Clinical practice guidelines for the management of patients with chronic regional pain syndrome: a systematic appraisal using the AGREE II instrument

Spinal Cord Stimulation Guidelines and Consensus Statements: Systematic Review and Appraisal of Guidelines for Research and Evaluation II Assessment

INTRODUCTION

Multiple guidelines and consensus statements have been established for spinal cord stimulation (SCS) for pain, including patient selection, indications, techniques of stimulation, and details of the procedure. Here, we sought to critically evaluate guidelines and consensus statements to provide insight into existing gaps in the SCS literature to help guide future endeavors.

MATERIALS AND METHODS

We performed a comprehensive and systematic literature search of PubMed, Web of Science, and Scopus on SCS guidelines and consensus statements for pain from 2000 to September 2024 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The extracted variables included patient selection, efficacy of therapy, pre- and postoperative care, techniques, holding certain medications, complication and infection avoidance and management, and indications. Guidelines and consensus statements were systematically evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool.

RESULTS

The literature search yielded 102 articles. Title, abstract, and full-text analysis determined that 19 articles addressed guidelines and consensus statements relevant to SCS therapy from 2014 to 2024. The 19 articles were systematically analyzed and independently scored by two authors using the AGREE-II instrument. The average global quality score was 5.6 of 7. Current SCS guidelines and consensus statements strongly emphasize evidence-based practice, patient selection, and perioperative management. Weaknesses and gaps include the lack of long-term data on SCS with new waveforms, recommendations on emerging indications, psychologic evaluations, and holistic outcomes.

CONCLUSION

Multiple guidelines and consensus statements attest to the field's commitment to high-quality, evidence-based practice and patient care. However, limitations and gaps remain. Updates on current guidelines should focus on long-term results, holistic assessment and outcomes, and new indications.

Do cytokines play a role in the transition from acute to chronic musculoskeletal pain?

Musculoskeletal pain has a high prevalence of transition to chronic pain and/or persistence as chronic pain for years or even a lifetime. Possible mechanisms for the development of such pain states are often reflected in inflammatory or neuropathic processes involving, among others, cytokines and other molecules. Since biologics such as blockers of TNF or IL-6 can attenuate inflammation and pain in a subset of patients with rheumatoid arthritis, the question arises to what extent cytokines are involved in the generation of pain in human musculoskeletal diseases. In numerous experimental non-human studies, cytokines have been shown to alter neuronal sensitivity in the peripheral and central nociceptive systems. In this review, we addressed the involvement of cytokines in postoperative pain, complex regional pain syndrome, rheumatoid arthritis, osteoarthritis, temporomandibular joint disease, low back pain and fibromyalgia using PubMed searches including meta-analyses of data. There is evidence that certain pro- and anti-inflammatory cytokines are regulated in all of these diseases, often in both acute and chronic disease states. However, within these data, we found a great deal of heterogeneity in the association between cytokine levels and pain. Neutralization of cytokines showed antinociceptive effects in subgroups of patients with chronic pain (e.g., in a proportion of patients with rheumatoid arthritis), but failed to reduce chronic pain in other diseases (e.g., osteoarthritis). More systematic studies are needed to unravel the pathogenic role of cytokines in human musculoskeletal pain, taking into account the disease process and the mechanisms of pain initiation and maintenance.

Complex regional pain syndrome: advances in epidemiology, pathophysiology, diagnosis, and treatment

Complex regional pain syndrome (CRPS) is a rare pain disorder that usually occurs in a limb after trauma. The features of this disorder include severe pain and sensory, autonomic, motor, and trophic abnormalities. Research from the past decade has offered new insights into CRPS epidemiology, pathophysiology, diagnosis, and treatment. Early identification of individuals at high risk of CRPS is improving, with several risk factors established and some others identified in prospective studies during the past 5 years. Better understanding of the pathophysiological mechanisms of CRPS has led to its classification as a chronic primary pain disorder, and subtypes of CRPS have been updated. Procedures for diagnosis have also been clarified. Although effective treatment of CRPS remains a challenge, evidence-based integrated management approaches provide new opportunities to improve patient care. Further advances in diagnosis and treatment of CRPS will require coordinated, international multicentre initiatives.