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Tonic, Burst, Dorsal Root Ganglion, and High Frequency

Which One to Choose?

Issa, Mohammed, MD; Gilligan, Christopher J., MD, MBA

doi: 10.1097/BRS.0000000000002568

Brigham and Women's Hospital, Boston, MA.

Address correspondence and reprint requests to Mohammed Issa, MD, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; E-mail:

Received 2 January, 2018

Accepted 11 January, 2018

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership.

The current environment of spinal cord stimulation is rapidly advancing, with new technologies and applications emerging constantly, allowing for more effective and individualized treatment of our patients. However, these new advances can be overwhelming for the practicing clinician, because there are no high-quality, head-to-head studies comparing these new technologies, making the clinician's choice a difficult one. High-level evidence already exists on the efficacy and safety of traditional tonic stimulation for the treatment of chronic refractory lower back with predominant limb pain. More recently, paresthesia-free high-frequency and burst stimulation was introduced, and has shown superiority over traditional stimulation for both chronic lower back and leg pain (Figure 1).1 Dorsal root ganglion stimulation is another novel form of neuromodulation that offers a highly targeted form of stimulation (Figure 2).2 Level I evidence now exists showing the superiority of both dorsal root ganglion and high-frequency stimulation over traditional stimulation.1,2 When attempting to choose between these different technologies, the main goal should be to achieve the best pain relief with minimal further interventions. Burst stimulation provides the option of alternating between tonic and paresthesia-free stimulation depending on patient preference and efficacy.3 High-frequency therapy is useful for patients who cannot tolerate paresthesia or have predominantly axial back pain. Dorsal root ganglion is particularly useful in covering areas that are hard to cover with conventional stimulation, such as the foot and groin. Overall, these different technologies provide drug-free, safe, and effective options for chronic pain.

Figure 1

Figure 1

Figure 2

Figure 2

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1. Kapural L, Yu C, Doust MW, et al. Novel 10-kHz high-frequency therapy (HF10 therapy) is superior to traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain: the SENZA-RCT randomized controlled trial. Anesthesiology 2015; 123:851–860.
2. Deer TR, Levy RM, Kramer J, et al. Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial. Pain 2017; 158:669–681.
3. De Ridder D, Plazier M, Kamerling N, et al. Burst spinal cord stimulation for limb and back pain. World Neurosurg 2013; 80:642–649.

chronic pain; neuromodulation; spinal cord stimulation

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