TITLE
EAN Guidelines on Central Neurostimulation Therapy in Chronic Pain Conditions

AUTHORS
Cruccu G; Garcia-Larrea L; Hansson P; Keindl M; Lefaucheur JP; Paulus W; Taylor R; Tronnier V; Truini A; Attal N. Institution Cruccu, G. EAN Scientific Panel Pain, Vienna, Austria. Cruccu, G. Department of Neurology and Psychiatry, Sapienza University, Rome, Italy. Garcia-Larrea, L. NeuroPain Laboratory, INSERM U1028, Hopital Neurologique and University Claude Bernard Lyon 1, Lyon, France. Hansson, P. EAN Scientific Panel Pain, Vienna, Austria. Hansson, P. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. Hansson, P. Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. Keindl, M. Department for Clinical Neurosciences and Preventive Medicine, Danube University, Krems, Austria. Lefaucheur, J-P. EA4391, Department of Physiology, Henri Mondor Hospital, University Paris-Est, Creteil, France. Paulus, W. Department of Clinical Neurophysiology, University Medical Center Gottingen, Gottingen, Sweden. Taylor, R. Institute of Health Research, University of Exeter Medical School, Exeter, UK. Tronnier, V. Department of Neurosurgery, University Hospital Lubeck, Lubeck, Germany. Tronnier, V. IASP Special Interest Group on Neuromodulation, Washington, USA. Truini, A. Department of Neurology and Psychiatry, Sapienza University, Rome, Italy. Attal, N. EAN Scientific Panel Pain, Vienna, Austria. Attal, N. INSERM U-987, Centre d’Evaluation et de Traitement de la Douleur, Hopital Ambroise Pare AP-HP, Boulogne-Billancourt and Universite Versailles-Saint-Quentin, Versailles, France.

ELECTRONIC ADDRESS
nadine.attal@aphp.fr

SOURCE
European Journal of Neurology. 23(10):1489-99, 2016 Oct.

BACKGROUND AND PURPOSE
Our aim was to update previous European Federation of Neurological Societies guidelines on neurostimulation for neuropathic pain, expanding the search to new techniques and to chronic pain conditions other than neuropathic pain, and assessing the evidence with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

METHODS
A systematic review and meta-analysis of trials published between 2006 and December 2014 was conducted. Pain conditions included neuropathic pain, fibromyalgia, complex regional pain syndrome (CRPS) type I and post-surgical chronic back and leg pain (CBLP). Spinal cord stimulation (SCS), deep brain stimulation (DBS), epidural motor cortex stimulation (MCS), repetitive transcranial magnetic stimulation (rTMS) and transcranial direct electrical stimulation (tDCS) of the primary motor cortex (M1) or dorsolateral prefrontal cortex (DLPFC) were assessed. The GRADE system was used to assess quality of evidence and propose recommendations.

RESULTS
The following recommendations were reached: ‘weak’ for SCS added to conventional medical management in diabetic painful neuropathy, CBLP and CRPS, for SCS versus reoperation in CBLP, for MCS in neuropathic pain, for rTMS of M1 in neuropathic pain and fibromyalgia and for tDCS of M1 in neuropathic pain; ‘inconclusive’ for DBS in neuropathic pain, rTMS and tDCS of the DLPFC, and for motor cortex tDCS in fibromyalgia and spinal cord injury pain.

CONCLUSIONS
Given the poor to moderate quality of evidence identified by this review, future large-scale multicentre studies of non-invasive and invasive neurostimulation are encouraged. The collection of higher quality evidence of the predictive factors for the efficacy of these techniques, such as the duration, quality and severity of pain, is also recommended.