Cervical Spinal Cord Stimulation Research Articles

Safety and efficacy of cervical 10kHz spinal cord stimulation in chronic refractory primary headaches: a retrospective case series.

BackgroundParesthesia-free cervical 10 kHz spinal cord stimulation (HF10 SCS) may constitute a novel treatment modality for headache disorders, when pharmacological approaches fail. We report the results of a retrospective analysis assessing the long-term safety, tolerability and efficacy of HF10 SCS in a group of patients with chronic refractory primary headache disorders.FindingsFour patients with chronic migraine (CM), two with chronic SUNA (Short-lasting Unilateral Neuralgiform headache attacks with Autonomic symptoms) and one with chronic cluster headache (CCH) refractory to medical treatments, were implanted with cervical HF10 SCS. Pre- and post-implantation data were collected from the medical notes and from headache charts. At an average follow-up of 28 months (range: 12–42 months) we observed an improvement of at least 50 % in headache frequency and/or intensity in all CM patients. One SUNA patient became pain free and the other reported at least 50 % improvement in attacks frequency an duration. The CCH patient reported a significant reduction in CH attacks duration. Two patients underwent a surgical revision due to lead migration.ConclusionsParesthesia-free high cervical HF10 SCS appears to be a long-term safe and likely effective therapeutic approach for patients with chronic refractory primary headache disorders. These results warrant further prospective studies in larger series of patients.

Rate of perioperative neurological complications after surgery for cervical spinal cord stimulation.

OBJECTIVE Cervical spinal cord stimulation (cSCS) is used to treat pain of the cervical region and upper extremities. Case reports and small series have shown a relatively low risk of complication after cSCS, with only a single reported case of perioperative spinal cord injury in the literature. Catastrophic cSCS-associated spinal cord injury remains a concern as a result of underreporting. To aid in preoperative counseling, it is necessary to establish a minimum rate of spinal cord injury and surgical complication following cSCS. METHODS The Nationwide Inpatient Sample (NIS) is a stratified sample of 20% of all patient discharges from nonfederal hospitals in the United States. The authors identified discharges with a primary procedure code for spinal cord stimulation (ICD-9 03.93) associated with a primary diagnosis of cervical pathology from 2002 to 2011. They then analyzed short-term safety outcomes including the presence of spinal cord injury and neurological, medical, and general perioperative complications and compared outcomes using univariate analysis. RESULTS Between 2002 and 2011, there were 2053 discharges for cSCS. The spinal cord injury rate was 0.5%. The rates of any neurological, medical, and general perioperative complications were 1.1%, 1.4%, and 11.7%, respectively. There were no deaths. CONCLUSIONS In the largest series of cSCS, the risk of spinal cord injury was higher than previously reported (0.5%). Nonetheless, this procedure remains relatively safe, and physicians may use these data to corroborate the safety of cSCS in an appropriately selected patient population. This may become a key treatment option in an increasingly opioid-dependent, aging population.

Patient Outcomes and Spinal Cord Stimulation: A Retrospective Case Series Evaluating Patient Satisfaction, Pain Scores, and Opioid Requirements.

Spinal cord stimulators (SCS) are used to treat various chronic pain states. Establishing patient outcomes in terms of pain control, opioid medication use, and overall satisfaction is vital in maintaining SCS's role in clinical practice. All patients who underwent SCS implantation between January 2001 and December 2011 at a tertiary academic pain medicine center were included if he or she underwent permanent cervical or thoracolumbar dorsal column SCS implantation and age was 18 or greater. For the 199 patients who met inclusion criteria, data were collected retrospectively. Preimplant information included indication for implantation, Numeric Rating Scale (NRS) score, and dose in oral morphine equivalents (OME). Postimplant NRS score was recorded at 6months and 1year. OME requirement and patient satisfaction were determined at 1year postimplantation. This data set showed an overall decrease in OME requirements and NRS scores at both 6months and 1year. These differences were statistically significant (P<0.01) compared to preimplantation values. Additionally, 84.27% of patients were satisfied with their implants at 1year. Patient outcomes were analyzed further in respect to implant indication; groups included failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), angina, and other. For all groups, there were statistically significant (P<0.01) decreases in NRS scores at 6months and 1year. In the FBSS and CRPS groups, statistically significant (P<0.02) decreases in OME usage existed. Retrospective review of patients with spinal cord stimulators revealed OME reduction at 1year for those patients in the FBSS and CRPS groups; patient satisfaction at 1year and NRS score reduction at 6months and 1year were statistically significant for all groups.

A hypothesis on possible neurochemical mechanisms of action of cervical spinal cord stimulation in prevention and treatment of cerebral arterial vasospasm after aneurysmal subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is associated with the high incidence of development of cerebral vasospasm that results in morbidity and mortality due to delayed cerebral ischemia. So far there are no consistently effective therapies for treatment of vasospasm in patients suffering from SAH. It is well known that cervical spinal cord stimulation (SCS) can induce vasodilatation and increase cerebral blood flow (CBF). Based on the experiments in animals and the studies in humans, we have proposed the possibility to use SCS as a therapeutic strategy for prevention and treatment of cerebral vasospasm after SAH. However, the physiological mechanisms of action of SCS in this regard are poorly understood. Better understanding of the pathophysiology of vasospasm after SAH may provide insight into the role of SCS in such conditions. We hypothesize that effect of SCS on vasodilatation may be related to modulation of activity of phosphodiesterases 5 (PDE-5) and nitric oxide synthase (eNOS), resulting in enhancement of nitric oxide (NO)-cyclic guanosine monophosphate (cGMP) pathway, which may help prevent and/or treat vasospasm after SAH. Further investigations on the physiological mechanisms of action of SCS would be necessary to support this hypothesis.

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

BackgroundThe role for spinal cord stimulation (SCS) in the management of chronic spinal cord forms of pain involving cervical dermatomes or the cervicomedullary junction (CMJ) for facial pain remains largely uncharted. ObjectiveTo review outcomes with cervical and CMJ SCS performed by a single surgeon, with particular emphasis on complications and efficacy. MethodsAll patients that underwent cervical or CMJ SCS by the lead author were identified and follow-up obtained by telephone questionnaires. Patient demographics, surgical details, outcomes and complications for all patients identified were critically reviewed. ResultsOf 121 patients identified that underwent at least trial SCS, 100 underwent permanent lead implantation. Indications for cervical SCS included brachial plexus lesions (8), complex regional pain syndrome (33), degenerative disc disease (4), failed neck surgery syndrome (23), chronic radiculopathy (6) and post-herpetic neuralgia (PHN) (1); for CMJ SCS, indications included trigeminal deafferetiation pain (10), trigeminal neuropathic pain (4), PHN (4) and occipital neuralgia (7). Pain relief was greater along the extremities than axially, and less in the occipital area than in the head or face. Mean pain reduction averaged 56.6% at a mean follow-up of 4.2 years. Of 24 revision surgeries required, 8 were for presumed lead migration or fracture. Complications included 4 CSF leaks, 5 wound infections, and 4 cases of persistent numbness or pain. Pain relief lasted an average of 3.6 years. ConclusionCervical and CMJ SCS are safe and efficacious and may provide greater relief along the upper extremities than axially, and in the head rather than in the occipital region.

EHMTI-0322. Effect of cervical epidural 10khz spinal cord stimulation on patients suffering from chronic, medically-refractory migraine

A significant minority of chronic migraine (CM) patients do not respond to conventional medical treatment. Occipital nerve stimulation is a therapeutic option for refractory CM (rCM). However, randomized studies have failed to demonstrate efficacy. Cervical 10kHz spinal cord stimulation (10kHz-SCS) may provide a superior alternative to occipital stimulation. We report the preliminary results of a prospective, open-label, feasibility study to assess safety and tolerability cervical 10kHz-SCS in rCM patients. The study had EC approval and the subjects gave informed consent. Included subjects were diagnosed with CM by an experienced headache specialist according to IHS guidelines, were refractory to medical treatments as defined by the Refractory Headache Special Interest Section of the AHS, and had failed Botox treatment. Medication Overuse headache was not excluded. Patients underwent a 10kHz SCS-trial followed by a permanent implant if a significant reduction in headache intensity/episodes was reported during the trial. One or two epidural leads were used to cover the C2-C4. At 6 months 7 out of 14 patients reported >30% reduction in headache days. The average headache days reduction from baseline was 6.9±7.3 days (p=0.04), while the reduction in the responder group was 12.9±5.3 days (p=0.001) . Three patients developed IPG tenderness and one had a lead migration that required surgical revision. Paresthesia-free cervical 10kHz-SCS may be an effective therapeutic option for chronic migraineurs refractory to conventional medications and Botox treatment. No conflict of interest.

Cervical spinal cord stimulation treatment of deafferentation pain from brachial plexus avulsion injury complicated by complex regional pain syndrome.

Brachial plexus avulsion is a rare and debilitating condition frequently associated with severe, intractable neuropathic pain. Interventional treatment modalities include dorsal root entry zone lesioning, stellate ganglion blockade, and neuromodulation such as spinal cord stimulation. We present a case of a 42-year-old woman with a traumatic left upper extremity brachial plexus avulsion injury after a motor vehicle accident and treatment of deafferentation pain complicated by complex regional pain syndrome type II. Previous unsuccessful interventions included repeated stellate ganglion blocks, transcutaneous electrical nerve stimulation, and opioid medication. After a successful trial of cervical spinal cord stimulator lead placement, she went on to an uneventful permanent implantation procedure. Spinal cord stimulation is an effective treatment for deafferentation pain and complex regional pain syndrome type II secondary to brachial plexopathy refractory to pharmacotherapy and conventional interventional attempts to modulate pain.

166 Cervical and Cervicomedullary Spinal Cord Stimulation for Chronic Pain

166 Cervical and Cervicomedullary Spinal Cord Stimulation for Chronic Pain

High Cervical Epidural Neurostimulation for Post-Traumatic Headache Management

Headache following head injuries has been reported for centuries. The majority of post-traumatic headache (PTH) patients will report resolution of their complaints within a few months from the time of the initial injury. PTHs can contribute to disability, lost productivity, and health care costs. In this article we discuss a 40-year-old male with a history of motor vehicle accident and basal skull fracture. The patient had no headache history prior to the accident. He presented with more than 3 years persistent daily headache. The patient described constant throbbing and stabbing quality headaches predominantly on the left hemicranium with constant facial pain. He denies having aura, nausea, or vomiting, but reported occasional neck tightness. An extensive workup was carried out under the direction of the patient’s primary neurologist. Secondary to persistent intractable pain, the patient was referred to the pain clinic for further evaluation. As his headaches were resistant to all trialed strategies, we decided to turn our therapeutic focus toward electrical neuromodulation along with continuing multimodal medications and multidisciplinary approach. During 7 days of high cervical dorsal column electrical nerve stimulation trial, he reported almost 90% pain reduction and significant improvement on his quality of life. On 12 months follow-up after he underwent a permanent implant of high cervical dorsal column electrical nerve stimulation, he reported the same level of pain reduction along with 100% satisfaction rate. To the best of our knowledge, there have been no publications to date concerning the application of high cervical nerve stimulation for PTH. Key words: Post-traumatic headache, migraine headache, cluster headache, electrical neurostimulation, neuromodulation, trigeminocervical complex, high cervical spinal cord stimulation

Spinal cord stimulation exerts neuroprotective effects against experimental Parkinson's disease.

In clinical practice, deep brain stimulation (DBS) is effective for treatment of motor symptoms in Parkinson’s disease (PD). However, the mechanisms have not been understood completely. There are some reports that electrical stimulation exerts neuroprotective effects on the central nervous system diseases including cerebral ischemia, head trauma, epilepsy and PD, although there are a few reports on neuroprotective effects of spinal cord stimulation (SCS). We investigated the neuroprotective effects of high cervical SCS on PD model of rats. Adult female Sprague-Dawley rats received hour-long SCS (2, 50 or 200 Hz) with an epidural electrode at C1–2 level for 16 consecutive days. At 2 days after initial SCS, 6-hydroxydopamine (6-OHDA) was injected into the right striatum of rats. Behavioral evaluations of PD symptoms were employed, including cylinder test and amphetamine-induced rotation test performed at 1 and 2 weeks after 6-OHDA injection. Animals were subsequently euthanized for immunohistochemical investigations. In order to explore neurotrophic and growth factor upregulation induced by SCS, another cohort of rats that received 50 Hz SCS was euthanized at 1 and 2 weeks after lesion for protein assays. Behavioral tests revealed that the number of amphetamine-induced rotations decreased in SCS groups. Immunohistochemically, tyrosine hydroxylase (TH)-positive fibers in the striatum were significantly preserved in SCS groups. TH-positive neurons in the substantia nigra pars compacta were significantly preserved in 50 Hz SCS group. The level of vascular endothelial growth factor (VEGF) was upregulated by SCS at 1 week after the lesion. These results suggest that high cervical SCS exerts neuroprotection in PD model of rats, at least partially by upregulation of VEGF. SCS is supposed to suppress or delay PD progression and might become a less invasive option for PD patients, although further preclinical and clinical investigations are needed to confirm the effectiveness and safety.

Cervical Spinal Cord Stimulation for the Management of Pain from Brachial Plexus Avulsion

Dear Editor, Almost 80% of patients with brachial plexus avulsion develop chronic pain. The pain can be treated medically or with more invasive surgical procedures. However, in most cases, the pain is resistant to medical treatment and has a high-recurrence rate after invasive procedures like dorsal root entry zone (DREZ) lesioning. Cervical spinal cord stimulation (SCS) is one of the underutilized treatment modalities with several reports of good outcome. We report a case of significant improvement in pain from brachial plexus avulsion injury after implanting a cervical SCS. A 25-year-old male patient was involved in a motor vehicle accident 5 years ago. He suffered from multiple injuries including injury to his right brachial plexus. Magnetic resonance imaging (MRI) showed complete nerve root avulsion from C6 to T1. He lost sensation and motor function below the deltoid in his right upper extremity, however his main debilitating problem was severe chronic pain. He described his pain as burning, stabbing, and sometime like an electric shock, starting at the shoulder and radiating to the arm and his five fingers, with an intensity of 7/10 on a numeric pain rating scale. On examination, he had no sensation or motor function below the deltoid. He was not interested in functional recovery and was only concerned about relieving the pain. Medical management with a combination of an antidepressant, an anticonvulsant, a …

Adjuvant spinal cord stimulation improves wound healing of peripheral tissue loss due to steal syndrome of the hand: clinical challenge treating a difficult case

Hand ischaemia due to arterial steal syndrome is an infrequent, but potentially serious complication of arteriovenous fistula (AVF) for haemodialysis. We present a case of hand ischaemia caused by steal syndrome in a 69-year-old haemodialysis patient, 10 months after a brachiobasilic fistula creation. The patient underwent multiple operations without resolution of hand pain and tissue loss. The implantation of an adjuvant cervical spinal cord stimulator allowed the patient to obtain complete hand pain relief and wound healing. Probably, the diffuse microangiopathy typical of haemodialysis patients could be responsible for the persistence of ischaemic signs and symptoms after a surgical revascularisation. The effect of sympathetic blockade and the subsequent improvement of the arterial blood flow and tissue oxygenation because of spinal cord stimulation (SCS) can be useful to achieve complete ischaemic pain relief in order to enhance wound healing and to limit the tissue loss. In conclusion, the association of cervical spinal cord stimulation and surgical revascularisation could represent a valid option to treat a critical upper limb ischaemia following steal syndrome due to AVF.

High frequency cervical spinal cord stimulation in the treatment of refractory trigeminal neuralgia

There are limited options to treat trigeminal neuralgia once medical, surgical and interventional approaches have been exhausted. Neuromodulation is a treatment modality that shows promise and so far case reports have used peripheral approaches to the trigeminal ganglion and its branches. We describe the use of high frequency spinal cord stimulation at the cervical spine as a novel approach to management of refractory trigeminal neuralgia.

Investigation of 10 kHz (HF10 SCS) high-frequency cervical spinal cord stimulation for upper and whole-body neuropathic pain syndromes

Investigation of 10 kHz (HF10 SCS) high-frequency cervical spinal cord stimulation for upper and whole-body neuropathic pain syndromes

Neuromodulation of chronic headaches: position statement from the European Headache Federation

The medical treatment of patients with chronic primary headache syndromes (chronic migraine, chronic tension-type headache, chronic cluster headache, hemicrania continua) is challenging as serious side effects frequently complicate the course of medical treatment and some patients may be even medically intractable. When a definitive lack of responsiveness to conservative treatments is ascertained and medication overuse headache is excluded, neuromodulation options can be considered in selected cases.Here, the various invasive and non-invasive approaches, such as hypothalamic deep brain stimulation, occipital nerve stimulation, stimulation of sphenopalatine ganglion, cervical spinal cord stimulation, vagus nerve stimulation, transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and transcutaneous electrical nerve stimulation are extensively published although proper RCT-based evidence is limited. The European Headache Federation herewith provides a consensus statement on the clinical use of neuromodulation in headache, based on theoretical background, clinical data, and side effect of each method. This international consensus further gives recommendations for future studies on these new approaches.In spite of a growing field of stimulation devices in headaches treatment, further controlled studies to validate, strengthen and disseminate the use of neurostimulation are clearly warranted. Consequently, until these data are available any neurostimulation device should only be used in patients with medically intractable syndromes from tertiary headache centers either as part of a valid study or have shown to be effective in such controlled studies with an acceptable side effect profile.

Effectiveness of Cervical Spinal Cord Stimulation for the Management of Chronic Pain

Scientific evidence supports spinal cord stimulation (SCS) as a cost-effective treatment option that, for many disease states, should be employed earlier in the treatment continuum. Reimbursement for SCS in the cervical spine has recently been challenged based on supposed lack of clinical literature. To refute this assumption, we analyzed data from an international registry to support the use of cervical SCS. The following outcomes were collected as part of an institutional review board-approved, prospective, multicenter, international registry: pain relief, Pain Disability Index (PDI) score, quality of life (QoL), and satisfaction at 3, 6, and 12 months post-implantation. Descriptive statistics are provided for all measures. Changes from baseline in PDI scores were analyzed using Tukey's pairwise comparisons. Thirty-eight patients underwent implantation of SCS leads in the cervical spine at 16 study sites in the United States and 3 international study sites. Direct patient report of percentage of pain relief was 54.2%, 60.2%, and 66.8% at 3, 6, and 12 months post-implantation, respectively. Pain relief was categorized as excellent/good by 61.6% of patients at 3 months, with similar results observed at 6 and 12 months. PDI scores were significantly reduced at all time points. At 3 months post-implantation, 92.4% of patients indicated they were very satisfied/satisfied with the SCS device. No patients indicated that they were dissatisfied. Overall QoL was reported as improved/greatly improved by 73.1% of patients at 3 months. Similar results for QoL and satisfaction were reported at 6 and 12 months. The results suggest that the use of SCS in the cervical spine is a medically effective method of pain management that satisfies and improves the QoL of most patients. The use of SCS can reduce the high cost of direct medical treatment of pain, as well as increasing the productivity of patients, and therefore should be reimbursed in appropriately selected patients.

Paddle lead cervical spinal cord stimulation for failed neck surgery syndrome

Spinal cord stimulation (SCS) is a reliable treatment option or chronic pain conditions such as failed back surgery syndrome FBSS) and complex regional pain syndrome (CRPS) [1,2]. However he use of SCS has thus far been limited largely to the thoracic pine, with enthusiasm for cervical SCS tempered by the challenge f securing an electrode in this inherently more flexible region. addle leads have here provided some advantages over percutaeous leads, minimizing lead migration. Yet, the role of cervical CS has largely remained unexplored, particularly in patients with ailed Neck Surgery Syndrome (FNSS). We employ the term FNSS o describe patients that have persistent, medically intractable pain f the upper extremities and/or neck despite having had at least ne prior cervical spine operation for degenerative disease, and xclude patients who have developed an iatrogenic CRPS. Such atients may present ideal candidates for cervical neuromodulaion. We herein briefly review our experience with cervical SCS for NSS.

S1-1. Spinal cord stimulation for post-stroke pain

Spinal cord stimulation (SCS) is used to treat for several types of intractable pain syndromes, but it is not commonly used for treating post-stroke pain. Therefore, in this study, we analyzed the effects of SCS in patients with post-stroke pain. Neurological imaging and pharmacological analysis using thiopental, ketamine and morphine tests were conducted for 30 patients with post-stroke pain. For all patients, percutaneous electrodes were inserted under local anesthesia, and trial stimulation was performed for 5–7 days. If the patient experienced pain relief during the trial stimulation, a pulse generator was implanted. Of the 30 patients, 26 (87%) experienced satisfactory pain relief and underwent implantation. Ten patients received dual-octad lead SCS. The stimulation induced adequate paresthesia in all 10 patients. Nine (90%) of the 10 patients experienced satisfactory pain relief and opted for pulse generator implantation in order to proceed with the treatment. Upper cervical SCS was performed for patients with pain in not only the upper and lower extremities but also the face. Upper cervical SCS provided good paresthesia coverage and was effective for such patients. We think that patients with post-stroke pain may respond favorably to dual-octad lead SCS, and advancements in devices for SCS would further improve treatment outcomes for such patients.

Cervical intraspinal microstimulation evokes robust forelimb movements before and after injury

Objective. Intraspinal microstimulation (ISMS) is a promising method for reanimating paralyzed limbs following neurological injury. ISMS within the cervical and lumbar spinal cord is capable of evoking a variety of highly-functional movements prior to injury, but the ability of ISMS to evoke forelimb movements after cervical spinal cord injury is unknown. Here we examine the forelimb movements and muscles activated by cervical ISMS both before and after contusion injury. Approach. We documented the forelimb muscles activated and movements evoked via systematic stimulation of the rodent cervical spinal cord both before injury and three, six and nine weeks following a moderate C4/C5 lateralized contusion injury. Animals were anesthetized with isoflurane to permit construction of somatotopic maps of evoked movements and quantify evoked muscle synergies between cervical segments C3 and T1. Main results. When ISMS was delivered to the cervical spinal cord, a variety of responses were observed at 68% of locations tested, with a spatial distribution that generally corresponded to the location of motor neuron pools. Stimulus currents required to achieve movement and the number of sites where movements could be evoked were unchanged by spinal cord injury. A transient shift toward extension-dominated movements and restricted muscle synergies were observed at three and six weeks following injury, respectively. By nine weeks after injury, however, ISMS-evoked patterns were similar to spinally-intact animals. Significance. The results demonstrate the potential for cervical ISMS to reanimate hand and arm function following spinal cord injury. Robust forelimb movements can be evoked both before and during the chronic stages of recovery from a clinically relevant and sustained cervical contusion injury.

Cervical spinal cord stimulation for neuropathic pain after brachial plexus avulsion injury: case report

Brachial plexus avulsion is a rare and debilitating condition frequently associated with severe, intractable neuropathic pain. Treatment modalities include dorsal root entry zone lesioning, stellate ganglion blockade, and neuromodulation. We present a case of a 42 year old female with left upper extremity brachial plexopathy and complex regional pain syndrome (CRPS) type 2 following a motor vehicle accident. Her pain report consisted of constant “crushing” pain, radiating from the left shoulder into her entire left upper extremity. Additionally, she reported muscle spasms, and constant sensations of burning, numbness, and tingling. On physical examination, she presented with gross atrophy from the left shoulder girdle distally. Motor control was limited to trace movements in her distal 4th and 5th digits. She exhibited increased temperature of > 3°C; localized swelling; and violaceous color tone as compared to her unaffected limb. Palpation to light touch revealed allodynia and hyperalgesia. MRI of the cervical spine was negative for obvious spinal cord or root pathology. MRI of her brachial plexus was unremarkable; however, electrophysiologic studies demonstrated upper and middle trunk lesions. Previous unsuccessful interventions included repeated stellate ganglion blockade, transcutaneous electrical nerve stimulation (TENS), and opioid medication. Present pain medications included Gralise® 600 mg TID, tramadol 50 mg PRN, and baclofen 10 mg BID. On these medications, her average pain level was consistently 9/10. After a successful trial of cervical spinal cord stimulator leads, she went on to an uneventful permanent implantation procedure. The left and right leads were positioned with their cephalad-most contacts at the C2-3 and C4-5 levels respectively. At two-week follow up her mood and sleep were both 90% improved and her average pain report decreased to 1/10. Spinal cord stimulation is an effective treatment for neuropathic pain secondary to brachial plexopathy refractory to pharmacotherapy and conventional interventional attempts to modulate pain.