Weird application of stimulators

[deleted993114]

The "Holy Grail" of stimulation has been axial or back pain. Traditionally, dorsal column stims have had fairly good coverage of radicular pain, but poor coverage of axial pain. Placement of stims (with the exception of recent root stimulation called DRG stim) has traditionally been in the dorsal epidural space.

However, if we look at the innervation of the lumbar discs, a presumed common source of pain, the innervation through the sinovertebral nerve and grey rami communicans is lateral and more ventral. Both of these branches exit off the root, proceed laterally, then return to innervate the disc. These nerves become "available" for access in the lateral epidural space before the segmental nerve root exits the foramen.

Given these anatomic issues, I got institutional approval to place stim leads laterally in the "gutters" of the epidural space, in exactly the position we never want leads to go. The leads cover about 2.5 segments, so I have placed leads covering L5,L4, and L3 bilaterally. Both patients (using high frequency stim with no paresthesias) have reported marked improvement of the back pain, but not buttock pain over the SI joint area. The L3 DRG has been implicated as a "gateway for axial pain, this the selection of L3, L4,and L5, rather than one segment lower.

I am going to publish this as a case report to generate further study/evaluation of this technique which seems to place the leads to the neural structures that actually contribute to axial pain, rather than traditional dorsal placement. Interestingly, in the absence of a retrograde placement, it is tough to get the leads going laterally rapidly enough, even when entering at L5/S1, thus the observed sparing of coverage of buttock pain. However, the previous back pain above this level seems to have good results- both patients implanted 3 months ago.

May be BS, but from an anatomic standpoint seems to be a technique which may warrant further study to address axial pain. Prior to high freq, this would not be possible, as one would get painful radicular stimulation.

Thoughts? Crazy? Not crazy? Potentially useful?

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[lobelsteve]

Already being done by BS or Abbott. Far lateral placement studies ongoing. More marketing nonsense.

The GRC does not send most pain signal to the level of origin. It hugs the spine in a network, migrates to the Sympathetic trunk, and coalesces at L2. I block grc at L2. Saw a big guy who came back for RF of same once his wore off. 14 months. Single lesion 20g 80d 90s

 

[deleted993114]

Already being done by BS or Abbott. Far lateral placement studies ongoing. More marketing nonsense.

The GRC does not send most pain signal to the level of origin. It hugs the spine in a network, migrates to the Sympathetic trunk, and coalesces at L2. I block grc at L2. Saw a big guy who came back for RF of same once his wore off. 14 months. Single lesion 20g 80d 90s

The sinovertebral nerve does go from the root laterally to the foramen and returns to the dorsal/medial aspect of the disc. I have not seen any case reports regarding this placement. Do you have a reference for a previous report? This seems to make anatomic sense and is more directly dealing with the actual innervation of the disc, rather than placing leads dorsally. There is evidence that the innervation of the disc from the SVN is not segmental, but ascends along with GRC fibers superiorly. However, these are not sympathetic fibers, but are nociceptive afferents that course along sympathetic fibers. There have been studies using local anesthetic administered ABOVE a presumed painful disc at the GRC that has supported this notion. Thus placement of leads (if this is feasible) would presumably have to be multi-segmental and above a painful segment with the possibility that L1 and L2 may have a more important role.

I ran this by Ken Follet (one of my friends) who happens to be one of the leading authorities on stim; he was not aware of that technique being used/published and thought it made sense anatomically. Ken is the chairman of neurosurgery at Nebraska, has a PhD in electrophysiology, and has published hundreds of papers in the literature, many in the area of neuromodulation both peripherally and DBS. I checked with both Medtronics and Boston Scientific, and they were unaware of anyone having used this technique.

I tried L2 and L3 DRG rf many years ago after the animal data papers from Japan. It did not seem to work, so I abandoned it. That was very popular in the late 90s for about a year or two and many others were trying that treatment at that time. All had similar results, in that it did not seem to work, and was thus abandoned.

Likewise, we all tried the GRC rf treatments with similar lack of efficacy. This stuff was really the rage in about '97-'98. That was really popular at the ISIS meetings and was a point of interest for a few years. The guys who published this were Indian and noted "partial relief" in five patients. It never caught on, as no one could really make this work well.

Radiofrequency lesioning of the L2 ramus communicans in managing discogenic low back pain - PubMed

Radiofrequency lesioning of the L2 ramus communicans seems to offer partial relief for patients suffering from discogenic pain. Further studies are needed to confirm our results.

www.ncbi.nlm.nih.gov

 

[lobelsteve]

Simopoulis at Harvard has a nice GRC paper. 2005 ish.

I think it was my Abbott rep talking about gutterballing

 

[deleted993114]

Simopoulis at Harvard has a nice GRC paper. 2005 ish.

I think it was my Abbott rep talking about gutterballing

Well- if he was talking about it, it was something different, as it is new to Follet and Medtronics and Boston had never heard of it. We used to do thoracic "gutter stim" for intercostal pain, but this is a different location/application.

There are no papers I can find at all in the literature, and I did a preliminary search and our research department subsequently performed a search. They contacted Medtronics as well who did an additional search and found nothing.

That is what we do prior to even developing a protocol- it is pretty thorough, as one does not want to expend time, energy, and money in something already done. Just to put a "stick in the spokes" of financial crooks, I gave the rights to medtronics for nothing and I think they already filed a use patent. I am not interested in such actions and just want to see how this works-
a. on a larger scale
b. different levels
c. modification/improvement I have not thought about.

 

[lobelsteve]

Sim published on grc rf.

Ongoing abbott or bs work on gutter stim. Nothing published but putting wires anywhere and everywhere has been done. Ive seen wires straight through the foramen ovale.

 

[deleted472101]

I am unaware of any work on this. There may be a small institutional study from a company but nothing else that I have heard from the companies or any meetings.

 

[deleted993114]

Sim published on grc rf.

Ongoing abbott or bs work on gutter stim. Nothing published but putting wires anywhere and everywhere has been done. Ive seen wires straight through the foramen ovale.

Ongoing work? Both Boston and Medtronics in their R&D departments said they had done nothing of the sort and a literature search has no description of that technique. Ken Follett (having published hundreds of papers in neuromodualtion ) was not aware of this technique being used before. Perhaps reps are not the best sources of medical information.

If GRC rf works that well (I could never seem to get any decent results with that or L2 ganglion rf, nor have I encountered anyone who has had excellent results with that procedure) then there is little utility for any other procedures or techniques to address discogenic back pain.
.

 

[DOctorJay]

I believe Ken Chapman presented at NANS on T12 DRG stim placement for axial/discogenic pain. I’ll see if I can find the lecture slides.

 

[DOctorJay]

This is all I could currently access:

T12 Dorsal Root Ganglion Stimulation to Treat Chronic Low Back Pain: a Case Series

Kenneth B. Chapman, MD, New York, United States
Pauline S. Groenen, BS
Kiran V. Patel, MD

Introduction: Dorsal root ganglion (DRG) stimulation is a recently introduced treatment for chronic pain syndromes that has been demonstrated to be more effective than conventional spinal cord stimulation (SCS) in treating complex regional pain syndrome (CRPS), particularly of the foot and ankle. Recent case reports and case series have demonstrated that DRG stimulation may be effective in the treatment of other pain syndromes than CRPS and in fact appears to be helping in some conditions that may be considered to be somatic pain rather than the traditional indication of neuropathic pain. There have been several studies demonstrating the efficacy of DRG stimulation for axial low back pain; however there is no consensus regarding the best location for lead placement. The aim of this report is to describe our experience with T12 DRG stimulation in a series of patients with chronic axial low back pain.

Methods: Fourteen (9 women/ 5 men, age: 33 - 71) consecutive patients with significant chronic axial low back pain unresponsive to conservative and other interventional treatments were included. Patients underwent implantation of DRG stimulation systems with leads placed at the T12 level. Pain (visual analogue scale, VAS), back pain related disability (Oswestry Disability Index, ODI), and health related quality of life (EuroQol, EQ-5D; 36-Item Short Form Survey, SF-36) were measured preoperatively and at follow-up.

Results: At follow-up (average 3.5 months, range 1-7 months) 11/14 of patients reported pain relief of 80% or more, with an average low back pain relief of 81% (from 91 ± 8 at baseline to 17 ± 18 mm at follow-up, p < 0.01 - Figure). There were concomitant substantial improvements in back pain related disability (ODI: from 65 ±14 to 18 ± 13%, p < 0.01), and health related quality of life (EQ-5D: from 0.33 ± 0.15 to 0.88 ± 0.10, SF-36 physical component: from 26 ± 5 to 46 ± 8, SF-36 mental component: from 12 ± 8 to 55 ± 11, all p < 0.01).

Conclusion: Although our follow up is still limited, it appears that targeting the T12 vertebral level with DRG stimulation is a very effective treatment option for chronic axial low back pain resulting in both pain relief and significantly improved quality of life.

 

[lobelsteve]

Ongoing work? Both Boston and Medtronics in their R&D departments said they had done nothing of the sort and a literature search has no description of that technique. Ken Follett (having published hundreds of papers in neuromodualtion ) was not aware of this technique being used before. Perhaps reps are not the best sources of medical information.

If GRC rf works that well (I could never seem to get any decent results with that or L2 ganglion rf, nor have I encountered anyone who has had excellent results with that procedure) then there is little utility for any other procedures or techniques to address discogenic back pain.
.

There may be more going on than you know about. Thats why we have this forum.

 

[deleted993114]

There may be more going on than you know about. Thats why we have this forum.

There may be more going on than you know about. Thats why we have this forum.

There may be more going on than you know about. Thats why we have this forum.

Of course there is more "going on" than I know about. That is true of all medicine, as no one can know everything, and we all have our practices biases. That is why we read the literature, go to meetings, and keep up with our CMEs.

However, I can feel very confident that the R&D departments of Boston and Medtronics, one of the physician world experts on neuromodulation who has been a leader for 30 years, and the known medical literature knows more than your equipment rep. Heck, I've been practicing 28 years and have done over 1,000 implants so I certainly know more about stim than your rep.

Are you actually being serious, as this is to the point of being ridiculous. I give stim reps about as much credence as I would an insurance salesman and really do not rely upon them for medical information. An equipment rep is not a physician and I know for fact with medtronics that :
a. they do not tell reps details of new technology in development
b. reps are legally bound NOT to discuss any new technology they are aware of until it is cleared through R&D.
c. they need to satisfy the FDA before they can even advertise any new technology

That is why we rely upon our literature, the experts in our field, and those in academics and industry to keep us informed. I ran this idea by three other department chairs who are tied in with Nevro and Abbott, who were not familiar at all with using stim in this fashion.

Are you really saying that your equipment rep is a more reliable literature search than all the above? I am sorry, that is simply absurd- a nod and a wink from a rep does not constitute medical evidence.

 

[lobelsteve]

Believe what you choose. Why would he ask me about gutter stim? And then tell me of folks doing it?
I would recommend against it either way. I like conventional care. Unlike seeing 70 patients a day.

 

[deleted472101]

I believe Boston Scientific was saying gutter stim for a DRG/DREZ type of procedure but I don’t think that was for Axial LB.

Like stated above reps should know their equipment inside and out but beyond that it’s up to you to learn from different meetings forums talks etc.

I believe different types of meetings are great because if you keep listening to the same people then it’s like only watching Fox News or CNN, you are probably very biased.

 

[deleted993114]

Believe what you choose. Why would he ask me about gutter stim? And then tell me of folks doing it?
I would recommend against it either way. I like conventional care. Unlike seeing 70 patients a day.

I was not asking you as a lit search to determine whether it has been done- it is not being done and that is already established by a thorough literature search, contacting industry R&D, and contacting a few of the leaders in the field. I have that area covered. I really don't need a foreign medical grad to guide me through the literature.

What I was asking about was what people considered to be the potential merits of such an approach, given that the innervation of the disc is more ventral and lateral, rather than dorsal.

I have never seen 70 pts per day. I used to see about 32, most of which were procedures, as I was a part of a neurosurgical group for about 20 years. I know of no one who could effectively see 70 pts. I cannot see that many patients any more, as I have cancer and am unable to physically see that many patients or do that many procedures anymore.

You say you "would not do it", yet embrace unproven fringe treatments like PRP, GRC rf, and L2 DRG rf, all of which are of dubious benefit. This procedure is defined as experimental, as it has not been adequately tested, yet makes anatomical sense and has had the endorsement of a few of the leaders in neuromodulation to pursue. This may turn out to be a "bust", but it worth pursuing to determine whether it has merit or not.

 

[Needlejockeys]

Boston Scientific Pushing Lateral Gutter Stim hard. I wouldn't even think about it for now as the cases they presented were anecdotal. Sounds thirsty to me. DRG maybe - historically L2 is the sweet spot (for pulsed RF of the DRG, and now SCS). Lots of smoke and mirrors. Just do no harm.

 

[deleted993114]

Boston Scientific Pushing Lateral Gutter Stim hard. I wouldn't even think about it for now as the cases they presented were anecdotal. Sounds thirsty to me. DRG maybe - historically L2 is the sweet spot (for pulsed RF of the DRG, and now SCS). Lots of smoke and mirrors. Just do no harm.

Interesting- they said they were not doing that in R&D. I talked to the Boston people about it two years ago.

Still nothing in the literature. Again, it is a potentially interesting application, but it is one of those things that may be great, or a complete flop.

Worth trying, particularly as you noted with the old L2 DRG information from animal studies in Japan from the mid to late 90s.

 

[epidural man]

Here is what I have on L2 for disc pain. The Simopoulos paper is included.

I think you should try taking a lead along the vertebral body (diagonal) at L2. This would get all the nerves coming into L2 (and L1). You would not go through epidural space though - just place like an LSB. I think some of the reason that the L2 treatment isn't all that great is some of the nerves travel up to L1 as well - so when I do this treatment for discogenic pain, I also add L1.

 

[epidural man]

Also, there is a good discussion about this stuff in the book "RadioFrequency" by Slutjer.

 

[Norepi]

Sorry for the bump - saw that Chapman has been basically arguing that the dermatomes of the low back at the cutaenous level have been erroneous for a while, stating that T12 level DRG stim may be helpful for discogenic pain as described prior.

I am not sure what to make of this - I find it hard to believe that a busy privademic doctor in NYC is redefining and describing somatosensory physiology in a breakthrough way through the Neuromodulation journal of all places, while us peons haven't caught on yet. Has anyone else seen this clinically work or seen other basic science data to back these claims?

The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment - PubMed

Branches of individual spinal nerve roots innervate facet joints and posterior spinal structures, while the discs and anterior vertebrae are carried via L2, and converge in the dorsal horn (DH) of the spinal cord at T8-T9. The T12 nerve root contains cutaneous afferents from the low back and...

pubmed.ncbi.nlm.nih.gov

The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment​

 

[TIVAndy]

Sorry for the bump - saw that Chapman has been basically arguing that the dermatomes of the low back at the cutaenous level have been erroneous for a while, stating that T12 level DRG stim may be helpful for discogenic pain as described prior.

I am not sure what to make of this - I find it hard to believe that a busy privademic doctor in NYC is redefining and describing somatosensory physiology in a breakthrough way through the Neuromodulation journal of all places, while us peons haven't caught on yet. Has anyone else seen this clinically work or seen other basic science data to back these claims?

The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment - PubMed

Branches of individual spinal nerve roots innervate facet joints and posterior spinal structures, while the discs and anterior vertebrae are carried via L2, and converge in the dorsal horn (DH) of the spinal cord at T8-T9. The T12 nerve root contains cutaneous afferents from the low back and...

pubmed.ncbi.nlm.nih.gov

The Pathways and Processes Underlying Spinal Transmission of Low Back Pain: Observations From Dorsal Root Ganglion Stimulation Treatment​

leads back to our original target for regular SCS- T8-T9 area. which begs the question - even if T12 stimulation is feasible and true, is DRG stimulation superior to targeting T8-T9 with traditional SCS?