Spinal Cord Stimulation Explantation and Chronic Pain: A Systematic Review and Technology Recommendations

Sayed E Wahezi,1 Ugur Yener,1 Tahereh Naeimi,1 Joshua B Lewis,1 Sandeep Yerra,1 Philip Sgobba,2 Hatice Begum Ciftci,3 Amaresh Vydyanathan,2 Elisa Chiu,1 Denis Cherkalin,4 Jay Y Darji,5 Ryan Masterson,6 Danielle Lee,7 Atthakorn Jarusriwanna,8 Suwannika Palee,9 Nicole R Ortiz,10 Moorice Caparo,1 Eli Dayon,11 Camille Fontaine,2 Marom Bikson,12 Michael E Schatman,13 Scott G Pritzlaff,14 Timothy R Deer,15 Corey W Hunter16 1Department of Physical Medicine & Rehabilitation, Montefiore Medical Center, Bronx, NY, USA; 2Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, USA; 3Physical Medicine and Rehabilitation, ROMMER International Physical Therapy and Rehabilitation Medical Center, Bursa, Turkey; 4Pain Management, New York Spine Specialist, New York, NY, USA; 5Pain Management, Regenerative Spine and Pain Institute, Plainsboro Township, NJ, USA; 6Pain Management, Old Mill District Clinic, Summit Health, Bend, OR, USA; 7Department of Neurology, Hackensack University Medical Center, Hackensack, NJ, USA; 8Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; 9Department of Rehabilitation Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand; 10Pain Management, Sage Pain & Wellness Institute, San Diego, CA, USA; 11Department of Physical Medicine & Rehabilitation, Burke Rehabilitation Hospital, White Plains, NY, USA; 12Department of Biomedical Engineering, the City College of New York, New York, NY, USA; 13Department of Anesthesiology, Perioperative Care and Pain Medicine, Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA; 14Department of Anesthesiology and Pain Medicine, University of California, Davis, CA, USA; 15The Spine and Nerve Center of the Virginias, West Virginia University Hospitals, Charleston, WV, USA; 16Ainsworth Institute of Pain Management, Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USACorrespondence: Sayed E Wahezi, Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, 1250 Waters Place, Tower #2  8th Floor, Bronx, NY, 10461, USA, Tel +1 718-920-7246, Fax +1 929-263-3950, Email [email protected]: Chronic pain affects 20.5% of the US population, costing $296 billion annually in lost productivity. Spinal cord stimulation (SCS) has become a key treatment for refractory neuropathic and nociceptive pain, with increasing usage due to technological advancements. However, the durability of SCS therapy, including explantation rates, remains a concern. Understanding explantation causes is essential for improving patient selection and device effectiveness. This study aims to analyze SCS explantation rates and reasons, as well as evaluate the financial burden of these procedures on the healthcare system.Methods: Three primary screening methods were used: manual search with keywords, MeSH term query, and reference list screening. The search covered PubMed, Cochrane, and Web of Science databases from inception to November 2024, yielding 719 articles. After applying eligibility criteria, 72 articles were identified, and 25 were selected for analysis. Data extraction was done by independent reviewers, with a second reviewer ensuring accuracy. Discrepancies were resolved by the corresponding editor.Results: We reviewed data from 13,026 patients who underwent permanent SCS implantation between 1984 and 2024, across 25 studies. A total of 1882 patients (9.82$35,000 to $70,000) and revision costs ($15,000 to $25,000) raise concerns among payors. The hardware-driven model limits waveform flexibility, highlighting the need for innovation.Keywords: chronic pain, spinal cord stimulation, explantation, implant removal, cost-effectivenes

In vitro and in vivo effects of serine and threonine on follicle growth, differentiation and atresia

This work was designed to test the effect of serine and threonine on follicle growth, differentiation and atresia under in vitro and in vivo conditions. Two experiments were conducted. In the first experiment, follicles 90-120 mum in diameter, from 21-day old mice, were dissected mechanically and cultured individually for 7 days. Follicles were subjected to 4 different treatments. Follicles in medium without amino acids and gonadotrophins were assigned as control groups. Follicles in medium with PMSG and without amino acids constituted a positive control whereas the other treatments were test groups. Every 24 h follicle diameters were measured and the media was changed. In the second experiment, the mice were injected daily with 0.2 ml of saline (control) or saline with a mixture of serine and threonine (test) for 5 days. After the last injection, the mice were cervically dislocated and the ovaries were removed and then stained with haematoxylin and eosin. The numbers of activated primordial follicles, primary follicles, preantral follicles, antral follicles and atretic follicles were blind counted in every 7 sections. In culture, neither of the treatments significantly increased the diameters of the follicles over those of the control group. According to the results of the second experiment, the injection of serine/threonine significantly reduced the number of activated primordial follicles entering the primary stage of growth, but after the primary stage the growth rate increased in the amino acid injected animals. Preantral follicle growth beyond the secondary stage was stimulated by amino acid injection and more follicles went through to the antral stage. As the growth rate increased, the number of atretic follicles was also increased by amino acid injection. In the early antral stage, the number of atretic follicles in the test animals was significantly lower, because atresia in the test group occurred mostly in the late antral stage

Comparison of Tc-99m-methoxyisobutyl isonitrile and Tl-201 scintigraphy in visualization of suppressed thyroid tissue

Both (TI)-T-201 and Tc-99m-methoxyisobutyl isonitrile (MIBI) have been used in the visualization of suppressed thyroid tissue in patients with autonomously functioning thyroid nodules (AFTNs). It has been suggested that thyroid-stimulating hormone (TSH) control is not a major determinant of both tracers. However, the mechanism of thyroid uptake of these agents is controversial. In this study, we compared (TI)-T-201 and MIBI in the visualization of suppressed thyroid tissue in patients with a solitary toxic AFTN. Methods: Thirty-two patients (13 triiodothyronine [T-3] and 19 T-3 + levorotatory thyroxine [T-4] hyperthyroid patients) with toxic AFTNs Visualized on Tc-99m-pertechnetate scanning were included in the study. All patients underwent MIBI and (TI)-T-201 thyroid scintigraphy within a 3-d interval. The scintigrams were analyzed both visually and semiquantitatively. For the semiquantitative analysis, regions of interest (ROIs) were generated over the nodule (N) and contralateral normal lobe (E), and the mean counts in each ROI were calculated. Results: The N/E uptakes (mean +/- SD) for pertechnetate, MIBI, and (TI)-T-201 were 11.37 +/- 4.53, 4.76 +/- 1.33, and 1.63 +/- 0.15, respectively, in T-3 +/- T-4 hyperthyroid patients and 9.46 +/- 3.64, 2.73 +/- 0.63, and 1.57 +/- 0.23, respectively, in T-3 hyperthyroid patients. Our results showed that (TI)-T-201 uptake of suppressed thyroid tissue compared with AFTN was more prominent and significantly higher than that of MIBI for both groups of patients (P = 1.08E-05 for T-3 and 6.15E-09 for T-3 + T-4 hyperthyroidism). There was no significant difference for either pertechnetate or (TI)-T-201 (P > 0.05) when the N/E uptakes of both groups of patients were compared. However, the N/E uptake of MIBI in T-3 + T-4 hyperthyroid patients was significantly higher than that in T-3 hyperthyroid patients (P = 6.69E-06). Conclusion: Clear Visualization of suppressed thyroid tissue with both (TI)-T-201 and MIBI in patients with low serum concentrations of TSH suggests that TSH is not a major factor in the thyroid uptake of either agent. (TI)-T-201 is superior to MIBI in the visualization of suppressed thyroid tissue in patients with a toxic thyroid nodule. An increased rate of metabolism in the follicular cells of AFTNs in T-3 + T-4 hyperthyroid patients compared with that in T-3 hyperthyroid patients might be responsible for the higher N/E for MIBI compared with that for (TI)-T-201

Comparison of Tc-99m-methoxyisobutyl isonitrile and Tl-201 scintigraphy in visualization of suppressed thyroid tissue

Both (TI)-T-201 and Tc-99m-methoxyisobutyl isonitrile (MIBI) have been used in the visualization of suppressed thyroid tissue in patients with autonomously functioning thyroid nodules (AFTNs). It has been suggested that thyroid-stimulating hormone (TSH) control is not a major determinant of both tracers. However, the mechanism of thyroid uptake of these agents is controversial. In this study, we compared (TI)-T-201 and MIBI in the visualization of suppressed thyroid tissue in patients with a solitary toxic AFTN. Methods: Thirty-two patients (13 triiodothyronine [T-3] and 19 T-3 + levorotatory thyroxine [T-4] hyperthyroid patients) with toxic AFTNs Visualized on Tc-99m-pertechnetate scanning were included in the study. All patients underwent MIBI and (TI)-T-201 thyroid scintigraphy within a 3-d interval. The scintigrams were analyzed both visually and semiquantitatively. For the semiquantitative analysis, regions of interest (ROIs) were generated over the nodule (N) and contralateral normal lobe (E), and the mean counts in each ROI were calculated. Results: The N/E uptakes (mean +/- SD) for pertechnetate, MIBI, and (TI)-T-201 were 11.37 +/- 4.53, 4.76 +/- 1.33, and 1.63 +/- 0.15, respectively, in T-3 +/- T-4 hyperthyroid patients and 9.46 +/- 3.64, 2.73 +/- 0.63, and 1.57 +/- 0.23, respectively, in T-3 hyperthyroid patients. Our results showed that (TI)-T-201 uptake of suppressed thyroid tissue compared with AFTN was more prominent and significantly higher than that of MIBI for both groups of patients (P = 1.08E-05 for T-3 and 6.15E-09 for T-3 + T-4 hyperthyroidism). There was no significant difference for either pertechnetate or (TI)-T-201 (P > 0.05) when the N/E uptakes of both groups of patients were compared. However, the N/E uptake of MIBI in T-3 + T-4 hyperthyroid patients was significantly higher than that in T-3 hyperthyroid patients (P = 6.69E-06). Conclusion: Clear Visualization of suppressed thyroid tissue with both (TI)-T-201 and MIBI in patients with low serum concentrations of TSH suggests that TSH is not a major factor in the thyroid uptake of either agent. (TI)-T-201 is superior to MIBI in the visualization of suppressed thyroid tissue in patients with a toxic thyroid nodule. An increased rate of metabolism in the follicular cells of AFTNs in T-3 + T-4 hyperthyroid patients compared with that in T-3 hyperthyroid patients might be responsible for the higher N/E for MIBI compared with that for (TI)-T-201