Spinal Cord Stimulation and Other Neuromodulation Therapies for the Treatment of Refractory Chronic Pain: What’s New? What’s Good? What’s Better?

Dear Colleagues,

Chronic refractory pain (CRP) is a major, worldwide health problem that generates considerable expenses for healthcare systems.  On top of this, post-operative back and/or leg pain, previously known as “Failed Back Surgery Syndrome / FBSS” and recently renamed “Persistent Spinal Pain Syndrome / PSPS”, represent one of its most disabling syndromes.

Ultimately, this devastating condition can become the substrate of potential indications for implanted neuromodulation therapy, once two crucial criteria have been fulfilled: (1) Optimal Medical Management has previously failed and, (2) Therapeutical strategies are to be discussed based on a Multidisciplinary team assessment.  Notwithstanding the existence of these recommendations and published guidelines, a number of controversial issues concerning the invasive management of PSPS are regularly debated worldwide at spine, pain and neuromodulation conferences, and no clear consensus has been reached.

Any lasting relief solution to failed back syndrome will be due to the physician who not only masters the pathology and the technical aspects, but who also understands the patient. Solutions to great problems usually come from men and women who are passionate, observing and skillful.

In CRP treatment, current practice in neurostimulation varies, from one center to another, and most clinical decisions are based on an individual diagnosis.

Given this context, neurostimulation evaluation tools and pain relief assessment are of major concern, especially insofar as they now constitute one of the main biases of clinical trials. Moreover, the proliferation of technological devices, in a promising yet unsettling market, fosters and furthers confusion.

At the epicenter of the refractory chronic pain enigma, this technological earthquake now underway can be considered as either a rare opportunity to better help the patient or a major source of opaqueness for physicians. 

There are three options available for scientific debates on our daily neurostimulation practice: intentional ignorance, standardized evidence-based practice or an alternative data mining approach.

With this Special Issue of JCM, our intent is to bridge the existing scientific gap and to fruitfully address these topics.

Aims

The articles of this Special Issue will be arranged according to four fields of discussion concerning:

1. Novel modalities of outcome assessment, with a focus on technological-clinical transfers to connect the potential mechanisms of action of newly available technologies to the patient and daily practice. Because pain is a physical sensation involving a psychological dimension, its assessment justifies the use of multidimensional and global evaluation scales. Given the formidable ongoing expansion of neurostimulation techniques and available devices, implanters and patients may remain confused when selecting the right tool for the right indication. To evaluate and objectively compare patient outcomes, depending on therapeutical strategies, it appears essential to develop a rational and quantitative approach to pain assessment for patients undergoing neurostimulation implantation.
2. New technological solutions (incl. spinal ganglion and peripheral nerve stimulation, novel waveforms, adaptors)
3. New targets and potential indications (incl. vegetative nervous system, conus medullaris, etc…)
4. The need for robust rational, network-based multicentric research and data collection. The future of SCS: will it come from prospective trials? This would probably be overly restrictive. There is a need for objective evaluation tools (“transducers”) to transpose electrical signals into clinical effects and to guide therapeutic choices. This will result from collective commitment and will illustrate how Artificial Intelligence can create a differentiator in the decision-making process, which is of paramount importance to the medical community.

Methodology

We are expecting original articles from internationally renowned orthopaedic, spine and neurosurgeons, anaesthesiologists, rheumatologists, psychiatrists and rehabilitation physicians, as well as health system experts and pain physicians. The manuscripts will be selected according to the following criteria:

-  Insofar as they provide a comprehensive and clearly outlined overview of neuromodulation management in a difficult context,

-  For their originality and their high scientific quality in the field of permanent innovation,

-  For their philosophical and ethical approach based on a patient-centric vision.

While this Special Issue does not claim to put an end to all current controversies, we hope it will provide implanters and pain physicians with a clearer understanding of the issues involved and will enable them to provide the best available treatment guided by an evidence-based medicine approach.

Prof. Philippe Rigoard
Guest Editor

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