Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain

Abstract

The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.

Implantable Peripheral Nerve Stimulation for Peripheral Neuropathic Pain: A Systematic Review of Prospective Studies

“…This reduction in pain was consistent across all types of peripheral neuropathic pain syndromes. These findings align with results from recent reviews of PNS treatment in chemotherapy-induced peripheral neuropathy [ 28 ] and other peripheral neuropathies [ 6 , 28 , 29 , 30 , 31 ].…”

Neuromodulation Therapy for Chemotherapy-Induced Peripheral Neuropathy: A Systematic Review

“…The decision to pursue a specific neuromodulation intervention should also weigh its respective adverse effect profile. Overall, studies have highlighted that SCS [ 53 , 54 , 55 ], DRG-S [ 56 ], and PNS [ 15 ] are safe interventions overall. Special considerations unique to patients with CIPN may include an immunocompromised status due to ongoing malignancy and/or chemotherapy, which is associated with an increased risk for infection.…”

“…DRG-S involves lead placement in the epidural space overlying the dorsal root ganglion [ 12 , 13 ]. PNS involves lead placement in close proximity to a target nerve that innervates the location of the painful area [ 14 , 15 ].…”

Peripheral Nerve Stimulation in Painful Conditions of the Upper Extremity—An Overview

“…However, there were several challenges that limited the use of peripheral nerve stimulation including off-label use, tunneling to the implantable pulse generator, the inability to selectively innervate the sensory components of the target nerve, prolonged operating times, and complications such as lead tethering, lead migration, and wound infection [ 4 ]. In addition, long-term success rates were poor [ 6 ].…”