WO2001000274A1 - Spinal cord stimulation as a treatment for addiction to nicotine and other chemical substances - Google Patents
Spinal cord stimulation as a treatment for addiction to nicotine and other chemical substances Download PDFInfo
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- WO2001000274A1 WO2001000274A1 PCT/US2000/017331 US0017331W WO0100274A1 WO 2001000274 A1 WO2001000274 A1 WO 2001000274A1 US 0017331 W US0017331 W US 0017331W WO 0100274 A1 WO0100274 A1 WO 0100274A1
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- lead
- leads
- spinal cord
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- implanted
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
- A61N1/00—Electrotherapy; Circuits therefor
- A61N1/18—Applying electric currents by contact electrodes
- A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
- A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
- A61N1/372—Arrangements in connection with the implantation of stimulators
- A61N1/378—Electrical supply
- A61N1/3787—Electrical supply from an external energy source
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
- A61N1/00—Electrotherapy; Circuits therefor
- A61N1/18—Applying electric currents by contact electrodes
- A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
- A61N1/00—Electrotherapy; Circuits therefor
- A61N1/18—Applying electric currents by contact electrodes
- A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
- A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
- A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
- A61N1/3606—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for a particular treatment
- A61N1/36071—Pain
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
- A61N1/00—Electrotherapy; Circuits therefor
- A61N1/18—Applying electric currents by contact electrodes
- A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
- A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
- A61N1/3605—Implantable neurostimulators for stimulating central or peripheral nerve system
- A61N1/3606—Implantable neurostimulators for stimulating central or peripheral nerve system adapted for a particular treatment
- A61N1/36082—Cognitive or psychiatric applications, e.g. dementia or Alzheimer's disease
- A61N1/36089—Addiction or withdrawal from substance abuse such as alcohol or drugs
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61N—ELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
- A61N1/00—Electrotherapy; Circuits therefor
- A61N1/18—Applying electric currents by contact electrodes
- A61N1/32—Applying electric currents by contact electrodes alternating or intermittent currents
- A61N1/36—Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
- A61N1/36014—External stimulators, e.g. with patch electrodes
- A61N1/36017—External stimulators, e.g. with patch electrodes with leads or electrodes penetrating the skin
Definitions
- the present invention relates to a new method for suppressing chemical substance craving comprising electrical stimulation of the spinal cord using one or more implantable leads containing at least two conducting electrodes.
- the method may be used to suppress craving for alcohol, narcotics, cocaine and amphetamines.
- the method is particularly suited to the suppression of nicotine craving.
- Tobacco related deaths are the largest single cause of premature death in developed countries. More than 400,000 deaths per year are linked to smoking related illness in the U.S. alone. However, despite the well publicized risks and consequences associated with tobacco use, more than 25% of adults in the United States continue to smoke with prevalence rates varying according to demographics.
- Non-pharmacologic interventions focus on altering the behavioral conditioning of smokers so that smoking is avoided or is a disfavored activity.
- Pharmacologic interventions are geared toward lessening the craving for nicotine and are divided into the current mainstay, nicotine replacement therapy (the only pharmacologic therapy with FDA approval) and other forms of drug therapy.
- the patented pharmacologic therapies employ transdermal azapirones (U.S. Pat. Nos. 5,837,280; 5,817,679; 5,633,009), nicotine receptor agonists and antagonists (U.S. Pat. Nos. 5,817,331; 5,691 ,365), nicotine lozenge (U.S. Pat. Nos. 5,662,920; 5,549,906), cotinine (U.S. Pat. No.
- the present invention relates to a method for treating addiction to nicotine and other chemical substances comprising electrical stimulation of the spinal cord or nervous system of the patient using one or more commercially available implantable spinal cord stimulation leads for a time period sufficient to suppress or extinguish the nicotine craving of the patient.
- the inventive method may be used either alone or in combination with drug or behavioral therapies.
- the effectiveness of the inventive method is believed to be related to the presence of nicotine receptors in the spinal cord which can be activated by spinal cord stimulation.
- Receptor and receptor systems, nerve and nerve endings of varying size, and neurotransmitters are distributed at all levels in the spinal cord.
- nicotine receptors are found in the central nervous system (brain and spinal cord) and analgesia is produced by nicotine both systemically and in the spinal cord.
- Potential mechanisms proposed for the production of analgesia by spinal cord stimulation suggest that stimulation of the dorsal horn of the spinal cord activates endogenous inhibitory systems which can modulate or block the sensation of pain.
- inhibitory systems include, but are not limited to, endorphin and enkephalin systems (opiate systems), serotonergic, adenosingergic, adrenergic, dopinamergic and finally cholinergic systems. Nicotine receptors are found within the cholinergic system. Stimulation of the cholinergic (inhibitory) systems in the spinal cord produces antinociception (pain relief). Therefore, stimulation of the cholinergic and thereby the nicotinic system in the spinal cord should also mimic the presence of nicotine by activating the nicotinic receptors, but by a non- pharmacologic method. Thus, stimulation of the nicotinic system should mimic nicotine both systemically and locally in the central nervous system. As a net result of this stimulation, a patient treated with spinal cord stimulation should experience decreased craving for nicotine and an ability to interrupt behavioral components thereby allowing the patient to overcome the addiction.
- the inventive method uses one or more implantable leads which are comprised of a plurality of conducting electrodes adapted for accurate placement within the human body, in particular the area of the spinal cord or nervous system to be stimulated.
- implantable leads which are comprised of a plurality of conducting electrodes adapted for accurate placement within the human body, in particular the area of the spinal cord or nervous system to be stimulated.
- Various devices for spinal cord stimulation used in chronic pain management and movement disorders are disclosed in United States patent numbers 3,654,933, 4,044,77, 4,379,462, 5,058,584, 5,417,719, 5,501 ,703 and 5,643,330 which are all herein incorporated by reference in their entirety.
- the method described is also applicable to the treatment of addiction to alcohol, narcotics, cocaine, amphetamines and other chemical substances since receptor systems (e.g. opiate receptors for narcotics) specific for these substances are also found in the spinal cord.
- the suitability of the inventive method for a particular patient is determined by first screening the patient using various psychological criteria to determine if he is a suitable candidate for the procedure. If the patient passes the screening procedure, a trial implantation and stimulation is carried out. The results of the trial are then evaluated. If the patient demonstrates successful suppression or extinction of nicotine craving as a result of the implantation and stimulation, the lead or leads are then permanently implanted in the patient.
- Figures 1a, 1b and 1c illustrate a 4-electrode, an 8-electrode percutaneous lead and a surgically implanted lead respectively suitable for use in the inventive method.
- Figure 2 illustrates schematically the spinal cord stimulation system used in the inventive method.
- Figures 3a and 3b illustrate a side view of lead placement in the inventive method and an anterior posterior view of lead placement in the inventive method respectively.
- Figure 4a illustrates a single lead in a midline thoracic placement according to the inventive method.
- Figure 4b illustrates the placement of a multiple electrode array system in a thoracic placement according to the inventive method.
- Figure 5 illustrates a permanent implantation of the spinal cord stimulation system used according to the inventive method.
- the basic elements needed for the method and application of spinal cord stimulation for suppression of chemical substance craving, in particular, nicotine, comprise a spinal cord stimulator lead and a power source connected to the lead to enable conduction of electrical impulses to the spinal cord.
- the spinal cord stimulator lead contains external contact electrodes at the distal tip which send impulses into the spinal cord. These distal contact electrodes are independently connected to corresponding contact terminals at the proximal end of the lead by separate stranded wires which run substantially parallel to each other.
- the proximal conductive terminals are in turn connected to an electrical power source through a lead extension connector which makes individual contact with the proximal lead terminals and allows transmission of electrical signals from the power source to the distal lead electrodes.
- the generator or electrical source provides electrical stimulation and allows for the selective and independent variation of characteristics of the electrical power including amplitude, frequency rate (heretofore referred to as "rate") and pulse width, as well as variation in the polarity of the conducting electrode contacts within the lead (any number of lead contacts from four to eight to sixteen in current technology).
- the lead extension connector may be omitted and the electrical power source connected directly to the proximal conductive terminals.
- the amplitude of the electrical power may be varied between about zero volts to about fifteen volts and is chosen to be as high as can be tolerated by the patient so as to achieve maximum stimulation.
- the voltage is varied between about 0.1 volts to about eight volts.
- the voltage is varied between about zero volts to about six volts and most preferably, the voltage is varied between about zero to about four volts.
- the pulse width of the electrical power may also be varied at the same time as one or more of the characteristics of the electrical power or may be separately varied with the other characteristics held constant. Preferably, the pulse width is varied between about zero to about 450 microseconds. More preferably, the pulse width is varied between about 180 to about 270 microseconds and most preferably, the pulse width is varied between about 240 to about 270 microseconds.
- the rate of the electrical power may also be varied at the same time as one or more of the characteristics of the electrical power or may be separately varied with the other characteristics held constant. Preferably, the rate is varied between about zero to about 150 cps. More preferably, the rate is varied between about 25 to about 80 cps and most preferably, the rate is varied between about 50 to about 80 cps.
- the number of leads implanted ranges from one lead to ten leads. Preferably, the number of leads implanted ranges from one lead to four leads. More preferably, the number of leads implanted ranges from one lead to two leads. Most preferably, the number of leads implanted is two.
- the lead or leads are inserted into the epidural space of the spinal cord and contact the external portion of the dura to stimulate the neural structures underneath.
- the lead or leads may be inserted into the sacral, caudal, lumbar, thoracic or cervical spines.
- the position of the implanted lead or leads ranges from the sacral position to the high cervical position of the spinal cord.
- the lead or leads are implanted from the upper lumbar to the lower cervical position in the spinal cord. More preferably, the lead or leads are implanted from the lower thoracic to the higher thoracic position of the spinal cord.
- the lead or leads are implanted from the lower thoracic to the middle thoracic position in the spinal cord.
- the lead or leads are positioned so that the lead or leads are parallel to the midline of the spinal cord and may be positioned to the right of the midline, directly on the midline or to the left of the midline.
- the lead or leads may also be placed oblique or transverse to the midline. If more than one lead is implanted, the leads may be positioned both to the right and left of the midline of the spinal cord.
- All lead contacts and conductors are electrically insulated by a suitable insulating material which is safe for implantation in the human body.
- the distal contact electrodes may have variable contact surface area as well as variable spacing between electrodes.
- the number of electrodes may be varied as well. Current technology allows a total of 16 electrodes to receive electrical transmission from a single energy source. For example, four quadripolar (four electrode) leads may be connected to a single power source or two eight electrode leads may be connected to a single power source.
- the number of electrodes per lead ranges from between at least two to sixteen electrodes per lead. Preferably, the number of electrodes per lead ranges from between four to eight per lead. Most preferably, the number of electrodes per lead is four. If multiple leads are implanted, the number of electrodes per lead may be the same or different.
- Electrode polarity refers to activation of lead electrodes by assigning positive or negative charge to the electrode.
- Polarity can include as few as two electrodes per lead (one positive, one negative) on up to as many electrodes as are contained on the lead (with at least one electrode positive and at least one electrode negative).
- Systematic electrode polarity assignments are made during trial stimulation beginning with the second and third most distal electrodes (in a four electrode system) as postive and negative respectively. Additional electrodes are added or substituted to improve coverage area and maximize stimulation.
- the lead or leads are positioned so that optimum stimulation occurs without using the most distal/proximal electrodes which allows these electrodes to be used in the event of lead migration (i.e., these electrodes can be activated if the lead moves up or down the spine respectively).
- Variation in the polarity of the electrodes is achieved by activating at least two electrodes per lead up to the maximum number of electrodes contained on the lead.
- the number of electrodes activated per lead ranges from at least two up to eight electrodes per lead. More preferably, the number of electrodes activated per lead ranges from at least two up to four electrodes per lead. Most preferably, three electrodes are activated per lead.
- Lead electrode systems may be percutaneous as described in U.S. Patent No. 4,004,774 or wider (paddle) systems may be inserted surgically through a laminotomy or laminectomy incision as described in U.S. Patent Nos. 3,822,708, and 3,654,933 which are hereby incorporated by reference in their entirety. If multiple leads are implanted, they may be inserted at the same or different levels and used for more complete stimulation coverage.
- totally external power systems include those systems which are used for temporary trial stimulation.
- Internally implanted systems include totally implanted generators or can include implanted receivers which are internalized but which receive input from an external power source transmitted through antennae.
- the external systems are radiofrequency power sources which may be used for patients with higher energy requirements.
- Figure 1 illustrates three different leads, a four-electrode percutaneous lead 50 (Fig. 1a), an eight-electrode percutaneous lead 60 (Fig. 1b) and a surgically implanted lead 70 (Fig. 1c).
- Four-electrode lead 50 comprises an insulated tube with a distal end 50a and a proximal end 50b with four external conducting electrodes at the distal end 50a as previously described.
- a first external conducting electrode 1 is positioned most distal on the lead (closest to the distal tip).
- a second external conducting electrode 2 is positioned a given distance proximally from external conducting electrode 1.
- a third conducting electrode 3 and a fourth conducting electrode 4 are respectively spaced at given distances proximal to electrode 2.
- the eight electrode lead 60 comprises a distal end 60a and a proximal end 60b.
- the lead 60 further comprises external conducting electrodes 1', 2', 3', 4' at the distal end 60a as described for lead 50 above and additionally comprises a fifth conducting electrode 5', a sixth conducting electrode 6', a seventh conducting electrode 7' and an eighth conducting electrode 8' as illustrated in Figure 1b.
- the lead comprises a distal end 70a and a proximal end 70b.
- the lead 70 illustrated in Figure 1c further comprises disc-shaped external conducting electrodes 1", 2", 3" and 4" at the distal end 70a. These electrodes are of greater size and have a larger conduction surface than the comparable structures in the percutaneous leads depicted in Figures 1a and 1b.
- the proximal end 50b of lead 50 comprises tube-conducting terminal connections, 9, 10, 11 and 12 which are connected by individually stranded wire running substantially parallel but separately. 9, 10, 11 and 12 extend to and are in contact with external conducting electrodes 1, 2, 3 and 4 respectively.
- the proximal end 60b of lead 60 comprises tube-conducting terminal connections 9', 10', 11', 12' and additionally comprises tube- conducting connecting terminal connections 13', 14', 15' and 16' which are connected by individual separate stranded wires to external conducting electrodes 1', 2', 3', 4', 5', 6', 7' and 8' respectively.
- the proximal end 70b of surgical lead 70 comprises tube conducting terminal connections 5", 6", 7" and 8" which are connected by individual separate stranded wires to external conducting electrodes 1", 2", 3" and 4" respectively.
- An insulating material 17 is interposed between each of the conductors on all three leads 50, 60 and 70 and exists throughout the lead.
- FIG. 2 illustrates in schematic the basic elements of the spinal cord stimulation system.
- Lead 50 comprises distal end 50a and proximal end 50b.
- Lead extension connector 19 is comprised of a distal end 19a and a proximal end 19b.
- Lead extension connector 19 is fitted to the proximal end 50b of lead 50 through the distal end 19a of the lead extension connector 19. This connection is made with tube conducting terminal connections 9, 10, 11 and 12 at the proximal end 50b of lead 50 fitting inside and surrounded by corresponding circular terminal connections 19c, 19d, 19e, and 19f on the distal extension connector.
- Distal extension connector terminals 19c, 19d, 19e and 19f contain tightening screws which are fastened using an alien wrench tool provided by the manufacturer.
- terminal connections 19c, 19d, 19e and 19f connects to the corresponding tube conducting terminal connections of the proximal lead 9, 10, 11 and 12 and each in turn corresponds to a distal external conducting electrode 1, 2, 3 and 4 in the distal lead.
- terminal connection 19c is connected to tube conducting terminal connection 9 which is in turn connected to distal external conducting electrode 1.
- the proximal end 19b of the lead extension connector 19 terminates in prong connectors 19g and 19h which fit into the source of energy transmission 20 (in this case an internal power source generator such as Medtronic 7425 Itrel 3).
- Prong connectors 19g and 19h fit snugly into receptacle outlets 20a and 20b within the energy source.
- Prong connectors 19g and 19h are tightened with two external screws per prong connector or energy source receptacles using an alien wrench tool provided by the manufacturer.
- a totally implantable internalized generator 20 is shown in Figure 2.
- An energy system with internalized receiver 21 which has input for the proximal 5 end of the lead extension similar to 19b is also illustrated.
- energy is transmitted through an externally placed antenna 22 with impulses transmitted through the skin of the patient to the receiver 21.
- the energy source is an external transmitter 23
- electrical impulses are transmitted from 23 Q through the antenna 22 through the skin to the internalized receiver 21 through the lead extension connector 19 to the spinal cord stimulator lead proximal end 50b and finally to the distal end 50a where stimulation is transmitted to the spinal cord.
- Implanted receiver 21 is inserted into and enclosed by the human body in identical fashion as the implanted generator 20 (assuming compatible 5 component lead or leads and lead extension connector(s)).
- compatible proximal lead extension connector 19b is inserted into receiver 21 which is implanted under the skin.
- the connection is made by inserting compatible prong connectors 19g and 19h into compatible inlets 21a 0 and 21b respectively.
- Antenna 22 is then placed on the skin externally, overlying the implanted receiver 21 and is connected to the external generator 23.
- the connection is made by inserting compatible antenna prong connectors 22a and 22b into external generator inlets 23a and 23b respectively.
- radiofrequency energy is transmitted from external generator 23 through the antenna 22 into the internalized receiver 21. Radiofrequency signals are converted to electrical energy and transmitted through compatible lead extension connector 19 into the lead 50 which stimulates the neural structures underneath.
- the first decision is whether to place a percutaneous or surgical lead for trial and/or permanent implantation.
- Percutaneous leads are advantageous in that they are less invasive to place, but they tend to cover a smaller area of stimulation and are more likely to migrate. These problems can be overcome with the placement of multiple lead systems with more electrodes for stimulation as well as dual channel systems which provide versatility in programming or with surgical leads for permanent implantation.
- the second decision which must be made is whether to use an internal or an external power source. Internal power sources are less cumbersome to the patient, but are more likely to need replacement for battery life at high output and are not currently capable of providing dual or multichannel stimulation.
- the third decision involves the appropriate selection of the number of leads placed and the number of electrodes per lead. As mentioned, multiple leads with multiple channels and multiple electrodes can overcome problems with coverage area and migration and can enable transverse stimulation with dual channel systems. Finally, single or multichannel systems must be chosen. Any system may be a viable option to provide stimulation for smoking cessation, with some possible advantages with certain systems (see preferred embodiment).
- the appropriateness of the therapy must be determined for each patient. This determination includes the patient presenting with a history of smoking refractory to other methods (i.e. prior relapse following attempted cessation).
- a psychological interview (similar to those conducted for pain management by spinal cord stimulation) is also necessary to evaluate the patient's psychological status and to prepare them for the implantation of foreign material.
- the interview should include the administration of an MMPI (Minnesota Multiphasic Psychological Inventory) which measures ten scales including hypochondriasis, depression, conversion/hysteria, psychopathic deviate, masculinity, masculinity, strignoia, psychastenia, schizophrenia, hypomania, and social introversion.
- MMPI Minnesota Multiphasic Psychological Inventory
- the MMPI also includes validity scales which test for consistency in answering.
- the MMPI is the gold standard of psychological tests and is the most frequently used test for patient screening prior to spinal cord stimulation.
- the 90-R symptom checklist is a fast and easy test measuring somatization, depression, anxiety, anger, and paranoia.
- the Beck Depression Inventory, Spielburg State Trait Anxiety Inventory, Chronic Illness Problem Inventory and Oswestry Disability Questionnaire may also be used in addition to the psychological interview.
- the patient will first undergo a screening trial of spinal cord stimulation to determine if the patient is a suitable candidate for this procedure.
- the screening trial comprises percutaneous placement through an epidurai needle of a temporary trial lead into the epidural space overlying the dura and spinal cord.
- Trial screening may also be performed through surgical incision but this method of placement is an overly extensive procedure in the event of a failed trial.
- the screening trial may also include the implantation of multiple leads with multiple electrodes. Leads may be placed along the spinal cord axis (parallel to the spinal cord), oblique to the spinal cord axis, or transverse to the spinal cord axis according to methods well know in the art of pain management.
- the patient is first taken into the operating room and placed prone on the operating room table. Using fluoroscopic guidance, the spinal levels are identified. The patient is prepped and draped in sterile fashion. The needle is inserted percutaneously into the epidural space using fluoroscopic guidance as well as the loss of resistance technique or whatever method was previously used for epidural needle placement. The spinal cord stimulator lead is passed under fluoroscopic guidance into the epidural space overlying the spinal cord until the desired position is achieved.
- Figure 3a illustrates epidural needle 24 inserted between spinous processes 25 and passing through ligamentum flavum 26 into the epidural space 27.
- the distal position of the lead in the cord is identified as 28.
- the distal lead electrodes overlie the dura 29 and the spinal cord 30.
- the needle passes through skin 31.
- Figure 3a illustrates the lead placement in the side or sagittal view.
- the anterior posterior view in Figure 3b illustrates the epidural needle placed at the midline 24b or in paramedian fashion 24b'.
- Figure 4a illustrates a lead 50 placed at the midline of the spinal cord with the tip at the level of the eighth thoracic vertebral level T8.
- two eight-electrode leads 60 and 60' are both placed in the spinal cord with lead 60 passed the eighth thoracic vertebral level T8 and 60' passed the ninth thoracic vertebral level T9.
- This configuration could also be achieved with 2 four electrode leads or a combination.
- Leads 60 and 60' may be connected to the same or separate power sources and receive identical or individual programs from the same or different power sources.
- the two eight-electrode leads 60 and 60' placed in the spinal cord represent an example of a multi- electrode array system.
- the trial lead or leads are connected to an external generator power source via a lead extension connector 19 which is disposable.
- Variations in amplitude are administered from 0 to 15 volts, variations in pulse width from 0-450 ⁇ s, variations in rate from 0-150 cps (Hz) and variations in electrode polarity (i.e. positive/negative polarity in the first, second, third, fourth, fifth, sixth, seventh, etc., conducting electrodes).
- the stimulation trial begins with basic settings in polarity with the second most distal lead negative and the third most distal lead positive with a rate of 80 and a pulse width of 270.
- the amplitude is slowly increased from 0 volts until stimulation is detected by the patient. Amplitude requirements are highly variable and depend on both the position of the lead or leads and the contact quality.
- Stimulation is detectable when the patient experiences tingling in areas of skin in the back and lower extremities in the case of a thoracic or lumbar spinal cord stimulation, in the areas of skin in the abdomen and chest wall with upper thoracic stimulation or in the areas of skin in the upper extremity and upper chest wall in the case of cervical spinal stimulation.
- the sensory feeling of tingling is preferable over the motor feeling of pulling or muscle twitching.
- Dorsal placement may also be verified fluoroscopically.
- the lead may be superficially fastened to the skin (e.g., with a single suture and sterile barrier dressing) for easy removal at the end of the trial.
- the lead may be partially internalized.
- the latter procedure involves extending the needle puncture site into a small incision, anchoring the lead to the spinous ligaments with suture and tunnelling a temporary lead extension connector to a distal exit site.
- the partial internalization procedure preserves the lead for permanent use (the temporary connector is discarded) but requires a more extensive removal procedure in the event of a failed trial.
- the screening trial may extend from about 3 to about 10 days or more with frequent evaluation of smoking habits.
- the evaluations will comprise subjective reports from the patient of smoking craving and a tally of the number of cigarettes smoked.
- the evaluations may also include objective evidence such as biochemical markers, preferably exhaled CO or saliva cotinine.
- a decision on whether on not to permanently implant the lead will be made based on criteria for success. These criteria will include significant diminution of craving, significant decreased intake of cigarettes (less than 50% intake of prior habit) and minimal or no withdrawal symptoms. Withdrawal symptoms may be subjective and compared to previous quitting attempts and interventions used. If the screening trial is considered successful, then the patient will proceed with permanent implantation of the spinal cord stimulator system. Permanent implantation may include removal of the trial screening lead (or leads) and subsequent re-implantation of a new spinal cord stimulator lead (or leads), power source and internal lead extension connector. Or the permanent implantation procedure may include internalization of the trial screening lead (or leads) if this lead (or leads) was anchored and tunneled (i.e. partially internalized to remain sterile) during the trial.
- Permanent implantation of the spinal cord stimulator lead or leads after a successful screening trial comprises the placement of a permanent spinal cord stimulator lead or leads (similar or identical to the trial lead if percutaneously placed, paddle lead if placed through laminotomy). Placement of the permanent lead or leads is performed by the same method used for implantation of the trial screening lead (if percutaneous not laminotomy). In the permanent implantation procedure, the patient is taken to the operating room and placed in the prone position with fluoroscopic guidance as described for the screening trial procedure. The spinal level selected is similar but not necessarily identical to the trial screening level in the sacral, lumbar, thoracic or cervical areas. A spinal cord stimulator lead or leads are placed as described for the screening trial procedure.
- the percutaneous insertion sites are extended as an incision using a scalpel to include the sterile lead extension connector pocket.
- laminotomy or laminectomy may be performed with placement of a surgical lead.
- a distal site is selected for permanent generator or receiver implantation and a tunnel is made from the midline incision (where lead placement occurs) to the distal pocket site for the energy source.
- the lead extension connectors pass through the tunnel to form a connection between the proximal end of the spinal cord stimulator lead and the power source generator or receiver as described previously.
- the proximal end of spinal cord stimulator permanent lead 50b extends from a midline incision 36.
- a tunnel 37 is made from the midline incision 36 to a distal pocket site commonly made in the upper buttocks 38, in the anterior abdomen 38a or the upper chest 38b in cervical stimulation.
- Lead extension connector distal connector site 19a is connected to the proximal end of the spinal cord stimulator lead 50b and the proximal end of the lead extension connector 19b is connected to the internal energy source (or receiver) 20 (or 21) which lies in the distal pocket.
- connections are made at the midline site between the spinal cord stimulator lead or leads and the lead extension connector(s). Connections are also made between the lead extension connector or connectors and the receiver generator or generators as power source.
- Electrical stimulus is now provided with an internal system after closure of the midline incision and distal pocket site or sites. This system is now internalized and will reproduce the successful results of the trial period. Changes in generator settings are performed by telemetry using an external compatible programmer.
- an implanted receiver with external power source transmitted to the receiver via an external antenna may be used for the permanent implantation.
- the receiver is implanted identically to the internal generator and is connected to the lead extension connector which connects to the lead. In this manner an external power source transmits electrical stimulation power through the antenna to the internal receiver which transmits the energy into the lead.
- the advantage of this system is primarily prolonged life as batteries are easily changed in the external system and therefore can be practically used for higher energy levels.
- the implanted lead or leads may remain in place for a time period between about one month to about ten years. Shorter time periods are also possible.
- the implanted lead or leads may remain in place for a time period between about one year to about five years.
- the time period of implantation may also extend between about one year to about two years.
- the patient is followed up immediately post-implantation according to standards for routine post-operative care and wound checks (approximately two times per week for the first week).
- the target quit date for smoking is set as the day of implantation.
- the patient keeps a diary to record cigarette intake as well as withdrawal symptoms. Symptoms of nicotine withdrawal include craving for cigarettes, depressed mood, insomnia, irritability, anger, anxiety, difficulty concentrating and increased appetite.
- the patient is seen twice a week for the first week, once per week for the next seven weeks and then once per month through the end of the first year.
- the success of the treatment is defined as greater than 50% reduction in the number of cigarettes smoked per day sustained to six months post quit date followed by complete cessation of smoking at the one year mark and sustained for a period of six months. Success criteria are evidenced by the patient report of cigarette number verified by concurrent reduction/elimination of exhaled carbon monoxide and saliva cotinine. Side effects should decrease over the
- Stimulation may also be terminated for a time period between about one day to about six months to evaluate the possibility of explantation of the lead or leads. Other time periods may be used for this evaluation, including a time
- the inventive method for treating addiction to tobacco products is nondestructive and reversible, does not involve any pharmacologic agents and its use of a trial screening period predicts the success of permanent
- spinal cord stimulation with pharmacologic therapy (both nicotine and non- nicotine) and behavioral programs is the preferred combination and should significantly increase the success of what have here-to-now been historically unsuccessful programs.
- Spinal cord stimulation may also be combined with
- Multicomponent behavioral programs contemplated for combination with spinal stimulation alone in combination with pharmacologic therapy include aversive techniques, coping strategies and relapse prevention.
- 35 treatments contemplated for combination with spinal cord stimulation alone or in combination with behavioral programs include antidepressant medication (e.g., bupropion) as well as nicotine replacement therapy using gum, patches or lozenges. Nicotine fading may also be used.
- antidepressant medication e.g., bupropion
- Nicotine fading may also be used.
- a percutaneous trial is preferably performed with one or two four-electrode (quadripolar) leads placed through an epidural needle. Most preferably, two leads are employed in the trial. The leads are not tunneled but are externalized to external lead extension connectors and a screening power source. Insertion of the leads are in the low thoracic or high lumbar region and the leads are placed to the area of the sixth to tenth thoracic vertebrae. Dual channel stimulation is performed for the trial which allows individual programs to be used for each lead. This combination also allows for the most versatility in setting combinations as well as "cross talk" (transverse stimulation) between individually programmed leads.
- the trial period lasts from seven to ten days with evaluation visits on the third, sixth and tenth day of the trial. Success is assessed by determining the extent to which the patient's nicotine dependence has been suppressed or extinguished.
- One way to monitor the patient's progress is by observing the number of cigarettes smoked per day before and after the trial.
- the exhaled carbon monoxide and saliva biochemistry (cotinine) levels maintained by the patient before and after the trial may also be used to monitor the success of the procedure.
- Trial leads are removed around the tenth day and if success parameters are met, permanent implantation is scheduled. Permanent implantation consists of similar lead placement compared to the trial leads with two quadripolar leads placed.
- the preferred power source is an external power source transmitting radiofrequency energy through an antenna to an internal receiver.
- the advantage of this approach is that the patient is spared a surgical procedure with percutaneous trial and lead removal and subsequent permanent implantation is minimally invasive.
- the two lead system gives the most versatility in parameters as well as in broad-based coverage and the duality of leads can compensate for lead migration.
- the advantage of an external power source enables not only dual channel (lead individuality in programming), but also enables the use of higher power levels without concern for battery rundown. Based on the following case report, energy levels may be higher and coverage area needed more broad than that needed for pain management.
- Improvements of the device and method may include the use of multiple lead types, electrode numbers, multi-channel leads placed, paddle leads, multiple generator input of multiple leads for single generator, multiple generators, implanted receivers with external power sources connected to single or multiple leads with various number of electrodes. Settings for these leads may be identical as when inserted into single generator power source or may be independent of each other. There can be transmission from one lead electrode to another electrode on the same lead or there can be transmission from lead electrode or electrodes on a single lead to electrodes on a different lead or to multiple other leads. Computer programs may also be used to program a complex network for transmission between multiple leads and multiple-lead electrodes for the maximum transmission into and through the spinal cord.
- Electrode polarities from distal to most proximal two electrode, four electrode, eight electrode, and even higher electrode numbered systems can vary polarity positive to negative in each of the two, four, eight, sixteen electrodes with all permutations of positive and negative included. Any electrode on a given lead can transmit and communicate to any electrode on a separate lead in combination with polarity changes and multiple permutations. Besides electrode polarity, placement of single or separate leads in addition to covering all levels of the spinal cord may comprise two or more separate locations within the spinal cord.
- one lead may be placed low lumbar with another lead placed thoracic with communication between the two leads or independent stimulation between the two leads.
- Paddle lead systems may be inserted through laminotomies or percutaneously (if feature variations are made), and these may be used independently, with multiple paddle leads or with combinations of percutaneous leads.
- the settings for electrical stimulation include amplitude, rate and pulse width along with polarity of contact electrodes.
- the current art for spinal cord stimulation includes continuous mode stimulation or cycling mode stimulation. Continuous mode stimulates continuously and may be required long-term for optimal results. Cycling mode stimulation is available in cycles which automatically stimulates on and off times in varying durations. This can significantly increase the battery life in totally implanted systems. In addition to continuous and cycling modes, biphasic stimulation is available which allows electrode polarity to reverse with every pulse. The previously mentioned are part of cycling modes. Single stimulation, dual stimulation and multiple electrode stimulation arrays are also available. This allows stimulation of single lead of 4, 8 or 16 electrodes (projected greater number of electrode leads to become available).
- Dual stimulation provides different stimulation programs for separate channels for the generator power source to two sets of electrodes (two four-electrode leads, two eight-electrode leads), or differing stimulation to the two sets of four electrodes or two sets of eight-electrode leads. Pulse width, amplitude and rate are the same for both channels. Future variations will provide versatility in multiple lead systems of any electrode number.
- the patient required a high degree of stimulation as evidenced by the significant feelings of tingling and stimulation in his legs combined with a subjective feeling of motor weakness. This may represent the required level of stimulation for smoking cessation or could indicate this particular patient to be one of a difficult population.
- the patient was taken to the operating room and lay prone on the operating room table and subsequently underwent placement of a trial screening spinal cord stimulator electrode. This involved insertion into the spinal interspace at T12-L1 and insertion of a percutaneous four-electrode system lead into the epidural space.
- the lead was advanced until the distal tip lay at the level of T8 at the midline.
- the proximal end was connected to an external power source and manipulated until the patient could feel tingling (stimulation) in both of his legs.
- the lead was secured at its percutaneous insertion site with #3.0 silk and an occlusive dressing.
- the patient was discharged home with an external power source, Medtronic's external power source Model No. 3625 with variations available for amplitude, pulse width and rate.
- the patient's electrode polarity was electrode 0 most distal electrode as the positive pole and electrode 2 the third most distal electrode as the negative electrode. Amplitude ranged 2.5 - 8.0 during the trial period with a pulse width of 300 (range 100-450) and a rate of 50 (range 25-120). The patient underwent a one-week trial period with the implanted lead during which time he was seen three times in the outpatient clinic.
- the patient made a notable observation which he reported at the end of the trial.
- the patient self-reported a heavy smoking habit of many years duration (two packs per day for greater than 25 years) but observed that he had no craving to smoke cigarettes during the entire trial.
- the patient reported that on the third day of the trial, he realized that he had not thought about smoking a cigarette for three days.
- the patient further reported that he had not smoked any cigarette for the entire duration of the trial nor did he note any significant withdrawal symptoms.
- the patient reported simply that he had "forgotten all about having to smoke”.
- the patient also observed that he had made many previous unsuccessful efforts to quit smoking using conventional interventions such as nicotine containing gum.
- the patient upon removal of the trial lead, the patient reported that his cravings returned in one day after spinal cord stimulation was discontinued.
- the target quit date is again selected as the day of implantation.
- the patient keeps a diary to record substance intake and any withdrawal symptoms specific to the chemical substance. Success criteria are chose to be compatible with established success criteria for that chemical substance.
Abstract
Description
Claims
Priority Applications (2)
Application Number | Priority Date | Filing Date | Title |
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AU57620/00A AU761045B2 (en) | 1999-06-25 | 2000-06-23 | Spinal cord stimulation as a treatment for addiction to nicotine and other chemical substances |
CA002377020A CA2377020A1 (en) | 1999-06-25 | 2000-06-23 | Spinal cord stimulation as a treatment for addiction to nicotine and other chemical substances |
Applications Claiming Priority (2)
Application Number | Priority Date | Filing Date | Title |
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US09/344,833 US6233488B1 (en) | 1999-06-25 | 1999-06-25 | Spinal cord stimulation as a treatment for addiction to nicotine and other chemical substances |
US09/344,833 | 1999-06-25 |
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WO2001000274A1 true WO2001000274A1 (en) | 2001-01-04 |
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Family Applications (1)
Application Number | Title | Priority Date | Filing Date |
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PCT/US2000/017331 WO2001000274A1 (en) | 1999-06-25 | 2000-06-23 | Spinal cord stimulation as a treatment for addiction to nicotine and other chemical substances |
Country Status (4)
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US (1) | US6233488B1 (en) |
AU (1) | AU761045B2 (en) |
CA (1) | CA2377020A1 (en) |
WO (1) | WO2001000274A1 (en) |
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US8845561B2 (en) | 2005-03-08 | 2014-09-30 | Aslam Khan | Non-invasive method of spinal intervention and use of devices effective for spinal intervention |
EP1916013A1 (en) * | 2006-10-25 | 2008-04-30 | Oncotherm Kft. | Hyperthermia device for the selective treatment and monitoring of surface tissue |
Also Published As
Publication number | Publication date |
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AU761045B2 (en) | 2003-05-29 |
AU5762000A (en) | 2001-01-31 |
CA2377020A1 (en) | 2001-01-04 |
US6233488B1 (en) | 2001-05-15 |
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