Song Jason J, Popescu Adrian, Bell Russell L
Hospital of the University of Pennsylvania, Philadelphia, PA.
Pain Physician. 2014 May-Jun;17(3):235-46.
Spinal cord stimulation is an intervention that has become increasingly popular due to the growing body of literature showing its effectiveness in treating pain and the reversible nature of the treatment with implant removal. It is currently approved by the FDA for chronic pain of the trunk and limbs, intractable low back pain, leg pain, and pain from failed back surgery syndrome. In Europe, it has additional approval for refractory angina pectoris and peripheral limb ischemia.
This narrative review presents the current evidence supporting the use of spinal cord stimulation for the approved indications and also discusses some emerging neuromodulation technologies that may potentially address pain conditions that traditional spinal cord stimulation has difficulty addressing.
Narrative review.
Spinal cord stimulation has been reported to be superior to conservative medical management and reoperation when dealing with pain from failed back surgery syndrome. It has also demonstrated clinical benefit in complex regional pain syndrome, critical limb ischemia, and refractory angina pectoris. Furthermore, several cost analysis studies have demonstrated that spinal cord stimulation is cost effective for these approved conditions. Despite the lack of a comprehensive mechanism, the technology and the complexity in which spinal cord stimulation is being utilized is growing. Newer devices are targeting axial low back pain and foot pain, areas that have been reported to be more difficult to treat with traditional spinal cord stimulation. Percutaneous hybrid paddle leads, peripheral nerve field stimulation, nerve root stimulation, dorsal root ganglion, and high frequency stimulation are actively being refined to address axial low back pain and foot pain. High frequency stimulation is unique in that it provides paresthesia free analgesia by stimulating beyond the physiologic frequency range. The preliminary results have been mixed and a large randomized control trial is underway to evaluate the future of this technology. Other emerging technologies, including dorsal root ganglion stimulation and hybrid leads, also show some promising preliminary results in non-randomized observational trials.
This review is a primer and not an exhaustive review for the current evidence supporting the use of spinal cord stimulation and precursory discussion of emerging neuromodulation technologies. This review does not address peripheral nerve stimulation and focuses mainly on spinal cord stimulation and touches on peripheral nerve field stimulation.
Spinal cord stimulation has demonstrated clinical efficacy in randomized control trials for the approved indications. In addition, several open label observational studies on peripheral nerve field stimulation, hybrid leads, dorsal root ganglion stimulation, and high frequency stimulation show some promising results. However, large randomized control trials demonstrating clear clinical benefit are needed to gain evidence based support for their use.
脊髓刺激是一种越来越受欢迎的干预措施，因为越来越多的文献表明其在治疗疼痛方面的有效性以及移除植入物后治疗的可逆性。目前，美国食品药品监督管理局（FDA）已批准其用于治疗躯干和四肢的慢性疼痛、顽固性腰痛、腿痛以及腰椎手术失败综合征引起的疼痛。在欧洲，它还被批准用于治疗难治性心绞痛和外周肢体缺血。
本叙述性综述介绍了支持将脊髓刺激用于已批准适应症的现有证据，并讨论了一些新兴的神经调节技术，这些技术可能潜在地解决传统脊髓刺激难以解决的疼痛状况。
叙述性综述。
据报道，在处理腰椎手术失败综合征引起的疼痛时，脊髓刺激优于保守药物治疗和再次手术。它在复杂性区域疼痛综合征、严重肢体缺血和难治性心绞痛方面也显示出临床益处。此外，多项成本分析研究表明，脊髓刺激对于这些已批准的病症具有成本效益。尽管缺乏全面的机制，但脊髓刺激技术及其应用的复杂性正在不断发展。新型设备针对轴向腰痛和足部疼痛，据报道这些部位用传统脊髓刺激更难治疗。经皮混合板状电极、外周神经场刺激、神经根刺激、背根神经节刺激和高频刺激正在积极改进，以解决轴向腰痛和足部疼痛。高频刺激的独特之处在于，它通过在生理频率范围之外进行刺激来提供无感觉异常的镇痛效果。初步结果喜忧参半，一项大型随机对照试验正在进行中，以评估该技术的未来前景。其他新兴技术，包括背根神经节刺激和混合电极，在非随机观察性试验中也显示出一些有前景的初步结果。
本综述是一篇入门文章，并非对支持使用脊髓刺激的现有证据以及新兴神经调节技术的前瞻性讨论的详尽综述。本综述未涉及外周神经刺激，主要关注脊髓刺激，并提及了外周神经场刺激。
脊髓刺激在针对已批准适应症的随机对照试验中已证明具有临床疗效。此外，一些关于外周神经场刺激、混合电极、背根神经节刺激和高频刺激的开放标签观察性研究显示出一些有前景的结果。然而，需要大型随机对照试验来证明其明显的临床益处，以便为其使用获得基于证据的支持。
