title: The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain.
abstract: Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. These procedures can be done with acceptably low morbidity and provide a cost-effective solution for those patients in whom medical therapies have failed. Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.
authors.affiliation: Division of Neurosurgery, Toronto West-ern Hospital, Toronto, Canada.|Depart-ment of Surgery, University of Toronto, Toronto, Canada.|Institute of Biomate-rials and Biomedical Engineering, Uni-versity of Toronto, Toronto, Canada.|Krembil Research Institute, Toronto, Canada.|Techna Research Institute, Toronto, Canada.
authors.forename: Mohammed F
authors.initials: MF
authors.lastname: Shamji
authors.affiliation: Medisch Spectrum Twente hospital, Enschede, Netherlands.
authors.forename: Cecile
authors.initials: C
authors.lastname: De Vos
authors.affiliation: Division of Neurosurgery, Thomas Jefferson University, Philadephia, PA.
authors.forename: Ashwini
authors.initials: A
authors.lastname: Sharan
mesh_terms: D059350:Chronic Pain / Q000628:therapy*; D003362:Cost-Benefit Analysis; D005727:Ganglia, Spinal; D006801:Humans; D009437:Neuralgia / Q000628:therapy*; D059408:Pain Management / Q000379:methods; D010148:Intractable Pain / Q000628:therapy*; D011788:Quality of Life; D062187:Spinal Cord Stimulation
keywords: Burst stimulation; Dorsal root ganglion stimulation; Failed back surgery syndrome; High-frequency stimulation; Neuromodulation; Neuropathic pain; Spinal cord stimulation