The efficacy of neurostimulation techniques for the management of chronic pain associated with bone disorders: A systematic review and meta-analysis

Abstract

Background: The management of chronic pain associated with bone problems has been accomplished by the use of neurostimulation methods, such as spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS). It is still unknown, however, how successful they are in comparison. The effectiveness of SCS and PNS in reducing chronic pain and enhancing functional results in patients with chronic pain related to bone abnormalities was assessed in this comprehensive review and meta-analysis.

Methods: To find randomized controlled trials (RCTs) comparing SCS or PNS to standard medical management or placebo/sham treatment in adults with chronic pain related to bone disorders, a comprehensive search of PubMed, MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov was carried out from the start of the database until February 2024. The main result was the absence of discomfort. Opioid usage, functional status, and quality of life were secondary outcomes. The Cochrane technique was used to evaluate bias risk. The risk ratios (RRs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs) were computed using random effects meta-analysis.

Results: We included 20 RCTs with a total of 2576 participants. In short-term (≤6 months) follow-up, SCS and PNS were both associated with substantially higher pain alleviation than conventional medical care or placebo/sham: SCS SMD -0.87 (95% CI -1.19--0.55), PNS SMD -0.56 (95% CI -0.91-0.21). SCS SMD -0.71 (95% CI -1.05--0.37) and PNS SMD -0.60 (95% CI -1.03--0.17) benefits were maintained at long-term (>6 months) follow-up. The physical and emotional functioning, as well as quality of life, were also markedly enhanced by SCS and PNS. It was shown that SCS (RR 0.57, 95% CI 0.44-0.74) and PNS (RR 0.58, 95% CI 0.43-0.77) reduced the risk of opioid usage.

Conclusion: When it comes to improving functionality and quality of life, SCS and PNS both reduce chronic pain linked to bone problems, both temporarily and permanently. In some individuals, SCS and PNS may assist in lowering opioid consumption. Neurostimulation treatments may be useful in the treatment of persistent pain associated with bone diseases.

Keywords: Bone disorders; Chronic pain; Meta-analysis; Peripheral nerve stimulation; Spinal cord stimulation; Systematic review.

Figure 1:

Preferred reporting items for systematic reviews and meta-analyses flow diagram.

Figure 2:

Forest plot of comparison of Pain Relief and the use of various techniques in reduction of pain sensation. M-H: Mantel-Haenszel, CI: Confidence interval

Figure 3:

Forest plot of comparison of Improved Function by the use of various techniques in the reduction of pain sensation. CI: Confidence interval, SD: Standard deviation

Figure 4:

Forest plot of comparison of pain severity by the use of various techniques in reduction of pain sensation. M-H: Mantel-Haenszel, CI: Confidence interval

Figure 5:

Forest plot of comparison of Physical Function by the use of various techniques in reduction of pain sensation. CI: Confidence interval

Figure 6:

WHO grade, severity, pain types, and percentages across populations for neurostimulation techniques in chronic pain from bone disorders.

Figure 7:

Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies. The white section denotes “Unclear or Insufficient Data,” suggesting that the provided information was not enough to assess the risk of bias.

Figure 8:

Risk of bias summary: Review authors’ judgments about each risk of bias item for each included study. Green color indicates “Yes (Low Risk of Bias),” meaning the study appropriately addressed bias in this domain. Red color represents “No (High Risk of Bias),” indicating significant concerns in handling bias for the corresponding criteria. The white section denotes “Unclear or Insufficient Data,” suggesting that the provided information was not enough to assess the risk of bias.

Figure 9:

(a-d) Funnel plot analysis of included studies. Each plot demonstrates study distribution and potential publication bias. Funnel plot shows very minimum deviation and smaller negative studies showing asymmetry and overall results support the intervention. X-Axis:For (a) and (c): The X-axis represents the Odds Ratio (OR) on a logarithmic scale For (b) and (d): The X-axis represents the Mean Difference (MD). Y-Axis:For all plots (a-d): The Y-axis represents the Standard Error (SE) of the respective measure, either log(OR) for (a) and (c) or MD for (b) and (d). Each dot corresponds to an individual study, with smaller SE indicating larger sample sizes. The dotted lines form a triangular region that highlights the expected distribution of studies with no bias.