Painful Peripheral Neuropathies of the Lower Limbs and/or Lower Extremities Treated with Spinal Cord Stimulation: A Systematic Review with Narrative Synthesis

Abstract

Introduction

Painful peripheral neuropathy (PPN) is a debilitating condition with varied etiologies. Spinal cord stimulation (SCS) is increasingly used when conservative treatments fail to provide adequate pain relief. Few published reviews have examined SCS outcomes in all forms of PPN.

Methods

We conducted a systematic review of SCS in PPN. The PubMed database was searched up to February 7th, 2022, for peer-reviewed studies of SCS that enrolled PPN patients with pain symptoms in their lower limbs and/or lower extremities. We assessed the quality of randomized controlled trial (RCT) evidence using the Cochrane risk of bias tool. Data were tabulated and presented narratively.

Results

Twenty eligible studies documented SCS treatment in PPN patients, including 10 kHz SCS, traditional low-frequency SCS (t-SCS), dorsal root ganglion stimulation (DRGS), and burst SCS. In total, 451 patients received a permanent implant (10 kHz SCS, n=267; t-SCS, n=147; DRGS, n=25; burst SCS, n=12). Approximately 88% of implanted patients had painful diabetic neuropathy (PDN). Overall, we found clinically meaningful pain relief (≥30%) with all SCS modalities. Among the studies, RCTs supported the use of 10 kHz SCS and t-SCS to treat PDN, with 10 kHz SCS providing a higher reduction in pain (76%) than t-SCS (38–55%). Pain relief with 10 kHz SCS and DRGS in other PPN etiologies ranged from 42–81%. In addition, 66–71% of PDN patients and 38% of nondiabetic PPN patients experienced neurological improvement with 10 kHz SCS.

Conclusion

Our review found clinically meaningful pain relief in PPN patients after SCS treatment. RCT evidence supported the use of 10 kHz SCS and t-SCS in the diabetic neuropathy subpopulation, with more robust pain relief evident with 10 kHz SCS. Outcomes in other PPN etiologies were also promising for 10 kHz SCS. In addition, a majority of PDN patients experienced neurological improvement with 10 kHz SCS, as did a notable subset of nondiabetic PPN patients.

Keywords:

• painful diabetic neuropathy
• peripheral neuropathy
• spinal cord stimulation
• 10 kHz SCS
• diabetes
• neuropathic pain
• systematic review

Disclosure

ARB has received consulting fees from Nevro and research support from Nevro. JLC has received consulting fees from Vertos and research support from Nevro. CEA has received consulting fees from Nevro, Vertex, Amgen, Lundbeck, Collegium, Gene Pharma, Clexio Biosciences, Biohaven, Teva; personal fees from Averitas, Gruenenthal, Kowa, Neumentum, Tioga Research, Triss, Xgene; research support from Abbvie, Amgen, Lilly, Vertex and Teva. DRE received a fee from Nevro in her capacity as an independent medical writer. EAP has received consulting fees from Abbott Neuromodulation, Biotronik, Boston Scientific, Medtronic Neuromodulation, Nalu, Neuros Medical, Nevro, Presidio Medical, Saluda, and Vertos; research support from Mainstay, Medtronic Neuromodulation, Nalu, Neuros Medical, Nevro, ReNeuron, Saluda, and SPR; and stock options from neuro42 and SynerFus

Additional information

Funding

Nevro Corp., Redwood City, CA, USA, funded this research.