Spinal cord stimulation for neuropathic pain: current perspectives

Figures & data

Figure 1 Flow chart of spinal cord stimulation procedure.

Figure 2 Anteroposterior and lateral view of a thoracolumbar spinal cord stimulation placement; the 8-pole lead (octrode) is positioned at level TH10–12, and the impulse generator is placed abdominally subcutaneously.

Abbreviations: R, right; L, left.

Figure 3 Anteroposterior and lateral view of a cervical spinal cord stimulation placement; the 8-pole lead (octrode) is positioned at level C3-5, and the spinal canal is entered at level TH2/3.

Abbreviation: R, right.

Table 1 Overview of indications and contraindications for spinal cord stimulation

Indications and contraindications
Indications
Neuropathic pain
Failed back surgery syndrome
Complex regional pain syndrome (type I and II)
Radicular pain
Nerve root pain (lumbar, thoracic, cervical)
Radiculopathy, radiculitis
Postherpetic neuralgia
Neuropathic pain secondary to peripheral nerve injury
Intercostal neuralgia
Phantom pain
Vascular pain
Angina pectoris
Peripheral arterial disease
Morbus raynaud
Potential indications
Polyneuropathy
Deafferentation pain
Spinal cord injury
Brachial plexus injury
Contraindications
Somatic
Sepsis
Coagulopathy
Infection
Inability to understand how SCS works and to handle the patients
Programming device
Obliteration of the spinal canal
Psychiatric
Psychosis
Schizophrenia
Substance abuse
Severe depression/anxiety

Abbreviation: SCS, spinal cord stimulation.

Table 2 Overview of randomized studies for SCS (and PNFS)

Title/author	Year	Diagnosis	Condition	Design	n	Result
Conventional SCS
PROCESS, Kumar et al^Citation82,Citation107	2005	Failed back surgery syndrome	SCS plus CMM vs CMM alone	Randomized prospective, multicenter	100	48% of the SCS patients had more than 50% pain relief compared with 9% with CMM, cross-over-rate was significantly lower in the SCS group than in the CMM group (5/50 vs 32/50)
North et al^Citation81,Citation108,Citation109	1994	Failed back surgery syndrome	SCS plus CMM vs reoperation plus CMM	Randomized prospective, multicenter	60	9/19 patients with SCS and 3/26 patients with reoperation had more than 50% pain relief; in the SCS group, the crossover rate was lower than in the reoperation group (5/24 vs 14/26)
Kemler et al^Citation84,Citation85,Citation110	2000	Complex regional pain syndrome type I	SCS plus physical therapy vs physical therapy	Randomized prospective, multicenter	54	24/36 patients had a successful test and were implanted, mean change in pain at 6 months; 2.4 VAS with SCS vs; 0.2 VAS without SCS
Subthreshold stimulation
Wolter et al^Citation111	2011	Neuropathic pain	SCS vs subthreshold SCS vs no stimulation	Randomized prospective, crossover design	10	SCS: mean VAS, 3.6; subthreshold: 5.6; no stimulation: 6.4; differences significant
Adaptive stimulation
Schultz et al^Citation47	2012	Neuropathic back and leg pain	Conventional SCS vs position adaptive SCS	Randomized prospective, multicenter crossover design	79	Improved convenience of adaptive stimulation compared with using manual programming adjustment alone
Schade et al^Citation46	2011	Neuropathic back and leg pain	Conventional SCS vs position adaptive SCS	Randomized prospective, multicenter crossover design	15	Improved convenience and overall satisfaction of adaptive stimulation
High-frequency stimulation
Perruchoud et al^Citation39	2013	Neuropathic back and leg pain	HF SCS vs SCS vs sham	Randomized prospective, crossover design	33	Switched from conventional SCS to 5 kHz SCS or to sham, VAS levels remained stable; authors concluded that HF SCS was equivalent to sham
Burst stimulation
De Ridder et al^Citation36	2013	Neuropathic back and leg pain	Burst vs tonic vs placebo	Randomized prospective, crossover design	15	Burst stimulation improved back, limb, and general pain by 51%, 53%, and 55% and tonic stimulation by 30%, 52%, and 31%
PNFS
McRoberts et al^Citation75	2013	Localized, chronic, intractable back pain	PNFS	Randomized prospective, multicenter crossover design	44	23 patients responded to stimulation (<50% pain reduction) and received impulse generators

Abbreviations: SCS, spinal cord stimulation; PNFS, peripheral nerve field stimulation; CMM, conventional medical management; HF SCS, high-frequency SCS; VAS, visual analog scale; vs, versus.

Table 3 Possible complications of spinal cord stimulation

Complication
Hardware-related
Lead migration
Lead breakage
Connection failure
Battery depletion
Unwanted paresthesia
Pain at the impulse generator site
Not hardware-related
Hematoma, seroma infection
Cerebrospinal fluid loss
Neurological deficit

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