Spinal Cord Stimulation as Treatment for Complex Regional Pain Syndrome Should Be Considered Earlier Than Last Resort Therapy

摘要

Background: Spinal cord stimulation (SCS), by virtue of its historically described up-front costs and level of invasiveness, has been relegated by several complex regional pain syndrome (CRPS) treatment algorithms to a therapy of last resort. Newer information regarding safety, cost, and efficacy leads us to believe that SCS for the treatment of CRPS should be implemented earlier in a treatment algorithm using a more comprehensive approach. Methods: We reviewed the literature on pain care algorithmic thinking and applied the safety, appropriateness, fiscal or cost neutrality, and efficacy (S.A.F.E.) principles to establish an appropriate position for SCS in an algorithm of pain care. Results and Conclusion: Based on literature-contingent considerations of safety, efficacy, cost efficacy, and cost neutrality, we conclude that SCS should not be considered a therapy of last resort for CRPS but rather should be applied earlier (e.g., three months) as soon as more conservative therapies have failed. To date, there are no scientifically well-established treatments for complex regional pain syndrome (CRPS) and, further, none are curative (1). Because of ignorance of precise end points for the CRPS, differing studies regarding CRPS probably inadvertently admix different syndromes. Some studies document a greater than 95% spontaneous remission in CRPS I, while others document persistent, disabling symptoms despite aggressive treatment (2). A previous algorithm of care for the treatment of chronic pain syndromes including CRPS based its algorithmic thinking on efficacy, initial costs, and levels of invasiveness (3) (Fig. 1). Today, the decision as to which treatment should be performed on what patient will be determined by the new realities of evidence-based medicine, the appropriateness of the therapy for a given patient, and the concept of cost neutrality. Based on our review of the most recent literature using the published S.A.F.E. evaluation principles (4,5), this paper is designed to establish a basis for algorithmic medical planning so that spinal cord stimulation (SCS) has priority and is not used as "last resort" therapy for CRPS and failed back surgery syndrome (FBSS) (6). The S.A.F.E. principles, an evaluative set of principles for pain therapies, stand for safety, appropriateness, fiscal or cost neutrality, and efficacy.