Joshua Rosenow, MD, director of functional neurosurgery and epilepsy surgery at Northwestern Medicine in Chicago, discusses neuromodulation and exciting developments in the future.
Question: What is the current state of neuromodulation? How has it advanced in recent years?
Dr. Joshua Rosenow: Neuromodulation has been employed for over 40 years for the treatment of chronic pain from such conditions as failed back and neck surgery syndromes, post-herpetic neuralgia, chronic regional pain syndrome and peripheral neuropathy.
In the last several years, we've seen unprecedented technological advancements in the neuromodulation space to allow for better outcomes for patients with chronic pain. Previously, spinal cord stimulation consisted of only conventional tonic stimulation at low frequencies. This option wasn't always the most effective for reducing neuropathic pain, and some patients disliked the paresthesia. Now, patients have the option of multiple other electrical waveforms such as high-frequency, burst or other waveforms that can reduce pain without accompanying paresthesia. More importantly, some of the newest devices can actually deliver two different waveforms simultaneously to further decrease the patient's pain.
We also have FDA-approved neuromodulation devices that target the spinal dorsal root ganglion for stimulation. These devices can selectively deliver therapy to a specific focal area. More importantly, many neurostimulation devices are now MRI-conditional so patients do not have to choose between the ability to have MRI scans and treating their pain.
Neuromodulation is just beginning to be routinely applied as a therapy for appropriately selected patients. As technologies continue to develop and physician training and adoption increase, the likelihood of neuromodulation therapies touching people's lives will increase drastically.
Q: Where does neuromodulation fit in the potential treatment pathways for spine pain patients? What are the advantages?
JR: In the past, neuromodulation was seen as the last resort after all other therapeutic options had failed. But with the positive results from research with the latest generation of devices, I am now able to offer neuromodulation as a therapeutic option earlier in the treatment plan. In addition, the limitations of chronic opioid use and the minimally invasive nature of a trial of spinal cord stimulation contribute to moving neuromodulation earlier in the treatment paradigm for chronic spinal pain.
Neuromodulation can help a person reduce pain medication and their associated side effects. The trial period gives a patient the option to try out and consider their response to the therapy to see whether it meets their goals before deciding to undergo a permanent implant. This is a huge advantage over other surgical therapies.
Q: Where do you see neuromodulation treatment advancing in the future? What are you most excited about?
JR: There are some exciting things coming to the forefront for neuromodulation. As consumer technologies are working more with complex medical devices, we'll see more integration of artificial intelligence and use of apps for the development of smart neuromodulation. There is also a lot of interest surrounding the use of activity trackers to better understand functional outcomes from neuromodulation therapies.
We'll also hear more discussions centered on neuromodulation and opioid abuse. Neuromodulation can help patients reduce or eliminate opioid use and that will continue to reduce the threshold for having a patient undergo a trial of stimulation.
All of this enthusiasm around neuromodulation has led to the proliferation of companies in this space. We now have more device options than ever, and several start up companies either have devices in trials or are nearing the pivotal trial stage.
We continue to gain a deeper understanding of the neurophysiologic mechanisms for these devices to reduce pain. As the knowledge advances, it opens up entire other realms for treating, or even preventing, chronic pain.
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