Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Chronic Neuropathic Pain

Evidence Grading

Compared with other grading systems (Manchikanti et al., 2003; Boswell et al., 2005; Snow et al., 2004; Gibbons et al., 2003; Ontario Medical Advisory Secretariat, 2005), our scheme is simpler, with fewer levels, yet broader because it incorporates practical considerations, e.g., only option, risk-benefit.

Strength of recommendation Evidence sources/rationale
A= Recommended or required
Valid, useful, or non-negotiable
  • Well-designed RCT(s)
  • Weighing risk versus potential benefit and expert consensus reveals a high likelihood of a favorable outcome
  • Computer modeling studies corroborated by clinical data
  • Medicare requirement
  • Only option
B = Recommended
Uncertain validity, apparently useful
  • Well-designed clinical studies (prospective, nonrandomized cohort studies, case-control studies, etc.)
  • RCT(s) with design problems
  • Weighing risk versus potential benefit and expert consensus reveals a good likelihood of a favorable outcome
C = Optional
Undetermined validity, might be useful
  • Flawed RCT(s)
  • Retrospective case series
  • Comparative studies with historical controls
  • Case report(s)
  • Weighing risk versus potential benefit and expert consensus reveals a moderate likelihood of a favorable outcome

Snow V, Barry P, Fihn SD, Gibbons RJ, Owens DK, Williams SV, Mottur-Pilson C, Weiss KB. Primary care management of chronic stable angina and asymptomatic suspected or known coronary artery disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 141(7):562-567, 2004.

Ontario Health Technology Advisory Committee OHTAC Recommends: Spinal cord stimulation for the management of neuropathic pain. 2005.

Manchikanti L, Staats PS, Singh V, Schultz DM, Vilims BD, Jasper JF, Kloth DS, Trescot AM, Hansen HC, Falasca TD, et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 6(1):3-81, 2003.

Boswell MV, Shah RV, Everett CR, Sehgal N, McKenzie Brown AM, Abdi S, Bowman RC 2nd, Deer TR, Datta S, Colson JD, et al. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician 8(1):1-47, 2005.