From pain intensity to a holistic composite measure for spinal cord stimulation outcomes

Abstract

Editor—Despite the beneficial effects of spinal cord stimulation in reducing pain intensity, 1 Grider J.S. Manchikanti L. Carayannopoulos A. et al. Effectiveness of spinal cord stimulation in chronic spinal pain: a systematic review. Pain Physician. 2016; 19: E33-E54 Google Scholar diminishing pain medication use, 2 Goudman L. Duarte R.V. De Smedt A. Copley S. Eldabe S. Moens M. Cross-country differences in pain medication before and after spinal cord stimulation: a pooled analysis of individual patient data from two prospective studies in the United Kingdom and Belgium. Neuromodulation. 2023; 26: 215-223 Google Scholar and improving return to work, 3 Moens M. Goudman L. Brouns R. et al. Return to work of patients treated with spinal cord stimulation for chronic pain: a systematic review and meta-analysis. Neuromodulation. 2019; 22: 253-261 Google Scholar the implantation of spinal cord stimulators involves a high cost. Reimbursement for a spinal cord stimulator implant is often conditional on a successful trial period with country-related definitions to determine success of such a trial with varying trial durations (i.e. without a standard, worldwide definition of a successful trial). 4 Eldabe S. Duarte R.V. Gulve A. et al. Does a screening trial for spinal cord stimulation in patients with chronic pain of neuropathic origin have clinical utility and cost-effectiveness (TRIAL-STIM)? A randomised controlled trial. Pain. 2020; 161: 2820-2829 Google Scholar Most reimbursement rules incorporate a 50% reduction in pain intensity, 5 Kumar K. Taylor R.S. Jacques L. et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007; 132: 179-188 Google Scholar whether or not combined with other criteria, such as reduction in pain medication use, and at least stable levels of daily activity. Moreover, guidelines for the management of neuropathic pain and number needed to treat have incorporated this threshold. The real meaning of a 50% threshold of improvement has not been subjected to trials that evaluate its validity in practical terms and its relationship to related factors, including psychological improvement, social adjustment, mood evaluation, and return to work. 6 Seres J.L. The fallacy of using 50% pain relief as the standard for satisfactory pain treatment outcome. Pain Forum. 1999; 8: 183-188 Google Scholar