Transcript SCS for CRPS Literature Summary Presentation

Neurostimulation
For Complex Regional Pain Syndrome
Literature Review Summary
Background
•
The second most common use of spinal cord stimulation (SCS) in the
United States is for the symptomatic management of complex regional
pain syndrome (CRPS).
•
CRPS is a neuropathic pain syndrome precipitated most commonly by
minor limb trauma.1,2,3,4
•
Continuous, severe pain, disproportionate to the inciting event, occurs
in the limb and may be accompanied by allodynia, hyperalgesia, skin
color changes, edema, joint stiffness, and bone demineralization.1,4,5
•
This literature review summary highlights results of studies to
demonstrate the clinical and cost-effectiveness of SCS for CRPS.
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Effectiveness Study
Kemler MA, et al. 20006, 20047
•
Prospective, randomized, controlled study
of 54 type I CRPS patients randomized to
receive SCS plus PT or PT alone.
•
At the 2-year follow-up, pain intensity in the
SCS group had decreased by a mean of
3.0 cm on the VAS, vs. 0 cm for PT-only
patients (P < 0.001).
•
At 24 months, global perceived effect
(GPE) was much improved in 63% of SCS
patients vs. 9% of PT-only patients
(P < 0.001).
•
At 24 months, as compared to PT-only
patients, SCS patients had significant
improvement in health-related quality of life
(HRQoL) (P = 0.02 affected hand,
P = 0.008 foot).
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Effectiveness Study
Harke H, et al. 20054
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Prospective study of 29 patients with
type I CRPS.
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At 12 months after implant, deep
pain and allodynia on the VAS were
reduced from a mean of 10 cm to 1.7
cm and from a mean of 10 cm to 0.03
cm, respectively (P < 0.01).
•
Disability scores decreased > 50%
(P < 0.01).
•
At a mean follow-up of 35 months,
59% of patients did not require
analgesics and 70% had returned
to work.
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Effectiveness Studies
Forouzanfar T, et al. 20045
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Prospective study of 36 type I
CRPS patients.
•
At 24 months: HRQoL (EQ-5D)
significantly improved (P < 0.02).
The number of patients reporting
“extreme problems” for the
categories “usual activities” and
“pain and discomfort” decreased for
both cervical (Figure A) and lumbar
(Figure B) patients (P < 0.01). The
percent of patients reporting “no
problems” in the
“anxiety/depression” dimension
increased (P < 0.02).
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Effectiveness Studies
Bennett DS, et al. 19998
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Retrospective, multicenter study of
101 CRPS patients.
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The mean improvement in VAS
was 6.0 cm for patients with dualoctapolar systems and 3.70 cm for
patients with single-lead
quadripolar systems (P < 0.0001).
•
Overall patient satisfaction scores
were 70% in single-lead patients
at 18.7 months mean follow-up
and 91% in dual-octapolar
patients at 23.5 months mean
follow-up (P < 0.05).
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Effectiveness Study
Kemler MA, et al. 19999
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Retrospective study of 23
consecutive patients with type I
CRPS (n = 18 implanted).
•
At a mean follow-up of 32 months,
mean VAS for implanted patients
had improved from 7.9 cm to 5.4 cm
(P < 0.001).
•
87% of patients reported a Global
Perceived Effect (GPE) of “much
improved” or “improved” and
therapy was regarded as a success.
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Cost Study
Kemler MA, et al. 200210
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Calculated health care costs (1998 Euros) for 54 CRPS patients randomized to
SCS plus physical therapy (PT) or PT alone.
•
Costs shown for SCS implanted patients are minus the cost of PT.
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Cost Study
Kumar K, et al. 200611
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Summary
•
The referenced effectiveness studies4,5,7,8,9 found that at long-term follow-up,
SCS provided significant pain relief and has been associated with substantial
long-term success as measured by global perceived effect.5,7,9
•
One study demonstrated that SCS led to a reduction in medication use.4 Two
studies have shown improvements in function and daily living4,9, and enabled
patients to return to work.4
•
The referenced cost studies show that mean first-year cost of SCS became
substantially less in the second year. This was also found in three studies of
SCS for FBSS.12,13,14
•
SCS has become increasingly successful due to refined patient selection
criteria, greater accuracy in electrode placement, and improvement in
multipolar and multichannel systems.1 However, complications still occur. The
most frequent complication of SCS system implantation has been electrode
migration.5,7,8,9 Various complications have also led to surgical revision of the
pulse generator, lead and/or system explantation.5,7,9
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Conclusions
• The referenced long-term clinical studies have shown that SCS
provides statistically significant pain relief in patients with CRPS.
• Despite a high cost the first year, SCS has been shown to be more
effective and less expensive than conventional treatment in the
long term.
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Neurostimulation Therapy for Chronic Pain
Truck and/or Limbs: Product manuals must be reviewed prior to use for detailed disclosure.
Indications:
Implantable neurostimulation systems: A Medtronic implantable neurostimulation system is indicated for spinal cord stimulation (SCS) system as an aid in the
management of chronic, intractable pain of the trunk and/or limbs—including unilateral or bilateral pain associated with the following conditions: Failed Back
Syndrome (FBS) or low back syndrome or failed back, radicular pain syndrome or radiculopathies resulting in pain secondary to FBS or herniated disk,
postlaminectomy pain, multiple back operations, unsuccessful disk surgery, degenerative Disk Disease (DDD)/herniated disk pain refractory to conservative and
surgical interventions, peripheral causalgia, epidural fibrosis, arachnoiditis or lumbar adhesive arachnoiditis, Complex Regional Pain Syndrome (CRPS), Reflex
Sympathetic Dystrophy (RSD), or causalgia.
Contraindications:
Diathermy: Do not use shortwave diathermy, microwave or therapeutic ultrasound diathermy (all now referred to as diathermy) on patients implanted with a
neurostimulation system. Energy from diathermy can be transferred through the implanted system and cause tissue damage at the locations of the implanted
electrodes, resulting in severe injury or death.
Warnings: Sources of strong electromagnetic interference (e.g., defibrillation, diathermy, electrocautery, MRI, RF ablation, and therapeutic ultrasound) can interact
with the neurostimulation system, resulting in serious patient injury or death. These and other sources of EMI can also result in system damage, operational changes
to the neurostimulator or unexpected changes in stimulation. Rupture or piercing of the neurostimulator can result in severe burns. An implanted cardiac device
(e.g., pacemaker, defibrillator) may damage a neurostimulator, and the electrical pulses from the neurostimulator may result in an inappropriate response of the
cardiac device.
Precautions: The safety and effectiveness of this therapy has not been established for pediatric use (patients under the age of 18), pregnancy, unborn fetus, or
delivery. Patients should be detoxified from narcotics prior to lead placement. Clinicians and patients should follow programming guidelines and precautions
provided in product manuals. Patients should avoid activities that may put undue stress on the implanted neurostimulation system components. Patients should not
scuba dive below 10 meters of water or enter hyperbaric chambers above 2.0 atmosphere absolute (ATA). Electromagnetic interference, postural changes, and other
activities may cause shocking or jolting.
Adverse Events: Adverse events may include undesirable change in stimulation described by some patients as uncomfortable, jolting or shocking; hematoma,
epidural hemorrhage, paralysis, seroma, CSF leakage, infection, erosion, allergic response, hardware malfunction or migration, pain at implant site, loss of pain relief,
chest wall stimulation, and surgical risks.
For further information, please call Medtronic at 1-800-328-0810 and/or consult Medtronic’s website at www.medtronic.com.
Rx only
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References
1.
Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year
experience. Neurosurgery. 2006;58:481-496.
2.
Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Seattle, WA: IASP Press; 1994.
3.
Baron R, Levine JD, Fields HL. Causalgia and reflex sympathetic dystrophy: does the sympathetic nervous system contribute to the generation of pain? Muscle
Nerve. 1999;22:678-695.
4.
Harke H, Gretenkort P, Ladleif HU, Rahman S. Spinal cord stimulation in sympathetically maintained complex regional pain syndrome type I with severe
disability. A prospective clinical study. Eur J Pain. 2005;9:363-373.
5.
Forouzanfar T, Kemler MA, Weber WEJ, et al. Spinal cord stimulation in complex regional pain syndrome: cervical and lumbar devices are comparably effective.
Br J Anaesth. 2004;92:349-353.
6.
Kemler MA, Barendse GAM, Van Kleef M, et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med. 2000;343:618-624.
7.
Kemler MA, de Vet HCW, Barendse GAM, et al. The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy: two years’ follow-up of
the randomized controlled trial. Ann Neurol. 2004;55:13-18.
8.
Bennett DS, Aló KM, Oakley J, Feler CA. Spinal cord stimulation for complex regional pain syndrome [RSD]: a retrospective multicenter experience from 1995 to
1998 of 101 patients. Neuromodulation. 1999;2:201-210.
9.
Kemler MA, Barendse GAM, Van Kleef M, et al. Electrical spinal cord stimulation in reflex sympathetic dystrophy; retrospective analysis of 23 patients. J
Neurosurg. 1999;90:79-83.
10.
Kemler MA, Furnée CA. Economic evaluation of spinal cord stimulation for chronic reflex sympathetic dystrophy. Neurology. 2002;59:1203-1209.
11.
Kumar K, Wilson JR, Taylor RS, Gupta S. Complications of spinal cord stimulation, suggestions to improve outcome, and financial impact. J Neurosurg Spine.
2006;5:191-203.
12.
Taylor RJ, Taylor, RS. Spinal cord stimulation for failed back surgery syndrome: a decision-analytic model and cost-effective analysis. Int J Technol Assess
Health Care. 2005;21:351-358.
13.
Bell GK, Kidd D, North RB. Cost-effective analysis of spinal cord stimulation in treatment of failed back surgery syndrome. J Pain Symptom Manage.
1997;13:286-295.
14.
Kumar K, Malik S, Demeria D, et al. Treatment of chronic pain with spinal cord stimulation versus alternative therapies: cost-effectiveness analysis.
Neurosurgery. 2002;51:106-116.
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200805142a EN
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