Practice parameters for the use of spinal cord stimulation in the treatment of chronic neuropathic pain

Introduction. Physicians, policy makers, and other interested parties require a synthesized, critical, and clear compilation of the following information to optimize spinal cord stimulation (SCS) for neuropathic pain: 1) indications and potential beneficial outcomes; 2) answers to key clinical questions; 3) cost/resource use implications; and 4) the quality and source of the evidence. This information must be nonjudgmental and noncoercive and have the sole objective of increasing the reader's expertise. Study Design. Evidence-based literature review and consensus statement. Methods. We consulted with experts to identify clinical-practice questions. Then, we conducted a critical literature review (MEDLINE, EMBASE, 1967 through March 2007) to grade treatment practices from "options" to "recommended." We created a bibliographical database of all citations pertinent to each practice question. Several experts not otherwise involved reviewed the draft document. Results. We answered 64 questions covering 1) indications; 2) potential beneficial outcomes; 3) prognostic factors; 4) patient selection for screening trial; 5) procedural risk management; 6) screening trial; 7) device options; 8) patient management; 9) factors affecting the delivery and quality of SCS treatment; and 10) cost-effectiveness. Most of our more than 300 references are cited multiple times ( in each pertinent category). This is the first overview that seeks to categorize and place the entire SCS clinical literature at the disposal of the reader. It presents the first grading system that incorporates, among other evidence sources, an assessment of the likelihood of a favorable outcome based on the evidence provided by expert consensus combined with consideration of the risk and potential benefit of an action. Conclusions. The Practice Parameters for Spinal Cord Stimulation in the Treatment of Neuropathic Pain answers important questions. It assesses supporting evidence and provides specific citations to enable the reader to conduct further study. The document will be updated regularly in a Webbased version.