Tonic, Burst, Dorsal Root Ganglion, and High Frequency

Abstract

The current environment of spinal cord stimulation is rapidly advancing, with new technologies and applications emerging constantly, allowing for more effective and individualized treatment of our patients. However, these new advances can be overwhelming for the practicing clinician, because there are no high-quality, head-to-head studies comparing these new technologies, making the clinician's choice a difficult one. High-level evidence already exists on the efficacy and safety of traditional tonic stimulation for the treatment of chronic refractory lower back with predominant limb pain. More recently, paresthesia-free high-frequency and burst stimulation was introduced, and has shown superiority over traditional stimulation for both chronic lower back and leg pain (Figure 1).1 Dorsal root ganglion stimulation is another novel form of neuromodulation that offers a highly targeted form of stimulation (Figure 2).2 Level I evidence now exists showing the superiority of both dorsal root ganglion and high-frequency stimulation over traditional stimulation.1,2 When attempting to choose between these different technologies, the main goal should be to achieve the best pain relief with minimal further interventions. Burst stimulation provides the option of alternating between tonic and paresthesia-free stimulation depending on patient preference and efficacy.3 High-frequency therapy is useful for patients who cannot tolerate paresthesia or have predominantly axial back pain. Dorsal root ganglion is particularly useful in covering areas that are hard to cover with conventional stimulation, such as the foot and groin. Overall, these different technologies provide drug-free, safe, and effective options for chronic pain.Figure 1: Burst spinal cord stimulation for limb and back pain. Reprinted with permission from Elsevier.3Figure 2: ACCURATE Study. Reprinted with permission.2 DRG indicates dorsal root ganglion; SCS, spinal cord stimulation.