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

ISI Current contents

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

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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