Spinal cord stimulation compared to spine surgery
Surgery can be a viable solution for patients with various pain conditions. According to the annual report from the Norwegian Registry for Spine Surgery (14), 6316 spine surgeries were registered in 2022 (2297 disc prolapse surgeries and 3030 decompression surgeries). Patients undergoing such surgery often experience radicular leg pain, which can be a neuropathic pain condition. As far as we know, no placebo-controlled trials have been conducted on surgical decompression of lumbar spinal stenosis (a current trial claims to be the first of its kind (15)).
Several thousand spine surgeries are thus performed in Norway annually without any evidence from placebo-controlled trials. This may be due to various factors, such as ethical, financial, organisational or recruitment challenges in carrying out such trials. Additionally, these types of trials will employ stringent patient selection criteria that may not accurately reflect the characteristics of a real-world population. It is therefore important to use other sources to supplement existing knowledge. Medical quality registries can help meet this need.
Spinal cord stimulation may be an option for some patients with neuropathic pain, both before and after spine surgery
A systematic review (5) conducted a meta-analysis of patient satisfaction with spinal cord stimulation, and showed that 82 % of patients who had received spinal cord stimulation reported being at least moderately satisfied with the treatment. The perceived benefit of surgery is presented in the 2022 annual report of the Norwegian Registry for Spine Surgery. A total of 61 % patients reported being 'completely recovered' or 'much better' (Table 2) (14. 44). The figures presented in the two publications are not entirely analogous, but we believe that the comparison can provide useful insight into the benefits patient derive from spinal cord stimulation. We have not yet published this data from our registry (16), but preliminary analyses suggest similar patient satisfaction as in the Norwegian Registry for Spine Surgery. Many of our patients with painful radiculopathy have undergone spine surgery that has not resulted in clinical improvement, and therefore constitute a subgroup with a relatively poor prognosis. Painful radiculopathy is an indication in 30–40 % of patients who receive a spinal cord stimulator at our department.
Table 2
Figures from the Norwegian Registry for Spine Surgery's annual report for 2022 (14), Table 3,5 p. 44.
| How much benefit has the patient derived from the surgery? | Percentage (%) |
|---|
| Completely recovered | 17.2 |
| Much better | 43.5 |
| Slightly better | 21.0 |
| No change | 7.7 |
| Slightly worse | 5.7 |
| Much worse | 3.6 |
| Worse than ever | 1.3 |
Spinal cord stimulation may be an option for some patients with neuropathic pain, both before and after spine surgery. A randomised controlled trial (17) comparing spinal cord stimulation with repeated lumbosacral spine surgery showed that a significant majority of patients experienced more than a 50 % reduction in pain intensity with spinal cord stimulation. There were also far fewer patients who wanted to switch from spinal cord stimulation to spine surgery compared to the other way around.
Spinal cord stimulation is associated with a low risk of serious complications. The most common complications are pain over the pulse generator and electrode dislocation (18). Furthermore, spinal cord stimulation is a reversible intervention, and the percutaneous technique causes little tissue trauma compared to other surgeries. We therefore believe that spinal cord stimulation should be seen as a treatment option for more patients with chronic peripheral neuropathic pain, regardless of the underlying aetiology.