The Neuromodulation Casebook

178 Pages·2020·3.079 MB·English

by  Jeffrey Arle (editor)

The Neuromodulation
Casebook
Edited by
Jeffrey Arle
Associate Professor of Neurosurgery,
Harvard Medical School,
Boston, MA, United States
Associate Chief of Neurosurgery,
Beth Israel Deaconess Medical Center,
Boston, MA, United States
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Contributors
Jeffrey E. Arle, Neurosurgery, Harvard Medical School, Boston, MA, United States;
Neurosurgery,BethIsrael DeaconessMedical Center,Boston,MA,UnitedStates
Jianwen Wendy Gu, Principal Field Engineer, Boston Scientific Neuromodulation,
Valencia,CA,UnitedStates
LauraLombardi-Karl,Anesthesiology,CriticalCare,andPainMedicine,BethIsrael
Deaconess MedicalCenter,Boston,MA,UnitedStates
Alon Mogilner, Neurosurgery and Anesthesiology, NYU Langone Medical Center,
NewYork,NY,UnitedStates
Musa Moris Aner, Anesthesiology, Critical Care, and Pain Medicine, Beth Israel
Deaconess MedicalCenter,Boston,MA,UnitedStates
Mohamed Osman, Anesthesiology, Critical Care, and Pain Medicine, Beth Israel
Deaconess MedicalCenter,Boston,MA,UnitedStates
TimothyRayDeer,TheCenter forPainRelief,Inc.,Charleston,WV,UnitedStates
PatriciaOsborneShafer,HealthInformationandResources,ProgramsandServices,
Epilepsy Foundation, Landover, MD, United States; Neurology, Beth Israel
Deaconess MedicalCenter,Boston,MA,UnitedStates
Jay L. Shils, Anesthesiology, Intraoperative Neurophysiologic Monitoring, Rush
UniversityMedical Center,Chicago, IL,UnitedStates
Tom Simopoulos, Department of Anesthesiology, Critical Care Medicine and Pain
Medicine, Division of Pain Medicine, Beth Israel Deaconess Medical Center,
Boston,MA, UnitedStates
Cyrus Yazdi, Department of Anesthesiology, Critical Care Medicine and Pain
Medicine, Division of Pain Medicine, Beth Israel Deaconess Medical Center,
Boston,MA, UnitedStates
ix
Preface
Neuromodulation is a very current, cutting-edge field and encompasses a va-
riety of techniques and therapies, ranging from deep brain stimulation for a
multitudeofdisorderstospinalcordstimulation,peripheralnervestimulation,
corticalstimulation,andcranialnervestimulation,nottomentionacollection
of growing noninvasive therapies and other implanted types of devices that
interface with the nervous system. It overlaps the boundaries of functional
neurosurgery, spine surgery, pain management, and bioengineering. I have
been happily involved in the field of neuromodulation for over 20 years and
canseethereisaneedforatypeof“mini-fellowship”wherepractitionerswho
want to start or add to their repertoire of neuromodulatory therapies can find
allthebasicsfromexpertmentorsinoneconvenientlocation.Thisbookseeks
tofillthatneedbyputtinginasinglebookallthepractical,hands-ondecision-
making using realistic case examplesdhow they are managed and how vari-
ations in this management would be handled.
Allneuromodulationtherapiesinvolveahostofdecisionsregardingpatient
selection, target, technical aspects, the technique itself, programming, and
follow-up care, as well as complication management. Complication manage-
ment alone, in fact, is critical in most surgical or procedural therapies and
drives the structure and depth of most training programs. As many surgeons
might recall hearing from their own mentors, anyone can put a device in, but
what is important is how to decide in whom to place the device and then in
managing the situation when things do not go as planned in placing or
following the patient and the device.
This book is case-based, for the simple reason that people learn best with
case-basedexamplesinthesetypesoffields.Asabookpresentswithaformat
and size, it cannot possibly do justice to every nuance and type of therapy
without becoming uninteresting and unwieldy; however, the format follows a
singlecasebutpausesperiodicallytoreviewtypicalvariationsthatcouldhave
arisen at that juncture of the care. Answers are succinctly given to each of
thesevariations,andthenthecasetimelineresumes.Overall,thegoalwiththis
formatistohavethereaderarriveattheendofeachchapter,andattheendof
thebookitself,withafeelingthattheyhaveseennotonlythetypicalcasesand
presentations and problems but also a large swath of the variations that can
occurinrealpractice,aswellashowtomanagethem.Inasense,thisiswhata
fellowship training year would accomplishdbutit is rare to find a fellowship
thatwouldallowonetogainexpertiseinalloftheseareasofneuromodulation
xi
xii Preface
since they span so many individual subfields (e.g., pain management, move-
mentdisorders,epilepsy).Mostlikely,astereotacticandfunctionalfellowship
will only cover one or two of these areas well.
Asnoted,thecasescoverthesemosttypicalareaswhereneuromodulation
is usedddeep brain stimulation for tremor, Parkinson disease, and dystonias;
spinal cord stimulation for failed back surgery and complex regional pain
syndromes;peripheralnervestimulationforpaininavarietyoftargets;vagus
nerve stimulation for epilepsy. This retains a practical grounding for the
bookdlikeahandbookandaguidebook,andapersonalmentoringallinone,
without straying too far into areas that only come up rarely if ever for the
majority of clinicians in these fields.
Finally,Ihavetriedtoinclude examplesthatinvolvenotjustsurgeonsper
se but also nonsurgeon proceduralists: the physiatrist who does spinal cord
stimulator trials, for example, or the pain management physician who places
peripheralnerveleadsusingultrasoundguidanceorfaceleads.Italsoincludes
expertinsight into programming these devices, in a similar type offormat. In
itsultimatestructure,itismorelikereadingaseriesofgoodshortstoriesthan
apedantic,bulletpointeriddenlistingofreferencesor“tips”perse,thoughno
doubt there is still some of that. My goal is to allow the reader to find real
examples of decisions they need to make every day and a frank discussion
fromthosewhoareconsidered“leaders”inthefieldonhowtheyworkthrough
them. In addition, the text serves as a companion (to Essential Neuro-
modulation and Innovative Neuromodulation) for a course in Biomedical
Engineering orareasonablereference fortheearly training offellows inpain
programs and functional neurosurgeons.

Chapter 1
Percutaneous trial lead
placement for failed back
surgery syndrome
Laura Lombardi-Karl, Musa Moris Aner
Anesthesiology,CriticalCare,andPainMedicine,BethIsraelDeaconessMedicalCenter,Boston,
MA,UnitedStates
Scenario
A 57-year-old female with a history of L4-L5 and L5-S1 laminectomy and
fusion presents with persistent axial back and left leg pain. She has been
diagnosed with failed back surgery syndrome (FBSS). She has trialed several
medial branch blocks and lumbar epidural steroid injections with minimal
relief. She is currently taking gabapentin 300mg three times daily and has
participatedinseveralcoursesofphysicaltherapywithminimalbenefit.Sheis
anxiousthatnosolutionswillbefoundforherchronicpainandseemswilling
to try alternative therapies. Discussion takes place to consider spinal cord
stimulationandthepossibilityofperformingatrialofthestimulationtoseeif
it can help her. She expresses interest in proceeding and is given some liter-
ature to review on the therapy.
Variation:Conservativemultimodalmanagementhasnotbeentrialed
– Spinal cord stimulation is generally considered after patients have
failed more conservative management with medication, physical ther-
apy,orotherlessinvasiveinterventionaltechniques,althoughthisisnot
necessarily required. Placement of SCS should not be viewed as a
replacement or contraindication to multimodal analgesia, especially
consideringthatpatientsoftenhavemultiplepaingeneratorsandpainis
often multifactorial. In many cases, patients will continue taking
adjuvant medications and pursuing physical therapy. However, there
shouldbeanefforttoreduceopioidconsumption,andaplanforopioid
reduction should be discussed with the patient as part of preoperative
planning.
TheNeuromodulationCasebook.https://doi.org/10.1016/B978-0-12-817002-1.00001-8
Copyright©2020ElsevierInc.Allrightsreserved. 3
4 SECTION | I Spinalcordstimulation
Variation:Thepatienthashadmultiplesurgeriesatdifferentlevels–
It is important to confirm the levelof a patient’s prior surgeries as this
may interfere with safe placement of percutaneous leads. Laminec-
tomies will result in a disrupted ligamentum flavum, while fusion
hardware may interfere with imaging. Prior surgery can result in
epidural scarring that extends beyond the level of surgery. This can
interfere with the loss of resistance technique and pose difficulty
threadingleads.Severecentralcanalstenosismaybeacontraindication
for an SCS as placement of a space-occupying lead may cause
myelopathy. Although this is of greater concern in cervical SCS
placement, it should be considered at all levels. Before SCS implant,
patients with FBSS should be reevaluated by their surgeon to ensure
there are no structural issues that would require further surgery. It is
alsovaluabletoobtainupdatedimagingwithcontrasttoassessfornew
or worsening pathology. Thoracic spine magnetic resonance imaging
(MRI)canalsobeincludedaspartofpreoperativeplanningforthoracic
SCS placement.
Variation: The patient is elderly and has mild cognitive impairment
butgoodfamilysupport–Althoughfamilymembershelpthepatientto
remember and effectively communicate at visits, using the device and
communicating eventual needs for reprogramming and functional im-
provements may be hampered. At times, the patient’s underlying pain
state or comorbidities may influence the surgeon’s choice of SCS
manufacturer. Device selection is a complex process taking into ac-
countthecharacteristicsofthepatient’spain,surgeon’spreference,and
patient’s ability to communicate. Patients with anxiety disorders or
difficultydescribingtheirpainmaybenefitfromplacement ofadevice
that does not require extensive intraoperative mapping and patient
cooperation,suchashigh-frequency10kHz.Allelderlypatientsshould
gothroughpsychiatricevaluationasstandardofcare,notnecessarilyto
rule out placement butto find ways to optimize the patient for a better
outcome.
Variation:Thepatienthasahistoryofbreastcancerthathasbeenin
remission for 2years – Patients with medical conditions requiring
frequentMRIimaging,suchascancer,mayinfluencethechoiceofSCS
device. Some SCS devices are fully MRI compatible, some are
conditionally compatible, while some are not compatible at all. A full
discussion with the patient’s oncologist or other relevant providers
regarding the likely need for future MRI imaging should occur before
SCS placement. Similarly, there may be less utility in selecting an
MRI-compatible device for patients who already have a contraindica-
tion to MRI, such as those with noneMRI-compatible pacemakers or
Percutaneoustrialleadplacementforfailedbacksurgery Chapter | 1 5
deep-brainstimulators.Otherpatientswhomayhaveanincreasedneed
for MRI imaging include those with a concern for intracranial pathol-
ogy, such as patients with a history of seizures or headache, as well as
patients with multiple joint complaints or surgeries.
Scenario (continued)
Afullphysicalexaminationiscompleted,andnonewneurologicaldeficitsare
noted. The patient’s MRIs and relevant laboratory test results are reviewed,
and she has had anunremarkable preoperativepsychological assessment.The
patient expresses reasonable expectations and understands SCS trial re-
strictions. The decision is made to proceed with a percutaneous SCS trial.
Variation: The patient reports that she expects her pain to resolve
after SCS placement – It is important to consider both disease- and
patient-specific factors when considering SCS. FBSS is an indication
with high probability of success with SCS. Newer technology has
enabledpainstatestraditionallyresistanttoSCS,suchasaxiallowback
pain,tohavebetter response. Proper patient education andexpectation
setting is key for success and reduction of placebo, as well as false
positives. Before trial, the potential range of outcomes should be dis-
cussed with the patient. Patients with unrealistic expectations, such as
anticipation of complete pain relief, those who seem hesitant to pro-
ceed, and any patient with uncontrolled anxiety, depression, addiction,
or other psychiatric issue, should be viewed with caution. We recom-
mend all patients meet with a psychiatric health-care provider before
SCS trial for a thorough evaluation of potential psychiatric barriers.
Patientswithahistoryofnoncompliancewithothertreatment,unstable
social or health insurance situations, and those with limited cognitive
ability require thoughtful evaluation before proceeding. In addition,
clinicians and patients should discuss possible differences in relief
provided by the trial versus permanent implant. Ideally, this conver-
sation should have been had at multiple times by multiple providers,
including the surgeon and pain psychologist.
Variation: The patient is on anticoagulation for atrial fibrillation –
Anticoagulation continues to be a barrier in SCS placement. Multiple
guidelines exist; American Society of Regional Anesthesia (ASRA)
guidelines are the most frequently used ones. Following these guide-
linesassumesthatplacementofanepiduralinfusioncatheterissimilar
toplacementofanSCSlead.RiskofstoppinganticoagulationforSCS
placementrequiresriskstratificationandathoroughdiscussionwiththe
patient’s neurologist, cardiologist, or hematologist. Although physi-
ciansinotherspecialtiesmaybefamiliarwithsurgicaltechniques,they