American Society of Regional Anesthesia and Pain Medicine May 2017 - 31

a tonic or continuous manner. Neuronal languages are transmitted
as firing patterns and allow communication from spinal cord to
brain. To intervene effectively, a SCS device should speak the same
language.
Experimental data extracted from laboratory and clinical studies
suggest both bursting and tonically firing neurons efficiently
transmit information to thalamus.13,14 Laboratory animal studies
suggest that burst firing is more powerful than tonic firing in
activating the cerebral cortex.15 Results have been interpreted as
showing that burst activation requires less temporal integration
and may activate dormant neurons not otherwise activated by tonic
stimulation.16
HIGH-DENSITY STIMULATION
As HF platforms were being trialed abroad and reported in
the United States, American investigators began researching
additional capabilities of existing stimulation technology to assess
if frequencies in the upper ranges would benefit patients.17
Although most programming in the United States falls in the
20-120 Hz range, existing technology can increase the frequency
of then-available systems to >1000 Hz. This option enhanced
opportunities to deliver more charge per second to the spinal
cord, often in a subperception threshold amplitude, resulting in
a greater charge delivered per second than with conventional
stimulation. This is without the higher frequencies of 10K
stimulation or burst patterns described by DeRidder.7,8,17 Thus,
SCS pulses are the equivalent of a charge dose delivered to the
spinal cord, consistent with medication daily dose in intrathecal
drug delivery.18 Specifically, the dose would be consistent
with charge (dose) per second. As such, delivery of maximum
frequency achievable by a conventional SCS, with manipulation of
amplitude and pulse width as needed, would increase time within
any given second that charge (dose) is delivered. Compared to
conventional SCS, a higher density of charge delivered would be
created. This concept became known as "high-density SCS [or]
HD" stimulation.19
CONCLUSION
Evolution of waveform technologies has been impressive. Pain
specialists should stay informed of advances in neuromodulation
to help more patients and to enhance generalizability of therapy.
The ASRA Neuromodulation Special Interest Group (SIG) (link
to www.asra.com/neurosig) was founded in 2014 and is an
important resource for members interested in learning more about
this therapy. The goals of the ASRA Neuromodulation SIG are to
promote the advancement of neuromodulation in the treatment of
chronic pain, provide leadership in the responsible and safe use
of neuromodulation therapies, and encourage scholarship and
research to support neuromodulation strategies in a patient-centric
fashion.

REFERENCES
1.

Meyerson B, Linderoth B. Mode of action of spinal cord stimulation in
neuropathic pain. J Pain Symptom Manage. 2006;31(4 suppl):S6-S12.

2.

Manola, L, Holsheimer J, Veltink P. Technical performance of percutaneous leads
for spinal cord stimulation: a modeling study. Neuromodulation. 2005;8(2):88-99.

3.

Alò K, Varga C, Krames E, et al. Factors affecting impedance of percutaneous
leads in spinal cord stimulation. Neuromodulation. 2006;9(2):128-135.

4.

Washburn S, Catlin R, Bethel K, Canlas B. Patient-perceived differences
between constant current and constant voltage spinal cord stimulation systems.
Neuromodulation. 2014;17(1):28-35; discussion 35-36.

5.

Benyamin R, Grider JS, Vallejo R, Tilley D, Kaye AD. Spinal cord stimulation:
principles and applications. In: Principles of Neurophysiological Assessment,
Mapping and Monitoring. Kaye AD, Davis SF (eds.). New York: Springer
2014;245-258.

6.

Tiede J, Brown L, Gekht G, Vallejo R, Yearwood T, Morgan D. Novel spinal
cord stimulation parameters in patients with predominant back pain.
Neuromodulation. 2013;16:370-375.

7.

Van Buyten JP, Al-Kaisy A, Smet I, Palmisani S, Smith T. High-frequency spinal
cord stimulation for the treatment of chronic back pain patients: results
of a prospective multicenter European clinical study. Neuromodulation.
2013;16(1):59-65.

8.

Al Kaisy A, Van Buyten JP, Smet I, Palmisani S, Pang D, Smith T. Sustained
effectiveness of 10 kHz high-frequency spinal cord stimulation for patients with
chronic, low back pain: 24-month results of a prospective multicenter study.
Pain Med. 2014;15(3):347-354.

9.

Kapural L, Yu C, Gliner B, et al. Comparison of 10 kHz high-frequency and
traditional low frequency spinal cord stimulation for the treatment of chronic back
and leg pain: 24-month results from a multicentre randomized controlled pivotal
trial [Abstract 143]. Abstract presented at: North American Neuromodulation
Society 19th Annual Meeting, December 10-13, 2015, Las Vegas, NV.

10. Nevro Corp. Patient Manual Rev B, 11052. Redwood City, CA;2015.
11. Kapural L, Yu C, Doust MW, et al. Comparison of 10-kHz high-frequency and
traditional low-frequency spinal cord stimulation for the treatment of chronic
back and leg pain: 24-month results from a multicenter, randomized, controlled
pivotal trial. Neurosurgery. 2016;79(5):667-677.
12. de Vos CC, Bom MJ, Vanneste S, Lenders MW, de Ridder D. Burst spinal cord
stimulation evaluated in patients with failed back surgery syndrome and painful
diabetic neuropathy. Neuromodulation. 2014;17(2):152-159.
13. De Ridder D, Vanneste S, Plazier M, van der Loo E, Menovsky T. Burst spinal
cord stimulation: toward paresthesia-free pain suppression. Neurosurgery.
2010;66(5):986-990.
14. Oswald AM, Chacron MJ, Doiron B, Bastian J, Maier L. Parallel processing of
sensory input by bursts and isolated spikes. J Neurosci. 2004;24(18):4351-
4362.
15. Guido W, Sherman SM. Response latencies of cells in the cat's lateral
geniculate nucleus are less variable during burst than tonic firing. Vis Neurosci.
1998;15(2):231-237.
16. Swadlow HA, Gusev AG. The impact of 'bursting' thalamic impulses at a
neocortical synapse. Nat Neurosci. 2001;4(4):402-408.
17. Grider JS, Harned ME, Newcom BA, et al. High frequency [1000 Hz] stimulation
using a commercially available implantable pulse generator [Abstract]. Abstract
presented at: North American Neuromodulation Society 17th Annual Meeting,
December 5-8, 2013, Las Vegas, NV.
18. Sweet J, Badjatiya A, Tan D, Miller J. Paresthesia-free high-density spinal cord
stimulation for postlaminectomy syndrome in a prescreened population: A
prospective case series. Neuromodulation. 2016;19(3);260-267.

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Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2017
