Chapter 18 - Spinal cord stimulation: therapeutic benefits and movement generation after spinal cord injury

https://doi.org/10.1016/B978-0-444-52137-8.00018-8Get rights and content

Abstract

Spinal cord injury (SCI) is a devastating neurological condition that leads to loss of motor and sensory function. It commonly causes impairments in limb movements, respiration, bowel and bladder function, as well as secondary complications including pain, spasticity, and pressure ulcers. Numerous interventions such as neuroprotection, regeneration, pharmacology, rehabilitation training, and functional electrical stimulation are under investigation for improving function after SCI. This chapter discusses the use of spinal cord stimulation (epidural and intraspinal electrical stimulation) for alleviating pain and spasticity, and restoring standing and walking. Epidural stimulation is effective in reducing the intensity of intractable pain, but its effectiveness in the treatment of spasticity remains unclear. It can induce rhythmic, locomotor-like movements in the legs, presumably due to the activation of afferent pathways. Intraspinal microstimulation is a new electrical stimulation approach that activates locomotor-related networks within the ventral regions of the lumbosacral spinal cord. In animals, this approach is capable of producing prolonged, fatigue-resistant standing and stepping of the hindlegs. While the results in animals have been very encouraging, technical advancements are necessary prior to its implementation in humans with SCI. Taken collectively, spinal cord stimulation holds substantial promise in restoring function after neural injury or disease.

Section snippets

General introduction

Spinal cord injury (SCI) leads to interruption in the sensory-motor interaction between supraspinal centers and segments of the spinal cord below the site of injury. However, motor neurons and neuronal networks below the site of injury involved in sensory processing, sensory-motor integration, and locomotion remain more or less intact. Accessing these neuronal elements presents a potentially viable opportunity to both restore function after SCI and alleviate some of the secondary side-effects

Epidural electrical spinal cord stimulation

An epidural spinal cord stimulation system consists of an electrode either connected directly to an implanted pulse generator, or radiofrequency coupled to an external pulse generator. The electrode or “lead” is an array of four or more contacts mounted at one end of a flexible insulating tube. Each contact is an electrically conductive surface from which current passes into the surrounding tissue. The contacts can be set to be cathode or anode depending on the output of the pulse generator to

Intraspinal microstimulation

Intraspinal microstimulation (ISMS) is a technique that uses fine microwires to apply stimulation within the ventral horn of the spinal cord below the level of a SCI in order to generate functional movements of the legs. The ISMS microwires are implanted in a compact and relatively motion-free region of the cord, thus minimal strain is experienced by the implant during evoked limb movements. The target region for implantation is the lumbosacral enlargement, which is ∼ 5 cm long in humans and

Summary

Methods of spinal cord stimulation currently under investigation or in clinical practice have been presented and assessed in terms of their safety, feasibility, and efficacy in either animal or human trials involving SCI. Exciting findings relating to the generation of locomotor patterns through epidural and intraspinal approaches were discussed. The results to date suggest that these approaches may be viable techniques for improving sensory-motor function after SCI or disease. The techniques

Acknowledgments

CHT would like to acknowledge the financial support of the Canadian Paraplegic Association, the Ontario Neurotrauma Foundation, and the Christopher and Dana Reeve Paralysis Foundation. KM would like to acknowledge the financial support of the Austrian Science Fund (FWF). VKM would like to thank Jeremy Bamford, Lisa Guevremont, Bernice Lau, Enid Pehowich, and Rajiv Saigal for their contributions to the ISMS work presented in this chapter. Funding for the ISMS work was provided by the Alberta

References (113)

  • V.K. Mushahwar et al.

    Spinal cord microstimulation generates functional limb movements in chronically implanted cats

    Exp Neurol

    (2000)
  • B.S. Nashold et al.

    Electrical activation of micturition by spinal cord stimulation

    J Surg Res

    (1971)
  • J.J. Pancrazio et al.

    Toward neurotechnology innovation: report from the 2005 Neural Interfaces workshop

    An NIH-sponsored event. Neuromodulation

    (2006)
  • M.M. Adams et al.

    Spasticity after spinal cord injury

    Spinal Cord

    (2005)
  • J.A. Bamford et al.

    Intraspinal microstimulation preferentially recruits fatigue-resistant muscle fibres and generates gradual force in rat

    J Physiol

    (2005)
  • G. Barolat

    Surgical management of spasticity and spasms in spinal cord injury: an overview

    J Am Paraplegia Soc

    (1988)
  • G. Barolat et al.

    Effects of spinal cord stimulation on spasticity and spasms secondary to myelopathy

    Appl Neurophysiol

    (1988)
  • D. Barthélemy et al.

    Characteristics and mechanisms of locomotion induced by intraspinal microstimulation and dorsal root stimulation in spinal cats

    J Neurophysiol

    (2007)
  • R.B. Borgens et al.

    Enhanced spinal cord regeneration in lamprey by applied electric fields

    Science

    (1981)
  • R.B. Borgens et al.

    Axonal regeneration in spinal cord injury: a perspective and new technique

    J Comp Neurol

    (1986)
  • R.B. Borgens et al.

    Transected dorsal column axons within the guinea pig spinal cord regenerate in the presence of an applied electric field

    J Comp Neurol

    (1986)
  • R.B. Borgens et al.

    Behavioral recovery induced by applied electric fields after spinal cord hemisection in guinea pig

    Science

    (1987)
  • R.B. Borgens et al.

    Functional recovery after spinal cord hemisection in guinea pigs: the effects of applied electric fields

    J Comp Neurol

    (1990)
  • R. Borgens et al.

    Effects of applied electric fields on clinical cases of complete paraplegia in dogs

    Restorative Neurol Neurosci

    (1993)
  • R.B. Borgens et al.

    An imposed oscillating electrical field improves the recovery of function in neurologically complete paraplegic dogs

    J Neurotrauma

    (1999)
  • J. Broseta et al.

    Spinal cord stimulation in peripheral arterial disease

    A cooperative study. J Neurosurg

    (1986)
  • R.E. Burke

    The use of state-dependent modulation of spinal reflexes as a tool to investigate the organization of spinal interneurons

    Exp Brain Res

    (1999)
  • R. Calixto

    Single cell recordings during intraspinal microstimulation of the feline spinal cord

    (2007)
  • A.W. Cook et al.

    Chronic dorsal column stimulation in multiple sclerosis. Preliminary report

    N Y State J Med

    (1973)
  • M.R. Dimitrijevic et al.

    Spinal cord stimulation as a tool for physiological research

    Appl Neurophysiol

    (1983)
  • M.R. Dimitrijevic et al.

    Evidence for a spinal central pattern generator in humans

    Ann N Y Acad Sci

    (1998)
  • S.M. Elbasiouny et al.

    Management of spasticity after spinal cord injury: current techniques and future directions

    Neurorehabil Neural Repair

    (2010)
  • H.K. Feirabend et al.

    Morphometry of human superficial dorsal and dorsolateral column fibres: significance to spinal cord stimulation

    Brain

    (2002)
  • M.G. Fehlings et al.

    The effect of direct-current field on recovery from experimental spinal cord injury

    J Neurosurg

    (1988)
  • M.G. Fehlings et al.

    Effect of a direct current field on axons after experimental spinal cord injury

    Can J Surg

    (1989)
  • R.A. Gaunt et al.

    Intraspinal microstimulation excites multisegmental sensory afferents at lower stimulus levels than local α-motoneurons

    J Neurophysiol

    (2006)
  • Y.P. Gerasimenko et al.

    Mechanisms of locomotor activity generation under epidural spinal cord stimulation

  • Y.P. Gerasimenko et al.

    Control of locomotor activity in humans and animals in the absence of supraspinal influences

    Neurosci Behav Physiol

    (2002)
  • Y.P. Gerasimenko et al.

    Epidural spinal cord stimulation plus quipazine administration enable stepping in complete spinal adult rats

    J Neurophysiol

    (2007)
  • S. Grillner et al.

    On the central generation of locomotion in the low spinal cat

    Exp Brain Res

    (1979)
  • L. Guevremont et al.

    Tapping into the spinal cord for restoring function after spinal cord injury

  • L. Guevremont et al.

    A physiologically-based controller for generating overground locomotion using functional electrical stimulation

    J Neurophysiol

    (2007)
  • B. Gustafsson et al.

    Direct and indirect activation of nerve cells by electrical pulses applied extracellularly

    J Physiol

    (1976)
  • C. Haberler et al.

    No tissue damage by chronic deep brain stimulation in Parkinson's disease

    Ann Neurol

    (2000)
  • E. Henneman

    Organization of the spinal cord and its reflexes

  • E. Henneman

    The size-principle: a deterministic output emerges from a set of probabilistic connections

    J Exp Biol

    (1985)
  • E. Henneman et al.

    Functional organization of motoneuron pool and its inputs

  • R. Herman et al.

    Spinal cord stimulation facilitates functional walking in a chronic, incomplete spinal cord injured

    Spinal Cord

    (2002)
  • L.P. Hiersemenzel et al.

    From spinal shock to spasticity: neuronal adaptations to a spinal cord injury

    Neurology

    (2000)
  • U.S. Hofstoetter et al.

    Modification of reflex responses to lumbar posterior root stimulation by motor tasks in healthy subjects

    Artif Organs

    (2008)

    • Cited by (48)

    • Spinal Cord Stimulation Attenuates Below-Level Mechanical Hypersensitivity in Rats After Thoracic Spinal Cord Injury

      2021, Neuromodulation
      Citation Excerpt :

      It is also important to test whether SCS applied above the injury level produces greater pain inhibition, and whether SCS efficacy persists after repetitive and long-term treatment. Besides improving sensory function, SCS also promotes motor function recovery and attenuates SCI-associated autonomic dysregulation (21, 22, 41) by mechanisms such as enhancement of oligodendrocyte survival and differentiation (42). These beneficial effects may also facilitate the alleviation of SCI pain-related behavior.

    • Electroceutical therapies for injuries of the nervous system

      2020, Handbook of Innovations in Central Nervous System Regenerative Medicine

    • Neuropathic pain and SCI: Identification and treatment strategies in the 21st century

      2018, Journal of the Neurological Sciences
      Citation Excerpt :

      A systematic review of the use of the DREZ procedure for NP after SCI showed that this treatment may be most effective in patients with specific segmental (dermatomal) pain, as opposed to diffuse pain [72]. Spinal cord stimulation (SCS) is a minimally invasive and reversible therapy for the treatment of NP in SCI [73,74]. A systemic review found that SCS are more effective than conventional medical management in patients with NP from a variety of disorders [75–77].

    • Neurogenic Bowel Dysfunction in Patients with Spinal Cord Injury and Multiple Sclerosis—An Updated and Simplified Treatment Algorithm

      2023, Journal of Clinical Medicine

    • Altered cutaneous reflexes to non-noxious stimuli in the triceps surae of people with chronic incomplete spinal cord injury

      2023, Journal of Neurophysiology

    • Association between brain N-Acetylaspartate levels and sensory and motor dysfunction in patients who have spinal cord injury with spasticity: An observational case-control study

      2023, Neural Regeneration Research
    View all citing articles on Scopus
    View full text
    Copyright © 2012 Elsevier B.V. All rights reserved.