Despite its proved efficacy, the favourable cost-effectiveness, when compared to the long-term use of poorly effective drugs and the expanding array of indications and technical improvements, spinal cord stimulation (SCS) is still worldwide largely neglected by general practitioners, neurologists, neurosurgeons and pain therapists, often bringing to a large delay in considering as a therapeutic option for patients affected by neuropathic chronic pain. Among them, spinal cord stimulation (SCS) or dorsal column stimulation constitutes an advanced neuromodulation procedure able to actually decrease neuropathic pain in many syndromes such as in failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS) type I and II, postherpetic neuralgia and pure radicular pain. Alternative options were lesional surgery at the dorsal root entry zone and, more recently, a number of neuromodulation procedures. In addition, common analgesic and opioid therapies carry a non-negligible risk of adverse events in the long term. Although given the continuous development of new molecules appearing on the market to control neuropathic pain, this invalidating symptom is currently poorly improved by available drug treatments. It affects 7–10% of the general population, entailing an overall physical and psychological burden more relevant than that seen with nociceptive pain.
The International Association for the Study of Pain defines neuropathic pain as the pain caused by a lesion or disorder of the somatosensory nervous system. The present state of the art of SCS in the treatment of chronic neuropathic pain is here overviewed and speculations on whether to use a trial period or direct implant, to choose between percutaneous leads or paddle electrodes and on the pros and cons of the different patterns of stimulation presently available on the market (tonic stim, high-frequency stim and burst stim) are described. Despite its proved efficacy, the favourable cost-effectiveness when compared to the long-term use of poorly effective drugs and the expanding array of indications and technical improvements, SCS is still worldwide largely neglected by general practitioners, neurologists, neurosurgeons and pain therapists, often bringing to a large delay in considering as a therapeutic option for patients affected by neuropathic chronic pain. The present therapeutic alternative considered as the gold standard for many kinds of chronic neuropathic pain is epidural spinal cord stimulation (SCS). For this reason, despite the wide variety of pain medications available on the market, neuropathic pain is challenging to treat. The origin and the neural pathways involved in chronic neuropathic pain are still not extensively understood.