An Era of Unimaginable Possibilities

“All of [these] advancements in neurostimulation offer treatment tailoring to patient selection characteristics, while focusing on maximizing the number needed to treat,” lead author Jason Pope, MD, president of Summit Pain Alliance in Santa Rosa, CA, told Clinical Pain Advisor.

“We are in an era of unimaginable possibilities, with the patient becoming the clear winner. For example, when a patient now presents to a pain clinician with peripheral causalgia of the lower extremity or with CRPS types 1 or 2, and is offered a trial, the patient has an 81% chance of achieving more than 50% pain relief in the affected extremity,” Dr Pope said.


Continue Reading

“To slice it a different way, if the patient is offered a permanent therapy (implant), there is a 93% chance that the patient will obtain 50% pain reduction or better. That is a game changer,” Dr Pope explained.

As neuromodulation techniques continue to evolve and more data becomes available, the approach is likely to gain a more prominent place in pain management algorithms.

Dr McRoberts emphasized that these are “exciting times” in neuromodulation research.

“In the past 5 years, there have been more innovations in neuromodulation than over the past 45 years combined, and the results are a profoundly improved experience for the patient,” Dr McRoberts concluded, indicating that the upswing in development is not expected to slow down any day soon.

Table. Types and Appropriate Use of Neuromodulation for Hand Pain

Type

Description

Appropriate Use*

Conventional spinal cord stimulation (SCS)

Leads are placed within the neuraxis epidural space to stimulate the dorsal columns of the spinal cord.

For neuropathic

pain emanating from the neck and upper extremity, potentially including:

·        Cervical radiculopathy

·        Brachial plexus avulsion injuries

·        Complex regional pain syndrome (type 1 and type 2 causalgia)

Dorsal root ganglion (DRG) spinal stimulation

Leads are placed within the epidural space of the neuraxis to stimulate the dorsal root ganglion of the spinal cord.

To provide more refined treatment of hand and upper extremity pain, such as by offering more specific dermatographic stimulation.

Peripheral nerve stimulation (PNS)

Leads are placed to stimulate the peripheral nerves outside of the neuroaxis.

For neuropathic pain of the hand following a peripheral nerve injury, including distal and proximal nerve injuries.

*Neuromodulation should only be used after conservative treatments have failed. These might include physical therapy or occupational therapy, ultrasound-guided injections, transcutaneous electrical stimulation, drug therapy (eg, NSAIDs, neuropathic pain medications, opioid analgesics, oral corticosteroids), and surgery, as appropriate.

Conflicts of Interest: Dr. Pope is a consultant for Medtronic, St. Jude, Flowonix, and Jazz Pharmaceuticals. Dr. Provenzano is a consultant for Halyard Health, Medtronic, St. Jude Medical, and Trevena. Dr. McRoberts is a consultant for St. Jude, Medtronic, Flowonix, and SPR therapeutics, and is a minor stockholder in Nevro. Dr. Deer is a consultant for Bioness, Nevro, Medtronic, St. Jude, Flowonix, and Jazz, and a minor stockholder in Nevro, Bioness, Spinal Therapeutics, and Axonics.

References

1. Pope JE, Provenzano D, McRoberts P, Deer T. The Proper Use of Neurostimulation for Hand Pain. Hand Clin. 2016;32(1):81-90. doi: 10.1016/j.hcl.2015.08.009.

2. ClinicalTrials.gov. Clinical Trial of the Senza™ SCS System in the Treatment of Chronic Upper Limb and Neck Pain (SENZA-ULN) (NCT02385201). https://clinicaltrials.gov/ct2/show/NCT02385201. Accessed January 23, 2016.

3. US Food and Drug Administration. FDA approves spinal cord stimulation system that treats pain without tingling sensation [press release]. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm446354.htm. Published May 8, 2015. Accessed January 23, 2016.

4. Bioness. Bioness Announces FDA 510K clearance of StimRouter® System; a novel, implantable neuromodulation device designed to treat chronic peripheral pain [new release]. http://www.businesswire.com/news/home/20150224005781/en/Bioness-Announces-FDA-510K-Clearance-StimRouter%C2%AE-System. Published February 24, 2015. Accessed January 25, 2016.