Nucelio Lemos, MD, PhD

Neuromodulation:
Mechanisms of Action, Indications,
Targets and Perspectives
Nucelio Lemos, MD, PhD
Doctorate in Gynecology by FCM Santa Casa SP
Fellowship in Neuropelveology by the International School of Neuropelveology, Zurich
Head of the Pelvic Neurodysfunctions Clinic, DepT. of Gynecology - Federal University of São Paulo
Interim Chairman of the Scientific Committee of the Intenational Continence Society
Founding Member of the ISON - International Society of Neuropelveology
Financial Disclosures
Nucelio Lemos, MD PhD
-Speaker/Proctor
-Medtronic®
-Johnson&Johnson®
-Research Grants
- Medtronic®
- Laborie®
Neuromodulation
-
Definition
Neuromodulation therapies allow focused delivery of modifying
agents – e.g. electrical, optical or chemical signals - to
targeted areas of the nervous system in order to improve
neural function. They range from non-invasive techniques to
techniques involving the surgical implantation of devices to
alter activity in discrete areas of the nervous system.
International Neuromodulation Society
- Surgical peripheral nerve modulation
www.neurodisfuncao.med.br
Mechanisms of Action
Mechanisms of Action
Mechanisms of Action
- Afferent Modulation (5Hz-15Hz)
- Induction of Relative Refractory State (Seol, 2007)
- Inhibition of Spinal and Supra-Spinal Centers (Malaguti, 2009)
- Direct Stimulation (≥20Hz)
- Smooth and Striated Muscle Contraction (Brindley, 1977; Possover, 2010)
Mechanisms of Action
- Synaptic Facilitation (5Hz-20Hz)
- Increase in number of vesicles that open up in synaptic cleft (Qian&Delaney, 1997;
Logsdon et al, 2006)
- Neuroplasticity
- Continuous electric stimulation induces axonal sprouting and synapse
formation (Manivannan, 1994; Brus-Ramer, 2007)
S3 Neuromodulation
Possible Targets for Treating PFD
- Sacral Nerve Roots
- Pudendal Nerve
- Other Nerves
Possible Applications in PFD
-
Urge-Incontinence/Frequency
Detrusor Overactivity
Detrusor-Sphincter Dissinergia
Non-Obstructive Urinary Retention
Fecal Incontinence
Constipation
Pelvic/Bladder Pain
®
Interstim na Incontinência Anal
Percentual de Pacientes com Redução de 100% nos
Acidentes em 12 Meses
50%
Estudo da Terapia InterStim no Controle Intestinal1,2
47%
40%
30%
Tjandra RCT3
36%
41%
20%
10%
0%
MWC
Por Protocolo
Grupo SNS
1. Wexner SD, Coller JA, et al. Ann Surg. 2010 Mar;251(3):441-9.
2. Pesquisa patrocinada pela Medtronic : Terapia InterStim - Resumo Clínico, 2011.
3. Tjandra JJ et al. Sacral nerve stimulation is more effective than optimal medical therapy for severe fecal incontinence: a randomized, controlled study. Dis Colon
Rectum. May 2008;51(5):494-502.
®
Interstim na Incontinência Anal
Número Médio de Episódios Semanais de Incontinência
10
7,5
5
2,5
0
MWC
Por Protocolo
1. Wexner SD, Coller JA, et al. Ann Surg. 2010 Mar;251(3):441-9.
2. Pesquisa patrocinada pela Medtronic : Terapia InterStim - Resumo Clínico, 2011.
Nivel de Evidência: 2B
Grau de Recomendação: B
®
Interstim in OAB
- Physiotherapy/Behaviral Treatment
- Sacra Stimulation
- Tibial Nerve Stimulation
- Medical Treatment
- Anticolinergics
- Beta-Agonists
- Antidepressants
- Botulinum Toxin
- 4th line treatment
- Refractory OAB
®
Interstim in OAB
- Physiotherapy/Behaviral Treatment
- Sacra Stimulation
- Tibial Nerve Stimulation
- Medical Treatment
- Anticolinergics
- Beta-Agonists
- Antidepressants
- Botulinum Toxin
- 3rd line treatment
- Refractory OAB
®
Interstim in OAB
Evidence Level: 1B
Recomendation Grade: A
Siddiqui (2010) Efficacy and Adverse Events of Sacral Nerve Stimulation for Overactive
Bladder- A Systematic Review
What if it Fails?
Evidence Level: 4
Recomendation Grade: C
®
Interstim in PBS/IC
Evidence Level: 2A
Recomendation Grade: B
Implantation Technique
Spinelli, 2005
LION Procedure
LION Procedure
LION Procedure
INDICATIONS
- Neuropathic Pain
- Phantom Pain - 4/C
- Post-Herniorrhaphy
Inguinodynia 4/C
- Chronic Pelvic Pain 2B/B
- Perineal Pain 2B/B
- Sciatica 4/C
- Post-Decompression Pain 4/C
- Anal Incontinence 4/C
- Detrusor Overactivity 4/C
- Rehabilitation of Spastic
Paraplegic Patients 1c/C
www.neurodisfuncao.med.br
LION Procedure
www.neurodisfuncao.med.br
Direct Stimulation / Neuromodulation
www.neurodisfuncao.med.br
Parasympathetic Stimulation
www.neurodisfuncao.med.br
Direct Stimulation
www.neurodisfuncao.med.br
Direct Stimulation / Neurplasticity
www.neurodisfuncao.med.br
Direct Stimulation
www.neurodisfuncao.med.br
Direct Stimulation
www.neurodisfuncao.med.br
Direct Stimulation
www.neurodisfuncao.med.br
Direct Stimulation
www.neurodisfuncao.med.br
LION Procedure
www.neurodisfuncao.med.br
Neuroplasticity / Muscular Recruitment / Neuromodulation /
Neurostimulation
www.neurodisfuncao.med.br
®
Interstim - Complications
Siddiqui (2010) Efficacy and Adverse Events of Sacral Nerve Stimulation for Overactive Bladder- A Systematic Review
In Conclusion…
In Conclusion…
- In what kind of OAB should we offer neuromodulation?
- Botulinum Toxin failure
- Repeated BoT injections
- Don’t accept the risk of urinary retention and self-cath
- Double Incontinence
- Associated Pain Symptoms
In Conclusion…
- Sacral or Pudendal?
- Sacral is less invasive and should be preferred in situations
of similar success rates
- Idiopathic OAB
- Fecal Incontinence
- Non-Obstructive urinary retention
In Conclusion…
- Pudendal Neuromodulation
- Pelvic/Neuropathic Pain
- Neurogenic DO
- IF YOU CAN ONLY DO SACRAL, TRY IT!!
- Remember that Pudendal Ncuromodulation is an option even
after failure of SNM
Obrigado!
[email protected]
www.neurodisfuncao.med.br
www.ison.org
[email protected]
www.neurodisfuncao.med.br
Save the Date! April 21-23 • 2016 • St. Louis, MO , USA
Advanced Retroperitoneal Anatomy
and Neuro-Anatomy of the Pelvis
Hands-on cadaver workshop
with Focus on Complication Prevention in Minimally Invasive Surgery
in Endometriosis, Urogynecology and Oncology
ICAPS Faculty
Nucelio Lemos, MD, PhD (Course Chair)
Adrian Balica, MD (Course Co-Chair)
Eugen Campian, MD, PhD
Vadim Morozov, MD
Jonathon Solnik, MD, FACOG, FACS
Faculty
Claudio Crispi, MD
Sidney P. Furtado, MD
Renato Moretti Marques, MD, PhD
Marco Aurelio P. Oliveira, MD, PhD
Thiers Soares Raymundo , MD
M. Brigid Holloran-Schwartz, MD
Patrick Yeung Jr., MD
http://pa.slu.edu
An offering through:
Practical Anatomy & Surgical Education Department of Surgery
Saint Louis University School of Medicine