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Combination Techniques:Combination Techniques:NANS 2010NANS 2010

Marc A. Huntoon, M.D.Marc A. Huntoon, M.D.

Professor of AnesthesiologyProfessor of Anesthesiology

Mayo Clinic, Rochester MNMayo Clinic, Rochester MN

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DisclosuresDisclosures

• Investigator initiated research support Investigator initiated research support from Boston Scientific from Boston Scientific

• Concluded involvement in multicenter Concluded involvement in multicenter trial for trial for MedtronicMedtronic supported research supported research

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Spinal Cord StimulationSpinal Cord Stimulation

• Doesn’t always workDoesn’t always work

• Sometimes it works for a while, but the Sometimes it works for a while, but the patients seem to exhibit a “tolerance”patients seem to exhibit a “tolerance”

• Are there neuro-humeral combinations Are there neuro-humeral combinations that might improve SCS outcomes?that might improve SCS outcomes?

• Would combining different stim types Would combining different stim types be helpful?be helpful?

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Multi-modal AnalgesiaMulti-modal Analgesia

• Is combination therapy the future?Is combination therapy the future?

• If so, which combinations are the right If so, which combinations are the right ones?ones?

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© 2010 American Society of Anesthesiologists, Inc. Published by Lippincott Williams & Wilkins, Inc. 2

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

Fig. 1.

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Possible CombinationsPossible Combinations

• SCS and PNSSCS and PNS

• SCS and Subcutaneous Field SCS and Subcutaneous Field StimulationStimulation

• PNS and TENSPNS and TENS

• SCS and IT infusionSCS and IT infusion

• PNS and perineural/DRG infusionPNS and perineural/DRG infusion

• New Stimulation TargetsNew Stimulation Targets

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Which is greater: Parent, Which is greater: Parent, offspring, or combination?offspring, or combination?

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GABA-ergic MechanismsGABA-ergic Mechanisms

• Addition of baclofen, a GABA-b Addition of baclofen, a GABA-b agonist converts non-SCS responders agonist converts non-SCS responders into respondersinto responders

• Follow up study of combination of IT Follow up study of combination of IT baclofen with SCS in humansbaclofen with SCS in humans

Cui JG; Linderoth B; Meyerson BA.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 MechanismCholinergic SCS Mechanism

• Basal release of acetylcholine (ACH) Basal release of acetylcholine (ACH) reduced in nerve injured ratsreduced in nerve injured rats

• Response to SCS blocked by atropine Response to SCS blocked by atropine & antimuscarinic agents in rats& antimuscarinic agents in rats

• SCS effect at least partially due to SCS effect at least partially due to cholinergic mechanismscholinergic mechanisms

Schectmann G, Song Z,Ultenius C, Meyerson B, Linderoth B. Pain 2008;139:136-45.

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Cholinergic Mechanisms of SCSCholinergic Mechanisms of SCS

• Responders to SCS release significantly Responders to SCS release significantly increased amount of acetylcholine in increased amount of acetylcholine in response to SCSresponse to SCS

Schectmann G, Song Z,Ultenius C, Meyerson B, Linderoth B. Pain 2008;139:136-45.

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Immune Modulation: Cytokine Immune Modulation: Cytokine AntagonistsAntagonists

Vallejo R, et al. Pain Practice 2010;10:167-84.

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Perineural ClonidinePerineural Clonidine

• ΑΑ-2 adrenoceptors cluster at sites of -2 adrenoceptors cluster at sites of peripheral nerve injuryperipheral nerve injury

• Perineural clonidine has prolonged Perineural clonidine has prolonged effect decreasing hyperalgesiaeffect decreasing hyperalgesia

• Clonidine is immune modulator, i.e. Clonidine is immune modulator, i.e. blocks cytokines (TNF-blocks cytokines (TNF-αα), IL-1), IL-1ββ, IL-6, 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 ClonidineTransforaminal Clonidine

Burgher AH, et al. Spine 2011,in press

RCT of transforaminal epidural (TFE) clonidine 200 or 400 mcg. versus triamcinolone 40 mg.

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Percutaneous PNS:Percutaneous PNS:Procedural PrerequisitesProcedural Prerequisites

• Ultrasound-guided nerve block ( clonidine Ultrasound-guided nerve block ( clonidine 100-200 mcg. in 0.25% bupivacaine- 100-200 mcg. in 0.25% bupivacaine- complete or excellent reliefcomplete or excellent relief

• Psychological screen (implant committee)Psychological screen (implant committee)

• Failed more conservative therapiesFailed more conservative therapies

• Pain in one nerve distributionPain in one nerve distribution

• Capable of understanding system Capable of understanding system requirementsrequirements

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Anatomy LabAnatomy Lab

Needle and Electrode Deep to Nerve

Radial nerve approach

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Nitinol Wire around Ulnar NerveNitinol Wire around Ulnar Nerve

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Peritrode Over Nitinol WirePeritrode Over Nitinol Wire

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Peritrode PlacementPeritrode Placement

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Fascicle

+

-+

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Drug Elution: Combine PNS and Drug Elution: Combine PNS and Pharmaceuticals ( e.g. clonidine) Pharmaceuticals ( e.g. clonidine)

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Back Pain in a Post-laminectomy Back Pain in a Post-laminectomy Syndrome PatientSyndrome 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 StimulationPeripheral Field Stimulation• 3 Cases of subcutaneous stim implant3 Cases of subcutaneous stim implant

• SCFS for 1-2 hours/day: 12-24 hrs reliefSCFS for 1-2 hours/day: 12-24 hrs relief

• Failed TCA’s, pregabalin, etc.Failed TCA’s, pregabalin, etc.

• Patients had all failed TENS previouslyPatients had all failed TENS previously

• Required low frequency 2-10 Hz, at low Required low frequency 2-10 Hz, at low amplitude (1-3 mA) and narrower pulse amplitude (1-3 mA) and narrower pulse widths (100 ms) than typical of SCSwidths (100 ms) than typical of SCS

• 1-3 year improvement in small series1-3 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 Subcutaneous Field Stimulation for Back PainBack Pain

• Longstanding FBSSLongstanding FBSS

• Predominately back painPredominately back pain

• Implanted subcutaneous peripheral Implanted subcutaneous peripheral field stimulation electrodes in patients field stimulation electrodes in patients backback

• 1 Year outcome good1 Year outcome good

Krutsch JP, McCeney MH, Barolat G, et al. Neuromodulation 2008;112-115

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Subcutaneous PNS for FBBSSubcutaneous PNS for FBBS

Krutsch JP, McCeney MH, Barolat G, et al. Neuromodulation 2008;112-115

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Combined PNFS and SCSCombined PNFS and SCS

• 20 patients with combined back and leg pain20 patients with combined back and leg pain

• Retrospective Chart ReviewRetrospective Chart Review

• Underwent simultaneous placement of Underwent simultaneous placement of transverse PFS at site of maximal pain as transverse PFS at site of maximal pain as well as SCS, some after SCS alone failed to well as SCS, some after SCS alone failed to relieve back painrelieve back pain

• Some leads placed at cluneal neuroma or Some leads placed at cluneal neuroma or other sensitive scar sitesother sensitive scar sites

Bernstein CA, Paicius RM, Barkow SH. Neuromodulation 2008;11:116-23.

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Interlead Communication: Interlead Communication: “Crosstalk”“Crosstalk”

1) 20 patients; 1) 20 patients; > > 60% axial back pain60% axial back pain

2) Epidural Octrode (guarded cathode)2) Epidural Octrode (guarded cathode)

3) perpendicular quadripolar SC lead at site of 3) perpendicular quadripolar SC lead at site of greatest back pain (alternating greatest back pain (alternating cathode/anode)cathode/anode)

4) Programs: #1 Epidural octrode alone; #2 4) Programs: #1 Epidural octrode alone; #2 Subcutaneous lead alone; #3 Both leads Subcutaneous lead alone; #3 Both leads simultaneouslysimultaneously

Mironer YE, Hutcheson JK, et al. Neuromodulation 2010; E-pub ahead of print

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Interlead CommunicationInterlead Communication “Crosstalk” Study Part 1: Results “Crosstalk” Study Part 1: Results

• 6 SC leads crossed midline; 14 leads 6 SC leads crossed midline; 14 leads unilateralunilateral

• 17/20 had FBS syndrome (1 pt. DNR)17/20 had FBS syndrome (1 pt. DNR)

• 15/19 picked program #3 favorite15/19 picked program #3 favorite

• 3/19 Program #1 (SCS) was favorite3/19 Program #1 (SCS) was favorite

Mironer YE, Hutcheson JK, et al. Neuromodulation 2010; E-pub ahead of print

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• Program 1:SCS and PNFS Program 1:SCS and PNFS independently programmedindependently programmed

• Program 2: Epidural Anode + PNFS Program 2: Epidural Anode + PNFS cathodecathode

• Program 3: Epidural Cathode + PNFS Program 3: Epidural Cathode + PNFS AnodeAnode

Interlead CommunicationInterlead Communication “Crosstalk” Study Part 2 “Crosstalk” Study Part 2

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: ResultsCrosstalk” Study Part 2: Results

• All but two could feel PNFS in P #1All but two could feel PNFS in P #1

• P #2, 4 patients P #2, 4 patients samesame as #1; 6 patients as #1; 6 patients with with larger arealarger area of stim; 10 patients of stim; 10 patients with with widewide coverage coverage

• P #3, All but one patient with P #3, All but one patient with wide axial wide axial coveragecoverage

• Most popular cycling of P#1 and 3Most popular cycling of P#1 and 3

Mironer YE, Hutcheson JK, et al. Neuromodulation 2010; E-pub ahead of print

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SummarySummary

• Substantial early excitement for SCS+ Substantial early excitement for SCS+ SCFSSCFS

• Some evidence for IT agents + SCSSome evidence for IT agents + SCS

• Possible role for PNS + Perineural Possible role for PNS + Perineural immune modulationimmune modulation

• Upcoming Study of PNS and SCSUpcoming Study of PNS and SCS

• Emerging role of DRGEmerging role of DRG

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huntoon.marc@mayo.eduhuntoon.marc@mayo.edu

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