The appropriate use of neurostimulation: stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation Appropriateness Consensus Committee.

INTRODUCTION: The International Neuromodulation Society (INS) has identified a need for evaluation and analysis of the practice of neurostimulation of the brain and extracranial nerves of the head to treat chronic pain. METHODS: The INS board of directors chose an expert panel, the Neuromodulation Appropriateness Consensus Committee (NACC), to evaluate the peer-reviewed literature, current research, and clinical experience and to give guidance for the appropriate use of these methods. The literature searches involved key word searches in PubMed, EMBASE, and Google Scholar dated 1970-2013, which were graded and evaluated by the authors. RESULTS: The NACC found that evidence supports extracranial stimulation for facial pain, migraine, and scalp pain but is limited for intracranial neuromodulation. High cervical spinal cord stimulation is an evolving option for facial pain. Intracranial neurostimulation may be an excellent option to treat diseases of the nervous system, such as tremor and Parkinson's disease, and in the future, potentially Alzheimer's disease and traumatic brain injury, but current use of intracranial stimulation for pain should be seen as investigational. CONCLUSIONS: The NACC concludes that extracranial nerve stimulation should be considered in the algorithmic treatment of migraine and other disorders of the head. We should strive to perfect targets outside the cranium when treating pain, if at all possible.

The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain. Neuromodulation Appropriateness Consensus Committee.

INTRODUCTION: The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes. METHODS: The Neuromodulation Appropriateness Consensus Committee (NACC) reviewed the world literature in English by searching MEDLINE, PubMed, and Google Scholar to evaluate the evidence for ways to reduce risks of neurostimulation therapies. This evidence, obtained from the relevant literature, and clinical experience obtained from the convened consensus panel were used to make final recommendations on improving safety and reducing risks. RESULTS: The NACC determined that the ability to reduce risk associated with the use of neurostimulation devices is a valuable goal and possible with best practice. The NACC has recommended several practice modifications that will lead to improved care. The NACC also sets out the minimum training standards necessary to become an implanting physician. CONCLUSIONS: The NACC has identified the possibility of improving patient care and safety through practice modification. We recommend that all implanting physicians review this guidance and consider adapting their practice accordingly.

The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states. Neuromodulation Appropriateness Consensus Committee.

INTRODUCTION: The International Neuromodulation Society (INS) has determined that there is a need to provide an expert consensus that defines the appropriate use of neuromodulation technologies for appropriate patients. The Neuromodulation Appropriateness Consensus Committee (NACC) was formed to give guidance to current practice and insight into future developments. METHODS: The INS executive board selected members of the international scientific community to analyze scientific evidence for current and future innovations and to use clinical experience to fill in any gaps in information. The NACC used PubMed and Google Scholar to obtain current evidence in the field and used clinical and research experience to give a more complete picture of the innovations in the field. RESULTS: The NACC has determined that currently approved neurostimulation techniques and technologies have expanded our ability to treat patients in a more effective and specific fashion. Despite these advances, the NACC has identified several additional promising technologies and potential applications for neurostimulation that could move this field forward and expand the applicability of neuromodulation. CONCLUSIONS: The NACC concludes that the field of neurostimulation is an evolving and rapidly changing one that will lead to improved patient access, safety, and outcomes.

Is impedance a parameter to be taken into account in spinal cord stimulation?

BACKGROUND: Over the last few decades, spinal cord stimulation (SCS) has become one of the main treatments in the therapeutic arsenal available to pain treatment units. New stimulation systems have been developed and the indications of neurostimulation have been expanded. The premises for a successful technique remain the same; good patient selection, good surgical technique, and good management of electrical parameters when programming. DESIGN: An observational report. OBJECTIVES: The primary objective of the study was to determine the relationship between changes in impedance (R) and energy requirement (E) elicited by changes in patients posture. The postures analyzed were supine (S), sitting (SI), standing (ST), and walking (W). As a second objective, the difference produced in the energy requirement when changing posture was analyzed. METHODS: A study was carried out in 70 patients with chronic intractable pain implanted with a neurostimulation system between January 2000 and March 2006. We define the perception threshold (Tp); the discomfort threshold (Td); and the therapeutic threshold (Tt). The amplitude of perception was measured in mA. With the resulting data, the therapeutic range (TR) was determined. After performing all measurements with the patient in the ST position, the neurostimulation system was shut off and the patient maintained in the other position for 5 minutes before performing the measurements. The variables R and E were compared by age groups, sex, implant duration, and the time since implant placement. Patients were divided into groups according to whether the location of the implanted electrodes was cervical or thoracic. The full analysis by age, sex, and implant duration was performed in the cervical and thoracic implant groups. RESULTS: No correlation was found between impedance and posture. When the results for R and E were analyzed by sex and age, no statistical differences were found in any of the values in any position. The analysis of time since implant greater than or less than 6 months did not find differences in the energy requirement, although there was a significant difference in the impedance value when patients were in the S position. No significant differences were observed in the analysis by age groups.

Sacral neuromodulation for chronic pain conditions.

Some of the pelvic pain syndromes seem to have features of neurogenic inflammation and neuropathic pain in common. As opposed to being separate disease entities, they may represent a spectrum of clinical presentations of CRPS I of the pelvis. Sacral nerve root stimulation provides good symptomatic relief of pain and voiding dysfunction. The techniques of retrograde root stimulation may offer superior results with fewer complications and lead migrations when compared with other methods. Perhaps neuromodulation should be used earlier in the treatment paradigm for these disorders, before the potentially injurious procedures of hydrodistention, bladder installations, and cystectomies.