Patients' experience with and perspectives on neuromodulation for pain: a systematic review of the qualitative research literature

A Semi-structured Interview Predicts Spinal Cord Stimulator Implantation in Patients with Chronic Pain

Pre-surgical psychological evaluations (PSPE) are required during the spinal cord stimulator (SCS) implantation process, but there is no standard protocol for SCS PSPE. In this study, we assessed the concurrent and predictive validity of the Stanford Integrated Pyschosocial Assessment for Transplantation (SIPAT) compared with patient-reported measures and election for SCS implantation. This study used prospectively collected data at the time of PSPE from N = 222 patients at a Midwestern academic medical center. We collected SIPAT scores and Patient-Reported Outcome Measurement Information Systems (PROMIS) scores, and recorded receipt of permanent SCS implantation as a binary (yes/no) outcome. The SIPAT correlated with patient-reported outcomes of Anxiety, Depression, Fatigue, Sleep, and Pain Interference in the expected direction. The SIPAT was a significant predictor of election for permanent SCS implantation when accounting for age and pain diagnosis, such that individuals with higher SIPAT scores were less likely to elect for surgery. Exploratory analyses showed that the SIPAT Patient Readiness subscale and patient-reported Anxiety and Depression PROMIS scales correlated with election for SCS surgery. Results of this study demonstrated validity of the SIPAT in a novel population, patients with chronic pain referred for SCS implantation.

Long-term lived experiences of patients with chronic pain or angina pectoris treated with spinal cord stimulation: a qualitative study

OBJECTIVE

To explore the short-term and long-term lived experiences of patients with chronic pain and angina pectoris with spinal cord stimulation.

DESIGN

An interpretive qualitative study with thematic analysis of one-off, semistructured interviews, following Braun and Clarke (2006).

SETTING

A multidisciplinary, publicly funded pain service in Auckland, New Zealand. Patients usually undergo a comprehensive medical, psychological and functional assessment and an in-house pain management programme before proceeding to spinal cord stimulator implantation.

PARTICIPANTS

Participants implanted with a spinal cord stimulator between 1998 and 2019 who had their stimulator for ≥1 year, purposively sampled to increase the range of ethnicities.

MAIN OUTCOME

The themes identified from the interviews.

RESULTS

24 participants with chronic pain of varied aetiology and a median (range) of 5.2 (2.4-23.2) years since stimulator implantation participated. 22 participants had the device in situ, and 2 had been explanted. Five main themes were identified: (1) embodiment: stimulator and body as one; (2) technical factors: batteries and type of stimulation; (3) improved well-being; (4) social connection and (5) healthcare system interaction. Most participants reported pain relief, but many had experienced complications and discomfort. They emphasised the importance of ongoing support from the pain service. Acceptance of pain, coping and embodiment emerged as common motifs across these themes. 21 participants were satisfied with their treatment.

CONCLUSION

Within the context of a multidisciplinary pain clinic, despite some discomfort and various complications, most participants valued the ongoing reduction of pain achieved with spinal cord stimulation. Timely access to support from the pain service influenced their experience and satisfaction with their stimulators. Acceptance of pain and embodiment of the stimulator helped participants adapt to living with their stimulator, often over many years.

Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial?

Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practiced to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialed and nontrialed implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multicenter cohort analysis was performed in 2 comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least 3 months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within 1 session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients (N = 570), respectively. A statistically but not clinically significant difference in pain intensity (P = .003; effect = 0.506 (.172-.839)) was found in favor of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialed SCS patients were more likely to cease opioid usage (P = .003; OR = .509 (.326-.792)), patients in the No-Trial group endured fewer infections (P = .006; proportion difference = .43 (.007-.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. PERSPECTIVE: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted.

To Trial or Not to Trial Before Spinal Cord Stimulation for Chronic Neuropathic Pain: The Patients' View From the TRIAL-STIM Randomized Controlled Trial

Objectives

Spinal cord stimulation (SCS) is an established treatment of chronic neuropathic pain. Although a temporary SCS screening trial is widely used to determine suitability for a permanent implant, its evidence base is limited. The recent TRIAL‐STIM study (a randomized controlled trial at three centers in the United Kingdom) found no evidence that an SCS screening trial strategy provides superior patient outcomes as compared with a no trial approach. As part of the TRIAL‐STIM study, we undertook a nested qualitative study to ascertain patients' preferences in relation to undergoing a screening trial or not.

Materials and Methods

We interviewed 31 patients sampled from all three centers and both study arms (screening trial/no trial) prior to SCS implantation, and 23 of these patients again following implantation (eight patients were lost to follow‐up). Interviews were undertaken by telephone and audio‐recorded, then transcripts were subject to thematic analysis. In addition, participants were asked to state their overall preference for a one‐stage (no screening trial) versus two‐stage (screening trial) implant procedure on a five‐point Likert scale, before and after implantation.

Results

Emergent themes favoured the option for a one‐stage SCS procedure. Themes identified include: saving time (off work, in hospital, attending appointments), avoiding the worry about having “loose wires” in the two‐stage procedure, having only one period of recovery, and saving NHS resources. Participants' rated preferences show similar support for a one‐stage procedure without a screening trial.

Conclusions

Our findings indicate an overwhelming preference among participants for a one‐stage SCS procedure both before and after the implant, regardless of which procedure they had undergone. The qualitative study findings further support the TRIAL‐STIM RCT results.