The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation.

INTRODUCTION: The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. METHODS: The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. RESULTS: The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation. CONCLUSION: The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.

Relevant Anatomy, Morphology, and Implantation Techniques of the Dorsal Root Ganglia at the Lumbar Levels.

OBJECTIVES: While dorsal root ganglion (DRG) stimulation has been available in Europe and Australia for the past five years and in the United States for the past year, there are no published details concerning the optimal procedures for DRG lead implantation. MATERIALS AND METHODS: We describe several techniques that can be applied to implant cylindrical leads over the DRG, highlighting some tips and tricks according to our experiences. Focus is mainly shifted toward implantations in the lumbar area. We furthermore give some insights in the results we experienced in Spain as well as some worldwide numbers. IMPLANT TECHNIQUES AND RESULTS: A 14-gauge needle is placed using a "2-Level Technique (2-LT)" or exceptionally a "1-Level Technique (1-LT)" or a "Primary- or Secondary Technique" at the level of L5. The delivery sheath, loaded with the lead, is advanced toward the targeted neural foramen. The lead is placed over the dorsal aspect of the DRG. A strain relief loop is created in the epidural space. Sheath and needle are retracted and the lead is secured using an anchor or anchorless technique. In Spain, 87.2% (N = 78) of the selected patients have been successfully implanted. Seven (8.9%) had a negative trial and three (4.2%) were explanted. Average VAS score decreased from 8.8 to 3.3 and on average 94.5% of the pain area was covered. In our center's subjects (N = 47 patients, 60.3% of all implanted patients in Spain), VAS scores decreased from an average of 8.8-1.7 and pain coverage averaged 96.4%. We used an average of 1.8 electrodes. Worldwide more than 4000 permanent cases have been successfully performed. CONCLUSIONS: We present implantation techniques whereby a percutaneous lead is placed over the DRG through the use of a special designed delivery sheath. Further investigation of the safety, efficacy, and sustainability of clinical outcomes using these devices is warranted.

Agricultural pesticides and veterinary substances in Uruguayan beeswax.

Over the last decade, Uruguay has expanded and intensified its rainfed crop production. This process has affected beekeeping in several ways: for example, by reducing the space available. This has increased the density of apiaries, the risk of varroosis and acaricide use. Additionally, the dominance of no-tillage crops has increased the frequencies of application and of loads of pesticides in regions where such crops share the land with beekeeping and honey production. Therefore, the exposure of bees to xenobiotics (agricultural pesticides and veterinary products) has increased in line with pollution of hives and their products. To document pollution from hive exposure to pesticides, we surveyed the presence of 30 xenobiotics normally used in Uruguay, in recycled beeswax (RB) and in honey cappings (HC) from the main Uruguayan beekeeping regions. There was contamination of all the analyzed samples (RB and HC) with the herbicide atrazine at a range of 1-2 ng g-1. At least three or four additional xenobiotics were detected: insecticides (chlorpyrifos-ethyl and thiacloprid); fungicides (azoxystrobin and tebuconazole); and veterinary products (coumaphos, ethion, and tau-fluvalinate). The frequency of detection of chlorpyrifos-ethyl and coumaphos in RB samples was higher than in those of HC. Moreover, the concentrations of azoxystrobin, coumaphos, and tebuconazole in RB samples were higher than in HC samples. Therefore, we suggest the use of HC to produce recycled printed beeswax films for use in hives to minimize pollution transfer.