What is the role of spinal cord stimulation (neuromodulation) in the treatment of complex regional pain syndrome (CRPS)?

Updated: Jun 20, 2018
  • Author: Gaurav Gupta, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

One prospective, comparative, randomized study had 36 patients with chronic upper extremity CRPS undergo trial epidural spinal cord stimulation (SCS) and physical therapy and 18 other patients were treated with physical therapy alone. Of the SCS group, 24 patients had a successful trial and received a permanent implant. At 6-month follow-up, the SCS group had a significantly greater reduction in pain and a higher percentage was rated as “much improved” overall. However, there were no clinically significant functional improvements, which led the authors to conclude that SCS was a valid treatment for CRPS of the upper extremities (short-term) just for pain relief and improved quality of life. [148] In a follow-up study, the SCS group was found to cost $4,000 more in the first year in terms of various medical expenses; however, a lifetime analysis revealed that SCS reduced expenditures by $60,000 per patient for the same cost parameters. [149]

A study published in 1998 looked at 36 patients with advanced CRPS of longer than 2 years duration who had completed a successful SCS trial. Patients were treated with either SCS or peripheral nerve stimulation, or both. At 36 months after implantation, visual analogue scale (VAS) pain measures averaged a 53% improvement, analgesic consumption was reduced in most patients, and up to 41% of patients had returned to some type of modified work. [150]

A literature review of SCS use with CRPS showed that overall results were judged as “good to excellent” in more than 72% of patients over time periods of 8-40 months. Therefore, this review strongly supported SCS as a treatment for patients with CRPS. [151]

A retrospective, 3-year, multicenter study of 101 patients with CRPS type I looked at the effectiveness of octapolar (8 electrode sites) versus quadripolar (4 sites) systems, as well as high frequency and multiprogram parameters. VAS reduction approached 70% with dual-octapolar systems and 50% in the quadripolar group. High frequency (>250 Hz) was found to be essential for obtaining adequate analgesia in 15% of the patients with dual-octapolar systems. Overall satisfaction with SCS was 91% in the dual-octapolar group versus 70% in the quadripolar group. At the end of the study, 86.3% of the quadripolar systems and 97.2% of the dual-octapolar systems were still being used. [152] A comprehensive review published in 2013 considering safety, cost, and efficacy suggested that SCS should be used earlier than it commonly is at present and that it should not be considered to be a last resort. [153]

Spinal cord stimulation has also demonstrated immunomodulatory properties in patients with CRPS. Kriek et al. measured inflammatory cytokines, chemokines, and growth factors from the interstial fluid from skin blisters before and after SCS therapy in patients with CRPS. They found expression of both pro- and anti-inflammatory cytokines decreased in the affected and contralateral extremity, correlating with improvement of sensory symptoms. Additionally, SCS attenuated T-cell activation, improved peripheral tissue oxygenation, and decreased anti-angiogenetic activity. [154]  Immunomodulatory therapies may play a future role in the treatment of CRPS. Further research is necessary to validate the potential of immunotherapy as a treatment modality.


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