Neurosurgery (66)

Abstract

Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. (Maastricht University Hospital, Maastricht, The Netherlands) N Engl J Med 2000;343:618–624.This randomized trial involved patients who had had reflex sympathetic dystrophy for at least 6 months. Thirty‐six patients were assigned to receive treatment with spinal cord stimulation plus physical therapy, and 18 were assigned to receive physical therapy alone. The spinal cord stimulator was implanted only if test stimulation was successful. The intensity of pain was assessed (on a visual‐analogue scale from 0 cm [no pain] to 10 cm [very severe pain]), as well as the global perceived effect (on a scale from 1 [worst ever] to 7 [best ever]), functional status, and the health‐related quality of life. The test stimulation of the spinal cord was successful in 24 patients; the other 12 patients did not receive implanted stimulators. In an intention‐to‐treat analysis, the group assigned to receive spinal cord stimulation plus physical therapy had a mean reduction of 2.4 cm in the intensity of pain at 6 months, as compared with an increase of 0.2 cm in the group assigned to receive physical therapy alone (P < 0.001 for comparison between the 2 groups). In addition, the proportion of patients with a score of 6 (“much improved”) for the global perceived effect was much higher in the spinal cord stimulation group than in the control group (39% vs. 6%, P = 0.01). There was no clinically important improvement in functional status. The health‐related quality of life improved only in the 24 patients who actually underwent implantation of a spinal cord stimulator. Six of the 24 patients had complications that required additional procedures, including removal of the device in 1 patient. Conclude in carefully selected patients with chronic reflex sympathetic dystrophy, electrical stimulation of the spinal cord can reduce pain and improve health‐related quality of life. Conmment by R. Ruiz‐López, MD.This is a well‐written article describing a prospective, randomized, controlled trial of spinal cord stimulation (SCS) for reflex sympathetic dystrophy, which is also known as complex regional pain syndrome type I (CRPS I). The results show clearly that in carefully selected patients suffering from this pain syndrome, SCS can reduce pain and improve health‐related quality of life compared to patients treated only with physical therapy. Functional status did not improve in either group of patients as SCS treats pain, but not the disease itself. The authors note that the improvement in the overall score for health‐related quality of life was derived mainly from the alleviation of pain as in the study population, pain was the primary source of distress. This study represents a major reference for pain doctors and neurosurgeons treating CRPS and chronic pain.