In conclusion, emerging evidence indicates that interventional therapies can be effective in the management of refractory PDN. Based on systematic review of evidence, we recommend that SCS should be considered to reduce pain and improve quality of life (evidence level: 1B+) for patients with refractory PDN in the lower extremities. Acupuncture or botulinum toxin injection can be considered as an adjunctive therapy for PDN (2B+/1B+). Surgical decompression of specific peripheral nerves in the lower extremity can be considered in PDN patients with superimposed compression of the nerves (2B±/1B+). Lumbar sympathetic block can be used in select patients if the patient had a favorable response to the block (2C+). High-quality RCTs are warranted to further strengthen the evidence for these interventional treatments and to bridge many gaps identified in this review.
J.X. is supported by a National Institutes of Health grant K08CA228039.
The authors are grateful to Dr Olivia Tianjiao Cheng, MD, Beaumont Eye Institute, Michigan, for her contributions in improving the quality of the manuscript.
AAN = American Academy of Neurology; AE = anhydrous ethanol; BMI = body mass index; BPIDPN = Brief Pain Inventory-Diabetic Painful Neuropathy; BTX-A = botulinum toxin-A; CHEP = contact heat-evoked potential; CMM = conventional medical management; DRG = dorsal root ganglion; DSP = diabetic sensorimotor polyneuropathy; EA = electroacupuncture; HF-10 = high frequency 10 kHz; IPG = implantable pulse generator; IPM – QRB = Interventional Pain Management techniques – Quality Appraisal of Reliability and Risk of Bias Assessment; MDNS = Michigan Diabetic Neuropathy Score; N/A = not available; NCV = nerve conduction velocity; NRS = numerical rating scale; PDN = painful diabetic neuropathy; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; QoL = quality of life; RCT = randomized clinical trial; RF = radiofrequency thermocoagulation; SAE = serious adverse event; SCS = spinal cord stimulation; VAS = visual analog scale
Anesth Analg. 2022;134(6):1215-1228. © 2022 International Anesthesia Research Society