Neuromodulación eléctrica en el tratamiento del dolor neuropático refractario. Colocación del primer estimulador medular en Cuba / Electric neuromodulation in the treatment of refractory pain. Placement of the first spinal stimulator in Cuba

El dolor es una causa importante de sufrimiento físico y emocional. El tratamiento médico de los pacientes con dolor crónico refractario es un gran reto. Se presenta el caso de una paciente de 19 años con un cuadro radicular compresivo secundario a Hernia discal L5-S1 derecha, que se le aplicó una discectomía L5-S1 por técnica de Caspar. Al mes de evolución regresa con igual sintomatología. A pesar de múltiples terapias farmacológicas y procederes intervencionistas, el dolor neuropático no mejora, después de múltiples estudios y discusiones en colectivo se determina la posibilidad de la colocación de un neuroestimulador medular, proceder que se lleva a cabo con mejoría considerable de su cuadro doloroso(AU)

Pain is a major cause of physical and emotional suffering. The management of patients with refractory chronic pain is a great challenge. The case is presented of a 19-year-old female patient with compressive radicular symptoms secondary to right L5-S1 disc herniation, who underwent L5-S1 discectomy with Caspar technique. After one month of evolution, she returned with the same symptoms. Despite multiple pharmacological therapies and interventional procedures, the neuropathic pain did not improve. After multiple studies and collective discussions, the possibility of placing a spinal neurostimulator was decided. After the procedure, the patient improved considerably with respect to her painful symptoms(AU)

Reducing VNS stimulation parameters: Is it safe?

Introduction Vagal nerve stimulation (VNS) is an adjuvant therapy used in the treatment of patients with refractory epilepsy who are not candidates for resective surgery or who have limited results after surgical procedures. Currently, there is enough evidence to support its use in patients with various types of epilepsy. Therefore, the present study was conducted to explore the possibility of optimizing therapy by reducing the consumption of the system's battery. Methods The prospective and double-blind analysis consisted in the evaluation of 6 patients submitted to VNS implantation for 3 months, followed by adjustment of the stimulation settings and continuity of follow-up for another month. The standard protocol was replaced by another with a frequency value of 20 Hz instead of 30 Hz to increase battery life. The safety of this procedure was evaluated through the assessment of two main variables: seizures and side effects. Results The stimulation at 20 Hz showed 68% reduction in the incidence of seizures (p»0.054) as well as low incidence of side effects. Conclusion The present study suggests that the reduction of the stimulation frequency from 30 to 20 Hz is a safe procedure, and it does not compromise the effectiveness of therapy.

Bloqueio do plexo braquial em jumento - relato de caso / Brachial plexus block in donkey - case report

A anestesia locorregional reduz o requerimento de agentes inalatórios e diminui as respostas autonômicas a estímulos cirúrgicos nocivos. Objetiva-se descrever um bloqueio anestésico do plexo braquial guiado por neuroestimulador em jumento, submetido à amputação do membro anterior direito. Foi realizada medicação pré-anestésica com detomidina 0,01mg.kg-1, indução com diazepam 0,05mg.kg-1 e cetamina 2mg.kg-1, todos pela via intravenosa (IV), e a manutenção da anestesia com isoflurano. O plexo braquial foi bloqueado por acesso subescapular, sendo usado neuroestimulador. Utilizou-se 1mg.kg-1 de bupivacaína 0,5% sem vasoconstritor, associada a 1mg.kg-1 de lidocaína 2% sem vasoconstrictor. Os valores de FC e ƒ durante o procedimento cirúrgico variaram de 62 a 78bpm e de 24 a 32rpm, respectivamente. Foram coletadas quatro amostras de sangue para dosagem de cortisol. Este, antes da aplicação da medicação pré-anestésica, foi de 6,4µg/dL e, 30 minutos após a MPA, foi de 2,8µg/dL. A recuperação anestésica foi rápida e sem complicações. O bloqueio do plexo braquial guiado por neuroestimulador mostrou-se eficaz em jumentos, fornecendo analgesia e anestesia satisfatória.(AU)

Locoregional anesthesia reduces the requirement for inhaled agents and reduces the autonomic responses to noxious surgical stimuli. The aim of this study was to describe an anesthetic block of the brachial plexus guided by a neurostimulator in a donkey submitted to right limb amputation. Preanesthetic medication was performed with detomidine 0.01mg.kg-1 induction with diazepam 0.05mg.kg-1 and ketamine 2mg.kg-1 all intravenously, and maintenance of anesthesia with isoflurane. The brachial plexus was blocked by subscapular access, using a neurostimulator. For this purpose, 1mg.kg -1 of bupivacaine 0.5%, without vasoconstrictor, and 1mg.kg- 1 of lidocaine 2%, without vasoconstrictor were used. The values of HR and ƒ during the surgical procedure ranged from 62 to 78bpm, and 24 to 32bpm, respectively. Four blood samples were collected for cortisol dosing. This, prior to the application of the pre-anesthetic medication was 6.4µg/dL and 30 minutes was 2.8µg/dL. Anesthesia recovery was rapid and uncomplicated. Neurostimulator-guided brachial plexus blockade proved to be effective in donkeys, providing satisfactory analgesia and anesthesia.(AU)

Non-invasive brain stimulation therapies / Terapias de neuroestimulação não invasivas

Noninvasive brain stimulation therapies are a promising field for the development of new protocols for the treatment of neuropsychiatric disorders. They are based on the stimulation of neural networks with the intent of modeling their synaptic activity to adequate levels. For this, it is necessary to precisely determine which networks are related to which brain functions, and the normal activation level of each of these networks, so that it is possible to direct the stimulation to the affected networks in order to induce the desired effects. These relationships are under intense investigation by the scientific community, and will contribute to the advancement of treatments by neurostimulation, with the emergence of increasingly accurate and effective protocols for different disorders. Currently, the most used techniques are Transcranial Direct Current Stimulation and Transcranial Magnetic Stimulation, with the most common applications being for treating Major Depressive Disorder. The advancement of research in this field may determine new target networks for stimulation in the treatment of other disorders, extending the application of these techniques and also our knowledge about brain functioning.

As terapias biológicas não invasivas se apresentam como um campo promissor para o desenvolvimento de novos protocolos de tratamento de transtornos neuropsiquiátricos. Elas se baseiam na estimulação de redes neurais com intuito de modular sua atividade sináptica para níveis adequados. Para isso, é necessário a determinação precisa de quais redes estão relacionadas a quais funções cerebrais, e do nível de ativação normal de cada uma dessas redes, para que então seja possível direcionar a estimulação às redes afetadas a fim de induzir os efeitos desejados. Essas relações estão sob intensa investigação pela comunidade científica, e vão contribuir para o avanço dos tratamentos por neuroestimulação, com o surgimento de protocolos cada vez mais precisos e efetivos para diferentes transtornos. Atualmente, as técnicas mais utilizadas são a Estimulação Transcraniana por Corrente Contínua e a Estimulação Magnética Transcraniana, sendo a aplicação mais comum no tratamento do Transtorno Depressivo Maior. O avanço das pesquisas possivelmente determinará novas redes alvo para estimulação no tratamento de outros transtornos, estendendo a aplicação dessas técnicas e também do nosso conhecimento sobre o funcionamento cerebral.

A Torso Simulator Design for Implantable Nerve Stimulator Test / 中国医疗器械杂志

This paper introduces ISO 14708-3:2017, the new edition of the international standard for implantable neurostimulator, and emphasizes the new requirements in the clause of protection from RF electromagnetic interference. To meet this new requirements, this paper presents a design of torso simulator for the testing of implantable neurostimulator. The design includes volume conductor, electrodes and grids, which can simulate the actual operating environment of implantable neurostimulator in RF electromagnetic interference testing. The torso simulator is verified by performance in the last part of the paper.

Interpretation of the International Standard 2017 Version of Implantable Neurostimulators / 中国医疗器械杂志

ISO 14708-3 "Implants for surgery-active implantable medical devices-Part 3:implantable neurostimulators" 2017 version and 2008 version are compared, and changes in the standard are interpreted combined with the characteristics of the neurostimulator. The new version of the standard for the first time in the introduction mentioned a new type of non-electrode or extension's neurostimulator. Key issues that have significant impact on safety concerns such as wireless charging temperature rise, MRI acceptance criteria, etc., are given for the first time in the new version. New requirements to the wireless communication section are added, and the electromagnetic compatibility part is greatly adjusted. With more miniature non-electrode or extension's neurostimulator entering the market, standards such as electromagnetic compatibility and MRI, there will be greater adjustments.

Detecting Bladder Biomarkers for Closed-Loop Neuromodulation: A Technological Review / 대한배뇨장애요실금학회지

Neuromodulation was introduced for patients with poor outcomes from the existing traditional treatment approaches. It is well-established as an alternative, novel treatment option for voiding dysfunction. The current system of neuromodulation uses an open-loop system that only delivers continuous stimulation without considering the patient’s state changes. Though the conventional open-loop system has shown positive clinical results, it can cause problems such as decreased efficacy over time due to neural habituation, higher risk of tissue damage, and lower battery life. Therefore, there is a need for a closed-loop system to overcome the disadvantages of existing systems. The closed-loop neuromodulation includes a system to monitor and stimulate micturition reflex pathways from the lower urinary tract, as well as the central nervous system. In this paper, we reviewed the current technological status to measure biomarker for closed-loop neuromodulation systems for voiding dysfunction.

C1-C4 Dorsal Column Stimulation for Refractory Occipital Neuralgia Treatment. Case Report

Introduction Refractory occipital neuralgia is a difficult medical condition, especially when the patient has already been submitted to occipital nerve neurectomy and radiofrequency rhizotomy. There is no case report of spinal cord stimulation in the C1- C4 cervical segments for this condition. Objective To evaluate if C1-C4 dorsal spinal cord stimulation is effective in a patient with refractory occipital neuralgia who was already submitted to neurectomy and rhizotomy. Methods After obtaining the approval from the Ethics Committee of one of our institutions, a unilateral laminectomy was performed between C3 and C4, and a neurostimulator lead was conducted until the posterior portion of the C1 arc was in full view. Then we performed an intraoperative test to evaluate the correspondence between pain location and stimulation-induced paresthesias. We could not put the subcutaneous lead for such condition because of the scar tissue of the area and the previous neurectomy. Results After one year of follow up, we noticed a dramatic improvement in pain control, as well as medication withdrawal. The score of the visual analogue scale was 9 before the surgery, and it dropped to 2 after 1 year of follow-up. Conclusion Spinal cord stimulation between the C1 and C4 cervical segments can be an option for selected cases of refractory occipital neuralgia, including those patients who have already been submitted to neurectomy or rhizotomy.

Neuralgia occipital refratária é uma condição médica difícil, especialmente em pacientes submetidos previamente a neurectomia nos nervos occipitais e rizotomia por radiofrequência. Não há na literatura relato de estimulação da medula espinhal entre os níveis C1 e C4 para essa condição. Objetivos Avaliar se a estimulação da coluna dorsal da medula nos níveis C1 a C4 é eficaz no controle da dor em paciente com neuralgia occipital refratária já submetido a neurectomia e rizotomia. Métodos Após aprovação do Conselho de Ética de uma de nossas instituições, foi realizada laminectomia unilateral de C3 e C4, com posterior introdução do conjunto de eletrodos em placa, que foi posicionado até que a porção anterior do arco de C1 estivesse sob visão direta. Posteriormente, foi realizado um teste intraoperatório para avaliar a correspondência entre a área dolorosa e a parestesia induzida pela estimulação. Não possível optar pelo uso de eletrodo subcutâneo devido ao extenso tecido cicatricial secundário às cirurgias prévias. Resultados Melhora significativa da dor ocorreu ao longo de um ano de acompanhamento, com redução progressiva da dose da medicação. O valor da escala visual analógica no pré-operatório era 9, e após 1 ano de acompanhamento, reduziu para 2. Conclusão Estimulação da coluna dorsal da medula espinhal entre os seguimentos C1 e C4 pode, em casos selecionados, ser uma opção terapêutica na neuralgia occipital refratária, incluindo pacientes que já foram submetidos a neurectomia e rizotomia.

Ultrasound-guided placement of a permanent peripheral nerve stimulator in a patient with complex regional pain syndrome: A case report

A 56-year-old man complained of continuous pain in the right foot that began 6 months after undergoing surgery on the right calcaneus bone. The patient was diagnosed with complex regional pain syndrome (CRPS) type I and was treated with medication, lumbar sympathetic ganglion blocks, epidural nerve blocks, and spinal cord stimulation. However, all treatments were halted because they were ineffective or complications developed. Peripheral nerve stimulation (PNS) was planned after confirming the analgesic effects of a sciatic nerve block, and the patient received PNS via minimally invasive ultrasound-guided electrode placement. PNS reduced the pain intensity and the incidence of paroxysmal pain. Other than discomfort at the battery insertion site (resolved with re-implantation), the patient developed no complications. These results suggest that ultrasound-guided minimally invasive PNS is a safe and effective treatment for patients with CRPS in the lower extremities.

Caudal Neuromodulation with the Transforaminal Sacral Electrode (InterStim(R)): Experience in a Pain Center Regarding 12 Implants

BACKGROUND: Sacral nerve stimulation is a therapeutic option with demonstrated efficacy for conditions presenting with perineal pain caused by different etiologies. We aimed to assess whether a sacral electrode (InterStim(R), Medtronic, Minneapolis, MN, USA) inserted through the caudal pathway is able to offer an acceptable level of sacral stimulation and rate of catheter migration. METHODS: We present 12 patients with pelvic pain who received sacral neuromodulation via the sacral hiatus with the InterStim electrode. We evaluated patient satisfaction as well as migration and removal of the electrode, if necessary. RESULTS: Our experience included 12 patients, 10 women and two men, with a mean age of 60 years. In eight of the 12 patients, the initial therapy was effective, and the final system implantation was performed. During subsequent follow-up, patient satisfaction was good. To date, there have been no cases of electrode displacement or migration. CONCLUSIONS: The caudal insertion of the InterStim electrode, with its own fixation system, and initially designed for transsacral insertion, appears in our experience to be a satisfactory option which can minimize electrode displacements, achieving similar results in therapeutic efficacy and causing no difficulties in removal.

Generation and Regulation Technology of Stimulating Signals for Implantable Neural Stimulators / 中国医疗器械杂志

The accuracy and robustness of stimulating signals are critical important for implantable neural stimulators since they stimulate neurons directly. The characteristics and applications of stimulating signals were depicted in the paper. The principles and features of five common generation and regulation technology of stimulating signals for implantable neural stimulators were introduced. The technical characteristics of them were analyzed. Finally, the development of the implantable neural simulators was prospected.

An Implantable Device for Treatment of Obstructive Sleep Apnea: Hypoglossal Nerve Stimulation Therapy / 대한이비인후과학회지

Among current treatment options for obstructive sleep apnea (OSA) including surgeries and oral appliances, positive airway pressure (PAP) is accepted as a standard modality, particularly for moderate to severe OSA patients. Because long-term compliance for PAP is less than 50%, however, strong demands for a novel therapy have existed. Based on the findings that electromyographic activities of pharyngeal dilator muscles are significantly decreased in OSA patients during sleep, researches on hypoglossal nerve stimulation (HGNS) have been conducted. Therapeutic effects of HGNS on OSA have been proven through a series of clinical trials, and the American Food and Drug Administration recently approved its application on moderate to severe OSA patients who failed or are intolerant to PAP treatment. Given recent advances in HGNS therapy, it would be timely to review the history of HGNS and discuss its clinical implications.

Perspectivas no tratamento da doença arterial coronária / Treatment perspectives for coronary artery disease

A despeito dos incontestáveis avanços no tratamento médico e em procedimentos de revascularização miocárdica (percutâneous e cirúrgicos), sintomas debilitantes relacionados à doença arterial coronária podem ocorrer devido à progressão da doença com envolvimento difuso arterial e oclusão de enxertos prévios ou reestenose pós-angioplastia, impossibilitando novos procedimentos de revascularização miocárdica. Característica desta condição (angina refratária) é o grande prejuízo dos afetados em termos de qualidade de vida, impedidos de realizar as atividades mais triviais do dia-a-dia (caminhar poucos metros no plano ou mesmo banha-se) sem que a dor anginosa ocorra; alguns pacientes são despertados frequentemente durante a noite por angina. Assim, para estes pacientes, o objetivo principal do tratamento é a melhoria na qualidade de vida, com maior tolerância ao esforço, e menor necessidade de hospitalizações e procedimentos diagnósticos ou terapêuticos. Neste contexto, elencaremos sucintamente as principais estratégias terapêuticas não farmacológica em desenvolvimento para o tratamento de pacientes com angina refratária, incluindo terapia gênica, terapia celular, revascularização transmiocárdica a laser, contrapulsação externa, estimulação de medula espinhal e revascularização miocárdica extracorpórea por ondas de choque.

Despite great advances in both medical management and myocardial revascularization procedures (percutaneous and surgical), disabling symptoms due to coronary artery disease may occur due to progression of the beds, grafts failures after successful bypass surgery, and/or stent restenosis, preventing further revacularization attempts. Patients with refractory angina have a mared impairment in quality of life, unable to perform any daily avtivity such as slowl walking or even taking a bath without chest pain; many patients are awaken during their sleep due to chest disconfort. For theses patients, the main objective f treatment is to improve their quality of life, with better exercise tolerance, and decreased number of hospitalizations and/or diagnosis/therapeutic procedures. In this paper, we briefly discuss new non-pharmacological therapeutic strategies being developed for patients with adavanced CAD including gene therapy, cell therapy, transmyocardial laser revascularization, enhanced external conter-pulsation, spinal cord stimulation and extracorporeal shockwave myocardial revascularization.

Complicaciones durante la neuromodulación de raíces sacras en el tratamiento de la incontinencia fecal grave / Complications during sacral nerve stimulation in the treatment of severe fecal incontinence

Objective: to evaluate the complications of sacral nerve stimulation for the treatment of fecal incontinence. Background: sacral nerve stimulation is considered to be nowadays an effective treatment for fecal incontinence in selected patients. Many authors have reported excellent results and indication for his use have increased. Nevertheless, even being a simple technique, not it exempts this from complications. Methods: fifty-two patients with severe faecal incontinence, treated with sacral nerve stimulation between january 2002 and december 2010, were analysed. All adverse events during follow-up were recorded. Results: there was not surgical complication during peripheral neural evaluation test. In our series, with an average follow-up to 55.52 +/- 31.84 months (range: 12-121), we had a rate of adverse effects of 14 percent, infection of surgical wound in two patients, break of electrode in two patients and the presence of pain in the place of the implant, with episodes of extremity pain and paresthesias in low members in 3 patients. Conclusions: sacral nerve stimulation in severe fecal incontinence is a safe treatment, with a low index of complications.

Objetivo: evaluar las complicaciones de la neuromodulación de raíces sacras en el tratamiento de la incontinencia fecal. Introducción: la neuromodulación de raíces sacras ha sido descrita como un tratamiento quirúrgico eficaz en pacientes con incontinencia fecal grave. Muchos autores han comunicado excelentes resultados y las indicaciones en su uso han aumentado. Sin embargo, a pesar de ser una técnica quirúrgica sencilla, no está exenta de complicaciones. Material y Método: 52 pacientes con incontinencia fecal grave, tratados mediante neuromodulación de raíces sacras entre enero de 2002 y diciembre de 2010, fueron analizados. Todas las complicaciones, tanto durante la implantación del dispositivo como durante el seguimiento, fueron registradas. Resultados: no se registraron complicaciones durante la prueba de estimulación. En nuestra serie, con un seguimiento de 55,52 +/- 31,84 meses, observamos un 14 por ciento de efectos adversos, infección de la herida quirúrgica en dos pacientes, rotura o movilización del electrodo en 2 pacientes y dolor y parestesias en 3 pacientes. Discusión: la neuroestimulación de raíces sacras en el tratamiento de la incontinencia fecal es un tratamiento seguro, con un bajo índice de complicaciones.

Artefactual spikes in electrocardiography: a worthwhile introspection

Electrical devices, which have become an integral part of our daily life, may influence the electrical recording of the heart. These disturbances from external sources outside of the heart's own activity produce changes in the electrocardiography (ECG) of the patient, simulating rhythmic disturbances of the heart. Understanding these disturbances is essential in order to better interprete the ECG. Common sources of electrical interferences include external devices, such as alternating current and improper earthing, and surgical procedures like diathermy. We report a case of electrical interference in a patient's ECG due to an inserted bladder stimulator. This case report highlights the importance of precise identification of artefacts in the interpretation of ECG, as well as prompt localisation and elimination of the source of interference.

Intervenção fisioterapêutica na incontinência fecal no idoso / Physiotherapeutic intervention in fecal incontinence in elderly

O objetivo deste estudo foi agrupar e atualizar conhecimentos referentes à intervenção fisioterapêutica na incontinência fecal no idoso. A pesquisa da literatura foi realizada nas bases de dados eletrônicas: MEDLINE, LILACS, Cochrane, PubMed e SciELO, no período de janeiro de 2006 a julho de 2011. As palavras-chave usadas em várias combinações foram: fecal incontinence, aged, physical therapy, physiotherapy, exercises, rehabilitation e electrotherapy. A intervenção fisioterapêutica incluiu a avaliação da incontinência fecal constituída pelos sinais e sintomas, exame físico e exames complementares, que incluíram a manometria anorretal,a retossigmoidoscopia, a defecografia, a eletromiografia anorretal, aultrassonografia endoanal e a latência motora terminal do nervo pudendo; os exercícios para fortalecimento da musculatura do assoalho pélvico, o biofeedback, o treinamento com balão retal e a eletroestimulação constituem a base do tratamento. Essa atualização demonstrou a escassez de estudos abordando tal temática, encontrando apenas cinco estudos publicados nos últimos anos com pacientes idosos incontinentes, os quais enfatizaram em sua maioria os procedimentos já consagrados na literatura refutando as evidências já conhecidas. Porém, uma modalidade consideravelmente nova de tratamento, a neuroestimulação sacral, tem sido investigada com resultados aparentemente positivos, suscitando a necessidade de novos estudos com desenhos metodológicos específicos sobre este problema.

The objective of this study was to group or classify and update knowledge related to physical therapy intervention in fecal incontinence in the elderly. The literature search was conducted in electronic databases: MEDLINE, LILACS, Cochrane, PubMed and SciELO, from January 2006 to July 2011. The keywords used in various combinations were: fecal incontinence, aged, physical therapy, physiotherapy, exercises, electrotherapy and rehabilitation. The physiotherapy intervention includes assessment of fecal incontinence consisted by the signs and symptoms, physical examination and laboratory tests, including anorectal manometry, the sigmoidoscopy, the defecography, anorectal electromyography, ultrasonography and endoanal terminal motor latency of the pudendal nerve; strengthen exercises pelvic floor muscles, biofeedback, rectal balloon training and electrostimulation are the mainstay of treatment. This update showed the lack of studies addressing this issue and found only five studies published in recent years with elderly incontinent patients, which emphasized mostly the procedures already established in the literature refuting the evidence already known. However, a new treatment modality considerably, sacral neurostimulation has been investigated with apparently positive results, raising the need for new studies with methodological designs on this specific problem.

Ventilação elétrica: indicações e aspectos técnicos do implante cirúrgico do marca-passo de estimulação diafragmática / Electric ventilation: indications for and technical aspects of diaphragm pacing stimulation surgical implantation

OBJETIVO: Pacientes com lesão medular cervical alta em geral são dependentes de ventilação mecânica, que, embora salve vidas, está associada a complicações e redução da expectativa de vida devido a infecções respiratórias. A estimulação do diafragma por marca-passo, às vezes chamada de ventilação elétrica, induz a inspiração por estimulação dos músculos inspiratórios. Nosso objetivo foi destacar as indicações e alguns aspectos da técnica cirúrgica empregada no implante laparoscópico dos eletrodos, assim como descrever cinco casos de pacientes tetraplégicos submetidos à técnica. MÉTODOS: A seleção dos pacientes envolveu estudos de condução do nervo frênico por via transcutânea para determinar se os nervos estavam preservados. A abordagem cirúrgica foi laparoscopia clássica, com quatro trocartes. A técnica foi iniciada com o mapeamento elétrico para encontrar os "pontos motores" (pontos de contração máxima do diafragma). Se o mapeamento era bem-sucedido, dois eletrodos eram implantados na face abdominal de cada lado do diafragma para estimular ramos do nervo frênico. RESULTADOS: Dos cinco pacientes, três e um, respectivamente, eram capazes de respirar somente com o uso do marca-passo por períodos superiores a 24 e 6 h, enquanto um não era capaz. CONCLUSÕES: Embora seja necessário um acompanhamento mais longo para chegar a conclusões definitivas, os resultados iniciais são promissores, pois, no momento, a maioria dos nossos pacientes pode permanecer sem ventilação mecânica por longos períodos de tempo.

OBJECTIVE: Patients with high cervical spinal cord injury are usually dependent on mechanical ventilation support, which, albeit life saving, is associated with complications and decreased life expectancy because of respiratory infections. Diaphragm pacing stimulation (DPS), sometimes referred to as electric ventilation, induces inhalation by stimulating the inspiratory muscles. Our objective was to highlight the indications for and some aspects of the surgical technique employed in the laparoscopic insertion of the DPS electrodes, as well as to describe five cases of tetraplegic patients submitted to the technique. METHODS: Patient selection involved transcutaneous phrenic nerve studies in order to determine whether the phrenic nerves were preserved. The surgical approach was traditional laparoscopy, with four ports. The initial step was electrical mapping in order to locate the "motor points" (the points at which stimulation would cause maximal contraction of the diaphragm). If the diaphragm mapping was successful, four electrodes were implanted into the abdominal surface of the diaphragm, two on each side, to stimulate the branches of the phrenic nerve. RESULTS: Of the five patients, three could breathe using DPS alone for more than 24 h, one could do so for more than 6 h, and one could not do so at all. CONCLUSIONS: Although a longer follow-up period is needed in order to reach definitive conclusions, the initial results have been promising. At this writing, most of our patients have been able to remain ventilator-free for long periods of time.