Philippe Magown, MD CM, PhD, FRCSC,

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Abstract: Neuropathic pain is a severe pain condition characterized by burning, tingling, or lancinating pain in the distribution of a nerve, dermatome, or sclerotome and affects patient function, quality of life, mood, and employment. Neuropathic pain is generally refractory to pain medications but amenable to gabapentinoids and antidepressants. When neuropathic pain is refractory to conservative medical management, neuromodulation is the next strategy. Neuromodulation is the modulation of neural signals, most commonly performed with electrical stimulation, such as spinal cord stimulation. Spinal cord stimulation can provide clinically significant pain relief, improve quality of life and function for neuropathic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.

Key Words: Spinal cord stimulation, failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, refractory angina.

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1. Neuromodulation outcomes for neuropathic pain are best if performed early upon confirmation of pain refractoriness to multimodal and multi-pharmacological management.

2. Level 1 and 2 evidences support the use of neuromodulation for neuropathic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.

3. Neuromodulation can provide 50% or more pain relief in a significant proportion of patients with neuropathic pain conditions refractory to pharmacotherapy.

1. Neuropathic pain is a severe pain condition along a nerve, dermatome, or sclerotome that is characterized by burning, lancinating, prickling, or shocking-like pain generally refractory to pain medications.

2. Neuropathic pain refractory to four or more pharmacological agents among TCAs, SNRIs, gabapentinoids, and tramadol can benefit from neuromodulation, even more so if performed within two years of onset.

3. Neuromodulation can provide 50% or more pain relief in a significant proportion of patients with failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.

A successful back school educates the patient about the benign nature of back pain and provides the tools to transfer knowledge about back hygiene into practice in the patient's life.

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Mohammed F. Shamji MD, PhD, FRCSC, Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Alina Shcharinsky RN (EC), MN, CNN(C), Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.

Abstract
Chronic pain is a complex disease state associated with substantial individual disability and suffering alongside societal economic impact. The entity of neuropathic pain is a diagnosis of specific clinical characteristics and underlying pathophysiology. Failed back surgery syndrome represents persistent neuropathic leg pain following structurally corrective spinal surgery, often being refractory to escalated pharmacological management. In appropriately selected patients, spinal cord stimulation is a surgical technique that may offer reduced disability and pain, and improved economic outcomes for patients where medical management has been unsuccessful. Contemporary technological advances continue to improve this approach with greater success, lessened morbidity, and expanding indications.
Key Words: failed back surgery syndrome, neuropathic pain, spinal cord stimulation, neuromodulation.