|
Clinical Question: Is Spinal Cord Stimulation useful in the
management of CRPS?
Clinical Bottom line: Yes, evidence from the published literature
suggests that Spinal Cord Stimulation is beneficial in managing
refractory pain due to CRPS.
Search Profile
Search Terms: ‘reflex sympathetic dystrophy AND spinal cord
stimulation’;‘complex regional pain syndrome AND spinal cord
stimulation’;
Databases
Pubmed http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed
ISI Current contents http://isicc.com/CCC.cgi
Citations used for evidence
Broseta J, Roldan P, Gonzalez-Darder J, Bordes V, Barcia-Salorio
JL. Chronic epidural dorsal column stimulation in the treatment
of causalgia pain. Appl Neurophysiol. 1982;45(1-2):190-4.
Kumar K, Nath RK, Toth C. Spinal cord stimulation is effective
in the management of reflex sympathetic dystrophy. Neurosurg.
1997;40(3):503-9.
Barolat G, Schwartzman R, Woo R. Epidural spinal cord
stimulation in the management of reflex sympathetic dystrophy.
Stereotact Funct Neurosurg. 1989;53(1):29-39.
Kemler MA, Barendse GA, Van Kleef M, Van Den Wildenberg
FA, Weber WE. Electrical spinal cord stimulation in reflex
sympathetic dystrophy: retrospective analysis of 23 patients.
J Neurosurg. 1999;90(1):79-83.
Broggi G, Servello D, Dones I, Carbone G. Italian multicentric
study on pain treatment with epidural spinal cord stimulation.
Stereotact Funct Neurosurg. 1994;62(1-4):273-8
Calvillo O, Racz G, Didie J, Smith K. Neuroaugmentation
in the treatment of complex regional pain syndrome of the
upper extremity. Acta Orthop Belg. 1998;64(1):57-63.
Miles J, Lipton S, Hayward M, Bowsher D, Mumford J, Molony
V. Pain relief by implanted electrical stimulators. Lancet. 1974;1(7861):777-9.
John C. Oakley, Richard L.Weiner.Spinal Cord stimulation
for Complex Regional Pain Syndrome: Prospective Study of
19 patients at Two Centers. Neurosurg. 1989;24(1):63-67.
Robaina FJ, Dominguez M, Diaz M, Rodriguez JL, de Vera
JA. Spinal cord stimulation for relief of chronic pain in
vasospastic disorders of the upper limbs. Neurosurg.
1989;24(1):63-7.
Sanchez-Ledesma MJ, Garcia-March G, Diaz-Cascajo P, Gomez-Moreta
J, Broseta J. Spinal cord stimulation in deafferentation
pain. Stereotact Funct Neurosurg. 1989;53(1):40-5.
Kemler MA, Barendse GA, van Kleef M, de Vet HC, Rijks
CP, Furnee CA, van den Wildenberg FA. Spinal cord stimulation
in patients with chronic reflex sympathetic dystrophy. N
Engl J Med. 2000 Aug 31;343(9):618-24.
Broggi G, Servello D, Franzini A, Giorgi C, Luccarelli
M, Ruberti U, Cugnasca M, Odero A, Tealdi D, Denale A. Spinal
cord stimulation for treatment of peripheral vascular disease.
Appl Neurophysiol. 1987;50(1-6):439-41.
Robaina FJ, Rodriguez JL, de Vera JA, Martin MA. Transcutaneous
electrical nerve stimulation and spinal cord stimulation
for pain relief in reflex sympathetic dystrophy. Stereotact
Funct Neurosurg. 1989;52(1):53-62.
The Studies
» View
the Demographics Study
» View
the Results Study
The Evidence
- Substantial evidence exists in the published literature
to support the use of spinal cord stimulation in the management
of refractory cases of complex regional pain syndrome.
- Most of the evidence is obtained from case series and
hence the quality of evidence may not be the best. However,
keeping in view, the paucity of randomized controlled clinical
trails conducted in this area, the above evidence is the
most that could be abstracted from published literature.
- In most of the above case series, spinal cord stimulation
was primarily used in patients who could not obtain sustained
pain relief with other treatment modalities such as narcotics
and sympathetic blockade. Hence, the role of spinal cord
stimulation during the early stages of CRPS is not known.
- The limited information available from the studies suggests
that a substantial proportion of patients that were subjected
to a trial stimulation have had success and progressed to
permanent implantation of stimulatory electrodes.
- The proportion of subjects with at least 25% pain relief
from baseline ranged from 54% to 100%, barring a single
case report in which the patient could not obtain any pain
relief even after 18 months of follow- up.
- The rate of complications in the reported studies ranged
from 9% to 47%. The complications were mostly related to
dislocation of the stimulatory electrodes.
Comments
- The search for articles with mention of ‘spinal cord stimulation’
and any synonym of ‘complex regional pain syndrome’, resulted
in forty-six citations encompassing the above mentioned
databases. Out of these, only thirteen articles contained
information relevant to the research question.
- The absence of a ‘ control’ group in Case-Series design
limits the validity of conclusions that can be drawn based
on the findings of such studies.
- In the case of randomized controlled trials examining
the role of spinal cord stimulation for pain relief in cases
with complex regional pain syndrome, at least two barriers
that are inherent to the intervention and the outcome could
potentially limit inferences:
- It is not possible to blind a subject to spinal cord
stimulation because of the simultaneous occurrence of
parasthesiae.
- The subjective nature of pain renders it difficult
to objectively determine the effectiveness of the procedure.
- The mechanisms underlying pain reduction obtained
from spinal cord stimulation are not known.
- It is not clear if other clinical features of CRPS
such as edema and abnormal sudomotor activity also respond
to spinal cord stimulation
Appraised by Prabhav Tella, September 2001 |
