Mapping method and system, method and system for evaluating the efficacy of medullary stimulation

A method for mapping painful zones, includes: on a first screen, displaying a first silhouette representing the rear face of a body; drawing at least one painful zone on the first displayed silhouette; indicating the location of a pain felt by a patient; determining a first number of pixels on the first screen corresponding to the painful zone; measuring a reference distance between two morphological reference points on the patient; converting the first number of pixels into a painful cutaneous surface, the reference distance being used as a parameter in the conversion.

CROSS-REFERENCE TO RELATED APPLICATIONS

This is the U.S. National Stage of PCT/EP2014/067231, filed Aug. 12, 2014, which in turn claims priority to French Patent Application No. 1358850, filed Sep. 13, 2013, the entire contents of all applications are incorporated herein by reference in their entireties.

TECHNICAL FIELD OF THE INVENTION

The invention relates to the medical field, and notably to the technique of medullary stimulation, in particular for the management of post-operational spinal pathology. The invention more particularly relates to systems and methods for mapping dorsal pain felt by a patient, and paraesthesias felt following medullary stimulation aiming to relieve said pains.

TECHNOLOGICAL BACKGROUND OF THE INVENTION

The technique of medullary stimulation, also known as stimulation of the spinal cord or neurostimulation, is used to provide relief to patients suffering from severe neuropathic pain. This technique consists in emitting electric pulses in the direction of the nerve fibres of the spinal cord of a patient, through the intermediary of at least one multi-contact electrode. The at least one electrode may be old generation (mono-column) or new generation (multi-column).

Medullary stimulation may be applied by surgical or percutaneous route (in this case, the central nervous system is stimulated; the stimulation is triggered from the electrode in the vertebral canal) or instead it may be sub-cutaneous nervous stimulation (the peripheral nervous system is then stimulated). To do so, the electrode has been surgically implanted beforehand on the spinal cord, or in sub-cutaneous tissues, at the level of the painful zone. “At the level of the painful zone” is taken to mean:for sub-cutaneous stimulation, in a region of the painful zonefor medullary, percutaneous or surgical stimulation, with regard to a certain region of the spinal cord in the vertebral canal, at the level of which are centralised the projections pertaining to a painful peripheral cutaneous zone (for example, a painful region of the lower limb is projected onto the level of the medullary region, situated at the level of the thoracic vertebrae T9 to T11).

The electrode is connected to a control box making it possible to activate the pads of the electrode in order to generate a controlled electric field. The electric field stimulates a neuronal population, which causes a paraesthesia leading to a relief of the pain.

The choice of the electrode(s) is crucial. In fact the results are variable as a function of the therapeutic tool used (more or less sophisticated electrodes; percutaneous or surgical electrodes, conventional or new generation electrodes, mono-column or multi-column electrodes, surface electrodes of more or less limited cover, etc.). The choice of the therapeutic tool is made as a function of pain quantification parameters, such as the size or instead the location of the painful zone. In fact, the evaluation of these parameters is a key step, making it possible to choose appropriately the electrode(s) to implant.

GENERAL DESCRIPTION OF THE INVENTION

The invention proposes a method for evaluating said pain quantification parameters.

The invention thus essentially relates to a method for mapping painful zones, including the following steps:Displaying a first silhouette representing the rear face of a body, on a first screenDrawing at least one painful zone on said first displayed silhouette, indicating the location of a pain felt by a patientDetermining a first number of pixels on the first screen, corresponding to said painful zoneMeasuring a reference distance between two morphological reference points on the patientConverting said first number of pixels into a painful cutaneous surface, said reference distance being used as a parameter in said conversion.

The cutaneous surface corresponding to the painful zone drawn by the patient is a first pain quantification parameter for which the method enables the evaluation. This first parameter helps to choose appropriately the therapeutic tool, i.e. the electrode, to use. In fact, if the cutaneous surface is 25 square centimeters, an electrode with a coverage of 10 square centimeters could be considered unsuitable. It may be noted that, advantageously, the screen is a touch screen, and the patient draws the painful zone with his fingers, which is more practical than using a mouse or a stylet.

At each touch pressure a delimitation by circling of the painful zone is captured at the mapping level, several zones being able to be drawn with or without superposition. This mapping is calibrated with respect to the reference distance in order to extrapolate the plots with respect to the individual concerned. The drawing is simple, quick to carry out and in addition makes it possible to delimit a surface, to identify a location and an evolution of the plot as the pain is treated.

Apart from the characteristics which have been evoked in the preceding paragraph, the mapping method according to the invention may have one or more additional characteristics among the following, considered individually or according to any technically possible combinations thereof.

In a non-limiting embodiment, the morphological reference points are the iliac crests of the patient. In fact, they are invariant reference points depending on the corpulence of the patient.

In a non-limiting embodiment, the mapping method includes the following step: correcting the converted painful cutaneous surface with the aid of a correction coefficient. This step is based on the Bland Altman test. This test is a statistical test making it possible to make up for the intra-individual error of appreciation of the plot by the operator (the patient or the clinician). A phase of taking measurements with exact surfaces different in shape and location has been carried out on a sample of significant size. Then comparisons between the drawn surfaces and the actual surfaces have made it possible to define a correction coefficient (corresponding to the standard deviation of the difference of averages observed).

In a non-limiting embodiment, the mapping method includes the following step: determining a ratio of painful cutaneous surface comprised in a region of the first silhouette. Said ratio of cutaneous surface comprised in the region is a second pain quantification parameter for which the method enables the evaluation. In fact, it is interesting to relate the painful cutaneous surface to known topographical notions of the organism, notably delimitations approved by specialized organizations such as the delimitations High Back/Low Back, or instead commonly accepted delimitations in anatomical terms, such as dermatomes. By correlating the location of the painful cutaneous surface with a chosen topographical frame of reference, the physician has access to data allowing him to choose appropriately his therapeutic tools, i.e. the electrodes to implant. For example, an electrode may be efficacious in a given region, and inefficacious in another. It may be noted that the quantification of pain by topographic surface is important for determining the predominance and the intensity of certain types of pain and thus explain the pain by a determinism linked to the nerve roots. This step thus moreover makes it possible to determine the nerve roots which are more or less involved in the pain mechanism.

In a non-limiting embodiment, the region corresponds to a dermatome. A dermatome is a strip of skin which corresponds to a selective innervation of a given nerve of the organism. Thanks to the mapping method according to the invention, the physician has access to the percentages of the painful cutaneous surface comprised in each dermatome. In another non-limiting embodiment, the region corresponds to a lumbar region.

In a non-limiting embodiment, the step of drawing at least one painful zone comprises the following sub-steps:Drawing in a first manner a neuropathic pain;Drawing in a second manner a mechanical pain.

In fact, certain scientists consider that medullary stimulation is not efficacious for mechanical pain. These sub-steps can make it possible to confirm or invalidate this consideration.

The invention also relates to a method for evaluating the efficacy of medullary stimulation, including the following steps:Displaying a second silhouette representing the rear face of a body, on a second screenDrawing at least one paraesthesia zone on said second displayed silhouette, indicating the location of a paraesthesia felt by the patient in response to medullary stimulationDetermining a second number of pixels on the second screen, corresponding to said paraesthesia zoneConverting said second number of pixels into a paraesthesic cutaneous surface, the reference distance being used as a parameter in said conversion.Comparing the paraesthesic cutaneous surface with a painful cutaneous surface determined beforehand.

It may be noted that in a non-limiting embodiment, the second screen is the aforementioned first screen. In a non-limiting embodiment, the second screen is a touch screen and the patient draws the paraesthesia zone with his fingers. In a non-limiting embodiment, the second silhouette is substantially identical to the aforementioned first silhouette. Advantageously, the painful surface has been predetermined using the aforementioned mapping method.

By comparing the paraesthesic cutaneous surface and the painful cutaneous surface, the physician can determine whether the medullary stimulation has been efficacious. In fact, the medullary stimulation has been efficacious if the paraesthesic cutaneous surface is substantially equal to the painful cutaneous surface.

The mapping method according to the invention thus makes it possible to determine pain quantification parameters:in a strict manner, by calculation of the painful surface, andin an indirect manner, by evaluation of the surface of the paraesthesias and finally the pain/paraesthesias ratio.

All of this is carried out as a function of the zones and somatotopic territories of the nerve fibres.

The two aspects of the invention may be noted:a method for evaluating a painful surface with regard to a medical device with a view to evaluating the efficacy thereof;a diagnostic and therapeutic method (pre, during and post-operation) making it possible to collect and to monitor the pain of the patient and its evolution, and to enable indication towards a therapeutic of choice: it can be considered as a medullary electronic stethoscope.

Apart from the characteristics that have been mentioned in the preceding paragraph, the method for evaluating the efficacy of medullary stimulation according to the invention may have one or more additional characteristics among the following, considered individually or according to any technically possible combinations thereof.

In a non-limiting embodiment, the comparison step comprises the following sub-step:Calculating a percentage coverage of the painful cutaneous surface by the paraesthesic cutaneous surface.

The physician may thus evaluate numerically the efficacy of the medullary stimulation.

In a non-limiting embodiment, the method for evaluating the efficacy of medullary stimulation comprises the following steps:Superimposing the second silhouette on a first silhouette including the painful zones.

Advantageously, the painful zones have been drawn beforehand on the first silhouette via the aforementioned mapping method. Advantageously, the first silhouette and the second silhouette are substantially identical. It is thus easy to know in which painful zones medullary stimulation has been efficacious.

In a non-limiting embodiment, the medullary stimulation is carried out during an operation of implantation of said electrode. This is particularly advantageous for implanting the electrode at a spot where the medullary stimulations will be efficacious. In practice, the patient is woken up during the implantation operation, and indicates to the physician, thanks to the method for evaluating the efficacy of medullary stimulation according to the invention, whether the electrode is placed at an appropriate spot. If this is not the case, the physician may then move the electrode before putting the patient back to sleep and finishing the implantation operation.

In a non-limiting embodiment, the medullary stimulation is carried out after an operation of implantation of said electrode, for example several months or several years after the operation. This makes it possible to check that the patient responds correctly to medullary stimulations, and that the painful zone is always covered by the paraesthesia zone. In fact, it is sometimes observed that the paraesthesias die down over time, or even disappear. Thus, monitoring of the patient is possible.

The invention also proposes a mapping system, including:Means for displaying a silhouette representing the rear face of a body, on a screenMeans for drawing at least one zone on said silhouetteMeans for determining a number of pixels on the screen, corresponding to said zoneMeans for converting said number of pixels into a cutaneous surface, by means of a reference distance being used as a parameter in said conversion.

The drawn zones may correspond to painful zones or to paraesthesia zones felt following medullary stimulation.

Apart from the characteristics which have been evoked in the preceding paragraph, the mapping system according to the invention may have one or more additional characteristics among the following, considered individually or according to any technically possible combinations thereof.

In a non-limiting embodiment, the mapping system includes:Means for correcting the cutaneous surface using a correction criterion.

In a non-limiting embodiment, the mapping system includes:Means for determining a ratio of said cutaneous surface comprised in a region of the silhouette.

In a non-limiting embodiment, the mapping system includes:Means for comparing the cutaneous surface with a second cutaneous surface determined beforehand.

The mapping system thus makes it possible to compare a painful cutaneous surface with a paraesthesia cutaneous surface, the paraesthesias being felt in response to medullary stimulation.

The invention also proposes a system for evaluating the efficacy of medullary stimulation, including:The mapping system described previouslyMedullary stimulation meansMeans for comparing a painful cutaneous surface with a paraesthesic cutaneous surface, said paraesthesia being felt in response to medullary stimulation by the medullary stimulation means.

Conventionally, the medullary stimulation means comprise at least one multi-contact electrode connected to a control box, said electrode being implanted at the level of painful zones of the patient.

In a non-limiting embodiment, the system for evaluating the efficacy of medullary stimulation includes:Means for calculating a percentage coverage of the painful cutaneous surface by the paraesthesic cutaneous surface.

The invention and its different applications will be better understood on reading the description that follows and by examining the accompanying figures.

DETAILED DESCRIPTION OF AT LEAST ONE EMBODIMENT OF THE INVENTION

Unless stated otherwise, a same element appearing in the different figures has a single reference.

The invention proposes a method for mapping painful zones, a method for evaluating the efficacy of medullary stimulation, a mapping system, and a system for evaluating the efficacy of medullary stimulation.

The mapping method is intended to:indicate the location of pains felt by a patient,indicate the type of said pains (neuropathic or mechanical) felt, andprovide the characteristics of said pains. These characteristics are notably the cutaneous surface concerned by the pain, and the percentage of painful cutaneous surface comprised in each dermatome or each lumbar region.

These results allow a physician to choose one or more electrodes to implant at the level of the painful zone(s), in order to implement the technique of medullary stimulation aiming to relieve the pain of the patient. In fact, as a function of the characteristics indicated previously, certain electrodes will be more or less suitable.

More precisely, with reference toFIG. 4, the mapping method400comprises the following steps:A1: with reference toFIG. 1, displaying a first silhouette100representing the rear face of a body, on a first screen102. The first screen102is for example a touch screen, advantageously a tablet touch screen. In fact, a touch screen enables ergonomic use, and a touch tablet is of sufficiently large size to enable an agreeable display, and sufficiently small to limit bulk. In the embodiment described, the silhouette100is a standard model, not suited to the morphology of the patient. However, an embodiment in which the silhouette100has a shape suited to the morphology of the patient is not excluded.B1: with reference toFIG. 2, drawing at least one painful zone104on said first displayed silhouette100, indicating the location of a pain felt by the patient. In a non-limiting embodiment in which the screen102is a touch screen, the patient delimits the painful zone104by circling it with his finger. In an embodiment, the patient has at his disposal a palette of two colours, each colour representing a type of pain. In another embodiment, the pain is represented by a single and same colour but hatching makes it possible to differentiate the type of pain. Type of pain is taken to mean mechanical or neuropathic pain. Determined criteria grouped together in a questionnaire make it possible to qualify neuropathic pain. The patient may thus indicate whether a painful zone corresponds to neuropathic pain or to mechanical pain.C1: determining a first number of pixels on the first screen102, corresponding to the painful zone104. It may be noted that the numbers of pixels corresponding to neuropathic and mechanical pains, or to different painful zones, are added together except in the case of an intersection: in this case, the common surface is only counted once.

D1: measuring a reference distance on the patient. In the embodiment described, the reference distance corresponds to the distance between the two iliac crests of the patient. In fact, this distance has the advantage of being invariant depending on the corpulence of the patient. It may be noted that other morphological reference points could be used, for example the distance between the shoulder blades or the distance between the mastoids, but the distance between the iliac crests is preferred. It is understood that the step of measuring the reference distance may be carried out before the steps described previously, or between two of said steps.E1: converting the first number of pixels into a painful cutaneous surface, the reference distance being used as a parameter in the conversion. The painful cutaneous surface is then displayed on the first screen102, which allows the physician to have the information at his disposal. The painful cutaneous surface is for example expressed in square centimeters.

To carry out this conversion step, two coefficients are calculated:a vertical coefficient equal to the actual size of the patient divided by the number of pixels representing the size of the silhouettea horizontal coefficient equal to the distance between the iliac crests of the patient divided by the number of pixels representing the distance between the iliac crests on the silhouette.

The painful cutaneous surface is then equal to the product of the horizontal coefficient, the vertical coefficient and the first number of pixel corresponding to the painful zone.F1: determining a ratio of painful cutaneous surface comprised in a region106of the first silhouette100. With reference toFIG. 3, in an embodiment, the considered region106corresponds to a dermatome. In an embodiment, the regions106are displayed on the silhouette100, superimposed on the drawn painful zone104. The region106could also be a lumbar region, or any other region corresponding to a known topographic notion. Advantageously, several ratios corresponding to several regions106of a topographical frame of reference are calculated. In an embodiment, these ratios are expressed in percentage in order to facilitate the reading thereof. The physician can thus know which dermatomes are engaged by the pain, and in which proportions. In an embodiment, a correspondence table is displayed beside the first silhouette100, showing the ratios or the percentages of painful cutaneous surface by considered region. The painful cutaneous surface is thus expressed in percentages with respect to the surface representation of the different dermatomes of the dorsolumbar region in particular.G1: in an embodiment, the first silhouette100on which the painful zone(s)104are drawn, as well as the characteristics of said pains, are saved on a server.

The mapping method400may be implemented at different moments in temporal space for a given patient. An initial mapping and follow-up mappings are thereby obtained, which makes it possible to compare the painful region before and after the patient has received a given treatment and in particular a medullary stimulation implantation. The evaluations may also be repeated over time and at several moments of the day which makes it possible, by data implementation, to arrive at an averaged approximation of the painful regions that is more accurate over time.

The method for evaluating the efficacy of medullary stimulation is used for:During an operation of implantation of one or more electrodes in the patient, to know whether the electrode is correctly positioned or if it is advantageous to move it, and/or post-operationally, to monitor the patient, i.e. checking19that the medullary stimulation is (still) efficacious, and whether it in fact relieves the patient over the whole of the painful zones.

More precisely, with reference toFIG. 5, the method for evaluating the efficacy of medullary stimulation500comprises the following steps:A2: carrying out the steps of the mapping method400described previously.B2: carrying out medullary stimulation of the patient with at least one electrode. In an embodiment, the electrode has been implanted beforehand during a surgical operation at the level of the painful zone104felt by the patient. In another embodiment, the medullary stimulation is carried out during a surgical operation intended to implant the electrode.C2: displaying a second representative silhouette substantially identical to the first silhouette100, on a second screen. The second screen is for example a touch screen, advantageously a touch tablet screen. In a non-limiting embodiment, the second screen is the first screen evoked previously.D2: drawing at least one paraesthesia zone on the second displayed silhouette, indicating the location of a paraesthesia felt by the patient in response to medullary stimulation.E2: determining a second number of pixels on the second screen, corresponding to the paraesthesia zone.F2: converting the second number of pixels into a paraesthesia cutaneous surface, the aforementioned reference distance being used as a parameter in the conversion. The conversion is carried out in the same way as at E1of the mapping method400. The paraesthesic cutaneous surface is then displayed on the second screen, which allows the physician to have the information at his disposal.G2: comparing the paraesthesic cutaneous surface with the painful cutaneous surface determined during step E1of the mapping method400.H2: superimposing the second silhouette and the first silhouette100on the second screen or on the first screen102.I2: in an embodiment, the second silhouette on which the paraesthesia zone(s) are drawn, as well as the paraesthesic cutaneous surface, are saved on the server.

With reference toFIG. 6, the mapping system600includes:Means for displaying610a silhouette representing the rear face of a body, on a screenMeans for drawing620at least one zone on said silhouetteMeans for determining630a number of pixels on the screen, corresponding to said zoneMeans for converting640said number of pixels into a cutaneous surface, by means of a reference distance being used as a parameter in said conversion.Means for determining650a ratio of said cutaneous surface comprised in a region of the silhouetteMeans for comparing660the cutaneous surface with a second cutaneous surface determined beforehand.

The mapping system600makes it possible to implement the mapping method400according to the invention. The zones drawn may correspond to painful zones or to paraesthesia zones felt following medullary stimulation.

The system for evaluating the efficacy of medullary stimulation700comprises:The mapping system600Medullary stimulation means710. Conventionally, it involves at least one multi-contact electrode implanted under the skin of the patient, connected to a control box.Means for comparing720a painful cutaneous surface with a paraesthesic cutaneous surface, said paraesthesia being felt in response to medullary stimulation by the medullary stimulation meansMeans for calculating730a percentage coverage of the painful cutaneous surface by the paraesthesic cutaneous surface.

The system for evaluating the efficacy of medullary stimulation700makes it possible to implement the method for evaluating the efficacy of medullary stimulation500.