Neuromodulation in patients with refractory angina pectoris: a review.

The number of patients with coronary artery disease (CAD) who have persisting angina pectoris despite optimal medical treatment known as refractory angina pectoris (RAP) is growing. Current estimates indicate that 5-10% of patients with stable CAD have RAP. In absolute numbers, there are 50 000-100 000 new cases of RAP each year in the USA and 30 000-50 000 new cases each year in Europe. The term RAP was formulated in 2002. RAP is defined as a chronic disease (more than 3 months) characterized by diffuse CAD in the presence of proven ischaemia which is not amendable to a combination of medical therapy, angioplasty, or coronary bypass surgery. There are currently few treatment options for patients with RAP. One such last-resort treatment option is spinal cord stimulation (SCS) with a Class of recommendation IIB, level of evidence B in the 2019 European Society of Cardiology guidelines for the diagnosis and management of chronic coronary syndromes. The aim of this review is to give an overview of neuromodulation as treatment modality for patients with RAP. A comprehensive overview is given on the history, proposed mechanism of action, safety, efficacy, and current use of SCS.

Feasibility of Spinal Cord Stimulation in Patients With Refractory Angina Pectoris and a Cardiac Implanted Electronic Device.

OBJECTIVES: Five to 10% of patients with stable coronary artery disease have refractory angina pectoris (RAP). These patients are restricted in performing daily activities due to angina pectoris. Spinal cord stimulation is a last resort treatment option. A number of this patient population also has an indication for a cardiac implanted electronic device (CIED) (pacemaker or implantable cardiac defibrillator). Manufacturers of spinal cord stimulators have stated a warning that interference can occur between the spinal cord stimulator and the CIED. Consequently, only a limited number of patients with RAP and a CIED have received a spinal cord stimulator. The aim of this retrospective cohort study is to determine whether spinal cord stimulation can be safely used in patients with RAP and a CIED. MATERIALS AND METHODS: All patients with RAP referred to our center were screened and included if 1) the patient received a spinal cord stimulator as treatment for RAP and if 2) the patient received a CIED either prior to or after spinal cord stimulator implantation. A transcutaneous electrical nerve stimulation (TENS) treadmill test was used as a screening tool to determine whether the patient was eligible for implantation of a spinal cord stimulator. Interference between the spinal cord stimulator and CIED was checked 1) after TENS treadmill test, 2) during implantation of spinal cord stimulator or CIED, 3) during mode switches of the SCS, and 4) during regular out patient follow-up. RESULTS: In total, 22 patients had both a spinal cord stimulator and a CIED with an average follow-up duration of 44.5 months. No interference between the spinal cord stimulator and CIED was found. CONCLUSION: Spinal cord stimulation can be safely applied in patients with a CIED provided that the CIED is checked for interference during implantation, if mode switches of the SCS occurred and once yearly after implantation according to routine follow-up.

Single-Center Experience With High-Density Spinal Cord Stimulation in Patients With Refractory Angina Pectoris.

OBJECTIVES: Spinal cord stimulation (SCS) is a treatment option for patients with refractory angina pectoris (RAP) which was first used in 1987 and led to a reduction in the number of angina pectoris episodes, less consumption of short-acting nitrates, and an improvement in the quality of life. The conventional mode of stimulation leads to paresthesia felt at the target area. In recent years novel modes of stimulation have been developed that are paresthesia free, such as "burst," "high-density (HD)," or "high-frequency/10 kHz" stimulation. To date, these new modes of stimulation have not been used in patients with RAP and a spinal cord stimulator. This retrospective, single-center, observational study gives a description of the experience of using HD stimulation in selected patients with RAP being treated with SCS. MATERIALS AND METHODS: All patients with RAP who received a spinal cord stimulator as treatment at our center from September 2009 to February 2021 were screened. Patients were eligible for inclusion into this retrospective, observational study if 1) patients had used HD stimulation, or 2) were currently using HD stimulation. RESULTS: Fifty-three patients out of a total of 157 patients who had a spinal cord stimulator due to RAP use or have used HD stimulation. In most patients (79.2%), the reason for switching from conventional to HD stimulation was due to progression of symptoms under conventional stimulation. The average duration of conventional stimulation use prior to switching to HD stimulation was 40.3 (± 29.6) months. In total, 26 patients (of 53 patients; 49.1%) were using HD stimulation at the end of the follow-up period or until lost to follow-up, and two patients used both forms of stimulation interchangeably. Five patients (9.4%) had stopped using SCS, and 20 patients (37.7%) switched back to conventional stimulation due to a variety of reasons. CONCLUSIONS: This retrospective study shows that the use of HD stimulation in patients with RAP being treated with SCS could be an alternative option for conventional stimulation. Due to the nature of this study, additional research is essential to confirm these initial findings.

Recovery 3 and 12 months after hysterectomy: epidemiology and predictors of chronic pain, physical functioning, and global surgical recovery.

Chronic postsurgical pain (CPSP) is 1 important aspect of surgical recovery. To improve perioperative care and postoperative recovery knowledge on predictors of impaired recovery is essential. The aim of this study is to assess predictors and epidemiological data of CPSP, physical functioning (SF-36PF, 0-100), and global surgical recovery (global surgical recovery index, 0-100%) 3 and 12 months after hysterectomy for benign indication.A prospective multicenter cohort study was performed. Sociodemographic, somatic, and psychosocial data were assessed in the week before surgery, postoperatively up to day 4, and at 3- and 12-month follow-up. Generalized linear model (CPSP) and linear-mixed model analyses (SF-36PF and global surgical recovery index) were used. Baseline data of 468 patients were collected, 412 (88%) patients provided data for 3-month evaluation and 376 (80%) patients for 12-month evaluation.After 3 and 12 months, prevalence of CPSP (numeric rating scale ≥ 4, scale 0-10) was 10.2% and 9.0%, respectively, SF-36PF means (SD) were 83.5 (20.0) and 85.9 (20.2), global surgical recovery index 88.1% (15.6) and 93.3% (13.4). Neuropathic pain was reported by 20 (5.0%) patients at 3 months and 14 (3.9%) patients at 12 months. Preoperative pain, surgery-related worries, acute postsurgical pain on day 4, and surgery-related infection were significant predictors of CPSP. Baseline level, participating center, general psychological robustness, indication, acute postsurgical pain, and surgery-related infection were significant predictors of SF-36PF. Predictors of global surgical recovery were baseline expectations, surgery-related worries, American Society of Anesthesiologists classification, type of anesthesia, acute postsurgical pain, and surgery-related infection.Several predictors were identified for CPSP, physical functioning, and global surgical recovery. Some of the identified factors are modifiable and optimization of patients' preoperative pain status and psychological condition as well as reduction of acute postsurgical pain and surgery-related infection may lead to improvement of outcome.

Does removal of steel wires relieve post-sternotomy pain after cardiac surgery?

BACKGROUND: Post-sternotomy pain in the absence of cardiac ischemia and sternal instability is most commonly due to the sternal wire sutures or a protruding wire. We performed a retrospective study to investigate the effect of removal of the steel wires for relief of post-sternotomy pain. METHODS: All 206 patients who underwent sternal wire removal in our institution from January 2003 through August 2011 were included in this study. Alive patients were contacted by telephone to inquire about the fate of their pain. Accordingly, patients were classified into 4 groups: group 1 were free of symptoms; group 2 were satisfied, significantly better than before wire removal; group 3 had unchanged symptoms; and group 4 had worsening of pain after wire removal. RESULTS: After excluding patients who died during the follow-up and those who had sternal instability and wound infection, 186 patients were available for the questionnaire. Complete relief of pain occurred in 83% of these patients, and 10% had improvement of their symptoms. CONCLUSIONS: We recommend removal of the steel wires in patients with persistent chest pain after median sternotomy, when sternal instability, mediastinitis, and cardiac causes such as ischemia are excluded.

Differences in sensory processing between chronic cervical zygapophysial joint pain patients with and without cervicogenic headache.

BACKGROUND: It is not known why some patients with underlying chronic nociceptive sources in the neck develop cervicogenic headache (CEH) and why others do not. This quantitative sensory testing (QST) study systematically explores the differences in sensory pain processing in 17 CEH patients with underlying chronic cervical zygapophysial joint pain compared to 10 patients with chronic cervical zygapophysial joint pain but without CEH. METHODS: The QST protocol comprises pressure pain threshold testing, thermal detection threshold testing, electrical pain threshold testing and measurement of descending inhibitory modulation using the conditioned pain modulation (CPM) paradigm. RESULTS: The main difference between patients with or without CEH was the lateralization of pressure hyperalgesia to the painful side of the head of CEH patients, accompanied by cold as well as warm relative hyperesthesia on the painful side of the head and neck. DISCUSSION: From this hypothesis-generating study, our results suggest that rostral neuraxial spread of central sensitization, probably to the trigeminal spinal nucleus, plays a major role in the development of CEH.

25. Ischemic pain in the extremities and Raynaud's phenomenon.

Two important groups of disorders result from an insufficient blood supply to the extremities: critical vascular disease and the Raynaud's phenomenon. The latter can be subdivided into a primary and a secondary type. Critical ischemic disease is often caused by arteriosclerosis due to hypertension or diabetes. Primary Raynaud's is idiopathic and will be diagnosed as such if underlying systemic pathology has been excluded. Secondary Raynaud's is often a manifestation of a systemic disease. It is essential to try to establish a diagnosis as soon as possible in order to influence the evolution of the disease. A sympathetic nerve block can be considered in patients with critical ischemic vascular disease after extensive conservative treatment, preferably in the context of a study (2B±). If this has insufficient effect, spinal cord stimulation can be considered in a selected patient group (2B±). In view of the degree of invasiveness and the costs involved, this treatment should preferably be applied in the context of a study and with the use of transcutaneous pO(2) measurements. In case of primary Raynaud's, life style changes are the first step. Sympathectomy can be considered as a treatment of Raynaud's phenomenon (2C+), but only after multidisciplinary evaluation of the patient and in close consultation with the patient's rheumatologist, vascular surgeon or internist.

7. Whiplash-associated disorders.

Whiplash-associated disorders are comprised of a range of symptoms of which neck complaints and headaches are the most significant spine related. In the acute and sub-acute stage of the disorder, conservative treatment for minimally 6 months is recommended, active mobilization is slightly better than passive treatment. Thereafter, interventional treatment may be considered. The available evidence for injection of Botulinum toxin A (2 B-) and intra-articular corticosteroid injections (2 C-) supports a negative recommendation. Radiofrequency treatment of the ramus medialis (medial branch) of the ramus dorsalis is recommended (2 B+).

6. Cervicogenic headache.

Cervicogenic headache is mainly characterized by unilateral headache symptoms which arise from the neck radiating to the fronto-temporal and possibly to the supra-orbital region. Physical examination to find evidence of a disorder known to be a valid cause of headache encompasses movement tests of the cervical spinal column and segmental palpation of the cervical facet joints and soft tissues of the neck. Injection of the nervus occipitalis major is recommended after unsatisfactory results with conservative treatments (1 B+). In the case of an unsatisfactory outcome after injection of the nervus occipitalis major, radiofrequency treatment of the ramus medialis (medial branch) of the cervical ramus dorsalis can be considered (2 B+/-). If the result is unsatisfactory pulsed radiofrequency treatment of the ganglion spinale (dorsal root ganglion) of C2 and/or C3 can be considered in a study context (O).

Pulsed radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double blind sham controlled randomized clinical trial.

Cervical radicular pain affects approximately 1 on 1000 adults per year. Although many treatment modalities are described in the literature, the available evidence for efficacy is not sufficient to allow definitive conclusions on the optimal therapy to be made. The effect of pulsed radiofrequency treatment for this type of patients was evaluated in a prospective audit that showed satisfactory pain relief for a mean period of 9.2 months, justifying a randomized sham controlled trial. Twenty-three patients, out of 256 screened, met the inclusion criteria and were randomly assigned in a double blind fashion to receive either pulsed radiofrequency or sham intervention. The evaluation was done by an independent observer. At 3 months the pulsed radiofrequency group showed a significantly better outcome with regard to the global perceived effect (>50% improvement) and visual analogue scale (20 point pain reduction). The quality of life scales also showed a positive trend in favor of the pulsed radiofrequency group, but significance was only reached in the SF-36 domain vitality at 3 months. The need for pain medication was significantly reduced in the pulsed radiofrequency group after six months. No complications were observed during the study period. These study results are in agreement with the findings of our previous clinical audit that pulsed radiofrequency treatment of the cervical dorsal root ganglion may provide pain relief for a limited number of carefully selected patients with chronic cervical radicular pain as assessed by clinical and neurological examination.

Randomised controlled trial of cervical radiofrequency lesions as a treatment for cervicogenic headache [ISRCTN07444684].

BACKGROUND: Cervicogenic headache (CEH) is a unilateral headache localised in the neck or occipital region, projecting to the frontal and temporal regions. Since the pathogenesis of this syndrome appears to have an anatomical basis in the cervical region, several surgical procedures aimed at reducing the nociceptive input on the cervical level, have been tested. We developed a sequence of various cervical radiofrequency neurotomies (facet joint denervations eventually followed by upper dorsal root ganglion neurotomies) that proved successful in a prospective pilot trial with 15 CEH patients. To further evaluate this sequential treatment program we conducted a randomised controlled trial METHODS: 30 patients with cervicogenic headache according to the Sjaastad diagnostic criteria, were randomised. 15 patients received a sequence of radiofrequency treatments (cervical facet joint denervation, followed by cervical dorsal root ganglion lesions when necessary), and the other 15 patients underwent local injections with steroid and anaesthetic at the greater occipital nerve, followed by transcutaneous electrical nerve stimulation (TENS) when necessary. Visual analogue scores for pain, global perceived effects scores, quality of life scores were assessed at 8, 16, 24 and 48 weeks. Patients also kept a headache diary. RESULTS: There were no statistically significant differences between the two treatment groups at any time point in the trial. CONCLUSION: We did not find evidence that radiofrequency treatment of cervical facet joints and upper dorsal root ganglions is a better treatment than the infiltration of the greater occipital nerve, followed by TENS for patients fulfilling the clinical criteria of cervicogenic headache.

Cervicogenic headache: practical approaches to therapy.

Cervicogenic headache is a relatively common and still controversial form of headache arising from structures in the neck. The estimated prevalence of the disorder varies considerably, ranging from 0.7% to 13.8%. Cervicogenic headache is a 'side-locked' or unilateral fixed headache characterised by a non-throbbing pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area. In patients with this disorder, attacks or chronic fluctuating periods of neck/head pain may be provoked/worsened by sustained neck movements or stimulation of ipsilateral tender points. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines and nitric oxide. Frequent coexistence of a history of head traumas suggests these also play an important role. A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group. Positive response after an appropriate nerve block is an essential diagnostic feature of the disorder. Differential diagnoses of cervicogenic headache include hemicrania continua, chronic paroxysmal hemicrania, occipital neuralgia, migraine and tension headache. Various therapies have been used in the management of cervicogenic headache. These range from lowly invasive, drug-based therapies to highly invasive, surgical-based therapies. This review evaluates use of drug therapy with paracetamol and NSAIDs, infliximab and botulinum toxin type A; manual modalities and transcutaneous electrical nerve stimulation therapy; local injection of anaesthetic or corticosteroids; and invasive surgical therapies for the treatment of cervicogenic headache. A curative therapy for cervicogenic headache will not be developed until increased knowledge of the aetiology and pathophysiology of the condition becomes available. In the meantime, limited evidence suggests that therapy with repeated injections of botulinum toxin type A may be the most safe and efficacious approach. The surgical approach, which includes decompression and radiofrequency lesions of the involved nerve structures, may also provide physicians with further options for refractory cervicogenic headache patients. Unfortunately, the paucity of experimental models for cervicogenic headache and the relative lack of biomolecular markers for the condition mean much is still unclear about cervicogenic headache and the disorder remains inadequately treated.

Quality of life of patients with cervicogenic headache: a comparison with control subjects and patients with migraine or tension-type headache.

OBJECTIVE: To establish the health-related quality of life of patients with cervicogenic headache and to compare it with a random Dutch sample of control subjects and with patients with migraine without aura or with episodic tension-type headache. METHODS: Thirty-seven patients with cervicogenic headache, 42 patients with episodic tension-type headache, and 39 patients with migraine without aura completed a Medical Outcomes Study 36-Item Short Form questionnaire. RESULTS: Domain scores for "physical functioning" of patients with cervicogenic headache were worse than those of patients with migraine or tension-type headache. Physical functioning scores were lower for patients with tension-type headache than for those with migraine. Migraineurs reported a diminished score for "social functioning" compared to patients with tension-type headache. All Medical Outcomes Study 36-Item Short Form domain scores were significantly lower for patients with cervicogenic headache relative to the control group. CONCLUSIONS: Patients with cervicogenic headache have a quality of life burden that is substantial. Although impairment in the quality of life of patients with cervicogenic headache is comparable to patients with migraine without aura and those with episodic tension-type headache, there are some specific differences.