Spinal Cord Stimulation: Difference between revisions

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== Introduction  ==
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[[File:Implantable Pulse Generator and Leads.jpg|thumb|348x348px|Implantable Pulse Generator and Leads]]
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Spinal cord stimulation (SCS) is a treatment method which targets to stimulate the spinal cord for various conditions.<ref name=":1" /> Based on the [[Gate Control Theory of Pain|gate control theory of pain]], the first device for SCS was introduced in 1968. <ref name=":0">Pérez JT. [https://www.sciencedirect.com/science/article/pii/S2173580821000663?via%3Dihub#bib0105 Spinal cord stimulation: beyond pain management]. Neurología (English Edition). 2022 Sep 1;37(7):586-95.</ref>


== Description  ==
In this method, the spinal cord is exposed to electrical stimulation either invasively (Epidural Spinal Cord Stimulation, eSCS) or noninvasively (Transcutaneous Spinal Cord Stimulation, tSCS).
 
== Action Mechanisms ==


The eSCS  involves the implantation of a '''pulse generator''' that applies electric impulses, and  '''stimulation leads''', a cable to connect the leads to a generator. <ref name=":1">Dydyk AM, Tadi P. [https://www.ncbi.nlm.nih.gov/books/NBK555994/#:~:text=The%20equipment%20needed%20for%20spinal,are%20various%20types%20of%20generators. Spinal cord stimulator implant.]
</ref> In TSCS, surface electrodes are used instead. <ref>Meyer C, Hofstoetter US, Hubli M, Hassani RH, Rinaldo C, Curt A, Bolliger M. [https://www.mdpi.com/2077-0383/9/11/3541 Immediate effects of transcutaneous spinal cord stimulation on motor function in chronic, sensorimotor incomplete spinal cord injury]. Journal of clinical medicine. 2020 Nov 2;9(11):3541.</ref>
== Stimulation Paradigms ==
== Stimulation Paradigms ==
The electrical impulses created by the pulse generator can be modified after the surgery. <ref name=":1" /> The stimulation can be applied through different stimulation paradigms including '''tonic''' (conventional), '''burst''' (also known as paraesthesia-free stimulation) and '''high-frequency''' stimulation. <ref name=":0" />


=== Tonic / Conventional Stimulation ===
The table below is an example of  the frequency, pulse width and amplitude numbers that can be used in the three different modes of the SCS.
 
{| class="wikitable"
* Generates paraesthesia in the target area.
|+
* Frequency: 35-80 Hz
!
* Pulse width: 200-450 μs
!'''Tonic Stimulation'''
* Amplitude: 5-6 mA
!'''Burst Stimulation'''
 
!'''High Frequency Stimulation'''
=== Burst Stimulation ===
|-
|'''Frequency'''
|35-80 Hz
|Low frequencies (40 Hz) with 5 closely spaced pulses (1 ms) at 500 Hz per burst, or 3 pulses at 100 Hz, followed by a repolarisation phase.
|10 000 Hz
|-
|'''Pulse width'''
|200-450 μs
|
|30 ms
|-
|'''Amplitude'''
|5-6 mA
|
|Low amplitude (approximately 2-3 A)
|}


* Also known as paraesthesia-free stimulation.
The important findings about these paradigms are:
* Activates some brain areas, including the dorsal anterior cingulate and the dorsolateral precentral cortex.
* Low frequencies (40 Hz) with 5 closely spaced pulses (1 ms) at 500 Hz per burst, or 3 pulses at 100 Hz, followed by a repolarisation phase.
* Compared to tonic stimulation, provides a lower charge per pulse and, at the same time, a higher charge per second. The higher charge per second modulates the neurons involved in pain transmission.


=== High Frequency Stimulation ===
* Tonic Stimulation generates paraesthesia in the target area. <ref>Miller JP, Eldabe S, Buchser E, Johanek LM, Guan Y, Linderoth B. Parameters of spinal cord stimulation and their role in electrical charge delivery: a review. Neuromodulation: Technology at the Neural Interface. 2016 Jun 1;19(4):373-84.</ref>
* Burst Stimulation activates some brain areas such as the dorsal anterior cingulate and the dorsolateral precentral cortex. <ref>De Ridder D, Plazier M, Kamerling N, Menovsky T, Vanneste S. Burst spinal cord stimulation for limb and back pain. World neurosurgery. 2013 Nov 1;80(5):642-9.</ref>
* Burst Stimulation provides greater pain relief over tonic stimulation. <ref>Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544556/ Burst spinal cord stimulation: a clinical review. Pain Medicine]. 2019 Jun 1;20(Supplement_1):S31-40.</ref> 
* High Frequency Stimulation may be more comfortable over tonic stimulation because of the absence of paraesthesia. <ref name=":0" />


* Frequency: 10 000 Hz
== Clinical Use ==
* Pulse width: 30 ms
{| class="wikitable"
* Low amplitude (approximately 2-3 A)
|+
* The advantages over tonic stimulation are still controversial, although it is clear that the absence of paraesthesia may make it more comfortable.
!'''Indications For Pain Management''' <ref name=":0" />
 
!'''Non-Pain-Related Indications <ref name=":0" />'''
== Indications  ==
!'''Absolute Contraindications''' <ref name=":1" />
 
!'''Relative Contraindications''' <ref name=":1" />
=== Indications For Pain Management ===
|-
 
|
* Failed back surgery syndrome, radiculopathy, and lumbago
*Failed back surgery syndrome, [[radiculopathy]], and lumbago
* Complex regional pain syndrome
* [[Complex Regional Pain Syndrome (CRPS)|Complex regional pain syndrome]]
* Diabetic neuropathy and other neuropathies
* [[Diabetic Neuropathy|Diabetic neuropathy]] and other neuropathies
* Phantom limb pain
* [[Phantom Limb Pain|Phantom limb pain]]
* Angina pectoris and peripheral vascular disease
* Angina pectoris and peripheral vascular disease
* Neuropathic pain secondary to tumour
* [[Neuropathic Pain|Neuropathic pain]] secondary to tumour  
 
|
=== Non-Pain-Related Indications ===
* [[Parkinson's|Parkinson’s disease]] and other movement disorders
* [[Spasticity]]
* Spinal trauma rehabilitation
|
* Severe thrombocytopenia
* Uncontrolled coagulopathy
* Active infection
|
* Pacemaker
* Cardiac defibrillator
|}


* Parkinson’s disease and other movement disorders
== Evidence ==
* Spasticity
Stimulating the spine with epidural stimulation can bring about changes in the excitability of the spinal and supraspinal networks. By adjusting the stimulation parameters, it is possible to facilitate standing or stepping, as well as potentially enhancing several other functions related to sensory, motor and autonomic systems. <ref>Hachmann JT, Yousak A, Wallner JJ, Gad PN, Edgerton VR, Gorgey AS. [https://journals.physiology.org/doi/full/10.1152/jn.00020.2021 Epidural spinal cord stimulation as an intervention for motor recovery after motor complete spinal cord injury]. Journal of Neurophysiology. 2021 Dec 1;126(6):1843-59.</ref>
* Spinal trauma rehabilitation


== Resources  ==
A review study <ref>Streumer J, Selvaraj AK, Kurt E, Bloem BR, Esselink RA, Bartels RH, Georgiev D, Vinke RS. [https://www.sciencedirect.com/science/article/pii/S1353802023000548 Does spinal cord stimulation improve gait in Parkinson's disease: A comprehensive review.] Parkinsonism & Related Disorders. 2023 Feb 27:105331.</ref> that included 25 studies with total 103 participants with Parkinson's Disease (PD) concluded that, the gait of most PD patients with concurrent pain complaints improved with spinal cord stimulation.
[[Percutaneous Electrical Nerve Stimulation]]


== References  ==
== References  ==
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[[Category:Interventions]]
[[Category:Interventions]]
[[Category:Pain]]
[[Category:Pain]]
[[Category:Neurological - Interventions]]

Latest revision as of 00:27, 3 April 2024

Original Editor - Sehriban Ozmen

Top Contributors - Sehriban Ozmen  

Introduction[edit | edit source]

Implantable Pulse Generator and Leads

Spinal cord stimulation (SCS) is a treatment method which targets to stimulate the spinal cord for various conditions.[1] Based on the gate control theory of pain, the first device for SCS was introduced in 1968. [2]

In this method, the spinal cord is exposed to electrical stimulation either invasively (Epidural Spinal Cord Stimulation, eSCS) or noninvasively (Transcutaneous Spinal Cord Stimulation, tSCS).

The eSCS involves the implantation of a pulse generator that applies electric impulses, and stimulation leads, a cable to connect the leads to a generator. [1] In TSCS, surface electrodes are used instead. [3]

Stimulation Paradigms[edit | edit source]

The electrical impulses created by the pulse generator can be modified after the surgery. [1] The stimulation can be applied through different stimulation paradigms including tonic (conventional), burst (also known as paraesthesia-free stimulation) and high-frequency stimulation. [2]

The table below is an example of the frequency, pulse width and amplitude numbers that can be used in the three different modes of the SCS.

Tonic Stimulation Burst Stimulation High Frequency Stimulation
Frequency 35-80 Hz Low frequencies (40 Hz) with 5 closely spaced pulses (1 ms) at 500 Hz per burst, or 3 pulses at 100 Hz, followed by a repolarisation phase. 10 000 Hz
Pulse width 200-450 μs 30 ms
Amplitude 5-6 mA Low amplitude (approximately 2-3 A)

The important findings about these paradigms are:

  • Tonic Stimulation generates paraesthesia in the target area. [4]
  • Burst Stimulation activates some brain areas such as the dorsal anterior cingulate and the dorsolateral precentral cortex. [5]
  • Burst Stimulation provides greater pain relief over tonic stimulation. [6]
  • High Frequency Stimulation may be more comfortable over tonic stimulation because of the absence of paraesthesia. [2]

Clinical Use[edit | edit source]

Indications For Pain Management [2] Non-Pain-Related Indications [2] Absolute Contraindications [1] Relative Contraindications [1]
  • Severe thrombocytopenia
  • Uncontrolled coagulopathy
  • Active infection
  • Pacemaker
  • Cardiac defibrillator

Evidence[edit | edit source]

Stimulating the spine with epidural stimulation can bring about changes in the excitability of the spinal and supraspinal networks. By adjusting the stimulation parameters, it is possible to facilitate standing or stepping, as well as potentially enhancing several other functions related to sensory, motor and autonomic systems. [7]

A review study [8] that included 25 studies with total 103 participants with Parkinson's Disease (PD) concluded that, the gait of most PD patients with concurrent pain complaints improved with spinal cord stimulation.

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Dydyk AM, Tadi P. Spinal cord stimulator implant.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Pérez JT. Spinal cord stimulation: beyond pain management. Neurología (English Edition). 2022 Sep 1;37(7):586-95.
  3. ↑ Meyer C, Hofstoetter US, Hubli M, Hassani RH, Rinaldo C, Curt A, Bolliger M. Immediate effects of transcutaneous spinal cord stimulation on motor function in chronic, sensorimotor incomplete spinal cord injury. Journal of clinical medicine. 2020 Nov 2;9(11):3541.
  4. ↑ Miller JP, Eldabe S, Buchser E, Johanek LM, Guan Y, Linderoth B. Parameters of spinal cord stimulation and their role in electrical charge delivery: a review. Neuromodulation: Technology at the Neural Interface. 2016 Jun 1;19(4):373-84.
  5. ↑ De Ridder D, Plazier M, Kamerling N, Menovsky T, Vanneste S. Burst spinal cord stimulation for limb and back pain. World neurosurgery. 2013 Nov 1;80(5):642-9.
  6. ↑ Kirketeig T, Schultheis C, Zuidema X, Hunter CW, Deer T. Burst spinal cord stimulation: a clinical review. Pain Medicine. 2019 Jun 1;20(Supplement_1):S31-40.
  7. ↑ Hachmann JT, Yousak A, Wallner JJ, Gad PN, Edgerton VR, Gorgey AS. Epidural spinal cord stimulation as an intervention for motor recovery after motor complete spinal cord injury. Journal of Neurophysiology. 2021 Dec 1;126(6):1843-59.
  8. ↑ Streumer J, Selvaraj AK, Kurt E, Bloem BR, Esselink RA, Bartels RH, Georgiev D, Vinke RS. Does spinal cord stimulation improve gait in Parkinson's disease: A comprehensive review. Parkinsonism & Related Disorders. 2023 Feb 27:105331.
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