Peripheral Nerve Stimulation for Chronic Shoulder Pain: A Proof of Concept Anatomy Study.

OBJECTIVES: Although spinal cord and dorsal root ganglia stimulation may be effective for managing regional pain syndromes, a more targeted approach is perhaps more appealing for discrete anatomical structures. Chronic shoulder pain is a common musculoskeletal problem with significant socioeconomic impact. A peripheral nerve stimulation of the axillary and suprascapular nerves may prove to be effective as a long-term solution for this indication. In anticipation of the future experimental research and clinical utilization, a sound methodology for the lead placement was developed, and its feasibility is tested in a cadaveric study. MATERIALS AND METHODS: Normal anatomy was corroborated with ultrasound scans of live models and cadaver specimens. A step-by-step ultrasound-guided implantation technique was designed. The procedure was completed targeting both the axillary and suprascapular nerves. The accuracy of the lead placement was confirmed by dissections. RESULTS: The implanted devices were found adjacent to the target nerves within 0.5-1 cm distance. CONCLUSIONS: The anatomical dissections confirmed the accuracy of ultrasound-guided placement of the lead. The described method is based on normal anatomy and appeared to be reproducible by following the outlined procedural steps.

Twelve-Month Follow-up of a Randomized Clinical Trial Comparing Intradiscal Biacuplasty to Conventional Medical Management for Discogenic Lumbar Back Pain.

Objective: This report conveys 12-month outcomes of subjects treated with intradiscal biacuplasty (IDB) and conservative medical management (CMM) for chronic low back pain of discogenic origin, and results for subjects who elected to receive IDB + CMM 6 months after CMM-alone. Methods: Sixty-three subjects were originally randomized to the IDB + CMM group (N = 29) or CMM-alone (N = 34). Six months following continuous CMM-alone treatment, participants in this study group were permitted to "cross-over" to IDB + CMM (N = 25), and followed for an additional 6 months. The original IDB + CMM study subjects were followed for a total of 12 months (N = 22). Results: Pain reduction at 12 months was statistically significant and clinically meaningful in the original IDB + CMM group compared to baseline. Functional and disability outcomes were also improved statistically and clinically. Fifty-five percent of the IDB + CMM patients responded to treatment with a mean VAS reduction of 2.2 points at 12 months. Furthermore, 50% and 64% of subjects reported clinically significant improvements in SF36-PF and in ODI, respectively. There was a 1.7-point reduction (improvement) on a 7-point PGIC scale, and a 0.13-point increase (improvement) in the EQ-5D Health Index. Fifty-percent of cross-over subjects responded to IDB + CMM intervention. Mean outcome scores for cross-over subjects were similar to those of the originally-treated subjects, and functional and disability endpoints were improved statistically and clinically compared to respective baseline values. Conclusions: The study demonstrated long-term clinical effectiveness of IDB + CMM for treating chronic lumbar discogenic pain. Furthermore, the cross-over study subjects experienced similar improvements in pain, function, disability, and satisfaction.

New horizons in neuromodulation.

Electrical stimulation of the nervous system is a method used for several centuries which just in the past decades received wide recognition as an effective and safe modality in the management of neuropathic pain and other maladies. Explosion of new technologies and discovery of new neuromodulation targets are two parallel and interconnected processes. Using a paraphrase from the famous novel of Samuel Sham, The House of God, one can say that there is no nervous tissue in the human body that cannot be reached with a stimulating lead directed by a good strong arm. Neuromodulation devices are being used for the stimulation of the entire nervous system, from the cutaneous terminals to brain centers. Autonomic regulation is also subject to stimulation via implanted devices. Future research and development is tightly related to the process of discovery, experimental courage, and philosophical exploration of neurobehavioral mechanisms.

Ultrasound-guided placement of a paddle lead onto peripheral nerves: surgical anatomy and methodology.

OBJECTIVES: Implanted peripheral nerve stimulation is one of the earliest developed methods of neuromodulation for the treatment of chronic neuropathic pain. It is traditionally performed by surgical exposure and implantation of a paddle lead. Ultrasound-guided percutaneous placement of cylindrical leads has been proposed as an alternative. However, those leads are fragile and prone to migration. Minimally invasive paddle lead implantation may improve long-term results while minimizing surgical insult. A feasibility laboratory study was performed. MATERIALS AND METHODS: Ultrasound-guided placements of a narrow paddle lead were performed in the upper and lower extremities of a human cadaver. Ultrasonography was used to record the lead position relative to the target nerves. Dissections were performed, and digital photography was completed. Anatomic images were analyzed. RESULTS: All experiments were successfully accomplished. Although ultrasound localization of the upper extremity nerves was straightforward and clear, all procedural steps were technically easier at the lower extremity. For the latter, fewer attempts were required to maintain the lead in the desired tissue plane. Ultrasound revealed an acoustic shadowing of the underlying nerves in both the short- and long-axis views by the inserted lead. All dissections revealed a parallel to the nerve lead placement with at least four contacts facing the nerve. The lead appeared to be more mechanically stable at the lower extremity. CONCLUSIONS: This anatomic study confirmed technical feasibility of percutaneous placement of a narrow paddle-type lead for the peripheral nerve stimulation that may potentially improve stimulation and reduce migrations.

Ultrasound-guided caudad epidural access for the lumbosacral neurostimulation: case report and technical note.

OBJECTIVES: This is a case report and description of a new ultrasound-guided caudad epidural needle placement for percutaneous stimulation of the lumbosacral roots. MATERIALS AND METHODS: Case report. RESULTS: Using ultrasonography pertinent spinal and neuroaxial anatomy was visualized. In-plane approach with continuous monitoring of the needle advancement was utilized. The needle was seamlessly placed in the epidural space on the first attempt. CONCLUSIONS: Spinal sonography is a promising imaging method to facilitate percutaneous caudad epidural access.

Ultrasonography in pain medicine: a critical review.

Recently, ultrasonography has been increasingly used in the field of regional anesthesia to assure reliable blockade of peripheral nerves and to visualize neuroaxial structures. As its popularity is steadily increasing, it may become a standard of care for both intraoperative analgesia and postoperative pain control. The application of ultrasound in chronic pain management, however, remains underutilized. Multiple reasons can be suggested to explain this situation. Nonetheless, numerous articles have been published and some interventionalists have gained experience and started to spread their knowledge through hands-on workshops and medical meetings. It, therefore, seems timely to describe the techniques of ultrasound-guided injections for chronic pain, to review accumulated experience in this field, to reappraise the scientific and clinical value of this method, and to outline potential future developments.