Wyniki neuromodulacyjnego leczenia bólu przewlekłego

Background and purpose Neuromodulative treatment of chronic pain syndromes is a modern mode of treatment of neuropathic and ischaemic pain. Its effectiveness is well documented in the literature. The objective of this work is to present the results of treatment of chronic pain syndromes on the basis of eight-year experience in our department. Material and methods Since 2002, we have conducted 9 operations of motor cortex stimulation (MCS), 2 of deep brain stimulation (DBS), 45 of spinal cord stimulation (SCS) and 5 of sacral root stimulation (SRS) in the treatment of chronic pain. Results We obtained good long-term results of neuromodulation in the form of clinical improvement (> 50%) in 4 of 9 patients with MCS (44%), in 13 diagnosed with failed back surgery syndrome (FBSS), 8 with other neuropathic pain, and 11 with angina pectoris from a group of 45 treated with SCS. Sacral root stimulation has been successful in 3 of 5 patients with perianal pain. The best treatment results in SCS, although not statistically significant, were observed in patients treated due to FBSS (13 out of 15) and angina pectoris (11 out of 15) (p = 0.12). In patients with neuropathic pain, peripheral and central, improvement was obtained in 8 out of 15 patients. Conclusions A good indication for spinal cord stimulation is FBSS and angina pectoris. Motor cortex stimulation is helpful in the treatment of chronic central neuropathic pain. Further observations and a larger group of patients are necessary for a reliable assessment of the effectiveness of neuromodulative treatment of chronic pain in our clinic.Wstęp i cel pracy Neuromodulacyjne leczenie bólu przewlekłego to nowoczesna forma leczenia bólu neuropatycznego i niedokrwiennego. Jego efektywność została dobrze udokumentowana w piśmiennictwie. Celem pracy jest przedstawienie wyników leczenia przewlekłych zespołów bólowych na podstawie ośmioletniego doświadczenia kliniki autorów. Materiał i metody Od 2002 r. w leczeniu bólu przewlekłego przeprowadzono 9 zabiegów stymulacji kory mózgu (MCS), 2 głębokiej stymulacji mózgu (DBS), 45 stymulacji rdzenia kręgowego (SCS) i 5 stymulacji korzeni krzyżowych (SRS). Wyniki Otrzymano dobre odległe wyniki neuromodulacji w postaci poprawy klinicznej (co najmniej o 50%) u 4 spośród 9 pacjentów z MCS (44%), u 13 z rozpoznaniem dyskopatii lędźwiowej (FBSS) oraz u 8 z innym bólem neuropatycznym, a także u 11 z dusznicą bolesną z grupy 45 poddanych SCS. Stymulacja korzeni krzyżowych była skuteczna u 3 spośród 5 pacjentek z bólem okolicy okołoodbytniczej. Najlepsze wyniki leczenia, choć nieznamienne statystycznie, zaobserwowano w SCS u pacjentów leczonych z powodu zespołu bólowego kręgosłupa o typie FBSS (13 spośród 15 pacjentów) oraz dławicy piersiowej (11 spośród 15) (p = 0,12). W grupie pacjentów z bólem neuropatycznym obwodowym i ośrodkowym poprawę uzyskano u 8 spośród 15 osób. Wnioski Dobrymi wskazaniami do stymulacji rdzenia kręgowego są przewlekły zespół bólowy o typie FBSS i dusznica bolesna. Stymulację kory mózgu można z powodzeniem stosować w leczeniu ośrodkowego bólu neuropatycznego. Do przeprowadzenia wiarygodnej oceny skuteczności leczenia neuromodulacyjnego bólu przewlekłego w klinice autorów niezbędne są dalsze obserwacje i większa grupa pacjentów poddanych różnym procedurom

Nucleus accumbens stimulation in pathological obesity

One of the potential treatment methods of obesity is deep brain stimulation (DBS) of nucleus accumbens. We describe the case of 19 years old woman with hypothalamic obesity. She weighted 151.4kg before DBS and the non-surgical methods proved to be inefficient. She was treated with implantation of DBS electrode to nucleus accumbens bilaterally. Results were measured with body mass index and neuropsychological tests. Follow-up was 14 months. Fourteen months after surgery weight was 138kg, BMI was 48.3. Neuropsychological test results were intact. The presented case supports the thesis of treatment of obesity with nucleus accumbens stimulation

Results of treatment of refractory depression by left vagus nerve stimulation – report of two cases

Zaburzenia depresyjne zajmują 4. miejsce pod względem częstości występowania na świecie wśród chorób powodujących niepełnosprawność. Są związane ze wzrostem zachorowalności i śmiertelności nie tylko z powodu zwiększonego ryzyka samobójstwa, lecz także wystąpienia powikłań kardiologicznych i udarów mózgu. Depresja powoduje również negatywne skutki ekonomiczne ze względu na wyłączenie, często na zawsze, leczonych osób z aktywności zawodowej. Chorzy na depresję zdecydowanie częściej wymagają konsultacji specjalistycznych i hospitalizacji. Średnio ponad 1/3 chorych słabo lub w ogóle nie odpowiada na leczenie zachowawcze i może być potencjalnie leczona za pomocą stymulacji nerwu błędnego. Procedura ta w marcu 2001 r. została uznana w Europie za metodę leczenia depresji u chorych opornych na leczenie zachowawcze lub nietolerujących leczenia, zarówno w przypadkach dużych epizodów depresyjnych, jak i w chorobie dwubiegunowej. W Stanach Zjednoczonych w lipcu 2005 r. Food and Drag Administration zatwierdziła tę metodę jako leczenie wspomagające długoterminowe przewlekłej lekoopornej depresji bądź nawracających dużych epizodów depresyjnych opornych na leczenie zachowawcze u osób od 18. roku życia, u których nie stwierdzono poprawy po zastosowaniu co najmniej czterech schematów leczenia przeciwdepresyjnego. W poniższym doniesieniu przedstawiono opis dwóch chorych na depresję leczonych stymulacją lewego nerwu błędnego

Comparison of the O-arm and C-arm guided pedicle screws placement

Background Transpedicular screw placement remains the gold standard technique for destabilization of the lumbar spine. Material and methods This is a retrospective study that analyzes patients that underwent the spinal stabilization surgical procedure. We compared results from two independent neurosurgical centers. At the turn of years 2012-2015, O-arm and StealthStation neuronavigation system was used for implantation of transpedicular screws. In 2018 to 2020 transcutaneous pedicle screw placement procedure was performed using standard C-arm device. Results In 208 procedures performed with the O-arm device, the accuracy of the positioning of the screws was 98.08 %. Screw repositioning was necessary in 1.92 % of all cases. In 30 procedures that were performed using the C-arm, the accuracy of the screws was 86.7% and the screw reposition procedure accounted for 10% (in one case crews were not replaced due to clinical sequelae). Conclusions Our data show that the spinal fusion with the O-arm tool has more accuracy, thus might be more indicated in procedures that require minimally invasive spinal stabilization

The Impact of Electrical Stimulation of the Brain and Spinal Cord on Iron and Calcium-Phosphate Metabolism

Background: Deep-brain stimulation (DBS) electrically modulates the subcortical brain regions. Under conditions of monopolar cerebral stimulation, electrical current flows between electrode’s contacts and an implantable pulse generator, placed in the subclavicular area. Spinal cord stimulation (SCS) delivers an electrical current to the spinal cord. Epidural electrical stimulation is associated with the leakage of current, which can cause a generalized reaction. The aim of our study was to investigate whether the electrical stimulation of the cerebrum and spinal cord could have generalized effects on biochemical parameters. Materials and methods: A total of 25 patients with Parkinson’s disease (PD, n = 21) and dystonia (n = 4), who underwent DBS implantation, and 12 patients with chronic pain, who had SCS, received electrical stimulation. The blood levels of selected biochemical parameters were measured before and after overnight stimulation. Results: After DBS, the mean ± interquartile range (IQR) values for iron (off 15.6 ± 13.53 µmol/L; on: 7.65 ± 10.8 µmol/L; p < 0.001), transferrin (off: 2.42 ± 0.88 g/L; on: 1.99 ± 0.59 g/L; p < 0.001), transferrin saturation (off: 23.20 ± 14.50%; on: 10.70 ± 11.35%; p = 0.001), phosphate (off: 1.04 ± 0.2 mmol/L; on: 0.83 ± 0.2 mmol/L; p = 0.007), and total calcium (off: 2.39 ± 0.29 mmol/L; on: 2.27 ± 0.19 mmol/L; p = 0.016) were significantly reduced, whereas ferritin (off: 112.00 ± 89.00 ng/mL; on: 150.00 ± 89.00 ng/mL; p = 0.003) and C-reactive protein (off: 0.90 ± 19.39 mg/L; on: 60.35 ± 35.91 mg/L; p = 0.002) were significantly increased. Among patients with SCS, significant differences were observed for ferritin (off: 35 ± 63 ng/mL; on: 56 ± 62 ng/mL; p = 0.013), transferrin (off: 2.70 ± 0.74 g/L; on: 2.49 ± 0.69 g/L; p = 0.048), and C-reactive protein (off: 31.00 ± 36.40 mg/L; on: 36.60 ± 62.030 mg/L; p = 0.018) before and after electrical stimulation. No significant changes in the examined parameters were observed among patients after thalamotomy and pallidotomy. Conclusions: Leaking electric current delivered to the subcortical nuclei of the brain and the dorsal column of the spinal cord exposes the rest of the body to a negative charge. The generalized reaction is associated with an inflammatory response and altered iron and calcium-phosphate metabolism. Alterations in iron metabolism due to electrical stimulation may impact the course of PD. Future research should investigate the influence of electric current and electromagnetic field induced by neurostimulators on human metabolism

The Impact of Electrical Stimulation of the Brain and Spinal Cord on Iron and Calcium-Phosphate Metabolism

Background: Deep-brain stimulation (DBS) electrically modulates the subcortical brain regions. Under conditions of monopolar cerebral stimulation, electrical current flows between electrode’s contacts and an implantable pulse generator, placed in the subclavicular area. Spinal cord stimulation (SCS) delivers an electrical current to the spinal cord. Epidural electrical stimulation is associated with the leakage of current, which can cause a generalized reaction. The aim of our study was to investigate whether the electrical stimulation of the cerebrum and spinal cord could have generalized effects on biochemical parameters. Materials and methods: A total of 25 patients with Parkinson’s disease (PD, n = 21) and dystonia (n = 4), who underwent DBS implantation, and 12 patients with chronic pain, who had SCS, received electrical stimulation. The blood levels of selected biochemical parameters were measured before and after overnight stimulation. Results: After DBS, the mean ± interquartile range (IQR) values for iron (off 15.6 ± 13.53 µmol/L; on: 7.65 ± 10.8 µmol/L; p p p = 0.001), phosphate (off: 1.04 ± 0.2 mmol/L; on: 0.83 ± 0.2 mmol/L; p = 0.007), and total calcium (off: 2.39 ± 0.29 mmol/L; on: 2.27 ± 0.19 mmol/L; p = 0.016) were significantly reduced, whereas ferritin (off: 112.00 ± 89.00 ng/mL; on: 150.00 ± 89.00 ng/mL; p = 0.003) and C-reactive protein (off: 0.90 ± 19.39 mg/L; on: 60.35 ± 35.91 mg/L; p = 0.002) were significantly increased. Among patients with SCS, significant differences were observed for ferritin (off: 35 ± 63 ng/mL; on: 56 ± 62 ng/mL; p = 0.013), transferrin (off: 2.70 ± 0.74 g/L; on: 2.49 ± 0.69 g/L; p = 0.048), and C-reactive protein (off: 31.00 ± 36.40 mg/L; on: 36.60 ± 62.030 mg/L; p = 0.018) before and after electrical stimulation. No significant changes in the examined parameters were observed among patients after thalamotomy and pallidotomy. Conclusions: Leaking electric current delivered to the subcortical nuclei of the brain and the dorsal column of the spinal cord exposes the rest of the body to a negative charge. The generalized reaction is associated with an inflammatory response and altered iron and calcium-phosphate metabolism. Alterations in iron metabolism due to electrical stimulation may impact the course of PD. Future research should investigate the influence of electric current and electromagnetic field induced by neurostimulators on human metabolism

Structural Connectivity Reorganization Based on DTI after Cingulotomy in Obsessive–Compulsive Disorder

Bilateral cingulotomy is a procedure applied to patients with obsessive–compulsive disorder (OCD). This report presents the structural changes occurring within the forceps minor and arcuate fascicles nerve fibers after a successful bilateral anterior cingulotomy in the patient with refractory OCD. Cingulotomy mainly affects the values of FA, MD, and ADC in the treatment of the examined nerve bundles. This structural reorganization coexists with a good clinical effect. However, it is necessary to expand the study group and to investigate the correlation between the parameters of diffusion and anisotropy and the patient’s clinical condition (Y-BOCS scale)

Sub-Perception and Supra-Perception Spinal Cord Stimulation in Chronic Pain Syndrome: A Randomized, Semi-Double-Blind, Crossover, Placebo-Controlled Trial

Background: The introduction of modern sub-perception modalities has improved the efficacy of spinal cord stimulation (SCS) in refractory pain syndromes of the trunk and lower limbs. The objective of this study was to evaluate the effectiveness of low and high frequency SCS among patients with chronic pain. Material and methods: A randomised, semi-double-blind, placebo controlled, four period (4 × 2 weeks) crossover trial was conducted from August 2018 to January 2020. Eighteen patients with SCS due to failed back surgery syndrome and/or complex regional pain syndrome were randomised to four treatment arms without washout periods: (1) low frequency (40-60 Hz), (2) 1 kHz, (3) clustered tonic, and (4) sham SCS (i.e., placebo). The primary outcome was pain scores measured by visual analogue scale (VAS) preoperatively and during subsequent treatment arms. Results: Pain scores (VAS) reported during the preoperative period was M (SD) = 8.13 (0.99). There was a 50% reduction in pain reported in the low frequency tonic treatment group (M (SD) = 4.18 (1.76)), a 37% reduction in the 1 kHz treatment group (M (SD) = 5.17 (1.4)), a 34% reduction in the clustered tonic settings group (M (SD) = 5.27 (1.33)), and a 34% reduction in the sham stimulation group (M (SD) = 5.42 (1.22)). The reduction in pain from the preoperative period to the treatment period was significant in each treatment group (p < 0.001). Overall, these reductions were of comparable magnitude between treatments. However, the modality most preferred by patients was low frequency (55% or 10 patients). Conclusions: The pain-relieving effects of SCS reached significance and were comparable across all modes of stimulation including sham. Sub-perception stimulation was not superior to supra-perception. SCS was characterised by a high degree of placebo effect. No evidence of carryover effect was observed between subsequent treatments. Contemporary neuromodulation procedures should be tailored to the individual preferences of patients