Percutaneous Nerve Stimulation Research Articles

Breath-by-breath comparison of a novel percutaneous phrenic nerve stimulation approach with mechanical ventilation in juvenile pigs: a pilot study

About one in three critically ill patients requires mechanical ventilation (MV). Prolonged MV, however, results in diaphragmatic weakness, which itself is associated with delayed weaning and increased mortality. Inducing active diaphragmatic contraction via electrical phrenic nerve stimulation (PNS) not only provides the potential to reduce diaphragmatic muscular atrophy but also generates physiological-like ventilation and therefore offers a promising alternative to MV. Reasons why PNS is not yet used in critical care medicine are high procedural invasiveness, insufficient evidence, and lack of side-by-side comparison to MV. This study aims to establish a minimal-invasive percutaneous, bilateral electrode placement approach for sole PNS breathing and thereby enable, for the first time, a breath-by-breath comparison to MV. Six juvenile German Landrace pigs received general anesthesia and orotracheal intubation. Following the novel ultrasound-guided, landmark-based, 4-step approach, two echogenic needles per phrenic nerve were successfully placed. Stimulation effectiveness was evaluated measuring tidal volume, diaphragmatic thickening and tomographic electrical impedance in a breath-by-breath comparison to MV. Following sufficient bilateral phrenic nerve stimulation in all pigs, PNS breaths showed a 2.2-fold increase in diaphragmatic thickening. It induced tidal volumes in the lung-protective range by negative pressure inspiration and improved dorso-caudal regional ventilation in contrast to MV. Our study demonstrated the feasibility of a novel ultrasound-guided, percutaneous phrenic nerve stimulation approach, which generated sufficient tidal volumes and showed more resemblance to physiological breathing than MV in a breath-by-breath comparison.

Vagus nerve stimulation rescues persistent pain following orthopedic surgery in adult mice.

Postoperative pain is a major clinical problem imposing a significant burden on patients and society. In a survey 2 years after orthopedic surgery, 57% of patients reported persisting postoperative pain. However, only limited progress has been made in the development of safe and effective therapies to prevent the onset and chronification of pain after orthopedic surgery. We established a tibial fracture mouse model that recapitulates clinically relevant orthopedic trauma surgery, which causes changes in neuropeptide levels in dorsal root ganglia and sustained neuroinflammation in the spinal cord. Here, we monitored extended pain behavior in this model, observing chronic bilateral hindpaw mechanical allodynia in both male and female C57BL/6J mice that persisted for >3 months after surgery. We also tested the analgesic effects of a novel, minimally invasive, bioelectronic approach to percutaneously stimulate the vagus nerve (termed percutaneous vagus nerve stimulation [pVNS]). Weekly pVNS treatment for 30 minutes at 10 Hz for 3 weeks after the surgery strongly reduced pain behaviors compared with untreated controls. Percutaneous vagus nerve stimulation also improved locomotor coordination and accelerated bone healing. In the dorsal root ganglia, vagal stimulation inhibited the activation of glial fibrillary acidic protein-positive satellite cells but without affecting microglial activation. Overall, these data provide novel evidence supportive of the use of pVNS to prevent postoperative pain and inform translational studies to test antinociceptive effects of bioelectronic medicine in the clinic.

Evolving types of pudendal neuromodulation for lower urinary tract dysfunction.

Sacral neuromodulation and posterior tibial nerve stimulation for lower urinary tract dysfunction (LUTD) and overactive bladder yield good and reliable results. However, neuromodulation research is continuously evolving because there is still need for more patient-friendly treatment options in the therapeutic management of LUTD. Pudendal neuromodulation (PNM) has been emerging as a promising alternative treatment option for the last few decades. The aim of this study is to review the current state of the art of PNM. A wide literature search was conducted in the field of PNM using Medline through the PubMed database and Elsevier using the Scopus database; a critical review of the results was then carried out. PNM has been studied in its various possible aspects: percutaneous PNM, transrectal/transvaginal PNM, and both percutaneous and transcutaneous dorsal genital nerve stimulation. Each technique was found to result in promising improvements in different clinical outcomes, with some trials reporting even better results than sacral neuromodulation. As a result of a comparison between the various PNM techniques with both sacral neuromodulation and posterior tibial nerve stimulation, we think that PNM should be seen as seriously promising, and we believe it will expand the treatment options for overactive bladder. Even though several studies accordingly showed PNM to be safe and effective, a systematic review and meta-analysis were not feasible. PNM in its various techniques is a promising treatment for LUTD. Nevertheless, further research is needed to include it in treatment algorithms.

Evaluation of the Safety of Percutaneous Sensory Nerve Stimulation in Patients with Head and Neck Cancer Receiving Chemoradiotherapy.

Chemoradiotherapy (CRT) is the standard treatment for locally advanced head and neck cancer; however, CRT may cause post-treatment dysphagia. Transcutaneous electrical sensory stimulation (TESS), developed in recent years for swallowing rehabilitation, is used at many medical facilities. Although TESS has been used for dysphagia in several fields, its safety and efficacy in patients with head and neck cancer remain to be clarified. Therefore, this study evaluated the safety of TESS in ten patients with head and neck cancers undergoing CRT. Swallowing rehabilitation intervention and TESS implementation were performed for all patients during CRT. Non-blood-toxicity adverse events (AEs), such as dermatitis and mucositis, occurred during CRT; however, the severity was less than grade 3. No patient experienced pain due to TESS. As survival time analysis using the Kaplan-Meier method for interferential current device implementation rates revealed a feasibility of 100% for up to 60 Gy and a feasibility of 78% for up to 70 Gy, TESS may be feasible until 70 Gy. This study confirmed the feasibility and safety of TESS in the head and neck region during CRT. Although the precise mechanism of TESS on dysphagia remains unclear, its continued use has great potential for improving sensory disturbance.

Motor Unit Identification in the M Waves Recorded by High-Density Electromyogram.

We describe and test the methodology supporting the identification of individual motor unit (MU) firings in the motor response (M wave) to percutaneous nerve stimulation recorded by surface high-density electromyography (HD-EMG) on synthetic and experimental data. A set of simulated voluntary contractions followed by 100 simulated M waves with a normal distribution (MU mean firing latency: 10 ms, Standard Deviation - SDLAT 0.1-1.3 ms) constituted the synthetic signals. In experimental condition, at least 52 progressively increasing M waves were elicited in the soleus muscle of 12 males, at rest (REST), and at 10% (C10) and 20% (C20) of maximal voluntary contraction (MVC). The MU decomposition filters were identified from 15-20 s long isometric plantar flexions performed at 10-70% of MVC and, afterwards, applied to M waves. Synthetic signal analysis demonstrated high accuracy of MU identification in M waves (precision ≥ 85%). In experimental conditions 42.6 ± 11.2 MUs per participant were identified from voluntary contractions. When the MU filters were applied to the M wave recordings, 28.4 ± 14.3, 23.7 ± 14.9 and 20.2 ± 13.5 MU firings were identified in the maximal M waves, with individual MU firing latencies of 10.0 ± 2.8 (SDLAT: 1.2 ± 1.2), 9.6 ± 3.0 (SDLAT: 1.5 ± 1.3) and 10.1 ± 3.7 (SDLAT: 1.7 ± 1.6) ms in REST, C10 and C20 conditions, respectively. We present evidence that supports the feasibility of identifying MU firings in M waves recorded by HD-EMG.

439 Percutaneous Electrical Nerve Stimulator for Treatment of Chronic Spinal Pain

INTRODUCTION: The percutaneous electrical nerve stimulator (PENS) is a relatively new device for the treatment of chronic spinal pain. This programmable device is worn for a recommended 10 to 12 days on the external ear, stimulating the auricular vagus nerve. It is postulated to release endorphins and relieve pain. There is minimal literature on the use of PENS as an adjunct to pain management in patients with chronic spinal pain. METHODS: Patients who had the PENS placed for chronic refractory spinal pain were included in the study. All patients failed multiple forms of treatment such as physical therapy, epidural steroid injections, and medication. RESULTS: In 2021, 114 patients had the PENS placed. The mean patient follow-up was 34.9 weeks. 67 patients (58.7%) felt pain relief due to the PENS. In patients with neck pain, the mean Neck Disability Index scores decreased from 43.8% to 25.4%, and the mean Numerical Rating Scores (NRS) decreased from 7.9 to 3.9. In patients with low back pain, the mean Oswestry Disability Index scores decreased from 47.6% to 33.5%, and the mean NRS scores decreased from 7.9 to 5.1. The rate of improvement in patients with neck pain (71.9%) was significantly greater (p-value <0.02) than in patients with back pain (56.4%). Interestingly, 33.3% of patients who responded to treatment remained improved at one year follow-up. CONCLUSIONS: Our study shows that a significant number of patients experienced reduced pain and disability as a result of treatment with the PENS. Patients with neck pain responded better than patients with low back pain. Many patients in this difficult patient population experienced durable relief, lasting over one year. Our study suggests that the PENS may be a useful adjunct in the management of patients with chronic spinal pain.

The Efficacy of Combined Alarm Therapy Versus Alarm Monotherapy in the Treatment of Monosymptomatic Nocturnal Enuresis: A Review of Current Literature.

Primary monosymptomatic nocturnal enuresis is a common clinical condition in childhood and affects the psychosocial development of the child. The management of this clinical condition, which includes the preschool and adolescence period, is very important for child development. Diagnostic evaluation should be performed in terms of diabetes mellitus, diabetes inspidus, neurogenic bladder, spinal anomalies, and congenital urogenital system anomalies. Treatment modalities in primary monosymptomatic nocturnal enuresis include enuretic alarm therapy, behavioral therapy, and pharmacological treatments such as desmopressin, tricyclic antidepressants, and anticholinergics. There are also experimental treatments such as percutaneous nerve stimulation, acupuncture, and manual therapy. In this study, we examined randomized controlled studies in the literature that included alarm monotherapy and combined therapy. We aimed to present the efficacy, advantages, and disadvantages of combined treatment with the results of the studies.

An ultrasound-guided percutaneous electrical nerve stimulation regimen devised using finite element modeling promotes functional recovery after median nerve transection.

Percutaneous electrical nerve stimulation of an injured nerve can promote and accelerate peripheral nerve regeneration and improve function. When performing acupuncture and moxibustion, locating the injured nerve using ultrasound before percutaneous nerve stimulation can help prevent further injury to an already injured nerve. However, stimulation parameters have not been standardized. In this study, we constructed a multi-layer human forearm model using finite element modeling. Taking current density and activated function as optimization indicators, the optimal percutaneous nerve stimulation parameters were established. The optimal parameters were parallel placement located 3 cm apart with the injury site at the midpoint between the needles. To validate the efficacy of this regimen, we performed a randomized controlled trial in 23 patients with median nerve transection who underwent neurorrhaphy. Patients who received conventional rehabilitation combined with percutaneous electrical nerve stimulation experienced greater improvement in sensory function, motor function, and grip strength than those who received conventional rehabilitation combined with transcutaneous electrical nerve stimulation. These findings suggest that the percutaneous electrical nerve stimulation regimen established in this study can improve global median nerve function in patients with median nerve transection.

Multielectrode Array-Based Percutaneous Nerve Stimulation Strategy With Ultrasound Guidance for Ulnar Nerve Injury.

Studies have shown that percutaneous nerve stimulation can promote repair of ulnar neuropathy. However, this approach requires further optimization. We evaluated multielectrode array-based percutaneous nerve stimulation for treatment of ulnar nerve injury. The optimal stimulation protocol was determined using a multi-layer model of the human forearm using the finite element method. We optimized the number and distance between electrodes, and used ultrasound to aid in electrode placement. Six electrical needles in series along the injured nerve at alternating distances of five and seven centimeters. We validated the model in a clinical trial. Twenty-seven patients were randomly assigned to a control group (CN) and an electrical stimulation with finite element group (FES). The results showed that disability of arm shoulder and hand (DASH) scores decreased and grip strength increased to a greater extent in the FES group than those in the CN group following treatment (P<0.05). Furthermore, the amplitudes of compound motor action potentials (cMAPs) and sensory nerve action potentials (SNAPs) improved in the FES group to a greater extent than those in the CN group. The results showed that our intervention improved hand function and muscle strength, and aided in neurologic recovery, as shown using electromyography. Analysis of blood samples indicated that our intervention may have promoted conversion of the precursor form of brain-derived neurotrophic factor (pro-BDNF) to mature brain-derived neurotrophic factor (BDNF) to promote nerve regeneration. Our percutaneous nerve stimulation regimen for ulnar nerve injury has potential to become a standard treatment option.

Ultrasound-guided percutaneous peripheral nerve stimulation for chronic refractory neuropathic pain: a unique series.

During the last two decades, with the advent of recent technology, peripheral nerve stimulation has become an appealing modality at the forefront of pain management. In this case series, we document the clinical rationale and technical considerations on three of the most challenging cases, refractory to previous interventions, that were treated by our team with an ultrasound-guided percutaneous peripheral nerve stimulator targeting the musculocutaneous, bilateral greater occipitaland subcostal nerves. At the6-month follow-up, all patients experienced greater than 50% relief of baseline pain, with a near-complete resolution of pain exacerbations. Furthermore, to our knowledge, this is the first report of an ultrasound-guided percutaneous technique of a peripheral nerve stimulator targeting the musculocutaneous and subcostal nerves.

Incidence of Temporary Peripheral Nerve Stimulator Lead Tip Retention: A Retrospective Review of 80 Lead Placements

ObjectivesThe primary objective of this study was to determine the current rate of lead fracture during temporary percutaneous peripheral nerve stimulator (PNS) lead removal at the Mayo Clinic Rochester Division of Pain Medicine. Materials and MethodsA retrospective review of electronic medical records was performed for patients implanted with a temporary percutaneous PNS device between January 1, 2018, and December 31, 2020. Patients were included if they underwent temporary percutaneous PNS system implant, with planned lead removal at 60 days. Data collection included date of implant, diagnosis, peripheral nerve target(s), number of leads, and lead tip status at the time of removal (intact vs fractured). ResultsFifty patients underwent a total of 80 temporary percutaneous PNS leads placed during the time frame analyzed. Of the 80 temporary percutaneous PNS leads implanted, there were five lead fractures at the time of intentional lead removal. ConclusionsThis retrospective review of 50 patients with 80 temporary percutaneous PNS leads implanted for chronic peripheral neuropathic pain resulted in a 6.25% rate of retained lead fragment at the time of lead removal by the provider at the end of 60-day treatment. This fracture and retention rate is consistent with previous published retrospective data on PNS, which has shown a 3% to 21% lead fracture rate during intentional lead removal.

NSS-Bridge Device for Post-Cesarean Delivery Analgesia: A Randomized Controlled Trial.

Percutaneous auricular nerve stimulation has been used for the treatment of symptoms associated with opioid withdrawal, including abdominal pain, nausea, and general discomfort. However, its potential utility for pain management and opioid minimization after surgery has not been investigated. The purpose of this study was to test the feasibility and acceptability of a trial protocol designed to assess the effectiveness of the NSS2-Bridge device as a non-pharmacologic alternative to opioids after cesarean delivery. In a randomized control design, healthy women receiving cesarean delivery were randomized to receive the active device, placebo device, or no device. Devices were placed on the ear following cesarean delivery and left in place for 5 days. Feasibility and acceptability of the device was assessed by patient reports of device tolerability (rated on a 100mm visual analog scale where 0 is not tolerable at all and 100 is the most tolerable) as well as qualitative reporting. Additional outcomes assessed included proportion of patients not using opioids in hospital, as well as pain at rest, pain with movement, and total opioid consumption in the hospital and for the first 5 days after surgery. There were 60 patients included in the final analysis. Device tolerability was rated highly, with an average daily score of >75 mm on the visual analog scale. The trial retention rate was 89.7% with most exclusions (42.9%) occurring due to unanticipated development of care complexity (e.g., hemorrhage and additional surgical procedures), with only 1 exclusion (14.3%) due to device discomfort. The active device group achieved the highest proportion of opioid-free hospitalizations (40%) compared to placebo (20%) and no device groups (30%). Pain at rest and with movement was similar between treatment groups. This trial protocol designed to test the efficacy of NSS2-Bridge device for post-cesarean pain management is feasible and acceptable. Larger proportions of patients not using opioids in the active device group justifies additional investigation on device effectiveness in pregnant and postpartum people at highest risk for pain.

Pupillary response to percutaneous vagal nerve stimulation in alcohol withdrawal syndrome

Pupillary response to percutaneous vagal nerve stimulation in alcohol withdrawal syndrome

Physiological basis of obesity treatment by percutaneous vagus nerve stimulation

<h3></h3> Пандемия ожирения становится все более актуальной проблемой современной медицины, обусловливая необходимость развития новых подходов к коррекции избыточной массы тела. К таковым относится электрическая стимуляция блуждающего нерва, возможности клинического применения которой активно изучают во всем мире. В обзоре обсуждаются современные представления о физиологических основах коррекции избыточной массы тела с использованием чрескожной стимуляции блуждающего нерва.

Efficacy and safety of transcutaneous auricular vagus nerve stimulation combined with conventional rehabilitation training in acute stroke patients: a randomized controlled trial conducted for 1 year involving 60 patients.

Transcutaneous auricular vagus nerve stimulation (ta-VNS) is a novel noninvasive treat-ment for stroke that directly stimulates the peripheral auricular branch of the vagus nerve. There have been recent reports that ta-VNS combined with conventional rehabilitation training promotes the recovery of neurological function of patients with acute stroke. However, these were small-sample-sized studies on the recovery of neurological function in patients after percutaneous vagus nerve stimulation in the subacute and chronic phases after stroke. This double-blinded randomized controlled trial involved 60 acute ischemic or hemorrhagic stroke patients aged 18-80 years who received treatment in the Second Affiliated Hospital of Chongqing Medical University. The subjects were randomly assigned to receive ta-VNS or sham ta-VNS combined with conventional rehabilitation training. The follow-up results over 1 year revealed that ta-VNS combined with conventional rehabilitation training greatly improved the recovery of motor and sensory functions and emotional responses compared with sham ta-VNS combined with conventional rehabilitation training. There were no obvious side effects. These findings suggest that ta-VNS combined with conventional rehabilitation training for the treatment of acute ischemic or hemorrhagic stroke patients is safe and effective.

Real world experience with minimally invasive wireless percutaneous neuromodulation in a tertiary care centre.

Wireless percutaneous nerve stimulation (PNS) for chronic pain is rapidly evolving in the ever expanding neuromodulation paradigm. Safety and lower risks with a potential of long-term analgesia cannot be over emphasised especially with the ongoing opioid pandemic. PNS with an implanted pulse generator (IPG) has also been shown to provide good benefit, without often unpleasant widespread paraesthesia from conventional spinal cord stimulators. We retrospectively extracted data on all wireless PNS implants in our highly specialised pain neuromodulation centre since initiation of wireless PNS service in August 2019. Patient demographics, pain history, analgesic intake and details on implant follow-up data within 1year post-implant including pain relief, EuroQol-5 Dimension (EQ-5D) and Patients' Global Impression of Change (PGIC) scores were extracted. The cases are presented in a narrative format. A total of five patients were implanted with wireless (Stimwave®) PNS from August 2019 to February 2020. Neuropathic pain was the most common presenting diagnosis. All patients showed >50% pain relief at 3months. EQ-5D and PGIC did not show any improvement in the subjects. Two of the patients managed to decrease their analgesics after implantation. Similar sustained benefits could not be demonstrated after 1year. PNS can provide analgesia in appropriately selected cases. Naivety of the technique and procedure might cause some degree of uncertainty. External pulse generator with wireless transmission avoids IPG and tunnelling related side effects, but requires individualised special wearable technology to power the lead. Minimally invasive nature of the technique might be attractive and preferable for patients with complex medical issues, nickel allergy and poor general health who may otherwise be unsuitable for Spinal Cord Stimulation (SCS) with conventional hardware. Robust prospective controlled studies and RCTs in future might provide further insights on utility in other neuropathic pain diagnosis, long-term outcomes and acceptability compared to conventional SCS.

Percutaneous vagus nerve stimulation modulates glia activity and rescues acute Aβ deposition in a mouse model of delirium superimposed on dementia.

Millions of Americans live with Alzheimer's disease (AD) and routinely require common surgical interventions, such as orthopedic surgery. However, these potentially life-saving procedures often increase the risk for further cognitive complications, such as delirium, which in many cases associate with worse prognosis and even death. Currently, we do not have effective strategies to prevent postoperative neuroinflammation and treat delirium. Using an AD-like mouse model (CVN-AD) we established a translational paradigm to study delirium superimposed on dementia [1]. Here we describe the effects of a minimally-invasive ultrasound guided percutaneous approach to stimulate the vagus nerve (termed pVNS) [2] in CVN-AD mice after orthopedic surgery. A 30-minute stimulation at 10 Hz was performed in 12-months-old CVN-AD mice before subjecting them to tibial fracture and repair. Surgery induced a robust neuroinflammatory response in these mice, with evident morphological changes in microglia and astrocytes, as well as an acute deposition of Aβ plaques in the hippocampus compared to age-matched controls. pVNS after surgery rescued morphological changes in microglia and astrocytes, as well as effectively reduced Aβ plaques deposition in the hippocampus at 24 hours. Notably, pVNS altered the autophagy-lysosomal pathway by increasing TFEB and LAMP1 expression, which are key regulators of autophagy and lysosomal biogenesis. These changes were observed using Nanostring assay on hippocampal tissue combined with immunofluorescence staining. Overall, these data highlight a novel role for vagus nerve stimulation in regulating neuroimmune interactions and resolving inflammation in delirium superimposed on dementia.

Percutaneous vagus nerve stimulation attenuates postoperative Aβ deposition in a mouse model of delirium superimposed on dementia

Percutaneous vagus nerve stimulation attenuates postoperative Aβ deposition in a mouse model of delirium superimposed on dementia

Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study.

BackgroundThe objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single‐center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments.Materials & MethodsParticipants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long‐term for 12 months after the 2‐month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow‐up visits thereafter in progress.ResultsClinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy‐three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2‐month percutaneous PNS treatment (n = 54/74). Whereas prospective follow‐up is ongoing, among those who had already completed the long‐term follow‐up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment.ConclusionGiven the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first‐line neurostimulation treatment option for patients with chronic axial back pain.

PHRENIC NERVE CONDUCTION STUDY IN HEALTHY POPULATION

The phrenic nerve provides the primary motor supply to the diaphragm Phrenic nerve conduction study provides a sensitive indicator of phrenic nerve function when the nerve is affected either by local lesions or by generalized neuropathies. Percutaneous phrenic nerve stimulation is an easy and rapid procedure that achieves successful stimulation of the nerve. It is associated with little or no discomfort. Amplitude, latency, area, and duration are measures used to evaluate phrenic nerve integrity. Only limited data has however been published on normative data of phrenic nerve conduction study. Aim of the work The aim of this study was to determine normative values of phrenic nerve conduction parameters in healthy population.Subjects & Methods • Seventy-three healthy individuals (47 men and 26 women) aged from 18 to 61 years participated in the study. • Motor conduction studies of the phrenic nerve were performed bilaterally both during inspiration and expiration. The phrenic nerve was stimulated at the posterior border of the sternocleidomastoid muscle at the level of the cricoid cartilage. Recording was made from both sternal and costal diaphragm. • Measured parameters were latency, amplitude, area and duration of the diaphragmatic compound muscle action potential )DCMAP( at each recording site. Side-side differences were determined.