NSUKI / DGNM ASM 2012 Programme and Abstracts

Transcription

8th Annual Meeting of the German
Society of Neuromodulation (DGNM)
Joint Meeting with the
Neuromodulation Society of the United
Kingdom and Ireland (NSUKI)
Berlin, Germany
23-24 November, 2012
www.dgnm-online.de
“Neuromodulation –
across all borders”
ProgrammE
The Neuromodulation
Society of the United
Kingdom and Ireland
Medtronic Neuromodulation
Your partner beyond technology
Innovating for life.
Table of Contents
Welcome Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Programme Committee | Organization | Venue | Registration
Hotels/Accomodation | Certification
Scientific Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Main topics | Programme overview
Scientific Programme Friday, 23rd November 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Lectures | Company symposia | Annual General Meeting of the NSUKI
Annual General Meeting of the DGNM
Scientific Programme Saturday, 24th November 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Lectures | Company symposia | Posters
Social Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Official Social Programme | Social Programme for accompanying persons
Sponsors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Opening hours | Symposia sponsors | Exhibitors | Advertiser
Coffee Breaks & Lunch
Exhibition plan
General Information for authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Opening hours of the media check | Speaking times | Language
Guidelines for posters | Projection equipment
Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Index of authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Imprint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
City Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
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PA100106
Welcome address from the President of the DGNM and the President of the NSUKI
Dear colleagues, dear friends, dear participants from science and medical industry,
On behalf of the German Society of Neuromodulation (DGNM) and the Neuromodulation Society
of the United Kingdom and Ireland (NSUKI), chapters of the International Neuromodulation
Society, it is our great pleasure to greet you in Berlin.
For the UK and Irish Neuromodulation group, it has been a pleasure to visit the excellent
congress in Aachen, to enjoy their hospitality and to collaborate in developing on a joint
programme.
Only some days before Christmas holidays we meet for an international joint meeting
dedicated to the every day growing and fascinating interdisciplinary field which leads to the
fundamentals of neuronal activities and balance.
We are glad that so many distinguished scientists are willing to share with us their expertises
and the medical industry is willing to present their innovations and support us that this
Congress will happen under these circumstances.
For the German Society it is the first joint meeting and we appreciate the confidential
and friendly cooperation, especially during the board meetings in Aachen and London in
preparation of this conference.
We are delighted for exciting two days, which we hope we’ll keep in mind and stimulate all
of us for further continous work for the benefit of the patients entrusted to us and also the
always stunning prospective insights of the interaction of central, spinal and peripheral
pathways of the nervous system modulated, corrected, augmented, enhanced by different
procedures of our profession.
Welcome to Berlin!
Werner E. K. Braunsdorf
Congress President and President of the German Society of Neuromodulation
Jon H. Raphael
President of the Neuromodulation Society of the United Kingdom and Ireland
3
General Information
Programme Committee
Werner E. K. Braunsdorf, Frank Hertel, Johan Moreau, Christian Mantsch
German Society of Neuromodulation (DGNM)
Jon Raphael, Sam Eldabe, Peter Toomey, Roger Strachan, Ganesh Baranidharan,
Stana Bojanic, Josh Keavney, Francis Luscombe
Neuromodulation Society of the United Kingdom and Ireland (NSUKI)
supported by the International Society of Neuromodulation
Scientific Programme Director
Werner E. K. Braunsdorf, Magdeburg, Germany
Congress President and President of the German Society of Neuromodulation
Organization
www.dgnm-online.de
Neuromodulation Society of United Kingdom and Ireland (NSUKI)
http://nsuki.memberclicks.net/
Administrative Office
Allee 38, 74072 Heilbronn, Germany
E-mail: [email protected]
www.dgnm-online.de
Porstmann Kongresse GmbH (PCO)
(Registration, Print, Office on site)
Alte Jakobstr. 77, 10179 Berlin, Germany
Phone +49 30 284499-0
Fax +49 30 284499-11
www.porstmann-kongresse.de
Congress Venue
Westin Grand Hotel Berlin
Friedrichstr. 158-164
10117 Berlin (Mitte), Germany
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General Information
Registration
For pre-registration please use the registration form on the website www.dgnm-online.de
and send it to Porstmann Kongresse GmbH by email [email protected]
or by fax (+49 30 284499 – 11).
Registration is also possible on site at the registration desk.
Please note the registration and payment terms. Bookings that are liable to pay have to be
balanced after the registration by credit card (VISA or MasterCard) or bank transfer. After
sending completed registration form you will receive a booking confirmation via email.
Registration Fees
Members DGNM/NSUKI
Entire Meeting (no day tickets)
50 €
Non-members100 €
Student, Allied Healthcare Professionals*
free
*A corresponding proof is required by fax or email to Porstmann Kongresse GmbH.
The registration fee includes congress participation, name badge, Get Together,
visit of industrial exhibition, coffee breaks and lunch.
Opening hours of the registration desk
Friday, 23rd November 2012
Saturday, 24th November 2012
11:00 – 18:30
07:00 – 16:30
Name Badges
All participants will receive a name badge as entry ticket at the registration desk. Please
wear this badge to get free access to all scientific sessions, industrial exhibition, coffee
breaks and lunch. In case of loss of this badge a processing fee of 10 € for a dublicate
name badge will be charged.
Congress Language
The congress language is English. No simultaneous translation.
Terms of Payment and Cancellation
Registration fees can be paid by bank transfer or credit card (VISA or MasterCard). Only
payments until October 31st, 2012 (date of receipt) can be accepted. Later payments have
to be done on-site cash or by credit card (VISA or MasterCard) at the registration desk.
In case of cancellation there is no refund of the registration fee possible.
5
General Information
Liability
Porstmann Kongresse GmbH acts solely as an agent and is not liable for any losses, accidents, injuries to persons or damage to property of any kind. This does not affect the liability
of persons or companies charged with providing the relevant service. Oral arrangements
require a written confirmation. The sole court of jurisdiction is Berlin. Participants accept
the above mentioned conditions by sending the online registration form.
Hotels/Accomodation
Rooms at the below mentioned hotels are only available on request and can be booked via
the PCO - Porstmann Kongresse GmbH.
Please send your reservation request by email: [email protected]
Hotel
Address
Distance
to venue
Westin Grand Hotel ***** Friedrichstr. 158-164 Congress
10117 Berlin
venue
Arcor John F ****
Price
Single Price
Double
Breakfast
159.00 € 179.00 € incl.
Werderscher Markt 11 10 minutes 117.00 € 137.00 € incl.
10117 Berlin
walking
Motel One Spittelmarkt ** Leipzigerstr. 50
15 minutes 76.50 €
10117 Berlin
walking
For further information please contact:
Phone +49 30 284499-0, Fax +49 30 284499-11
99.00 € incl.
Certification
The 8th Annual Meeting of the German Society of Neuromodulation (DGNM) and Joint
Meeting with the Neuromodulation Society of the United kingdom and Ireland is certified
with 15 CME credits by the Accreditation Council for Continuing Education and will be
accredited by the Royal College of Anaesthetists to provide continuing medical education
credits for physicians from abroad.
Tip: Save your EFN – Number in your mobile phone (for German participants).
A certificate of attendance will be handed out to all participants on site.
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Scientific Programme
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Main topics
Neuroimaging of Pain
Spinal Stimulation: Pathophysiology, Fundamentals,
New Insights and New Treatment Modalities
Occipital Stimulation for Migraine and Cluster Headache
Enhancing Cognitive Functions and Memory by Stimulation
Neuromodulation and Malpractise Risks
Spinal Modulation with High Frequency
Neuromodulation and Chronic Visceral Pain
Neuromodulation by Peripheral Nerve Stimulation
Deep Brain Stimulation for Psychiatric Disorders, for Movement
Disorders and for Central Neuropathic Pain
Intrathecal Therapies: New Drugs, New Technology, New Targets,
Pathophysiology of CSF Dynamics or a Dawn of Intrathecal Therapy
Neuromodulation and Vertigo and Tinnitus
Neuromodulation and Neurorehabilitation
Neuromodulation and New Indications
Neuromodulation for Bladder, Bowl, Sexual Dysfunctions
7
Scientific Programme · Programme Overview
11:00Registration desk opens
13:00 - 14:00
FR.01 Opening Session
14:00 – 15:00
FR.02 Intrathecal Therapies
15:00 – 15:00
Coffee Break
15:15 – 17:15
FR.03 – FR.06 Company Symposia
17:15 – 17:45
FR.07 Ethics in Neuromodulation
17:45 – 18:30Annual General Meeting of the NSUKI
17:45 – 18:30Annual General Meeting of the DGNM
20:00 – 22:30Get Together at the restaurant “Deponie Nr. 3”
07:00Registration desk opens
08:00 – 09:00
SA.01 Functional Neurostimulation
09:00 – 11:00
SA.02 – SA.05 Company Symposia
11:00 – 11:15
Coffee Break
11:15 – 12:45
SA.06 Deep Brain Stimulation (DBS)
12:45 – 13:30
Lunch
13:00 – 13:30 Poster walks I and II
13:15 – 13:30 Poster walk III
13:30 – 14:15
SA.07 Additional Indications
14:15 – 14:30
SA.08 Documentation of the Neuromodulation
14:30 – 14:45
Coffee Break
14:45 – 16:00
SA.09 Miscellaneous
16:00 – 16:30
SA.10 Closing Ceremony
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Scientific Programme Friday, 23rd November 2012
13:00 – 14:00 Chairs:
13:00
13:10
13:35
Room: Lecture Hall Unter den Linden/Friedrichstadt
FR.01 Opening Session
Werner E. K. Braunsdorf (Magdeburg/GER)
Jon H. Raphael (Dudley/UK)
FR.01.01 Welcome Addresses
FR.01.02 Introduction by Frank Hertel
Guest lecture: Spinal cord Stimulation ‑ From the Gate Theory to
present concepts
Bengt Linderoth (Stockholm/S)
FR.01.03 Introduction by Werner Braunsdorf
Guest lecture: The future of Neuromodulation and INS strategy
Simon Thomson (Basildon/UK)
14:00 – 15:00 FR.02 Intrathecal Therapies
Chairs:
Francis Luscombe (Plymouth/UK)
Matthias Winkelmüller (Hannover/GER)
14:00
FR.02.01 Safety of implantable devices for intrathecal drug delivery –
results of an international registry for reliability and durability
Dirk Rasche, Volker M. Tronnier (Lübeck/GER)
14:15 FR.02.02 Cost effectiveness of intrathecal drug delivery systems for chronic
non-cancer pain: preliminary results of a systematic review
Rui V. Duarte, Jon H. Raphael, Robert L. Ashford (Birmingham/UK,
Dudley/UK)
14:30 FR.02.03 Intrathecal hydromorphon and pregnancy: case report and
implications for clinical care
Michael Kretzschmar, Walter Groß, Jörg Seidel, Frank T. Peters,
Daniela Remane (Gera/GER, Jena/GER)
14:45 FR.02.04 Cost effective outcomes in intrathecal drug delivery devices (ITDD) for
chronic non cancer pain management (CNMP)
Richard J. Sawyer, S. Blowey (Plymouth/UK)
15:00 – 15:15
Coffee Break
Please visit the exhibition and the posters.
9
15:15 – 17:15
Company Symposia
Chairs:
Ganesan Baranidharan (Leeds/UK)
15:15
FR.03
Transcutaneous access to the vagus nerve:
A new treatment option in CNS diseases
Speaker: Jens Ellrich (Erlangen/GER)
This Symposia is sponsored by cerbomed GmbH
15:45
FR.04
Epidural pulsed radiofrequency in the treatment of chronical
neuropathic, cervical and/or lumbodorsal pain
Speaker: Frank Hertel (Luxembourg/L)
This Symposia is sponsored by OMT GmbH & Co. KG
16:15 FR.05
Programmable and fixed-rate infusion pumps in children
Speaker: Beatriz Elida Mantese (Buenos Aires/RA)
This Symposia is sponsored by Tricumed Medizintechnik GmbH
16:45 FR.06
Title tba.
Speaker: tba.
This Symposia is sponsored by
Johnson & Johnson MEDICAL GmbH
10
17:15 – 17:45 17:15
17:20
FR.07 Ethics in Neuromodulation
FR.07.01 Introduction by Werner Braunsdorf
FR.07.02 Advances directives ‑ a means to facilitate
follow-up care in Parkinson DBS?
Karsten Witt (Köln/GER)
17:45 – 18:30 Room: Club Diana
Annual General Meeting of the NSUKI
17:45 – 18:30 Room: Lecture Hall Unter den Linden/Friedrichstadt
Annual General Meeting of the DGNM
Official Social Programme
20:00 – 22:30 Get Together at the Restaurant “Deponie Nr. 3”
For further information please see page 19.
11
Scientific Programme Saturday, 24th November 2012
08:00 – 09:00 Chairs:
08:00
08:15
08:30
08:45
Room: Lecture Hall Unter den Linden/Friedrichstadt
SA.01 Functional Neurostimulation
Johan Moreau (Aachen/GER)
Peter Toomey (York/UK)
SA.01.01A cadaveric feasibility study of neurostimulator lead placement and
anchoring adjacent to the trigeminal ganglion
Jon H. Raphael, Dalvina E. Hanu-Cernat, Liviu M. Hanu-Cernat,
Rui V. Duarte (Birmingham/UK, Coventry/UK)
SA.01.02 Neuromodulation for facial pain and headache
Athanasios Koulousakis, Doris Lenartz (Köln/GER)
SA.01.03 Peripheral nerve stimulation – state of the art
Dirk Buschmann (Herford/GER)
SA.01.04 Long-term results of peripheral nerve stimulation in neuropathic
postherniorraphy pain
Matthias Winkelmüller (Hannover/GER)
09:00 – 11:00
Company Symposia
Chairs:
Sam Eldabe (Middlesbrough/UK)
Peter Hügler (Bottrop/GER)
09:00
SA.02 Results of high frequency stimulation
High frequency stimulation for spinal neuromodulation in patients
with chronic lumbar pain of different origin and spinal stenosis
Werner E. K. Braunsdorf, Antje Marianne Siebel, Ronald Richter
(Magdeburg/GER)
Paraesthesia free, high frequency stimulation of the spinal cord:
Technique and 1 year follow-up
Gregor Bara (Düsseldorf/GER)
First results of high frequency stimulation
Karl Wohak (Vienna/A)
Round Table discussion
This Symposia is sponsored by NEVRO Corporation
12
09:30 SA.03
Evidence and quality driven clues for state of the
art neuromodulation solutions
Speaker: Paul W. Wacnik (Boston/USA)
This Symposia is sponsored by Medtronic GmbH
10:00 SA.04
The first choice for my patients with complex pain patterns is a
perc paddle lead!
Chair:
Stefan Schu (Duesseldorf/GER)
Contra:
Pro:
Christian Wille (Krefeld/GER)
This Symposia is sponsored by St. Jude Medical GmbH
10:30 SA.05
Can technology address migration and coverage challenges?
Speaker: tba.
This Symposia is sponsored by Boston Scientific GmbH
11:00 – 11:15
Coffee Break
13
11:15 – 12:45 SA.06 Deep Brain Stimulation (DBS)
Chairs:
Frank Hertel (Luxembourg/L)
Liong Liem (Nieuwegein/NL)
11:15
11:30
11:45
12:00
12:15
12:30
SA.06.01 Frameless implantation of DBS electrodes with the Nexframe®
System – first personal experience
Frank Hertel (Luxembourg/L)
SA.06.02Road Map for patient-centered 3D Planning and Navigation in Deep
Brain Stimulation – Automatic Registration of STN Morphology
Peter Gemmar, Andreas Husch, Florian Bernard,
Frank Hertel (Trier/GER, Luxembourg/L)
SA.06.03 System for measurement of the electrical field distribution of
implantable electrodes used for verification of field distribution
simulation models in deep brain simulation
Pascal Martini, Hamid Reza Daneshvar, Martin Schenk,
Klaus Peter Koch (Trier/GER)
SA.06.04Are we underreporting technical problems?
Francois Alesch (Vienna/A)
SA.06.05 Deep brain stimulation for neuropsychiatric diseases –
New indications
Jürgen Voges (Magdeburg/GER)
SA.06.06 Treatment of central deafferential and trigeminal neuropathic pain by
motor cortex stimulation
Dieter Hellwig, Malgorzata Kolodziej (Hannover/GER, Gießen/GER)
12:45 – 13:30 14
Lunch
13:00 – 13:30
P.01 Poster Walk I: Spinal Cord Stimulation/Percutaneous
Electrical Nerve Stimulation
Chairs:
Jan Mehrkens (München/GER)
Dirk Rasche (Lübeck/GER)
P 01
P 02
P 03
P 04
P 05
P 06
P 07
P 15
P 16
Intra-individual comparison of target area paraesthesia between
standard percutaneous SCS octrode leads against paddle SCS lead.
Nagaraju Morubagal, Hirachand S. Mutagi, Dr. Kaffafy,
Sandeep Kapur (Dudley/UK)
The application of pulsed radio frequency in chronic pain
Dimitrios Koulousakis, Athanasios Koulousakis, Volker Sturm (Köln/GER)
Transabdominal electrical stimulation speeds up bowel motility in piglets
Andre Tan, Magdy Sourial, Megan French, Daniela Bodemer,
John M. Hutson, Bridget R. Southwell (Parkville/AUS)
Spinal cord stimulation of the dorsal root ganglion for complex
regional pain syndrome (CRPS)
Sam Eldabe, Ashish Gulve, S. West, Fay Garner, Raymond Chadwick,
V. Robinson, R. King (Middlesbrough/UK)
Spinal cord stimulation of the dorsal root ganglion for groin pain
Ashish Gulve, John H. Hughes, S. West, Fay Garner (Middlesbrough/UK)
Spinal cord stimulation for the treatment of central pain in MS
Turo J. Nurmikko, Kate MacIver, Christin Bird, Mark Draper, Mike
Boggild (Liverpool/UK)
A case series: Evaluating 2x8 contact stimulation for the treatment of
combined back and leg pain
Rajiv Chawla, Alison Cox, Mark Draper, Paul Eldridge,
Jibril Osman-Farah, Bernhard Frank, Andreas Goebel, Selina Johnson,
Turo J. Nurmikko, Manohar Sharma (Liverpool/UK)
Lumbar and cervical treatments with epidural pulsed
radiofrequency – A retrospective overview
Hector de Paz (Schwerte/GER)
Percutaneous Electrical Nerve Stimulation (PENS) Therapy for treating
neuropathic back pain – case reports of two patients with back pain
following surgery for soft tissue tumours of the back
Arun K. Bhaskar, S. Rose, G. Beirne (Manchester/UK)
15
13:00 – 13:15
P.02 Poster Walk II: Deep Brain Stimulation
Chairs:
Stefan Schu (Düsseldorf/GER)
P 08
P 09
P 10
P 11
SWAN sequence in comparison to T2 for STN visualization
in DBS surgery
Nitisch Guness, Andreas Husch, Florian Bernard, Frank Hertel,
Peter Gemmar (Luxembourg/L, Trier/GER)
Suite for computer supported planning and navigation in
deep brain stimulation
Andreas Husch, Florian Bernard, Frank Hertel, Peter Gemmar
(Trier/GER, Luxembourg/L)
Development of a patient specific model for simulation of
DBS field distribution
Klaus Peter Koch, Pascal Martini, Peter Gemmar (Trier/GER)
Effects of thalamic deep brain stimulation in Tourette syndrome
Daniel Huys, Philip Köster, Doris Lenartz, Veerle Visser-Vandewalle,
Jens Kuhn (Köln/GER, Maastricht/NL)
13:15 – 13:30
P.03 Poster Walk III: Intrathecal Therapies
Chairs:
Stefan Schu (Düsseldorf/GER)
P 12
P 13
P 14
16
Intrathecal Baclofen Therapy (ITB) in cerebral spasticity
Athanasios Koulousakis, D. Weiss, Doris Lenartz (Köln/GER)
Improvement of intrathecal drug delivery for chronic pain
syndromes using a patient therapy manager PTM®
Dirk Rasche, Volker M. Tronnier (Lübeck/GER)
Experiences with intrathecal baclofen pump therapy in Slovenia
Klemen Grabljevec, Katja Groleger Sršen, Marta Gorišek,
Branka Vipavec, Roman Bošnjak (Ljubljana/SI)
13:30 – 14:15 SA.07 Additional Indications
Chairs:
Jon H. Raphael (Dudley, West Midlands/UK)
Jürgen Voges (Magdeburg/GER)
13:30
13:45
14:00
SA.07.01 Effects of dorsal root ganglion stimulation in the treatment of
chronic, intractable pain: Long-term results from two prospective
clinical trials
Liong Liem, Frank J. P. M. Huygen, Marc A. Russo, Jean Pierre
van Buyten, Iris Smet (Nieuwegein/NL, Rotterdam/NL, Broadmeadow/
AUS, Sint-Niklaas/B)
SA.07.02 Successful GPi-Deep Brain Stimulation in Tourette’s syndrome (TS) –
Much more than scales can tell
Jan H. Mehrkens, Bianka Leitner, Berend Feddersen, Norbert Müller,
Kai Bötzel, Sandra Dehning (München/GER)
SA.07.03 Experiences in peroneus nerve implanted
stimulation for central drop foot
Guy Matgé, Paul Filipetti (Luxembourg/L)
14:15 – 14:30
14.15
SA.08 Documentation on the Neuromodulation
SA.08.01 NemoQM – a registry for quality management in Neuromodulation
Hermann Keller (Founder of NemoQM) (Muttenz/CH)
On behalf of the working group NemoQM of the German Pain
Society & German Neuromodulation Society
14:30 – 14:45 Coffee Break
17
14:45 – 16:00 SA.09 Miscellaneous
Chairs:
Roger D. Strachan (Middlesbrough/UK)
Vassilios Vadokas (Heilbronn/GER)
14:45 SA.09.01 Sacral nerve stimulation of the bladder – a unicentral Study
Daher Majed, Harald Voepel, Rainer Hein (Magdeburg/GER)
15:00 SA.09.02 Trans-abdominal electrical stimulation using interferential current is
able to treat chronic constipation in children
Yee Ian Yik, Khairul A. Ismail, John M. Hutson,
Bridget R. Southwell (Parkville/AUS)
15:15 SA.09.03 Predictive model of spinal cord stimulation efficacy based on
psychological characteristics
Elizabeth Sparkes, Jon H. Raphael, Rui V. Duarte, Ian Hume,
Robert L. Ashford (Birmingham/UK, Dudley/UK, Coventry/UK)
15:30 SA.09.04 Treating of sacroiliac joint pain with peripheral nerve stimulation
Marin Guentchev, Christian Preuss, Rainer Rink, Levente Peter,
Ernst-Ludwig Wocker, Jochen Tüttenberg (Idar-Oberstein/GER)
15:45 SA.09.05 Initial Experience of High Frequency Spinal Cord Stimulators in the
Leeds Teaching Hospitals NHS Trust.
Robert Jackson, Ganesan Baranidharan (Leeds/UK)
16:00 – 16:30 SA.10 Closing Ceremony
Chairs:
18
Social Programme
Official Social Programme
Friday, November 23rd, 2012
Get Together at the Restaurant “Deponie Nr. 3”
Doors open: 19:30 hrs
20:00 – 22:30 hrs
In the middle of Berlin, between the S-Bahn arches. A UNESCO World Heritage site,
Museum Island, Friedrichstr. and the Brandenburg Gate, is our cozy old Berlin restaurant.
The design of furniture with the turn of the century and the fine German cuisine invite you
to linger. The landfill 3 is an atmospheric venue of Berliners, tourists and celebrities just
that creates a special atmosphere. An informal, open and pleasant atmosphere awaits
you in the Deponie Nr. 3!
Venue
Deponie Nr. 3.
Georgenstr. 5
10117 Berlin (Mitte), Germany
Free access for all congress participants incl. buffet, drinks and special music
entertainment.
Registration is required due to the limited number of participants.
No bus shuttle, walking distance from the congress venue
Social programme for accompanying persons
If you are interested in pre-booking of Berlin City Highlights please contact:
Interklassik CS & Event GmbH
Friedrichstr. 150
10117 Berlin, Germany
Tel.: +49 (0)30 3010 411 152
Fax: + 49 (0)30 3010 411 550
Email: [email protected]
Booking is also possible on site at the registration desk.
Further details regarding social programme for accompanying persons please find on the
congress website: www.dgnm-online.de.
19
Sponsors
The organizing committee wishes to express their gratitude to all sponsors and the companies
for their support of the 8th Annual meeting of the German Society of Neuromodulation
(DGNM) and Joint Meeting with the Neuromodulation Society of the United Kingdom and
Ireland (NSUKI) in Berlin.
Opening hours of industrial exhibition
12:00 – 18:00
th
Saturday, 24 November 2012
08:00 – 16:00
Symposia Sponsors
(in alphabetical order)
Boston Scientific GmbH, Ratingen/GER
Cerbomed GmbH, Erlangen/GER
Johnson & Johnson Medical GmbH, Norderstedt/GER
Medtronic GmbH, Meerbusch/GER
NEVRO Corporation, Menlo Park/USA
OMT GmbH & Co. KG, Minden/GER
St. Jude Medical GmbH, Erkrath/GER
Tricumed Medizintechnik GmbH, Kiel/GER
20
Sponsors
Exhibitors
(in alphabetical order)
ALGOTEC Research and Development Limited, Crawley/UK
Archimedes Pharma GmbH, Mannheim/GER
Cerbomed GmbH, Erlangen/GER
Cyberonics Europe BVBA, Dortmund/GER
Eisai GmbH, Frankfurt am Main/GER
Johnson & Johnson Medical GmbH, Norderstedt/GER
OMT GmbH & Co. KG, Minden/GER
Otto Bock HealthCare Products GmbH, Wien/A
Spinal Modulation, Menlo Park/USA
Tricumed Medizintechnik GmbH, Kiel/GER
Advertiser
Coffee Breaks & Lunch
All participants are cordially invited to visit the industrial exhibition. Coffee breaks, lunch
and soft drinks will be served within the area of the industrial exhibition.
21
Sponsors
1st floor
Exhibition plan
Poster exhibition
Lecture Hall
Unter den Linden/
Friedrichstadt
1st floor
Poster exhibition
Lecture Hall
Unter
den Linden/
Media-Check
Friedrichstadt
14
Archimedes
12
Meeting room
Club Diana
Lift
Lift
Lift
3x2m
2
1
Meeting
room
4x3m
Club Diana
4x3m
3
Lift
Lift
Catering
4
En
4x3m
14
tra
2
10
4
7
4x3m
3x2m
11
3x2m
Lift
3x2m
3x3m
rin
g
te
6
9
12
3x2m
3x2m
13
Registration
3x2m
10
7
3x2m
11
WC
8
St. Jude= catering area
1
Tricumed
6
= catering area
Restaurant
3x2m
4x3m
Catering
Restaurant
12
3x2m
13
3x2m
Registration
5
9
e
8
2
Spinal Modulation
= booth area
Catering
3x3m
1410
12
4
7
2
3
5
13
9
11
8
10
1
46
Otto Bock
Status: 17 October 2012
nc
tra
4x3m
Ca
Catering
3x2m
WC
En
5
te
rin
9
3
3x3m
Ca
4x3m
3x2m
4x3m
3x3m
11 be r
B o o t h num
JohnsonUK& Johnson
Algotec
Medical - Codman
Archimedes
Medtronic
Boston Scientific
Nevro Corporation
Cerbomed
OMT
Cyberonics
Otto Bock
Eisai
Spinal Modulation
Johnson
& Johnson
Medical
St. Jude- Codman
Medtronic
Tricumed
= booth area
Lift
3x2m
g
8
13
OMT
Status: 17 October 2012
e
1
3x3m
nc
5
3
Cyberonics
Nevro Corporation
Lift
3x3m
7
Cerbomed
CEisai
o m pa ny
14
22
B o o t h num be r
Algotec UK
Boston Scientific
Media-Check
6
C o m pa ny
General Information for authors
Presentations should be handed over to the service staff at the media check at any time during
the conference, but not later than 60 minutes prior to the according session. The presentation
will be stored by our technical personnel for the duration of the conference on the central server.
The use of own laptops is not allowed due to the closed information system which provides
the session room with the respective part of the scientific programme. Slide and overhead
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Porstmann Kongresse GmbH.
All data will be deleted irrevocably after the Annual Meeting.
Opening hours of the media check
11:00 – 18:00
07:00 – 16:00
Speaking times for free presentations
The speaking time (unless otherwise indicated) is 12 min. plus 3 min. for the discussion. In
order to guarantee punctual organization of the entire programme, all speakers are requested
to stick to their allocated presentation times. The chairperson of each session will be entitled to
interrupt a presentation if a speaker exceeds the allocated time.
Congress Language
The congress language is English. No simultaneous translation.
Guidelines for posters
The maximum poster size is (H x W) 118.90 cm x 84.10 cm (DIN A0). Appropriate adhesive
material will be available at the registration desk.
Poster authors are responsible for setting up their poster at the beginning of the Annual
Meeting:
11:00 – 15:00
The posters will be discussed in the poster exhibition area on:
from 13:00 to 13:30
Poster authors are responsible for removing it at the end of the Annual Meeting:
16:00 – 17:00
23
General Information for authors
The PCO and German Society of Neuromodulation (DGNM) are not responsible for lost or damaged
posters removed after Saturday, 17:00 hrs.
Poster presenters are requested to be present at their posters during the poster walk at lunch
time as indicated in the scientific programme.
Projection equipment in the lecture rooms
All presentation files of oral presentations and lectures will be stored on the central server
during the Annual Meeting. The speakers have access to their presentations for the respective
session from a personal computer at the speaker’s desk.
In order to guarantee a smooth flow within the sessions, all speakers are asked to hand in solely
files in English in Microsoft Power-Point format version XP or newer Mac presentations might
create conversion problems that the service staff at the media check would try to solve.
The files should be saved under the name of the speaker and the lecture number, possibly under
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Following data storage media are suitable to copy your presentation into the information system:
MS-Windows CD-ROM compatible (ISO 9660) or DVD-ROM
USB stick (as a precaution bring the driver with you)
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with DIVX (as of version 7) or uncompressed) must be linked with the presentation and should
be added separately. Please apply exclusively Windows-compatible fonts.
24
Abstracts
Please note that all abstracts which has been submitted until 3rd October 2012 are published
in this printed programme of the Annual Meeting.
Furthermore all abstracts which has been submitted until 10th October 2012 will be
published in the medical journal “Neuromodulation: Technology at the Neural Interface”.
FR.01.02
Spinal cord stimulation: Mechanisms of action – From
the Gate Theory to the present concepts
Bengt Linderoth
Department Clin. Neuroscience, Karolinska Institutet & Department of
Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
Background: Spinal cord stimulation (SCS) emerged as a direct clinical spin-off from the gate control
theory by Melzack & Wall in 1965 with the first clinical report in 1967. It has been estimated that, presently, more than 40.000 SCS systems (incl. battery replacements) are implanted every year worldwide.
Paradoxically, and in contrast to predictions from the Gate Theory, SCS proved inefficacious in acute
nociceptive pain conditions, and neuropathic pain of peripheral origin eventually emerged as the cardinal
indication for this mode of treatment. However, during the 80-ties studies demonstrated that SCS could
alleviate also certain types of nociceptive pain, I e selected ischemic pain states in eg peripheral arterial
occlusive disease (PAOD), in vasospastic conditions and in therapy-resistant angina pectoris. The exact
mechanisms of action for SCS are still largely unknown and only during the last years have more solid
evidence for the underlying physiological mechanisms has emerged. Experimental evidences from the
laboratory paired with clinical observations clearly demonstrate that SCS applied to different sites of the
neuroaxis exerts fundamentally different effects on various target organs or parts of the body.
Thus, the present concepts concerning the mechanisms of pain relief with SCS differ fundamentally
between the use of this therapy in neuropathic and in ischemic/ vasculopathic pain conditions.
In this short review the focus is on the mechanisms of SCS when used for neuropathic pain, and ischemic
pain (PAOD and angina) are only superficially covered.
SCS in neuropathic pain: The animal studies have mainly been performed in rats with various types of
nerve lesions displaying pain-like neuropathic symptoms. A mixture of behavioral studies, microdialysis
in the spinal cord and brain, immunohistochemistry and microelectrode recordings have been performed
in such models implanted with miniature SCS systems. In short, GABAergic mechanisms have proven to
be pivotal for the SCS-induced pain suppression but also cholinergic, adenosinergic and other neuronal
circuits seem to be involved in the local segmental suppression of the increased WDR cell activity, these
cells becoming hypersensitized after the nerve injury. Up to recently the focus has been on antidromic activation of the segmental spinal mechanisms but a present it is realized that a significant part of the pain
inhibitory effect of SCS is relayed via the ortodromic stimulation of the dorsal columns activating centers
in the brain stem. Especially 5-HT cells in the rostroventromedial medulla with descending projections
25
Abstracts
have been demonstrated to be important. Additionally, SCS evokes strong activation in the locus coeruleus
area where noradrenergic neurons are located probably adding to the descending inhibition. New data will
be presented during the lecture.
SCS in vasculopathic conditions: As already mentioned above, it is by now widely recognized that SCS
does not alleviate acute nociceptive pain. However, in ischemic extremity pain, which is mainly nociceptive,
SCS-induced relief of tissue ischemia seems to be the primary event either by increasing or redistributing
blood flow to the ischemic tissues. In PAOD, experimental studies favour the notion that SCS induces
peripheral vasodilatation by suppressing efferent sympathetic activity resulting in diminished peripheral
vasoconstriction and secondary relief of pain but more recent evidence indicate that also antidromic
mechanisms may be activated by SCS intensities far below the motor threshold and that this may result
in peripheral CGRP and NO release with subsequent peripheral vasodilatation. The knowledge in this field
is mainly based on studies in the rat.
SCS in angina pectoris: For coronary ischemia, manifesting as angina pectoris, the mechanisms are also
only fragmentarily known. Although early animal data demonstrated direct inhibitory effects of SCS on
cardiac nociception, it has later been clearly shown in clinical studies that SCS does not merely cause
a pain blockade; resolution of cardiac ischemia remains the primary factor. Some researchers favour a
stimulation-induced flow increase or redistribution of cardiac blood supply, while others interpret the
reduction of coronary ischemia (decreased ST changes; reversal of lactate production) as mainly due
to decreased cardiomyocyte oxygen demand. Experimental studies (in the rat, rabbit, dog and pig) have
hitherto been unable to demonstrate a local flow increase or redistribution of blood in the myocardium by
SCS), but instead pre-emptive SCS seems to induce protective changes in the myocardium making it more
resistant to critical ischemia. Studies in dog and rabbit hearts with ischemia indicate that SCS-induced
local catecholamine release in the myocardium could trigger protective changes in the cardiomyocytes
related to mechanisms behind “ischemic pre-conditioning”.
Furthermore, SCS seems to exert arrhythmia control in the heart. In ischemia the intrinsic cardiac nervous
system is profoundly activated. If this activity persists it may result in spreading dysrhythmias leading
to more generalized ischemia. SCS stabilizes activity of these intrinsic ganglia especially at ischemic
challenge and may in this way protect the heart from more severe ischemic threats due to generalized
arrhythmia.
Conclusions: In conclusion SCS (as used today) exerts its beneficial effects via fundmentally different
mechanisms. In neuropathic pain a direct effect on the pathophysiological dysfunction in the spinal cord
via different routes converging onto segmental inhibitory interneurons seem to be pivotal. In contrast, in
ischemic pain conditions the effects of SCS seem to be mediated via a resolution of the local ischemia
and the decrease of the ischemic pain being secondary to this.
With the arrival of new SCS paradigms (kilohertz frequencies; burst stim.; dorsal root ggl. Stim.) other
mechanisms may be activated but at present these are largely unknown – but research to uncover these
are ongoing.
26
Abstracts
FR.02.01
Safety of implantable devices for intrathecal drug delivery – results
of an international registry for reliability and durability
Dirk Rasche, Volker M. Tronnier
Department of Neurosurgery, University of Lübeck
Objective: Intrathecal drug delivery (IDD) can be performed with different kinds of implantable pump
devices. On the one hand electronic pumps with flexible flow rates and on the other hand gas pressure
pumps with fixed daily flow-rates are available. The results of an international data registry and product
performance report for flexible electronic pumps regarding safety, reliability and durability are presented.
Material and Methods: So far no guidelines for intrathecal therapy exist in Germany. This includes patient
and drug selection also as technical device related considerations. In 2012 the polyanalgesic consensus
conference published revised guidelines for intrathecal pain therapy related to trialing and testing and
also management of complications. No information is given regarding the safety and efficacy of drug
delivery devices. The product performance report of 2011 is based on data of an international registry of
more than 4500 implanted devices worldwide.
Results: A high percentage of > 96% of flexible pump systems was documented for stability and durability after 5 years of implantation. In addition to these data the percentage of event-free rates is lesser for
intrathecal catheters (80-90% after 5 years). A variability of ±14.5% and a reproducibility of ±0.3 % for
the constant daily flow-rate were documented of the electronic devices.
Conclusion: Intrathecal pain therapy with IDD is a certain part of invasive pain therapy for chronic pain
patients. Review of the device related registry shows that flexible electronic pumps for intrathecal drug
delivery are safe, stable and consistently. Problems regarding technical issues were mostly related to the
intrathecal catheter systems. The management of IDD systems and device related complications should
be performed in certified experienced centres.
FR.02.02
Cost effectiveness of intrathecal drug delivery systems for chronic
non-cancer pain: preliminary results of a systematic review
Rui V. Duarte1,2, Jon H. Raphael1,2, Robert L. Ashford1
1
Faculty of Health, Birmingham City University, Birmingham, UK; 2Department
of Pain Management, Russells Hall Hospital, Dudley, UK
Background and aims: The cost effectiveness of a treatment is an important factor in decision making in
the United Kingdom. The UK National Institute for Health and Clinical Excellence (NICE) considers as acceptable cost-effectiveness a range of £20,000-£30,000 per Quality Adjusted Life Year (QALY). Intrathecal
drug delivery (IDD) systems involve a high initial cost and its cost-effectiveness remains debatable. The
aim of this study was to review the cost-effectiveness of IDD for the management of chronic non-cancer
pain.
27
Abstracts
Methods: A Boolean search was conducted in the electronic databases Medline, EMBASE and the NHS
Economic Evaluation Database (NHS EED). A combination of MESH/Thesaurus terms and free text were
used, including intrathecal, cost-effectiveness and cost-benefit analysis. The year of publication was
restricted to between 1981 (first IDD system implanted) and 8th August 2012. There were no language
restrictions. Hand searches of reference lists of included studies and previous reviews were performed.
Only full economic evaluations were considered for review.
Results: The search resulted in a total of 153 abstracts after removal of duplicates. Following screening
of abstracts and hand search of reference lists, 10 articles were retrieved for review. Five of these papers
were reviews, partial economic evaluations, selection trial cost analysis or cancer pain related and were
excluded after review (Bedder et al 1991; Hassenbusch et al 1997; Mueller-Schwefe et al 1999; Anderson
et al 2003; Nguyen & Hassenbusch 2004). In a computer-generated model, de Lissovoy et al (1997)
focused on IDD for failed back surgery syndrome. However, none of the studies used to structure the
cost-effectiveness model were exploring exclusively this condition. The authors concluded that except on
a worst case scenario, IDD would be more cost-effective than conventional pain therapies (CPT). Kumar
et al (2002) compared IDD therapy (N=23) with CPT (N=44). The results of this study can be questioned
due to several limitations including selective reporting (effectiveness results for CPT group). IDD was
considered to be less expensive than CPT even in a worst case scenario. In a simulation model comparing
the cost-effectiveness of intrathecal ziconotide with best supportive care, Dewilde et al (2009) reported
that at a willingness to pay £30,000 per QALY, the likelihood that ziconotide was cost-effective was 74%,
while at £20,000 per QALY, it was 8.5%. In a pre-post cohort pilot study (N=12) (Biggs et al 2011), the
incremental cost per QALY gained with IT versus CPT was £26,079.54 which is within the NICE cost
effectiveness range per QALY. In a recent cost-effectiveness analysis, it was verified that the probability of
IDD providing a cost-effective alternative to CPT at a willingness to pay threshold of $14,200 and $20,000
per QALY was 50% and 84% respectively (Kumar et al 2012).
Conclusion: There is limited available literature on the cost-effectiveness of IT and several methodological weaknesses in the studies reviewed. Despite these limitations, all the studies suggest that IT can be
a cost-effective therapy for appropriately selected non-cancer patients.
FR.02.03
Intrathecal hydromorphon and pregnancy: case report and implications for clinical care
Michael Kretzschmar1, Walter Groß2, Jörg Seidel3, Frank T. Peters4, Daniela Remane4
1
Zentrum für Interdisziplinäre Schmerztherapie, 2Klinik für Gynäkologie und Geburtshilfe, 3Kinderklinik
am SRH Wald-Klinikum Gera gGmbH; 4Institut für Rechtsmedizin, Universitätsklinikum Jena
Pregnancy in patients with intrathecal therapy is rare. So far only five cases of pregnancy with intrathecal
baclofen pumps are published. As far as we are aware, there is no information available about intrathecal
hydromorphon pain therapy in pregnancy and delivery.
We present a case of pregnancy in a patient with an implanted intrathecal hydromorphon pump. As
intrathecal systems become more popular in the management of nonmalignant pain, pain therapist may
face this situation more often in the future.
28
Abstracts
The patient was a 41-year-old with a history of failed back surgery syndrome whose intractable pain has
been managed with intrathecal hydromorphon 1.2 mg per day via an implanted pump for 1.5 years. This
was the third pregnancy, the patient already has two children (9 and 18 years).
The pregnancy was uneventful up to the 23rd week without any problems. At that stage she developed short
lived hypertensive episode for a few days which were well controlled by antihypertensive drugs. From the
30th week back pain increased in the area of previous back surgery. At 35 + 3rd a preterm normal-to-dates
infant (weight 2400 g, length 47 cm) was delivered by Caesarean section (LSCS). Because of respiratory
distress the child was admitted to special care baby unit for 8 day. The child was discharged home in
stable conditions.
The analysis of umbilical cord blood and 24 hour-urine sample of the newborn child for hydromorphon and
its metabolites showed unequivocal results (proof border: 0.5 pg/ml).
This paper reviews literature to date and presents the particularity of our case. It also discusses management of pregnant patients with an intrathecal pump including information about safety and efficacy
of this treatment.
FR.02.04
Cost effective outcomes in intrathecal drug delivery devices (ITDD)
for chronic non cancer pain management (CNMP). Richard J. Sawyer, S. Blowey Plymouth Pain Management Centre, Derriford Hospital, Derriford
Road, Plymouth, PL6 8DH, United Kingdom
Background and aims: In the current global fiscal recession, appropriate use of healthcare resources
is seen as priority. Consequently, healthcare providers are under increasing pressure to ensure value for
money. Increasingly outcomes data is being seen as vital to test treatment effectiveness. Our institution
has many years of ITDD implant experience and have collected primary outcome data (e.g. VAS score)
accordingly. For CNMP, ITDD is an expensive therapeutic option. In the UK a standard implant will cost
approximately £20,000.
In our institution we have become increasingly aware that recorded secondary outcome data post ITDD
implantation may not be indicative of a successful outcome. These negative outcomes may not justify the
expenses associated with implantation. This view has been voiced in a Neuromodulation editorial. Methods: We undertook a retrospective review of all current ITDD implant patient charts specifically
looking at the following recorded primary and secondary outcome data: Current daily average pain score,
percentage pain relief, current level of satisfaction, percentage improvement in activities of daily living,
improvement in mood and sleep. Results: 20 patient charts were retrospectively reviewed. Reason for implantation of ITDD were: spinal
pain (13), neuropathic pain (5) and visceral pain (3).
Average post implant pain score was 6.6 and 53% patients reported a greater than 50% reduction in
pain.
53% of patients reported a greater than 50% satisfaction with having an ITDD implanted.
29
Abstracts
However, self reported secondary outcomes in the following domains showed the following:
1. 30% improvement in activities in daily living (ADLs)
2. 26% improvement in sleep
3. 33% improvement in mood.
Estimated total cost for these patients= £460,000.00. £24,000.00 per patient. Conclusions: ITDD therapy for non-malignant pain is an expensive intervention. The findings of this review
have shown that although patients report satisfaction in ITDD the secondary outcome results are no better
than those which can be obtained by more conservative therapies. It is the improvement in secondary
outcomes which can show “a return on investment” for commissioners. It is this institution’s view that
secondary outcome data post ITDD implantation is vital to accurately assess the cost effectiveness, and
ongoing implantation, of ITDD for CNMP.
FR.03.01
Transcutaneous access to the vagus nerve: A new treatment option in CNS diseases
Jens Ellrich1,2,3
1
Department of Medicine, cerbomed GmbH, Medical Valley Center, Erlangen, Germany;
2
Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; 3Institute
of Physiology and Pathophysiology, University of Erlangen-Nuremberg, Erlangen, Germany
Invasive vagus nerve stimulation (i VNS) is an alternative treatment option in epilepsy, depression, and
chronic pain. After an initial neurosurgical intervention the cervical vagus nerve is electrically stimulated.
Due to surgery and electrical stimulation of afferent and efferent nerve fibers frequent side effects include
hoarseness, cough, and pain. It has been assumed, that the vagus nerve can be stimulated transcutaneously at the outer ear [1]. This procedure would avoid any neurosurgical intervention and possibly would
reduce side effects.
Anatomical studies provide evidence for cutaneous receptive fields at the outer ear with exclusive innervation by the auricular branch of the vagus nerve (ABVN) [2]. Transection of the intracranial roots of the
human vagus nerve causes complete sensory loss in ABVN receptive fields [3]. Correspondingly, isolated
vagus nerve palsy due to herpes zoster infection is characterized by painful herpetic vesicles in the concha
area of the outer ear [4].
Transcutaneous vagus nerve stimulation (t-VNS) and i-VNS aim at the same afferent thick-myelinated
fiber class. Both afferents from the cervical branch of the vagus nerve and from ABVN project to sensory
neurons of the nucleus of the solitary tract (NTS) in the brainstem which is the main target of vagus nerve
stimulation [5;6].
Preclinical experiments in rats document similar reduction of epileptic seizures with t-VNS and i VNS
[7]. A recent case series in patients suffering from drug resistant epilepsy indicates reduction of seizure
frequency by t-VNS as well [8]. A randomized trial in healthy volunteers provides evidence for analgesic
effects of t-VNS as assessed by quantitative sensory testing [9].
30
Abstracts
Anatomical and neurophysiological data indicate that t-VNS and i-VNS both share a common mode of
action and may be equivalent in the treatment of central nervous system diseases such as epilepsies,
depression, and pain.
References
[1] Ellrich J, Transcutaneous vagus nerve stimulation, European Neurological Review 6 (2011) 262-264.
[2] E.T.Peuker, T.J.Filler, The nerve supply of the human auricle, Clin. Anat. 15 (2002) 35-37.
[3] T.Fay, Observations and results from intracranial section of glossopharyngeus and vagus
nerves in man, Journal of Neurology and Psychopathology 8 (1927) 110-123.
[4] T.Ohashi, M.Fujimoto, H.Shimizu, T.Atsumi, [A case of isolated vagus nerve palsy
with herpes zoster], Rinsho Shinkeigaku 34 (1994) 928-929.
[5] S.Nomura, N.Mizuno, Central distribution of primary afferent fibers in the Arnold’s nerve (the auricular branch
of the vagus nerve): a transganglionic HRP study in the cat, Brain Res. 292 (1984) 199-205.
[6] X.Y.Gao, P.Rong, H.Ben, K.Liu, B.Zhu, S.Zhang, Morphological and electrophysiological characterization
of auricular branch of vagus nerve: Projections to the NTS in mediating cardiovascular inhibition evoked
by the acupuncture-like stimulation, Society for Neuroscience Abstracts (2010) 694.22.
[7] W.He, B.Zhu, P.Rong, A new concept of transcutaneous vagus nerve stimulation for
epileptic seizure, Society for Neuroscience Abstracts (2009) 539.4.
[8] H.Stefan, G.Kreiselmeyer, F.Kerling, K.Kurzbuch, C.Rauch, M.Heers, B.S.Kasper, T.Hammen, M.Rzonsa,
E.Pauli, J.Ellrich, W.Graf, R.Hopfengartner, Transcutaneous vagus nerve stimulation (t-VNS) in
pharmacoresistant epilepsies: A proof of concept trial, Epilepsia 53 (2012) e115-e118.
[9] V.Busch, F.Zeman, A.Heckel, F.Menne, J.Ellrich, P.Eichhammer, The effect of transcutaneous vagus nerve stimulation
on pain perception - An experimental study, Brain Stimul. (2012) doi: 10.1016/j.brs.2012.04.006. FR.05.01
Programmable and fixed-rate infusion pumps in children
Beatriz Elida Mantese
Buenos Aires, Argentina
-Objective: To analyze the differences between programmable pumps and fixed-rate pumps in children.
- Variables: Age, sex, etiology, motor compromise, spasticity level, kinesthetic assessment scale: GMFCS
- Mechanism: Battery-driven and N-Butane gas driven
- Durability: 5 years and 20 years, respectively
- Inlusion criteria: Muscle hypertonia spastic pyramidal type of lower limbs. Invalidating spasticity.
Medical and physical treatment failure
- Exclusion criteria: Ongoing sepsis. Subarachnoid blockage. Uncontrolled epilepsy.
- Implantation of small-sized pumps (IP 1000) in little children with: Poor panniculus adiposus, abdominal surgical wounds, gastrostomy, etc.
- Treatment of patients with serious burns and upper motor neuron lesions after hypoxia. Three cases.
- Replacement of programmable pumps for fixed-rate pumps. Daily life activity assessment. Pre and
post-op EMG. H-Reflex. Ashworth scale.
- Dystonic storm with unknown etiology. Two cases.
- Complications. Malfunctions. Case studies.
- Conclusions
31
Abstracts
FR.07.02
Advances directives – a means to facilitate follow-up care in Parkinson DBS?
Karsten Witt
Research Unit Ethics, University Hospital Cologne
In discussions of personality changes occurring in connection with deep brain stimulation (DBS) of
Parkinson patients, it is sometimes proposed to resort to a special kind of advance directives, so-called
ulysses contracts. In these documents patients preoperatively define under which circumstances stimulations parameters may later be changed even if they then refuse such an intervention. In my talk I ask
whether such advance directives can be morally binding for health professionals engaged in follow-up
care of Parkinson patients having received DBS.
SA.01.01
A cadaveric feasibility study of neurostimulator lead placement
and anchoring adjacent to the trigeminal ganglion
Jon H. Raphael1,2, Dalvina E. Hanu-Cernat3, Liviu M. Hanu-Cernat4, Rui V. Duarte1,2
1
Faculty of Health, Birmingham City University, Birmingham, UK; 2Department of Pain
Management, Russells Hall Hospital, Dudley, UK; 3Department of Pain Management,
Queen Elizabeth Hospital, Birmingham, UK; 4Department of Oral and Maxillofacial
Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
Background and aims: Trigeminal neuralgia is a severe painful condition that is not always well managed
by medication. Invasive procedures of destruction are with risk and vascular decompression is not always
appropriate. Neuromodulation has been tried in the past but experience is limited and concerns over lead
migration have been raised.1-3
Methods: In an attempt to investigate possible ways of reducing lead migration, we undertook a bench
feasibility study with tined sacral nerve stimulation leads because these have been shown to have a low
rate of migration in the sacrum. Under fluoroscopic guidance, using mentoposterior and lateral skull
imaging, we passed a modified 14G epidural needle (Interstim, Medtronic) into the foramen ovale of skull
base of cadaver via intraoral entry point above 2nd upper molar. A tined lead was passed through the
needle and needle withdrawn, to deploy the tines. The lead was connected to a pulley system to measure
the force needed to displace it. An observer blinded to the forces applied, recorded lead movement, while
another recorded the forces. Four different foramen ovale of cadaveric skulls were used.
Results: In all four cases we were able to pass the lead into the foramen and to deploy the tines in adjacent tissues. The forces at which the lead started to move were as follows: Cadaver 1 right side - 850gr;
Cadaver 1 left side - 600gr; Cadaver 2 right side - 1050gr; Cadaver 2 left side - 1100gr. We dissected the
specimens to determine the tissues that held the tines.
32
Abstracts
Conclusion: In this pilot cadaveric feasibility study, we have demonstrated that tined neurostimulator
leads can be passed through the foramen ovale of the skull base and maintained in position against
reasonable forces.
References:
1. Meyerson BA, Håkanson S. Alleviation of atypical trigeminal pain by stimulation of the Gasserian
ganglion via an implanted electrode. Acta Neurochir Suppl 1980;30:303-09.
2. Meyerson BA, Håkanson S. Suppression of pain in trigeminal neuropathy by electric
stimulation of the gasserian ganglion. Neurosurgery 1986;18(1):59-66.
3. Machado A, Ogrin M, Rosenow JM, Henderson JM. A 12-month prospective study of gasserian ganglion
stimulation for trigeminal neuropathic pain. Stereotact Funct Neurosurg 2007;85(5):216-24.
SA.01.02
Neuromodulation for facial pain and headache
Athanasios Koulousakis, Doris Lenarzt
University Hospital Cologne, Stereotaxy and Functional Neurosurgery, Cologne, Germany
Introduction: During the last 40 years there was a progressive distribution of the application of neuromodulative techniques in many disciplines, now also in special forms of neuropathic facial pain and
headache. Weiner reported in 1999 on a peripheral nerve stimulation for occipital neuralgia and Popney
and Alo in 2003 on peripheral nerve field stimulation for migraine.
Patients and Method: During the last 5 years 12 patients with neuropathic facial pain, 6 patients with
occipital neuralgia and 1 patient with central thalamic pain high parietal and 2 patients with migraine
were treated with peripheral nerve field stimulation (PNFS) or ONS. Therefore 2 electrodes on either side
were subcutaneously implanted on the borders of the pain area. After a test phase of 1-2 weeks and pain
reduction of more than 50%, the electrodes were connected to a neurostimulator.
Results: Except one patient with a postherpetic neuralgia of V1 left, all other patients with different
indications, achieved a pain reduction of more then 60% during a follow-up of 5 years. 9 patients had a
significant reduction in pain medication, and all patients a significant improvement of their quality of
life.
Discussion: The mechanism can be an interruption of the trigeminal-cervical circuit with connection
to the G.Pterygopallatinum and G.cervical superior, similar to the cluster headache, which is an other
indication for neuromodulation.
Summary: We can say that neuromodulative treatments such as Cervical Spinal Cord stimulation, Deep
Brain Stimulation and especially Peripheral Nerve Field Stimulation or ONS can be successfully applied
with low risk for certain forms of facial pain, chronic headache and migraine.
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Abstracts
SA.01.03
Peripheral nerve stimulation – state of the art
Dirk Buschmann
Neurochirurgische Gemeinschaftspraxis Herford
Objectives: We performed more than 350 peripheral nerve stimulation procedures since 1991. We mostly
treated patients with Causalgia (CRPS II). Incomplete or complete lesion of the stimulated peripheral
nerves was determined in all patients. Surgical treatment failed or wouldn’t be indicated in all cases. All
patients have extensively been treated with conservative pain therapy.
Material and Method: The aim was to define a standardised method, which would be as objective as
possible, to verify the success of treatment, by measuring the pain-related disability assessment, the
subjective intensity of pain and the subjective perception of pain. A long-term follow-up was arranged
in addition to determine social and occupational re-integration. The implantation of the stimulating
device, proximal to the lesion, was performed after microsurgical neurolysis of the peripheral nerves. Post
surgically patients were to test stimulate with a stimulation unit externally connected to the lead. After
concluding and discoussing the results of the trial stimulation period, a stimulation unit was permanently
implanted in most (more than 85 %) cases, with a remarkable reduction of pain. Only in very few cases,
the evaluation of the trial stimulation period was unsatisfactory to the patient and did not indicate the
implantation of permanent devices.
Results: After implanting the stimulator unit an average pain-related disability of 10 % was achieved by
all the patients fitted with a permanent implant. More than 85 % of the patients have used the permanent
stimulation device implants with lasting, good to excellent success. The stimulator system was removed
in only 12 cases, due to full and permanent pain relief, due to a malfunction or lack of lasting success.
SA.01.04
Long-term results of peripheral nerve stimulation in neuropathic postherniorraphy pain
Matthias Winkelmüller Praxis und Klinik für Neurochirurgie, Friederikenstift Hannover, Hannover
One of the most often executed operation in general surgery is the surgery of hernia repair. After this
operation 30 – 60 % of the patiens complain about modest pain and 11 % report severe and devastating
pain. Other reasons for groin pain can be seen in gynaecological or urological operations and in cases
of trauma. The pain is described as burning, throbbing and lancinating into the anatomical distribution
area. Also, there is often a local tender point and an area of distinct allodynia. The pain syndrome is classified as neuropathic pain. The chronic neuropathic pain is often not amenable to further nerve-surgery
(neurolysis, nerve decompression, nerve resection) and oral pain killers are not always working without
severe side effects or even are not able to significantly reduce the pain.
This therapeutic dilemma can be solved in the majority of the cases with the utilisation of the subcutaneous peripheral nerve stimulation (sPNS). This procedure consists of the percutaneous insertion of a
34
Abstracts
stimulation electrode directed to the area of the localized tender spot in the subcutaneous tissue. After a
positive trial period a pulse generator is implanted into a subcutaneous pocket in the lower abdomen. The
stimulation device is being activated by the patient either the whole day or most often only some hours per
day. In this prospective and single center study 21 patients are described with a follow-up time of almost
10 years. 2 Patients were no candidates for implantation (1 patient did not meet the selection criteria and
1 patient had no immediate effect from the test stimulation, but after explantation of the electrode he
surprisingly experienced sustained pain relief). From the implanted 21 patients, 16 patients (76%) had a
good long-term outcome. 5 Patients (24%) were considered as long-term failures (4 patients with later on
ineffectivity of neurostimulation and ongoing pain most probably due to bio-psycho-social chronification
processes and 1 patient had an improper trouble-shooting in an other hospital). There were 4 electrode
revisions (breakages in 2 patients and changing of paraesthesias in 2 other patients, both later being
classified as failures), 1 generator was exchanged because of malfunction after NMR scan of the lumbar
spine and 2 generators were repositioned because of local tenderness). There were malpractice suites in
4 out of 21 patients (19%) against the physician’s pre-treatment.
In summary, the peripheral nerve stimulation offers a good therapeutic option in chronic groin pain providing a long lasting stimulation effect with only a few hardware complications. In some cases (2 pts),
the effect of neurostimulation has led to a complete cessation of the pain states („wind-down“?) and
also the allodynia was markedly diminished in nearly all patients. The neurostimulation should be offered
in specialized centers to those patients who experience prolonged pain states not responding to revision
surgeries or to oral pain medications in the early beginning of their pain career to prevent a further pain
chronification process with loss of work and social withdrawal.
SA.02.01
High frequency stimulation for spinal neuromodulation in patients with
chronic lumbar pain of different origin and spinal stenosis
Werner E. K. Braunsdorf, Antje M. Siebel, Ronald Richter
Clinic for Neurosurgery and Spine Surgery, Klinikum Magdeburg gGmbH; Teaching
Hospital of Otto-von-Guericke-University, Magdeburg, Germany
Introduction: Chronic lumbar pain, the failed-back-surgery-syndrome(fbss) is one of the main objections
of health professionals as patients refusing a spinal surgical treatment. Now for more than 4 decades
Spinal Cord Stimulation (SCS) for neuromodulation is a well established and evaluated treatment modality
for chronic pain due to spinal fibrosis, but the back itself often was not covered. Since only one year (2011)
also in Europe we have the option for high frequency stimulation (about 10000Hz). First international
multicentric studies give hope for an new horizon of these crucial circumstances.
Material and Method: Since December 2011 the new method of high frequency stimulation (up to 10000Hz)
(SENZA/NEVRO) of the spinal cord was applied to 36 patients with fbss and 14 patients with lumbar
spinal stenosis and neurogenic claudication. A minimal invasive insertion by a percutaneous procedure
positioning the octade twin leads at the level of TH8. By the intraoperative impedance measurement a
35
Abstracts
correct placement was verified. Evaluation was performed by the VAS, Oswestry Disabilty Score, the shorten SF 36 as also an treadmill test pre- and postoperatively. There are follow-ups for the first six months.
Results: There was a surprising distinct improvement concerning pain, daily handicaps and a extraordinary extension of walking distance in the group of neurogenic claudication. There were no complications
and no failures. Especially the deep localised back pain was relaxed.
Conclusion: By high frequency stimulation the severe chronic lumbar back pain of different origin is
effectively treated. In contrary to the conventional spinal cord stimulation (30-50Hz) the so called widerange/convergent neurons of the dorsal horn are achived with an impressive pain reduction, decrease of
the pain threshold of nociceptive and neuropathic pain. Our experiences and those of other study groups
and multicentric studies recommend this treatment as a therapy of choice for the indication of fbss and
multilevel moderately concentric lumbar spinal stenosis and neurogenic claudication.
SA.02.02
Paraesthesia free, high frequency stimulation of the spinal
cord: Technique and one-year follow-up
Georg Bara, Stefan Schu, Jan Vesper
Department of Neurosurgery, University of Düsseldorf, Germany
Background and aims: Spinal cord stimulation (SCS) is an established method for the treatment of
chronic pain in the legs and in the lower back. Cylindrical type leads can be implanted percutaneously,
most paddle type leads (lamitrodes) require more invasive surgery. Dominant back pain syndromes still
are a challenge for all kinds of commonly used systems. The study presents the first year experience with a
minimally invasive percutaneously implantable paraesthesia free, high frequency spinal cord stimulation
system.
Methods: Data was collected prospectively. The patients were implanted with 2 percutaneous leads.
All implantations have been done under general anaesthesia. Prior to the final implantation of the implantable pulse generator (Nevro senza), all patients underwent seven days of trial stimulation. Median
follow-up was 6 months.
Results: 38 patients have been implanted so far. All suffered from failed back surgery syndromes with a
dominant back pain. The data shows excellent clinical outcome for paraesthesia free pain reduction in
the back with a risk profile comparable to known percutaneous techniques (median VAS reduction 8 to
3). There were no major complications. Compared to the literature (up to 30 %) the rate of lead migration
was low (n= 1, 2.5 %).
Conclusion: Our data shows high frequency, thus paraesthesia free stimulation, to be effective and safe.
Placement is done under general anaesthesia, The approach offers a novel elegant procedure for back
dominant FBSS patients.
36
Abstracts
SA.03.01
Evidence and quality driven clues for state of the art neuromodulation solutions
Paul W. Wacnik
Neuromodulation Research, Medtronic Inc., Minneapolis, MN, United States
As medical technology advances, the role of neuromodulation in treating diseases is expanding. Concurrently, it is essential that the scientific basis of these new technologies is understood as new indications
are explored, and technology is developed and brought to market. Priority areas of research include investigation of Stimulation Parameters, Patient Safety, Nervous system Sensing, Biomarkers, and Targeting,
two of which are highlighted in this talk.
Brain Sensing: Deep Brain Stimulation (DBS) for tremor and Parkinson’s disease is an effective method for
reducing tremor and motor disabilities. Local field potential recordings from the DBS lead have been used
to record the success of treatment. In this way, the effectiveness of DBS may be improved by sensing the
disease state and its successful treatment in real time.
Spinal Cord Stimulation (SCS) Sensing: Many patients achieve satisfactory pain control with SCS. However, with position changes and subsequent spinal cord movement, patients may experience a decrement
in paresthesia coverage and/or sub-optimal therapy (reduced energy) in some body positions, thus
compromising efficacy. Restore Sensor is an SCS system designed to detect the patient’s position and
automatically respond with full parameter changes optimized to each position.
SCS Parameters: SCS-induced analgesia may be crucially dependent on the frequency and amplitude of
stimulation. However, optimal parameters for SCS have not been systematically investigated, particularly
in the high-frequency (HF-KHz) range. Evidence is presented that efficacy of SCS-induced analgesia is
intensity- and frequency-dependent in a nerve injury model.
SA.06.02
Road map for patient-centered 3D planning and navigation in deep
brain stimulation – Automatic registration of STN morphology
Peter Gemmar1, Andreas Husch1, Florian Bernard1, Frank Hertel2
1
Trier University of Applied Sciences, Institute of Innovative Informatics-Applications (i3A), Trier, Germany;
2
Centre Hospitalier de Luxembourg (CHL), Dep. of Neurosurgery, Luxembourg (City), Luxembourg
Objective: Deep brain stimulation (DBS) has proven a successful treatment of movement disorders
like dystonia or advanced Parkinson’s Disease (PD), and it is strongly considered for treatment of other
neural diseases like deep depression or cluster headache. During DBS procedure, positioning of the electrodes must be carried out very precisely and is based on image guided planning combining computer
tomography (CT) and magnetic resonance imaging (MRI) for target selection and trajectory planning.
Unfortunately, current imaging technology doesn’t clearly display neural areas considered for stimulation,
as for example the subthalamic nucleus (STN) in PD cases. Our work aims at providing objective views
37
Abstracts
about the actual neural structures of the patient and a visualization of the prospective propagation of the
stimulation field in the target area.
Methods: We are developing computer methods for planning and navigation in DBS and we already provided methods for automatic detection of the anterior and posterior commissure (AC, PC), indirect STN
targeting, trajectory planning, and classification of neural areas in microelectrode recordings (MER).
We now complete this approach by methods for patient-specific 3D-modeling of neural target areas,
combining these data with simulation of electrical field propagation from electrode poles into surrounding
neural areas for preoperative planning, and finally registering these model data with 3D target data from
classified MER for intraoperative navigation.
As the STN target is morphologically not completely discriminable from its neighborhood in MRI, we consider a model-based method for STN segmentation in a primary task. Practically we first segment STN
and substantia nigra (SNr) as a single entity and then we extract STN from SNr-STN using a statistical
approach. For SNr-STN segmentation we use a method based on Active Shape Models (ASM). In order to
create the shape model ASM require training images that are annotated with landmarks describing the
SNr-STN object. In our approach we automatically generate these landmarks from SNr-STN objects segmented by experts. Principal component analysis (PCA) is then used for modelling the variability of objects
from the mean shape and in new query images the determination of the SNr-STN object is achieved by
model approximation.
Results: Automatic AC-PC localization, trajectory planning, and MER classification correlate in more than
90% of clinical cases compared with manual results from experts. Landmark generation for SNr-STN
shapes performs very well for ongoing development of patient-specific SNr-STN segmentation.
Conclusion: Altogether, the patient’s 3D data of the target area, the 3D MER data, and the simulated
stimulation field can be visualized and hence support the surgeon planning the electrode’s optimal
position and navigating the electrode to this position. DBS procedures are getting more objective and
treatment results can better be validated.
Acknowledgment: Parts of this work are funded by “Stiftung Rheinland-Pfalz für Innovation”.
SA.06.03
System for measurement of the electrical field distribution of implantable electrodes
used for verification of field distribution simulation models in deep brain simulation
Pascal Martini, Hamid R. Daneshvar, Martin Schenk, Klaus P. Koch
Fachhochschule Trier, Fachbereich Technik, Trier, Projekt: Computerunterstützte Neuromodulation
Introduction: Simulations of the electrical field distribution or further the volume of tissue activated can
be a usefully tool to optimize electrode position, electrode configuration and stimulation patterns and
gain a better therapeutic outcome in deep brain stimulation. Considering the accuracy of the simulation
models as well as the different approaches of modeling shown in recent publications ([1], [2], [3], [4],
[5], [6]) a verification of the modeling would be helpful to determine the accuracy and figure out the errors
of the modeling.
38
Abstracts
Methods: This paper presents the development of a system to measure the three dimensional electrical
potential distribution around implantable electrodes in saline solution. The electrical field distribution
around the electrodes is the negative gradient (3D derivation) of the potential distribution measured by
the system. The main components of the system are:
- stimulator unit, generates the stimulation signal for the DBS electrode,
- measurement unit, recording the electrical potential via needle electrode
- 3D positioning system, controls the position of the needle electrode
- workstation, controls the automated measurement
The 3D positioning system changes the position of the needle electrode for measuring the electrical
potential on different positions around the DBS electrode. The control software of the workstation can
change the spatial resolution. The spatial resolution can be defined considering measurement time and
need of resolution for the application. The software also controls the stimulation parameters to generate
the electrical field that will be investigated.
A 3D cone plot was used to visualize the direction information of the electrical field. The tips of the
cones points in the direction of the gradient (electrical field) and the scaling of the cones representing
the strength of the electrical field. According to the scaling of the cones additional coloring of the cones
related to the strength of the electrical field add more information to the visualization.
The measurements of the electrical field distribution around a typical DBS electrode (Medtronic 3387)
were performed in saline solution. Stimulation signal was set to a sinusoidal constant current signal with
amplitude of 100-500µA and frequency of 1 kHz. This untypical stimulation signal was used because of
the better capabilities in evaluation of the potential distribution and calculation of the field distribution
results. A simulation model to simulate the DBS electrode inside homogenous and isotropic saline solution
was build in addition to the measurement setup. Stimulation signal was set to parameters according
to the measurement setup. In the next step the measurement results and the simulation results will be
compared to verify the simulation model by measurement.
Results and Conclusion: This modeling and measurement represent the first simple approaches. In
further investigations it is planned to include more complex properties of modeling deep brain stimulation application in the model. These properties are the anisotropy of the tissue extracted from DTI data
and the inhomogeneous tissue of the target areas (e.g. STN). Consideration of the electrode-electrolyte
interface in the model is also planned. To improve the clinical use of the simulation an automatic model
generation will be build, this means a patient specific geometry generation for the FEM simulation (from
automatic MRI segmentation [8]) as well as postoperative electrode position evaluation and integration
in simulation. By modeling more properties of tissue and DBS application the complexity of the model will
rise and therefore a verification of the model will become more necessary. For evaluation of the electrical
field distribution the field distribution of implanted electrodes can be measured inside tissue. With this
approach more complex simulation models can be verified. First measurements in an ex vivo tissue of
musculus cricoarytaenoideus dorsalis in horses has been shown [7] with this system.
Literaturverzeichnis
[1] D. R. Cantrell, S. Inayat, A. Taflove, R. S. Ruoff und J. B. Troy, „Incorporation of the electrode-electrolyte interface
into finite-element models of metal micorelectrodes,“ Journal of Neural Engineering, Nr. 5, pp. 54-67, 2008.
[2] P. F. Grant und M. M. Lowery, „Effect of dispersive conductivity and permittivity in volume conductor models of
deep brain stimulation,“ IEEE Transactions on Biomedical Engineering, Nr. 57, pp. 2386-2393, Oct 2010.
39
Abstracts
[3] M. Aström, J. D. Johansson, M. I. Hariz, O. Eriksson und K. Wardell, „The effect of cystic cavities on deep brain stimulation
in the basal ganglia: a simulation-based study,“ Journal of Neural Engineering, Nr. 3, pp. 132-138, 2006.
[4] C. R. Butson, S. E. Cooper, J. M. Henderson und C. C. McIntyre, „Patient-Specific Analysis of the Volume of
Tissue Activated Durign Deep Brain Stimulation,“ Neuroimage, Bd. 34, Nr. 2, pp. 661-670, 2007.
[5] S. Sotiropoulos und P. N. Steinmetz, „A biolphysical model of deep brain stimulation of
the subthalamic nucleus“ Society for Neuroscience, Nr. 1011.5, 2004.
[6] S. Miocinovic, S. F. Lempka, G. S. Russo, C. B. Maks, C. R. Butson, K. E. Sakaie, J. L. Vitek und C.
C. McIntyre, „Experimental and theoretical characterization of the voltage distribution generated
by deep brain stimulation,“ Experimental Neurology, Nr. 216, pp. 166-176, 2009.
[7] P. Martini, M. Cercone, J. Cheetham und K. P. Koch, „Experimental electrical field distribution measurements in a perfused
ex vivo model,“ in 46th Annual Conference of the German Society for Biomedical Engineering, Jena, Germany, 2012.
[8] F. Bernard, P. Gemmar, A. Husch und F. Hertel, „Improvements on the Feasibility of Active Shape Model-based Subthalamic
Nucleus Segmentation,“ in 46th Annual Conference of the German Society for Biomedical Engineering, Jena, Germany, 2012.
SA.06.05
Deep brain stimulation for neuropsychiatric diseases – New indications
Jürgen Voges
Department of Stereotactic Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
Deep Brain Stimulation (DBS) is meanwhile established for the treatment of Parkinson’s disease, tremor
and generalized or segmental dystonia. During the last years DBS has increasingly been used to treat
patients with neuropsychiatric diseases such as major depression, obsessive compulsive disorder, or
epilepsy. In 2011 electrical stimulation of the Nucleus accumbens for obsessive-compulsive disorder got
a CE mark for Europe. Emerging indications are DBS for addiction or dementia. Reports of significant
improvement in single cases or small case series gave rise for the initiation of larger clinical studies.
This review will focus in particular on these new indications; will discuss the different targets used for
electrical stimulation in light of the hypotheses anticipated for the expected positive stimulation effect
and will critically review the outcome.
SA.06.06
Treatment of central deafferential and trigeminal
neuropathic pain by motor cortex stimulation
Dieter Hellwig1, Malgorzata Kolodziej2
1
Neurosurgery, International Neuroscience Institute (INI), Hannover;
2
Department of Neurosurgery, University Hospital Giessen, Giessen
Objective: Motor cortex stimulation (MCS) is an alternative treatment modality indicated for the care of
central neuropathic pain. MCS is a fast, effective and less invasive method of treating refractory neuropathic pain. Conservative methods of treatment for these cases had been unsuccessful, thus selected
patients received an implanted electrode for stimulation of the motor cortex.
Material and methods: This study did a retrospective case series review of patients who had undergone
surgical management of central, deafferentation and neuropatic trigeminal pain using MCS between April
2001 and May 2011. Patient data were collected for analysis, including the follow-up (6 months-6 years).
40
Abstracts
Pain control was assessed by a four-level scale. The patients were classified into three groups, those with
central pain, those with trigeminal-neuropathic pain and those with deafferentation pain. All patients
under local anesthesia had four-contact paddle electrodes (Resume®, Medtronic) placed in the epidural
space overlying the motor cortex. The test stimulation was preformed after a neurological investigation
of the awake patient over a period of time between 2 and 12 days. Different combinations of stimulation
were used with a goal of achieving a pain reduction of 75%. The patients were implanted with permanent
internal pulse-generators after the successful test stimulation.
Results: Twenty patients (9 male, 11 female) were treated surgically. Mean patient age was 59.8 years,
with ages ranging from 31 to 79-years-old.
In the central pain group, 3 patients described complete pain control and 4 patients claimed satisfactory
pain control. In the trigeminal-neuropathic pain group, 7 patients experienced complete pain relief and
2 patients experienced satisfactory pain relief. In the deaffererentation pain group, 1 patient reported
absence of pain and 2 patients reported satisfactory pain relief. In one case, an electrode cable brake was
recognized, and in another individual a wound infection occurred.
In two cases, a loss of stimulation after a time of one year was noticed, which was followed up by new,
successful placements of electrodes.
Conclusions: MCS is an effective treatment modality for neuropathic central and trigeminal pain with a
low morbidity and mortality rate. Future studies are necessary to evaluate and optimize this treatment
option in more detail.
SA.07.01
Effects of dorsal root ganglion stimulation in the treatment of chronic,
intractable pain: Long-term results from two prospective clinical trials
Liong Liem1, Frank Huygen2, Marc Russo3, Jean Pierre Van Buyten4, Iris Smet4
1
St. Antonius Hospital, Nieuwegein, Netherlands; 2Center for Pain Medicine,
Erasmus MC, Rotterdam, Netherlands; 3Hunter Pain Clinic, Broadmeadow,
Australia; 4Multidisciplinary Pain Centre AZ, Sint-Niklaas, Belgium
Introduction: Chronic, intractable pain refractory to conservative and aggressive treatment options
remains a clinical challenge. In order to evaluate the efficacy of dorsal root ganglion stimulation in the
treatment of this condition, 2 prospective, multicenter, twin trials were conducted in Europe and Australia.
Methods: Ethics committee approval was obtained for all centers involved in the multi-national, prospective clinical trials. Patients with chronic intractable pain for 6 months or more were included in the
study. Patients were provided a trial spinal cord stimulator (Spinal Modulation™ Spinal Cord Stimulator)
with leads placed in the lateral epidural space near the dorsal root ganglion. If successful, patients were
then provided a fully-implantable system. Pain scores (VAS; itemized by anatomical location), quality of
life (EQ-5D), activity (BPI), psychological disposition (POMS) and measures of subject satisfaction were
obtained at multiple time points for up to 12 months.
Results: A total of 32 patients were implanted with the Spinal Modulation Axium spinal cord stimulator.
The majority of patients have been followed for 6 months and a subset for 12 months. Back pain, leg
41
Abstracts
pain and foot pain relief all showed >70% reduction in each cohort at 6 months and 12 months. The
percentage of patients demonstrating >50% pain relief at 12 months in each anatomic area was 63%
(back pain), 83% (leg pain) and 100% (foot pain).
Conclusions: Spinal cord stimulation of the dorsal root ganglion is a safe and effective means of treating
a variety of chronic intractable pain conditions that are typically difficult to treat with other spinal cord
stimulator systems. Further data collection is being pursued to more clearly define mechanisms of action
as well as provide more data on different and specific pain populations.
SA.07.02
Successful GPi-Deep Brain Stimulation in Tourette’s
syndrome (TS) – Much more than scales can tell
Jan H. Mehrkens1, Bianka Leitner2, Berend Feddersen3, Norbert Müller2, Kai Bötzel3, Sandra Dehning2
1
Neurochirurgische Universitätsklinik, 2Psychiatrische Universitätsklinik, 3Neurologische
Universitätsklinik der Ludwig-Maximilians-Universität München
Objective: Deep brain stimulation (DBS) in different targets for intractable Tourette’s syndrome (TS) has
been in the focus for some years with over 70 cases published. However, there is hardly any data on
“psychosocial” outcome after DBS for GTS. Aim of the present naturalistic observational study therefore
was to focus on the “psychosocial changes” in 6 GTS-patients` life after GPi-DBS.
Methods: All patients (mean age at surgery 34 years (range 26-44), 3 female / 3 male) had undergone GPi-DBS (posteroventrolateral (motor) part). Outcome was assessed by Clinical Global Impression
(CGI), Tourette Syndrome Global Scale (TSGS), Yale Global Tic Severity Scale (YGTSS), Verbal Learning
Memory Test (VLMT) and the Stroop-Test. Moreover, “psychosocial changes” were assessed using the
Global Assessment of Functioning Scale (GAF) and the GTS-Quality-of-Life scale. Moreover, any “major
psycho-social event” was recorded. Median follow-up was 36 months (range 12-84 months).
Results: There was a significant (p=0.001) tic-improvement in 4/6 patients: Reduction in the YGTSS of
100% (tic-free) in Pat. I (12/72 months), 90% in Pat. IV (21/48 months), 80% in Pat. V (8/18 months) and
60% in Pat VI (10 months). “Symptomatic” improvement was associated with significant “functional”
improvement in all responders: we found an increase in the GAF with mean values from 53.75 (± 7.5) on
admission to 83.75 (± 7.5) at last observation together with a strong association between the courses
of GTS-QOL and symptomatic resolution (R2= 0.62). In addition, we also documented psychosocial “lifeevents”, not adequately assessed by the applied “scales”: Pat. I: going through a severe episode of depression despite being tic-free after loss of secondary benefit. Pat. IV: after being-off any “GTS-specific”
medication post-DBS, the patient became pregnant and gave birth to a healthy baby-boy. Pat. V: struck
with self-inflicted blindness, the patient realized this severe deficit with the tics no longer dominating his
life post-DBS – he is now in search of a partner for life.
Conclusion: GPi-DBS – in the posteroventrolateral part – seems to offer a promising therapy in otherwise
intractable GTS in selected patients. However, “success” is not only to be assessed and determined by the
classic “tic-scales” but must also take into account the functional outcome. Both – the patient and the
clinician in charge – should be prepared for possible significant psychosocial changes.
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Abstracts
SA.07.03
Experiences in peroneus nerve implanted stimulation for central drop foot
Guy Matgé1, Paul Filipetti2, Frédéric Chantraine2, Florent Moissenet2, Céline Schreiber2
1
Neurosurgical Department, CH Luxembourg; 2Rehazenter Luxembourg
This is a preliminary report of an ongoing study to document short and long term results of quadripolar
functional electric stimulation (FES) of peroneus nerve with ActiGait in central drop foot. Inclusion criteria
are adult patients with spastic hemiparesis stable over a minimum of 6 months, positive external peroneus test-stimulation, and agreement of the multidisciplinary staff for secure implantation. Peripheral
nerve lesions, too much fat, epilepsy, bad medical or psychological conditions are excluded as well as
contraindications for magnetic examinations. Preoperative evaluation includes neurological, osteoarticular and functional examination, video gait analysis on walking table, and neurophysiology (EMG, fMR, PET,
EEG, TMS, MEP). 3TMR of the knee assesses common peroneal nerve anatomy in the popliteal fossa (nerve
bifurcations, depth), knee incision site, necessity of nerve dissection and required cuff size. Highlights of
surgical technique are documented from skin incision to microdissection of motor and sensory branch,
and finally rules for ActiGait implantation. Neurostimulation and dynamic radio-check are done on the table before immobilising the knee in a splint for 3 weeks to avoid electrode displacement in flexion. Patient
moves next day, leaves 2 days later and shows up at 10 days for removal of stitches and re-examination.
Following fMR, the system is generally activated at 3 weeks when patients follow-up there rehabilitation
program, with gait analysis.
Actually, we have an experience using ActiGait in 13 patients (2010 to 2012), with positive postoperative
activation in all but one case. This patient had atypical anatomy, a plexiforme peroneus nerve which was
probably hurt during dissection. We are waiting for recovery as actually there is no stimulation, although
there was a weak response during operation and the day after at beside. Another patient with progressive
loss of dorsiflexion activation required revision for a secondary kink of the electrode, documented on
imaging compared to preoperative views. A third patient had a secondary displacement of the electrode
(ascending) with pain in territory of the sensory branch obliging a transient stimulation stop. To avoid
these complications we now use knee splint in every patient for 3 weeks when the electrode should be
stabilised in the healed wound.
From rehabilitation point of view, the pre-operative phase optimizes the muscle tendon trophicity: first,
ensuring sufficient flexibility of plantar flexor muscles (minimal dorsal flexion of the ankle about 10°) to
ensure the 3 “rollers” of the ankle. Then, reconditioning the muscles of the antero-external leg (Tibialis
Anterior, Extensor Digitorum Communis, Extensor Hallucis Longus, Peroneus Longus and Brevis) atrophied
and fatigable (switch I-fibers in fibers-IIa) because of their underutilization since stroke, using FES.
Reprogramming muscle continues for several months in search of an effective FES and continuous correction of compensation developed by the hemiplegic patient since his stroke (genu recurvatum, anterior
pelvic tilt …). The duration of the reconditioning is related to the importance of the under activity since
stroke. A battery of clinical tests, 3D gait analysis, neurophysiologic procedure appreciates the analytical
(strength, reduction of spasticity by reducing the ratio HMax/MMax ...) and functional gain (activities of
daily living, Canadian Occupational Performance Measure) and also possible “remnant effect”.
43
Abstracts
First experience in our ongoing study seems promising for improved locomotor effect. Pitfalls and
technical problems are reduced with learning curve (nerve dissection, electrode position, knee splint).
Reconditioning hemiplegic patient in preoperative and postoperative phase by a devoted rehabilitation
team is mandatory. Interest in research may improve long-term results.
SA.09.01
Sacral nerve stimulation of the bladder – a unicentral study
Daher Majed, Harald Voepel, Hein Rainer
Department of Urology, Klinikum Magdeburg, Germany
The sacral nerve stimulation (SNM) is a useful tool for the treatment of voiding dysfunction and it is a
meaningful part in an armamentarium.
The idea is to stimulate the plexus sacralis and thereby to activate the physological residual function of
the bladder detrusor and the pelvic diaphragm. Electrical stimulation has been used for a variety of lower
urinary tract symptoms including those of OAB, painful bladder syndrom and non obsturctive urinary
retention. However the precise mechanism of action by which electrical stimulation is working remains
ambiguous.
It is thought that the efficacy of the neuromodulation is dependent on stimulation of the afferent nerves
which modulate sensory processin of the voiding reflex and its pathway to the central nervous system.
Sacral neuromodulation involves a staged process, including a screening trial and delayed formal implantation for those with substantial improvement.
The first step is a percutaneous nerve evaluation with a foramen needle. If a contraction of the pelvic floor
can be observed, the second step consists of introducing a test electrode and an external pulse generator
for a screening phase of 10-14 days. The screening is responsible for a nearly perfect patient selection
and makes this technique unique. In patient with a positive response, which is the decrease of the symptoms of more than 50% measured by a continence diary, the third step is to replace the test electrode with
a permanent electrode and the definitive implantation of the internal pulse generator (Interstim II). Within
regular controls we will observe the optimal adjustment of the advice.
Conclusions: We will present our dates based on 3 years of our experience and 30 patients. Further in our
paper we will cover also the preoperative, operative and postoperative procedure.
In the selected patient groups SNM is a promising and, in experienced hands, a low-complication second-line therapy for the treatment of LUTS of neurogenic and non-neurogenic origins and overactive bladder.
44
Abstracts
SA.09.02
Trans-abdominal electrical stimulation using interferential
current is able to treat chronic constipation in children
Yee Ian Yik1,2,3, Khairul A. Ismail1, John M. Hutson1,2,4, Bridget R. Southwell1,2,5
1
Surgical Research Group, Murdoch Children’s Research Institute, Melbourne, Australia;
2
Department of Paediatrics, University of Melbourne, Australia; 3Department of General Surgery,
Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 4Department of Urology,
5
Department of Gastroenterology, Royal Children’s Hospital, Melbourne, Australia.
Background and Aims: Transcutaneous electrical stimulation (TES) using interferential current (IFC) is
thought to penetrate deeper without causing pain. TES-IFC uses a beating current and is used by physiotherapists to treat musculoskeletal pain and bladder incontinence. Since 2005 we have investigated the
potential for TES-IFC to treat chronic constipation in children. Initially we tested TES-IFC delivered in physical-therapists’ clinics, (20 mins/session, 3 times/week for 4 weeks) (1-2), then battery-operated devices
used at home (3-4). Aim: Determine the effects of daily TES-IFC delivered at home on bowel symptoms in
children with slow transit constipation (STC).
Methods: STC was confirmed by radio-nuclear transit study (NTS) at a tertiary pediatric hospital. Patients/
parents were taught to administer stimulation with 2 electrodes on the abdomen and 2 on the back. IFC was
80-150 Hz beat using a 4 kHz carrier frequency at the highest tolerated setting using Fuji INF4160 devices
added onto existing laxative treatment. Daily bowel diaries were recorded throughout and quality of life
(QOL, PedsQL4.0) questionnaires administered before and after treatment. Defecation frequency, sensation
of defecation (urge-initiated defecation), soiling frequency and QOL were assessed at 6 months.
Results: Good patient contact was needed to ensure understanding, proper use of the machine and compliance. 62 STC children completed 3-6 months treatment, but 3 did not return bowel diaries. 94% had
improvement in at least one symptom. Defecation frequency increased in 54/56 children who started with <3
BA/wk (from mean±SEM 1.43±0.6 to 4.0±1.5 episodes/wk, p<0.0001) with 32/56 increasing to >3 defecations/wk. Urge-initiated defecation increased in 54/62. 37/39 (95%) who had abdominal pain reduced pain
(2.7±1.6 to 0.4±0.6 episodes/wk, p<0.0001). Soiling decreased in 54/62 (87%) from 5.3±1.7.4 to 1.1±1.5
episodes/wk p<0.0001. Both child-reported and parent-reported QOL improved significantly: total PedsQL
Scores, child-reported (pre 64±7 vs post 77±6; p<0.01) and parent-reported (61±6 vs 73±6; p<0.01).
Conclusions: TES-IFC administered at home on top of existing treatment increased defecation, reduced soiling and improved QOL in STC children. TES-IFC is delivered across the skin and is non-invasive. Home-based
self-administration is possible provided good education and contact is established. Additional studies are
required to optimize the treatment.
References:
1. Chase J, Robertson VJ, Southwell B, Hutson J, Gibb S. Pilot study using transcutaneous electrical stimulation (interferential current)
to treat chronic treatment-resistant constipation and soiling in children. J Gastroenterol Hepatol. 2005 Jul;20(7):1054-61.
2. Clarke MC, Chase JW, Gibb S, Robertson VJ, Catto-Smith A, Hutson JM, et al. Decreased colonic transit time after transcutaneous
interferential electrical stimulation in children with slow transit constipation. Journal of pediatric surgery. 2009 Feb;44(2):408-12.
3. Ismail KA, Chase J, Gibb S, Clarke M, Catto-Smith AG, Robertson VJ, et al. Daily transabdominal electrical stimulation at home
increased defecation in children with slow-transit constipation: a pilot study. Journal of pediatric surgery. 2009 Dec;44(12):2388-92.
4. Yik YI, Ismail KA, Hutson JM, Southwell BR. Home transcutaneous electrical stimulation to treat children
with slow-transit constipation. Journal of pediatric surgery. 2012 Jun;47(6):1285-90.
45
Abstracts
SA.09.03
Predictive model of spinal cord stimulation efficacy based on psychological characteristics
Elizabeth Sparkes1,2, Jon H. Raphael1,3, Rui V. Duarte1,3, Ian Hume2, Robert L. Ashford1
1
Faculty of Health, Birmingham City University, Birmingham, UK; 2Psychology and Behavioural Sciences,
Coventry University, Coventry, UK; 3Department of Pain Management, Russelsl Hall Hospital, Dudley, UK
Background and aims: Spinal cord stimulation (SCS) is an effective treatment for neuropathic pains,
but long-term benefit of more than one year is only found in a proportion of patients treated. Previously
technical factors have been suggested as predominantly responsible. It is hypothesised that psychological factors may be important as determinants of outcome. A literature review in this field demonstrated a
lack of reliable psychological predictors of SCS treatment.1
Methods: A prospective study over one year of patients implanted with spinal cord stimulators was conducted. Forty consecutive patients were included in the final analysis. Improvement in pain was selected
as ≥ 30% reduction in pain. Twenty-six participants reported receiving < 30% reduction in pain and
14 reported ≥ 30% reduction in pain. Pain intensity was assessed using the visual analogue scale,
disability was evaluated using the Oswestry Disability questionnaire and psychological measures were
also recorded at baseline, six and twelve months. Psychological measures included coping strategies
using the Pain Coping Strategies Questionnaire and anxiety and depression assessed via the Hospital
Anxiety and Depression questionnaire.
Results: Gender (p = 0.370), pain duration (p = 0.738) and age (p = 0.173) were not significantly different across groups (< 30% and ≥ 30% pain reduction). The < 30% pain reduction group included 11
males and 15 females, average age 46 ± 2 years (32-69) and average duration in pain was 10 ± 1.4 years
(1.5-25). The = 30% pain reduction group included 8 males and 6 females, average age 50 ± 3 years
(34-70) and average duration in pain was 9.1 ± 2.8 years (2- 40). Topography of pain was also similar
(areas included back, arm/hand, buttock/leg/back and head/neck). Results demonstrated that as pain
improved disability decreased. Psychological predictors were not significant at six months but significant
predictors were found at twelve months. Greater catastrophising, paired with greater anxiety and less
perceived control were associated with a < 30 % reduction in pain.
Conclusion: Successful responses to SCS at one year in this cohort of patients could be predicted by a
higher score on control over pain associated with lower scores of catastrophising and moderate levels of
anxiety. Control over pain, anxiety and catastrophising appear to have a clear relationship. Belief in an
aptitude to have some control may result in increased ability to engage in normal daily activity, less helplessness and catastrophising behaviours, which have been known to lead to a withdrawal behaviour and
activity avoidance which has the potentially to lead to further disability. The predictive equation generated
from this study needs to be tested on further cohorts of SCS patients in order to investigate its reliability.
References: 1. Sparkes E, Raphael JH, Duarte RV, LeMarchand K, Jackson C, Ashford RL. A systematic
literature review of psychological characteristics as determinants of outcome for spinal cord stimulation
therapy. Pain 2010;150(2):284-289.
46
Abstracts
SA.09.04
Treating of sacroiliac joint pain with peripheral nerve stimulation
Marin Guentchev1, Christian Preuss1, Rainer Rink1, Levente Peter1,
Ernst-Ludwig Wocker2, Jochen Tuettenberg1 1
Department of Neurosurgery, Klinikum Idar-Oberstein, Idar-Oberstein, Germany;
2
Department of Radiology, Klinikum Idar-Oberstein, Idar-Oberstein, Germany
Sacroiliac joint (SIJ) pain is a chronic pain condition affecting older adults with a prevalence of 20%
among patients with chronic low back pain. While pain medication, physical therapy, joint blocks and
denervation procedures achieve pain relive in most patients some cases fail to improve.
We developed a new technique for directly stimulating the SIJ as a last minimal invasive option to treat SIJ
pain. Here we present three patients with severe therapy-refractory pain receiving a SIJ peripheral nerve
stimulation. Patients satisfaction, pain and quality of life was evaluated by means of the International
Patient Satisfaction Index (IPSI), Oswestry Disability Index 2.0 (ODI) and Visual Analog Scale (VAS) using
standard questionnaires adapted to a German-speaking population. For stimulation we placed a 8 pole
electrode parallel to the SIJ. In all three cases test stimulation achieved more than 50% pain reduction
and a permanent neurostimulator was implanted. Postoperatively patient A reported an ODI reduction
from 33% to 18% and VAS from 9 to 2. IPSI was 1. Patient B reported an ODI reduction from 50% to 15%,
VAS from 8 to 1 and a IPSI of 1. Patient C reported an ODI reduction of 44% to 29%, VAS 9 to 2 and IPSI
of 1.
We conclude that SIJ stimulation is an useful therapeutic strategy in the treatment of intractable SIJ
pain when denervation procedures fail to produce the desired effect. Further studies on larger patients
collectives and longer follow-up times are required to study the precise target group and long-term effect
of this novel treatment method.
SA.09.05
Initial experience of high frequency spinal cord stimulators
in the Leeds teaching hospitals NHS Trust.
Robert Jackson, Ganesan Baranidharan
Seacroft Hospital, Leeds, West Yorkshire, UK
Introduction: Proposed benefits of high frequency spinal cord stimulators (HF-SCS) over conventional
spinal cord stimulation (SCS) are to improve back and leg pain with no paraesthesia and discomfort
during stimulation[1], thereby enabling the device to be used for longer periods and during a wider range
of activities including driving, and improving quality of life.
Since July 2011, 17 patients have had trials of HF-SCS (Nevro, Menlo Park, California) in Leeds Teaching
Hospitals NHS Trust for treatment of chronic back, leg and arm pain. 11 patients had permanent implants
fitted since October 2011.
We aim to assess the changes in pain scores following trials and implantation of HF-SCS.
47
Abstracts
Method: Region specific pain scores (visual analogue scores) were collected before use of HF-SCS, post
trial or implantation of HF-SCS, and at intervals following implantation in clinics by pain specialist nurses. Descriptive statistic for all recorded pains, leg pain and back pain were calculated retrospectively.
Results: Of 17 patients who had trial of HF-SCS, 15 (88.2%) had an initial positive response. 11 of these
patients had permanent HF-SCS implants, 9 of which (81.8%) had had previous SCS implantation. In
these 11 patients a total of 22 region specific pain scores were recorded. For all recorded pain scores,
there was a reduction of mean pain score from 7.45 to 2.68 (n=22) after initial trial or implantation.
With mean scores of 2.5 at three months (n=10), and 2.75 at six months (n=4). For recorded leg pain
scores there was a reduction of mean pain score from 6.78 (n=9) to 1.56 post trial or implantation. With
mean pain scores of 2.25 (n=4) at three months. For recorded back pain, there was a reduction of mean
pain score from 8.57 (n=7) to 3.57 post trial or implantation. With mean pain scores of 2 (n=2) at three
months.
Discussion: HF-SCS implants are being introduced at the Leeds Teaching Hospitals Trust. The majority of
patients who have had the system trialled have failed with conventional SCS. Results show improvements
in pain scores in leg and back pain following trials and implantation. In the limited number of patients
who have had devices implanted for 3 or 6 months these improvements have been sustained. HF-SCS is a
relatively new technology for which randomised control trial evidence from the SENZA-RCT trial is awaited.
Acknowledgements: Anthony Lister, Carol Bourke (Pain Specialist Nurses, Seacroft Hospital).
References: [1] I. Smet, J. P. van Buyten, and A. Al-Kaisy, “Successful treatment of low back pain with
a novel neuromodulation device,” in Proceedings of the 14th North American Neuromodulation Society
Annual Meeting, Las Vegas, Nev, USA, 2010.
P 01
Intra-individual comparison of target area paraesthesia between standard
percutaneous SCS octrode leads against paddle SCS lead.
Nagaraju Morubagal, Hirachand S. Mutagi, Dr Kaffafy, Sandeep Kapur
Russells Hall NHS hospital, Dudley, DY1 2HQ, United Kingdom
Introduction: Paddle SCS Leads are demonstrated to offer advantages over standard percutaneous cylindrical SCS leads by way of improved target area paraesthesia coverage, unidirectional electrical field
reducing power consumption and low risk of lead migration1,2. These conclusions are based on case
series comparing them among 2 groups of individuals.
Objective: We would like to present two cases of intra-individual comparison of target area paraesthesia
coverage achieved with Standard percutaneous Spinal cord system octrode leads against paddle leads.
Methods/ Practice settings: A single practitioner at a tertiary care centre undertook trial of SCS therapy
in two patients with peripheral neuropathic pain that proved refractory to conventional conservative
management. After completing a multidisciplinary assessment, they were deemed suitable candidates
for neuromodulation.
Case 1: Standard SCS percutaneous dual trial leads (St. Jude Medical. USA) placed in the dorsal epidural
space at differing position between T 7-12 failed to achieve target area paraesthesia in the foot. With the
48
Abstracts
aid of Epiducer lead delivery system (St Jude’s Medical. USA) one lead was substituted with a S-lamitrode
paddle lead (St. Jude Medical. USA) positioned in dorsal epidural space at T8-10 resulting in achieving
target area paresthesia. The patient preference for paddle lead induced paresthesia compared to Standard lead may be explained by limiting electrical stimulation of the posterior spinal canal wall.
Case 2: Standard SCS percuateaneous dual leads placed in dorsal epidural space at C2-4 failed to
achieve spread of paraesthesia distal to wrist, a significant target area. With the aid of Epiducer lead
delivery system (St Jude’s Medical. USA), one lead was substituted with a S-lamitrode paddle lead (St.
Jude Medical. USA) positioned in dorsal epidural space at C2-3 which improved paresthesia coverage
beyond the palm without the need to utilise the adjacent percutaneous octrode lead.
Conclusion: Our experience of improved target area paraesthesia coverage achieved by substituting
standard percutaneous SCS lead with Paddle SCS leads reconfirms existing literature demonstrating
advantages for the latter.
Refrences:
1
2
North RB, Kidd DH, Olin JC, Sieracki JM. Spinal cord stimulation electrode design: prospective, randomized, controlled trial
comparing percutaneous and laminectomy electrodes – part I: technical outcomes. Neurosurgery. 2002;51:381-390
Stephan Scu, Dept of Neurosurgery, University of Dusseldorf, Germany; two years paddle
leads for SCS-technique & follow up, presented at NANS, Las vegas 2011
P 02
The application of pulsed radio frequency in chronic pain
Dimitrios Koulousakis, Athanasios Koulousakis, Volker Sturm
Introduction: In the last 25 years, neuromodulative techniques, such as spinal cord stimulation (SCS)
or the intrathecal application of opioids, have replaced the old ablative neurosurgical methods. The
application of pulsed radio frequency (PRF) represents another addition to the arsenal of non-ablative
techniques.
Methods: 50 Patients with chronic, non-maligne pain, who underwent a PRF treatment using the PASHA
Multi-Cath Electrode, from Jan. 2005 - July 2007, were included in this study. The major part, namely
19% suffered from FBSS (Failed Back Surgery Syndrome), while other diagnosis included spinal stenosis,
degenerative processes, facette syndrome, trigeminous neuropathia and others. The patients were treated
with various stimulation parameters, including duration and number of pulses. After lumbar puncture, the
electrode is placed epiduraly, at the dorsolateral region of the spinal column, right above the dorsal root
entry zone. The dorsal roots are then stimulated, until noticed by the patient. Very low voltages (< 0.8V)
are used, in order to ensure the best possible proximity to the nerve root.
Results: Results were assessed, using a questionnaire, which included the severity of pain (using the
visual analogue scale (VAS)), pain reduction, reduction of pain medication, as well as various parameters,
which contribute to the patients’ quality of life, such as overall activity, mood, mobility, the ability to work,
sleep and vitality. The latter variables were used to determine a mean value, which represented quality of
life. Follow-ups were conducted after four weeks, 3, 6, 12 and 18 months respectively. The results show,
that half the patients experienced a significant pain reduction of up to 61%, in comparison to their initial
49
Abstracts
pain severity, which lasted for about six months. Thirteen patients remained after 18 months, displaying
a mean pain reduction of 78%, the other patients dropped out, mainly due to recurring pain.
Conclusion: The application of PRF to the spinal roots can be considered as a viable first-line, minimal
invasive method, which can be easily repeated and has next to no side effects. The ability to conduct
an SCS trial, as well as to apply a test-bolus of opioids in addition to the application of PRF, make the
PASHA-Cath Electrode the perfect tool for determining the best course of action in the invasive treatment
of chronic pain.
P 03
Transabdominal electrical stimulation speeds up bowel motility in piglets
Andre Tan1,3, Magdy Sourial2, Megan French1,3, Daniela Bodemer1,
John M Hutson1,2,3, Bridget R Southwell1,2,3
1
Surgical Research Group, The Murdoch Childrens Research Institute, Flemington
Road, Parkville, Victoria, 3052, Australia; 2The Royal Children’s Hospital, Flemington
Road, Parkville, Victoria, 3052, Australia; 3Department of Paediatrics, University
of Melbourne. Flemington Road, Parkville, Victoria, 3052, Australia
Background and Aim: Transabdominal Electrical Stimulation (TES) has been shown to improve bowel
motility in clinical studies of children with Slow-Transit Constipation (STC) (1). The mechanism of action
of TES is not understood, and we do not know if the effect of TES is immediate. Human studies have shown
that at least one month of TES is required for therapeutic benefit & effects can last up to 6 months after
TES. Many physiological processes and systems may be affected by TES. We aimed to determine if TES had
an effect on stool water content over 2 weeks, and oral-rectal transit over 1 week.
Methods: All studies were on Large White pigs (5 and 6 weeks old). TES was given for 30 minutes/day.
In one group of animals (n = 12, 6 experimental, 6 control), daily TES was administered for two weeks,
and stools were collected and weighed to determine wet and dry weight. In a second group (n = 20, 10
experimental, 10 control) daily TES was administered for one week and oral-anal transit was measured
using Sitzmarks radio-opaque plastic markers with x-ray images of the pigs’ abdomen taken at 6, 30,
54 & 78 hours after ingestion of markers. Transit times were calculated to determine the average time
markers spent in the animal.
Results: Water content in stools from TES-treated animals were higher compared to shams (mean ± SEM,
73.14% ± 0.68% vs. 67.99% ± 0.71%, P < 0.0001) and difference in water content was greatest in the
first 5 days of TES. Oral-anal transit was slower in sham animals than TES-treated animals (mean ± SEM,
25.91±3.41 hours vs. 18.26±3.57 hours, P = 0.0433, Mann Whitney test).
Discussion: TES increased stool water content transiently and sped up oral-rectal transit in healthy pigs.
TES may have an effect on the smooth muscle of the bowel, the enteric nerves that innervate the bowel
or the sacral nerve. The transient increase in water content of stool may mean that the healthy bowel
compensates for changes in luminal water content.
Conclusion: TES sped up oral-rectal transit and increased stool water content in healthy pigs. Developing
this pig model is the first step in understanding the mechanism of action of TES on bowel motility.
50
Abstracts
Reference: 1. Clarke MC, Chase JW, Gibb S, Robertson VJ, Catto-Smith A, Hutson JM, et al. Decreased
colonic transit time after transcutaneous interferential electrical stimulation in children with slow transit
constipation. Journal of pediatric surgery. 2009;44(2):408-12. Epub 2009/02/24.
P 04
Spinal cord stimulation of the dorsal root ganglion for
complex regional pain syndrome (CRPS)
Sam Eldabe1, Ashish Gulve1, S. West2, Fay Garner2, Raymond Chadwick3, V. Robinson4, R. King5
1
Consultants in Pain & Anaesthesia, 2Specialist Nurses in Neuromodulation, 3Consultant Clinical
Psychologist, 4Senior Physiotherapists, The James Cook University Hospital, Middlesbrough, UK Introduction: Spinal Cord Stimulation (SCS) for chronic neuropathic pain has become a standard
treatment option in many pain clinics over the years, however, it is often impossible to get sustained
paraesthesia coverage to some discreet anatomical pain distributions such as foot. A recently approved
alternative to traditional SCS is stimulation of the Dorsal Root Ganglion (DRG). We present four patients
with failed conservative management who were successfully treated with the Axium Neurostimulator
System for CRPS Type I of the lower limb/foot.
Methods: Four patients suffering with CRPS Type 1 of the lower extremity were treated with DRG stimulation. Patients underwent a trial of the therapy where the specifically designed leads were implanted at
the target DRGs at L3, L4 and L5. Following a successful trial these were connected to the implantable
neurostimulator in the gluteal area. Patients reported pain scores on a Visual Analogue Scale (VAS) and
completed an EQ-5D quality of life questionnaire at baseline and at regular follow-up intervals.
Results: With stimulation at two leads, we could cover 92.5% of the painful area and achieved 80%
pain relief with DRG stimulation. The overall VAS scores reduced from 69.25 mm preoperatively to 16
mm postoperatively over an average follow-up period of 5.25 months. The average improvement on the
EQ-5D was 0.479. 50% patients were able to reduce their analgesic medication. All the patients would
recommend the therapy to others and if required undergo the procedure again.
Conclusions: This small case series of four patients suggests that SCS of the DRG may be an effective
treatment for chronic neuropathic pain conditions due to CRPS involving lower extremity and feet. As such
SCS of the DRG offers a useful alternative to traditional SCS for neuropathic pain in the feet that does not
always respond optimally to traditional SCS.
51
Abstracts
P 05
Spinal cord stimulation of the dorsal root ganglion for groin pain
Ashish Gulve1, John H. Hughes1, S. West2, Fay Garner2
1
Consultants in Pain & Anaesthesia, 2Specialist Nurses in Neuromodulation,
The James Cook University Hospital, Middlesbrough, UK
Introduction: Spinal Cord Stimulation (SCS) for chronic neuropathic pain has become a standard treatment option in many pain clinics over the years, however, it is often impossible to get the paraesthesia to
some discreet anatomical pain distributions. A recently approved alternative to traditional SCS is stimulation of the Dorsal Root Ganglion (DRG). We present two patients with failed conservative management
who were successfully treated with the Axium Neurostimulator System for groin pain.
Methods: Two patients suffering with neuropathic pain in the groin area were treated with DRG stimulation. One of these was a lady with abdomino-cutaneous nerve entrapment syndrome with neuropathic
pain for 12 years. The other was post-inguinal orchiectomy pain of 8 years duration. Patients underwent a
trial of the therapy where the specifically designed leads were implanted at the target DRGs at T12, L1 and
L2. Following a successful trial these where connected to the implantable neurostimulator in the gluteal
area. Patients reported pain scores on a Visual Analogue Scale (VAS) and completed an EQ-5D quality of
life questionnaire at baseline and at regular follow up intervals.
Results: With stimulation at a single lead, we could cover 95% of the painful area and achieved 85%
pain relief with DRG stimulation. The overall VAS scores reduced from 66.5 mm preoperatively to 6 mm
postoperatively over an average follow up period of 6.5 months. The average improvement on the EQ-5D
was 0.554. There is also significant carryover analgesia. Both the patients would recommend the therapy
to others and if required undergo the procedure again.
Conclusions: This small case series of two patients suggests that SCS of the DRG may be an effective
treatment for chronic neuropathic pain conditions of the groin. As such SCS of the DRG offers a useful
alternative to traditional SCS for conditions such as these reported that do not always respond optimally
to traditional SCS.
P 06
Spinal cord stimulation for the treatment of central pain in MS
Tuto J. Nurmikko, Kate MacIver, Christin Bird, Mark Draper, Mike Boggild
Pain Research Institute, Clinical Sciences Centre, University of Liverpool, Liverpool, UK
Background and Aims: There is experimental and clinical evidence for a segmental spinal analgesic
mechanism of spinal cord stimulation (SCS). However, it has also been suggested that a “supraspinal loop” could be activated by SCS to produce additional analgesia (El-Khoury et al. Neuroscience
2002;112:541-553). Such a mode of action would be beneficial in the management of central neuropathic
pain associated with multiple sclerosis (MS) where the lesions are present throughout the central nervous
system and beyond segmental inhibition.
52
Abstracts
The present study was designed to assess (i) short-term and intermediate/long-term efficacy of SCS in
MS-related central pain (MSCP), and (ii) its impact on sensory abnormalities in these patients. Rather
than using a sham control, we chose to compare the effect SCS in MS against the “benchmark” of SCS
used for peripheral neuropathic pain (PNP), the commonly accepted and approved indication for SCS.
Methods: 10 patients with MSCP and 10 patients with PNP underwent trial SCS for 7 days with daily assessment of pain, function and analgesic medication. In both patient groups, SCS-induced paresthesias
were targeted to cover the painful area. On days 2 and 3 each patient had a detailed quantitative sensory
testing (QST) performed within the painful are and a control area, with the trial stimulator switched ON
and switched OFF (order randomised, counterbalanced). Pain relief of minimum of 40% plus evidence for
improved function and/or reduction of analgesic medication prompted permanent SCS (implantation of a
paddle electrode) followed by regular follow-up.
Results: In patients with PNP, 9 of 10 had a positive trial. In 6 of these 9 patients QST showed improved
sensibility for touch within the painful site during ON. 7 of 10 MSCP patients had a positive trial, with no
alteration found in tactile sensibility during ON. All 3 patients with MSCP who failed to benefit from the
trial also failed to perceive any heat pain in the tested pain area either during ON or OFF.
Eight patients with PNP and 6 patients with MSCP were implanted with a paddle electrode. Good intermediate-term pain control was reported by 6 patients with PNP (follow-up: 6-15 months) and 4 patients
with MSCP (follow-up: 6-23 months).
Conclusions: This small pilot suggest that SCS provides pain relief in MSCP which, while somewhat less
than in PNP, is still meaningful in selected patients. This effect is likely mediated through an endogenous
analgesic mechanism, rostral to the stimulation site, possibly mediated by activation of brainstem structures involved in descending pain inhibition. Complete lack of heat pain sensation as measured using QST
may be a negative predictive factor. A larger study in MSCP with a longer follow-up is warranted.
Supported by MS Society UK (grant 869/07) P 07
A case series: Evaluating 2x8 contact stimulation for the
treatment of combined back and leg pain
Rajiv Chawla, Alison Cox, Mark Draper, Paul Eldridge, Jibril Farah, Bernhard Frank,
Aandreas Goebel, Selina Johnson, Turo J. Nurmikko, Manohar Sharma Walton Centre for Neurology and Neurosurgery, Liverpool, UK
and the Pain Research Institute, Liverpool, UK
Background and Aims: In carefully chosen patients spinal cord stimulation (SCS) has been shown to
provide effective pain relief (Taylor et al 2005; Kumar et al 2006). The primary outcome in terms of efficacy
is often described as 50% or more pain relief in the affected area (Kumar et al 2007). This means of
evaluation becomes more complicated when persons describe pain in more than one affected area. This is
especially salient in failed back surgery syndrome (FBSS) were persons often describe axial pain and limb
pain requiring stimulation applied at 2 separate cord levels. In such cases although patients are told they
53
Abstracts
are likely to benefit from SCS they are often advised the stimulation will target primarily one rather than
both areas of their pain due to stimulator coverage limitations.
Advances in electrodes design have led to the availability of a variety of sizes and designs of electrodes.
This has provided the clinician with a choice of different electrode configurations and with this the potential possibility of treating longer sections of the cord capturing axial and limb pain sites. The authors
wanted to assess whether axial and limb pain could be successfully targeted using one electrode. By
evaluation such as this we hoped to be able to prepare patients more appropriately for the procedure in
the future.
Methods: A case series of 14 FBSS patients implanted with 2x8 (specify) contact electrodes who reported
both back (BP) and leg pain(LP) were identified from the WCNN neuromodulation database. Patients were
telephoned and case notes audited. Data retrieved comprised of: pre-trial and post implant pain scores,
coverage, symptom profile and period of follow-up.
Results: 11/14 reported a reduction in both leg and back pain, whilst 3/14 reported relief of leg pain only.
Mean pain intensity (NRS 0-10) was 7.58 BP (range 4-10) and 9.08 LP (range 8-10) pre-implant compared
to 5.83 BP (range 1-10) and 4.91 LP (range 3-7) at follow-up post implant. Average pain reduction was
30.4% BP (range 0-80%), 55% LP (range 20-80%) and overall 52% (range 15-80%). Mean percentage of
stimulation coverage was 32.5% BP (range 0-80%) and 87.75 % LP (range 50-100%). 10/14 experienced
improvements in leg pain only at time of trial using a 4 contact percutaneous electrode. 4/14 underwent
revision of an existing 4 contact electrode. 3/4 of these reporting some relief of back pain in addition to leg
pain post revision whilst prior to this reported no reduction of low back pain. Electrodes were implanted
at levels T8-12, with electrodes implanted between levels T9-11 associated with the best pain reduction
for both BP and LP (9/14≥50%).
Conclusions: From the case series it appears that 2x8 contact stimulation is potentially more effective
than 4 contact stimulation for treating a combination of back and leg pain. More robust evaluation of the
2x8 stimulation coverage in contrast to other electrode configurations and manufacturers is required to
confirm findings and draw more definite conclusions regarding configuration/ coverage benefits.
P 09
Suite for computer supported planning and navigation in deep brain stimulation
Andreas Husch1, Florian Bernard1, Frank Hertel2, Peter Gemmar1
1
Trier University of Applied Sciences, Institute of Innovative Informatics
Applications (i3A), Trier, Germany; 2Centre Hospitalier de Luxembourg
(CHL), Dep. of Neurosurgery, Luxembourg (City), Luxembourg
Objective: Over the last years various software components for supporting the planning and navigation
procedures of deep brain stimulation (DBS) were developed at our site. However, no integrated solution for
effective testing, demonstration and prototyping was available. We aim to develop a software suite, which
covers the entire DBS processes including pre- and intraoperative tasks and allows the rapid integration
of new algorithms and techniques.
54
Abstracts
Methods: We are implementing a framework using the MATLAB programming language, integrating existing components for automatic determination of an optimal trajectory to the selected target point and
automatic fusion of microelectrode recordings (MER) with MRI-volume-data indicating the most likely
penetration of the target volume by the electrodes to support intraoperative navigation. To enable the
integration of ongoing research on algorithms for the automatic creation of patient specific models of
the subthalamic nucleus (STN), an MRI processing pipeline utilizing the Advanced Normalization Tools
Package (ANTS) is used. Different MRI modalities of a patient are registered in a preprocessing step. Patient MRI-data is then aligned to a brain template using a rigid body transformation. Algorithms are then
carried out in MATLAB in a standard coordinate space simplifying the use of model driven approaches.
All steps are accompanied by a user friendly graphical interface (GUI) including 2D and 3D visualization
capabilities of the individual processing steps.
Results: The creation of an integrated suite allows shorter development cycles and simplifies the prototyping and evaluation of new algorithms. The concept of a simplified GUI, which builds upon industry
standard layout approaches, allows a better participation of medical professionals in early stages of
research and development on future techniques. After all modules are entirely implemented, we will be
able to play through the whole DBS procedure with computer-aid in all steps.
Conclusion: Integration of different modules into a single product with a common user interface allows
that new research approaches, like modeling of target structures or simulation of the stimulation field,
can be more tightly followed by medical professionals from the very beginning. Interdisciplinary work is
promoted and new perspectives can be established.
Acknowledgment: Parts of this work are funded by the “Stiftung Rheinland-Pfalz für Innovation”.
P 11
Effects of thalamic deep brain stimulation in Tourette syndrome
Daniel Huys1, Philip Köster1, Doris Lenartz2, Veerle Visser-Vanderwalle2, Jens Kuhn1
1
Klinik für Psychiatrie und Psychotherapie der Uniklinik Köln; 2Klinik für
Stereotaxie und Funktionelle Neurochirurgie der Uniklinik Köln
Introduction: Tourette Syndrome (TS) is characterized by the chronic occurrence of vocal and motor tics,
which can lead to severe impairments in quality of life and in the level of functioning. Regarding pathophysiology a dysfunction in basalganglia-cortex-loops and hyperactivity in the dopaminerg system are
assumed. In patients without satisfying results under pharmacological treatment, Deep Brain Stimulation
(DBS) has been proven effective in different target areas.
Method: Cortico-striato-cortical loops were modulated by DBS in thalamic areas with mainly pallidal
and nigral input. Outcome measures were quantity and intensity of tics (YGTSS), scales for depression
and anxiety, the global assessment of functioning (GAF) and personality traits. For baseline evaluation 9
patients with TS and as many healthy control subjects were examined. All patients were evaluated again
6 month after implantation of DBS. Additionally longitudinal and cross-sectional studies were performed.
Results: Longitudinal analysis showed a significant reduction of tics after 6 month (p= .006), similar
effects could be shown in anxiety-scores. Further a non-significant improvement in the level of func-
55
Abstracts
tioning was found. Allthough the group of patients showed an accentuation in dependent, avoiding and
anankastic personal traits, these differences were not significant.
Therefore our data supports the hypothesis, that DBS in thalamic regions is able to reduce tics effectively.
It should be the aim of further studies to work on more specific psychpathologic parameters and potentially predictors for the effectivity of DBS in patients with TS.
P 12
Intrathecal Baclofen Therapy (ITB) in cerebral spasticity
Athanasios Koulousakis, D. Weiss, Doris Lenartz
Introduction: Since 1986, intrathecal application of baclofen has replaced all other ablative techniques
in the treatment of severe spasticity.
Aim of this study was to emphasize the efficacy of continuous intrathecal application of baclofen via
implantable pump-systems in the treatment of cerebral spasticity in terms of reduction of spasticity,
improvement in quality of life, as well as safety and cost-effectiveness.
Methods: Thirty-one women and 26 men between suffering from cerebral spasticity, who had exhausted
any available conservative options were assessed in this study.
Eleven patients suffered from cerebral spasticity (CP), 13 patients had an accident, which led to traumatic brain injury with coma, 17 patients suffered from hypoxic brain damage, 15 patients had suffered
an intracranial hemorrhage and one patient suffered from tumor related cerebral spasticity. Katheter and
pump were implanted in one step after bolus-application. Follow-up was for up to 20 years.
Results: Examinations yielded the following results: Ashworth-Score improved by a mean value of 1,64
points (32,8%). Barthel-Index (daily life activities) showed a mean improvement of 5,52 points (10,5
points if excluding appalic patients). Cologne Score Scale (CSS), which incorporates 10 items such as
pain, quality of life, side effects, improvement of physiotherapy, sleep, mood etc., decreased by 12 points
(20%). Complications and side effects are less when compared to other publications and to oral treatment.
Summary: Our findings show, that long-term ITB-Therapy in patients with therapy refractory cerebral
spasticity is effective and safe. We observed a significant tone-reduction, less side-effects and improvement in quality of life. 96% of patients or relatives were satisfied with therapy and would recommend or
repeat it.
56
Abstracts
P 13
Improvement of intrathecal drug delivery for chronic pain
syndromes using a patient therapy manager PTM®
Dirk Rasche, Volker M. Tronnier
Department of Neurosurgery, University of Lübeck
Objective: In a certain percentage of chronic pain patient´s intrathecal drug delivery (IDD) is an individual
option to achieve pain reduction or decrease of analgesics and related side effects. The use of flexible
pump programming with adjustment of the daily medication dose to the individual needs of the patient is
possible. The clinical significance and experience with PTM® should be presented.
Material and Methods: Implantable electronic IDD systems offer the possibilities to reduce the opioids
induced side effects with minimized daily dosages and to potentiate pain reduction by direct intrathecal
application. In case of breakthrough pain or increased physical activity additional analgesics may be
required. Therefore the use of short-acting opioids in different application forms is generally accepted. In
patients with IDD also a bolus application via the implanted pump is programmable as a form of “patient
controlled analgesia”. Therefore the patient uses a PTM®.
Results: The technical handling of the PTM® device was rated easy and no unexpected side effects or
complications like overdosage were detected. An additional and satisfactory pain reduction was achieved
by bolus application. Patients rated the PTM® positive, were actively involved in their pain therapy and an
increase of quality of life and decreased need of oral opioids and co-analgesics was observed.
Conclusion: The possibility of intrathecal bolus application enables the patient to gain more pain reduction and control in cases of temporary pain increase. The PTM® is safe, easy to use and leads to an
improvement of intrathecal pain therapy and quality of life of the chronic pain patient.
P 14
Experiences with intrathecal baclofen pump therapy in Slovenia
Klemen Grabljevec1, Katja Groleger Sršen1, Marta Gorišek1, Branka Vipavec1, Roman Bošnjak2
1
Spasticity & pain treatment service, University rehabilitation Institute, Ljubljana, Slovenia; 2Clinical
Department of Neurosurgery, University Clinical Center, Ljubljana, Slovenia
Background/aims: Complete intrathecal baclofen therapy programme for treatment of intractable
spasticity is available in Slovenia for last eleven years. From the year 1993 to 2000, few patients were
transferred abroad (Austria) for pump implantation. Current programme is run by the single ITB therapy
unit, which is a national refferal center and consists of multidisciplinary team that serves for the nation´s
population of two millions. The aim of the review is to present the experiences with demographic and
clinical characteristics of patients, type of treatments and treatment related complications in population
of patients with ITB pump in Slovenia.
57
Abstracts
Methods: Review of the documentation of all patients after implantation of intrathecal delivery pump. Demographic data, diagnosis, time since implantation, type of drug, dose, concentration and complications
connected to pump or follow-up were extracted.
Results: Demographic data: Together 52 patients with baclofen intrathecal delivery pump were treated for
intractable spasticity in Slovenia since 1993. Currently there are 41 patients having baclofen intrathecal
delivery pump implanted and 14 of them are female. Average age of patients is 40.6 yrs (9-68). The
leading pathology in the population is spinal cord injury (17/41), followed by aquired brain injury (9/41),
cerebral palsy (7/41), multiple sclerosis (6/41) and cerebrovascular disease (2/41). Seven patients died
since the beginning of the programme and no death was connected with the ITB pump tratment. In three
cases pump explantation was performed and on patient moved to live abroad.
Treatment: Average dose of the daily baclofen is 347 micrograms (70 – 1.500). Ten patients have delivered
baclofen in concentration of 500 mg/ml and others of 2.000 mg/ml. Average pump refill periode is 146
days, which means close to three refill sessions per patient per year.
Complications: During 230 „pump years“ in all treated 52 patients. Thirteen catheter revisions in 10
patients were needed due to migration of the tip of the catheter epidurally, three patients had implanted
system infected and in one patient the revision of subcutaneous pocket was done due to aseptic cellulitis.
In 14 patients we performed CT w/ contrast scan of the system due to suspected catheter problems and
we comfirmed that in 10 patients. Ten patients needed to be hospitalized in rehabilitation unit after discharge from neurosurgery department. No life treathening conditions regarding drug infusion or adverse
effects were noticed.
Conclusion: Frequency of patients treated for spasticity with ITB in Slovenia is 26 / million and current
needs seems to be 10 - 15 first pump implantations per year in the population of two millions. Majority (44
%) of all patients treated, had spasticity due to spinal cord injury. The number of all complications needed
surgical intervention with hospitalization in Slovenian population is 17 in 230 pump years, which means
ratio of one complication in 13,5 „pump years“. Major part of complications happened in early pariod of
intrathecal therapy programme and due to catheter problems.
P 15
Lumbar and cervical treatments with epidural pulsed
radiofrequency – A retrospective overview
Hector de Paz
Marienhospital Schwerte
Introduction: Epidural pulsed radiofrequency has been applied in Germany in the last 6 years for treating
neuropatic pain in the lumbar and cervical spine. 900 patients have been treated in the Marienhospital
in Schwerte operated with this technique and we realized that the epidural pulsed radiofrequency in the
cervical spine showed better results than in the lumbar spine.
Method: 100 patients with chronic cervical pain syndroms were treated with an epidural pulsed radiofrequency using the multifunctional electrode Pasha between 2011-2012. The major part suffered from
cervical stenosis and cervical disc prolapses, while other diagnosis included degenerative processes and
58
Abstracts
facette syndroms always with neuropatic symptoms. Another group of patients at the same time with
chronic lumbar pain were treated with the same electrode. In this group the main diagnosis were lumbar
stenosis and lumbar disc prolapses and protrusions.
Cervical spine group: After punction in TH 7-9 the electrode was positioned from C2 down to TH2 on both
sides. The patients were treated with 4 minutes pulsed radiofrequency each nerve root
Lumbar spine group: after punction L4-L5 the electrode was positioned from the conus down to L4 on both
sides. The patients were also treated for 4 minutes each nerve root.
Results: Follow-ups were conducted after 4 weeks, 3,6,12 months. Results were assesed, using a questionaire which included the severity of pain using the visual analogue scala .The results show that the
patients had a reduction of pain in the cervical pain group of 75% while the lumbar group showed a
reduction of pain of 63%. In each group more than 60 patients had a reduction of pain aftr 12 month
over 50%.
We had no significant complications during the interventions in both groups. 6 Patients in the lumbar and
3 in the cervical group had spinal syndroms with
1-2 days headache
Conclusions: The application of epidural pulsed radiofrequency can be considered a viable first line,
minimal invasive method, which can be easily repeated and has next to no side effects. We showed that
the results of the application of epidural pulsed radiofrequency are better in the cervical spine than in the
lumbar, although both methods have pain reductions over 60%.The ability to conduct an SCS trial and to
reduce drugs by the patients make the multifunctional electrode the perfect tool in the invasive treatment
of chronic pain.
P 16
Percutaneous Electrical Nerve Stimulation (PENS) Therapy for treating
neuropathic back pain – case reports of two patients with back
pain following surgery for soft tissue tumours of the back
Arun K. Bhaskar, S. Rose, G. Beirne
Department of Anaesthesia, Pain Medicine & Critical care,
The Christie NHS Foundation Trust, Manchester, UK
Background & Aims: Neuromodulation techniques like spinal cord stimulation have been proven to be
very effective in the management of failed back surgery syndromes and also other neuropathic pain
conditions in the spine, particularly when local interventions have not been successful or when pharmacological means have been limited by inadequate analgesia or dose escalation was limited by undesirable
systemic side-effects. or. has always posed a challenge to the clinician and though topical and systemic
neuropathic pain medications and also opioids are capable of controlling the pain in most cases, this
may be limited by inadequate analgesia or undesirable side-effects. The use of an implantable neurostimulator with spinal or peripheral electrodes is often unsuitable in cancer patients who frequently
require MRI scans for follow-up of their disease and treatment and this is particularly relevant in patients
59
Abstracts
with tumours in the vicinity of the spine. PENS therapy using a percutaneous disposable electrode offers
an effective peripheral neuromodulation technique for providing good analgesia for the neuropathic and
nociceptive back pain in these patients and facilitates their rehabilitation. We present the case reports of
two patients who have benefitted from neuromodulation using PENS therapy still having uncontrolled pain
despite maximal medical management as tolerated and other pain interventions like nerve blocks and
radiofrequency median branch neurotomies have not been met with success in producing good analgesia.
Method: Two male patients with longstanding back pain following the diagnosis and treatment of fibromatosis of the lumbar region and multiple soft tissue sarcomas of the left lower back respectively underwent PENS therapy using a 20 gauge 100 mm disposable electrode (Algotec) placed to close proximity of
the spine in the deep tissues under imaging guidance to do peripheral field stimulation at the affected
area at alternating frequencies of 2 Hz and 100 Hz every 3 seconds for a period of 25 minutes. The majority
of treatments were in the head and neck region, trunk and groin for scar pain and post-radiotherapy
neuropathic pain. We looked at the improvement in pain scores, Patient Global Impression of Change
and more objectively, improvement in mobility and the subsequent reduction in opioid analgesics and
systemic neuropathic pain medications.
Results: The first patient reported a dramatic improvement in analgesia and mobility after the first
treatment, which lasted for nearly six weeks; the second treatment did not have the same effect and there
was some flare-up of pain, but the patient is keen to have another treatment as he has noted that the
muscles are more relaxed and easier to mobilise. The second patient who had increasing numbness and
pain reported good analgesia and the effect has now lasted for nearly six weeks – he is awaiting follow-up
and would be offered repeat treatment once the pain recurs, should the patient wishes to proceed with it.
Conclusion: PENS is minimally invasive, cheaper and gives an option to deliver neuromodulation where
the use of implantable peripheral nerve stimulators are limited due to factors like MRI scans or patient
choice. We also propose to evaluate the use of PENS to deliver neuromodulation to facilitate early physiotherapy, mobilisation and rehabilitation as a part of the multidisciplinary approach for patients with
mechanical low back pain. 60
Index of authors
Alesch F.
Ashford R. L.
Bara G.
Baranidharan G.
Beirne G. Bernard F.
Bhaskar Arun K. Bird C.
Blowey S.
Bodemer D.
Boggild M.
Bošnjak R.
Bötzel K.
Braunsdorf W. E. K.
Buschmann D.
Chadwick R.
Chantraine F.
Chawla R.
Cox A.
Daneshvar H. R.
Dehning S.
de Paz H.
Draper M.
Duarte R. V.
Eldabe S.
Eldridge P.
Ellrich J.
Feddersen B.
Filipetti P.
Frank B.
French M.
Garner F.
Gemmar P.
SA.06.04
FR.02.02, SA.09.03
SA.02.02
SA.04.01, SA.09.05
P 16
SA.06.02, P 08, P 09
P 16
P 06
FR.02.04
P 03
P 06
P 14
SA.07.02
FR.01.01, FR.07.01,
SA.02.01
SA.01.03
P 04
SA.07.03
P 07
P 07
SA.06.03
SA.07.02
P 15
P 06, P 07
FR.02.02, SA.01.01,
SA.09.03
P 04
P 07
FR.03.01
SA.07.02
SA.07.03
P 07
P 03
P 04, P 05
SA.06.02, P 08, P 09,
P 10
Goebel A.
Gorišek M.
Grabljevec K.
Groleger Sršen K.
Groß W.
Guentchev M.
Gulve A.
Guness N.
Hanu-Cernat D. E.
Hanu-Cernat L. M.
Hein R.
Hellwig D.
Hertel F.
Hughes J. H.
Hume I.
Husch A.
Hutson J. M.
Huygen F. J. P. M.
Huys D.
Ismail K. A.
Jackson R.
Johnson S.
Kaffafy
Kapur S.
Keller H.
King R.
Koch K. P.
Kolodziej M. Köster P.
Koulousakis A.
Koulousakis D.
Kretzschmar M.
Kuhn J.
Leitner B.
Lenartz D.
P 07
P 14
P 14
P 14
FR.02.03
SA.09.04
P 04, P 05
P 08
SA.01.01
SA.01.01
SA.09.01
SA.06.06
FR.04.01, SA.06.01,
SA.06.02, P 08, P 09
P 05
SA.09.03
SA.06.02, P 08, P 09
SA.09.02, P 03
SA.07.01
P 11
SA.09.02
SA.09.05
P 07
P 01
P 01
SA.08.01
P 04
SA.06.03, P 10
SA.06.06
P 11
SA.01.02, P 02, P 12
P 02
FR.02.03
P 11
SA.07.02
SA.01.02, P 11, P 12
61
Index of authors
Liem L.
Linderoth B.
MacIver K.
Majed D.
Mantese B. E.
Martini P.
Matgé G.
Mehrkens J. H.
Moissenet F.
Morubagal N.
Müller N.
Mutagi H. S.
Nurmikko T. J.
Osman-Farah J.
Peter L.
Peters F. T.
Preuss C.
Raphael J. H.
Rasche D.
Remane D.
Richter R.
Rink R.
Robinson V.
Rose S. Russo M. A.
Sawyer R. J.
Schenk M.
Schreiber C.
Schu S.
Seidel J.
Sharma M.
Siebel A. M.
Smet I.
Sourial M.
Southwell B. R.
62
SA.07.01
FR.01.02
P 06
SA.09.01
FR.05.01
SA.06.03, P 10
SA.07.03
SA.07.02
SA.07.03
P 01
SA.07.02
P 01
P 06, P 07
P 07
SA.09.04
FR.02.03
SA.09.04
FR.01.01, FR.02.02,
SA.01.01, SA.09.03
FR.02.01, P 13
FR.02.03
SA.02.01
SA.09.04
P 04
P 16
SA.07.01
FR.02.04
SA.06.03
SA.07.03
SA.02.02
FR.02.03
P 07
SA.02.01
SA.07.01
P 03
SA.09.02, P 03
Sparkes E.
Sturm V.
Tan A.
Thomson S.
Tronnier V. M.
Tüttenberg J.
van Buyten J. P.
Vesper J.
Vipavec B.
Visser-Vandewalle V.
Voepel H.
Voges J.
Wacnik P. W.
Weiss D.
West S.
Wille C.
Winkelmüller M.
Witt K.
Wocker E.-L.
Wohak K.
Yik Y. I.
SA.09.03
P 02
P 03
FR.01.03
FR.02.01, P 13
SA.09.04
SA.07.01
SA.02.02
P 14
P 11
SA.09.01
SA.06.05
SA.03.01
P 12
P 04, P 05
SA.04.02
SA.01.04
FR.07.02
SA.09.04
SA.02.03
SA.09.02
Imprint
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a Less Invasive Procedure
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percutaneouslya through a novel lead delivery system or placed with a small laminotomy procedure, providing
placement flexibility and extensive lead configuration options. Shielded to provide unidirectional stimulation,
S-Series leads deliver focused energy that results in greater system longevity.1,2 With this combination of efficiency
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a. When implanted using the Epiducer™ lead delivery system
1. North RB, Kidd DH, Olin JC, Sieracki JM. Spinal cord stimulation electrode design: prospective, randomized, controlled trial comparing percutaneous and laminectomy
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2. Manola L, Holsheimer J. Technical performance of percutaneous and laminectomy leads analyzed by modeling. Neuromodulation. 2004;7:231-241.
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Indications for Use: Chronic, intractable pain of the trunk and limbs. Contraindications: Demand-type cardiac pacemakers, patients who are unable to operate the system or who fail
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