Peripheral nerve stimulation (PNS) has evolved substantially over recent decades in terms of hardware and evidence supporting efficacy. Treatment targets continue to expand and address both pain and functional applications. The American Society of Pain and Neuroscience (ASPN) seeks to substantially update and expand upon a review of the evidence supporting PNS as well as provide guidelines for clinical practice. A diverse multidisciplinary panel of experts was selected to provide opinions and guidance based on evidence-graded assessment and clinical knowledge. This document aims to serve as a resource for clinicians and payors in the interest of expanding awareness of the breadth of research in the field of PNS and expanding access to therapy.
OBJECTIVES:The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of spinal cord stimulation (SCS) on pain intensity, physical function, and health-related quality of life (HRQoL) for people experiencing persistent spinal pain syndrome type 1 (PSPS-T1), also known as nonsurgical refractory back pain with or without leg pain, and to assess the durability of SCS treatment effects. MATERIALS AND METHODS:MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and WikiStim data bases were searched from inception to December 19, 2024. Eligible studies included randomized controlled trials (RCTs) with any follow-up duration, and non-RCTs with ≥12-month follow-up. Outcomes included pain intensity, physical function, and HRQoL. Risk of bias was assessed using the revised Cochrane risk-of-bias and National Institutes of Health tools. Certainty of the evidence for the comparisons and outcomes included in the meta-analysis was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. The measure of treatment effect was mean difference (MD) or odds ratio and 95% CI. RESULTS:Overall, 19 reports of 16 unique studies were included in the review. Meta-analysis shows significant reductions in pain with SCS compared with conventional medical management (CMM) at six-month follow-up (MD 5.67; 95% CI: 4.60-6.74). Statistically significant results in favor of SCS compared with CMM were observed for physical function and HRQoL. Meta-analysis of non-RCT data showed significant improvements in pain intensity, physical function, and HRQoL up to 24 months compared with baseline. CONCLUSIONS:All included studies of SCS for PSPS-T1 indicated significant improvements in pain intensity, physical function, and HRQoL when compared with CMM or baseline.
INTRODUCTION:Placement of a spinal cord stimulator (SCS) is a neuromodulatory technique with several indications, including persistent spinal pain syndrome type 2 (PSPS2), painful diabetic neuropathy, non-surgical chronic low back pain, and complex regional pain syndrome. SCS is conventionally placed in a caudal to cranial fashion (anterograde), yet there are cases such that spinal fusion hardware and adhesions prevent this insertion technique. CASE PRESENTATION:Our patient is a 57-year-old man with PSPS2 who had extensive spinal fusion and epidural scarring extending from the sacrum to T10. The patient trialed and failed conservative medical management for his PSPS2 pain, with limited options available for pain relief. The decision was made to place the SCS leads in a retrograde manner at C7-T1, which were then threaded to the T10 level, offering the patient complete relief of back pain and >80% of bilateral lower extremity radicular symptoms. CONCLUSION:Here, we present another case in the literature of a permanently placed SCS performed in the retrograde fashion by an interventional chronic pain physician. Though the technique was off label, the retrograde approach offered the patient significant relief when all other treatment modalities failed. Despite the effective use of the retrograde approach, more studies are needed, including guidelines as to when to offer the retrograde approach for patients with inaccessible anatomy for a typical anterograde technique.
