The Effectiveness of Spinal Cord Stimulation for the Treatment of Axial Low Back Pain: A Systematic Review with Narrative Synthesis

Abstract

Objective Determine the effectiveness of spinal cord stimulation (SCS) for the treatment of axial low back pain (LBP) with or without leg pain. Design Systematic review. Subjects Persons aged ≥18 with axial LBP with or without accompanying leg pain. Intervention Traditional low-frequency, burst, or high-frequency SCS. Comparison Sham, active standard of care treatment, or none. Outcomes The primary outcome was ≥50% pain improvement, and the secondary outcome was functional improvement measured six or more months after treatment intervention. Methods Publications in PubMed, MEDLINE, and Cochrane databases were reviewed through September 19, 2019. Randomized or nonrandomized comparative studies and nonrandomized studies without internal controls were included. The Cochrane Risk of Bias Tool and GRADE system were used to assess individual study characteristics and overall quality. Results Query identified 262 publications; 17 were suitable for inclusion. For high-frequency SCS, the only level 1 study showed that 79% (95% confidence interval = 70–87%) of patients reported ≥50% pain improvement. For low-frequency SCS, the only level 1 study reported no categorical data for axial LBP-specific outcomes; axial LBP improved by a mean 14 mm on the visual analog scale at six months. Meta-analysis was not performed due to study heterogeneity. Conclusions According to GRADE, there is low-quality evidence that high-frequency SCS compared with low-frequency SCS is effective in patients with axial LBP with concomitant leg pain. There is very low-quality evidence for low-frequency SCS for the treatment of axial LBP in patients with concomitant leg pain. There is insufficient evidence addressing the effectiveness of burst SCS to apply a GRADE rating.

Pain Relief and Safety Outcomes with Cervical 10 kHz Spinal Cord Stimulation: Systematic Literature Review and Meta-analysis

“…The Senza SCS system has already been approved by the FDA in the management of chronic intractable pain of the trunk or limbs associated with failed back surgery syndrome or intractable low back or leg pain. Prior systematic reviews support the use of any SCS in this particular indication; however, they have also found evidence suggesting that 10 kHz SCS devices demonstrate more favorable outcomes relative to traditional devices [ 41 – 46 ]. More specifically, the reviews by Vallejo et al and Conger et al found similar values for the percentage of patients who experienced ≥ 50% reduction in pain following 10 kHz SCS as estimated in the current meta-analysis on those with upper limb or neck pain (i.e., 83% [95% CI 77–89%]) [ 41 , 46 ].…”

“…Prior systematic reviews support the use of any SCS in this particular indication; however, they have also found evidence suggesting that 10 kHz SCS devices demonstrate more favorable outcomes relative to traditional devices [ 41 – 46 ]. More specifically, the reviews by Vallejo et al and Conger et al found similar values for the percentage of patients who experienced ≥ 50% reduction in pain following 10 kHz SCS as estimated in the current meta-analysis on those with upper limb or neck pain (i.e., 83% [95% CI 77–89%]) [ 41 , 46 ]. In terms of pain medication consumption, Pollard et al found that 10 kHz SCS resulted in increased odds of reducing opioid use and greater mean medication dose reduction compared to traditional SCS in patients with intractable spine and limb pain, though there was limited evidence and the results were not statistically significant [ 45 ].…”

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

“…Superior analgesia and functionality scores have been noted with the advent of neuromodulation, including SCS and PNS. [44][45][46] Although systematic reviews of SCS for the treatment of chronic low back pain have been published, 47,48 evidence supporting PNS for the treatment of this condition is currently emerging.…”

The Role of Spinal Cord Stimulation in Axial Back Pain

“…It also demonstrated superiority compared to traditional stimulation [7]. More recently, in 2020, a systematic review of 17 independent studies showed low-quality evidence that SCS can be utilized effectively to treat axial LBP [8]. What these studies lack is a specific target in the spinal cord for optimal coverage of axial LBP.…”