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Spinal Cord Stimulator for treating Chronic pain

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  1. Spinal Cord Stimulator for treating Chronic pain BME525: Biomedical Materials and Artificial Organs Tara Gu, Sophia Kim, Phil Lin & Joyce Yu Duke University 1 Go to Abstract

  2. Title Page > Module Instructions > Executive Summary Click to start Click in the dark blue bar above to return to the slides you are interested in within each section. The words that are in white indicate the slides left in the section. You can click green buttons, underlined words, highlighted green graphics to navigate and learn more throughout the presentation. Red buttons indicate the end of the section. Enjoy. Click for previous slide Click for next slide Go to Main Menu Go to References Return to Sub Menu Next Section

  3. Title > Executive Summary > SCS Devices for Chronic intractable painspinal cord stimulators & intrathecal pumps Advanced stage chronic pain is an intractable affliction affecting 100 million people in the U.S. [2]. There are two therapies that manage advanced stage chronic pain: spinal cord stimulators (SCS) and intrathecal (IT) pumps. • IT Pump • Treats larger regions of chronic pain • Pain drugs delivered to cerebral spine fluid • BOTH • Reduce chronic lower limb or back pain • Trial periods offered • Easily adjustable doses and frequencies by the user • SCS • Treats localized regions of chronic pain • Electrical impulses delivered to dorsal column 1 3 4 This particular module covers spinal cord stimulators. To learn more about IT pumps, download the presentation on the Duke CBTE website. Go to Instructions Start SCS Module

  4. Title > Executive Summary > SCS Spinal cord stimulatorssynopsis Spinal cord stimulators (SCS) are used to treat chronic pain that arises from neuropathic pain, damage or disease that arises from the body’s sensory system. It consists of an electric pulse generator stored in the abdomen, connected to electrodes that stimulate the epidural space as shown in the picture. This method, however, is also controversial as it only has a 55% reported “success rate,” defined as 50% pain relief [6]. This module will review advanced chronic back physiology, investigate Boston Scientific’s SCS implant design and fabrication in-depth, and evaluate the clinical performance and socioeconomic impact of SCS. 5 Return to Executive Summary Go to Main Menu

  5. Executive Summary > SCS > Main Menu Main MenuSpinal cord nerve stimulation for relief of chronic intractable pain 7 Return to Executive Summary

  6. Executive Summary > SCS > Main Menu Main MenuSpinal cord nerve stimulation for relief of chronic intractable pain Return to Executive Summary Go Straight to Quiz

  7. Executive Summary > SCS > Main Menu Main MenuSpinal cord nerve stimulation for relief of chronic intractable pain Return to Executive Summary Go Straight to Quiz

  8. Executive Summary > SCS > Main Menu Main MenuSpinal cord nerve stimulation for relief of chronic intractable pain Return to Executive Summary Go Straight to Quiz

  9. Executive Summary > SCS > Main Menu Main MenuSpinal cord nerve stimulation for relief of chronic intractable pain Return to Executive Summary Go Straight to Quiz

  10. Executive Summary > SCS > Main Menu Main MenuSpinal cord nerve stimulation for relief of chronic intractable pain Return to Executive Summary Go Straight to Quiz

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  12. Correct!

  13. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry Spinal cord stimulation Overview Click to go to slide of interest.Why are SCS important? What does SCS do? What is SCS? How does the therapy work? Watch a video on SCS therapy. Learn about the underlying mechanism of therapy. Learn about neurochemistry behind therapy. Return to Sub Menu Next Slide in Section

  14. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry WHY scs?Because they can reduce chronic BACK pain dramatically • Spinal cord stimulators (SCS) play a key role in pain relief and is important, considering the following: • Back pain’s the leading cause of disability for those under 45 • Cost of back pain in lost productivity and decreased wages is estimated to be between $100-200 billion in 2009 • 8 in 10 Americans will experience back pain in their lifetime • Back pain affects 31 million people (10% of US population) daily 8 Return to Chapter Overview Next Slide in Section

  15. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry What Does SCS DO?Relieve chronic intractable pain Return to Chapter Overview Next Slide in Section Sources: http://www.mayfieldclinic.com/PE-PUMP.htm

  16. Main Menu > Sub-section > Why > What > SCS > How > Spinal Neurochemistry What is scs?Spinal cord nerve stimulation for relief of chronic intractable pain Spinal cord stimulators (SCS) are a type of pain therapy before resorting to complex spine surgery.2 The leads are connected to the IPG and have multiple contact regions to spread the electrical stimulus and relieve pain [9]. The implanted pulse generator (IPG) produces electrical currents to the spinal cord’s dorsal column [9]. 10 Return to Chapter Overview Next Slide in Section Sources: http://www.mayfieldclinic.com/PE-PUMP.htm

  17. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry HOW does SCS WORK?By stimulating the spinal cord to block release of pain neurotransmitters • Activate large Aβ afferent neurons. • Block transmission of pain to the spinothalamictrack [2]. Click here to learn more on the Gate Theory. • Enhance pain inhibition in the supraspinal region via serotonin • Activate GABA, SP, and Ach [11]. Click here to learn more on spinal neurochemistry. • Reduce vasoconstriction and increase vasodilation, which increases blood flow and increases oxygen and nutrient availability to muscles [11]. Watch a video on how SCS works! Return to Chapter Overview Next Slide in Section Sources: http://www.mayfieldclinic.com/PE-PUMP.htm

  18. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry 12 To watch on an internet browser, click here. Return to Chapter Overview Next Slide in Section

  19. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry Blocking Pain via the gate CONTROL theory The Gate Control Theory is the primary concept behind SCS pain relief. Below illustrates a simplified version of the nerves involved in the pain transmission process [3]. Click the PAIN or PARASTHESIA buttons to learn more. PAIN C FIBER GATE Inhibitory Interneuron PROJECTION NEURON Aβ FIBERS 3 PARASTHESIA (pain relief) Return to Chapter Overview Next Slide in Section

  20. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry Blocking Pain via the gate CONTROL theory Pain Signal A pain signal to the small diameter C fibers will inhibit the inhibitory interneurons leaving the GATE open. This allows the pain signal to transmit to the projection neuron and thus to the nerve center of the body where pain is felt [3]. PAIN C FIBER GATE Inhibitory Interneuron PROJECTION NEURON Aβ FIBERS 3 PARASTHESIA (pain relief) Return to Previous Selection Next Slide in Section

  21. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry Blocking Pain via the gate CONTROL theory SCS stimulates large diameter AαAβ fibers which excites the Inhibitory Interneurons to close the GATE. This blocks any pain transmission to the projection neuron [3]. PAIN C FIBER GATE Inhibitory Interneuron PROJECTION NEURON Aβ FIBERS 3 PARASTHESIA (pain relief) SCS Return to Previous Selection Next Slide in Section

  22. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry large nerve fiber stimulation To ensure pain inhibition SCS stimulate peripheral nerve fibers like C and Aβ fibers. The implant specifically sends electrical pulses to large diameter Aβ fibers not small diameter C fibers in order to block transmission of pain to the brain. Large diameter nerves require lower thresholds of electrical pulses and have higher conduction velocities than small diameter nerves [13]. Peripheral nerves 14 Cfibers Aβ fibers Return to Chapter Overview Next Slide in Section

  23. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry Spinal neurochemistrythere are 2 main neurotransmitter pathways involved in how scs works Small-molecule TP is one general neurotransmitter pathway. ..… 15 Return to Chapter Overview Next Slide in Section

  24. Main Menu > Sub-section > Why > What > SCS > How > Video > Gate Theory > Spinal Neurochemistry Spinal neurochemistrythere are 2 main neurotransmitter pathways involved in how scs works Peptide TP is another general neurotransmitter pathway. ..… ..… 15 Return to Chapter Overview Quiz

  25. Quiz How many Americans experience back pain? 1 in 10 5 in 10 8 in 10 What does SCS do? Treat people with nociceptive pain. Treat people with neuropathic pain. Increase tolerance to pain medications. What is SCS? Delivery of drugs to spinal cord. Electrical stimulation of spinal cord. Excites the inhibitory interneurons to open the gate. Which of the following is not a neurotransmitter pathway? Small-molecule TP. Peptide TP. DNA TP. Return to Sub Menu Answers

  26. Quiz How many Americans experience back pain? 1 in 10 5 in 10 8 in 10 What does SCS do? Treat people with nociceptive pain. Treat people with neuropathic pain. Increase tolerance to pain medications. What is SCS? Delivery of drugs to spinal cord. Electrical stimulation of spinal cord. Excites the inhibitory interneurons to open the gate. Which of the following is not a neurotransmitter pathway? Small-molecule TP. Peptide TP. DNA TP. Return to Sub Menu Next Section on SCS History

  27. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 historical milestones Overview on scs Click to go to slide of interest.Overall Timeline 1840 1965 1967 1994 2010 2011 Return to Sub Menu Next Slide in Section

  28. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 1967 2010 Milestones related to spinal cord stimulation 1965 1840 2011 1994 Return to Chapter Overview Next Slide in Section

  29. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 1967 2010 Milestones related to spinal cord stimulation 1965 1840 2011 • Moritz-Heinrich Romberg introduced galvanopuncture. Ancient Chinese used needle punctures with electricity [16]. 17 1994 Return to Chapter Overview Next Slide in Section

  30. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 • Melzack and Wall discovered the gate control theory [18]. 1967 2010 Milestones related to spinal cord stimulation 1965 19 1840 2011 1994 Return to Chapter Overview Next Slide in Section

  31. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 21 1967 2010 • Wall and Sweet’s patients experienced pain relief after square-wave stimulation [20]. Milestones related to spinal cord stimulation 1965 1840 2011 1994 Return to Chapter Overview Next Slide in Section

  32. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 1967 2010 Milestones related to spinal cord stimulation 1965 1840 2011 • Chandler et al. proved that spinothalamic tract neurons can be inhibited by dorsal column stimulation [22]. 1994 22 Return to Chapter Overview Next Slide in Section

  33. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 • Boston Scientific’s Precision PlusTM SCS System was approved [23]. 1967 2010 1 Milestones related to spinal cord stimulation 1965 1840 2011 1994 Return to Chapter Overview Next Slide in Section

  34. Main Menu > Sub-section > Milestones > 1 > 2 > 3 > 4 > 5 > 6 1967 2010 Milestones related to spinal cord stimulation 1965 1840 2011 1 • Boston Scientific’s Infinion 16 Percutaneous Lead is discovered[24]. 1994 Return to Chapter Overview Quiz

  35. Quiz What happened in 1840? Square wave stimulation was invented. Medtronic created its first IT pump. The Chinese introduced galvanopuncture. What happened in 1967? Melzack discovered gate theory. Square wave stimulation was invented. Spinal cord stimulation was invented. What happened in 2010? Boston Scientific’s new leads were made. Boston Scientific’s new SCS implant was approved. Boston Scientific’s new atrel implant was made. Return to Sub Menu Answers

  36. Quiz What happened in 1840? Square wave stimulation was invented. Medtronic created its first IT pump. The Chinese introduced galvanopuncture. What happened in 1967? Melzack discovered gate theory. Square wave stimulation was invented. Spinal cord stimulation was invented. What happened in 2010? Boston Scientific’s new leads were made. Boston Scientific’s new SCS implant was approved. Boston Scientific’s new atrel implant was made. Return to Sub Menu Next Section on Implants

  37. Main Menu > Sub-section > Implants Menu > Renew > Itrel > Eon Mini > Precision Plus Current implantsoverview Return to Sub Menu Next Slide in Section Sources: Elliot S. Krames, P. Hunter Peckham, Ali R. Rezai, ed. Neuromodulation. London: Elsevier, 2009.

  38. Main Menu > Sub-section > Implants Menu > Renew > Itrel > Eon Mini > Precision Plus renewCurrent Implants for scs Differentiating Factors Radio-coupled system Implanted receiver External transmitter with antennae interface Made by Advanced Neuromodulation Systems in Plano, Texas 25 25 Return to Selection Next Slide in Section Sources: Elliot S. Krames, P. Hunter Peckham, Ali R. Rezai, ed. Neuromodulation. London: Elsevier, 2009.

  39. Main Menu > Sub-section > Implants Menu > Renew > Itrel > Eon Mini > Precision Plus Itrel-3Current Implants for scs Differentiating Factors Totally implanted neuropulse generator Provide pulses to implanted electrodes in the epidural space Non-rechargeable Accommodates 1 extension and 1 program of stimulation Made by Medtronic in Minneapolis, Minnesota 26 26 Return to Selection Next Slide in Section Sources: Elliot S. Krames, P. Hunter Peckham, Ali R. Rezai, ed. Neuromodulation. London: Elsevier, 2009.

  40. Main Menu > Sub-section > Implants Menu > Renew > Itrel> Eon Mini > Precision Plus Eon miniCurrent Implants for scs Differentiating Factors 16 contact header Constant, consistent current stimulation Rechargeable Seamless control of 8 pain regions Made by St. Jude Medical 26 26 Return to Selection Next Slide in Section Sources: Elliot S. Krames, P. Hunter Peckham, Ali R. Rezai, ed. Neuromodulation. London: Elsevier, 2009.

  41. Main Menu > Sub-section > Implants Menu > Renew > Itrel> Eon Mini > Precision Plus Precison plusCurrent Implants for scs Learn more about design Differentiating Factors Personalized neurostimulation system Totally implanted pulse generator Special 16 contact percutaneous lead External remote control to adjust frequency, amplitude, etc. Made by Boston Scientific in Natick, Massachusetts 1 27 Return to Selection Next Section on Disease State Sources: Elliot S. Krames, P. Hunter Peckham, Ali R. Rezai, ed. Neuromodulation. London: Elsevier, 2009.

  42. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis disease state overview Click to go to slide of interest.Start Neuropathic Pain Overview Statistics on Neuropathic Pain Statistics on Lower Back Pain Mechanism of Lower Back Pain Lower Back Anatomy Important Questions for Diagnosis The Faber Test Other Means of Diagnosis Return to Sub Menu Next Slide in Section

  43. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis Disease stateoverview of neuropathic pain Neuropathic pain arises from a disease or lesion from the somatosensory system. The hallmark of neuropathic pain is abnormal neural activity in peripheral nerve(s) or the central nervous system [28]. Most common examples shown below[ 29]: Lower Back Pain ~635 million Diabetic Polyneuropathies ~610 million Postherpetic Neuralgia ~500 million 30 31 32 Return to Chapter Overview Next Slide in Section

  44. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis lower back painOverview Click on the numbers below to learn more about the extent of those affected by the disease in the US. 80 300,000 41 26 3rd 38 to 50 billion Return to Chapter Overview Continue to Mechanism

  45. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis lower back painOverview Click on the numbers below to learn more about the extent of those affected by the disease in the US. 80 300,000 Over a lifetime of % people have lower back pain [8]. 41 26 3rd 38 to 50 billion Return to Chapter Overview Continue to Mechanism

  46. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis lower back painOverview Click on the numbers below to learn more about the extent of those affected by the disease in the US. 80 300,000 41 Back operations are the most common form of surgery in the United States [8]. 26 3rd 38 to 50 billion Return to Chapter Overview Continue to Mechanism

  47. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis lower back painOverview Click on the numbers below to learn more about the extent of those affected by the disease in the US. 80 300,000 41 26 3rd In the United States, estimates of the costs of low back pain range between dollars a year [8]. 38 to 50 billion Return to Chapter Overview Continue to Mechanism

  48. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis lower back painOverview Click on the numbers below to learn more about the extent of those affected by the disease in the US. 80 300,000 41 % of adults aged between 26 and 44 years reported having back pain in the previous 6 months [8]. 26 3rd 38 to 50 billion Return to Chapter Overview Continue to Mechanism

  49. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis lower back painOverview Click on the numbers below to learn more about the extent of those affected by the disease in the US. 80 300,000 41 26 3rd % of American adults reports pain of at least one day in duration every three months [8]. 38 to 50 billion Return to Chapter Overview Continue to Mechanism

  50. Main Menu > Sub-section > Overview > Statistics > Lower Back Pain > Diagnosis lower back painOverview Click on the numbers below to learn more about the extent of those affected by the disease in the US. 80 300,000 There are lower back pain operations annually [8]. 41 26 3rd 38 to 50 billion Return to Chapter Overview Continue to Mechanism