Neuronal & Non-neuronal Modulations by Spinal Cord Stimulation (SCS) in Pain Control

An exploration of the neuronal and non-neuronal modulatory effects of SCS.

Abstract

Chronic pain is difficult to treat. Spinal Cord Stimulation (SCS) has been used for over 50 years for pain treatment. Although it is useful, conventional SCS is associated with suboptimal clinical efficacy and short-lived pain relief. Mechanistic study for better understanding the biological actions of SCS will help to improve clinical efficacy of SCS.

This presentation reviews spinal neuronal mechanisms for pain inhibition from SCS, including new evidence suggesting mode of action beyond traditional gate control theory of pain. Despite the ability of glial cells to modulate neuronal excitability and pain processing, glial mechanisms often have been overlooked in the study of SCS.

We will discuss recent findings which suggest non-neuronal modulation by SCS, and the potential of targeting neuron-glial interaction and neuro-immune responses for improving pain control by SCS.

Outcomes

Learners completing this activity routinely report improved abilities in:

• Utilize mechanistic understanding of the effects of spinal cord stimulation (SCS)
• Explaining to patients non neuron-glial interaction and neuro-immune mechanisms of action of SCS besides neuronal stimulation
• Identifying patients who may benefit from SCS therapies
• Selecting the right neurostimulation therapy for each patient
• Making informed referrals

Learning Objectives

As a result of participating in this activity, learners will be better able to:

• Integrate the concept of non-neuronal activation via spinal cord stimulation into the process of identifying patients for whom bioelectronic therapies may or may not be advisable 
• Utilize a mechanistic understanding of the effects of SCS to select the right neurostimulation therapies for a variety of patients

Desirable Physician Attributes

• Medical Knowledge [ACGME/ABMS] about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
  
• Employ Evidenced-based Practice [IOM] Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible
• Patient Care [ACGME/ABMS] Provide care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health

Pain management domains and core competencies

• 1. Multidimensional nature of pain: What is pain?
  • 1.2: Present theories and science for understanding pain
  • 1.3: Define terminology for describing pain and associated conditions

• 3. Management of pain: How is pain relieved?
  • 3.2: Identify pain treatment options that can be accessed in a comprehensive pain management plan
  • 3.4: Develop a pain treatment plan based on benefits and risks of available treatments

Accreditation & Designation

Release date: This activity was released 8/15/2020.

Termination date: The content of this activity remains eligible for CME Credit until 8/14/2023, unless reviewed or amended prior to this date.

Neurovations Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Neurovations Education designates this other activity (blended learning) for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Financial Relationships & Measures to Resolve Conflicts of Interest

[Speaker] Yun Guan discloses the following financial relationships: Grants/Research Support: Medtronic, TissueTech, Inc. Consulting: Medtronic

Neither the peer reviewers nor any other person with control of, or responsibility for, the development, management, presentation or evaluation of the CME activity (planners) has, or has had within the past 12 months, any financial relationships to disclose. This includes any relationships of an involved person's spouse/partner.

Materials were peer-reviewed in advance of the activity by person(s) that do not have conflicts of interest related to the content. All clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines).

Additional Reading

• Chen, Z., Wang, T., Fang, Y., Luo, D., Anderson, M., Huang, Q., ... & Xie, Y. (2019). Adjacent intact nociceptive neurons drive the acute outburst of pain following peripheral axotomy. Scientific Reports, 9(1), 1-12.
• Beauchene, C., Sacré, P., Yang, F., Guan, Y., & Sarma, S. V. (2019, July). Modeling Responses to Peripheral Nerve Stimulation in the Dorsal Horn. In 2019 41st Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) (pp. 2324-2327). IEEE.
• Sivanesan, E., Stephens, K. E., Huang, Q., Chen, Z., Ford, N. C., Duan, W., ... & Guan, Y. (2019). Spinal cord stimulation prevents paclitaxel-induced mechanical and cold hypersensitivity and modulates spinal gene expression in rats. Pain Reports, 4(5).
• Sdrulla, A. D., Guan, Y., & Raja, S. N. (2018). Spinal cord stimulation: clinical efficacy and potential mechanisms. Pain Practice, 18(8), 1048-1067.
• Miller, J. P., Eldabe, S., Buchser, E., Johanek, L. M., Guan, Y., & Linderoth, B. (2016). Parameters of spinal cord stimulation and their role in electrical charge delivery: a review. Neuromodulation: Technology at the Neural Interface, 19(4), 373-384.
• Sivanesan, E., Maher, D. P., Raja, S. N., Linderoth, B., & Guan, Y. (2019). Supraspinal Mechanisms of Spinal Cord Stimulation for Modulation of PainFive Decades of Research and Prospects for the Future. Anesthesiology: The Journal of the American Society of Anesthesiologists, 130(4), 651-665.
• Guan, Yun. "Spinal cord stimulation: neurophysiological and neurochemical mechanisms of action." Current Pain and Headache Reports 16.3 (2012): 217-225.