Spinal Cord Stimulation vs Medical Management for Chronic Back and Leg Pain

Importance Chronic back and lower extremity pain is one of the leading causes of disability worldwide. Spinal cord stimulation (SCS) aims to improve symptoms and quality of life. Objective To evaluate the efficacy of SCS therapies compared with conventional medical management (CMM). Data Sources MEDLINE, Embase, and Cochrane Library were systematically searched from inception to September 2, 2022. Study Selection Selected studies were randomized clinical trials comparing SCS therapies with sham (placebo) and/or CMM or standard treatments for adults with chronic back or leg pain who had not previously used SCS. Data Extraction and Synthesis Evidence synthesis estimated odds ratios (ORs) and mean differences (MDs) and their associated credible intervals (CrI) through bayesian network meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for network meta-analyses was followed. Main Outcomes and Measures The primary outcomes were pain-related end points, including pain intensity (measured by visual analog scale) and proportion of patients achieving at least 50% pain relief (responder rate) in the back or leg. Quality of life (measured by EQ-5D index score) and functional disability (measured by the Oswestry Disability Index score) were also considered. Results A total of 13 studies of 1561 patients were included in the network meta-analysis comparing conventional and novel SCS therapies with CMM across the 6 outcomes of interest at the 6-month follow-up. Both conventional and novel SCS therapies were associated with superior efficacy compared with CMM in responder rates in back (conventional SCS: OR, 3.00; 95% CrI, 1.49 to 6.72; novel SCS: OR, 8.76; 95% CrI, 3.84 to 22.31), pain intensity in back (conventional SCS: MD, −1.17; 95% CrI, −1.64 to −0.70; novel SCS: MD, −2.34; 95% CrI, −2.96 to −1.73), pain intensity in leg (conventional SCS: MD, −2.89; 95% CrI, −4.03 to −1.81; novel SCS: MD, −4.01; 95% CrI, −5.31 to −2.75), and EQ-5D index score (conventional SCS: MD, 0.15; 95% CrI, 0.09 to 0.21; novel SCS: MD, 0.17; 95% CrI, 0.13 to 0.21). For functional disability, conventional SCS was superior to CMM (MD, −7.10; 95% CrI, −10.91 to −3.36). No statistically significant differences were observed for other comparisons. Conclusions and Relevance This systematic review and network meta-analysis found that SCS therapies for treatment of chronic pain in back and/or lower extremities were associated with greater improvements in pain compared with CMM. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management.