New uses of SCS

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The Lancet, Early Online Publication, 20 May 2011doi:10.1016/S0140-6736(11)60547-3Cite or Link Using DOI

Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: a case study

Prof Susan Harkema PhD a b, Yury Gerasimenko PhD c d, Jonathan Hodes MD a, Prof Joel Burdick PhD e, Claudia Angeli PhD a b, Yangsheng Chen PhD a b, Christie Ferreira BSc a b, Andrea Willhite BA a b, Enrico Rejc MSc f, Prof Robert G Grossman MD g, Prof V Reggie Edgerton PhD d
Summary

Background
Repeated periods of stimulation of the spinal cord and training increased the ability to control movement in animal models of spinal cord injury. We hypothesised that tonic epidural spinal cord stimulation can modulate spinal circuitry in human beings into a physiological state that enables sensory input from standing and stepping movements to serve as a source of neural control to undertake these tasks.
Methods
A 23-year-old man who had paraplegia from a C7—T1 subluxation as a result of a motor vehicle accident in July 2006, presented with complete loss of clinically detectable voluntary motor function and partial preservation of sensation below the T1 cord segment. After 170 locomotor training sessions over 26 months, a 16-electrode array was surgically placed on the dura (L1—S1 cord segments) in December 2009, to allow for chronic electrical stimulation. Spinal cord stimulation was done during sessions that lasted up to 250 min. We did 29 experiments and tested several stimulation combinations and parameters with the aim of the patient achieving standing and stepping.
Findings
Epidural stimulation enabled the man to achieve full weight-bearing standing with assistance provided only for balance for 4·25 min. The patient achieved this standing during stimulation using parameters identified as specific for standing while providing bilateral load-bearing proprioceptive input. We also noted locomotor-like patterns when stimulation parameters were optimised for stepping. Additionally, 7 months after implantation, the patient recovered supraspinal control of some leg movements, but only during epidural stimulation.
Interpretation
Task-specific training with epidural stimulation might reactivate previously silent spared neural circuits or promote plasticity. These interventions could be a viable clinical approach for functional recovery after severe paralysis.
Funding
National Institutes of Health and Christopher and Dana Reeve Foundation.
 
Patient was ASIA B C7-T1 injury s/p fusion of this segment.

Most of our patients are ASIA A.

All of the authors are sharing a patent on an electrode array, likely for the purpose of SCS locomotion.

I'm less than enthused clinically, but from a research standpoint we are heading in the right direction.
 
Most of our patients are ASIA A.

http://www.fscip.org/facts.htm

The most frequent neurologic category at discharge of persons reported to the database is incomplete tetraplegia (30.1%), followed by complete paraplegia (25.6%), complete tetraplegia (20.4%), and incomplete paraplegia (18.5%). Less than 1% of persons experienced complete neurologic recovery by hospital discharge. Over the last 15 years, the percentage of persons with incomplete tetraplegia has increased slightly while complete paraplegia has decreased slightly.
 
That's nice, but most of the SCI patients I have encountered were ASIA A. A good mix of C5 and mid thoracic folks.

They also picked a standout college athlete and not our typical SCI patient.

An n=1 with that much confounding bias is still interesting, but not clinically applicable in the next 5 years. Hopefully it is what is coming down the pike.
 
I just heard that Reggie Edgerton works with St. Jude in his lab.

Also

From the Lancet article:

"These same mechanisms might also explain the
improved autonomic function in bladder, sexual, and
thermoregulatory activity that has been of substantial
benefit to the patient. The areas of lumbosacral spinal
cord stimulated included at least parts of the neural
circuits that regulate these autonomic functions and
might have also resulted in activity-dependent changes."

Interestingly, from another source:

"Clin J Pain. 2010 Jun;26(5):433-4.
Rare adverse effect of spinal cord stimulation: micturition inhibition.
La Grua M, Michelagnoli G.
Source
Department of Anaesthesiology and Critical Care, Pain Unit, Misericordia e Dolce Hospital, Prato, Italy. [email protected]
Abstract
OBJECTIVES:
In current medical literature, most of the reported complications of spinal cord stimulation concern technical problems, such as lead malfunction, migration, breakage, or internal pulse generator dysfunction, whereas reports about the side effects on internal organ function caused by spinal cord stimulation are rare.

METHODS:
In this clinical report, we describe uncommon side effects owing to spinal cord stimulation in a patient with chronic neuropathic pain. Our patient developed unexpected urinary retention during electrical epidural stimulation.

RESULTS AND DISCUSSION:
This case report highlights the incomplete knowledge about the mechanism of action of spinal cord stimulation and its influence on the interactions between the autonomic nervous system and voluntary control of urinary function. The complete recovery of bladder function after the interruption of stimulation suggests that electrical stimulation caused the adverse effects in this clinical case.
 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2809374/?tool=pubmed

Arch Phys Med Rehabil. 2009 May;90(5):726-32.
Lower thoracic spinal cord stimulation to restore cough in patients with spinal cord injury: results of a National Institutes of Health-Sponsored clinical trial. Part II: clinical outcomes.
DiMarco AF, Kowalski KE, Geertman RT, Hromyak DR, Frost FS, Creasey GH, Nemunaitis GA.
Source
Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH, USA. [email protected]
Abstract
OBJECTIVE:
To evaluate the clinical effects of spinal cord stimulation (SCS) to restore cough in subjects with cervical spinal cord injury.
DESIGN:
Clinical trial assessing the clinical outcomes and side effects associated with the cough system.
SETTING:
Outpatient hospital or residence.
PARTICIPANTS:
Subjects (N=9; 8 men, 1 woman) with cervical spinal cord injury.
INTERVENTIONS:
SCS was performed at home by either the subjects themselves or caregivers on a chronic basis and as needed for secretion management.
MAIN OUTCOME MEASURES:
Ease in raising secretions, requirement for trained caregiver support related to secretion management, and incidence of acute respiratory tract infections.
RESULTS:
The degree of difficulty in raising secretions improved markedly, and the need for alternative methods of secretion removal was virtually eliminated. Subject life quality related to respiratory care improved, with subjects reporting greater control of breathing problems and enhanced mobility. The incidence of acute respiratory tract infections fell from 2.0+/-0.5 to 0.7+/-0.4 events/subject year (P<.01), and mean level of trained caregiver support related to secretion management measured over a 2-week period decreased from 16.9+/-7.9 to 2.1+/-1.6 and 0.4+/-0.3 times/wk (P<.01) at 28 and 40 weeks after implantation of the device, respectively. Three subjects developed mild hemodynamic effects that abated completely with continued SCS. Subjects experienced mild leg jerks during SCS, which were well tolerated. There were no instances of bowel or bladder leakage.
CONCLUSIONS:
Restoration of cough via SCS is safe and efficacious. This method improves life quality and has the potential to reduce the morbidity and mortality associated with recurrent respiratory tract infections in this patient population.
 
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