Elsevier

Mayo Clinic Proceedings

Volume 92, Issue 9, September 2017, Pages 1427-1444
Mayo Clinic Proceedings

Symposium on neurosciences
Neurostimulation Devices for the Treatment of Neurologic Disorders

https://doi.org/10.1016/j.mayocp.2017.05.005Get rights and content

Abstract

Rapid advancements in neurostimulation technologies are providing relief to an unprecedented number of patients affected by debilitating neurologic and psychiatric disorders. Neurostimulation therapies include invasive and noninvasive approaches that involve the application of electrical stimulation to drive neural function within a circuit. This review focuses on established invasive electrical stimulation systems used clinically to induce therapeutic neuromodulation of dysfunctional neural circuitry. These implantable neurostimulation systems target specific deep subcortical, cortical, spinal, cranial, and peripheral nerve structures to modulate neuronal activity, providing therapeutic effects for a myriad of neuropsychiatric disorders. Recent advances in neurotechnologies and neuroimaging, along with an increased understanding of neurocircuitry, are factors contributing to the rapid rise in the use of neurostimulation therapies to treat an increasingly wide range of neurologic and psychiatric disorders. Electrical stimulation technologies are evolving after remaining fairly stagnant for the past 30 years, moving toward potential closed-loop therapeutic control systems with the ability to deliver stimulation with higher spatial resolution to provide continuous customized neuromodulation for optimal clinical outcomes. Even so, there is still much to be learned about disease pathogenesis of these neurodegenerative and psychiatric disorders and the latent mechanisms of neurostimulation that provide therapeutic relief. This review provides an overview of the increasingly common stimulation systems, their clinical indications, and enabling technologies.

Section snippets

Historical Perspective

The earliest history of what became neuromodulation therapy started with ablative procedures in stereotactic and functional neurosurgery in the mid-20th century to treat neuropsychiatric disorders. At that time, without pharmaceutical options for psychiatric disorders, desperate measures were taken to mitigate debilitating symptoms. The American neurophysiologist John Farquhar Fulton observed that modulation of regions of the cerebral cortex affected behavior in nonhuman primate studies.1 These

Historical Perspective

Another fortuitous discovery in neurosurgery came in the early 1990s, when Tsubokawa hypothesized that stimulation of the somatosensory cortex could alleviate central pain and implanted cortical electrodes into patients with central pain syndromes. To his surprise, these electrodes covering the sensory cortex did not alleviate pain, but at times worsened it. Serendipitously, the stimulating electrodes just anterior to the somatosensory cortex, on the primary motor cortex, inhibited pain.72, 73

Historical Perspective

Epilepsy is a common neurologic disorder that results in regular occurring seizures, which may be broadly categorized as partial or generalized, and manifest in various ways, such as a person having a blank stare for a couple of seconds to incapacitating convulsions and loss of consciousness. Approximately 1% to 2% of the US population has experienced epileptic seizures, with nearly 30% of those patients having treatment-refractory seizures that are unresponsive to antiepileptic drugs.75 In

Historical Perspective

In 1965, Ronald Melzack and Patrick Wall proposed the gate control theory of pain to describe the complex interaction between the central and peripheral nervous systems to process pain and haptic signals. The dorsal horn is thought of as the gate of the spinal cord, in which peripheral nerve fibers carrying pain signals are blocked from ascending the central nervous system, when nerve fibers carrying touch, pressure, or vibration signals are activated. During that time, DBS targets to treat

Historical Perspective

The first publications on VNS were in 1990, and then in 1997 the US FDA's neurologic devices panel met to consider approval of the Cyberonics (now LivaNova) VNS device for the treatment of epilepsy.96 The device consists of a pulse generator that is implanted under the skin below the patient's clavicle and lead wires that are tunneled up to the patient's neck and wrapped around the left vagus nerve at the carotid sheath. In addition, VNS has been used as a therapy for treatment-resistant

Enabling Technologies Evolving Neurostimulation Therapies

To date, the therapeutic mechanisms underlying neurostimulation therapies are not well understood; even so, such approaches are the only effective treatment option for several refractory neurologic disorders and are rapidly expanding to other clinical application domains. Decades of advances in neural activity monitoring technologies have resulted in powerful investigative and clinical tools that are providing remarkable noninvasive, in vivo, multimodal views of the brain. In 2013, the US White

Conclusion

As outlined, the rapid advancements in neurostimulation technologies are providing the necessary tools to treat patients living with many debilitating neurologic and psychiatric disorders. Here, we discussed the established invasive electrical stimulation systems used clinically to induce therapeutic neuromodulation of dysfunctional neural circuitry. Although we are on an accelerated path toward an adaptable and precise neuromodulation therapy, much remains to be accomplished. This includes

References (149)

  • W.K. Goodman et al.

    Deep brain stimulation in psychiatry: concentrating on the road ahead

    Biol Psychiatry

    (2009)
  • H.S. Mayberg et al.

    Deep brain stimulation for treatment-resistant depression

    Neuron

    (2005)
  • A.M. Lozano et al.

    Subcallosal cingulate gyrus deep brain stimulation for treatment-resistant depression

    Biol Psychiatry

    (2008)
  • P. Krack et al.

    Deep brain stimulation: from neurology to psychiatry?

    Trends Neurosci

    (2010)
  • H.K. Min et al.

    Subthalamic nucleus deep brain stimulation induces motor network BOLD activation: use of a high precision MRI guided stereotactic system for nonhuman primates

    Brain Stimul

    (2014)
  • M.S. Troche et al.

    Swallowing and deep brain stimulation in Parkinson's disease: a systematic review

    Parkinsonism Relat Disord

    (2013)
  • P. Testini et al.

    Centromedian-parafascicular complex deep brain stimulation for Tourette syndrome: a retrospective study

    Mayo Clin Proc

    (2016)
  • A.A. Moustafa et al.

    Motor symptoms in Parkinson's disease: a unified framework

    Neurosci Biobehav Rev

    (2016)
  • H.K. Min et al.

    Deep brain stimulation induces BOLD activation in motor and non-motor networks: an fMRI comparison study of STN and EN/GPi DBS in large animals

    Neuroimage

    (2012)
  • A. Castrioto et al.

    Mood and behavioural effects of subthalamic stimulation in Parkinson's disease

    Lancet Neurol

    (2014)
  • B. Nuttin et al.

    Electrical stimulation in anterior limbs of internal capsules in patients with obsessive-compulsive disorder

    Lancet

    (1999)
  • B.D. Greenberg et al.

    Neurosurgery for intractable obsessive-compulsive disorder and depression: critical issues

    Neurosurg Clin N Am

    (2003)
  • C.M. Honey et al.

    Deep brain stimulation versus motor cortex stimulation for neuropathic pain: a minireview of the literature and proposal for future research

    Comput Struct Biotechnol J

    (2016)
  • F.T. Sun et al.

    Responsive cortical stimulation for the treatment of epilepsy

    Neurotherapeutics

    (2008)
  • M.J. Morrell et al.

    Responsive direct brain stimulation for epilepsy

    Neurosurg Clin N Am

    (2016)
  • K.J. Meador et al.

    Quality of life and mood in patients with medically intractable epilepsy treated with targeted responsive neurostimulation

    Epilepsy Behav

    (2015)
  • K. Haddadan et al.

    The effect of spinal cord stimulation, overall, and the effect of differing spinal cord stimulation technologies on pain, reduction in pain medication, sleep, and function

    Neuromodulation

    (2007)
  • J.C. Kleiber et al.

    Is spinal cord stimulation safe? A review of 13 years of implantations and complications

    Rev Neurol (Paris)

    (2016)
  • A. Sharan et al.

    Evolving patterns of spinal cord stimulation in patients implanted for intractable low back and leg pain

    Neuromodulation

    (2002)
  • F.T. Sun et al.

    Closed-loop neurostimulation: the clinical experience

    Neurotherapeutics

    (2014)
  • S. Harkema et al.

    Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: a case study

    Lancet

    (2011)
  • P.J. Grahn et al.

    Enabling Task-Specific Volitional Motor Functions via Spinal Cord Neuromodulation in a Human With Paraplegia

    Mayo Clin Proc.

    (2017)
  • A.J. Rush et al.

    Vagus nerve stimulation (VNS) for treatment-resistant depressions: a multicenter study

    Biol Psychiatry

    (2000)
  • H.A. Sackeim et al.

    Vagus nerve stimulation (VNS) for treatment-resistant depression: efficacy, side effects, and predictors of outcome

    Neuropsychopharmacology

    (2001)
  • L.B. Marangell et al.

    Vagus nerve stimulation (VNS) for major depressive episodes: one year outcomes

    Biol Psychiatry

    (2002)
  • E. Ben-Menachem

    Vagus-nerve stimulation for the treatment of epilepsy

    Lancet Neurol

    (2002)
  • J.M. Delgado et al.

    Technique of intracranial electrode implacement for recording and stimulation and its possible therapeutic value in psychotic patients

    Confin Neurol

    (1952)
  • R.G. Heath

    Common characteristics of epilepsy and schizophrenia: clinical observation and depth electrode studies

    Am J Psychiatry

    (1962)
  • R.G. Heath

    Electrical self-stimulation of the brain in man

    Am J Psychiatry

    (1963)
  • R.G. Heath

    Modulation of emotion with a brain pacemaker: treatment for intractable psychiatric illness

    J Nerv Ment Dis

    (1977)
  • R. Rokyta et al.

    Neurostimulation methods in the treatment of chronic pain

    Physiol Res

    (2012)
  • A.E. Walker

    Cerebral pedunculotomy for the relief of involuntary movements. II. Parkinsonian tremor

    J Nerv Ment Dis

    (1952)
  • K. Das et al.

    Irving S. Cooper (1922-1985): a pioneer in functional neurosurgery

    J Neurosurg

    (1998)
  • M. Pederzoli et al.

    L-dopa long-term treatment in Parkinson's disease: age-related side effects

    Neurology

    (1983)
  • I.S. Cooper et al.

    Reversibility of chronic neurologic deficits: some effects of electrical stimulation of the thalamus and internal capsule in man

    Appl Neurophysiol

    (1980)
  • A.L. Benabid et al.

    Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease

    Appl Neurophysiol

    (1987)
  • A.L. Benabid et al.

    Deep brain stimulation of the subthalamic nucleus for Parkinson's disease: methodologic aspects and clinical criteria

    Neurology

    (2000)
  • K. Shahlaie et al.

    Intraoperative computed tomography for deep brain stimulation surgery: technique and accuracy assessment

    Neurosurgery

    (2011)
  • M. Longhi et al.

    The role of 3T magnetic resonance imaging for targeting the human subthalamic nucleus in deep brain stimulation for Parkinson disease

    J Neurol Surg A Cent Eur Neurosurg

    (2015)
  • D. Dormont et al.

    Neuroimaging and deep brain stimulation

    AJNR Am J Neuroradiol

    (2010)
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