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Bipolar dual-lead spinal cord stimulation between two electrodes on the ventral and dorsal sides of the spinal cord: consideration of putative mechanisms

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Abstract

We have applied bipolar dual-lead spinal cord stimulation (SCS) between two cylinder-type electrodes placed on the ventral and dorsal sides of the spinal cord (dual-VD-SCS). A 36-year-old man suffered from burning pain from his right elbow down to his hand after brachial plexus avulsion. The areas with paresthesia induced by conventional SCS did not include the painful hand area. However, dual-VD-SCS completely induced paresthesia in the painful hand area. We speculate that dual-VD-SCS can be applied to stimulate deeper sites of the dorsal column and dorsal horn than conventional SCS and is useful for pain reduction.

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Acknowledgements

This work was funded by a Grant-in-Aid for Scientific Research (C-15 K10375) from the Ministry of Education, Culture, Sports, Science and Technology (MEXT) of Japan.

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Authors and Affiliations

  1. Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, 173-8610, Japan

    Mitsuru Watanabe, Takamitsu Yamamoto, Chikashi Fukaya, Toshiki Obuchi, Toshikazu Kano, Kazutaka Kobayashi, Hideki Oshima & Atsuo Yoshino

Authors
  1. Mitsuru Watanabe
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  2. Takamitsu Yamamoto
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  3. Chikashi Fukaya
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  4. Toshiki Obuchi
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  5. Toshikazu Kano
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  6. Kazutaka Kobayashi
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  7. Hideki Oshima
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  8. Atsuo Yoshino
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Corresponding author

Correspondence to Takamitsu Yamamoto.

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Ethics approval

This study was approved by the Ethics committee of Nihon University Hospital. Informed consent was obtained from the patient and his family. Additional informed consent was obtained from the patient for whom identifying information is included in this article.

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Comments

This report is a demonstrative illustration of the mechanism why Dorsal Column Stimulation (DCS) is not effective in the patients harboring neuropathic pain after root avulsion. In complete root avulsion, like in this case of brachial plexus injury after motor cycle accident, it is quite logical that DCS do not work. As a matter of fact the dorsal column fibers that must be targeted have degenerated up to the level of brainstem. This is the reason why in those conditions DCS never elicits paresthesias covering the painful (avulsed) territory. Noteworthy, this can be predicted by Somato-Sensory-Evoked Potentials (SSEPs) measurements, when the Central Conduction Time is severely altered or even more abolished at the segmental levels injured [1].

In root avulsions, as well-studied, anatomical-physiological alterations involve the spinal cord itself [2]. Dorsal horn is generally modified by atrophy, cavitations, gliotic tissue, etc. Normal dorsal horn electrogenesis [3] is severely destructured. Micro-electrode recordings show spontaneous hyperactivity in the deafferented neurons [4]. Therefore present consensus is that the more effective method is destruction of these hyperactive neurons by lesioning the Dorsal Root Entry Zone (DREZ) and the dorsalmost layers of the Dorsal Horn [5, 6, 7, 8, 9]. Long-term studies of outcome show that the paroxystic component of the pain is totally suppressed in almost all patients after DREZ-lesioning, whereas the permanent continuous pain component, especially when of the burning type—like in the presented case—is less constantly alleviated [2, 10, 11].

In the authors’ reported case, it might be that the Dorsal (cathode)/Ventral (anode) segmental stimulation works (1) by “jamming” the hyperactive local hyperactivity created by the deafferented neurons and/or (2) by stimulating the (still alive) neurons at the origin of the spino-reticular-thalamic pathways (altered neurons and pathways which can be the source of the burning pain).

Although this reported case is still unique in the literature, we think it must be taken into account within the frame of the pain surgery armamentarium for treating neuropathic pain syndromes, especially pain after deafferentation syndromes.

Marc Sindou,

Lyon, France

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Watanabe, M., Yamamoto, T., Fukaya, C. et al. Bipolar dual-lead spinal cord stimulation between two electrodes on the ventral and dorsal sides of the spinal cord: consideration of putative mechanisms. Acta Neurochir 160, 639–643 (2018). https://doi.org/10.1007/s00701-017-3421-8

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