Epidural stimulation with locomotor training ameliorates unstable blood pressure after tetraplegia. A case report

Gorgey, Ashraf S.; Sutor, Tommy W.; Goldsmith, Jacob A.; Ennasr, Areej N.; Lavis, Timothy; Cifu, David X.; Trainer, Robert

doi:10.1002/acn3.51508

Cited by 3 publications

(3 citation statements)

References 23 publications

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“…The novelty of this case report needs to be highlighted. We have utilized percutaneous SCES implantation and not paddle implantation as has been demonstrated with several other groups ( Aslan et al, 2018 ; Darrow et al, 2019 ; Ditterline et al, 2020 ; Squair, 2021 ; Gorgey et al, 2022 ). The point is not to emphasize the use of percutaneous leads over paddle implantation but to demonstrate the fact that there is an alternative approach that may yield positive results similar to the paddle.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, the mechanisms for regulating hemodynamic challenges after SCI has been recently highlighted in rodents, primates and humans with SCI ( Squair, 2021 ). We have recently shown that 14 weeks of body weight supported treadmill training with SCES, resulted in normalized unstable resting seated blood pressure, increased the number of training bouts per session, and decreased the percentage of body weight support to 69% ( Gorgey et al, 2022 ). The aforementioned studies focused primarily on studying paddle implantation with limited evidence about the feasibility of using implanted percutaneous SCES to enhance autonomic functions in persons with SCI.…”

Section: Introductionmentioning

confidence: 99%

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Effects of percutaneously-implanted epidural stimulation on cardiovascular autonomic function and spasticity after complete spinal cord injury: A case report

Gorgey

Goldsmith²,

Alazzam³

et al. 2023

Front. Neurosci.

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ImportanceThere is a revived interest to explore spinal cord epidural stimulation (SCES) to improve physical function after spinal cord injury (SCI). This case report highlights the potential of eliciting multiple functional improvements with a single SCES configuration, a strategy which could improve clinical translation.ObjectiveTo determine whether SCES intended to facilitate walking also acutely yields benefits in cardiovascular autonomic regulation and spasticity.DesignCase report from data collected at two timepoints 15 weeks apart from March to June 2022 as part of a larger clinical trial.SettingResearch lab at Hunter Holmes McGuire VA Medical Center.Participant27-year-old male, 7 years post a C8 motor complete spinal cord injury.InterventionA SCES configuration intended to enhance exoskeleton-assisted walking training applied for autonomic and spasticity management.Main outcomes and measuresThe primary outcome was cardiovascular autonomic response to a 45-degree head-up-tilt test. Systolic blood pressure (SBP), heart rate (HR), and absolute power of the low-frequency (LF) and high-frequency (HF) components of a heart-rate variability analysis were collected in supine and tilt with and without the presence of SCES. Right knee flexor and knee extensor spasticity was assessed via isokinetic dynamometry with and without SCES.ResultsAt both assessments with SCES off, transitioning from supine to tilt decreased SBP (assessment one: 101.8 to 70 mmHg; assessment two: 98.9 to 66.4 mmHg). At assessment one, SCES on in supine (3 mA) increased SBP (average 117 mmHg); in tilt, 5 mA stabilized SBP near baseline values (average 111.5 mmHg). At assessment two, SCES on in supine (3 mA) increased SBP (average 140 mmHg in minute one); decreasing amplitude to 2 mA decreased SBP (average 119 mmHg in minute five). In tilt, 3 mA stabilized SBP near baseline values (average 93.2 mmHg). Torque-time integrals at the right knee were reduced at all angular velocities for knee flexors (range: −1.9 to −7.8%) and knee extensors (range: −1 to −11.4%).Conclusions and relevanceThese results demonstrate that SCES intended to facilitate walking may also enhance cardiovascular autonomic control and attenuate spasticity. Using one configuration to enhance multiple functions after SCI may accelerate clinical translation.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/, identifier NCT04782947.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Effects of percutaneously-implanted epidural stimulation on cardiovascular autonomic function and spasticity after complete spinal cord injury: A case report

Gorgey

Goldsmith²,

Alazzam³

et al. 2023

Front. Neurosci.

Self Cite

View full text Add to dashboard Cite

show abstract

“…It has not been until recently that the applications of scES have emerged for the restoration of motor recovery in neurological disorders, especially in persons with spinal cord injury (SCI) [ 3 , 4 , 5 ]. We have previously used scES to enhance motor and autonomic functions in a person with complete SCI [ 6 , 7 ]. Unlike paddle implantation, percutaneous lead implantation provides access to the epidural space without the need to perform surgical laminectomy or laminotomy.…”

Section: Case Reportmentioning

confidence: 99%

Single Lead Epidural Spinal Cord Stimulation Targeted Trunk Control and Standing in Complete Paraplegia

Gorgey

Gouda

2022

JCM

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A 25-year-old male with T3 complete AIS A was implanted with percutaneous spinal cord epidural stimulation (scES; eight contacts each) leads and a Medtronic Prime advance internal pulse generator. The two leads were placed at the midline level to cover the region of the T11–T12 vertebrae. Five days after implantation, X-ray showed complete migration of the left lead outside the epidural space. Two weeks after implantation, reprogramming of the single right lead (20 Hz and 240 µs) after setting the cathode at 0 and the anode at 3 resulted in target activation of the abdominal muscles and allowed for the immediate restoration of trunk control during a seated position, even with upper extremity perturbation. This was followed by achieving immediate standing after setting the single lead at −3 for the cathode and +6 for the anode using stimulation configurations of 20 Hz and 240 µs. The results were confirmed with electromyography (EMG) of the rectus abdominus and lower extremity muscles. Targeted stimulation of the lumbosacral segment using a single lead with a midline approach immediately restored the trunk control and standing in a person with complete paraplegia.

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MRI Spinal Cord Reconstruction Provides Insights into Mapping and Migration Following Percutaneous Epidural Stimulation Implantation in Spinal Cord Injury

Venigalla,

Rehman,

Deitrich

et al. 2024

JCM

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Background: Spinal cord epidural stimulation (SCES) has the potential to restore motor functions following spinal cord injury (SCI). Spinal cord mapping is a cornerstone step towards successfully configuring SCES to improve motor function, aiming to restore standing and stepping abilities in individuals with SCI. While some centers have advocated for the use of intraoperative mapping to anatomically target the spinal cord locomotor centers, this is a resource-intensive endeavor and may not be a feasible approach in all centers. Methods: Two participants underwent percutaneous SCES implantation as part of a clinical trial. Each participant underwent a temporary (1-week, two-lead) trial followed by a permanent, two-lead implantation. SCES configurations were matched between temporary and permanent mappings, and motor evoked potential in response to 2 Hz, for a duration of 250–1000 µs and with an amplitude of 1–14 mA, was measured using electromyography. T2 axial MRI images captured prior to implantation were used to retrospectively reconstruct the lumbosacral segments of the spinal cord. The effects of lead migration on mapping were further determined in one of the participants. Results: In both participants, there were recognized discrepancies in the recruitment curves of the motor evoked potentials across different muscle groups between temporary and permanent SCES mappings. These may be explained by retrospective MRI reconstruction of the spinal cord, which indicated that the percutaneous leads did not specifically target the entire L1-S2 segments in both participants. Minor lead migration appeared to have a minimal impact on spinal cord mapping outcomes in one of the participants but did dampen the motor activity of the hip and knee muscle groups. Conclusions: Temporary mapping coupled with MRI reconstruction has the potential to be considered as guidance for permanent implantation considering target activation of the spinal cord locomotor centers. Since lead migration may alter the synergistic coordination between different muscle groups and since lead migration of 1–2 contacts is expected and planned for in clinical practice, it can be better guided with proper spinal cord mapping and a diligent SCES lead trial beforehand.

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Epidural stimulation with locomotor training ameliorates unstable blood pressure after tetraplegia. A case report

Cited by 3 publications

References 23 publications

Effects of percutaneously-implanted epidural stimulation on cardiovascular autonomic function and spasticity after complete spinal cord injury: A case report

Effects of percutaneously-implanted epidural stimulation on cardiovascular autonomic function and spasticity after complete spinal cord injury: A case report

Single Lead Epidural Spinal Cord Stimulation Targeted Trunk Control and Standing in Complete Paraplegia

MRI Spinal Cord Reconstruction Provides Insights into Mapping and Migration Following Percutaneous Epidural Stimulation Implantation in Spinal Cord Injury

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