Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Chronic Neuropathic Pain

Abstract

Introduction. Physicians, policy makers, and other interested parties require a synthesized, critical, and clear compilation of the following information to optimize spinal cord stimulation (SCS) for neuropathic pain: 1) indications and potential beneficial outcomes; 2) answers to key clinical questions; 3) cost/resource use implications; and 4) the quality and source of the evidence. This information must be nonjudgmental and noncoercive and have the sole objective of increasing the reader's expertise. Study Design. Evidence‐based literature review and consensus statement. Methods. We consulted with experts to identify clinical‐practice questions. Then, we conducted a critical literature review (MEDLINE, EMBASE, 1967 through March 2007) to grade treatment practices from “options” to “recommended.” We created a bibliographical database of all citations pertinent to each practice question. Several experts not otherwise involved reviewed the draft document. Results. We answered 64 questions covering 1) indications; 2) potential beneficial outcomes; 3) prognostic factors; 4) patient selection for screening trial; 5) procedural risk management; 6) screening trial; 7) device options; 8) patient management; 9) factors affecting the delivery and quality of SCS treatment; and 10) cost‐effectiveness. Most of our more than 300 references are cited multiple times (in each pertinent category). This is the first overview that seeks to categorize and place the entire SCS clinical literature at the disposal of the reader. It presents the first grading system that incorporates, among other evidence sources, an assessment of the likelihood of a favorable outcome based on the evidence provided by expert consensus combined with consideration of the risk and potential benefit of an action. Conclusions. The Practice Parameters for Spinal Cord Stimulation in the Treatment of Neuropathic Pain answers important questions. It assesses supporting evidence and provides specific citations to enable the reader to conduct further study. The document will be updated regularly in a Web‐based version.

Recommendations for patient selection in spinal cord stimulation

“…For instance, the provision of analgesia on demand at any time makes patients feel more in control and less restricted in their daily activities, including return to work. 3 This can lead to improved morale, treatment satisfaction and improvement in depressive symptoms. 3 Studies have also demonstrated that SCS can reduce the requirement for additional pain medications, thereby avoiding the side effects of, and reliance on, pharmacotherapy.…”

“…Unlike surgical pain relief procedures, it does not ablate pain pathways or change anatomy. 3 SCS has come a long way in the last 40 years, with more than 14,000 SCS implantations performed worldwide each year for a range of indications. 4 In 1965, Melzac and Wall announced the ''gate theory'', proposing that activating large, myelinated afferent nerve fibers would inhibit transmission in small, unmyelinated primary afferent nerves in the dorsal horn of the spinal cord.…”

Spinal Cord Stimulation: A Review

“…Often times, the psychiatrist/psychologist will have only one encounter with the patient, compared to the longitudinal relationship developed between the patient and pain practitioner. Indeed, a 40-year literature review by North and Shipley assessing "psychological predictors" concluded, "We lack sufficient information to predict SCS outcome from the result of a pretreatment psychological evaluation, but SCS, as is the case for every interventional pain treatment, is reserved for patients with no evident unresolved major psychiatric co-morbidity" [26].…”

Spinal cord stimulation for patients with inoperable chronic critical leg ischemia

“…[19][20] Whereas the power to detect clinically meaningful differences in ischemic pain trials is still quite inadequate. [13,[21][22][23][24][25] In recent years, research into the therapeutic effect of SCS in control of ischemic pain secondary to peripheral vascular disease particularly in inoperable CLI has become a hot topic around the world. For more than ten million patients, it would be good news if the curative effect of SCS on CLI has been confi rmed clinically.…”