Mimicking the brain: evaluation of St Jude Medical’s Prodigy Chronic Pain System with Burst Technology

Abstract

The Prodigy is a new type of internal pulse generator that controls the delivery of electrical stimuli to nervous tissue. It is capable of delivering burst stimulation, which is a novel waveform that consists of closely spaced high-frequency electrical impulses delivered in packets riding on a plateau, and followed by a quiescent period. Its inception was based on mimicking burst firing in the nervous system and usually delivered by unmyelinated fibers that uniformly have a motivational affective homeostatic function. It thereby targets a multimodal salience network, even though the stimuli are delivered at the level of the spinal cord. As such, it is specifically capable of influencing the affective/attentional components of pain. Burst stimulation was initially safely applied off-label to the auditory cortex for tinnitus, and later also to the spinal cord, the somatosensory cortex for neuropathic pain, subcutaneously for failed back surgery syndrome, and cingulate cortex for addiction and tinnitus.

Keywords:

• brain
• burst
• neuromodulation
• Prodigy
• stimulation

Disclaimer

DD Ridder has IP on burst stimulation. This study was conducted without financial support from St Jude Medical, who commercializes burst stimulation in Europe. T Van Camp is also an employee of St. Jude Medical. He has received no financial or other support for this study.

Financial & competing interests disclosure

D De Ridder has IP on burst stimulation. This study was conducted without financial support from St Jude Medical, which commercializes burst stimulation in Europe. T Van Camp is also an employee of St. Jude Medical. He has received no financial or other support for this study. D De Ridder and M Plazier have received educational grants and speakers' fees from St Jude Medical. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Burst stimulation mimics burst firing in the nervous system.

• Burst firing has different characteristics than tonic firing

  • – It is more powerful in eliciting both inhibitory postsynaptic potential and excitatory postsynaptic potential

    • ○ Burst firing has a nonlinear build-up of the inhibitory postsynaptic potential and excitatory postsynaptic potential

    • ○ It has a higher signal to noise ratio

  • – Burst firing can route and multiplex information selectively

    • ○ The medial (affective/motivational) pathway fires in burst mode

    • ○ Burst firing is electrophysiological correlate of motivational salience

  • Chronic pain arises when myelinated fibers are damaged resulting in spontaneous burst firing in C-fibers, thereby activating salience network (dACC + insula), generating pain and unpleasantness.

  • This results in an urging for action via activation of the sympathetic system, which suppresses the antinociceptive system, causing the pain to remain present and become chronic as long as bursting continues.

  • Treatment can be developed by silencing bursting – this is only possible by using burst stimulation.

  • Bursts have a nonlinear build-up, that is, are stronger activator of inhibitory postsynaptic potential or excitatory postsynaptic potential and can route stimuli to medial pain system, thereby removing salience from pain, and thus attention to pain as well as unpleasantness.

Notes