Photo Credit: Dr Microbe

Spinal cord stimulation (SCS) is an end-of-line treatment option for patients with chronic pain. However, controversies circle this topic, leading to a ‘trench war’ between neuromodulation practitioners and opponents. Dr. Cecile de Vos, PhD, from the Erasmus University Medical Center, in the Netherlands, discussed the current evidence and ongoing developments in the field.

“The clinical evidence on SCS up to 2010 is based on conventional SCS, for paresthesia, a modality for which blinded randomized-controlled trials were not possible,” explained Dr. de Vos. Although systematic reviews showed long-term pain relief of SCS for patients with persistent spinal pain syndrome or complex regional pain syndrome, the 2016 EAN guideline on central neurostimulation therapy in chronic pain conditions only provided ‘weak recommendation’ for SCS. “Again, mainly due to the lack of placebo-controlled trials.”

In recent years, high-frequency, paresthesia-free paradigms of SCS have been developed. “This innovation makes it possible to conduct placebo-controlled trials,” according to Dr. de Vos. Although SCS appears to outperform placebo for pain relief, the studies that were included in a more recent systematic review on this topic have large methodological differences. “The heterogeneity of study designs, the unknown role of the placebo effect, the balance between efficacy and complications, and heavy industry involvement in clinical trials are still controversial elements in the domain of SCS,” clarified Dr. de Vos. Moreover, SCS is an expensive treatment, with device costs being $20,000.

Dr. de Vos argued that with an average success rate of over 50% in a heavily pre-treated population of patients with neuropathic pain, the efficacy of SCS compares favorably versus pharmaceutical therapies. “Moreover, severe complications are very uncommon.”

“We need well-designed, independent, multicenter, placebo-controlled studies, in one pain condition, with objective outcome measures, to gain a better understanding of SCS therapy and to develop personalized approaches and treatment guidelines,” Dr. de Vos concluded.

Medical writing support was provided by Robert van den Heuvel.

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