US20070021803A1 - Systems and methods for neuromodulation for treatment of pain and other disorders associated with nerve conduction - Google Patents

Abstract

Methods and apparatus are provided for selective destruction or temporary disruption of nerves and/or conduction pathways in a mammalian body for the treatment of pain and other disorders. Apparatus comprises catheters having electrodes for targeting and affecting nerve tissue at a cellular level to reversible and irreversible nerve poration and incapacitation.

Description

CROSS-REFERENCES TO RELATED APPLICATIONS
• This application claims the benefit of provisional application No. 60/701,747 (Attorney docket No. 020979-003500US), filed on Jul. 22, 2005, the full disclosure of which is incorporated herein by reference.
BACKGROUND OF THE INVENTION
• 1. Field of the Invention
• The present invention relates to methods and apparatus for the treatment of nerve function, and more particularly, for selective disruption of conduction pathways in the body for the treatment of pain and other disorders associated with nerve conduction in various regions within the body.
• Approximately 50 million Americans suffer with persistent (chronic) pain. The number of people suffering with chronic pain is higher than the number suffering from serious or terminal illnesses. Yet, unlike major illnesses, most chronic pain is untreated or under-treated. Pain surveys report that 42% of those experiencing chronic pain have such severe pain that they are unable to work, and 63% of pain sufferers are unable to engage in the routine activities of daily life. It has been estimated that among active workers, the loss of productivity from common pain syndromes costs over 60 billion dollars annually. In recent years, consumer advocacy, demographics, and advances in pain control technology have highlighted the clinical need for solutions and advanced the practice of pain management to a priority for healthcare providers.
• Irreversible surgical ablation has been relied upon for the treatment of chronic pain. Lesions are placed on or in the peripheral nerves, spinal chord or brain, but such placement can have side effects such as unintended motor system effects, and required open, surgical procedures. More recently, reversible electrical and localized pharmacologic solutions started to be used.
• Electrical techniques, such as neurostimulation, which deliver a low voltage electrical stimulation to a targeted peripheral nerve or spinal chord to essentially block the sensation of pain as recognized by the brain. First used in the 1960's, electrical stimulation of the peripheral nerves was shown to mask pain with a tingling sensation (paresthesia). This mechanism is part of the “gate control theory of pain” (Melzack and Wall,Science(1965) 150: 971-979.), proposing that a “gate” exists in the spinal chord that controls the transmission of pain signals to the brain. The theory suggests that activation of certain nerve fibers in the dorsal horn of the spinal chord can “close the gate” thereby inhibiting or muting the pain signals.
• A variety of different electrical stimulation techniques have been employed to achieve such blocking of the pain signals, including Transcutaneous Electrical Nerve Stimulation (TENS) which provides non-invasive (skin surface) electrical stimulation to the large mylenated fiber spinal afferents, which functionally blocks nerve signal transmission to essentially create a “short circuit” between the nerve fibers and the sensory pathway to the brain. TENS may be applied to peripheral nerve stimulation, as well as spinal chord stimulation utilizing electrodes placed at the site of the targeted nerve.
• In addition, a technique utilizing stronger electrical stimulation applied to acupuncture needles placed beneath the skin, referred to as Electroacupuncture or Acupuncture Like Transcutaneous Nerve Stimulation (ALTENS), has been employed with the goal of optimizing the release of endorphins and serotonin to combat pain. Various electrical stimulation devices are described in U.S. Pat. Nos. 4,573,481, 3,911,930 and 4,141,365, each of which is hereby incorporated by reference in their entirety.
• The LISS Cranial Stimulator (LCS) and the LISS Body Stimulator (LBS) which deliver a monopolar current at a frequency of 15,000 Hz, modulated at 50 ms “on” and 16.7 ms “off” has been used for pain treatment. (Liss, et al., (1996)Behavioral Science31: 88-94) U.S. Pat. Nos. 5,983,141 and 6,246,912 to Sluijter describe the application of an electromagnetic signal to neural tissue for pain relief through an electrode to alter the function of the tissue without causing temperatures that are lethal to the tissue.
• Stimulation of the sensory thalamus and periaqueductal or periventricular gray in the deep brain has also shown promise in treating patients that have not been helped by other less invasive modalities of treatment. In this approach, electrodes are placed in the targeted regions of the brain under stereotactic guidance. Stimulation is then applied and when a satisfactory results is achieved, a signal generator may be implanted for long term use. A variety of severe side effects can result from this approach however, including intracerebral hemorrhage and life threatening infections.
• Another approach used widely is orally administered opiates and narcotics, however the systemic effect and addictive nature of the oral medications make them less likely to provide a long term solution. Localized drug delivery or intraspinal drug administration has also shown promise, due to the fact that the approach requires significantly lower doses of narcotics that are delivered directly to the targeted region of the spinal chord either through epidural or intrathecal administration. In these approaches, percutanoues catheters may be placed at the target region, and attached to implantable (subcutaneous) reservoirs or pumps, or external drug pumps. Even though the narcotics are localized, side effects may still present, including impairment of motor function, nausea, constipation, ulcers and other side effects attendant oral narcotic administration.
• Various technologies are currently marketed to treat pain and other motor dysfunctions. Advanced Neuromodulation Systems (Plano, Tex.) manufactures an RF transmitter and probe for spinal chord stimulation as well as an implantable drug delivery system to relieve chronic pain, the latter being described in U.S. Pat. No. 5,938,690, hereby incorporated by reference in its entirety. Vertis Neuroscience (Vancouver, Wash.) provides externally placed, targeted electrode arrays that provide stimulation to the upper and lower back to provide relief to chronic pain referred to as Percutaneous Neuromodulation Therapy (PNT™). Synaptic Corporation (Aurora, Colo.) provides a product for external stimulation for chronic pain by creating electrical impulses along specific sensory nerve pathways to inhibit pain signals to the brain, effect tissue healing, and produce general tissue anesthesia, as further depicted in U.S. Pat. No. 6,161,044, hereby incorporated by reference in its entirety. US2004/0186532 describes an electrode implantable in the brain stem to deliver electrical stimulation to treat pain.
• Additional implantable systems include, a rechargeable spinal chord stimulation system that includes an implantable pulse generator and leads attached to various regions of the spine that are connected to an external remote control or alternative charging system. Such systems are available from Advanced Bionics, a division of Boston Scientific, Natick, Mass. and from Medtronic, Inc. Minneapolis, Minn. Such systems are described in U.S. Pat. No. 6,847,849. The Medtronic system may also include drug delivery technology including intrathecal drug delivery.
• Although promising, many of these systems do not provide a lasting effect, and for some, the therapeutic effect is only felt while the therapy is being administered. The treatment of intractable chronic pain remains a challenge.
• In light of the foregoing, it would be desirable to provide methods and apparatus for treating pain and other disorders associated with nerve conductivity within the human body. The methods and apparatus preferably are minimally invasive or non-invasive, are targeted to specific tissue, such as nerve tissue, and provide a long therapeutic effect. It would further be desirable to provide devices and methods that modify nerve function without necessarily causing permanent physical nerve damage (neuralgia) that can occur once the treated nerve regenerates. At least some of these objectives will be met by the inventions described below.
• All publications and patents or patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication, patent or patent application was specifically and individually so incorporated by reference.
BRIEF SUMMARY OF THE INVENTION
• The present invention provides methods and apparatus for treating pain and other nerve related disorders where the methods and apparatus are minimally or non-invasive, controlled and selective, and/or offer a more durable effect.
• Methods and apparatus according to the present invention treat chronic pain and other neural defects by delivering energy to disrupt nerve tissue at the cellular level to cause permeabolization (poration) of the cell membrane to affect the viability of the nerves at the targeted region. Target nerves include nerves in the spine, particularly cervical, thoracic, lumbar and sacral regions of the spine; peripheral nerves; nerves of the head and neck; and the brain stem. Depending on the amplitude and duration of the applied field, the “poration” of the target nerve may be reversible or irreversible, as desired. Reversible electroporation may be used in conjunction with a nerve blocking agent, chemical or other therapeutic agent to enhance, modify or otherwise modulate disruption of the nerves and/or targeted tissue.
• In one aspect of the present invention methods and apparatus are provided for treating chronic pain and other neural defects by delivering an electric, ultrasonic or other energy field generated by a pulse or pulses of a designated duration and amplitude to disrupt nerve or other tissue at the cellular level via permeabolization of the cell or cell membrane.
• In a further aspect of the invention, the energy may be delivered under conditions selected to cause irreversible cell damage by the creation of pores in the cell membrane which result in the death of the cell. Alternatively, the conditions may be selected to cause reversible or partially reversible cell damage.
• In another aspect of the invention, intracellular electromanipulation of the targeted tissue (such as nerve tissue) using ultrashort electric field pulses leading to apoptosis of the targeted cell may be desirable.
• A further aspect of the invention is to provide methods and apparatus for treating chronic pain and other neural defects by utilizing an electric field to disrupt tissue at the cellular level via permeabolization of the cell causing reversible electroporation of the cellular membrane, preferably by delivering an electric pulse or chain of pulses having a voltage between 40V and 1,000,000V. Such reversible electroporation may be applied in conjunction with a therapeutic agent such as a nerve blocking agent, a neurotoxin or neurotoxin fragment, such as the light chain portion of botulinim toxin serotype A.
• In a further aspect of the invention, it may be desirable to provide methods and devices that selectively disrupt certain cell types and not others, to provide a therapy that can be applied from multiple locations within the body.
• In a preferred aspect of the present invention, the target nerves are frequently located adjacent to arteries which can be used for percutaneous access to the nerves for example, vascular catheters having electrodes, ultrasonic transducers, or other energy sources at their distal ends may be advanced through an artery to an arterial site adjacent to the target nerve which often runs directly along the outside of the artery energy can be applied which denervates the nerve while leaving the arterial wall intact as the nerve cells are more susceptible to injury. Thus, a single treatment can damage the adjacent nerve for extended periods of months or more without damaging the artery used for access.
• Examples of arteries that can be used to access particular target nerves of the body regions include:

  	Artery	Nerve
  	Carotid	Cranio-facial
  	Vertebral	Cranio-facial
  	Radial	Peripheral (Arms and Hands)
  	Femoral	Lower limbs, Sciatica, Disc Pain
  	Popliteal	Lower limbs, Sciatica, Disc Pain

• In a specific aspect of the present invention, patients suffering from refactory angina may be treated by reversible or irreversible disruption of the stellate ganglion in the neck in the area of the C6 vertebra (FIG. 1B) and/or of the paravertebral nerves in the spine in the area of the T6 vertebra (FIG. 1B). The stellate ganglion and associated nerves can be treated or denervated by passing a nerve poration catheter into the common, internal or external arteries, placing the treatment electrode(s) or other component adjacent the nerve level to be treated, and delivering energy to cause irreversible poration to the target nerves. Some nerves may be better accessed via catheter placement in the vertebral or subclavian arteries. Nerves in the area of T6 can be accessed by placing the treatment catheter in the aorta, anterior or posterior spinal arteries, radicular arteries, intercostal arteries, or medullary arteries.
• The examples of arteries accessed and nerves treated to address various pain syndromes should be considered exemplary in nature and not limiting. It should be recognized that any syndrome which is amenable by treatment by denervation will be amenable to treatment via by the inventive technology.
BRIEF DESCRIPTION OF THE DRAWINGS
• Further features of the invention, its nature and various advantages will be more apparent from the accompanying drawings and the following detailed description, in which:
• FIG. 1A—depicts a Dermatome showing areas of the body (skin) supplied by corresponding nerve fibers on front of body;
• FIG. 1B—depicts a Dermatome showing areas of the body (skin) supplied by corresponding nerve fibers on rear of body;
• FIG. 2—depicts a side view of three vertebrae in a vertebral column showing certain relationships between spinal nerve roots and vertebrae;
• FIG. 3—depicts a schematic of spinal nerve and vertebrae.
• FIG. 4—depicts a generator and catheter system capable of supply pulsed electric fields to effect reversible or irreversible electroporation in targeted cells.
• FIG. 4A and4B—depict catheter distal tips of the present invention in various configurations showing spaced apart electrodes, including an optional monitoring electrode.
• FIGS.5A-D—depict various electrode catheter configurations adapted to deliver energy or energy and therapeutic agents to target tissue.
• FIG. 6—depicts a fully implantable pulse generator and lead of the present invention.
• FIG. 7—depicts an implantable receiver and external transmitter and controller for delivering energy according to the present invention.
• FIG. 8—depicts a schematic representing placement of the implantable version of the present invention.
• FIGS. 9A and B—depict an electrode pad for placement on the skin of a patient, including one or multiple circuits, either smooth or incorporating microneedles.
• FIG. 10—depicts a method of use of the invention according toFIGS. 9A and 9B.
• FIG. 11—depicts a method of use of the invention according toFIG. 6.
• FIG. 12—depicts a method of use of the invention according toFIGS. 5A-5D.
• FIG. 13—depicts a method of use of the invention according toFIG. 7.
• FIG. 14—depicts a schematic of a nerve fiber showing the relative cell size allowing selective cell permeabolization of nerve cells.
• FIG. 15—depicts a schematic of a target nerve region being treated by a poration catheter in an adjacent artery.
DETAILED DESCRIPTION OF THE INVENTION
• The present invention is directed to methods and apparatus for targeting, stimulating, and disrupting nerve tissue, or tissue adjacent nerve tissue (collectively “target tissue”) usually at the cellular level, in order to selectively denervate or disrupt nerves and nerve pathways responsible for creating a pain response in a mammalian body. Target tissue may be treated from one or more locations either adjacent to or at a distance from target tissue. The target tissue may include the nerve directly associated with the pain response and/or conduction pathways contributing directly or indirectly to the pain response.
• Pain syndromes that may be treated utilizing the present invention include, neuropathic and nociceptive pain, for example, musculoskeletal pain (back, neck shoulder), myofascial (muscle) pain, neuropathic pain (complex regional pain syndrome, central pain syndrome, neuralgia, neuropathy), headaches, cancer pain, fibromyalgia, pelvic pain, arachnoiditis, arthritis, facial pain (TMJ, Temporomandibular disorders (TMD)), sciatica, skin disorders (burn pain, shingles, herpes, tumors, vasculitis), spacicity, spinal chord injury or stenosis, sickle cell disease, and pain associated with vascular disease, both peripheral and cardiac.
• The body's nervous system consists of the central nervous system (brain), spinal chord nerves and the peripheral nervous system (sensory nerve fibers and motor nerve fibers outside of the brain and spinal chord). The system includes nerves (bundles of axons enclosed in connective tissue) and can be characterized as sensory/afferent, motor/efferent, or a combination of both sensory and motor fibers. The spinal nerves include fused nerve roots, for example, the dorsal root nerves are associated with sensory functions, and the ventral root nerves are associated with motor functions. Peripheral nerves may be cranial (arising from the brain), or spinal (arising from the spinal column), and are usually associated with sensations or motor functions in the hands, arms, legs or feet.
• Cranial nerves are mostly associated with motor function, or a combination of motor and sensory functions. As shown inFIG. 2, the spinal nerves consist of 31 pairs of nerves organized into various regions along the spine the cervical (C), thoracic (T), lumbar (L), and sacral (S). The spinal nerves are further organized into nerve networks or nerve plexus including C1-C4 (cervical plexus), C5-C8 and T1 (brachial plexus), L1-14 (lumbar plexus), and L4-S4 (sacral plexus). The relationship between the spinal nerve and the muscle (myotome) and between spinal nerve and skin (dermatome) are depicted inFIGS. 1A and1B, showing the nerves associated with the particular region of the body. In treating pain or other disorders associated with nerve conduction in the body, devices can target a relatively localized region of the spinal column depending on the type of pain or motor function and location of pain or motor function (dermatome or myotome) to be treated.
• Devices of the present invention may be directed to “targeted regions” such as cervical, thoracic, lumbar and sacral regions of the spine, peripheral nerves, nerves of the head and neck, brain stem, and deep brain. Some particular examples include, spinal chord modulation for chronic pain (for example application of energy of the present invention to the region of the spine at L1-L5 to treat lower limb and/or back pain), peripheral nerve modulation for chronic pain (for example the radial or ulnar nerve to treat hand or finger pain or dysesthesias.), and sacral nerve modulation to treat pelvic pain. In some instances, the devices and methods of the present invention may also be employed to treat certain motor dysfunctions; for example, spinal chord nerve modulation to treat peripheral vascular disease (PVD), deep brain nerve modulation for tremor, Parkinsons, depression, obsessive compulsive disorder, motor dysfunction, and brain injury, and vagus nerve modulation for treatment of epilepsy, or obesity.
• High Voltage Pulsed Electric Fields. To achieve the goals of the present invention, it may be desirable to employ methods and apparatus for achieving nerve modulation and/or denervation utilizing pulsed electric fields and/or electroporation applied directly to the targeted region or in proximity to the targeted region to produce the desired denervation or nerve disruption. For purposes of this disclosure, the term “electroporation” can encompass the use of pulsed electric fields (PEFs), nanosecond pulsed electric fields (nsPEFs), ionophoreseis, electrophoresis, electropermeabilization, sonoporation and/or combinations thereof, permanent or temporary, reversible or irreversible, with or without the use of adjuctive agents, without necessitating the presence of a thermal effect. Similarly, the term “electrode” used herein, encompasses the use of various types of energy producing devices, including antennas (microwave transmitters) and ultrasonic elements. In practice, sonoporation, cell membrane manipulation by application of ultrasonic energy, may have advantages in performing the therapeutic treatment of the present invention due to its ability to manipulate the membrane without producing as much heat at the treatment site as other energy modalities that have been used, and its ability to focus at a specific treatment site.
• The methods and apparatus of the present invention can employ reversible electroporationof the type used in medicine and biology to transfer chemicals, drugs, genes and other molecules into targeted cells for a variety of purposes such as electrochemotherapy, gene transfer, transdermal drug delivery, vaccines, and the like. Irreversible electroporation may also be employed as used for cell separation in debacterilization of water and food, stem cell enrichment and cancer cell purging (U.S. Pat. No. 6,043,066 to Mangano), directed ablation of neoplastic prostate tissues (US2003/0060856 to Chornenky), treatment of restenosis in body vessels (US2001/0044596 to Jaafar), selective irreversible electroporation of fat cells (US 2004/0019371 to Jaafar) and ablation of tumors (Davalos, et al.Annals of Biomedical Engineering33: 223-321. The entire contents of each of these references are expressly incorporated herein by reference.
• Energy fields applied in ultrashort pulses, or nanosecond pulsed electric fields (nsPEFs) may also be used to porate target nerve and other cells in accordance with the present invention. Ultrashort pulse lengths are directed at target subcellular structures without permanently disrupting the outer membrane. An example of this technology is described by Schoenbach et al. (2001)J. Bioelectromagnetics22: 440-448, and in U.S. Pat. No. 6,326,177, the contents of which is expressly herein incorporated by reference. The short pulses target the intracellular apparatus, and although the cell membrane may exhibit an electroporative effect, such effect is reversible and does not lead to permanent membrane disruption. Following application of nanosecond pulses, apoptosis is induced in the intracellular contents, affecting the cell's viability (for example limiting the ability to reproduce).
• In a specific embodiment of the present invention, electroporation may be achieved by energizing an electrode or series of electrodes to produce an electric field. Such a field can be generated in a bipolar or monopolar electrode configuration. When applied to cells, depending on the duration and strength of the applied pulses, this field operates to increase the permeabolization of the cell membrane and either (1) reversibly open the cell membrane for a short period of time by causing pores to form in the cell lipid bilayer allowing entry of various therapeutic elements or molecules, after which, when energy application ceases, the pores spontaneously close without killing the cell, or (2) irreversibly opening or porating the cell membrane causing cell instability resulting in cell death utilizing higher intensity (longer or higher energy) pulses, or (3) applying energy in nanosecond pulses resulting in disruption of the intracellular matrix leading to apoptosis and cell death, without causing irreversible poration of the cellular membrane. As characterized by Weaver (1993),Journal of Cellular Biochemistry51: 426-435, short(1-100 μs) and longer (1-10 ms) pulses have induced electroporation in a variety of cell types. In a single cell model, most cells will exhibit electroporation in the range of 1-1.5 V applied across the cell (membrane potential).
• Certain factors determine how a delivered electric field will affect a targeted cell, including cell size, cell shape, cell orientation with respect to the applied electric field, cell temperature, distance between cells (cell-cell separation), cell type, tissue heterogeneity, properties of the cellular membrane and the like. Larger cells may be more vulnerable to injury. For example, skeletal muscle cells have been shown to be more susceptible to electrical injury than nearby connective tissue cells (Gaylor et al. (1988) J. Theor. Biol. 133: 223-237). In addition, how cells are oriented within the applied field can make them more susceptible to injury, for example, when the major axis of nonspherical cells is oriented along the electric field, it is more susceptible to rupture (Lee et al. (1987)Plastic and Reconstructive Surgery______: 672-679.)
• Various waveforms or shapes of pulses may be applied to achieve electroporation, including sinusoidal AC pulses, DC pulses, square wave pulses, exponentially decaying waveforms or other pulse shapes such as combined AC/DC pulses, or DC shifted RF signals such as those described in Chang, (1989)Biophysical JournalOctober 56: 641-652, depending on the pulse generator used or the effect desired. The parameters of applied energy may be varied, including all or some of the following: waveform shape, amplitude, pulse duration, interval between pulses, number of pulses, combination of waveforms and the like.
• Catheter Devices.FIGS. 4 and 4A-4B depict asystem10 comprising anelectroporation catheter12 for selective denervation/disruption of nerve tissue. For purposes of this specification, the term “catheter” may be used to refer to an elongate element, hollow or solid, flexible or rigid and capable of percutaneous introduction to a body (either by itself, or through a separately created incision or puncture), such as a sheath, a trocar, a needle, a lead. In certain configurations of the present invention, voltages may be applied via theelectroporation catheter12 to induce irreversible electroporation, without requiring the use of any other agents to achieve the desired cell destruction and/or denervation. It is a further advantage of this type of energy that any thermal effect may be minimized thereby preventing or minimizing collateral damage to tissues near the target tissues, or the type of physical damage to the nerves themselves that can lead to permanent neuralgia when the nerve fibers generate A further advantage of this type of energy is that the electroporation or electropermeabilization effect is largely cell-size specific. That is, larger cells will be porated (either reversibly or irreversibly) at lower energy levels than smaller cells. This will allow the denervation effect to be directed at the relatively large nerve cells while sparing smaller adjacent cell types. In addition, the electric field may be controlled by the size and relative positioning of the electrodes on the treatment device or patient.
• Theelectroporation catheter system10 further comprises apulse generator14 such as those generators available from Cytopulse Sciences, Inc. (Columbia, Md.); Bio-Rad, Inc. (Hercules, Calif.) (the Gene Pulser Xcell); and IGEA (Carpi, Italy). The pulse generator is electrically connected to thecatheter12 which has aproximal end20 and adistal end22 and is adapted for either surface placement (cutaneous) or minimally invasive insertion into the desired region of the body as described herein. Thegenerator14 may be modified to produce a higher voltage, increased pulse capacity or other modifications to induce irreversible electroporation. Thecatheter12 further comprises an electroporation element at the distal end thereof comprising afirst electrode30 and a second axially spaced-apartelectrode32 operatively connected to the pulse generator throughcables34 for delivering the desired number, duration, amplitude and frequency of pulses to affect the targeted nerve tissue. The energy delivery parameters can be modified either by the system or the user, depending on the location of the catheter within the body (e.g., the nature of the intervening tissues or structures) and whether a reversible or irreversible cell poration is desired. For example energy in the range of 10 V/cm to 10⁴V/cm for a duration of 10 μs to 100 ms may be used to achieve reversible electroporation and in the range of 100 V/cm to 10⁶V/cm for a duration of 10 μsec to 100 msec to achieve irreversible electroporation or apoptosis. As shown inFIG. 4A,electrodes30 and32 may be axially aligned on one side ofcatheter12 to produce an electric field concentrated in a lateral direction from the catheter body. Usingring electrodes30 and32 as shown inFIG. 4B, creates a more uniform electric field about the shaft of thecatheter12. Additional monitoring electrode(s), may be located on thecatheter12.
• Further catheter devices and electrode configurations are shown inFIGS. 5A-5D.FIG. 5A depicts anelongate catheter50 having afirst electrode52 andsecond electrode54 near its distal tip. A monitoring orstimulation electrode56 is disposed in the vicinity of theporating electrodes52 and54 for monitoring or localizing the treatment area. In some embodiments, the monitoring or stimulating function may be performed by one or more of the treatment electrodes. Thecatheter50 may have an optional sharp tip58 (shown in broken line) to facilitate percutaneous introduction.Electrodes52,54 and56 are shown as axially aligned on one side of thecatheter50 but could also have ring or other structures.
• FIG. 5B illustrates asteerable catheter60 adapted to bend or articulate at aregion62 near its distal end.Active electrodes64 and66 are disposed adjacent to or within the articulatedregion62 and a monitoring orstimulation electrode68 is optionally disposed proximally of the active electrodes. Such steering ability enables the operator to introduce the device into tight or tortuous spaces so that optimal placement of the device may be achieved.
• FIG. 5C depicts acatheter70 that includes aninjection element72 to allow for the injection of a therapeutic agent before, during or after the application of the pulsed energy or electroporation fromactive electrodes74 and76 and monitoring or stimulatingelectrode78. The injection element may be a needle as shown inFIG. 5C, an infusion port, or other infusion means. Such a therapeutic agent may be, for example, lidocaine, botulinum toxin (either full or in fragment as detailed copending application No. 11/______ (Attorney Docket No. 020979-003410US, filed on Jul. 21, 2006, the full disclosure of which has been incorporated herein by reference), capsaicin or a variety of nerve blocking agents. The use of the devices and methods of the present invention can increase the effectivity and provide for alternative means of delivery for botulinum toxin to treat pain by inhibiting the release of the neurotransmitter responsible for the transmission of pain, such as various neuropathic diseases and disorders as described in U.S. Pat. Nos. 6,113,915, 6,333,037, 6,372,226, 6,841,156, 6,896,886 and 6,869,610 to Aoki, the contents of which are expressly incorporated herein by reference in their entirety. Further, to aid the electroporation process, it may be advantageous to heat the targeted cells or surrounding tissue by either applying thermal energy directly to the region, or directing a heated fluid, such as saline to the region through the injection element.
• FIG. 5D depicts acatheter80 havingdeployable electrode elements82 and84 that are adapted to extend laterally from the main catheter body, and in some cases, penetrate the surrounding tissue prior to application of energy. In doing so the depth and direction of the energy field created by the electroporative process, may be further controlled. As with the previous embodiments, a stimulating ormonitoring electrode86 may optionally be provided proximally of the active electrodes.
• In certain configurations it may be advantageous to use the poration catheters and methods of the present invention in conjunction with a nerve blocking agent, neurotoxin, neurotoxin fragment or other therapeutic agents according to methods and devices described in co-pending patent application no 11/______ (Attorney Docket No. 020979-003410US), filed on Jul. 21, 2006, the full disclosure of which has been incorporated by reference in its entirety. In this instance, the voltage applied to the electrode elements would preferably be in the range applicable to create a reversible electroporation of the nerve or tissue cells, thereby porating the cell to allowing the therapeutic agent to be delivered to achieve the desired effect, but not destroying the cell or otherwise irreversibly damaging the targeted tissue or nerve structures.
• Any of the foregoing systems may include electrodes or other monitoring systems either located on the treatment catheter, or external to the patient, to determine the degree of treatment to the region, including, thermocouple, ultrasound transducers, fiberoptics, sensing or stimulating electrodes. Further, it may be desirable to incorporate multiple pairs of electrodes that may be activated in pairs, in groups, or in a sequential manner in order to maximize the desired shape of the lesion while minimizing the field strength requirements. Also, the devices of the present invention may be used in conjunction with more traditional neuromodulation techniques, such as TENS, to mediate pain attributable to the treatment (the presence of which may depend on the level of voltage applied) or neuromuscular response to the applied electric field as further noted in published U.S. application No. 2003/0149451, hereby incorporated by reference in its entirety.
• Implantable Devices. A fully implantable spinalcord modulation system100 includes animplantable pulse generator102 which incorporates a power supply or battery as depicted inFIG. 6. Thesystem100 connects to animplantable lead104 which includes electrodes106 and108. As shown inFIG. 7, a partially implantable system120 includes a transmitter122, and a receiver124 that relies upon radio frequency to transmit the energy to the lead or electrode. In this system the antenna and transmitter are carried outside the body, while the receiver connected to thelead126 with electrodes128 and130) is implanted inside the body.FIG. 8 shows the placement of the fullyimplantable pulse generator100 device in the region of the sacral plexus of a patient which has been implanted according to the steps set forth in U.S. Pat. No. 6,847,849, previously incorporated by reference herein. Implantation of the partially implantable system120 could be achieved in the identical manner.
• Cutaneous or Subcutaneous Devices. For some conditions, it may be desirable to apply the poration energy from the surface of the skin (transcutaneously), or from just below the skin (subcutaneously).FIG. 9A depicts adermal patch150 having anelectrode pair152 and154 for delivery of therapeutic energy of the present invention to the targeted region. Alternatively, the pad may include one electrode, while the other (a ground) may be positioned elsewhere on the patient's skin (not shown). Depending on the type of voltage applied and condition to be treated, it may be desirable to have multiple electrode pairs on the surface of the patch or pad, and in some cases as shown inFIG. 9B, such electrodes may be in the form ofmicroneedles160 that puncture the skin some distance to deliver the therapeutic energy of the present invention subcutaneously. The patch or pad carrying the electrodes should be flexible and conformable and may be formed of a polymer such as silicone, urethane, nylon, polyethylene or other thermoplastic elastomers, or could be substantially rigid and formed of a rigid polymer (such as PEEK or polysulfone)or insulated stainless steel, nickel titanium alloy, or other metal. As noted above, various monitoring devices and methods may be employed to track the progress of the therapy. Similarly, algorithms to activate pairs of electrodes or regions of the pad or patch may be employed to enhance the therapeutic effect while reducing the overall power requirements.
• Intraluminal Devices. It may further be advantageous to position poration catheters through vessels in the body, particularly arteries to treat adjacent nerves, to direct poration energy to various regions to effect pain reduction. Such intraluminal catheters are described in published U.S. applications 2001/0044596 to Jaafar and 2002/0198512 to Seward, hereby incorporated by reference in their entirety, could be used for such energy delivery.
• Methods of Use.FIG. 10 illustrates a method for nerve poration by applying energy to the surface of the skin S via theelectrode patch150.FIG. 11 depicts the implantation ofelectrode lead104 or126 that is then operatively connected to the implantable generator and described herein.FIG. 12 shows percutaneousnerve poration catheter12 implanted in a region within the spine. InFIGS. 11 and 12, the active tip region of the catheter or lead is shown placed alongside the nerve region NR to be treated, but in fact may be positioned within the nerve sheath, or along the spine (SP), or within the muscular layer (MP).
• In yet another embodiment shown inFIG. 13, areceiver200 may be placed at the target location (here alongside the nerve region NR in the spine SP), while a transmitter202 is placed outside or on the skin of the patient. Once in place adjacent the nerve region NR to be treated, a pulse generator in the transmitter202 may be activated, causing an electric field to be generated in the target area. Prior to activation of therapeutic voltages, once the catheter(s) have been appropriately positioned, stimulation using one or more electrodes may be used to elicit a nerve response. By observing the nerve reflex, a target treatment location can be confirmed, and then application of poration energy is employed to eliminate or disrupt the nerve and associated pain response, thereby selectively denervating the conduction pathways for the particular type of pain to be treated.
• In operation, effects of poration on nerve tissue may be selective due to the cellular structure and orientation of the nerve cells. For example as shown inFIG. 14, targeted nerve cells may be preferentially affected due to size, sparing smaller or cross-oriented muscle tissue. As shown, the energy may selectively rupture thenerve cells220 at ends222 while the energy dissipates over the main body of the cells.
• As shown inFIG. 15,poration catheter12 can be introduced into a lumen of artery A to a location immediately adjacent to a nerve region NR to be treated. Thecatheter12 will typically be introduced over a guidewire GW under fluoroscopic guidance using well-known intravascular intervention methods and protocols. Once in place, electroporation or other poration energy can be applied across the arterial wall toward the nerve region NR to denervate the nerve as described previously. As the nerve cells will typically be more susceptible to energy induced damage, the desired temporary or permanent denervation can usually be achieved with minimum or no damage to the artery. Thecatheter12 can be removed after the treatment session is completed. The treatment can be repeated months or years later if and when nerve function returns.
• Although various illustrative embodiments of the present invention are described above, it will be evident to one skilled in the art that various changes and modifications may be made without departing from the scope of the invention. It will also be apparent that various changes and modifications may be made herein without departing from the invention. The appended claims are intended to cover all such changes and modifications that fall within the true spirit and scope of the invention.

Claims (30)

1. Apparatus for selective denervation of target tissue, comprising:

an electrode support having one or more electrodes disposed thereon, wherein said electrode(s) are adapted to transmit an electrical pulse and/or series of electrical pulses; and

a pulse generator operatively connected to the catheter, wherein the electrodes and generator are configured to deliver cellular poration energy in the range from 10 V/cm to 10⁶V/cm to disrupt membranes of target cells to disrupt pain conduction pathways.

2. The apparatus ofclaim 1, wherein the support comprises a catheter which is adapted to be positioned percutaneously in an artery at a location adjacent to a region of the spine in a human patient selected from the group consisting of the cervical, thoracic, sacral and lumbar regions.

3. The apparatus ofclaim 1, wherein the support comprises a catheter which is adapted to be positioned percutaneously at a region of the peripheral nerves in a human patient.

4. The apparatus ofclaim 1, wherein the support comprises a catheter which is adapted to be implantable within the body and a pulse generator adapted to be located outside the human body.

5. The apparatus ofclaim 1, wherein the support and pulse generator are implantable within the human body.

6. The apparatus ofclaim 1, wherein the support comprises a patch and the one or more electrodes are configured on the patch to be applied to the skin.

7. The apparatus ofclaim 6, wherein the one or more electrodes comprise one or more micro needles.

8. The apparatus ofclaim 1, wherein the pulse generator and electrodes are adapted to deliver poration energy at from 10 V/cm to 10⁴V/cm for durations from 10 μsec to 100 msec to achieve reversible poration.

9. The apparatus ofclaim 1, wherein the pulse generator and electrodes are adapted to deliver poration energy at from 100 V/cm to 10⁶V/cm for durations from 10 μsec to 100 msec to achieve irreversible poration.

10. A method for selective denervation of targeted tissue of a patient, said method comprising delivering energy to target cells of said target tissue under conditions selected to permeabilize the cell membrane to disrupt a pain conduction pathway provided by the cell.

11. A method as inclaim 10, wherein the target cells are nerve cells.

12. A method as inclaim 11, wherein the nerve cells are selected from the group consisting of nerves of the spine, peripheral nerves, nerves of the head and neck, and the brain stem.

13. A method as inclaim 12, wherein the nerve cells are in the spine.

14. A method as inclaim 13, wherein the target spinal nerve cells are in the region of the sacral plexus.

15. A method as inclaim 13, wherein the target spinal nerve cells comprise those in the stellate ganglion in the region of C6.

16. A method as inclaim 12, wherein the target spinal nerve cells are in the area of T6.

17. A method as inclaim 11, wherein the nerve cells are immediately adjacent to an artery.

18. A method as inclaim 17, wherein said energy is delivered from a catheter positioned in the artery.

19. A method as inclaim 10, wherein the energy is electric delivered in the range from 10 V/cm to 10⁶V/cm for a period in the range from 10 μsec to 100 msec.

20. A method as inclaim 10, wherein the energy is delivered under conditions which provide a reversible poration.

21. A method as inclaim 20, wherein the energy is electrical in the range from 10 V/cm to 10⁴V/cm.

22. A method as inclaim 10, wherein the energy id delivered under conditions which provide an irreversible poration.

23. A method as inclaim 22, wherein the energy is electrical in the range from 100 V/cm to 10⁶V/cm.

24. A method as inclaim 10, wherein the energy comprises ultrasonic energy.

25. A method as inclaim 10, further comprising delivering a nerve blocking agent under conditions to act together with the energy to block the pain conduction pathway.

26. A method as inclaim 25, wherein the nerve blocking agent is delivered simultaneously with the energy delivery.

27. A method as inclaim 10, wherein the energy is delivered with a catheter.

28. A method as inclaim 27, wherein the catheter is implanted.

29. A method as inclaim 27, wherein the catheter is percutaneously positioned in an artery.

30. A method as inclaim 10, wherein the energy is delivered transcutaneously from a surface of the patient's skin.

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