therapeutic device, which generally precludes paddle placement. These features make the percutaneous method an appealing alternative to the traditional laminotomy technique. The traditional laminotomy approach for paddle lead placement has been well described in the literature. However, detailed and indexed techniques of the percutaneous alternative are lacking. This technical description provides the first, easily accessible technical guide for the percutaneous placement of thoracic spinal cord stimulators. The operative technique was documented with images and detailed descriptions at the authors home institution.

Cervical and cervicomedullary spinal cord stimulation for chronic pain: Efficacy and outcomes

Spinal cord stimulation (SCS) may provide pain relief in approximately 60%-70% of well selected patients with pain caused by peripheral nerve injury. We have previously demonstrated that intrathecal (IT) administration of small doses of certain drugs, both in experimental animals and in patients, significantly enhances the pain-relieving effect of SCS. The alpha2-adrenoceptor agonist, clonidine, is extensively used as an adjunct to spinal morphine and is suggested to be particularly effective for neuropathic pain, but its clinical use is limited by side effects such as sedation and hypotension. In this study, we investigated the dose-response characteristics of IT clonidine, and whether a subeffective dose of clonidine could enhance the effect of SCS in nerve-injured rats with tactile hypersensitivity (allodynia). Results showed that clonidine, in doses of 1-20 microg, reduced the hypersensitivity in a dose-dependent manner. In rats in which SCS per se failed to suppress tactile hypersensitivity, the combination of SCS and a subeffective dose of clonidine appeared to be highly synergistic and markedly attenuated the hypersensitivity. These results suggest that small doses of IT clonidine may be combined with SCS in neuropathic pain patients who do not obtain satisfactory relief with SCS alone.

Computerized percutaneous multi-level spinal cord stimulation in motor disorders.

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.

Complex regional pain syndrome I (reflex sympathetic dystrophy).

The clinical entity of thoracic radiculopathy following spinal cord stimulator (SCS) placement has not been previously described. A retrospective review of prospectively acquired data on 172 patients, having undergone thoracic SCS placement at our institution, was performed. In addition, four patients were implanted at outside institutions, and were referred for revision. We examine our early experience with placement of thoracic SCS in surgically treated patients with chronic pain and 15 associated specific postoperative radicular pain complications along respective thoracic dermatomes. We postulate that preexisting thoracic spinal pathology affords less compliance in the placement of larger paddles, and subsequent radicular pain in a band-like abdominal fashion. A syndrome of thoracic radiculopathy, presenting as intractable lower thoracic or abdominal wall pain occurring in the immediate postoperative period, was identified in 15 patients. These patients subsequently underwent revision surgery, with either a more extensive laminectomy to further decompress the dorsal nerve roots or lead removal, both of which resulted in near immediate relief of symptoms. Thoracic radiculopathy may occur following SCS paddle lead placement. This clinical syndrome is characterized by its immediate postoperative development, band-like thoracic or abdominal pain pattern, severe pain that both overwhelms the incisional pain and is refractory to medications, and absence of motor deficit. The lateral placement of paddle leads increases the risk of radicular symptoms. Preoperative thoracic spine magnetic resonance imaging may be helpful in identifying patients who may be susceptible to this syndrome.

A decrease in cerebral blood flow (CBF) and brain metabolic activity are well-known complications of stroke. Spinal cord stimulation (SCS) is successfully being used for the treatment of several low-perfusion syndromes. The aim of this chapter is to describe the data that support the effect of SCS on CBF and the use of SCS in the treatment of stroke and cerebral low perfusion syndromes. In addition, we present our relevant studies. Since April 1995, we have assessed 49 non-stroke patients. The following parameters were measured pre- and post-stroke: (1) CBF in healthy contralateral tissue by single photon emission computed tomography (SPECT), (2) systolic and diastolic velocity in the middle cerebral artery (MCA) by transcranial Doppler, (3) blood flow quantification in the common carotid artery (CCA) by color Doppler, and (4) glucose metabolism in healthy contralateral tissue by positron emission tomography (PET). Our results showed that during cervical SCS there was a significant (p < 0.001) increase in systolic (> or =21%) and diastolic (>26%) velocity in the MCA, and CCA blood flow (> or =51%) as well as glucose metabolism (44%). We concluded that cervical SCS (cSCS) can modify CBF and brain metabolism. Its potential role in the management of stroke and low-perfusion syndromes is further investigated by experimental studies and reports describing clinical experience. Appropriate clinical trials are warranted.

Background: Despite the good clinical results elicited by spinal cord stimulation (SCS), the physiological basis of action of SCS is widely unknown. Inhibition of somatosensory evoked potential (SEP) amplitudes by SCS has been described, but it is unclear whether this displays dose dependency. Moreover, it is unknown whether the pain-relieving effect elicited by SCS correlates with the inhibition of SEPs. Finally, this study aimed to answer the question whether there is a difference in the effect on SEPs between SCS and transcutaneous electrical nerve stimulation (TENS), thus between central nervous system stimulation and peripheral nervous system stimulation. Methods: Ten patients (4 men and 6 women, age range 40-77 years) with neuropathic lower limb pain were included in the study. All patients had implanted SCS systems with percutaneous type electrodes. Cortical SEPs under SCS and TENS were measured without stimulation, under stimulation at perception threshold (PT), and at maximal threshold (MT) in a crossover design. Results: Cortical SEP amplitudes were significantly inhibited by SCS. Stimulation at PT and at MT both led to a statistically significant inhibition of the SEP amplitude. The difference between amplitude reduction at PT and MT showed a tendency towards significance. The degree of SEP amplitude inhibition did not correlate with pain relief. Inhibition of SEP amplitudes by TENS was weaker than that elicited by SCS. The average percentage of amplitude reduction at MT was twice as high under SCS as it was under TENS. No effects on SEP latencies were seen. Conclusions: SCS exerts a significantly stronger inhibition of SEP amplitudes than TENS. The data hint at a dose dependency of SCS-induced SEP amplitude inhibition. No correlation between SEP amplitude inhibition and pain relief was found. Key words: spinal cord stimulation, SCS, transcutaneous electrical nerve stimulation, TENS, neuropathic pain, somatosensory evoked potentials, SEP

Spinal Cord Stimulation and Evidence-Based Medicine—Cui Bono