A Scoping Review of Epidural Spinal Cord Stimulation for Improving Motor and Voiding Function Following Spinal Cord Injury.

Objectives: To identify and synthesize the existing evidence on the effectiveness and safety of epidural spinal cord stimulation (SCS) for improving motor and voiding function and reducing spasticity following spinal cord injury (SCI). Methods: This scoping review was performed according to the framework of Arksey and O'Malley. Comprehensive serial searches in multiple databases (MEDLINE, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, LILACS, PubMed, Web of Science, and Scopus) were performed to identify relevant publications that focused on epidural SCS for improving motor function, including spasticity, and voiding deficits in individuals with SCI. Results: Data from 13 case series including 88 individuals with complete or incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] grade A to D) were included. In 12 studies of individuals with SCI, the majority (83 out of 88) demonstrated a variable degree of improvement in volitional motor function with epidural SCS. Two studies, incorporating 27 participants, demonstrated a significant reduction in spasticity with SCS. Two small studies consisting of five and two participants, respectively, demonstrated improved supraspinal control of volitional micturition with SCS. Conclusion: Epidural SCS can enhance central pattern generator activity and lower motor neuron excitability in individuals with SCI. The observed effects of epidural SCS following SCI suggest that the preservation of supraspinal transmission is sufficient for the recovery of volitional motor and voiding function, even in patients with complete SCI. Further research is warranted to evaluate and optimize the parameters for epidural SCS and their impact on individuals with differing degrees of severity of SCI.

Quality of chronic pain interventional treatment guidelines from pain societies: Assessment with the AGREE II instrument.

BACKGROUND AND OBJECTIVE: Procedures to relieve pain are performed frequently but there are concerns about patient selection, appropriate image guidance, frequency and training for physicians. Patients, healthcare providers, policymakers and licensing bodies seek evidence-based recommendations to use these interventions judiciously. In this review we appraised the methodological quality of recent clinical practice guidelines (CPGs) for interventional pain procedures. DATABASE AND DATA TREATMENT: A systematic search of the medical literature was performed. Three trained appraisers independently evaluated the methodological quality of the CPGs using a validated instrument, the Appraisal of Guidelines in Research and Evaluation II (AGREE II). Six domains were considered: 1) score and purpose; 2) stakeholder involvement; 3) rigour of development; 4) clarity of presentation; 5) applicability and 6) editorial independence. A total of 23 items were scored. CPGs were deemed 'high quality' if a mean scaled score above 60% for rigour of development and for two other domains was obtained. RESULTS: Mean scaled domain quality scores ranged from 61.72% to 69.99%. Despite being based on modest levels of evidence, two of the four included CPGs were considered to be of high methodological quality. The AGREE II scores across the four guidelines exhibited good inter-rater reliability. None of the guidelines involved key stakeholders such as patients, other healthcare providers, and payers. CONCLUSIONS: All four CPGs were limited by a weak execution of the guideline development process. There is a need to develop methodologically sound evidence-based guidelines for the use of interventional pain procedures using a rigorous process that involves all relevant stakeholders. SIGNIFICANCE: This systematic review appraises the methodological quality of existing CPGs on interventional procedures using a validated epidemiological tool (AGREE II). The aims of this review were to identify methodological and knowledge gaps in existing CPGs. Findings of this study will help in development of a high-quality CPG that can assist healthcare providers and patients in making informed decisions while ensuring that the right intervention is performed for the right patient at the right time. The quality of the evidence provided by the CPGs provided in support of their recommendations was also evaluated.

Effectiveness of "Transgrade" Epidural Technique for Dorsal Root Ganglion Stimulation. A Retrospective, Single-Center, Case Series for Chronic Focal Neuropathic Pain.

BACKGROUND: The recent interest in targeting the dorsal root ganglion (DRG) has led to the development of new techniques of electrode placement. In this article, we describe a new "Transgrade" approach to the DRG, accessing the contralateral interlaminar space and steering the lead out the opposite foramen. OBJECTIVES: The purpose of this study was to evaluate the Transgrade technique to the DRG in the management of focal neuropathic pain, predominately complex regional pain syndrome in terms of efficacy and safety. STUDY DESIGN: A retrospective, observational review of all patients selected for DRG stimulation using the Transgrade technique to the DRG. SETTING: Pain Management and Neuromodulation Centre, Guys and St. Thomas NHS Foundation Trust, London, United Kingdom. METHODS: Data were taken from a hospital password-protected database. All patients were contacted by telephone for Numeric Rating Scale (NRS-11) score, Patient Global Impression of Change (PGIC) score, and complications. A patient responder was defined as having a PGIC score of 6 or 7, and a 2-point reduction from baseline NRS-11. RESULTS: A total of 39 patients (46% women) with a mean age of 46 years (± 2) underwent a trial of DRG stimulation that resulted in an implantation rate of 82% (32 of 39). The responder rates, according to NRS-11 and PGIC results, were 87% (28 of 32) at 6 weeks and 66% (21 of 32) at a mean of 18 months (± 1.8) follow-up. Pocket pain was the most common complication, occurring in 7 of 32 (22%) patients, and the lead migration rate was 3 out of 57 leads placed (5.2%). A burst protocol was the favored method of stimulation in the majority of patients, 25 of 32 (78%). LIMITATIONS: Retrospective nature of design, small sample size. CONCLUSIONS: The Transgrade technique of placing DRG leads offers an alternative method that is safe and effective. New methods of stimulation to the DRG offer more choice and potentially better efficacy for patients with chronic neuropathic pain. KEY WORDS: Neuromodulation, dorsal root ganglion, neuropathic pain, complex regional pain syndrome, spinal cord stimulation, chronic pain, implantable neurostimulators, spinal nerve root stimulation.

A scoping review of novel spinal cord stimulation modes for complex regional pain syndrome.

Background: Paresthesia-based spinal cord stimulation (PB-SCS) is used for the treatment of complex regional pain syndrome (CRPS), but many patients are refractory to PB-SCS or experience attenuation of analgesic effect over time due to tolerance. Novel SCS modes including high-frequency, BurstTM, and high-density (HDTM) stimulation were introduced recently and this systematic review was conducted to summarize the evidence on their role for CRPS. Materials and Methods: We searched MEDLINE and other databases (up to September 21, 2017) for studies including adults with refractory CRPS treated by paresthesia-free SCS (PF-SCS) modes compared to placebo, conventional medical treatment, or PB-SCS. We determined the posttreatment intensity of pain (up to 24 months after intervention), changes in CRPS-associated symptoms, and associated domains. Sustainability and adverse effects were also assessed. Results: We identified 13 studies (seven case series, five conference abstracts, one randomized controlled trial) including 62 patients with upper or lower limb CRPS. Eleven papers reported on outcomes of high-frequency stimulation at 10 kHz (HF-10) and other high frequencies, two papers were on Burst, and one paper was on HD. In 59 patients, pain intensity with novel SCS modes was reduced by 30% to 100% with a corresponding reduction in analgesic medications. Novel SCS modes also attenuated CRPS-associated symptoms and six papers reported significant improvement of quality of life. Conclusions: Novel SCS modes have the potential to provide analgesia in patients with CRPS. However, the low quality of available evidence necessitates definitive and prospective comparative effectiveness studies to establish the role of these modes in CRPS.

Contexte: La stimulation médullaire par induction de paresthésies est utilisée pour le traitement du syndrome douloureux régional complexe (SDRC), mais de nombreux patients y sont réfractaires ou ressentent une atténuation de l'effet analgésique avec le temps dû à la tolérance. De nouvelles modalités de stimulation médullaire, dont la stimulation à haute fréquence, la stimulation par rafales (BurstTM) et la stimulation à haute densité (HDTM), ont récemment facommentcé à être utilisés. Cette revue systématique a été menée afin de résumer les données probantes portant sur leur rôle dans le SDRC.Matériel et méthodes: Nous avons fait des recherches dans MEDLINE et d'autres bases de données (jusqu'au 21 septembre 2017) pour trouver des études portant sur des adultes souffrant d'un SDRC réfractaire traité par stimulation médullaire sans parasthésie comparativement à un placebo, à un traitement médical conventionnel ou à une stimulation médullaire par induction de paresthésies. Nous avons déterminé l'intensité post-traitement de la douleur (jusqu'à 24 mois après l'intervention), ainsi que les changements dans les symptômes associés au SDRC et dans des domaines connexes. La pérennité et les effets défavorables ont aussi été évalués.Résultats: Nous avons répertorié 13 études (7 séries de cas, 5 résumés de conférence, un essai contrôlé randomisé) auxquelles ont participé 62 patients souffrant d'un SDRC aux membres supérieurs ou inférieurs. Onze articles portaient sur les résultats de la HF-10 et d'autres hautes fréquences, deux articles portaient sur la stimulation Burst TM et un article portait sur la HDTM. Chez 50 patients, les modalités novatrices de stimulation médullaire ont donné lieu à une diminution de l'intensité de la douleur allant de 30 % à 100 %, accompagnée d'une réduction similaire des médications analgésiques. Les nouveaux modes de stimulation médullaire atténuaient également les symptômes associés au SDRC. De plus, six articles faisaient état d'une amélioration considérable de la qualité de vie.Conclusions: Les nouveaux modes de stimulation médullaire peuvent avoir un effet analgésique pour les patients souffrant d'un SDRC. Toutefois, la qualité médiocre des données probantes disponibles rend nécessaire la conduite d'études comparatives et prospectives sur leur efficacité des afin d'établir leur rôle dans le SDRC.