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Brown A, Lam L, Huh B, D'Souza RS, Javed S. Atypical Applications of Neuromodulation for Non-Painful Conditions. Curr Pain Headache Rep 2025; 29:82. [PMID: 40317388 DOI: 10.1007/s11916-025-01389-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2025] [Indexed: 05/07/2025]
Abstract
PURPOSE OF REVIEW This narrative review explores the expanding applications of neuromodulation beyond pain management, focusing on its use in treating non-painful conditions such as heart failure, renal failure, spinal cord injuries, overactive bladder syndrome, and cognitive impairment in neurodegenerative diseases. RECENT FINDINGS Neuromodulation techniques, including dorsal root ganglion stimulation, sacral neurostimulation, and deep brain stimulation, have shown promising results in various non-painful medical conditions: Heart and Renal Failure: Dorsal root ganglion stimulation induces diuresis in diuretic-resistant patients, offering a novel approach to managing fluid overload. Spinal Cord Injuries: Epidural spinal cord stimulation and brain-spine interfaces have demonstrated the potential to restore motor function, enhancing mobility and quality of life for paralyzed individuals. Overactive Bladder Syndrome: Sacral neurostimulation and tibial nerve stimulation have proven effective in improving urinary continence and reducing symptoms in patients unresponsive to conventional treatments. Cognitive Impairment in Neurodegenerative Diseases: Techniques such as deep brain stimulation and transcranial magnetic stimulation are being investigated for their ability to enhance cognitive and motor functions in conditions like Parkinson's and Alzheimer's disease. The review highlights the transformative potential of neuromodulation in non-painful conditions, demonstrating its ability to address complex medical issues beyond its traditional scope. Continued research and optimization of these techniques may lead to broader therapeutic applications and improved patient outcomes.
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Affiliation(s)
- Ashlyn Brown
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA.
| | - Loc Lam
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Billy Huh
- Department of Pain Medicine, Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Saba Javed
- Department of Pain Medicine, Division of Anesthesiology, Critical Care Medicine, and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Machi A, Patel A, Ottestad E. Nerve stimulation and neuromodulation for painful nerves: a narrative review. INTERNATIONAL ORTHOPAEDICS 2025; 49:989-996. [PMID: 40111452 DOI: 10.1007/s00264-025-06498-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2024] [Accepted: 03/08/2025] [Indexed: 03/22/2025]
Abstract
Nerve injury primarily leads to neuropathic pain but may also have overlapping elements of nociplastic pain or ongoing nociceptive pain. Electrical stimulation is particularly effective in the treatment of neuropathic pain and may be effective for nociplastic and nociceptive pain. While multiple mechanisms contribute to the analgesic effect of electrical stimulation, the most widely accepted theory for the predominant effect is that of Melzack and Wall's gate control theory. According to this theory, non-painful sensory input carried by low-threshold large-diameter Aβ fibres disrupt the transmission of pain signals in small pain fibers (Aδ and C fibres). This occurs through the activation of inhibitory interneurons in the dorsal horn, which ultimately blocks pain signal transmission.This theory has been employed for different forms of stimulation, including transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS), and peripheral nerve stimulation (PNS). Each of these methods offers a different approach to localized stimulation and neuromodulation for the treatment of pain. TENS is a non-invasive technique, that delivers electrical currents via surface electrodes placed on the skin. PENS, in contrast, is a minimally invasive method that applies electrical currents through small needles inserted near a target muscle or neural structure. PNS involves the implantation of temporary or permanent electrodes to deliver electrical stimulation directly to peripheral nerves. These modalities are widely used to manage various pain conditions including non-malignant, chronic musculoskeletal and neuropathic pain, such as chronic low back pain, neck pain, neuropathic pain, myofascial pain, and post-operative pain. TENS is particularly notable as a non-invasive device that is affordable, over-the-counter, self-administered, and nonpharmacological option that does not pose the risk of toxicity or overdose. PENS stands out for its ability to integrate electrical stimulation therapy with electroacupuncture through a minimally invasive technique. PNS, on the other hand, is unique in its capacity to precisely target specific nerves and provide a range of stimulation options for extended treatment durations.This article provides a narrative overview of TENS, PENS and PNS with a particular focus on their application for neuropathic pain management and for athletes. We will review mechanisms of action, indications, diagnostic and treatment algorithms, as well as complications and limitations. The overview concludes with a complex case study demonstrating the use of various electrical stimulation therapies, ultimately to successful pain resolution for the patient.
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Affiliation(s)
| | - Ankur Patel
- Novant Health Spine Specialists, Winston Salem, USA
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Kleppel DJ, Copeland R, Hussain N, Karri J, Wang E, D'Souza RS. Methodological and statistical characteristics of meta-analyses on spinal cord stimulation for chronic pain: a systematic review. Reg Anesth Pain Med 2025; 50:358-366. [PMID: 38388015 PMCID: PMC12015056 DOI: 10.1136/rapm-2023-105249] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/09/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND A growing number of meta-analyses (MA) have investigated the use of spinal cord stimulation (SCS) as a treatment modality for chronic pain. The quality of these MAs has not been assessed by validated appraisal tools. OBJECTIVE To examine the methodological characteristics and quality of MAs related to the use of SCS for chronic pain syndromes. EVIDENCE REVIEW An online literature search was conducted in Ovid MEDLINE(R), Ovid EMBASE, Ovid Cochrane Database of Systematic Reviews, and Scopus databases (January 1, 2000 through June 30, 2023) to identify MAs that investigated changes in pain intensity, opioid consumption, and/or physical function after SCS for the treatment of chronic pain. MA quality was assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) critical appraisal tool. FINDINGS Twenty-five MAs were appraised in the final analysis. Three were considered "high" quality, three "low" quality, and 19 "critically low" quality, per the AMSTAR-2 criteria. There was no association between the publication year and AMSTAR-2 overall quality (β 0.043; 95% CI -0.008 to 0.095; p=0.097). There was an association between the impact factor and AMSTAR-2 overall quality (β 0.108; 95% CI 0.044 to 0.172; p=0.002), such that studies published in journals with higher impact factors were associated with higher overall quality. There was no association between the effect size and AMSTAR-2 overall quality (β -0.168; 95% CI -0.518 to 0.183; p=0.320).According to our power analysis, three studies were adequately powered (>80%) to reject the null hypothesis, while the remaining studies were underpowered (<80%). CONCLUSIONS The study demonstrates a critically low AMSTAR-2 quality for most MAs published on the use of SCS for treating chronic pain. Future MAs should improve study quality by implementing the AMSTAR-2 checklist items. PROSPERO REGISTRATION NUMBER CRD42023431155.
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Affiliation(s)
- Donald J Kleppel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Royce Copeland
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Jay Karri
- Departments of Orthopedic Surgery and Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eric Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Christopher Morris, Vorenkamp K, Ward J. PNS for management of intercostal neuralgia: A case report. INTERVENTIONAL PAIN MEDICINE 2025; 4:100573. [PMID: 40177302 PMCID: PMC11964615 DOI: 10.1016/j.inpm.2025.100573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Revised: 02/21/2025] [Accepted: 02/22/2025] [Indexed: 04/05/2025]
Abstract
Intercostal neuralgia is a rare but potentially debilitating condition that manifests as neuropathic pain in any rib space. This pain can typically be treated with typical mainstays of neuropathic pain treatment, such as over-the-counter analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and opioids. However, as detailed in this case, patients can have refractor pain despite the use of these mainstays of treatment. In these patients, peripheral nerve stimulator (PNS) placement can be a possible treatment modality. In our case detailing a 75 year old male with refractory intercostal neuralgia, we have shown that PNS placement for this indication can provide analgesia in this debilitating condition.
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D'Souza RS, Hussain N. A novel single-lead percutaneous approach for multi-nerve peripheral stimulation in upper extremity pain: A case report. INTERVENTIONAL PAIN MEDICINE 2025; 4:100546. [PMID: 39975858 PMCID: PMC11836491 DOI: 10.1016/j.inpm.2025.100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2024] [Revised: 01/17/2025] [Accepted: 01/18/2025] [Indexed: 02/21/2025]
Abstract
Peripheral nerve stimulation (PNS) is an emerging modality for managing painful peripheral neuropathy, offering potential long-term relief when conservative treatments fall short. Conventionally, each PNS lead targets a single nerve, necessitating multiple leads in cases involving pain across multiple nerve distributions. This case report presents a novel approach using a single PNS lead to target multiple peripheral nerves in the upper extremity via an axillary brachial plexus approach. We describe a 47-year-old female with a three-year history of intractable neuropathic pain localized to the ulnar and median nerve distributions, who underwent a temporary PNS trial after failing conventional therapies, including physical therapy, medications, and corticosteroid injections. Under ultrasound guidance, a single PNS lead was placed at the brachial plexus, targeting both ulnar and median nerves. Optimal stimulation thresholds were achieved, and the patient reported 80-100% pain relief throughout the 60-day trial period, with sustained relief for six months post-lead removal. This approach leverages the anatomical proximity of the ulnar, median, and radial nerves at the axilla, enabling multi-nerve targeting with a single lead. The technique offers potential advantages, including reduced procedural complexity, fewer risks, and cost savings, especially in the current landscape of increasing insurance denials for neuromodulation procedures.
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Affiliation(s)
- Ryan S. D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH, USA
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Fawaz R, Haegelen C, Simon E, Curtet M, Giner AM, Thomas A, Mertens P, Duraffourg M. Multimodal use of endoscopy in pain surgery: Overview, applications, and future directions. Neurochirurgie 2025; 71:101634. [PMID: 39818017 DOI: 10.1016/j.neuchi.2025.101634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Accepted: 01/08/2025] [Indexed: 01/18/2025]
Affiliation(s)
- Rayan Fawaz
- Department of Neurosurgery, Percy Military Teaching Hospital, 2 rue Lieutenant Raoul Batany, 92140 Clamart Cedex, France; Neuromodulation Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Department of Functional Neurosurgery, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France.
| | - Claire Haegelen
- Neuromodulation Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Department of Functional Neurosurgery, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Pain Department, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
| | - Emile Simon
- Department of Functional Neurosurgery, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Pain Department, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
| | - Muriel Curtet
- Neuromodulation Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
| | - Anne-Marie Giner
- Neuromodulation Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
| | - Audrey Thomas
- Neuromodulation Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
| | - Patrick Mertens
- Neuromodulation Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Department of Functional Neurosurgery, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Pain Department, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
| | - Manon Duraffourg
- Neuromodulation Unit, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Department of Functional Neurosurgery, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France; Pain Department, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Bron, France
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D'Souza RS, Klasova J, Saini C, Chang A, Music S, Shah JD, Elmati PR, Chitneni A, To J, Prokop LJ, Hussain N. Global Burden of Complex Regional Pain Syndrome in At-Risk Populations: Estimates of Prevalence From 35 Countries Between 1993 and 2023. Anesth Analg 2025:00000539-990000000-01163. [PMID: 39932867 DOI: 10.1213/ane.0000000000007421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2025]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a debilitating and painful condition accompanied by sensory, autonomic, trophic, and/or motor abnormalities. Although CRPS is rare in the general population, the prevalence among individuals at higher risk, particularly posttraumatic and postsurgical patients, remains unknown. This study aims to provide a benchmark that quantifies CRPS prevalence in high-risk groups, and offers insights on potential predictors of developing CRPS. METHODS We conducted a systematic review and meta-analysis to identify studies reporting prevalence of CRPS after an inciting event (eg, fracture, surgery), specifically 12-month and 24-month prevalence (primary outcomes), as well as 3-month and 6-month prevalence (secondary outcomes). Estimates from individual studies were transformed using double-arcsine transformation, and the resulting estimates with 95% confidence interval (CI) were pooled in a meta-analysis using a random-effects model. RESULTS We included 214 articles with data from 2491,378 participants worldwide (35 countries), of which 16,873 had CRPS. The pooled 12-month and 24-month global prevalence was 3.04% (95% CI, 2.64-3.48) and 6.46% (95% CI, 5.46-7.53), respectively. Subgroup analysis and meta-regression were performed to understand the impact of population-dependent (mechanism of injury, type of CRPS), contextual-dependent (socioeconomic status), and methodological-dependent (study design, publication year) factors. The 12-month prevalence was higher in countries with a high human development index (HDI) compared to those with a medium or very high HDI, was higher in participants with a traumatic inciting injury only versus those with surgical injury only or traumatic/surgical injury, and was higher in prospective versus retrospective studies. Meta-regression analysis showed that publication year was a significant moderator, with more recent articles reporting lower 12-month prevalence. CONCLUSIONS This study provides a benchmark of the global prevalence of CRPS, which anesthesiologists and pain specialists can use to prioritize early diagnosis and identify those at the highest risk for CRPS.
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Affiliation(s)
- Ryan S D'Souza
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Johana Klasova
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chandan Saini
- Department of Physical Medicine and Rehabilitation, Rush University Medical Center, Chicago, Illinois
| | - Albert Chang
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Stephen Music
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jay D Shah
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
| | - Praveen Reddy Elmati
- Department of Anesthesiology and Interventional Pain, Saint Clare's Health, Denville, New Jersey
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital-Columbia and Cornell, New York, New York
| | - Jimmy To
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, Ohio
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Fawaz R, Thomas A, Curtet M, Giner AM, Duraffourg M. Peripheral nerve field stimulation following dorsal root entry zone lesion: a technical note. Pain Manag 2025; 15:59-63. [PMID: 39945050 PMCID: PMC11853551 DOI: 10.1080/17581869.2025.2463875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2025] [Accepted: 02/04/2025] [Indexed: 02/25/2025] Open
Abstract
Peripheral nerve field stimulation (PNFS) can effectively manage pain localized to one or two dermatomes that are refractory to conventional approaches, such as chronic low back pain. However, its utility in pain management in the upper limbs is limited due to the risk of lead displacement related to articular and mobile segment constraints.In this technical note, we describe a 58-year-old man with neuropathic pain refractory to extensive medical treatment, and dorsal root entry zone lesion. Considering the patient's favorable response to transcutaneous electrical nerve stimulation, we used a two-step lead placement approach to improve the permanent placement of the electrode leads in the upper limb. After 1 year follow-up, the patient achieved at least 50% pain relief, with no signs of lead displacement or resistance during flexion and extension movements of the involved upper limb, illustrating the success of PNFS.
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Affiliation(s)
- Rayan Fawaz
- Department of Neurosurgery, Percy Military Teaching Hospital, Clamart Cedex, France
- Service de Neurochirurgie Fonctionnelle, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Audrey Thomas
- Service de Neurochirurgie Fonctionnelle, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Muriel Curtet
- Service de Neurochirurgie Fonctionnelle, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Anne-Marie Giner
- Service de Neurochirurgie Fonctionnelle, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon, France
| | - Manon Duraffourg
- Service de Neurochirurgie Fonctionnelle, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Hospices Civils de Lyon, France
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Hoffmann C, Wang J, Ali RP, D’Souza RS. Neuromodulation guide for the non-neuromodulator clinician: What it is and how it can benefit patients? BIOMOLECULES & BIOMEDICINE 2025; 25:304-313. [PMID: 39132949 PMCID: PMC11734817 DOI: 10.17305/bb.2024.10967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 08/13/2024]
Abstract
Neuromodulation is being utilized across a variety of medical subspecialties to treat both painful and non-painful medical conditions. However, publications on neuromodulation topics infrequently occur in journals targeting generalists and medical specialties outside of pain medicine and neurosurgery. This study reviewed implantable neuromodulation devices, their respective Food and Drug Administration-approved indications for use, as well as off-label usage, and the associated potential risks and benefits for each device. PubMed and Medline databases were queried for systematic reviews with or without meta-analyses and randomized controlled trials of implantable neuromodulation devices. The literature review resulted in 106 studies eligible for inclusion, and 67 were included in the final review. In conclusion, as the clinical volume of neuromodulation continues to grow, supporting and educating medical professionals who care for patients that receive implanted neuromodulation devices is paramount. It is likely the use of neuromodulation will continue to expand across all medical subspecialties, and as such, every clinician should have a baseline understanding of this treatment.
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Affiliation(s)
- Chelsey Hoffmann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jinlan Wang
- Department of Spine, Mayo Clinic, Rochester, MN, USA
| | - Rushna P Ali
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Ryan S D’Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Peripheral Nerve Stimulation for Chronic Neuropathic Pain: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2024; 24:1-131. [PMID: 39886278 PMCID: PMC11778797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/01/2025]
Abstract
Background Chronic neuropathic pain is a major health problem that adversely affects people's physical and mental well-being, as well as their quality of life. Percutaneous peripheral nerve stimulation (PNS) may offer a minimally invasive option earlier in the treatment continuum for adults with chronic neuropathic pain that is refractory to conventional medical management. We conducted a health technology assessment of PNS for adults with chronic neuropathic pain, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding PNS, and patient preferences and values. Methods We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool for randomized controlled trials and the Risk of Bias in Non-randomized Studies - of Interventions for observational studies, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 3-year horizon from a public payer perspective. We also analyzed the budget impact of publicly funding PNS in adults with chronic neuropathic pain in Ontario. To contextualize the potential value of PNS, we spoke to people with chronic pain, and to care partners of patients with chronic pain. Results We included 17 publications (2 randomized controlled trials and 12 nonrandomized studies) in the clinical evidence review. These studies included chronic neuropathic pain in the trunk and the upper and lower extremities. Compared with placebo controls in adults with chronic neuropathic pain that is refractory to conventional medical management, permanent PNS likely decreases pain scores, likely improves functional outcomes, and likely improves health-related quality of life, but it has little to no effect on the use of pain medications (all GRADEs: Moderate). Compared with before implantation in adults with chronic neuropathic pain, permanent PNS may decrease pain scores, may decrease the use of pain medications, may improve functional outcomes, and may improve health-related quality of life (all GRADEs: Low). Compared with placebo controls in adults with chronic postamputation pain, temporary PNS may decrease pain scores, may decrease use of pain medications, may improve functional outcomes, and may improve health-related quality of life (all GRADEs: Low). Compared with before implantation in adults with chronic postamputation pain, temporary PNS may decrease pain scores, may decrease the use of pain medications, may improve functional outcomes, and may improve health-related quality of life (all GRADEs: Low). We did not find any studies that compared permanent PNS to temporary PNS. Implantation of a PNS system is a reasonably safe procedure; most adverse events were localized and mild in intensity (GRADEs: Moderate to Low).The incremental cost-effectiveness ratio of PNS in addition to standard care compared with standard care alone is $87,211 per quality-adjusted life-year (QALY) gained. The probability of PNS in addition to standard care being cost-effective versus standard care alone is 1.02% at a willingness-to-pay of $50,000 per QALY gained and 64.88% at a willingness-to-pay of $100,000 per QALY gained. The annual budget impact of publicly funding PNS in Ontario over the next 5 years ranges from an additional $0.97 million in year 1, increasing to $3.15 million in year 5, for a total of $10.09 million over 5 years. People with chronic pain and their family members and care partners viewed PNS favourably. Those who had direct experience with permanent PNS perceived it to be effective in reducing their pain levels, leading to a positive impact on their quality of life and mental health. Current barriers to accessing PNS include lack of awareness, cost, and geography. Conclusions In adults with chronic neuropathic pain that is refractory to conventional medical management, permanent PNS likely improves pain outcomes, functional outcomes, and health-related quality of life but has little to no effect on the use of pain medications compared with placebo controls. Temporary PNS may improve pain outcomes, functional outcomes, and health-related quality of life, and it may reduce the use of pain medications. Implantation of a permanent or temporary PNS system is reasonably safe. The incremental cost-effectiveness ratio of PNS in addition to standard care compared with standard care alone is $87,211 per QALY gained. We estimate that publicly funding PNS in Ontario would result in additional costs of $10.09 million over the next 5 years. People who had direct experience with permanent PNS spoke of its effectiveness in reducing their pain levels and its positive impact on their quality of life and mental health. Barriers to accessing PNS include lack of awareness, cost, and geography.
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Zhong T, William HM, Jin MY, Abd-Elsayed A. A Review of Remote Monitoring in Neuromodulation for Chronic Pain Management. Curr Pain Headache Rep 2024; 28:1225-1233. [PMID: 39066995 DOI: 10.1007/s11916-024-01302-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE OF REVIEW Neuromodulation techniques have emerged as promising strategies for managing chronic pain. These techniques encompass various modalities of nerve stimulation, including Spinal Cord Stimulation (SCS), Dorsal Root Ganglion Stimulation (DRG-S), and Peripheral Nerve Stimulation (PNS). Studies consistently demonstrate significant improvements in pain intensity, quality of life, and reduced opioid usage among patients treated with these modalities. However, neuromodulation presents challenges, such as the need for frequent in-person follow-up visits to ensure proper functionality of the implanted device. Our review explored factors impacting compliance in current neuromodulation users and examined how remote monitoring can mitigate some of these challenges. We also discuss outcomes of recent studies related to remote monitoring of neuromodulation. RECENT FINDINGS While remote monitoring capabilities for neuromodulation devices is an emerging development, there are promising results supporting its role in improving outcomes for chronic pain patients. Higher patient satisfaction, improved pain control, and reduced caretaker burdens have been observed with the use of remote monitoring. This review discusses the current challenges with neuromodulation therapy and highlights the role of remote monitoring. As the field continues to evolve, understanding the importance of remote monitoring for neuromodulation is crucial for optimizing pain management outcomes.
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Affiliation(s)
- Tammy Zhong
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Hannah M William
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Max Y Jin
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Abd-Elsayed A, Attanti S, Anderson M, Dunn T, Maloney J, Strand N. Mechanism of Action of Temporary Peripheral Nerve Stimulation. Curr Pain Headache Rep 2024; 28:1219-1224. [PMID: 37889467 DOI: 10.1007/s11916-023-01184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW Peripheral nerve stimulation (PNS) refers to the technique of utilizing electrical stimulation of peripheral nerves to inhibit the transmission of pain signals. PNS is used to treat chronic intractable pain and post-surgical or post-traumatic pain alongside a variety of other pain conditions, including headaches, facial pain, pelvic and urogenital pain, chest wall pain, residual limb or phantom limb pain, and back pain. RECENT FINDINGS More recently, PNS has been used temporarily for periods of time less than 60 days to treat acute post-surgical pain. Peripheral nerve stimulation is believed to be effective due to its effects on both central and peripheral pathways. Centrally, it is proposed that the electrical pulses of PNS inhibit alpha-delta and C fibers, which decreases pain signaling in the higher centers of the central nervous system. Peripherally, gate theory is applied as it is theorized that PNS downregulates inflammatory mediators, endorphins, and neurotransmitters associated with pain signaling to decrease the transmission of efferent nociception and reduce pain sensations.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Management, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sumedha Attanti
- Mayo Clinic Alix School of Medicine, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Meredith Anderson
- Mayo Clinic Alix School of Medicine, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Tyler Dunn
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Jillian Maloney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Natalie Strand
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Karcz M, Abd-Elsayed A, Chakravarthy K, Aman MM, Strand N, Malinowski MN, Latif U, Dickerson D, Suvar T, Lubenow T, Peskin E, D’Souza R, Cornidez E, Dudas A, Lam C, Farrell II M, Sim GY, Sebai M, Garcia R, Bracero L, Ibrahim Y, Mahmood SJ, Lawandy M, Jimenez D, Shahgholi L, Sochacki K, Ramadan ME, Tieppo Francio V, Sayed D, Deer T. Pathophysiology of Pain and Mechanisms of Neuromodulation: A Narrative Review (A Neuron Project). J Pain Res 2024; 17:3757-3790. [PMID: 39583192 PMCID: PMC11581984 DOI: 10.2147/jpr.s475351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 10/29/2024] [Indexed: 11/26/2024] Open
Abstract
Pain serves as a vital innate defense mechanism that can significantly impact an individual's quality of life. Understanding the physiological effects of pain well plays an important role in developing novel pain treatments. Nociceptor neurons play a key role in pain and inflammation. Interactions between nociceptors and the immune system occur both at the site of injury and within the central nervous system. Modulating chemical mediators and nociceptor activity offers promising new approaches to pain management. Essentially, the sensory nervous system is essential for modulating the body's protective response, making it critical to understand these interactions to discover new pain treatment strategies. New innovations in neuromodulation have led to alternatives to opioids individuals with chronic pain with consequent improvement in disease-based treatment and nerve targeting. New neural targets from cellular and structural perspectives have revolutionized the field of neuromodulation. This narrative review aims to elucidate the mechanisms of pain transmission and processing, examine the characteristics and properties of nociceptors, and explore how the immune system influences pain perception. It further provides an updated overview of the physiology of pain and neuromodulatory mechanisms essential for managing acute and chronic pain. We assess the current understanding of different pain types, focusing on key molecules involved in each type and their physiological effects. Additionally, we compare painful and painless neuropathies and discuss the neuroimmune interactions involved in pain manifestation.
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Affiliation(s)
- Marcin Karcz
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | | | - Mansoor M Aman
- Aurora Pain Management, Aurora Health Care, Oshkosh, WI, USA
| | - Natalie Strand
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Mark N Malinowski
- OhioHealth Neurological Physicians, OhioHealth Inc, Columbus, OH, USA
| | - Usman Latif
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - David Dickerson
- Department of Pain Medicine, Northshore University Health System, Skokie, IL, USA
| | - Tolga Suvar
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Oak Park, IL, USA
| | - Timothy Lubenow
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Oak Park, IL, USA
| | - Evan Peskin
- Department of Pain Management, Insight Institute of Neurosurgery & Neuroscience, Flint, MI, USA
| | - Ryan D’Souza
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Andrew Dudas
- Mays and Schnapp Neurospine and Pain, Memphis, TN, USA
| | - Christopher Lam
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael Farrell II
- Department of Pain Management, Erie County Medical Center, Buffalo, NY, USA
| | - Geum Yeon Sim
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Mohamad Sebai
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rosa Garcia
- Department of Physical Medicine & Rehabilitation, Larkin Hospital Health System, Miami, FL, USA
| | - Lucas Bracero
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
| | - Yussr Ibrahim
- Department of Pain Management at Northern Light Health – Eastern Maine Medical Center, Bangor, ME, USA
| | - Syed Jafar Mahmood
- Department of Pain Medicine, University of California Davis Health System, Sacramento, CA, USA
| | - Marco Lawandy
- Department of Physical Medicine & Rehabilitation, Montefiore Medical Center, Bronx, NY, USA
| | - Daniel Jimenez
- Department of Physical Medicine & Rehabilitation, Michigan State University, Lansing, MI, USA
| | - Leili Shahgholi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kamil Sochacki
- Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vinicius Tieppo Francio
- Division of Pain Medicine, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Dawood Sayed
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV, USA
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Gallacher DM, Gastelum P, Park SA. Intercostal Neuralgia Successfully Managed With Peripheral Nerve Stimulation. Cureus 2024; 16:e71964. [PMID: 39569214 PMCID: PMC11576495 DOI: 10.7759/cureus.71964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2024] [Indexed: 11/22/2024] Open
Abstract
Intercostal neuralgia is characterized by neuropathic pain along the distribution of the intercostal nerve, which can cause debilitating pain and interfere with daily activities. The literature is extremely limited in assessing the use of neuromodulation to treat trauma-induced intercostal neuralgia. This case reports a 40-year-old patient who presented with decades of refractory, long-standing thoracic pain. The pain ranged from a four out of 10 to a nine out of 10 on the numeric rating scale (NRS). The patient failed pharmacologic therapy, physical therapy, chiropractic care, injection therapy, transcutaneous electrical nerve stimulation (TENS), and spinal cord stimulation (SCS). The patient underwent a 60-day peripheral nerve stimulation (PNS) trial, which temporarily relieved the pain until it was explanted. The patient subsequently underwent placement of a permanent PNS implant, which provided between 80-100% daily pain relief at a six-month follow-up. At the two-year follow-up, the patient continued to experience sustained pain relief, had weaned from opioid medications, and returned to all desired daily activities. This case suggests that minimally invasive PNS can effectively manage pain for patients with intercostal neuralgia who fail conservative measures. Further, to our knowledge, this two-year follow-up is the longest-reported outcome in the literature for using PNS for intercostal neuralgia after traumatic injury.
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Affiliation(s)
- David M Gallacher
- Physical Medicine and Rehabilitation, University of Colorado, Aurora, USA
| | - Paul Gastelum
- Pain Management, Desert Orthopaedic Center, Las Vegas, USA
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D'Souza RS, Her YF, Hussain N, Karri J, Schatman ME, Calodney AK, Lam C, Buchheit T, Boettcher BJ, Chang Chien GC, Pritzlaff SG, Centeno C, Shapiro SA, Klasova J, Grider JS, Hubbard R, Ege E, Johnson S, Epstein MH, Kubrova E, Ramadan ME, Moreira AM, Vardhan S, Eshraghi Y, Javed S, Abdullah NM, Christo PJ, Diwan S, Hassett LC, Sayed D, Deer TR. Evidence-Based Clinical Practice Guidelines on Regenerative Medicine Treatment for Chronic Pain: A Consensus Report from a Multispecialty Working Group. J Pain Res 2024; 17:2951-3001. [PMID: 39282657 PMCID: PMC11402349 DOI: 10.2147/jpr.s480559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024] Open
Abstract
Purpose Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial. Methods The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of "disagree" or "abstain", they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved. Results Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies. Conclusion In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose-response associations, and comparative analysis between different injectable biologics.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yeng F Her
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH, USA
| | - Jay Karri
- Departments of Orthopedic Surgery and Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | | | - Christopher Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Thomas Buchheit
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Brennan J Boettcher
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | | | - Scott G Pritzlaff
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA
| | | | - Shane A Shapiro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Johana Klasova
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay S Grider
- Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Ryan Hubbard
- Department of Sports Medicine, Anderson Orthopedic Clinic, Arlington, VA, USA
| | - Eliana Ege
- Department of Physical Medicine & Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Shelby Johnson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Max H Epstein
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Eva Kubrova
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Mohamed Ehab Ramadan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alexandra Michelle Moreira
- Department of Physical Medicine & Rehabilitation, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Swarnima Vardhan
- Department of Internal Medicine, Yale New Haven Health - Bridgeport Hospital, Bridgeport, CT, USA
| | - Yashar Eshraghi
- Department of Anesthesiology & Critical Care Medicine, Ochsner Health System, New Orleans, LA, USA
| | - Saba Javed
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Newaj M Abdullah
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sudhir Diwan
- Department of Pain Medicine, Advanced Spine on Park Avenue, New York City, NY, USA
| | | | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy R Deer
- Department of Anesthesiology and Pain Medicine, West Virginia University School of Medicine, Charleston, WV, USA
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16
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West T, Hussain N, Bhatia A, ElSaban M, Kilgore AE, Palettas M, Abdel-Rasoul M, Javed S, D'Souza RS. Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis. Reg Anesth Pain Med 2024:rapm-2024-105704. [PMID: 39060006 DOI: 10.1136/rapm-2024-105704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE Peripheral nerve stimulation (PNS) is an emerging neuromodulation modality, yet there remains limited data highlighting its long-term effectiveness. The objective of this study was to report real-world data on pain intensity and opioid consumption after temporary and permanent PNS for chronic pain up to 24 months postimplantation. METHODS A retrospective study was conducted on all patients who received PNS implants at a multi-centered enterprise between January 1, 2014 and February 24, 2022. The two co-primary outcomes were: (1) change in pain intensity (11-point Numerical Rating Scale) from baseline to 12 months postimplant; and (2) comparison of the change in pain intensity between temporary and permanent PNS cohorts 12 months postimplant. RESULTS 126 patients were included in this analysis. Pain intensity significantly decreased 12 months postimplant in the overall cohort (mean difference (MD) -3.0 (95% CI -3.5 to -2.4), p<0.0001). No significant difference in this reduction was identified between temporary and permanent PNS cohorts (MD 0.0 (95% CI -1.1 to 1.0), p=1.00) 12 months postimplantation. Pain intensity significantly decreased in the overall, temporary, and permanent cohorts at all secondary time points (3, 6, and 24 months). No change in daily opioid consumption was observed at 6 and 12 months postimplant in the overall cohort. CONCLUSION This study found that both temporary and permanent PNS may be effective for reducing pain intensity in patients with chronic pain up to 24 months postimplantation, although no changes in opioid consumption were observed. The decrease in pain intensity was comparable between patients receiving temporary versus permanent implants, highlighting that temporary PNS may achieve long-lasting clinical benefits. However, given the substantial loss to follow-up, further large-scale studies are needed to solidify conclusions about the efficacy of PNS.
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Affiliation(s)
- Tyler West
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anuj Bhatia
- Anesthesia and Pain Medicine, University of Toronto Health Policy Management and Evaluation, Toronto, Ontario, Canada
| | - Mariam ElSaban
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony E Kilgore
- Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Marilly Palettas
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Saba Javed
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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17
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Valimahomed A, Dickerson D, Vucetic H, Rutledge J, Zurn CA, Crosby ND, Boggs JW. Real-world evidence of durable multi-dimensional improvement after 60-day peripheral nerve stimulation treatment used for shoulder pain. Pain Manag 2024; 14:355-364. [PMID: 39041738 PMCID: PMC11486131 DOI: 10.1080/17581869.2024.2371779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/20/2024] [Indexed: 07/24/2024] Open
Abstract
Aim: This real-world analysis aims to quantify improvements in multiple health domains in patients who received 60-day peripheral nerve stimulation (PNS) for shoulder pain.Materials & methods: Patients reported percent pain relief and Patient Global Impression of Change in quality of life, physical function and sleep at the end of treatment (EOT), 3 months, and 6 months.Results: Of 768 patients, 80.7% were responders in at least one domain at EOT. In a subset who were followed up, a cumulative 75% continued to respond in at least one domain through 6 months (85% [n = 140/165] at 3 months and 88% [n = 53/60] at 6 months).Conclusion: 60-day PNS used for shoulder pain produced multi-dimensional improvements across health domains at EOT and through 6 months.
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Affiliation(s)
- Ali Valimahomed
- Advanced Orthopedics and Sports Medicine Institute, Freehold, NJ07728, United States
| | | | - Henry Vucetic
- University Hospital Lake Health Pain Management, Willoughby, OH44094, United States
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18
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Sheen S, Riazuddin I, Javed S. Suprascapular nerve peripheral nerve stimulation for pediatric cancer pain: a case series. Pain Manag 2024; 14:247-250. [PMID: 39056193 PMCID: PMC11340734 DOI: 10.1080/17581869.2024.2376523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Aim: Despite the growing evidence supporting the use of peripheral nerve stimulation (PNS) for cancer pain in adults, it is underutilized in the pediatric oncology population.Method: We describe the use of temporary, percutaneous PNS for pain management in pediatric patients suffering from cancer related pain.Results: Two adolescent patients underwent an ultrasound-guided suprascapular nerve PNS placement utilizing the percutaneous 60-day therapy system. Both patients reported approximately 60% pain relief during the therapy, as well as up to 90 days post lead removal.Conclusion: PNS may play a crucial role in the pediatric oncology population. Further studies are warranted to investigate the efficacy and safety of PNS for various cancer-related pain conditions in pediatric populations.
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Affiliation(s)
- Soun Sheen
- Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston,TX 77006, USA
| | - Imad Riazuddin
- Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston,TX 77006, USA
| | - Saba Javed
- Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston,TX 77006, USA
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Guzzi G, Della Torre A, Bruni A, Lavano A, Bosco V, Garofalo E, La Torre D, Longhini F. Anatomo-physiological basis and applied techniques of electrical neuromodulation in chronic pain. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:29. [PMID: 38698460 PMCID: PMC11064427 DOI: 10.1186/s44158-024-00167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
Chronic pain, a complex and debilitating condition, poses a significant challenge to both patients and healthcare providers worldwide. Conventional pharmacological interventions often prove inadequate in delivering satisfactory relief while carrying the risks of addiction and adverse reactions. In recent years, electric neuromodulation emerged as a promising alternative in chronic pain management. This method entails the precise administration of electrical stimulation to specific nerves or regions within the central nervous system to regulate pain signals. Through mechanisms that include the alteration of neural activity and the release of endogenous pain-relieving substances, electric neuromodulation can effectively alleviate pain and improve patients' quality of life. Several modalities of electric neuromodulation, with a different grade of invasiveness, provide tailored strategies to tackle various forms and origins of chronic pain. Through an exploration of the anatomical and physiological pathways of chronic pain, encompassing neurotransmitter involvement, this narrative review offers insights into electrical therapies' mechanisms of action, clinical utility, and future perspectives in chronic pain management.
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Affiliation(s)
- Giusy Guzzi
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Attilio Della Torre
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Angelo Lavano
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Vincenzo Bosco
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy
| | - Domenico La Torre
- Neurosurgery Department, "R. Dulbecco" Hospital, Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, "R. Dulbecco" Univesity Hospital, Department of Medical and Surgical Sciences, Magna Graecia University, Viale Europa, Catanzaro, 88100, Italy.
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20
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Reddy J, Singhal R, Gaikwad AP, Patel D, Patel P, Gandhi SK. Unraveling the Potential of Electroanalgesia: A Literature Review of Current Therapeutics. Cureus 2024; 16:e61122. [PMID: 38919207 PMCID: PMC11198869 DOI: 10.7759/cureus.61122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/27/2024] Open
Abstract
Neuropathic pain (NP), arising from dysfunction in the neurological system, poses a significant challenge in pain management due to its intricate origin and unpredictable response to conventional treatments. Electroanalgesia, a collection of techniques such as transcutaneous electric nerve stimulation (TENS), peripheral electrical nerve stimulation (PENS), spinal cord stimulation (SCS), deep brain stimulation (DBS), and electroacupuncture (EA), presents a potential alternative or complementary approach. This review brings together evidence from 56 studies to evaluate the effectiveness and safety of electroanalgesia in chronic NP. It discusses the mechanisms underlying NP, the indications for electroanalgesia, and the techniques utilized, emphasizing the diverse applications and potential benefits. However, despite its potential uses, electroanalgesia has its limitations, including variable effectiveness and potential adverse effects. Furthermore, the review recognizes the limitations of the methodology and the need for further research to refine treatment protocols and enhance the understanding of electroanalgesia's role in comprehensive pain management strategies.
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Affiliation(s)
- Jyothsna Reddy
- Department of Internal Medicine, The Tamil Nadu Dr. M.G.R. (M.G.Ramachandran) Medical University, Chennai, IND
| | - Rohan Singhal
- Department of Internal Medicine, Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, IND
| | - Anand P Gaikwad
- Department of Internal Medicine, King Edward Memorial Hospital, Mumbai, IND
| | - Diya Patel
- Department of Internal Medicine, Gujarat Medical Education and Research Society, Sola, Ahmedabad, IND
| | - Priyansh Patel
- Department of Internal Medicine, Medical College Baroda, Vadodara, IND
| | - Siddharth Kamal Gandhi
- Department of Internal Medicine, Shri M.P. (Meghaji Pethraj) Shah Government Medical College, Jamnagar, IND
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Chappell AG, Kalainov DM, Samworth A, Yuksel SS, Rangwani S, Nader A. Permanent Peripheral Nerve Stimulator for Complex Regional Pain Syndrome of the Forearm and Hand. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5764. [PMID: 38798938 PMCID: PMC11124668 DOI: 10.1097/gox.0000000000005764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/06/2024] [Indexed: 05/29/2024]
Abstract
A 51-year-old woman with diabetes and depression was referred to the anesthesia pain clinic with a 15-year history of complex regional pain syndrome type I of the right forearm and hand in the radial sensory nerve distribution. There was no recognized antecedent trauma and she had failed both medical treatment and radial sensory nerve decompression surgery. An ultrasound-guided local anesthetic block of the radial nerve in the upper arm resulted in partial and temporary improvement in pain. She subsequently underwent trial of a peripheral nerve stimulator (PNS) followed by permanent PNS implant placement over the radial nerve proper proximal to the elbow. Within the first month of use, she endorsed substantially improved pain and strength in her right hand. These improvements were sustained for more than 1 year. Applications of PNS technology for treatment of extremity complex regional pain syndrome and neuropathic extremity pain in general are reviewed.
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Affiliation(s)
- Ava G. Chappell
- From the Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - David M. Kalainov
- Department of Orthopaedic Surgery, Northwestern University Feinberg School Medicine, Chicago, Ill
| | - Alexander Samworth
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Selcen S. Yuksel
- Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Sean Rangwani
- Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Antoun Nader
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Pomeranz L, Li R, Yu X, Kelly L, Hassanzadeh G, Molina H, Gross D, Brier M, Vaisey G, Wang P, Jimenez-Gonzalez M, Garcia-Ocana A, Dordick J, Friedman J, Stanley S. Magnetogenetic cell activation using endogenous ferritin. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.06.20.545120. [PMID: 37786709 PMCID: PMC10541561 DOI: 10.1101/2023.06.20.545120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
The ability to precisely control the activity of defined cell populations enables studies of their physiological roles and may provide therapeutic applications. While prior studies have shown that magnetic activation of ferritin-tagged ion channels allows cell-specific modulation of cellular activity, the large size of the constructs made the use of adeno-associated virus, AAV, the vector of choice for gene therapy, impractical. In addition, simple means for generating magnetic fields of sufficient strength have been lacking. Toward these ends, we first generated a novel anti-ferritin nanobody that when fused to transient receptor potential cation channel subfamily V member 1, TRPV1, enables direct binding of the channel to endogenous ferritin in mouse and human cells. This smaller construct can be delivered in a single AAV and we validated that it robustly enables magnetically induced cell activation in vitro. In parallel, we developed a simple benchtop electromagnet capable of gating the nanobody-tagged channel in vivo. Finally, we showed that delivering these new constructs by AAV to pancreatic beta cells in combination with the benchtop magnetic field delivery stimulates glucose-stimulated insulin release to improve glucose tolerance in mice in vivo. Together, the novel anti-ferritin nanobody, nanobody-TRPV1 construct and new hardware advance the utility of magnetogenetics in animals and potentially humans.
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Affiliation(s)
- Lisa Pomeranz
- Laboratory of Molecular Genetics, Rockefeller University, New York, NY 10065, USA
| | - Rosemary Li
- Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Xiaofei Yu
- School of Life Sciences, Fudan University, Shanghai, 200433
| | - Leah Kelly
- Laboratory of Molecular Genetics, Rockefeller University, New York, NY 10065, USA
| | | | - Henrik Molina
- Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daniel Gross
- Current address, Dept. of Radiology, Weill Cornell Medicine, 1300 York Avenue New York, NY 10065
| | - Matthew Brier
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180
| | - George Vaisey
- Laboratory of Molecular Neurobiology and Biophysics, Rockefeller University, New York, NY 10065, USA
| | - Putianqi Wang
- Laboratory of Molecular Genetics, Rockefeller University, New York, NY 10065, USA
| | - Maria Jimenez-Gonzalez
- Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Adolfo Garcia-Ocana
- Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Molecular and Cellular Endocrinology, Arthur Riggs Diabetes and Metabolism Research Institute, Beckman Research Institute, City of Hope, Duarte, CA, 91010
| | - Jonathan Dordick
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY 12180
| | - Jeffrey Friedman
- Laboratory of Molecular Genetics, Rockefeller University, New York, NY 10065, USA
| | - Sarah Stanley
- Diabetes, Obesity and Metabolism Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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23
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Sayed D, Deer TR, Hagedorn JM, Sayed A, D’Souza RS, Lam CM, Khatri N, Hussaini Z, Pritzlaff SG, Abdullah NM, Tieppo Francio V, Falowski SM, Ibrahim YM, Malinowski MN, Budwany RR, Strand NH, Sochacki KM, Shah A, Dunn TM, Nasseri M, Lee DW, Kapural L, Bedder MD, Petersen EA, Amirdelfan K, Schatman ME, Grider JS. A Systematic Guideline by the ASPN Workgroup on the Evidence, Education, and Treatment Algorithm for Painful Diabetic Neuropathy: SWEET. J Pain Res 2024; 17:1461-1501. [PMID: 38633823 PMCID: PMC11022879 DOI: 10.2147/jpr.s451006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/19/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Painful diabetic neuropathy (PDN) is a leading cause of pain and disability globally with a lack of consensus on the appropriate treatment of those suffering from this condition. Recent advancements in both pharmacotherapy and interventional approaches have broadened the treatment options for PDN. There exists a need for a comprehensive guideline for the safe and effective treatment of patients suffering from PDN. Objective The SWEET Guideline was developed to provide clinicians with the most comprehensive guideline for the safe and appropriate treatment of patients suffering from PDN. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations for PDN. A multidisciplinary group of international experts developed the SWEET guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus to identify and compile the evidence for diabetic neuropathy pain treatments (per section as listed in the manuscript) for the treatment of pain. Manuscripts from 2000-present were included in the search process. Results After a comprehensive review and analysis of the available evidence, the ASPN SWEET guideline was able to rate the literature and provide therapy grades for most available treatments for PDN utilizing the United States Preventive Services Task Force criteria. Conclusion The ASPN SWEET Guideline represents the most comprehensive review of the available treatments for PDN and their appropriate and safe utilization.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Timothy Ray Deer
- Pain Services, Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Asim Sayed
- Podiatry/Surgery, Susan B. Allen Memorial Hospital, El Dorado, KS, USA
| | - Ryan S D’Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Nasir Khatri
- Interventional Pain Medicine, Novant Spine Specialists, Charlotte, NC, USA
| | - Zohra Hussaini
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Scott G Pritzlaff
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA
| | | | - Vinicius Tieppo Francio
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Yussr M Ibrahim
- Pain Medicine, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | | | - Ryan R Budwany
- Pain Services, Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | - Kamil M Sochacki
- Department of Anesthesiology and Perioperative Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Anuj Shah
- Department of Physical Medicine and Rehabilitation, Detroit Medical Center, Detroit, MI, USA
| | - Tyler M Dunn
- Anesthesiology and Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Morad Nasseri
- Interventional Pain Medicine / Neurology, Boomerang Healthcare, Walnut Creek, CA, USA
| | - David W Lee
- Pain Management Specialist, Fullerton Orthopedic, Fullerton, CA, USA
| | | | - Marshall David Bedder
- Chief of Pain Medicine Service, Augusta VAMC, Augusta, GA, USA
- Associate Professor and Director, Addiction Medicine Fellowship Program, Department Psychiatry and Health Behavior, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kasra Amirdelfan
- Director of Clinical Research, Boomerang Healthcare, Walnut Creek, CA, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
| | - Jay Samuel Grider
- Anesthesiology, Division of Pain Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
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24
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Gargya A, Zats A, Lake T. Peripheral Nerve Stimulation for the Management of Pediatric Neuropathic Pain. Pediatrics 2023; 152:e2023061843. [PMID: 37946580 DOI: 10.1542/peds.2023-061843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 11/12/2023] Open
Abstract
The management of neuropathic pain in children poses an enormous challenge for pediatricians and pain management physicians. Current treatment options include physical therapy and medication management. Peripheral nerve stimulation/neuromodulation is a novel and minimally invasive treatment that can be initiated and monitored in an outpatient setting. This new technology can be a useful tool for treating pain secondary to pediatric neuropathy and chronic refractory pain after conservative management. Our case report describes the use of a peripheral nerve stimulator in the successful management of pediatric neuropathic leg pain.
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Affiliation(s)
- Akshat Gargya
- Department of Anesthesiology, Division of Interventional Pain, The University of Vermont Health Network, South Burlington, Vermont
| | - Alan Zats
- Department of Anesthesiology, Division of Interventional Pain, The University of Vermont Health Network, South Burlington, Vermont
| | - Tiffini Lake
- Department of Anesthesiology, Division of Interventional Pain, The University of Vermont Health Network, South Burlington, Vermont
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25
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Tieppo Francio V, Westerhaus BD, Carayannopoulos AG, Sayed D. Multifidus dysfunction and restorative neurostimulation: a scoping review. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1341-1354. [PMID: 37439698 PMCID: PMC10690869 DOI: 10.1093/pm/pnad098] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/14/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Chronic low back pain (CLBP) is multifactorial in nature, with recent research highlighting the role of multifidus dysfunction in a subset of nonspecific CLBP. This review aimed to provide a foundational reference that elucidates the pathophysiological cascade of multifidus dysfunction, how it contrasts with other CLBP etiologies and the role of restorative neurostimulation. METHODS A scoping review of the literature. RESULTS In total, 194 articles were included, and findings were presented to highlight emerging principles related to multifidus dysfunction and restorative neurostimulation. Multifidus dysfunction is diagnosed by a history of mechanical, axial, nociceptive CLBP and exam demonstrating functional lumbar instability, which differs from other structural etiologies. Diagnostic images may be used to grade multifidus atrophy and assess other structural pathologies. While various treatments exist for CLBP, restorative neurostimulation distinguishes itself from traditional neurostimulation in a way that treats a different etiology, targets a different anatomical site, and has a distinctive mechanism of action. CONCLUSIONS Multifidus dysfunction has been proposed to result from loss of neuromuscular control, which may manifest clinically as muscle inhibition resulting in altered movement patterns. Over time, this cycle may result in potential atrophy, degeneration and CLBP. Restorative neurostimulation, a novel implantable neurostimulator system, stimulates the efferent lumbar medial branch nerve to elicit repetitive multifidus contractions. This intervention aims to interrupt the cycle of dysfunction and normalize multifidus activity incrementally, potentially restoring neuromuscular control. Restorative neurostimulation has been shown to reduce pain and disability in CLBP, improve quality of life and reduce health care expenditures.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Physical Medicine & Rehabilitation, The University of Kansas Medical Center, Kansas City, KS 66160, United States
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, United States
| | - Benjamin D Westerhaus
- Cantor Spine Institute at the Paley Orthopedic & Spine Institute, West Palm Beach, FL 33407, United States
| | - Alexios G Carayannopoulos
- Department of Neurosurgery and Neurology, Warren Alpert Medical School of Brown University, Providence, RI 02903, United States
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, United States
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Shlobin NA, Wu C. Current Neurostimulation Therapies for Chronic Pain Conditions. Curr Pain Headache Rep 2023; 27:719-728. [PMID: 37728863 DOI: 10.1007/s11916-023-01168-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW Neurostimulation treatment options have become more commonly used for chronic pain conditions refractory to these options. In this review, we characterize current neurostimulation therapies for chronic pain conditions and provide an analysis of their effectiveness and clinical adoption. This manuscript will inform clinicians of treatment options for chronic pain. RECENT FINDINGS Non-invasive neurostimulation includes transcranial direct current stimulation and repetitive transcranial magnetic stimulation, while more invasive options include spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), dorsal root ganglion stimulation, motor cortex stimulation, and deep brain stimulation. Developments in transcranial direct current stimulation, repetitive transcranial magnetic stimulation, spinal cord stimulation, and peripheral nerve stimulation render these modalities most promising for the alleviating chronic pain. Neurostimulation for chronic pain involves non-invasive and invasive modalities with varying efficacy. Well-designed randomized controlled trials are required to delineate the outcomes of neurostimulatory modalities more precisely.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Floor 2, Philadelphia, PA, 19107, USA.
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27
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Haider N, Gargya A. Management of Osteoarthritic Axial Neck Pain With Cervical Neuromodulation. Cureus 2023; 15:e46890. [PMID: 37841979 PMCID: PMC10569083 DOI: 10.7759/cureus.46890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 10/17/2023] Open
Abstract
Chronic refractory facetogenic axial neck pain is a challenging diagnosis to manage long-term. With limited options available for patients who have failed cervical medial branch blocks, patients often have to endure a poor quality of life. Although neuromodulation devices such as peripheral nerve stimulators are currently available for the management of various chronic conditions, their role in the treatment of axial neck pain has not been studied. We present a case of successful management of facetogenic axial neck pain with cervical medial branch peripheral nerve stimulation.
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Affiliation(s)
- Naeem Haider
- Anesthesiology, University of Vermont Health Network, Burlington, USA
| | - Akshat Gargya
- Anesthesiology, University of Vermont Health Network, Burlington, USA
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28
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Pritzlaff SG, Goree JH, Hagedorn JM, Lee DW, Chapman KB, Christiansen S, Dudas A, Escobar A, Gilligan CJ, Guirguis M, Gulati A, Jameson J, Mallard CJ, Murphy MZ, Patel KV, Patel RG, Sheth SJ, Vanterpool S, Singh V, Smith G, Strand NH, Vu CM, Suvar T, Chakravarthy K, Kapural L, Leong MS, Lubenow TR, Abd-Elsayed A, Pope JE, Sayed D, Deer TR. Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation: A Proposal for Standardization in Fellowship and Training Programs. J Pain Res 2023; 16:3101-3117. [PMID: 37727682 PMCID: PMC10505612 DOI: 10.2147/jpr.s424589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/23/2023] [Indexed: 09/21/2023] Open
Abstract
The need to be competent in neuromodulation is and should be a prerequisite prior to completing a fellowship in interventional pain medicine. Unfortunately, many programs lack acceptable candidates for these advanced therapies, and fellows may not receive adequate exposure to neuromodulation procedures. The American Society of Pain and Neuroscience (ASPN) desires to create a consensus of experts to set a minimum standard of competence for neurostimulation procedures, including spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), and peripheral nerve stimulation (PNS). The executive board of ASPN accepted nominations for colleagues with excellence in the subject matter of neuromodulation and physician education. This diverse group used peer-reviewed literature and, based on grading of evidence and expert opinion, developed critical consensus guides for training that all accredited fellowship programs should adopt. For each consensus point, transparency and recusal were used to eliminate bias, and an author was nominated for evidence grading oversight and bias control. Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation sets a standard for neuromodulation training in pain fellowship training programs. The consensus panel has determined several recommendations to improve care in the United States for patients undergoing neuromodulation. As neuromodulation training in the United States has evolved dramatically, these therapies have become ubiquitous in pain medicine. Unfortunately, fellowship programs and the Accreditation Council for Graduate Medical Education (ACGME) pain program requirements have not progressed training to match the demands of modern advancements. PEAK sets a new standard for fellowship training and presents thirteen practice areas vital for physician competence in neuromodulation.
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Affiliation(s)
- Scott G Pritzlaff
- Department of Anesthesiology and Pain Medicine, University of California, Davis, Sacramento, CA, USA
| | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Mayo Clinic, Rochester, MN, USA
| | - David W Lee
- Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | | | - Sandy Christiansen
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Andrew Dudas
- Mays & Schnapp Neurospine and Pain, Memphis, TN, USA
| | | | - Christopher J Gilligan
- Division of Pain Medicine, Brigham and Women’s Hospital Harvard Medical School, Boston, MA, USA
| | - Maged Guirguis
- Division of Pain Management, Ochsner Health, New Orleans, LA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | - Kiran V Patel
- Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | | | - Samir J Sheth
- Interventional Pain Management, Sutter Health, Roseville, CA, USA
| | | | - Vinita Singh
- Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | - Gregory Smith
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Natalie H Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | - Chau M Vu
- Evolve Restorative Center, Santa Rosa, CA, USA
| | - Tolga Suvar
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | | | - Michael S Leong
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Timothy R Lubenow
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas, Kansas City, KS, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Chow RM, Lee RY, Rajput K. Peripheral Nerve Stimulation for Pain Management: A Review. Curr Pain Headache Rep 2023; 27:321-327. [PMID: 37523121 DOI: 10.1007/s11916-023-01143-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW Peripheral nerve stimulation has seen a recent upsurge in utilization for various chronic pain conditions, specifically from a neuropathic etiology, where a single peripheral nerve can be pinpointed as a culprit for pain. RECENT FINDINGS There is conflicting evidence about the efficacy and long-term outcomes of peripheral nerve stimulation for chronic pain, with most studies being small sized. The focus of this article is to review available evidence for the utilization of peripheral nerve stimulation for chronic pain syndromes as well as upcoming evidence in the immediate postoperative realm. The indications for the use of PNS have expanded from neuropathic pain such as occipital neuralgia and post-amputation pain, to more widespread disease processes such as chronic low back pain. Percutaneous PNS delivered over a 60-day period may provide significant carry-over effects including pain relief, potentially avoiding the need for a permanently implanted system while enabling improved function in patients with chronic pain.
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Affiliation(s)
- Robert M Chow
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT, TMP306510, USA
| | - Ryan Yesung Lee
- Medical Student-3, Yale University School of Medicine, New Haven, USA
| | - Kanishka Rajput
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT, TMP306510, USA.
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Lu YH, Fu Y, Shu J, Yan LY, Shen HJ. Application of cross-migration theory in limb rehabilitation of stroke patients with hemiplegia. World J Clin Cases 2023; 11:4531-4543. [PMID: 37469730 PMCID: PMC10353507 DOI: 10.12998/wjcc.v11.i19.4531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Stroke is a common cause of neurological dysfunction, often resulting in hemiplegia. Thus, rehabilitation of limb function in stroke patients is an important step towards accelerating recovery and improving quality of life.
AIM To investigate whether unilateral strength training in hemiplegic stroke patients could lead to cross-migration, an increase in bilateral muscle strength, and an improvement in lower limb motor function.
METHODS We randomly divided 120 patients with hemiplegic stroke into two groups: Eexperimental and control groups, with 60 patients in each group. Both groups received routine rehabilitation treatment, while the experimental group additionally received ankle dorsiflexion resistance training on the healthy side for 6 wk. We measured the maximum voluntary contract (MVC), changes in surface electromyography (EMG), and the lower limb motor function using the simplified Fugl Meyer Motor Function Assessment Scale (FMA) before and within 1 wk after training.
RESULTS The FMA score in the experimental group improved significantly compared to both their pre-training score and the control group's post-training score (P < 0.05). The integrated EMG of the anterior tibialis muscle and pulmonary intestine muscle in the experimental group were significantly different after training than before (P < 0.05). Furthermore, the MVC of the anterior tibialis muscle on both the healthy and affected sides and the MVC of the pulmonary intestine muscle on both sides showed significant improvement compared with before training and the control group (P < 0.05).
CONCLUSION Our findings suggest that ankle dorsiflexion resistance training on the healthy side in hemiplegic stroke patients can increase strength in the opposite tibialis anterior muscle and antagonist's muscle, indicating a cross-migration phenomenon of strength training. Furthermore, this type of training can also improve lower limb motor function, providing a new exercise method for improving early ankle dorsiflexion dysfunction.
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Affiliation(s)
- Yan-Hong Lu
- Geriatric Rehabilitation Department, Shanghai Jing'an District Shibei Hospital, Shanghai 200040, China
| | - Yi Fu
- Geriatric Rehabilitation Department, Shanghai Jing'an District Shibei Hospital, Shanghai 200040, China
| | - Jin Shu
- Geriatric Rehabilitation Department, Shanghai Jing'an District Shibei Hospital, Shanghai 200040, China
| | - Li-Yan Yan
- Department of Nursing, Shanghai Jing'an District Shibei Hospital, Shanghai 200040, China
| | - Hai-Jian Shen
- Department of Nursing, Shanghai Jing'an District Shibei Hospital, Shanghai 200040, China
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31
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Haider N, Gargya A. Fluoroscopy-Guided Lumbar Spinal Nerve Stimulation to Treat Chronic Scrotal Pain. Cureus 2023; 15:e42298. [PMID: 37484790 PMCID: PMC10362928 DOI: 10.7759/cureus.42298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2023] [Indexed: 07/25/2023] Open
Abstract
Chronic scrotal pain (CSP) is a challenging problem for both pain physicians and urologists. Depending on the cause, treatment options may include pharmacological management, spermatic cord blocks, microsurgical denervation of the spermatic cord, botulinum toxin injections, and ultrasound-guided peripheral nerve stimulation (PNS) of ilioinguinal and iliohypogastric nerves. We describe a new target for the treatment of CSP by PNS of the L2 spinal nerve and a novel technical approach of using fluoroscopic guidance to stimulate lumbar spinal nerves, which can potentially be used for different indications.
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Affiliation(s)
- Naeem Haider
- Anesthesiology and Pain Medicine, University of Vermont Medical Center, Burlington, USA
| | - Akshat Gargya
- Anesthesiology and Pain Medicine, University of Vermont Medical Center, Burlington, USA
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32
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Li AHY, Bhatia A, Gulati A, Ottestad E. Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts. Reg Anesth Pain Med 2023; 48:312-318. [PMID: 37080584 DOI: 10.1136/rapm-2022-104073] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 04/22/2023]
Abstract
Interventional pain management (IPM) options for refractory neuropathic pain (NP) have recently increased with availability of peripheral nerve stimulation (PNS) equipment and expertise. Given a lack of high-quality evidence and guidelines on this topic, we sought to understand the perception of physicians with expertise in treating NP regarding IPM and the role of PNS. We emailed a survey in March 2022 to international NP experts including pain medicine physicians, researchers, and leaders of 11 professional pain societies. No representatives from vendors of PNS systems were included in the design of the survey nor as respondents. Among 24 respondents (67% of those contacted), the distal common peroneal, tibial, and sural nerves were most frequently targeted (60%) with PNS. Persistent postsurgical pain of more than 3 months was the most common indication for PNS (84%). The aggregate NP treatment algorithm in order of median rank was non-opioid medications as first line, IPM including epidural/perineural steroid injections tied with transcutaneous electrical nerve stimulation as second line, pulsed radiofrequency (RF) tied with RF ablation/denervation as third line, temporary then permanent PNS as fourth line, followed by spinal cord stimulation, opioids, cryoablation, botulinum, peripheral nerve field stimulation, intrathecal targeted drug delivery, and others. Before offering PNS, 12 respondents (50%) indicated their preference for trialing non-neuromodulation treatments for 1-3 months. Twenty-two respondents (92%) agreed PNS should be offered early in the treatment of neuropathic pain. The most common barriers to PNS use were cost, lack of high-quality evidence in support of its use, lack of exposure to PNS in training programs, and lack of familiarity with the use of ultrasound guidance. PNS appears to have an increasing role in the treatment of NP but more research is needed on the outcomes of PNS to elucidate its role.
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Affiliation(s)
- Alice Huai-Yu Li
- Department of Anesthesia, Stanford University, Stanford, California, USA
| | - Anuj Bhatia
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amit Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Einar Ottestad
- Anesthesiology and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Gargya A, Dhaliwal S, Haider N. Peripheral Nerve Stimulator for Chronic Pain From Quadriceps Tendon Rupture: A Case Report. Cureus 2023; 15:e39916. [PMID: 37287822 PMCID: PMC10241987 DOI: 10.7759/cureus.39916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/09/2023] Open
Abstract
Chronic pain from quadriceps tendon rupture (QTR) presents a significant challenge for both orthopedic surgeons and pain management physicians. Current treatment options include physical therapy and medication management. Patients with refractory pain often end up using opioids and suffer from a prolonged disability that affects the quality of their life. A peripheral nerve stimulator is a novel treatment option for QTR. It is a minimally invasive treatment option that can be used to manage refractory cases in the future. We report a case of successful management of chronic pain in a patient with bilateral QTR with a femoral peripheral nerve stimulator.
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Affiliation(s)
- Akshat Gargya
- Anesthesia and Pain Medicine, University of Vermont, South Burlington, USA
| | - Sampreet Dhaliwal
- Anesthesia, Trinity Health Oakland/Wayne State University, Oakland, USA
| | - Naeem Haider
- Anesthesia and Pain Medicine, University of Vermont, South Burlington, USA
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D'Souza RS, Jin MY, Abd-Elsayed A. Peripheral Nerve Stimulation for Low Back Pain: A Systematic Review. Curr Pain Headache Rep 2023; 27:117-128. [PMID: 37060395 DOI: 10.1007/s11916-023-01109-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE OF REVIEW Low back pain (LBP) is a prevalent condition that is associated with diminished physical function, poor mental health outcomes, and reduced quality of life. Peripheral nerve stimulation (PNS) is an emerging modality that has been utilized to treat LBP. The primary objective of this systematic review is to appraise the level of evidence on the efficacy of PNS for treatment of LBP. RECENT FINDINGS Twenty-nine articles were included in this systematic review, consisting of 828 total participants utilizing PNS as the primary modality for LBP and 173 participants using PNS as salvage or adjunctive therapy for LBP after SCS placement. Different modalities of PNS therapy were reported across studies, including conventional PNS systems stimulating the lumbar medial branch nerves, peripheral nerve field stimulation (PNFS), and restorative neuromuscular stimulation of the multifidus muscles. All studies consistently reported positive modest to moderate improvement in pain intensity with PNS therapy when comparing baseline pain intensity to each study's respective primary follow-up period. There was a very low GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) quality of evidence supporting this finding. Inconsistency was present in some comparative studies that demonstrated no difference between PNS therapy versus control cohorts (sham or SCS therapy alone), which therefore highlighted the potential for placebo effect. This systematic review highlights that PNS, PNFS, and neuromuscular stimulation may provide modest to moderate pain relief in patients with LBP, although evidence is currently limited due to risk of bias, clinical and methodological heterogeneity, and inconsistency in data.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Max Y Jin
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA.
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D'Souza RS, Alvarez GAM, Dombovy-Johnson M, Eller J, Abd-Elsayed A. Evidence-Based Treatment of Pain in Chemotherapy-Induced Peripheral Neuropathy. Curr Pain Headache Rep 2023; 27:99-116. [PMID: 37058254 DOI: 10.1007/s11916-023-01107-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE OF REVIEW Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and often painful condition that occurs after administration of chemotherapeutic agents. The primary objective of this systematic review was to appraise the literature on conservative, pharmacological, and interventional treatment options for CIPN pain. RECENT FINDINGS There is level I evidence supporting modest to moderate improvement in CIPN pain from duloxetine treatment, as well as short-term modest improvement from physical therapy and acupuncture. Although opioid and cannabis administration may provide short-term modest improvement, administration is commonly limited by side effects. Generally, most studies reported no clinical benefit from yoga, topical neuropathic agents, gabapentinoids, and tricyclic antidepressants. Evidence is currently equivocal for scrambler therapy and transcutaneous electrical nerve stimulation. Finally, evidence on neuromodulation options is limited to mostly case reports/series and one observational study highlighting moderate improvement with auricular nerve stimulation. This systematic review provides an overview of conservative, pharmacologic, and interventional treatment modalities for CIPN pain. Furthermore, it provides a level of evidence and degree of recommendation based on the United States Preventive Services Task Force (USPSTF) criteria for each specific treatment modality.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | | | - Marissa Dombovy-Johnson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Rochester, MN, USA
| | - Jennifer Eller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA.
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Jin MY, Weaver TE, Farris A, Gupta M, Abd-Elsayed A. Neuromodulation for Peripheral Nerve Regeneration: Systematic Review of Mechanisms and In Vivo Highlights. Biomedicines 2023; 11:biomedicines11041145. [PMID: 37189763 DOI: 10.3390/biomedicines11041145] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/24/2023] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
While denervation can occur with aging, peripheral nerve injuries are debilitating and often leads to a loss of function and neuropathic pain. Although injured peripheral nerves can regenerate and reinnervate their targets, this process is slow and directionless. There is some evidence supporting the use of neuromodulation to enhance the regeneration of peripheral nerves. This systematic review reported on the underlying mechanisms that allow neuromodulation to aid peripheral nerve regeneration and highlighted important in vivo studies that demonstrate its efficacy. Studies were identified from PubMed (inception through September 2022) and the results were synthesized qualitatively. Included studies were required to contain content related to peripheral nerve regeneration and some form of neuromodulation. Studies reporting in vivo highlights were subject to a risk of bias assessment using the Cochrane Risk of Bias tool. The results of 52 studies indicate that neuromodulation enhances natural peripheral nerve regeneration processes, but still requires other interventions (e.g., conduits) to control the direction of reinnervation. Additional human studies are warranted to verify the applicability of animal studies and to determine how neuromodulation can be optimized for the greatest functional restoration.
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Affiliation(s)
- Max Y Jin
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Tristan E Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH 43214, USA
| | - Adam Farris
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH 43214, USA
| | - Mayank Gupta
- Kansas Pain Management & Neuroscience Research Center, Overland Park, KS 66210, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI 53706, USA
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Mysior C, Walch N, Gargya A. Peripheral Nerve Stimulator for Pain After Surgery for Ulnar Neuropathy at the Elbow. Cureus 2023; 15:e37297. [PMID: 37168195 PMCID: PMC10166575 DOI: 10.7759/cureus.37297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/13/2023] Open
Abstract
Neuropathy secondary to ulnar nerve entrapment is a painful condition that often persists following surgical decompression. We present the case of a 43-year-old female with Ehlers-Danlos syndrome and left ulnar neuritis refractory to surgical management. Peripheral nerve stimulation of the ulnar nerve proximal to the elbow resulted in a significant reduction in pain and improvement in disability post-implantation. This case suggests that peripheral nerve stimulation is a promising minimally invasive technique that should be considered for treating non-operative upper extremity neuropathic pain.
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Affiliation(s)
- Casandra Mysior
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, USA
| | - Nicole Walch
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, USA
| | - Akshat Gargya
- Department of Anesthesiology and Pain Management, The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, USA
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Stark CW, Isaamullah M, Hassan SS, Dyara O, Abd-Elsayed A. A Review of Chronic Pain and Device Interventions: Benefits and Future Directions. Pain Ther 2023; 12:341-354. [PMID: 36581788 PMCID: PMC10036715 DOI: 10.1007/s40122-022-00470-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/01/2022] [Indexed: 12/31/2022] Open
Abstract
Chronic pain is a debilitating condition with a growing prevalence both in the USA and globally. The complex nature of this condition necessitates a multimodal approach to pain management that extends beyond the established pharmaceutical interventions currently employed. A variety of devices comprising both invasive and noninvasive approaches are available to patients, serving as adjuvants to existing regimens. The benefits of these interventions are notable for their lack of addiction potential, potential for patient autonomy regarding self-administration, minimal to no drug interaction, and overall relative safety. However, there remains a need for further research and more robust clinical trials to assess the true efficacy of these interventions and elucidate if there is an underlying physiological mechanism to their benefit in treating chronic pain or if their effect is predominantly placebo in nature. Regardless, the field of device-based intervention and treatment remains an evolving field with much promise for the future chronic pain management.
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Affiliation(s)
- Cain W Stark
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Mir Isaamullah
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | | | - Omar Dyara
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI, 53726, USA.
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Ong Sio LC, Hom B, Garg S, Abd-Elsayed A. Mechanism of Action of Peripheral Nerve Stimulation for Chronic Pain: A Narrative Review. Int J Mol Sci 2023; 24:ijms24054540. [PMID: 36901970 PMCID: PMC10003676 DOI: 10.3390/ijms24054540] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
The use of stimulation of peripheral nerves to test or treat various medical disorders has been prevalent for a long time. Over the last few years, there has been growing evidence for the use of peripheral nerve stimulation (PNS) for treating a myriad of chronic pain conditions such as limb mononeuropathies, nerve entrapments, peripheral nerve injuries, phantom limb pain, complex regional pain syndrome, back pain, and even fibromyalgia. The ease of placement of a minimally invasive electrode via percutaneous approach in the close vicinity of the nerve and the ability to target various nerves have led to its widespread use and compliance. While most of the mechanism behind its role in neuromodulation is largely unknown, the gate control theory proposed by Melzack and Wall in the 1960s has been the mainstay for understanding its mechanism of action. In this review article, the authors performed a literature review to discuss the mechanism of action of PNS and discuss its safety and usefulness in treating chronic pain. The authors also discuss current PNS devices available in the market today.
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Affiliation(s)
- Lady Christine Ong Sio
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Brian Hom
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Shuchita Garg
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA
- Correspondence: ; Tel.: +1-608-263-8100; Fax: +1-608-263-0575
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40
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Montenegro MM, Kissoon NR. Long term outcomes of occipital nerve stimulation. FRONTIERS IN PAIN RESEARCH 2023; 4:1054764. [PMID: 37021077 PMCID: PMC10067723 DOI: 10.3389/fpain.2023.1054764] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/22/2023] [Indexed: 04/07/2023] Open
Abstract
Background Occipital nerve stimulation (ONS) has been investigated as a potential treatment for disabling headaches and has shown promise for disorders such as chronic migraine and cluster headache. Long term outcomes stratified by headache subtype have had limited exploration, and literature on outcomes of this neuromodulatory intervention spanning 2 or more years is scarce. Measures We performed a narrative review on long term outcomes with ONS for treatment of headache disorders. We surveyed the available literature for studies that have outcomes for 24 months or greater to see if there is a habituation in response over time. Review of the literature revealed evidence in treatment of occipital neuralgia, chronic migraine, cluster headache, cervicogenic headache, short lasting unilateral neuralgiform headache attacks (SUNHA) and paroxysmal hemicrania. While the term "response" varied per individual study, a total of 17 studies showed outcomes in ONS with long term sustained responses (as defined per this review) in the majority of patients with specific headache types 177/311 (56%). Only 7 studies in total (3 cluster, 1 occipital neuralgia, 1 cervicogenic headache, 1 SUNHA, 1 paroxysmal hemicrania) provided both short-term and long-term responses up to 24 months to ONS. In cluster headache, the majority of patients (64%) were long term responders (as defined per this review) and only a minority of patients 12/62 (19%) had loss of efficacy (e.g., habituation). There was a high number 313/439 (71%) of adverse events per total number of patients in the studies including lead migration, requirements of revision surgery, allergy to surgical materials, infection and intolerable paresthesias. Conclusions With the evidence available, the response to ONS was sustained in the majority of patients with cluster headache with low rates of loss of efficacy in this patient population. There was a high percent of adverse events per number of patients in long term follow-up and likely related to the off-label use of leads typically used for spinal cord stimulation. Further longitudinal assessments of outcomes in occipital nerve stimulation with devices labelled for use in peripheral nerve stimulation are needed to evaluate the extent of habituation to treatment in headache.
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Affiliation(s)
| | - Narayan R. Kissoon
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
- Correspondence: Narayan R. Kissoon
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41
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Heros R, Gilligan CJ, Chakravarthy KV. Re: Strand N et al. Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain. J Pain Res. 2022 Aug 23;15:2483-2504 [Letter]. J Pain Res 2022; 15:4029-4030. [PMID: 36575720 PMCID: PMC9790153 DOI: 10.2147/jpr.s389970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/20/2022] [Indexed: 12/29/2022] Open
Affiliation(s)
- Robert Heros
- Spinal Diagnostics, Tualatin, OR, USA,Correspondence: Robert Heros, Spinal Diagnostics PC, Tualatin, OR, 97062, USA, Email
| | - Christopher J Gilligan
- Division of Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Yaccarino V, Jin MY, Abd-Elsayed A, Kraemer JM, Sehgal N. Peripheral Nerve Stimulation in Painful Conditions of the Upper Extremity-An Overview. Biomedicines 2022; 10:2776. [PMID: 36359295 PMCID: PMC9687108 DOI: 10.3390/biomedicines10112776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 08/01/2023] Open
Abstract
Our objective is to present a brief history of the evolution of peripheral nerve stimulation, the current understanding of peripheral nerve stimulation mechanisms in chronic pain, peripheral nerve stimulation applications in upper extremity chronic pain conditions, and complications of peripheral nerve stimulation. The evolution of peripheral nerve stimulation from the early ages to the current status has been facilitated by discoveries in neurobehavioral mechanisms of pain, advances in technology and percutaneous lead development, and the availability of high-quality portable ultrasound units. Peripheral nerve stimulation application in managing upper extremity pain of amputated limbs, post-stroke shoulder pain, complex regional pain syndrome (CRPS), and median, ulnar, and radial neuropathies are discussed. Finally, we describe complications of peripheral nerve stimulation. The availability of ultrasound-guided peripheral nerve stimulation techniques and superior peripheral nerve stimulation technology have opened up new and minimally invasive treatment options for chronic intractable neuropathic pain of the upper extremity. Additionally, the ability to place peripheral nerve stimulation leads percutaneously without open peripheral nerve surgery expands the pool of implanting physicians, while simultaneously decreasing the risks and complications that are associated with open surgery.
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Affiliation(s)
- Vincent Yaccarino
- Department of Orthopedics & Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, USA
| | - Max Y. Jin
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792, USA
| | | | - Nalini Sehgal
- Department of Orthopedics & Rehabilitation, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, USA
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Char S, Jin MY, Francio VT, Hussain N, Wang EJ, Morsi M, Orhurhu V, Prokop LJ, Fink A, D’Souza RS. Implantable Peripheral Nerve Stimulation for Peripheral Neuropathic Pain: A Systematic Review of Prospective Studies. Biomedicines 2022; 10:biomedicines10102606. [PMID: 36289867 PMCID: PMC9599770 DOI: 10.3390/biomedicines10102606] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
Peripheral nerve stimulation (PNS) has been utilized for over 50 years with accumulating evidence of efficacy in a variety of chronic pain conditions. The level and strength of evidence supporting the use of PNS for peripheral neuropathic pain remains unclear. The purpose of this review is to synthesize data from prospective studies on the efficacy of PNS for neuropathic pain as it pertains to pain intensity, neurological deficits/neuropathy (e.g., weakness, sensory deficits, gait/balance), and other secondary outcomes (quality of life, satisfaction, emotional functioning, and adverse events). In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, this review identified articles from MEDLINE(R), EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Overall, per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, pooled results demonstrate very low quality or low quality of evidence supporting modest to substantial improvement in pain and neurological function after PNS implantation for treatment of peripheral neuropathic pain. PNS for phantom limb pain was the only indication that had moderate level evidence. Future prospective and well-powered studies are warranted to assess the efficacy of PNS for peripheral neuropathic pain.
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Affiliation(s)
- Steven Char
- Department of Anesthesiology & Perioperative Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Max Y. Jin
- Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Nasir Hussain
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Eric J. Wang
- Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA
| | - Mahmoud Morsi
- Department of Anesthesiology & Pain Management, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Vwaire Orhurhu
- Department of Anesthesiology, University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA 17701, USA
- MVN Health, East Stroudsburg, PA 18301, USA
| | - Larry J. Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN 55902, USA
| | - Adam Fink
- 1st Faculty of Medicine, Charles University, 110 00 Prague, Czech Republic
| | - Ryan S. D’Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN 55902, USA
- Correspondence:
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