Stellenwert der Rückenmarkstimulation bei schmerzhafter diabetischer Polyneuropathie

Zusammenfassung

Hintergrund

Die Prävalenz der diabetischen sensomotorischen Polyneuropathie (DSPN) liegt bei ca. 30% der Patienten mit Diabetes, während bis zur Hälfte von denen mit DSPN neuropathische Schmerzen entwickeln. Die schmerzhafte DSPN geht mit erhöhtem Mortalitätsrisiko und eingeschränkter Lebensqualität einher. Die analgetische Pharmakotherapie einschließlich Kombinationen kann in ihrer Wirksamkeit begrenzt sein und mit unerwünschten Arzneimittelwirkungen einhergehen.

Methode

Eine multidisziplinäre Gruppe von sieben Experten entwickelte in mehreren Diskussionsrunden Consensus-Empfehlungen zum Stellenwert der Rückenmarkstimulation bei therapierefraktärer schmerzhafter DSPN basierend auf systematischen Reviews, aktuellen Leitlinien sowie randomisierten kontrollierten Studien (RCTs) und Kohortenstudien.

Ergebnisse

Chronisch neuropathischer Schmerz wird als therapierefraktär angesehen, wenn trotz leitliniengerechter analgetischer Kombinationstherapie keine ausreichende Schmerzlinderung erreicht wird. Mehrere RCTs mit einer Behandlungsdauer bis zu 2 Jahren sowie Meta-Analysen konnten übereinstimmend zeigen, dass die zusätzliche epidurale Rückenmarkstimulation (spinal cord stimulation: SCS) im Vergleich zur konventionellen analgetischen Pharmakotherapie bei Teilnehmern mit therapierefraktärer schmerzhafter DSPN zu einem klinisch relevanten, langfristig anhaltendem Schmerzrückgang führt. Dieser geht einher mit einer Verbesserung der Schlaf- und Lebensqualität sowie Funktionalität bei günstigem Sicherheitsprofil und geringen Abbruchraten der SCS. Nach spätestens 9 Monaten einer refraktären multimodalen analgetischen Therapie bei schmerzhafter DSPN soll daher eine Vorstellung der Patienten in einem spezialisierten Zentrum zwecks Indikationsprüfung bzw. -stellung zum Einsatz der SCS erfolgen.

Schlussfolgerung

Die SCS wird bei hohem Evidenzgrad und Expertenkonsens als integraler Bestandteil der Behandlung der therapierefraktären schmerzhaften DSPN empfohlen.

Abstract

Background

The prevalence in diabetic sensorimotor polyneuropathy (DSPN) is around 30% in patients with diabetes, while up to half of those with DSPN develop neuropathic pain. Painful DSPN is associated with an increased risk of mortality and reduced quality of life. Analgesic pharmacotherapy, including combinations, may be limited in efficacy and associated with adverse drug reactions.

Methods

A multidisciplinary group of seven experts developed consensus recommendations on the value of spinal cord stimulation for refractory painful DSPN based on systematic reviews, current guidelines, randomized controlled trials (RCTs), and cohort studies.

Results

Chronic neuropathic pain is considered refractory or resistant to treatment if adequate pain relief is not achieved despite analgesic combination therapy in line with guidelines. Several RCTs with a treatment duration of up to 2 years and meta-analyses have consistently shown that additional epidural spinal cord stimulation (SCS) leads to a clinically relevant, long-term pain reduction compared to conventional analgesic pharmacotherapy in participants with refractory painful DSPN. This benefit is accompanied by an improvement in sleep and quality of life as well as functionality with a favorable safety profile and low discontinuation rates of SCS. Therefore, after a maximum of 9 months of refractory multimodal analgesic therapy for painful DSPN, patients should be referred to a specialized center to assess the indication for the use of SCS.

Conclusion

With a high level of evidence and expert consensus, SCS is recommended as an integral part of the treatment of painful DSPN refractory to pharmacotherapy.

Schlüsselwörter

Diabetes - schmerzhafte Neuropathie - therapierefraktär - Rückenmarkstimulation

Keywords

Diabetes - painful neuropathy - treatment resistant - spinal cord stimulation

Publication History

Received: 05 February 2025

Accepted after revision: 13 February 2025

Article published online:
07 April 2025

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