Systematic Review and Network Meta-analysis of Neurostimulation for Painful Diabetic Neuropathy

Abstract

BACKGROUND Different waveforms of spinal cord stimulation (SCS) have now been evaluated for the management of painful diabetic neuropathy (PDN). However, no direct or indirect comparison between SCS waveforms has been performed to date. PURPOSE To conduct a systematic review and network meta-analysis to evaluate the effectiveness of SCS for PDN. DATA SOURCES MEDLINE, CENTRAL, Embase, and WikiStim were searched from inception until December 2021. STUDY SELECTION Randomized controlled trials (RCTs) of SCS for PDN were included. DATA EXTRACTION Pain intensity, proportion of patients achieving at least a 50% reduction in pain intensity, and health-related quality of life (HRQoL) data were extracted. DATA SYNTHESIS Significant reductions in pain intensity were observed for low-frequency SCS (LF-SCS) (mean difference [MD] −3.13 [95% CI −4.19 to −2.08], moderate certainty) and high-frequency SCS (HF-SCS) (MD −5.20 [95% CI −5.77 to −4.63], moderate certainty) compared with conventional medical management (CMM) alone. There was a significantly greater reduction in pain intensity on HF-SCS compared with LF-SCS (MD −2.07 [95% CI −3.26 to −0.87], moderate certainty). Significant differences were observed for LF-SCS and HF-SCS compared with CMM for the outcomes proportion of patients with at least 50% pain reduction and HRQoL (very low to moderate certainty). No significant differences were observed between LF-SCS and HF-SCS (very low to moderate certainty). LIMITATIONS Limited number of RCTs and no head-to-head RCTs conducted. CONCLUSIONS Our findings confirm the pain relief and HRQoL benefits of the addition of SCS to CMM for patients with PDN. However, in the absence of head-to-head RCT evidence, the relative benefits of HF-SCS compared with LF-SCS for patients with PDN remain uncertain.