Spinal cord stimulation for chronic pain: state-of-affairs in 2024

Spinal cord stimulation (SCS) is an end-of-line treatment option for patients with chronic pain. However, controversies circle this topic, leading to a ‘trench war’ between neuromodulation practitioners and opponents. Dr Cecile de Vos (Erasmus University Medical Centre, the Netherlands) discussed the current evidence and ongoing developments in the field.

“The clinical evidence on SCS up to 2010 is based on conventional SCS, for paraesthesia, a modality for which blinded randomised-controlled trials were not possible,” explained Dr de Vos [1]. Although systematic reviews showed long-term pain relief of SCS for patients with persistent spinal pain syndrome or complex regional pain syndrome [2,3], the 2016 EAN guideline on central neurostimulation therapy in chronic pain conditions only provided a ‘weak recommendation’ for SCS [4]. “Again, mainly due to the lack of placebo-controlled trials.”

In recent years, high-frequency, paraesthesia-free paradigms of SCS have been developed. “This innovation makes it possible to conduct placebo-controlled trials,” according to Dr de Vos. Although SCS appears to outperform placebo for pain relief, the studies that were included in a more recent systematic review on this topic have large methodological differences [5]. “The heterogeneity of study designs, the unknown role of the placebo effect, the balance between efficacy and complications, and heavy industry involvement in clinical trials are still controversial elements in the domain of SCS,” clarified Dr de Vos. Moreover, SCS is an expensive treatment, with device costs being around $20,000.

Dr de Vos argued that with an average success rate of over 50% in a heavily pre-treated population of patients with neuropathic pain, the efficacy of SCS compares favourably versus pharmaceutical therapies [6]. “Moreover, severe complications are very uncommon [7].”

“We need well-designed, independent, multicentre, placebo-controlled studies, in 1 pain condition, with objective outcome measures, to gain a better understanding of SCS therapy and to develop personalised approaches and treatment guidelines,” Dr de Vos concluded.

1. De Vos C, et al. Spinal cord stimulation for the treatment of chronic pain. 10th EAN Congress, 29 June–2 July 2024, Helsinki, Finland.
2. Simpson EL, et al. Health Technol Assess. 2009;13(17):iii,ix-x,1-154.
3. Frey ME, et al. Pain Physician. 2009;12(2):379-397.
4. Cruccu G, et al. Eur J Neurol. 2016;23(10):1489-1499.
5. Duarte RV, et al. Pain. 2020;161:24-35.
6. Finnerup NB, et al. Lancet Neurol. 2015;14(2):162-173.
7. Eldabe S, et al. Pain Med. 2016;17:325-336.

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Posted on 25 July 2024