Karri Jay, Sivanesan Eellan, Gulati Amitabh, Singh Vinita, Sheen Soun, Yalamuru Bhavana, Wang Eric J, Javed Saba, Chung Matthew, Sohini Rohan, Hussain Nasir, D'Souza Ryan S
Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA.
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
Neuromodulation. 2025 Feb;28(2):348-361. doi: 10.1016/j.neurom.2024.08.011. Epub 2024 Oct 11.
Clinical interest in and utilization of peripheral nerve stimulation (PNS) for treating chronic pain has significantly increased in recent years owing to its potential for providing analgesia and improved function and quality of life in comparison with pharmacologic treatments. However, the relative infancy of PNS-specific systems and limited clinical practice guidance likely contribute to significant variation in PNS utilization patterns.
We sought to conduct a survey study to characterize PNS-specific clinical practices and propose the next steps in standardizing key practices for PNS utilization.
A 19-question survey exploring PNS-relevant clinical parameters was disseminated online to pain physicians in practice. Descriptive statistics were used to summarize results.
A total of 94 responses were collected. Regarding patient selection, most practitioners would apply PNS to treat nociceptive pain from major joint osteoarthritis (77.7%) and chronic low back pain (64.9%), but not for axial neck pain (50.0%). In contrast, most would apply PNS to treat neuropathic pain from peripheral neuralgia (94.7%), pericranial neuralgia (77.7%), and cancer-related neuropathic pain (64.9%). In treating complex regional pain syndrome, most practitioners would apply PNS before all other forms of neuraxial neuromodulation (>50% for each form). Similarly, for treating nonsurgical low back pain, most would apply PNS before neuraxial neuromodulation (>50% for each form) but not before radiofrequency ablation (19.2%). Most routinely performed nerve blocks before PNS, mainly to confirm anatomical coverage (84.0%), and regarded a 50% to 75% interquartile range as the minimum analgesic benefit required before proceeding with PNS. Regarding nerve target selection for treating complex regional pain syndrome of the wrist/hand or ankle/foot, or knee osteoarthritis, we observed a very wide variance of PNS target locations and discrete nerves. Regarding "minor" adverse events, most reported not changing PNS utilization on encountering skin/soft tissue reactions (85.1%), minor infections (76.6%), or lead migration/loss of efficacy (50.0%). In comparison, most reported reducing PNS utilization on encountering skin erosion (58.5%), major infections (58.5%), or lead fractures (41.5%).
There is significant practice variation regarding the utilization of PNS across numerous key clinical considerations. Future research that explores the reasons driving these differences might help optimize patient selection, target selection, periprocedural management, and ultimately outcomes.
近年来，由于与药物治疗相比，外周神经刺激（PNS）具有提供镇痛、改善功能和生活质量的潜力，临床对其治疗慢性疼痛的兴趣和应用显著增加。然而，PNS特定系统尚处于起步阶段，临床实践指导有限，这可能导致PNS应用模式存在显著差异。
我们试图开展一项调查研究，以描述PNS的临床实践特征，并提出规范PNS应用关键实践的下一步措施。
在网上向执业疼痛科医生发放了一份包含19个问题的调查问卷，以探究与PNS相关的临床参数。采用描述性统计方法总结结果。
共收集到94份回复。在患者选择方面，大多数从业者会应用PNS治疗主要关节骨关节炎引起的伤害性疼痛（77.7%）和慢性下腰痛（64.9%），但不会用于治疗轴性颈部疼痛（50.0%）。相比之下，大多数从业者会应用PNS治疗外周神经痛（94.7%）、颅周神经痛（77.7%）和癌症相关神经病理性疼痛（64.9%）引起的神经病理性疼痛。在治疗复杂性区域疼痛综合征时，大多数从业者会在所有其他形式的轴索神经调节之前应用PNS（每种形式均超过50%）。同样，在治疗非手术性下腰痛时，大多数从业者会在轴索神经调节之前应用PNS（每种形式均超过50%），但不会在射频消融之前应用（19.2%）。大多数人在进行PNS之前常规进行神经阻滞，主要是为了确认解剖覆盖范围（84.0%），并将四分位数间距50%至75%视为进行PNS之前所需的最小镇痛效益。在治疗手腕/手部或脚踝/足部的复杂性区域疼痛综合征或膝关节骨关节炎时，我们观察到PNS靶点位置和离散神经的差异非常大。关于“轻微”不良事件，大多数人报告在遇到皮肤/软组织反应（85.1%）、轻微感染（76.6%）或导线移位/疗效丧失（50.0%）时不会改变PNS的应用。相比之下，大多数人报告在遇到皮肤糜烂（58.5%）、严重感染（58.5%）或导线断裂（41.5%）时会减少PNS的应用。
在众多关键临床考量因素中，PNS的应用存在显著的实践差异。未来探索导致这些差异原因的研究可能有助于优化患者选择、靶点选择、围手术期管理，并最终改善治疗结果。
