Neuromodulation : journal of the International Neuromodulation Society
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Patients with refractory chronic pain may be considered for spinal cord stimulation (SCS) as an interventional therapy. Studies have shown that psychiatric disorders are associated with worse outcomes. However, this relationship may not be understood by all healthcare professionals. Despite psychologic clearance and proper indication, pain medicine physicians often find themselves questioning the appropriateness of some candidates. The authors conducted a scoping review to identify assessments ascertaining patients with pronounced psychiatric burden that may complicate optimal response, to identify any clearly defined psychiatric contraindications, and to review ways psychiatric comorbidities may be addressed in patients at risk for suboptimal long-term response. ⋯ This review indicates a need for a standardized, evidence-based, algorithmic psychologic clearance protocol for SCS implantation. The authors designed such a protocol using multiple assessments targeted at establishing true contraindications and identifying barriers requiring further intervention to optimize outcomes, while ensuring individual accommodation.
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Spinal cord stimulation (SCS) has been challenged by the lack of neurophysiologic data to guide therapy optimization. Current SCS programming by trial-and-error results in suboptimal and variable therapeutic effects. A novel system with a physiologic closed-loop feedback mechanism using evoked-compound action potentials enables the optimization of physiologic neural dose by consistently and accurately activating spinal cord fibers. We aimed to identify neurophysiologic dose metrics and their ranges that resulted in clinically meaningful treatment responses. ⋯ For the first time, an evidence-based neural dose regimen is available for a neurostimulation intervention as a starting point to enable optimization of clinical benefit, monitoring of adherence, and management of the therapy.
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Review Meta Analysis
Systematic Review and Meta-analysis of Stimulation of the Medial Branch of the Lumbar Dorsal Rami for the Treatment of Chronic Low Back Pain.
Chronic low back pain (CLBP) is often associated with impaired motor control and degeneration of the lumbar multifidus muscles. Several studies have reported on the utility of multifidus or medial branch stimulation as a treatment. We present a systematic review and meta-analysis of studies reporting on the change in low back pain intensity with multifidus stimulation. ⋯ Medial branch stimulation for the treatment of CLBP shows a high probability of a clinically significant change in pain intensity. Longer duration of stimulation was associated with decreased low back pain intensities.
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Randomized Controlled Trial Multicenter Study
Long-Term Treatment of Chronic Postamputation Pain With Bioelectric Nerve Block: Twelve-Month Results of the Randomized, Double-Blinded, Cross-Over QUEST Study.
The multicenter, randomized, double-blinded, active-sham controlled trial (high-freQUEncy nerve block for poST amputation pain [QUEST]) was conducted to show the safety and efficacy of a novel, peripherally placed high-frequency nerve block (HFNB) system in treating chronic postamputation pain (PAP) in patients with lower limb amputations. The primary outcomes from QUEST were reported previously. This study presents the long-term, single-cross-over, secondary outcomes of on-demand HFNB treatment for chronic PAP. ⋯ Overall, HFNB delivered directly to the damaged peripheral nerve provided sustained, on-demand relief of acute PAP exacerbations, reduced opioid utilization, and improved QOL for patients with lower limb amputations with chronic PAP.
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Complex regional pain syndrome (CRPS) is a debilitating chronic condition characterized by severe, nociplastic pain along with various other symptoms. Neuromodulation, particularly electrical stimulation of the dorsal root ganglion (DRG), has emerged as a promising intervention for patients with CRPS unresponsive to conventional treatments. However, little is known about the anatomical characteristics of DRGs in patients with CRPS. This study aimed to assess DRG size in patients with CRPS compared with healthy controls. ⋯ The findings suggest that CRPS is associated with a smaller DRG size in affected dermatomes, potentially indicating neuronal atrophy. Importantly, the study offers insights for DRG stimulation therapy especially among concerns for DRG compression after placement. This pilot study reveals a significant size difference in DRGs between affected and unaffected sides in patients with CRPS compared with controls, highlighting potential implications for treating CRPS. Further research is warranted to validate these findings and explore implications for clinical practice, including optimized neuromodulation strategies.