Nerve Stimulation In Children Research Articles

47. Subcortical far-field components recorded to median nerve stimulation in children

Far field potentials are generated in structures remote from the surface electrodes and can be recorded from a widespread distribution over the scalp. A far field potential may be generated by abrupt constriction of the volume conductor or by a discontinuity in propagation of the action potential, where the nerve trunk bends or terminates. Here we present our laboratory normative data of the subcortically generated median nerve SEPs in normal children. The median nerve SEPs were recorded in n°48 children after sedation with chloralhydrate (50 mg/kg orally). The recording electrodes were placed on the ipsilateral Erb point (referred to Fz), cv6 (referred to anterocollis) and controlateral centroparietal (referred to ipsilateral auricolar, Erb and centroparietal points). All subjects have normal brain and cervicomedullary junction MRI. We evaluate for all subjects P9-P11-P13-P14-N18 far-field components including both latencies and interpeak latencies. In our case series we identified clearly all far field components in all subjects. Latencies and interpeak latencies will be then reported.

Editorial Comment

The authors report interesting findings in their review of a very large series of children who underwent implantation of a sacral neuromodulator. Some of the important points to note are the limited success with this approach and the high complication rate. These factors, along with the expense and invasive nature of this therapeutic approach, require that its use be limited to a select population. The present study does not address how the severity of symptoms related to outcome, but future studies from this group or others should help to better define which select population is most likely to benefit from this technique based on a variety of predictive factors. The patients in this study were noted to be refractory to a variety of other therapies including urotherapy, biofeedback, medications, and, in some, botulinum toxin injection. Our group, as well as others, has reported success with neuromodulation in a similar group of children using surface patch electrodes (transcutaneous electrical nerve stimulation) or posterior tibial nerve stimulation. 1 Malm-Buatsi E. Nepple K.G. Boyt M.A. et al. Efficacy of transcutaneous electrical nerve stimulation in children with overactive bladder refractory to pharmacotherapy. Urology. 2007; 70: 980-983 Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar , 2 De Gennaro M. Capitanucci M.L. Mosiello G. et al. Current state of nerve stimulation technique for lower urinary tract dysfunction in children. J Urol. 2011; 185: 1571-1577 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar A trial of these less-invasive forms of neuromodulation in children seems prudent before implanting a sacral neuromodulator given the limitations noted previously. Sacral Neuromodulation for the Dysfunctional Elimination Syndrome: A 10-Year Single-center Experience With 105 Consecutive ChildrenUrologyVol. 84Issue 4PreviewTo evaluate our initial experience using sacral neuromodulation via implanted pulse generator as a treatment for children with dysfunctional elimination syndrome and symptoms refractory to maximum medical therapy. Full-Text PDF ReplyUrologyVol. 84Issue 4PreviewWe agree with the important points that Dr Cooper has identified and with maximizing the available noninvasive and minimally invasive options before proceeding with sacral neuromodulation. We have been treating patients with posterior tibial nerve stimulation for a number of years with varying degrees of success. We do not require a trial of posterior tibial nerve stimulation before sacral neuromodulation because, for many patients, age- or family-related geographic, financial, and time constraints preclude this option. Full-Text PDF

Implantation of Vagal Nerve Stimulation in Children

Aim: Data concerning the benefit of vagal nerve stimulation (VNS) in children under the age of 12 years is sparse. In addition these studies include mostly patients above the age of 5 years. We therefore assessed the safety and efficacy of VNS in the children operated on at our institution.

Vagal nerve stimulation in children under 12 years old

Vagal nerve stimulation in children under 12 years old

Vagal nerve stimulation in children under 12 years old with medically intractable epilepsy

This study aims to assess the efficacy and safety of vagal nerve stimulation (VNS) in children less than 12years old operated on at the University Hospital Wales. Retrospective review of patients undergoing VNS insertion, over a 3-year period, was undertaken. All children had a minimum follow-up period of 2years. Sixteen patients were identified via the paediatric epilepsy surgery database. A case note review and telephone evaluation was conducted. Seizure frequency using the McHugh classification was the primary outcome measure, with anti-epileptic drug (AED) use as a secondary outcome measure. There were 10 males and 6 females. The mean time with epilepsy prior to surgery was 5.7years and the mean age at the time of surgery was 7.6years. Overall, nine (56%) children experienced a reduction in their seizure frequency of 50% or more. Of these, four (25%) had a reduction of more than 80%. Seven children (44%) had no reduction in their seizure frequency, although two of these patients reported benefit regarding seizure control and post-ictal recovery. The VNS system was removed in two patients due to infection and no benefit, respectively. Half of the cohort (50%) reduced the number of anti-epileptic drugs post-surgery, and there was an overall mean reduction of AED of 0.5. This study suggests that VNS is a safe and effective adjuvant therapy in children under 12years old, with over half reporting significant benefit. Further studies are needed to enable preoperative selection of patients in order to maximise the potential benefit.

Transcutaneous Parasacral Electrical Neural Stimulation in Children with Primary Monosymptomatic Enuresis: A Prospective Randomized Clinical Trial

Parasacral transcutaneous electrical neural stimulation is widely used to treat hyperactive bladder in children and adults. Its use in nonmonosymptomatic enuresis has demonstrated improvement in number of dry nights. We assessed the effectiveness of parasacral transcutaneous electrical neural stimulation in the treatment of monosymptomatic primary enuresis. This prospective randomized clinical trial included 29 girls and 16 boys older than 6 years with primary monosymptomatic enuresis. Children were randomly divided into 2 groups consisting of controls, who were treated with behavioral therapy, and an experimental group, who were treated with behavioral therapy plus 10 sessions of parasacral transcutaneous electrical neural stimulation. Neural stimulation was performed with the electrodes placed in the sacral region (S2/S3). Sessions always followed the same pattern, with duration of 20 minutes, frequency of 10 Hz, a generated pulse of 700 μs and intensity determined by the sensitivity threshold of the child. Sessions were done 3 times weekly on alternate days. Patients in both groups were followed at 2-week intervals for the first month and then monthly for 6 consecutive months. Rate of wet nights was 77% in controls and 78.3% in the experimental group at onset of treatment (p = 0.82), and 49.5% and 31.2%, respectively, at the end of treatment (p = 0.02). Analyzing the average rate of improvement, there was a significantly greater increase in dry nights in the group undergoing neural stimulation (61.8%) compared to controls (37.3%, p = 0.0038). At the end of treatment percent improvement in children undergoing electrical stimulation had no relation to gender (p = 0.391) or age (p = 0.911). Treatment of primary monosymptomatic enuresis with 10 sessions of parasacral transcutaneous electrical neural stimulation plus behavioral therapy proved to be effective. However, no patient had complete resolution of symptoms.

Posterior Tibial Nerve Stimulation vs Parasacral Transcutaneous Neuromodulation for Overactive Bladder in Children

Parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation have emerged as effective methods to treat overactive bladder in children. However, to our knowledge no study has compared the 2 methods. We evaluated the results of parasacral transcutaneous electrical nerve stimulation and posterior tibial nerve stimulation in children with overactive bladder. We prospectively studied children with overactive bladder without dysfunctional voiding. Success of treatment was evaluated by visual analogue scale and dysfunctional voiding symptom score, and by level of improvement of each specific symptom. Parasacral transcutaneous electrical nerve stimulation was performed 3 times weekly and posterior tibial nerve stimulation was performed once weekly. A total of 22 consecutive patients were treated with posterior tibial nerve stimulation and 37 with parasacral transcutaneous electrical nerve stimulation. There was no difference between the 2 groups regarding demographic characteristics or types of symptoms. Concerning the evaluation by visual analogue scale, complete resolution of symptoms was seen in 70% of the group undergoing parasacral transcutaneous electrical nerve stimulation and in 9% of the group undergoing posterior tibial nerve stimulation (p = 0.02). When the groups were compared, there was no statistically significant difference (p = 0.55). The frequency of persistence of urgency and diurnal urinary incontinence was nearly double in the group undergoing posterior tibial nerve stimulation. However, this difference was not statistically significant. We found that parasacral transcutaneous electrical nerve stimulation is more effective in resolving overactive bladder symptoms, which matches parental perception. However, there were no statistically significant differences in the evaluation by dysfunctional voiding symptom score, or in complete resolution of urgency or diurnal incontinence.

Epileptologists probe vagus nerve stimulation in children with refractory epilepsy: a promise against sudden unexpected death in epilepsy

It is clear that sudden unexpected death in epilepsy (SUDEP) is mainly a problem for people with refractory epilepsy, but our understanding of the best way to its prevention is still incomplete. Although the pharmacological treatments available for epilepsies have expanded, some antiepileptic drugs are still limited in clinical efficacy. In the present paper, we described an experience with vagus nerve stimulation (VNS) treatment by opening space and providing the opportunity to implement effective preventative maps to reduce the incidence of SUDEP in children and adolescents with refractory epilepsy.

Role of Posterior Tibial Nerve Stimulation in the Treatment of Refractory Monosymptomatic Nocturnal Enuresis: A Pilot Study

We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis. We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup. The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2. Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.

Vagus nerve stimulation in children with refractory epilepsy: age at implantation as a predictor of better efficacy

In this study, the efficacy of vagus nerve stimulation treatment was analyzed in a cohort of 70 children with refractory epilepsy. Both children with partial (n=16) and generalized epilepsies (n=54) were included. Age at implantation varied between 19 months and 25 years. Overall, responder rate was 54% with 5.7% of the children becoming seizure free. The only factor in our analysis that could predict good outcome was age at implantation. In the youngest age group (<5 years), responder rate was 77% and this group also included 3 of the 4 seizure free children. These 3 seizure free children were known to suffer from tuberous sclerosis. There were no outcome differences comparing generalized with partial epilepsies.

Long-term vagus nerve stimulation in children with focal epilepsy

The aim of the study was to evaluate the long-term efficacy and hospitalization rates in children with refractory focal epilepsy treated by vagus nerve stimulation. We retrospectively analyzed 15 children with intractable focal epilepsy treated by vagus nerve stimulation (mean age of 14.6 ± 2.5 years at the time of implantation). We analyzed the treatment effectiveness at 1, 2, and 5 year follow-up visits. We counted the average number of urgent hospitalizations and number of days of urgent hospitalization per year for each patient before and after the VNS implantation. The mean seizure reduction was 42.5% at 1 year, 54.9% at 2 years, and 58.3% at 5 years. The number of responders was 7 (46.7%) at 1 year and 9 (60%) at both 2 and 5 years. The mean number of urgent hospitalizations per patient was 1.0 ± 0.6 per year preoperatively and 0.3 ± 0.5 per year post-operatively (P < 0.0001). The mean number of days of urgent hospitalization per patient was 9.3 ± 6.1 per year preoperatively and 1.3 ± 1.8 per year post-operatively ( < 0.0001). Vagus nerve stimulation is an effective method of treating children with refractory focal epilepsy. It leads to a substantial decrease in the number and duration of urgent hospitalizations.

Behavioural and cognitive effects during vagus nerve stimulation in children with intractable epilepsy – A randomized controlled trial

Background/AimsIn addition to effects on seizure frequency in intractable epilepsy, multiple studies report benefits of vagus nerve stimulation (VNS) on behavioural outcomes and quality of life. The present study aims to investigate the effects of VNS on cognition, mood in general, depression, epilepsy-related restrictions and psychosocial adjustment in children with intractable epilepsy, as well as the relation between these effects and seizure reduction. MethodsWe conducted a randomized, active-controlled, double-blinded, add-on study in 41 children (age 4–18) with medically refractory epilepsy. We performed cognitive and behavioural testing at baseline (12 weeks), at the end of the blinded phase (20 weeks) in children receiving either high-output or low-output (active control) stimulation, and at the end of the open label phase (19 weeks) with all children receiving high-output stimulation. Seizure frequency was recorded using seizure diaries. ResultsVNS did not have a negative effect on cognition nor on psychosocial adjustment. At the end of the follow-up phase we noted an improvement of mood in general and the depression subscale for the entire group, unrelated to a reduction of seizure frequency. At the end of the blinded phase a ≥50% reduction of seizure frequency occurred in 16% of the high-stimulation group and 21% of the low-stimulation group. At the end of the open-label follow-up phase, 26% of the children experienced a seizure frequency reduction of 50% or more (responders). ConclusionsVNS has additional beneficial effects in children with intractable epilepsy. As opposed to anti-epileptic drugs, there are no negative effects on cognition. Moreover, we observed an improvement of mood in general and depressed feelings in particular, irrespective of a reduction in seizure frequency. These beneficial effects should be taken into account when deciding whether to initiate or continue VNS treatment in these children.

Vagus nerve stimulation in children with intractable epilepsy

This commentary is on the original article by Klinkenberg et al. on pages 855‐861 of this issue.

Vagus nerve stimulation in children with intractable epilepsy: a randomized controlled trial

The aim of this study was to evaluate the effects of vagus nerve stimulation (VNS) in children with intractable epilepsy on seizure frequency and severity and in terms of tolerability and safety. In this study, the first randomized active controlled trial of its kind in children, 41 children (23 males; 18 females; mean age at implantation 11y 2mo, SD 4y 2mo, range 3y 10mo-17y 8mo) were included. Thirty-five participants had localization-related epilepsy (25 symptomatic; 10 cryptogenic), while six participants had generalized epilepsy (four symptomatic; two idiopathic). During a baseline period of 12 weeks, seizure frequency and severity were recorded using seizure diaries and the adapted Chalfont Seizure Severity Scale (NHS3), after which the participants entered a blinded active controlled phase of 20 weeks. During this phase, half of the participants received high-output VNS (maximally 1.75mA) and the other half received low-output stimulation (0.25mA). Finally, all participants received high-output stimulation for 19 weeks. For both phases, seizure frequency and severity were assessed as during the baseline period. Overall satisfaction and adverse events were assessed by semi-structured interviews. At the end of the randomized controlled blinded phase, seizure frequency reduction of 50% or more occurred in 16% of the high-output stimulation group and in 21% of the low-output stimulation group (p=1.00). There was no significant difference in the decrease in seizure severity between participants in the stimulation groups. Overall, VNS reduced seizure frequency by 50% or more in 26% of participants at the end of the add-on phase The overall seizure severity also improved (p<0.001). VNS is a safe and well-tolerated adjunctive treatment of epilepsy in children. Our results suggest that the effect of VNS on seizure frequency in children is limited. However, the possible reduction in seizure severity and improvement in well-being makes this treatment worth considering in individual children with intractable epilepsy.

Long-term results of vagus nerve stimulation in children and adolescents with drug-resistant epilepsy

The purpose of this study was to evaluate long-term seizure reduction and on-demand magnet use in children and adolescents with drug-resistant epilepsy who were treated with vagus nerve stimulation therapy. Fifty-seven children and adolescents under 18 years of age with drug-resistant epilepsy were implanted with a vagus nerve stimulation therapy device. Seizure reduction was evaluated at 6, 12, 24, 36, and 48 months after implantation. Magnet effect on seizure frequency was evaluated during the first week after implantation and after 6, 12, 24, 36, and 48 months of treatment. The mean reduction in seizure frequency compared with baseline was significant at all time points up to 48 months post-implantation. At 12 months, the average reduction in seizure frequency was 52.4%, and at 48 months, it was 53.1% (observed case analysis). The use of a magnet to deliver extra "on-demand" stimulation between cycles resulted in cessation of seizures in 16.1% of patients, partial effect in 73.2%, and no effect in 10.7%, when evaluated within 1 week of implantation. The magnet effect decreased slightly with increasing time after implantation. A sub-analysis of children ≤12 years of age (N = 34) showed similar results after 36 months of follow-up. The therapy was well tolerated regardless of age. Vagus nerve stimulation therapy is a safe and effective adjunctive treatment for children and adolescents of all ages with drug-resistant epilepsy.

1FC1.6 Long-term efficacy of vagal nerve stimulation in children and adolescents with pharmaco-resistant epilepsy: how to predict better response

1FC1.6 Long-term efficacy of vagal nerve stimulation in children and adolescents with pharmaco-resistant epilepsy: how to predict better response

Transcutaneous Electrical Nerve Stimulation in Children With Overactive Bladder: A Randomized Clinical Trial

We evaluated the effectiveness of parasacral transcutaneous electrical nerve stimulation to treat overactive bladder in children. We designed a prospective randomized trial with sham control for this evaluation. We prospectively randomized 25 girls and 12 boys with an average age of 7.6 years (range 4 to 12) into the test (active treatment) or sham (superficial scapular electrical stimulation) group. A total of 20 sessions, 20 minutes each (10 Hz) were performed 3 times weekly. The criteria used to evaluate the rate of success were 1) self-reported cure, or significant, mild or no improvement; 2) visual analogue scale (level of success 0 to 10); 3) percent improvement; 4) modified Toronto score; and 5) maximum voided volume, average voided volume and number of voids daily based on bladder diary entries. After completion of the 20 sessions controls who were not cured underwent active treatment. A total of 21 patients in the test group and 16 in the sham group underwent treatment. Among the active treatment group 61.9% of parents reported cure. In the sham group no parent reported cure (p <0.001). Regarding visual analogue scale a score of 10 was indicated by 13 parents in the test group, while 1 parent in the sham group indicated a score of 9 (p = 0.002). Additionally 100% improvement was reported by 12 parents in the test group and no parent in the sham group. Toronto score improved significantly in the test group (p <0.001) and sham group (p = 0.008). However, the score was reduced more significantly in the test group compared to the sham group (p = 0.011). In the test group average and maximum voided volumes showed a statistically significant increase and the number of voids daily decreased. After superficial scapular electrical stimulation 13 of the 16 patients who underwent parasacral transcutaneous electrical nerve stimulation were cured. This is the first known randomized clinical trial to demonstrate that parasacral transcutaneous electrical nerve stimulation is effective in the treatment of children with overactive bladder.

The efficacy of vagal nerve stimulation in children with pharmacoresistant epilepsy: Practical experience at a Turkish tertiary referral center

Background Vagus nerve stimulation (VNS) is an effective therapy for pharmacoresistant epilepsy. Nevertheless, information regarding the long-term outcome of VNS in children is limited. Aim To describe the long-term outcome of VNS in patients with pharmacoresistant epilepsy treated at the Gazi University Medical Faculty Epilepsy Center, Turkey. Patients and methods The study included 24 patients – all younger than 18 years of age (mean age: 14.31 years). Median age at the time of VNS device implantation was 11 years. Median age at onset of epilepsy was 21 months and median duration of epilepsy was 126 months. All the patients’ seizures were intractable with antiepileptic drug treatment and all had been treated with an average of 6 ± 2 antiepileptic medications. In all, 12 patients had secondary generalized seizures and 12 had partial seizures. Because this was a retrospective open study, the number of seizures could not be enumerated in most of these cases. Results The only factor that was associated with seizure reduction was duration of follow-up. Age at seizure onset and age at VNS device implantation were not associated with seizure reduction. The difference in seizure reduction between patients >12 years of age and patients <12 years of age was not significant. Mean percentage of seizure reduction after 6 months–7 years of treatment was, respectively, 22.5% ( n = 24) (6th month), 32% ( n = 20) (1st year), 42% ( n = 16) (2nd year), 50.45% ( n = 11) (3rd year), 52% ( n = 10) (4th year), 60% ( n = 8) (5th year), 61.25% ( n = 8) (6th year), and 61.6% ( n = 6) (7th year). The positive effect of VNS persisted throughout the follow-up period. Conclusions Although it is an expensive method, VNS is an effective treatment method. This series shows the necessity of long-term follow-up series for understanding the efficacy and advantages of VNS. Prospective, long-term double-blind studies with large samples are needed to confirm the present study's findings.

Transcutaneous Electrical Nerve Stimulation for Refractory Daytime Urinary Urge Incontinence

We studied the effect of transcutaneous electrical nerve stimulation in children with overactive bladder and treatment refractory daytime urinary incontinence. We recruited 27 children 5 to 14 years old with daytime urge incontinence refractory to timer assisted standard urotherapy and anticholinergics who had normal urinalysis, and unremarkable urinary tract ultrasound and physical examination. Study exclusion criteria were bladder underactivity, lower urinary tract obstruction, ongoing defecation disorders, lower urinary tract surgery and previous transcutaneous electrical nerve stimulation. After a 2-week run-in of standard urotherapy the children underwent natural fill ambulatory urodynamics to confirm detrusor overactivity. Subsequently they were randomly allocated to 4 weeks of 2 hours of daily active or placebo S2-S3 transcutaneous electrical nerve stimulation. The severity of incontinence and urgency, and 48-hour bladder diaries were recorded before randomization and during intervention week 4. Children withdrew from anticholinergics throughout the study period. Two children were excluded from randomization due to urodynamic signs of lower urinary tract obstruction. After 4 weeks of intervention 8 children (61%) in the active group showed a significant decrease in incontinence severity but this occurred in only 2 (17%) in the sham treated group (p <0.05). The active group had a significantly greater decrease in daily incontinence episodes compared to the sham treated group (p <0.01). Transcutaneous electrical nerve stimulation did not alter maximal and average voided volumes. Sacral transcutaneous electrical nerve stimulation seems superior to placebo for refractory daytime incontinence in children with overactive bladder. This effect does not seem to be a consequence of improved bladder reservoir function.

Does Ultrasound Guidance Improve the Success Rate of Infraclavicular Brachial Plexus Block When Compared with Nerve Stimulation in Children with Radial Club Hands?

The classical response to nerve stimulation may be altered in cases of radial club hand. Ultrasound guidance may prove to be a useful tool in such situations. In this study, we compared the success rate of ultrasound-guided infraclavicular brachial plexus block with nerve stimulation for children undergoing radial club hand repair. Fifty children, aged 1-2 yr, undergoing radial club hand repair were randomly assigned to receive infraclavicular brachial plexus block guided by nerve stimulator (Group NS) or ultrasound (Group U) in combination with light general anesthetic. Bupivacaine 0.5 mL/kg of 0.5% was injected in both groups. Pain response to surgical stimulus was considered as block failure. The Children's Hospital Eastern Ontario Pain Scale pain score was recorded at 1, 4, 6, 8, and 10 postoperative hours. In Group NS, the blocks were successful in 16 of 25 patients (64%), whereas in Group U, 24 of 25 patients had successful blocks (P = 0.0053). There was no difference in the time to first analgesia or analgesic consumption in the 10-h study period. Ultrasound-guided infraclavicular brachial plexus block improves the success rate in patients with radial club hands when compared with nerve stimulation in patients undergoing radial club hand correction.