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Peripheral Nerve Stimulation for Pain Suppression
Disclosures
Joseph Boggs, PhD, is an employee of and owns equity in SPR Therapeutics.
John Chae, MD, ME, is a consultant to and owns equity in SPR Therapeutics.
Maria Bennett, MS, is an employee of and owns equity in SPR Therapeutics.
Introduction
It is common for electrical stimulation of named peripheral nerves to produce consistently high success rates in achieving pain relief (60%–80%) in well-selected patients when delivered by skilled clinicians ( ). The potential for peripheral nerve stimulation (PNS) to reduce opioid analgesic usage has also been demonstrated ( ). Conventionally, the goal of PNS has been to place the lead as close as possible to the nerve innervating the region of pain ( ). The primary challenge has been to achieve pain relief without unwanted side-effects ( ).
Multiple Theories Exist as to the Exact Mechanism/s Through Which PNS Achieves Pain Relief
While there are some differences in the theories, review and analysis of theories, approaches, and outcomes across multiple studies suggest that to achieve a successful clinical outcome electrical stimulation should be delivered to the nerve innervating the painful region to provide pain relief and stimulation should be comfortable for the patient, confirming that the unwanted effects of nontarget fiber activation have been avoided ( ). This guidance is consistent with the results of animal studies indicating that PNS can reduce signaling within the central nervous system (CNS) pathways that is often associated with the perception of pain ( ). Other studies in animals ( ) and humans ( ) also suggest that PNS may have the potential to reduce peripheral mediators of pain. In both scenarios of pain suppression through central and peripheral mechanisms, the potential to reduce activity within the pain pathways appeared to be most significant when PNS is delivered to the nerve innervating the peripheral region of pain, which is consistent with the majority of clinical studies ( ).
PNS Has a Long History of Success, But Existing Technology and Early Methods of Implantation Previously Required Precise Neurosurgical Placement, Limiting Clinical Use
Early approaches to PNS were successful, but often time consuming, complex ( ), and requiring a high level of specialized skill, which greatly limited the number of clinicians who could offer PNS as part of their practice ( ). Overall, PNS has been used in various forms on multiple peripheral nerves in multiple anatomical locations to provide highly clinically significant pain relief, and in some cases reduction or elimination of reliance on opioid analgesics ( ). But early successes with PNS, replicated in multiple studies, were mixed with challenges that limited enthusiasm ( ). Clinical adoption beyond major academic centers was significantly limited, largely due to the state of the technology at that time and the invasive surgery and neurosurgical expertise required to place the existing leads correctly ( ). Improvements to both the technology and the approach to placement have begun to move PNS from a treatment of last resort to something that is becoming more accepted and offered more commonly across a range of medical centers as a practical modality for multiple types of pain ( ).
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