Painful diabetic neuropathy (PDN) is a common complication of diabetes mellitus that is associated with a significant decline in quality of life. Like other painful neuropathic conditions, PDN is difficult to manage clinically, and a variety of pharmacological and non-pharmacological options are available for this condition. Recommended pharmacotherapies include anticonvulsive agents, antidepressant drugs, and topical capsaicin; and tapentadol, which combines opioid agonism and norepinephrine reuptake inhibition, has also recently been approved for use. Additionally, several neuromodulation therapies have been successfully used for pain relief in PDN, including intrathecal therapy, transcutaneous electrical nerve stimulation (TENS), and spinal cord stimulation (SCS). Recently, 10 kHz SCS has been shown to provide clinically meaningful pain relief for patients refractory to conventional medical management, with a subset of patients demonstrating improvement in neurological function. This literature review is intended to discuss the dosage and prospective data associated with pain management therapies for PDN.

Background. Spinal cord stimulation (SCS) has been used over decades for pain management, but migration of percutaneous leads has been the most common complication. Better surgical techniques and newer SCS technologies likely reduced the incidence of lead migration requiring surgical revision, although data are sparse. This study aimed to retrospectively evaluate the incidence of clinically significant percutaneous lead migration in patients permanently implanted with a 10kHz SCS system. Methods. Consecutive patients with chronic trunk and/or limb pain, permanently implanted between January 2016 and June 2019, were included in the analysis. Data were collected from the hospitals electronic medical records and the manufacturers database. Clinically significant lead migration, defined as diminished pain relief followed by surgery to correct lead location, was assessed at the 6-month follow-up. Results. At the 6-month follow-up, there were no cases of clinically significant lead migration, average pain relief was 65.2, 82 of patients had response (50 pain relief), improvement of function was noted in 72 of patients, and decrease of medication was observed in 42 of patients. Therapy efficacy was sustained in patients with >12 months follow-up; the average pain relief was 58.5, and the response rate was 82. Conclusions. The surgical techniques in use today are designed to minimise the risk of percutaneous lead migration and may have reduced its incidence. In addition, new SCS systems may give greater opportunity to mitigate cases of minor lead movement using alternative stimulation programs.

Introduction: Ideally, a physical or chemical nonsurgical neurolytic procedure provides targeted neurolysis to relieve pain for a suitable length of time without causing complications. This narrative review focuses on five nonsurgical neurolytic procedures that are well-established and well-documented in the literature for the treatment of refractory neuropathic pain and peripheral neuropathies, in particular: two physical nonsurgical neurolytic techniques (cryoablation and radiofrequency ablation) and three chemoneurolytic agents (alcohol injection, phenol injection, and a high-concentration capsaicin 8% topical system). Methods: Using the definition of nonsurgical physical and chemical neurolytic procedures for neuropathic pain, a focused literature search of the PubMed database for English-language, human studies published through July 2024 included, but was not limited to, the following search terms: “neuropathic pain” AND “cryoablation”, “cryoneurolysis”, “radiofrequency ablation”, “alcohol neurolysis”, “alcohol injection”, “phenol neurolysis”, “phenol injection”, “chemoneurolysis”, “topical capsaicin”, and “TRPV1.” While attempts were made to identify prospective clinical trials for each type of neurolytic procedure, information regarding the conduct and safety and efficacy of some of these nonsurgical neurolytic procedures was primarily limited to case studies and anecdotal evidence. Results: The risk benefit basis of each technique is discussed, and recommendations for proper use based on the literature are summarized. Most techniques require ultrasound or fluoroscopy guidance. Pain relief typically ranges from 3 to 12 months, with repeat neurolytic procedures often required to maintain suitable levels of pain relief. Conclusion: The authors provide their insights as to the best utilization of these identified nonsurgical physical and chemoneurolytic procedures for the treatment of refractory neuropathic pain in different patient populations based on neural targets. Together, these five nonsurgical neurolytic techniques provide patients and physicians with a variety of options for the treatment of refractory neuropathic pain.

Background: Chronic pain is a common condition associated with decreased quality of life and increased health-care costs. Opioid analgesics are routinely used to treat chronic pain despite limited evidence of long-term efficacy. Spinal cord stimulation at a frequency of 10 kilohertz (10kHz-SCS) has been shown to be effective for treating chronic pain. Objective: This study was conducted to evaluate the effects of 10kHz-SCS on patients’ pain intensity, volume of pain interventions, and opioid intake in a real-world setting. Study Design: This study was a retrospective review of patient data. Setting: The study was conducted at a single, community-based clinic. Methods: Outcomes including pain relief, quality of life, opioid intake, and rate of health-care usage were evaluated using data from patients who were implanted with a 10kHz-SCS device to treat chronic pain. These outcomes were then compared for the pre- and post-implant periods. Results: A total of 47 patients with a mean follow-up duration of 15.6 ± 6.2 months were included in this analysis. Mean pain relief was 73 ± 22% and 89% were responders at the final follow-up visit. The rate of medical interventions fell from 3.48± 3.05 per year before starting 10kHz-SCS to 0.49± 1.16 per year afterward (P < 0.001). Of 30 patients with available opioid consumption data, 89% maintained or decreased their intake after implant. Conclusion: Retrospective data from a single center, with minimal exclusion criteria shows clinically significant pain relief with 10kHz-SCS, accompanied by significant indirect benefits including stable or reduced opioid use and reduced interventional procedures.

Long-term outcomes of percutaneous image-guided lumbar decompression for treatment of lumbar spinal stenosis with neurogenic claudication secondary to hypertrophic ligamentum flavum were assessed using extended follow-up of the treatment group in the MOTION prospective, multicenter randomized controlled trial. Originally performed with a control group consisting solely of conventional medical management (CMM-Alone), follow-up of the treatment group was extended to five years and analyzed as a modified intent-to-treat group. Spinal decompression was performed using the mild® Procedure (Stryker Corporation, Portage, MI, USA), with the treatment group also receiving CMM with no restrictions post-procedure (mild + CMM). Subjective outcomes were measured using validated patient-reported questionnaires including the Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and Numeric Pain Rating Scale (NPRS). Objective measurements included a validated Walking Tolerance Test (WTT), the rate of subsequent lumbar spine interventions (SLSI), and the occurrence of adverse events. An ad hoc analysis comparing 5-year outcomes for patients who were at least 65 years of age at the time of treatment to those of younger patients was also performed. In addition, long-term (4-year) outcomes were assessed for CMM-Alone patients who subsequently received the mild Procedure for relief of ongoing symptoms (crossover group). As with the 1-, 2- and 3-year follow-up visits, all outcomes at the 5-year visit for the mild + CMM group remained significantly improved over baseline (N = 34, p < 0.0001), with ODI, NPRS back and leg, and ZCQ Symptom Severity and Physical Function improving by 20.6, 2.5, 4.6, 0.9, and 0.7, respectively. Walking times increased 326% from baseline, with three additional SLSI performed since the 3-year follow-up. No device- or procedure-related adverse events were reported over the entire 5-year follow-up period. At 5 years post-treatment, no significant differences in outcomes between older and younger patients were seen for any outcome. No significant differences were found in the crossover group when compared to the mild + CMM group using 4-year follow-up results. The use of the percutaneous mild Procedure, together with CMM, is shown to provide a safe, effective and durable treatment for symptomatic LSS. The procedure appears effective regardless of patient age at the time of treatment. Further, the ability of the mild Procedure to improve patient outcomes does not appear to be affected in those patients whose treatment is delayed by continued use of CMM.