EFNS guidelines on neurostimulation therapy for neuropathic pain
Published article online:
21 Jul 2007
Issue online:
20 Aug 2007
Received 24 April 2007 Accepted 26 June 2007
To cite this article: G. Cruccu, T. Z. Aziz, L. Garcia-Larrea, P. Hansson, T. S. Jensen, J.-P. Lefaucheur, B. A. Simpson, R. S. Taylor (2007)
EFNS guidelines on neurostimulation therapy for neuropathic pain
European Journal of Neurology 14 (9), 952Ò970.
doi:10.1111/j.1468-1331.2007.01916.x
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G. Cruccua,baEFNS Panel on Neuropathic Pain, Vienna, AustriabDepartment of Neurological Sciences, La Sapienza University, Roma, Italy, T. Z. AzizccOxford Functional Neurosurgery, Department of Neurosurgery, Radcliffe Infirmary, Oxford, UK, L. Garcia-Larreaa,daEFNS Panel on Neuropathic Pain, Vienna, AustriadINSERM ÎCentral integration of painÌ (U879) Bron, University Lyon 1, France, P. Hanssona,eaEFNS Panel on Neuropathic Pain, Vienna, AustriaeDepartment of Neurosurgery, Pain Center, Karolinska University Hospital and Pain Section, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden, T. S. Jensena,faEFNS Panel on Neuropathic Pain, Vienna, AustriafDanish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark, J.-P. LefaucheurggDepartment of Physiology, Henri Mondor Hospital, AP-HP, Cr»teil, France, B. A. SimpsonhhDepartment of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff, UK and R. S. TayloriiPeninsula Medical School, Universities of Exeter & Plymouth, UK
Dr G. Cruccu, Dipartimento Scienze Neurologiche, Viale Universitá 30-00185 Roma, Italy (tel.: +39 06 49694209; fax: +39 06 49314758; e-mail: cruccu@uniroma1.it).
This is a Continuing Medical Education article, and can be found with corresponding questions on the Internet at http://www.efns.org/content.php?pid=132. Certificates for correctly answering the questions will be issued by the EFNS.
Abstract
Pharmacological relief of neuropathic pain is often insufficient. Electrical neurostimulation is efficacious in chronic neuropathic pain and other neurological diseases. European Federation of Neurological Societies (EFNS) launched a Task Force to evaluate the evidence for these techniques and to produce relevant recommendations. We searched the literature from 1968 to 2006, looking for neurostimulation in neuropathic pain conditions, and classified the trials according to the EFNS scheme of evidence for therapeutic interventions. Spinal cord stimulation (SCS) is efficacious in failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS) type I (level B recommendation). High-frequency transcutaneous electrical nerve stimulation (TENS) may be better than placebo (level C) although worse than electro-acupuncture (level B). One kind of repetitive transcranial magnetic stimulation (rTMS) has transient efficacy in central and peripheral neuropathic pains (level B). Motor cortex stimulation (MCS) is efficacious in central post-stroke and facial pain (level C). Deep brain stimulation (DBS) should only be performed in experienced centres. Evidence for implanted peripheral stimulations is inadequate. TENS and r-TMS are non-invasive and suitable as preliminary or add-on therapies. Further controlled trials are warranted for SCS in conditions other than failed back surgery syndrome and CRPS and for MCS and DBS in general. These chronically implanted techniques provide satisfactory pain relief in many patients, including those resistant to medication or other means.
Background and objectives
Although pharmacological research is making major efforts in the field of neuropathic pain, a considerable number of patients do not achieve sufficient pain relief with medication alone. In real life, a sufficient level of pain relief is probably one that allows the patient to have an acceptable quality of life. In evidence-based studies on pain it is customary to consider as ÎrespondersÌ to treatment those patients that report a pain relief >50%. On that basis, it would appear from the most recent reviews and the European Federation of Neurological Societies (EFNS) guidelines that only 30Ò40% of the patients with chronic neuropathic pain achieve that target with pharmacotherapy [1,2]. However, the 50% rule is being increasingly argued because in many patients objective markers of satisfactory improvement may co-exist with nominal levels of scaled pain relief much <50% [3,4]. It was thereby proposed that a clinically meaningful reduction of chronic pain in placebo-controlled trials would be a two-point decrease or 30% reduction on a 0Ò10 numerical rating scale [5].
Ancillary treatments that are harmless, such as physical and psychological therapies, are often used. Although they may help them to cope, this is often not enough for the patients with severe pain. Amongst the alternatives, a number of previously common surgical lesions aimed at relieving neuropathic pain (such as neurotomies) have now been abandoned.
Neurostimulation therapy is increasingly being used either as a substitute for surgical lesions or in addition to the current medical therapy in several conditions, including Parkinson's disease, dystonia, obsessive-compulsive disorder and refractory pain, whilst trials are in progress in other movement and psychiatric disorders, epilepsy and migraine. The neurostimulation techniques proposed for treating pain are: transcutaneous electrical nerve stimulation (TENS), peripheral nerve stimulation (PNS), nerve root stimulation (NRS), spinal cord stimulation (SCS), deep brain stimulation (DBS), epidural motor cortex stimulation (MCS), and repetitive transcranial magnetic stimulation (rTMS). These techniques vary greatly in their degree of invasiveness, stimulated structures and rationale, but they are all adjustable and reversible.
Our Task Force aimed at providing the neurologist with evidence-based recommendations that may help to determine when a patient with neuropathic pain should try a neurostimulation procedure. To provide a better understanding, the results are preceded by a description of the procedure and its supposed rationale.
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Ron Cole says: | 2010-12-09 04:17:58 |
| Have a trapped verve in spinal cord resulting in severe pain in my right big toe. Had an operation to relieve the pain but no success. I am 82 years old but healthy.My doctor has given me Gabapentin tabs and i take 1,100 mg 3 x a day Can you help |
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