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Jadad A, O'Brien MA, Wingerchuk D, et al. Management of Chronic Central Neuropathic Pain Following Traumatic Spinal Cord Injury. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001 Sep. (Evidence Reports/Technology Assessments, No. 45.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Management of Chronic Central Neuropathic Pain Following Traumatic Spinal Cord Injury.

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3General Results

Results of the Literature Search

The results of the searches of electronic databases and reference lists are found in Evidence Table 3.1. The EMBASE database yielded the greatest number (784) of potentially relevant titles and abstracts, followed by MEDLINE with 577.

MEDLINE contributed the highest number of unique studies, followed by EMBASE. Screening of reference lists contributed three unique studies. The number of unique studies contributed by each source is shown in Evidence Table 3.1.

The sensitivity and specificity of the electronic searches are found in Evidence Table 3.1a. The MEDLINE search was the most sensitive, and the Cochrane Library search was the most specific. Overall, 591 full text articles were retrieved and screened by two reviewers.

Results of the Screening Process

The results of the screening process are found in Evidence Table 3.2. Of the 591 full text articles screened, 201 met the screening inclusion criteria, 386 were excluded, and 4 articles could not be retrieved through a variety of sources. The citations for all included and excluded articles are found in the Bibliography section of this Evidence Report. The reasons for exclusion are found in Evidence Table 3.2. Fifty-one percent were excluded because they did not describe a primary study in humans, and 48 percent were excluded because the participants did not have a TSCI or did not have CNP. The citations for these articles are found in Evidence Table 3.2.

The screening of 60 articles required assistance from translators. Of these, 14 were included. The language of the publication and key question (s) addressed are found in Evidence Table 3.3. Of the 201 selected articles, information from 42 reports representing 16 unique studies were combined and considered as a single data set. Evidence Table 3.4 lists the studies that we considered to be "primary," and the "related" studies are listed after the primary study. During the data extraction process, we excluded an additional 27 studies. The study citation and reasons for exclusion are found in Evidence Table 3.5.

After considering multiple reports and several levels of screening, there were 132 unique studies forming the basis for the Evidence Report. Of these, there were six randomized trials and 126 observational studies, including 47 case series and at least 56 single or multiple case reports.

Sixty-four per cent of the studies were published between 1990 and 1999, 25 percent between 1980 and 1989, and the remainder were published between 1965 and 1979. Just under half of the studies were centered in the United States (48%), followed by the United Kingdom (9%), and Germany (5%). Evidence Table 3.6.3 lists the other countries.

General Characteristics of All Included Studies

Single or multiple case reports (usually with fewer than eight individuals with TSCI) are described in supplemental evidence tables within each chapter and are not included in the characteristics featured below. The most salient characteristics of all the studies included (Evidence Tables 3.6.5 to 3.6.29) were the following:

  • The number of studies has been doubling in less than 10 years since 1965.
  • Sixty-one percent of the reports did not report any information about the source of funding for the research. Government supplied funding in 22 percent of the reports, and charities provided funding for 9 percent.
  • Most papers (68) were published in the United States, while the United Kingdom published 12. No other country had greater than 7 (Germany had 7) studies included.
  • Case reports (56) and case series (47) accounted for 78 percent of all included reports. There were 10 surveys included and 6 RCTS, 6 validation, 4 nonrandomized controlled trials, and 3 case-control studies.
  • Excluding the case reports, across the remaining 75 studies, there were 3,873 patients. In one study, the number of included patients was not clear.
  • There were over 100 patients included in the study sample of 17 studies; 30 percent of the studies had 25 or fewer patients.
  • In four studies, there were more than 100 patients with TSCI/CNP included; 35 studies had 20 or fewer patients with TSCI/CNP.
  • Studies conducted in a tertiary care setting accounted for 82 percent of the reports.
  • Eligibility criteria were explicitly reported in 34 percent of the papers.
  • Preplanning of the study duration was clearly reported in 49 percent of the papers, with 18 studies using a time cutoff and 29 studies using another endpoint. Times used varied from 1 week to 50 months.
  • Seventy-four percent of the studies included just one treatment group.
  • Forty-two percent of the studies included patients with cervical injury, and 49 percent included patients with thoracic injury. In 58 percent of studies, the completeness of the injury was not reported; and in 33 percent of the studies, there were multiple levels of injury reported.
  • Five studies used the American Spinal Injuries Association (ASIA) classification scale, and six studies used Frankel's Classification scale.
  • The most common causes of injury were road traffic accidents, falls, and gunshot wounds.
  • Seventy percent of the studies did not report whether surgical stabilization was used, and 29 percent reported some surgical stabilization.
  • Fifty-four percent of the reports did not specify the length of time since injury.
  • Forty-one percent of the reports did not specify the age of participants. Of those that did specify, 45 percent had participants in the age group between 30 and 50 years.
  • Sixty-two percent of the authors did not define neuropathic pain.
  • The most common descriptor for pain was "burning," with 53 percent of studies reporting usage of the term. The second most common was "dysesthesia," reported in 24 percent of studies.
  • The length of time between injury and start of pain was not reported in 83 percent of studies. The most frequently cited length of time was between 1 month and 6 months (12%).
  • The duration of pain was not reported in 82 percent of studies, and the area of the body affected by the pain was not reported in 57 percent of studies.
  • The most commonly used outcome measures were: interview or narrative about the pain (29%), visual analogue scale (26%), and the McGill Pain Questionnaire (16%).

In keeping with the questions proposed by our partners, the studies featured in subsequent chapters of this Evidence Report include:

  • Assessment and natural history: 58 unique studies, of which 20 were case reports or case series with fewer than 8 patients.
  • Pharmacological interventions of interest: 27 unique studies, of which 15 were case reports or case series with fewer than 8 patients.
  • Spinal cord and deep brain stimulation: 25 unique studies, of which 17 were case reports or case series with fewer than 8 patients.
  • DREZ lesions and other surgical interventions: 23 unique studies, of which 8 were case reports.
  • There were no studies evaluating the role of pharmacological algorithms or multidisciplinary approaches, and two studies assessed a self-management program in patients with CNP following TSCI. One study focused on relaxation techniques in four single case reports (Grzesiak, 1977) and the second on laughter and was a pilot study of 11 patients (Henderson and Mowry, 1995) (see Evidence Tables 3.1.30 and 3.1.31). No adverse effects or safety issues were found in either study. No other studies were located that addressed self-management approaches.

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