1. 2016;19;E33-E54Effectiveness of Spinal Cord Stimulation in Chronic Spinal Pain: A Systematic Review
   Systematic Review
   Paul J. Christo, MD, Ricardo Vallejo, MD, PhD, Salim M. Hayek, MD, PhD, Kent H Nouri, MD, Rafael Justiz, MD, Carl C Balog, MD, Michael E. Harned, MD, Vahid Grami, MD, Manohar Lal Sharma, MD, Alexios Carayannopoulos, DO, MPH, Laxmaiah Manchikanti, MD, and Jay S. Grider, DO, PhD.

BACKGROUND: Chronic neuropathic pain has been recognized as contributing to a significant proportion of chronic pain globally. Among these, spinal pain is of significance with failed back surgery syndrome (FBSS), generating considerable expense for the health care systems with increasing prevalence and health impact.

OBJECTIVE: To assess the role and effectiveness of spinal cord stimulation (SCS) in chronic spinal pain.

STUDY DESIGN: A systematic review of randomized controlled trials (RCTs) of SCS in chronic spinal pain.

METHODS: The available literature on SCS was reviewed. The quality assessment criteria utilized were Cochrane review criteria to assess sources of risk of bias and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment (IPM – QRB) criteria for randomized trials.

The level of evidence was based on a best evidence synthesis with modified grading of qualitative evidence from Level I to Level V.

Data sources included relevant literature published from 1966 through March 2015 that were identified through searches of PubMed and EMBASE, manual searches of the bibliographies of known primary and review articles, and all other sources.

OUTCOME MEASURES: RCTs of efficacy with a minimum 12-month follow-up were considered for inclusion. For trials of adaptive stimulation, high frequency stimulation, and burst stimulation, shorter follow-up periods were considered.

RESULTS: Results showed 6 RCTs with 3 efficacy trials and 3 stimulation trials. There were also 2 cost effectiveness studies available. Based on a best evidence synthesis with 3 high quality RCTs, the evidence of efficacy for SCS in lumbar FBSS is Level I to II. The evidence for high frequency stimulation based on one high quality RCT is Level II to III. Based on a lack of high quality studies demonstrating the efficacy of adaptive stimulation or burst stimulation, evidence is limited for these 2 modalities.

LIMITATIONS: The limitations of this systematic review continue to require future studies illustrating effectiveness and also the superiority of high frequency stimulation and potentially burst stimulation.

CONCLUSION: There is significant (Level I to II) evidence of the efficacy of spinal cord stimulation in lumbar FBSS; whereas, there is moderate (Level II to III) evidence for high frequency stimulation; there is limited evidence for adaptive stimulation and burst stimulation.