Department of Anaesthesiology, Basildon and Thurrock University Hospitals, Basildon, UK.
Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Eur J Pain. 2020 Jul;24(6):1169-1181. doi: 10.1002/ejp.1562. Epub 2020 Apr 4.
Spinal cord stimulation (SCS) is an established treatment for chronic neuropathic, neuropathic-like and ischaemic pain. However, the heterogeneity of patients in daily clinical practice makes it often challenging to determine which patients are eligible for this treatment, resulting in undesirable practice variations. This study aimed to establish patient-specific recommendations for referral and selection of SCS in chronic pain.
A multidisciplinary European panel used the RAND/UCLA Appropriateness Method (RUAM) to assess the appropriateness of (referral for) SCS for 386 clinical scenarios in four pain areas: chronic low back pain and/or leg pain, complex regional pain syndrome, neuropathic pain syndromes and ischaemic pain syndromes. In addition, the panel identified a set of psychosocial factors that are relevant to the decision for SCS treatment.
Appropriateness of SCS was strongly determined by the neuropathic or neuropathic-like pain component, location and spread of pain, anatomic abnormalities and previous response to therapies targeting pain processing (e.g. nerve block). Psychosocial factors considered relevant for SCS selection were as follows: lack of engagement, dysfunctional coping, unrealistic expectations, inadequate daily activity level, problematic social support, secondary gain, psychological distress and unwillingness to reduce high-dose opioids. An educational e-health tool was developed that combines clinical and psychosocial factors into an advice on referral/selection for SCS.
The RUAM was useful to establish a consensus on patient-specific criteria for referral/selection for SCS in chronic pain. The e-health tool may help physicians learn to apply an integrated approach of clinical and psychosocial factors.
Determining the eligibility of SCS in patients with chronic pain requires careful consideration of a variety of clinical and psychosocial factors. Using a systematic approach to combine evidence from clinical studies and expert opinion, a multidisciplinary European expert panel developed detailed recommendations to support appropriate referral and selection for SCS in chronic pain. These recommendations are available as an educational e-health tool (https://www.scstool.org/).
脊髓刺激（SCS）是一种成熟的治疗慢性神经性、神经性样和缺血性疼痛的方法。然而，在日常临床实践中，患者的异质性使得确定哪些患者适合这种治疗变得具有挑战性，从而导致了不理想的实践差异。本研究旨在为慢性疼痛患者的 SCS 转诊和选择制定具体的建议。
一个多学科的欧洲专家组使用 RAND/UCLA 适宜性方法（RUAM）来评估 SCS 在四个疼痛领域的 386 个临床场景的适宜性（转诊）：慢性下腰痛和/或腿痛、复杂区域疼痛综合征、神经性疼痛综合征和缺血性疼痛综合征。此外，专家组确定了一组与 SCS 治疗决策相关的心理社会因素。
SCS 的适宜性主要取决于神经性或神经性样疼痛成分、疼痛的位置和扩散、解剖异常以及以前针对疼痛处理的治疗反应（如神经阻滞）。被认为与 SCS 选择相关的心理社会因素如下：缺乏参与、功能失调的应对方式、不切实际的期望、日常活动水平不足、有问题的社会支持、继发性获益、心理困扰和不愿意减少高剂量阿片类药物。开发了一种电子健康教育工具，将临床和心理社会因素结合起来，为 SCS 的转诊/选择提供建议。
RUAM 有助于就慢性疼痛患者的 SCS 转诊/选择建立具体的共识标准。电子健康工具可以帮助医生学习应用临床和心理社会因素的综合方法。
确定 SCS 在慢性疼痛患者中的适用性需要仔细考虑各种临床和心理社会因素。使用系统的方法将来自临床研究和专家意见的证据结合起来，一个多学科的欧洲专家小组制定了详细的建议，以支持慢性疼痛中 SCS 的适当转诊和选择。这些建议可作为一个教育性电子健康工具（https://www.scstool.org/）获得。
