ID: 214064 Ketamine-Augmentation of Brain Stimulation (rTMS) for Chronic Low Back Pain: A Proof-of-Concept Model

Abstract

Chronic low back pain (CLBP), the most common chronic pain condition and the most common cause of years lived with disability, affects 15-45% of adults yearly1. CLBP is frequently comorbid with depression, suicidality, and substance abuse and less than half of patients with CLBP receive meaningful pain relief with oral opioid pharmacotherapy. In the United States, opioids have accounted for the highest number of overdose deaths, peaking at 96,000 in March 2021. Given these unnerving trends, novel and efficacious treatments are direly needed2. Ketamine infusion has proven analgesic, anti-inflammatory, and opioid-sparing effects in prior well-designed studies3. The descending pain modulatory systems (DPMS) dysregulation maintains CLBP chronically which is partly mediated by NMDA receptor overactivity and can be offset by ketamine, an NMDA antagonist. Similarly, noninvasive brain stimulation using high frequency rTMS (hf-rTMS) of the left primary motor cortex (M1) produced greater analgesic effects than other brain areas4 and the analgesia produced from 5-sessions could last up to one month5. Goal of this study is to produce robust and durable analgesia in CLBP patients in the outpatient setting, by synergistically combining these two proven treatments with very low side effects.