Current Waveforms in Spinal Cord Stimulation and Their Impact on the Future of Neuromodulation: A Scoping Review.

BACKGROUND: Neuromodulation is a standard and well-accepted treatment for chronic refractory neuropathic pain. There has been progressive innovation in the field over the last decade, particularly in areas of spinal cord stimulation (SCS) and dorsal root ganglion stimulation. Improved outcomes using proprietary waveforms have become customary in the field, leading to an unprecedented expansion of these products and a plethora of options for the management of pain. Although advances in waveform technology have improved our fundamental understanding of neuromodulation, a scoping review describing new energy platforms and their associated clinical effects and outcomes is needed. The authors submit that understanding electrophysiological neuromodulation may be important for clinical decision-making and programming selection for personalized patient care. OBJECTIVE: This review aims to characterize ways differences in mechanism of action and clinical outcomes of current spinal neuromodulation products may affect contemporary clinical decision-making while outlining a possible path for the future SCS. STUDY DESIGN: The study is a scoping review of the literature about newer generation SCS waveforms. MATERIALS AND METHODS: A literature report was performed on PubMed and chapters to include articles on spine neuromodulation mechanism of action and efficacy. RESULTS: A total of 8469 studies were identified, 75 of which were included for the scoping review after keywords defining recent waveform technology were added. CONCLUSIONS: Clinical data suggest that neuromodulation remains a promising tool in the treatment of chronic pain. The evidence for SCS for treating chronic pain seems compelling; however, more long-term and comparative data are needed for a comparison of waveforms when it comes to the etiology of pain. In addition, an exploration into combination waveform therapy and waveform cycling may be paramount for future clinical studies and the development of new technologies.

Did we do the right thing? The appropriateness of orthopedic operative interventions during the height of the coronavirus disease 2019 pandemic.

PURPOSE: During the coronavirus disease (COVID) pandemic elective surgeries were cancelled and operative indications curtailed to counteract shortages in resources. We aimed to review each orthopedic operative indication at an urban Level 1 Trauma Center inundated with COVID. We aimed to classify the appropriateness of each operative intervention and determine if exposure to COVID impacted morbidity or mortality. METHODS: All orthopedic procedures between March 16, 2020 and May 16, 2020 were reviewed. The most urgent surgical indication for each procedure was classified by 2 fellowship trained orthopedic trauma surgeons and 2 senior residents. The appropriateness of the operative intervention was determined. The American Academy of Orthopedic Surgery (AAOS) and American College of Surgeons (ACS) guidelines for surgery during the pandemic were considered. RESULTS: Seventy-six surgical encounters were performed on 71 inpatients including 99 total procedures. No outpatient procedures were performed. Fifty-four of 71 patients were male. There was a mean age of 51.6 years. Of 71 patients, 41 presented to the emergency department without trauma activation with a mean time to presentation of 2.7 days post injury. The most urgent surgical indications included 18 hip fractures, 18 periarticular fractures, 17 open fractures, 7 severe infections, 5 pelvic fractures, 5 femoral shaft fractures, 3 spinal injuries, 1 tibial fracture, 1 tendon injury, and 1 clavicle fracture. Four procedures could have been delayed for conservative management without causing significant harm. Upon discharge 13/71 patients had tested positive for COVID, 41/71 had remained negative throughout their hospital stay, and 17/71 patients never were tested. Four patients contracted COVID in the hospital. There were 4 in hospital deaths, 2 attributed to hypoxemic respiratory failure secondary to COVID pneumonia. CONCLUSION: It was determined that 72/76 cases were considered appropriate in following guidelines of the AAOS and ACS. This highlights the value of halting outpatient procedures and limiting patient exposure to COVID. Comprehensive patient/provider discussions addressing the risks, benefits, alternatives to surgery, and the risk of exposure to respiratory illness are vital. It behooves the surgical team to follow established guidelines such as those of the AAOS and ACS when triaging orthopedic patients for a surgical admission.