Jay Karri1, Vwaire Orhurhu2, Sayed Wahezi3, Tuan Tang4, Timothy Deer5, Alaa Abd-Elsayed6. 1. Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX. 2. Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. 3. Montefiore Medical Center Multidisciplinary Pain Program, Bronx, NY; Albert Einstein College of Medicine; Bronx, NY. 4. McGovern Medical School, The University of Texas HSC, Houston, TX. 5. Center for Pain Relief, Charleston, WV. 6. Department of Anesthesiology University of Wisconsin, School of Medicine and Public Health, Madison, WI.
Abstract
BACKGROUND: The treatment of chronic refractory low back pain (LBP) is challenging. Conservative and pharmacologic options have demonstrated limited efficacy. Spinal cord stimulation (SCS) has been shown to be effective in reducing chronic LBP in various contexts. With emerging SCS technologies, the collective evidence of novel waveforms relative to traditional tonic stimulation for treating chronic LBP has yet to be clearly characterized. OBJECTIVES: To provide evidence for various SCS waveforms-tonic, burst, and high frequency (HF)-relative to each other for treating chronic LBP. STUDY DESIGN: Systematic review and meta-analysis. METHODS: PubMed, Medline, Cochrane Library, prior systematic reviews, and reference lists were screened by 2 separate authors for all randomized trials and prospective cohort studies comparing different SCS waveforms for treatment of chronic LBP. RESULTS: We identified 11 studies that included waveform comparisons for treating chronic LBP. Of these, 6 studies compared burst versus tonic, 2 studies compared burst versus HF, and 3 studies compared tonic versus HF. A meta-analysis of 5 studies comparing burst versus tonic was conducted and revealed pooled superiority of burst over tonic in pain reduction. One study comparing burst versus tonic was excluded given technical challenges in data extraction. LIMITATIONS: Both randomized controlled trials and prospective cohort studies were included for meta-analysis. Several studies included a high risk of bias in at least one domain. CONCLUSIONS: Burst stimulation is superior to tonic stimulation for treating chronic LBP. However, superiority among other waveforms has yet to be clearly established given some heterogeneity and limitations in evidence. Given the relative novelty of burst and HF SCS waveforms, evidence of longitudinal efficacy is needed.
BACKGROUND: The treatment of chronic refractory low back pain (LBP) is challenging. Conservative and pharmacologic options have demonstrated limited efficacy. Spinal cord stimulation (SCS) has been shown to be effective in reducing chronic LBP in various contexts. With emerging SCS technologies, the collective evidence of novel waveforms relative to traditional tonic stimulation for treating chronic LBP has yet to be clearly characterized. OBJECTIVES: To provide evidence for various SCS waveforms-tonic, burst, and high frequency (HF)-relative to each other for treating chronic LBP. STUDY DESIGN: Systematic review and meta-analysis. METHODS: PubMed, Medline, Cochrane Library, prior systematic reviews, and reference lists were screened by 2 separate authors for all randomized trials and prospective cohort studies comparing different SCS waveforms for treatment of chronic LBP. RESULTS: We identified 11 studies that included waveform comparisons for treating chronic LBP. Of these, 6 studies compared burst versus tonic, 2 studies compared burst versus HF, and 3 studies compared tonic versus HF. A meta-analysis of 5 studies comparing burst versus tonic was conducted and revealed pooled superiority of burst over tonic in pain reduction. One study comparing burst versus tonic was excluded given technical challenges in data extraction. LIMITATIONS: Both randomized controlled trials and prospective cohort studies were included for meta-analysis. Several studies included a high risk of bias in at least one domain. CONCLUSIONS: Burst stimulation is superior to tonic stimulation for treating chronic LBP. However, superiority among other waveforms has yet to be clearly established given some heterogeneity and limitations in evidence. Given the relative novelty of burst and HF SCS waveforms, evidence of longitudinal efficacy is needed.
Entities:
Keywords:
Chronic low back pain; burst; spinal cord stimulation; tonic
Authors: Gerrit Eduard Gmel; Rosana Santos Escapa; John L Parker; Dave Mugan; Adnan Al-Kaisy; Stefano Palmisani Journal: Front Neurosci Date: 2021-01-21 Impact factor: 4.677