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  • Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts

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Special article
Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts
  1. Alice Huai-Yu Li1,
  2. Anuj Bhatia2,
  3. Amit Gulati3 and
  4. Einar Ottestad4
  1. 1 Department of Anesthesia, Stanford University, Stanford, California, USA
  2. 2 Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3 Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
  4. 4 Anesthesiology and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
  1. Correspondence to Dr Anuj Bhatia, Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Canada; anuj.bhatia{at}uhn.ca

Abstract

Interventional pain management (IPM) options for refractory neuropathic pain (NP) have recently increased with availability of peripheral nerve stimulation (PNS) equipment and expertise. Given a lack of high-quality evidence and guidelines on this topic, we sought to understand the perception of physicians with expertise in treating NP regarding IPM and the role of PNS. We emailed a survey in March 2022 to international NP experts including pain medicine physicians, researchers, and leaders of 11 professional pain societies. No representatives from vendors of PNS systems were included in the design of the survey nor as respondents. Among 24 respondents (67% of those contacted), the distal common peroneal, tibial, and sural nerves were most frequently targeted (60%) with PNS. Persistent postsurgical pain of more than 3 months was the most common indication for PNS (84%). The aggregate NP treatment algorithm in order of median rank was non-opioid medications as first line, IPM including epidural/perineural steroid injections tied with transcutaneous electrical nerve stimulation as second line, pulsed radiofrequency (RF) tied with RF ablation/denervation as third line, temporary then permanent PNS as fourth line, followed by spinal cord stimulation, opioids, cryoablation, botulinum, peripheral nerve field stimulation, intrathecal targeted drug delivery, and others. Before offering PNS, 12 respondents (50%) indicated their preference for trialing non-neuromodulation treatments for 1–3 months. Twenty-two respondents (92%) agreed PNS should be offered early in the treatment of neuropathic pain. The most common barriers to PNS use were cost, lack of high-quality evidence in support of its use, lack of exposure to PNS in training programs, and lack of familiarity with the use of ultrasound guidance. PNS appears to have an increasing role in the treatment of NP but more research is needed on the outcomes of PNS to elucidate its role.

  • pain management
  • peripheral nerve injuries
  • spinal cord stimulation

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/rapm-2022-104073

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Twitter @DrAnujBhatia

    • Contributors AH-YL, AB, AG, and EO are all guarantors of this paper. AH-YL and EO conceived of the initial idea and AB and AG fundamentally contributed to the design of the project and survey. AH-YL distributed, collected, and analyzed the survey data, and wrote the manuscript with essential input from AB, AG, and EO. The guarantors accept full responsibility for the finished work and the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests AH-YL is a consultant for SPR Therapeutics. AB is engaged in an Industry (Medtronic)-funded study on long-term outcomes of neuromodulation for pain. AG is a consultant for Medtronic, Nalu Medical, Rivanna Medical (NIH supported), Somme Therapeutics, Maxwell Therapeutics, and Averitas Medical, and is on the advisory board for AIS Healthcare, Hinge Health, and Tersera Medical. EO is a consultant for Medtronic, Abbott, SPR Therapeutics, Nalu, BioVentus, Invicta – equity, and Coloplast.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.