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5 Articles in this Series
Audience Q&A: My Patients Don't See a Need for a Psychologist
Debate: Radiofrequency Ablation of the Hip (and Shoulder) Joint is Effective
Debate: SCS Is Better Than PNS for Back Pain
Inside the Poster: Methylnaltrexone for Opioid-Induced Constipation
The Deprescribing of Opioids: Toward Whole-Person Pain Care

Debate: SCS Is Better Than PNS for Back Pain

with Stephanie A. Neuman MD, and David Provenzano, MD

As part of its annual debate session, AAPM 2020 presenters weighed the pros and cons of spinal cord stimulation. Below are the highlights from the debaters.

To set the stage, presenter David Provenzano, MD, who served as an author of the North American Spine Society (NASS) Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Low Back Pain, shared: It is worth noting that spinal cord stimulation (SCS) can be a very helpful treatment for many patients. When examining this treatment for just axial non-specific low back pain, the evidence base is not as strong. In individuals with low back pain and radicular symptoms (ie, leg symptoms), the data do demonstrate that SCS improves both aspects of pain. It is also important to point out that the NASS evidence-based review was initiated in 2014; the literature review was completed early in the process but the final publication did not come out until 2020. As a result, research conducted since that time was not part of the literature reviewed.

The new NASS Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Low Back Pain have sparked some questions. (Image: iStock)


Pro: Stephanie A. Neuman, MD, chair of pain medicine at Gundersen Health System, La Crosse, Wisconsin

Dating back 4,500 years ago to Egyptian times, pointed out Dr. Neuman, humans have used electrical fish ​to relieve pain. In 1967, Dr. C. Norm Shealy (a PPM editorial advisor) implanted the first spinal cord stimulator. In comparing spinal cord stimulation (SCS) treatment of chronic low back pain to peripheral nerve stimulation (PNS), we know a lot today about the former option, said Dr. Neuman. For instance, she pointed out that: 

  • SCS leads are designed for the epidural space and are durable.
  • Placement ​of the leads and accessing ​the epidural space is well described.
  • We know our targets.
  • Complications are low and rates ​of lead migration are decreasing.

Plus, she added: programming is well defined​, programing options have expanded, infection prevention measures are defined, and the procedure is not only well supported in the literature but also reimbursed by payers.

In terms of patient benefit, “There is evidence in the literature going back two decades,” said Dr. Neuman, who cited studies on SCS for chronic back ​and/or leg pain by Taylor et al, and Barolat, et al. ​Additionally, ​she noted there are a tremendous amount of new ​data and options. ​She stated “It is an exciting time to be ​doing SCS” as she highlighted the EVOKE, SENZA-RCT, SUNBURST, Vectors/Evolve, and Stimgenics trials​/data of late. ​

Dr. Neuman also shared that, “For high frequency stimulation, patients have had superior outcomes for back pain compared to regular stimulation.” Differential target multiplexed (DTM) SCS ​claims to modulate glial and neural cells and its preliminary data ​described a high rate of patients receiving greater than 80% relief ​of back pain. ​Similarly, she highlighted data from the recent EVOKE study describing how closed loop SCS ​using evoked compound action potentials (ECAPS) results in greater ​pain relief than traditional SCS in patients with leg and back pain. Overall, concluded Dr. Neuman, “SCS should be our first option for patients given the data.”


Con: David A. Provenzano, MD, Pain Diagnostics and Interventional Care, Pittsburgh PA / Treasurer, American Society of Regional Anesthesia and Pain Medicine He disclosed his consulting and funding roles with Abbott, Boston Scientific, Medtronic, Stimgenics, Nevro, Avanos, and Esteve.

I cannot convince you that SCS is better than PNS, but I can convince you to be more cautious, Dr. Provenzano told the AAPM audience. Most studies include leg pain not just axial (non-specific mechanical) back pain and with that target, there is less data, he noted. A majority of explants for loss of efficacy with SCS occur around 1.5 years and therefore it is critical to have long-term data when evaluating the efficacy of the modality for specific medical conditions such as non-specific low back pain.

Limitations have existed with neuromodulation when targeting the low back, especially with paresthesia-based systems that require mapping, he noted. Capturing the low back with paresthesia and maintaining paresthesia coverage and pain relief may be challenging. Similar to Dr. Neuman, Dr. Provenzano highlighted recent advancements in SCS programming parameters, including HF-10, burst, closed loop, and differential target multiplexed (DTM), which he said have helped to overcome some of the limitations of paresthesia-based systems. However, long-term studies specifically examining only low back pain are required to truly assess efficacy, he clarified.

As part of this talk, Dr. Provenzano shared that he was an author in the recently published NASS Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Low Back Pain. These guidelines were initiated in 2014 and evaluated treatments for adult patients with low back pain defined as pain of musculoskeletal origin extending from the lowest rib to the gluteal fold that may at times extend as somatic referred pain into the thigh (above the knee). He also served as the American Society of Regional Anesthesia and Pain Medicine Stakeholder and, prior to participating in the guidelines, had to complete 30 hours of evidence-based medicine training. "When evaluating the specific condition highlighted in the NASS guidelines, it was concluded that the data at the time of the review were inconclusive for axial low back pain alone," he said.

Overall, “SCS patient identification should be specific to people with no pain extending beyond the gluteal fold and the guidelines were not covering the treatment of pain in patients that had previous back surgery, per the current NASS recommendations,” he said. The NASS guide to Diagnosis and Treatment of Low Back Pain states, “There is insufficient evidence to make a recommendation for or against the use of spinal cord stimulation as a treatment for low back pain" (Recommendation Grade I). The work group recommended RCTs utilizing SCS in patients with only low back pain. Concluded Dr. Provenzano, “There are many structures in the lower back, and we need to consider both SCS and PNS specifically to the candidate and their medical condition.”



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