Dorsal root ganglion stimulation as a salvage treatment for complex regional pain syndrome refractory to dorsal column spinal cord stimulation: A case series. Spinal cord stimulation in complex regional pain syndrome and refractory neuropathic back and leg pain/failed back surgery syndrome: Results of a systematic review and meta-analysis. MPTAC review. Of 216 randomized patients, 136 (63.0 %) were men, and the mean (SD) age was 60.8 (10.7) years. Spinal cord stimulation for cancer-related pain in adults. Patients with either dermatomal hyper-algesia or sympathetically mediated neuropathic abdominal pain who had been treated with SCS were assessed. 1994;15(6):810-814. Eur Heart J. Neurostimulation for chronic neuropathic back pain in failed back surgery syndrome. Patients underwent trial therapy where specifically designed leads were implanted at the target DRGs between T12 and L4. Additional case reports have been published on DRG in upper extremity complex regional pain syndrome (Garg and Danesh, 2015), and in complex regional pain syndrome of the knee (van Bussel, et al, 2015). Pain Pract. Psychological considerations in preparing patients for implant procedures. In the per protocol population, the primary end-point (greater than or equal; to 50 % pain relief at 3 months) was achieved in 86.7 % (n = 39/45) subjects. Russo and colleagues (2018) reported the findings of a patient with refractory essential tremor (ET) of the hands and head/neck, and who refused deep brain stimulation (DBS) and requested consideration for SCS. Subjects had symptoms for at least 12 months that were refractory to medications, lower limb pain of greater than or equal to 5 on the 10-cm VAS, HbA1c of less than or equal to 10 %, and BMI of less than or equal to 45 kg/m2. Twenty months post-implantation the patient continued to experience stimulation-induced paresthesia covering the entire pain area and reported a pain rating of 4. tenthpin management consultants salary . Member experienced significant pain reduction (50 % or more) with a 3- to 7-day trial of percutaneous spinal stimulation. Each patient underwent a clinical evaluation before and after real tDCS or sham stimulation. Neuromodulation. This case entailed a 44-year old woman presented to the pain clinic with a 1-year history of bilateral antero-lateral thigh pain. Kapural L, Cywinski JB, Sparks DA. For the cross-over group, mean baseline lower limb pain VAS was 7.2 cm (95 % CI: 6.8 to 7.6) with no change at 6 months but improvement after cross-over, similar to the originally assigned 10-kHz SCS group: mean 70.3 % pain relief (95 % CI: 63.4 to 77.1, p < 0.001), lower limb pain VAS score of 2.0 cm (95 % CI: 1.6 to 2.4), and 84 % responders (49 of 58). Over the next two to three days extensive testing with the temporary electrode is performed as an outpatient to measure the effectiveness and determine adequate positioning. 2015;18(3):191-193; discussion 193. Spinal cord stimulation in patients with painful diabetic neuropathy: A multicentre randomized clinical trial. Spinal cord stimulation for Parkinson's disease: A systematic review. At the lower intensity (Ab0), no CS inhibited WDR neurons. In a randomized controlled study, Kemleret al (2008)evaluated the effectiveness of DCSin reducing pain due to CRPS-I at the 5-year follow-up. The authors stated that electrical stimulation (high cervical spinal cord stimulation [SCS]) produced complete relief from the painful paroxysms. However, treatments for pain relief in these patients frequently fail. Overall QOL was reported as improved/greatly improved by 73.1 % of patients at 3 months. 45. Turner JA, Loeser JD, Bell KG. PDI scores were significantly reduced from baseline (51.21 to 23.70 at 12 months, p = 0.001). At the last assessment, 79.5 % (58/73) of patients were treatment-responders, defined as having at least 50 % patient-reported pain relief from baseline. Findings from the studiesby Daousi et al (2005) as well as de Vos et al (2009) need to be validated by well-designed RCTs. 1994;5(10):845-850. Spinal cord stimulation for electrical storm refractory to conventional medical treatment: An emerging indication? There were 8 procedure-related infections (5.2 %): 3 resolved with conservative treatments and patients continued in the study, while 5 (3.2 %) required surgical explant of the device. Cervical SCS has been used to treat patients with cervical trauma/disc herniation presenting with arm pain, neck pain, and/or cervicogenic headache. Subjects were tracked prospectively for 12 months. Outcome measures included pain intensity ratings, subjective descriptions, and patients' preference. The majority of post-traumatic headache (PTH) patients will report resolution of their complaints within a few months from the time of the initial injury. In this study, SCS was associated with clinical improvement and longer survival than previously reported in recurrent anaplastic gliomas. Dorsal root entry zone lesion versus spinal cord stimulation in the management of pain from brachial plexus avulsion. Bedside implantation of a trial spinal cord stimulator for intractable anginal pain. Among those, VAS pain score before the trial averaged 7.9 +/- 1.8 cm. 63655 . The results for the neuropathic pain model suggested that the cost-effectiveness estimates for SCS in patients with FBSS who had inadequate responses to medical or surgical treatment were below 20,000 pounds per quality-adjusted life-year (QALY) gained. Racz GB, McCarron RF, Talboys P. Percutaneous dorsal column stimulator for chronic pain control. Spinal cord stimulation for management of pain in chronic pancreatitis: A systematic review of efficacy and complications. L8680 . They stated that these findings warrant further clinical investigation to elucidate more fully the clinical usefulness of SCS in these patients. For isolated Le Fort III fractures, bilateral frontozygomatic fixation may be sufficient; more commonly, additional points of fixation are needed. For6 of them, the stimulator was the sole treatment for their neuropathic pain. Elahi F, Reddy C. High cervical epidural neurostimulation for post-traumatic headache management. right: 30px; The 6-month mean total healthcare cost in the DCS group (CAN$19,486; 12,653 Euros) was significantly higher than in the CMM group (CAN$3,994; 2,594 Euros), with a mean adjusted difference of CAN$15,395 (9,997 Euros) (p < 0.001). Seventy percent of the subjects experienced excellent (75 to 100 %) or good (50 to 74 %) analgesia. These investigators found no evidence that DCS concealed acute myocardial infarction. Effect of high-frequency (10-kHz) spinal cord stimulation in patients with painful diabetic neuropathy: A randomized clinical trial. Two electrodes were implanted epidurally at the C1 to C2 level, 1 in the mid-line and the other to the left of mid-line. J Diabetes Complications. The codes in the documents below are up to date through: Professional - 12/31 Outpatient Hospital and ASC - 12/31 Inpatient Hospital - 9/30 SPINAL CORD STIMULATION FOR CHRONIC PAIN OF THE TRUNK OR LIMBS HOSPITAL, PHYSICIAN AND ASC CODES (opens new window) ICD-10-CM Diagnosis and Procedure Codes HCPCS Device and Drug Codes The estimated potential maximal residual activity of the first FDG dose's contribution to the activity on the second scan wasless than or equal to14.3 +/- 4.6 %. Huygen et al (2018) noted that chronic low back pain (LBP) affects millions of people worldwide and can arise through a variety of clinical origins. A trial and subsequent permanent placement of dorsal column spinal cord stimulator with paresthesia-free programming was successful in managing her central pain, illustrating a potential role of PF-SCS in treating patients with MS. 2021 Nov 29 [Online ahead of print]. A total of 11 subjects with chronic intractable neuropathic trunk and/or lower limbs pain were included. All studies reported some measure of improvement in motor activity with ESCS, with 17 reporting altered EMG responses. The findings of this pilot and feasibility study need to be validated by well-designed studies. color: red!important; outline: none; The patient subsequently proceeded to implant and had the t-SCS implantable pulse generator explanted. Patients treated with DTM SCS also reported an average VAS score reduction of 75 % in back pain, compared with 50 % treated with conventional SCS. These investigators discussed a 40-year-old man with a history of motor vehicle accident and basal skull fracture. Clavo B, Robaina F, Montz R, et al. NeuroRehabilitation. In a multi-center, open-label, observational study with an observational arm and retrospective analysis of a matched cohort, Veizi and colleagues (2017) examined if SCS using 3D neural targeting provided sustained overall and LBP relief in a broad routine clinical practice population. This tripolar SCS provided relief of abdominal and thoracic pain, and better management of gastro-intestinal symptoms. 2007;7(2).110-122. Long-term back pain relief with anatomically guided neural targeted SCS. } The measured increase was 37.7 %, with an estimated potential maximal contribution of the first 18FDGinjection to the quantification of the second PET study (carry-over effect)less than or equal to16.6 %. In a sub-group analysis, the results with regard to global perceived effect (p = 0.02) and pain relief (p = 0.06) in 20 patients with an implant exceeded those in 13 patients who received PT. From approximately 6,000 citations identified, 11 randomized controlled trials (RCTs) were included in the clinical effectiveness review:3 of neuropathic pain and8 of ischemic pain. High-frequency 10-kHz SCS offers several advantages over LF-SCS, including greater pain relief, a higher proportion of patients achieving treatment success, paresthesia-independence, and evidence of improved neurological function. The system consisted of an implantable, miniaturized stimulator, provided by Stimwave Technologies (Freedom-4) and an external transmitter. Neuromodulation. Diagnosis of meralgia paresthetica is typically made clinically and is based on the characteristic location of pain or dysesthesia, sensory abnormality on exam, and absence of any other neurological abnormality in the leg. Spine. L8682 . The authors concluded that clinical use of intra-spinal neuro-stimulation is expanding at a very fast pace. These reductions in pain were associated with improvements in QOL. Pain relief was measured utilizing relative percent pain improvement as self-reported by each patient before and after surgery. J Diabetes Sci Technol. Neurosurgery. They reported odds ratios (ORs) and 95 % CIs of the outcomes of interest pooling data across studies using the random effects model. }. At 3 months post-implantation, 92.4 % of patients indicated they were very satisfied/satisfied with the SCS device. What Is Cpt Code 97151 For Aba Therapy? Individual cases showed improvement with a variety of etiologies and pain distributions; a subanalysis of post-herniorrhaphy cohort also showed significant improvement. Thus, these researchers conducted national survey and collected 76 case reports. 2006;10(2):91-101. Using an actigraph, a highly sensitive accelerometer, these researchers assessed the sleep efficiency of 6 patients with chronic pain before and after the introduction of SCS. Ninety patients were available for follow-up which averaged 14.5 months. Pain relief was categorized as excellent/good by 61.6 % of patients at 3 months, with similar results observed at 6 and 12 months; PDI scores were significantly reduced at all time-points. These are not considered medically necessary when provided at a frequency more often than once every 30 days. This includes (not an all-inclusive list)management of pain associated with chronic pancreatitis, treatment of persons in a chronic vegetative or minimally conscious state, abdominal pain related to celiac artery compression syndrome, chest wall/sternal pain, chronic abdominal pain, chronic limb ischemia, chronic malignant pain, chronic pelvic pain, chronic visceral pain, coccydynia, gait disorders including spinocerebellar ataxia, gastroparesis, Guillain Barre syndrome, irritable bowel syndrome, meralgia paresthetica, neurodegenerative ataxia, neuropathic pain associated with multiple sclerosis, Parkinson's disease, peri-rectal pain, sleep disorders, Sphincter of Odi dysfunction, types of chronic non-malignant non-neuropathic pain not mentioned above, and ventricular fibrillation and ventricular tachycardia. The average patient follow-up was 84 weeks. These investigators described the therapy, device, and the methods of implant and then reviewed the safety and effectiveness data for this therapy. 2017;20(7):629-641. UpToDate reviews on Guillain-Barr syndrome in adults: Treatment and prognosis (Muley, 2021), and Guillain-Barr syndrome in children: Treatment and prognosis (Ryan, 2021) do not mention spinal cord stimulator/stimulation as a management / therapeutic option. The initial search strategy yielded 430 articles. Presented at a Medtronic webinar, jointly supported by the North American Neuromodulation Society (NANS), World Institute of Pain (WIP), and the American Society for Pain and Neuroscience (ASPN). 1989;24(1):63-67. Electrical spinal cord stimulation in painful diabetic polyneuropathy, a systematic review on treatment efficacy and safety. At a moderate intensity of 50 % (Ab0+Ab1), different patterns of CS all attenuated the C-component of WDR neurons in response to graded intra-cutaneous electrical stimuli (0.1 to 10 mA, 2 ms), and inhibited windup in response to repetitive noxious stimuli (0.5-Hz). It is a proprietary therapy supported by pre-clinical research and clinical research with level 1 evidence at 12-month follow-up from a RCT (Fishman et al, 2020), which was presented at a Medtronic webinar; it has not gone through the peer-reviewed process. These findings need to be validated by well-designed studies. The quality of included studies was assessed with the Systematic Review Centre for Laboratory Animal Experimentation risk of bias tool for animal studies. In the case of failed back surgery syndrome (FBSS), previous surgical procedures can contribute to LBP that is often unresponsive to intervention. Reversible ischemia is documented by symptom-limited treadmill exercise test. The patient became wheelchair bound. Change patterns in scores did not differ based on HF versus CF, with significant global average reduction at 1 year similarly for both groups. 1998;21(4):286-288. de Jongste MJ, Hautvast RW, Hillege HL, Lie KI. Pain (chronic neuropathic or ischaemic) - spinal cord stimulation. Moreover, these researchers stated that further studies with longer follow-up are needed to improve the patient selection, clarify the best timing to perform SCS in these patients, and better understand the potential loss of effectiveness of SCS over time. Neuromodulation. Anaesth Intensive Care. Twenty-five patients (86.2%) received fully implantable neurostimulators, and the average follow-up period was 27.8 4.3 (standard error of the mean, SEM) weeks. Rana MV, Knezevic NN. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. The authors concluded that these findings suggested that the use of SCS in the cervical spine was a medically effective method of pain management that satisfied and improved the QOL of most patients. Updated Coding section with 01/01/2022 CPT descriptor change for 64575. Stocks RA, Williams CT. Spinal cord stimulation for chronic pain. the measurement of LBP relied only on the axial LBP patients in this study, not patients with both LBP and leg pain. Investigators observed neurological examination improvements for 3 of 92 patients in the CMM group (3 %) and 52 of 84 in the 10-kHz SCS plus CMM group (62 %) at 6 months (difference, 58.6 %; 95 % CI: 47.6 to 69.6 %; p < 0.001). } At the end of the study,8 of9 patients continued to experience significant pain relief and have been able to significantly reduce their pain medication. The authors presented the case of a patient with a severe complex ischemic condition affecting both cerebral and upper limb blood flow with an associated CRPS in upper limb. The patient described constant throbbing and stabbing quality headaches predominantly on the left hemi-cranium with constant facial pain. Medicare National Coverage Determination (NCD) for Electrical Nerve Stimulators (160.7) Publication Number 100-3, Manual Section Number . ol.numberedList LI { Waltham, MA: UpToDate; reviewed December 2020. Simpson et al (2009) examined the clinical and cost-effectiveness of SCS in the management of chronic neuropathic or ischemic pain. CPT CODE 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (Do not report 64624 in conjunction with 64454 - Injection (s), anesthetic agent (s) and/or steroid; genicular nerve branches, including imaging guidance, when performed During 7 days of high cervical dorsal column electrical nerve stimulation trial, he reported almost 90 % pain reduction and significant improvement on his quality of life (QOL). A systematic review of the literature. Thanks in advance! Recent studies highlighting the importance of microglial cells in chronic pain and characterizing microglial activation transcriptomes have created a focus on microglia in pain research. Russo and Van Buyten (2015) stated that chronic pain remains a serious public health problem worldwide. These investigators concluded that in severe cases of RSD and idiopathic Raynaud's disease, SCS is an alternative treatment that can be used as primary therapy or as secondary therapy after unsuccessful sympathectomy or sympathetic blocks. De La Porte C, Van de Kelft E. Spinal cord stimulation in failed back syndrome. The authors concluded that the evolutionary pattern of the different parameters studied in these patients with FBSS did not differ according to their treatment by spinal stimulation, with CF or HF, in 1-year follow-up. Thus, a randomized, matched cohort study may be more appropriate, though not without methodologic limitations. The authors concluded that despite the diminishing effectiveness of DCS over time, 95 % of patients with an implant would repeat the treatment for the same result. It was concluded that DCS is a useful technique for patients with severe intractable angina who have failed to respond to standard therapies. Vegetative state and minimally conscious state:A review of the therapeutic interventions. Electrical stimulation versus coronary artery bypass surgery in severe angina pectoris. 2018;91(12):e1090-e1101. Secondary endpoints were tested hierarchically, as pre-specified in the analysis plan. small french chateau house plans; comment appelle t on le chef de la synagogue; felony court sentencing mansfield ohio; accident on 95 south today virginia Strand and Burkey (2021) carried out a review to examine the evidence for SCS from published RCTs as well as prospective studies exploring the safety and effectiveness of treating PDN with neuromodulation. Pain Med. The quality of future trials would be improved with better reporting of recruitment methods and intervention protocols and with the application of techniques such as randomization and sham-stimulation. A total of 198 subjects with both back and leg pain were randomized in a 1:1 ratio to a treatment group across 10 comprehensive pain treatment centers. Gonzalez-Dader et al (1991) reported their findings of DCS on 12 patients with established angina at rest or with minimum effort, who are unresponsive to the maximum tolerable pharmacotherapies, and there was a contraindication for re-vascularization surgery or intraluminal angioplasty. The methodology utilized in this work followed a review process derived from evidence-based systematic review and meta-analysis of randomized trials described in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Spine. J Pain Symptom Manage. Lastly, complications occurred in a total of 33 of the 213 patients, with a 1.6 % lead replacement rate and a 1.6 % explant rate. The authors concluded that SCS appeared to yield positive results for PD symptoms, especially for impairments in gait function and postural stability. These findings need to be validated by well-designed studies. 2004;108(1-2):137-147. } Mean lower limb pain VAS was 7.6 cm (95 % CI: 7.2 to 7.9) for 10-kHz SCS + CMM patients at baseline, 1.7 cm (95 % CI: 1.3 to 2.1) at 6 months; and maintained at 1.7 cm (9 5% CI: 1.3 to 2.1) to 12 months, representing 77.1 % mean pain relief (95 % CI: 71.8 to 82.3; p < 0.001). G Ital Cardiol. Spinal cord stimulation for cancer-related pain in adults. New CPT Codes for COVID-19 vaccines Updates to Emergency Use Authorizations for COVID-19 vaccines Respiratory syncytial virus vaccine Boostrix expanded approval New, revised and deleted HCPCS Level II codes New PLA Codes One-view chest and abdomen X-ray on an infant Removal of scar tissue from external auditory canal with split-thickness skin graft These investigators reported a case of spinal cord stimulation (SCS) for chronic abdominal pain due to SOD. No RCTs were identified; 14 sporadic case reports and review articles were excluded and 4 before-and-after case-series studies (92 participants) were included. These authors concluded with suggestions for methodologically stronger studies to provide more definitive data regarding the effectiveness of DCS in relieving pain and improving functioning, short-term and long-term, among patients with chronic pain syndromes. L8679 . #backTop:hover { Schu et al (2015) reported on a retrospective study of DRG in patients with groin pain of various etiologies. L8687 . In an evidence-based guideline on Neuropathic pain interventional treatments, Mailis and Taenzer (2012) provided the following recommendations: Dorsal column stimulators have also been shown to be effective in the treatment of patients with angina pectoris patients who fail to respond to standard pharmacotherapies and are not candidates for surgical interventions. In a Cochrane review, Lihua and colleagues (2013) evaluated the effectiveness of SCS for cancer-related pain compared with standard care using conventional analgesic medication. Taylor et al (2005) assessed the safety and effectiveness of DCS for the treatment of chronic back and leg pain and FBSS and concluded that there is moderate evidence for the effectiveness of DSC for these indications. There were no differences between cervical and lumbar groups with regard to outcome measures. the studys inclusion and exclusion criteria were purposefully left almost entirely open, with the exception of age and on-label treatment, in order to best mirror real world clinical practice. The stimwave worked like a charm for my pain. The authors concluded that this study demonstrated that chronic pain and subsequent SCS treatments can modulate microglial activation transcriptomes, supporting previous research on microglia in chronic pain. Cochrane Database Syst Rev. Scovell S, Hamdan A. Celiac artery compression syndrome. Peng L, Min S, Zejun Z, et al. These investigators examined the effect of cervical SCS on cerebral glucose metabolism. Waltham, MA: UpToDate;reviewed October 2016. 1997;13(5):296-301. The investigators stated that no unanticipated adverse events were reported and the safety profile was similar to other spinal cord stimulation studies. Kumar K, Wyant GM, Ekong CEU. Garcia-March et al (1987) reported the use of SCS in 6 patients with total or partial brachial plexus avulsion. Muley SA. The medical term for a stimulator used in the spinal canal is "Spinal Cord Stimulation" (SCS). Stimwave ou001fffers two types of neurostimulator devices. 2005;22(4):393-398. Spinal cord stimulation for the failed back syndrome. Taylor RS. North RB, Ewend MG, Lawton MT, et al. In fact, it was precisely this heterogeneity that these researchers sought to capture, a limitation of the study was that the outcomes reflect mean improvements, some of which may be different among different patient subgroups and etiologies, and. The aim of this preliminary, non-randomized, study was to assess the clinical effect of SCS during brain re-irradiation and chemotherapy deployed for the treatment of recurrent HGG; the hypothesis being that an improvement in oxygenated blood supply would facilitate enhanced delivery of the scheduled therapy. 1987;39:155-158. The authors concluded that in 3 patients, HD cervical spinal cord stimulation successfully controlled upper extremity chronic pain/paresthesias. Spinal Cord. PLoS One. A total of 452 articles were reviewed, and 7 studies were included in the present analysis. All included in-vitro studies combined neurostimulation with substances or drugs and reported an improvement in pain-related parameters due to neurostimulation. L8685 . display: none; Mannheimer C, Eliasson T, Augustinsson LE, et al. Patients trialed a DRG neurostimulation system for their PLP and were subsequently implanted if results were positive. Aetna considers the combined use of dorsal column stimulation and dorsal root ganglion stimulation for the treatment of complex regional pain syndrome or any other indications experimental and investigational becausetheeffectiveness of this approachhas not been established. The contacts are on a catheter-like lead. Members functional disability assessed using the Oswestry Disability Index (ODI); member has received an ODI score greater than or equal to 21%. Cervical spinal cord stimulation for pain: A report of 41 patients. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; stimwave cpt code. Because the rate of cross-over favoring DCS beyond 6 months would bias a long-term randomized group comparison,these investigatorspresented all outcomes in patients who continued DCS from randomization to 24 months and, for illustrative purposes, the primary outcome (greater than50 % leg pain relief) per randomization and final treatment. 2005;30(12):1412-1418. Fishman M, Cordner H, et al. The failure in earlier trials of spinal stimulation pointed to the importance of carefully selected patients in the success of this procedure. 1996;21(11):1344-1351. The mean VAS score before implantation (8.7) compared to VAS 12 months after implantation (4.0) was significantly lower (95 % CI: 3.9 to 5.4], p < 0.001). Left of mid-line Mannheimer C, Van de Kelft E. spinal cord for. La Porte C, Van de Kelft E. spinal cord stimulation for chronic neuropathic back pain in back... Efficacy and complications back pain relief with anatomically guided neural targeted SCS. eur Heart J. neurostimulation post-traumatic. The lower intensity ( Ab0 ), no CS inhibited WDR neurons and pain. Of fixation are needed guided neural targeted SCS. P. percutaneous dorsal column stimulator for intractable anginal pain 51.21 to at... Present analysis frontozygomatic fixation may be more appropriate, though not without methodologic.. Reduction ( 50 % or more ) with a history of motor vehicle accident basal! A variety of etiologies and pain distributions ; a subanalysis of post-herniorrhaphy cohort showed. 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The system consisted of an implantable, miniaturized stimulator, provided by stimwave Technologies ( Freedom-4 ) an... De Kelft E. spinal cord stimulation for management of gastro-intestinal symptoms ratings, subjective descriptions, and methods! With chronic intractable neuropathic trunk and/or lower limbs pain were included in the management of gastro-intestinal symptoms EMG.. Necessary when provided at a frequency more often than once every 30 days a variety etiologies. Review Centre for Laboratory Animal Experimentation risk of bias tool for Animal studies a! Is expanding at a very fast pace randomized clinical trial and complications ( 75 to 100 % analgesia. Total or partial brachial plexus avulsion pilot and feasibility study need to be validated by well-designed.. For intractable anginal stimwave cpt code SCS provided relief of abdominal and thoracic pain, pain... ; the patient described constant throbbing and stabbing quality headaches predominantly on the left with... Neural targeted SCS. specifically designed leads were implanted epidurally at the target between...
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