5 New Concepts Up for Discussion at the North American Neuromodulation Society Meeting

Pain Management

David Caraway MD, PhD, pain management specialist and board member for the North American Neuromodulation Society, talks about five concepts that will be discussed at the 2011 North American Neuromodulation Society Meeting in Las Vegas this week.
"What we're finding is a number of different things," he says. "Improvement in technology is happening at a fairly rapid pace. The basic trend is toward more complex arrays [in stimulator device design] and technology that adapts to the patient rather than the patient adapting to the technology."

1. Technology is adapting to the patient. The FDA recently approved Medtronic's AdaptiveStim with the RestoreSensor neurostimulation system. The device automatically responds to the patient's body position instead of the patient needing to manually change the device's settings.

"The problem this seeks to resolve is that when you change to another position, the thickness of the spinal cord fluid changes," he says. "There can be uncomfortable stimulation or no stimulation or some range in between when you go from standing to lying down."

The patient is initially brought into the office to set the stimulation levels for each position, and the system remembers the levels and can tell when the patient changes positions.

2. More complex arrays for spinal cord stimulators. Spinal cord stimulators traditionally have 16 contact points — eight on each lead. Dr. Caraway says Boston Scientific is working to develop a system that has 16 contact points on each lead for a total of 32 points. The logic is that more contact points means greater coverage of the painful area.

"Traditionally you try to give the patients pleasant sensations, or paraesthesia," he says. "By having more contacts on the leads, the device may more completely cover these painful areas."

The Infinion 16 Percutaneous Lead was recently approved by the FDA. In addition, St. Jude recently earned FDA approval for its Epiducer device that allows placement of multiple leads through a single needle.

3. High-frequency stimulation. However, one new device from Nevro claims to remove the painful sensations without paraesthesia. The device uses such a high frequency that the patient does not feel the tingling sensation associated with spinal cord stimulators. Dr. Caraway says that more research is needed in the technology, but it represents a new way of doing neuromodulation for pain and is something to watch.

4. New targets to stimulate. In addition to new technologies, researchers are also finding new targets to stimulate for pain relief. One such target is the dorsal root ganglia, nodules on the sensory root of spinal nerves that lie along the vertebral column by the spine. Dr. Caraway says there are currently clinical trials underway in Europe and Australia. Spinal Neruomodulation's Spinal Modulation Neurostimulator System, which targets the dorsal root ganglia, recently received the CE Mark in Europe.

"Physiological advances are allowing better coverage of the stimulus with less power requirement," he says. "The devices are changing. We're learning more about the targets."

Peripheral nerves, the nerves that are outside the brain and spinal cord, are also being used for stimulation.

"This involves placing the leads not into the spinal column but under the skin," he says. "You stimulate those nerves through the subcutaneous lead. There has been a lot of research on this. It's been used to treat headaches for a long time."

Current research focuses on using the technique for low-back and facial pain.

5. Using neuromodulation for treatment of medical disease. Neuromodulation has traditionally been used for the treatment of pain, but some studies show it can be beneficial in the treatment of diseases and conditions such as urinary incontinence, depression, movement disorders, seizure disorders, Parkinson's and some gastrointestinal issues.

"One of the most exciting cases was a single case published in the Lancet looking at spinal cord stimulation in conjunction with intensive physical therapy and rehabilitation for catastrophic spinal cord injuries," he says.

In that case, a 23-year-old man had paraplegia from the C7 to the T1 vertebra after a motor vehicle accident. After 170 training sessions on a treadmill where he was supported by a harness while therapists moved his legs over more than two years, a 16-electrode array was surgically placed on the L1 to the S1 cord segments. The man was able to stand on his own during stimulation almost immediately after implantation, and seven months later, he recovered control of some leg movements.

Related Articles on Neuromodulation:
Spinal Modulation System Receives CE Mark for the Management of Chronic Intractable Pain
Stellate Ganglion Block Shown to Relieve PTSD Symptoms
BioLineRx Drug Gets Positive Results in Clinical Trial for Neuropathic Pain

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