Combination Techniques:
NANS 2010
Marc A. Huntoon, M.D.
Professor of Anesthesiology
Mayo Clinic, Rochester MN
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Disclosures
• Investigator initiated research support
from Boston Scientific
• Concluded involvement in multicenter
trial for Medtronic supported research
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Spinal Cord Stimulation
• Doesn’t always work
• Sometimes it works for a while, but
the patients seem to exhibit a
“tolerance”
• Are there neuro-humeral
combinations that might improve
SCS outcomes?
• Would combining different stim types
be helpful?
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Multi-modal Analgesia
• Is combination therapy the future?
• If so, which combinations are the right
ones?
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Fig. 1.
Spinal Cord Stimulation: Exploration of the Physiological Basis of a Widely Used Therapy.
Linderoth, Bengt; Meyerson, Bjorn
Anesthesiology. 113(6):1265-1267, December 2010.
DOI: 10.1097/ALN.0b013e3181fcf590
© 2010 American Society of Anesthesiologists, Inc. Published by Lippincott Williams & Wilkins, Inc.
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Possible Combinations
• SCS and PNS
• SCS and Subcutaneous Field
Stimulation
• PNS and TENS
• SCS and IT infusion
• PNS and perineural/DRG infusion
• New Stimulation Targets
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Which is greater: Parent,
offspring, or combination?
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GABA-ergic Mechanisms
• Addition of baclofen, a GABA-b
agonist converts non-SCS responders
into responders
• Follow up study of combination of IT
baclofen with SCS in humans
Cui JG; Linderoth B; Meyerson BA. Effects of spinal cord
stimulation on touch-evoked allodynia involve GABAergic
mechanisms. An experimental study in the mononeuropathic
rat. Pain 1996; 66:287-95.
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Cholinergic SCS Mechanism
• Basal release of acetylcholine (ACH)
reduced in nerve injured rats
• Response to SCS blocked by atropine
& antimuscarinic agents in rats
• SCS effect at least partially due to
cholinergic mechanisms
Schectmann G, Song Z,Ultenius C, Meyerson B,
Linderoth B. Pain 2008;139:136-45.
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Cholinergic Mechanisms of SCS
• Responders to SCS release significantly
increased amount of acetylcholine in
response to SCS
Schectmann G, Song Z,Ultenius C, Meyerson B,
Linderoth B. Pain 2008;139:136-45.
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Immune Modulation: Cytokine
Antagonists
Vallejo R, et al. Pain Practice 2010;10:167-84.
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Perineural Clonidine
• Α-2 adrenoceptors cluster at sites of
peripheral nerve injury
• Perineural clonidine has prolonged
effect decreasing hyperalgesia
• Clonidine is immune modulator, i.e.
blocks cytokines (TNF-α), IL-1β, IL-6
Lavand’homme P, et al. Anesthesiology 2002;97:972-80.
Romero-Sandoval A. Eisenach JC. Anesthesiology 2006;104:351-5
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Transforaminal Clonidine
RCT of transforaminal epidural (TFE) clonidine 200 or 400 mcg.
versus triamcinolone 40 mg.
Burgher AH, et al. Spine 2011,in press
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Percutaneous PNS:
Procedural Prerequisites
• Ultrasound-guided nerve block ( clonidine
100-200 mcg. in 0.25% bupivacainecomplete or excellent relief
• Psychological screen (implant committee)
• Failed more conservative therapies
• Pain in one nerve distribution
• Capable of understanding system
requirements
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Anatomy Lab
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Needle and Electrode
Deep to Nerve
Radial nerve approach
Nitinol Wire around Ulnar Nerve
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Peritrode Over Nitinol Wire
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Peritrode Placement
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+
+
Fascicle
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Drug Elution: Combine PNS and
Pharmaceuticals ( e.g. clonidine)
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Back Pain in a Post-laminectomy
Syndrome Patient
Which orientation of electrodes
is superior?
Is a wide spaced electrode better
than a closely spaced one?
How many leads is “reasonable”?
What is the mechanism of analgesia?
Is there a way to optimize location of
Leads?
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Peripheral Field Stimulation
•
•
•
•
•
3 Cases of subcutaneous stim implant
SCFS for 1-2 hours/day: 12-24 hrs relief
Failed TCA’s, pregabalin, etc.
Patients had all failed TENS previously
Required low frequency 2-10 Hz, at low
amplitude (1-3 mA) and narrower pulse
widths (100 ms) than typical of SCS
• 1-3 year improvement in small series
Goroszeniuk T, Kothari S, Hamann W. Reg Anesth Pain Med 2006;31:168-71.
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Subcutaneous Field Stimulation for
Back Pain
• Longstanding FBSS
• Predominately back pain
• Implanted subcutaneous peripheral
field stimulation electrodes in patients
back
• 1 Year outcome good
Krutsch JP, McCeney MH, Barolat G, et al. Neuromodulation 2008;112-115
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Subcutaneous PNS for FBBS
Krutsch JP, McCeney MH, Barolat G, et al. Neuromodulation 2008;112-115
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Combined PNFS and SCS
• 20 patients with combined back and leg pain
• Retrospective Chart Review
• Underwent simultaneous placement of
transverse PFS at site of maximal pain as
well as SCS, some after SCS alone failed to
relieve back pain
• Some leads placed at cluneal neuroma or
other sensitive scar sites
Bernstein CA, Paicius RM, Barkow SH. Neuromodulation
2008;11:116-23.
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Interlead Communication:
“Crosstalk”
1) 20 patients; > 60% axial back pain
2) Epidural Octrode (guarded cathode)
3) perpendicular quadripolar SC lead at site of
greatest back pain (alternating
cathode/anode)
4) Programs: #1 Epidural octrode alone; #2
Subcutaneous lead alone; #3 Both leads
simultaneously
Mironer YE, Hutcheson JK, et al. Neuromodulation 2010; E-pub ahead
of print
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Interlead Communication
“Crosstalk” Study Part 1: Results
• 6 SC leads crossed midline; 14 leads
unilateral
• 17/20 had FBS syndrome (1 pt. DNR)
• 15/19 picked program #3 favorite
• 3/19 Program #1 (SCS) was favorite
Mironer YE, Hutcheson JK, et al. Neuromodulation 2010; E-pub ahead of
print
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Interlead Communication
“Crosstalk” Study Part 2
• Program 1:SCS and PNFS
independently programmed
• Program 2: Epidural Anode + PNFS
cathode
• Program 3: Epidural Cathode + PNFS
Anode
Patients “blinded”; All PNFS contacts active,
only selective (sweet spot) contacts for SCS
Mironer YE, Hutcheson JK, et al. Neuromodulation 2010; E-pub ahead of
print
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++
++++++++
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“Crosstalk” Study Part 2: Results
• All but two could feel PNFS in P #1
• P #2, 4 patients same as #1; 6 patients
with larger area of stim; 10 patients
with wide coverage
• P #3, All but one patient with wide axial
coverage
• Most popular cycling of P#1 and 3
Mironer YE, Hutcheson JK, et al. Neuromodulation 2010; E-pub ahead
of print
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Summary
• Substantial early excitement for SCS+
SCFS
• Some evidence for IT agents + SCS
• Possible role for PNS + Perineural
immune modulation
• Upcoming Study of PNS and SCS
• Emerging role of DRG
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Lost?
J Wallace PA
huntoon.marc@mayo.edu
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