Best Practices for Dorsal Root Ganglion Stimulation for Chronic Pain: Guidelines from the American Society of Pain and Neuroscience

Abstract

With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion stimulation (DRG-S) has significantly improved the treatment of complex regional pain syndrome (CRPS), and it has broad applicability across a wide range of other conditions. Through funding and organizational leadership by the American Society for Pain and Neuroscience (ASPN), this best practices consensus document has been developed for the selection, implantation, and use of DRG stimulation for the treatment of chronic pain syndromes. This document is composed of a comprehensive narrative literature review that has been performed regarding the role of the DRG in chronic pain and the clinical evidence for DRG-S as a treatment for multiple pain etiologies. Best practice recommendations encompass safety management, implantation techniques, and mitigation of the potential complications reported in the literature. Looking to the future of neuromodulation, DRG-S holds promise as a robust intervention for otherwise intractable pain.

Keywords:

• dorsal root ganglion
• neurostimulation
• chronic pain
• best practice
• guidelines

Abbreviations

ACNES, anterior cutaneous nerve entrapment syndrome; AP, action potential; ASF, anterior sacral foramen; ASPN, American Society of Pain and Neuroscience; BDI, Beck Depression Inventory; BPI, Brief Pain Inventory; CGRP, calcitonin gene-related peptide; CNS, central nervous system; CRPS, complex regional pain syndrome; CSF, cerebrospinal fluid; DH, dorsal horn; DPN, diabetic peripheral neuropathy; DRG, dorsal root ganglia; DRG-S, dorsal root ganglion stimulation; DRR, dorsal root reflex; EMG, electromyography; EOS, endogenous opioid system; EQ-5D, EuroQOL health-related quality of life instrument; FBSS, failed back surgery syndrome; GABA, gamma-aminobutyric acid; HADS, Hospital Anxiety and Depression Scale; HIV, human immunodeficiency virus; IONM, intraoperative neuromonitoring; IPG, implantable pulse generator; LBP, low back pain; LTMR, low-threshold mechanoreceptor; MCS, mental component scale (of SF-36 family of scales); MME, morphine milligram equivalent; MRI, magnetic resonance imaging; MSNA, multiunit postganglionic sympathetic nerve activity; NRS, numeric rating scale; NSLBP, non-surgical low back pain; ODI, Oswestry Disability Index; PCS, Pain Catastrophizing Scale; PCS, physical component scale (of SF-36 family of scales); PDI, Pain Disability Index; PHN, postherpetic neuralgia; PLP, phantom limb pain; PN, peripheral neuropathy; POMS, Profile of Mood Scale; PSF, posterior sacral foramen; PSPS, post-surgical pain syndromes; PVD, peripheral vascular disease; pW, pulse width; QLIP, Quality of Life Impairment by Pain Inventory; QST, quantitative sensory testing; RF, radiofrequency; SAP, superior articular process; SCS, spinal cord stimulation; SNS, sympathetic nervous system; SP, spinous process; SSEP, somatosensory evoked potentials; TKA, total knee arthroplasty; t-SCS, tonic spinal cord stimulation; USPSTF, United States Preventive Services Task Force; VAS, visual analog scale.

Acknowledgments

Third-party editing assistance was provided by Allison Foster, PhD, of Foster Medical Communications.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Dr. Deer and Dr. Chakravarthy both served as senior corresponding authors.

Disclosure

Kenneth B Chapman has research funded by Abbott. Krishnan Chakravarthy is a consultant to Medtronic, Biotronik, SI Bone, Vertos, and Vivex Biologics, a shareholder in Mainstay Medical, Aya Biosciences, Higgs Boson Health, Oska Wellness, Rune Labs, UMEHEAL, Yantra Biomedical, and Nalu Medical, and founder of Accufix Medical, Douleur Therapeutics, and NXTSTIM. Jacqueline Weisbein is a consultant for Abbott, Medtronic, Saluda, Biotronik, and SI Bone. Kiran V Patel is a consultant and speaker for Abbott. Jonathan M Hagedorn is consultant for Abbott, Boston Scientific, Medtronic, Nevro, and Saluda. Timothy Deer is a consultant for Abbott, Ethos, Medtronic, Boston Scientific, Nevro, Nalu, Tissue Tech, Spinal Simplicity, and Saluda, has equity in Saluda, SPR, Spinethera, Nalu, Cornerloc, Ethos, PainTEQ, Spinal Simplicity, and Vertos, and has research funding with Boston Scientific, Abbott, and Saluda. He also is a research investigator for Abbott, Avanos, Mainstay Medical, and PainTEQ. He reports a patent pending to Abbott. Dawood Sayed reports personal fees from Abbott, Medtronic, Merit, and Boston Scientific, outside the submitted work. Corey Hunter reports personal fees from Abbott, during the conduct of the study; grants and/or personal fees from Saluda, Nalu, Biotronik, Boston Scientific, PainTEQ, outside the submitted work. David Dickerson reports grants and/or personal fees from Abbott, SPR Therapeutics, Pfizer, Nalu, Myovant Biosciences, and Vertos Medical, outside the submitted work. David W Lee is a consultant for Abbott, Medtronic, Boston Scientific, Mainstay Medical, Petal Surgical. The authors report no other conflicts of interest in this work.