A 48-year-old patient has presented to the pain clinic after referral from their spinal surgeon. The patient has a history of three previous lumbar decompressions with microdiscectomy at L4/5 to treat left leg pain. The patient has unfortunately developed lower back pain and persistent left leg pain which is refractory to surgical treatment. Additionally, after an up to date MRI, the patient was discussed in a spinal MDT which does not recommend further surgical intervention (including instrumentation), but does recommend referral to the pain team for assessment for spinal cord stimulation (SCS).
- What are the indications and evidence for spinal cord stimulation?
SCS was first approved by NICE in 2008 (TA159) and reviewed in 2014. SCS is recommended for severe prolonged pain, which is responsive to a trial of stimulation, in failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS) and neuropathic pain. NICE concluded that there is insufficient evidence to recommend SCS use outside of trials for ischaemic pain. SCS is one of the neuromodulation therapies available to treat chronic pain.
There are several RCTs which NICE used for their recommendation, supporting the use of SCS for FBSS (North 2005) (Kumar ‘PROCESS’ study 2008) and CRPS (Kemler 2000 and 2004).
A recent Cochrane review (Traeger 2023), which is based on evidence from a randomised clinical trial published in JAMA(Hara 2022), concludes that the data does not support the use SCS to treat back pain outside of a clinical trial, and SCS probably does not have sustained clinical benefits that would outweigh the costs and risks. However, current NHS pain medicine specialists in clinical practice use NICE guidance (MTG41, revised August 2023) to inform suitability of patients for implantation.
