Intervention Review

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Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome

  1. Sebastian Straube1,*,
  2. Sheena Derry2,
  3. R Andrew Moore2,
  4. Peter Cole3

Editorial Group: Cochrane Pain, Palliative and Supportive Care Group

Published Online: 2 SEP 2013

Assessed as up-to-date: 2 JUL 2013

DOI: 10.1002/14651858.CD002918.pub3


How to Cite

Straube S, Derry S, Moore RA, Cole P. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD002918. DOI: 10.1002/14651858.CD002918.pub3.

Author Information

  1. 1

    University Medical Center Göttingen, Institute of Occupational, Social and Environmental Medicine, Göttingen, Germany

  2. 2

    University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences, Oxford, Oxfordshire, UK

  3. 3

    Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford Pain Relief Unit, Oxford, UK

*Sebastian Straube, Institute of Occupational, Social and Environmental Medicine, University Medical Center Göttingen, Waldweg 37 B, Göttingen, D-37073, Germany. sebastian.straube@googlemail.com.

Publication History

  1. Publication Status: Stable (no update expected for reasons given in 'What's new')
  2. Published Online: 2 SEP 2013

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Characteristics of included studies [ordered by study ID]
Manjunath 2008

MethodsRandomised, double blind, active control

Radiofrequency lesioning carried out at 80ºC for 90 s at each site; phenol ablation carried out with 7% phenol. For both procedures, radiofrequency cannula was positioned, with stimulation at 50 and 2 Hz to identify proximity to sensory and motor nerves, and maintain blinding. Participants remained in prone position for 30 minutes

Participants monitored on ward for 24 hours. Follow up at 1 and 7 days, and 2 and 4 months


ParticipantsComplex regional pain syndrome. History of failure to respond (pain intensity > 6/10) to treatment with oral pregabalin, amitriptyline, carbamazepine over >6 months, and response (pain intensity < 4/10) after diagnostic sympathetic block with lidocaine on three occasions

N = 20

Males/females not reported

Mean age 52 years in radiofrequency group, 39 years in phenol group


InterventionsRadiofrequency lumbar sympathectomy, n = 10

Phenol lumbar sympathectomy, n = 10


OutcomesNine pain outcomes, each assessed on a 0 to 10 scale

Adverse events

Withdrawals


NotesOxford Quality Score: R = 2, DB = 2, W = 1; Total = 5/5

Oxford Pain Validity Score: 13/16


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"computer-generated" random numbers

Allocation concealment (selection bias)Unclear riskNot reported

Blinding (performance bias and detection bias)
All outcomes
Low riskParticipants blinded by creating similar scene for both procedures. Investigator collecting data not involved in procedures and unaware of the groups to which participants were assigned

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskOne participant in the phenol group was not included in the efficacy analysis

SizeHigh risk< 50 participants per treatment group

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

AbuRahma 1994Not RCT (included in 2002 review)

Greipp 1990Not RCT (included in 2002 review)

Haynsworth 1991Not double blind (included in 2002 review)

Mailis 1994Not RCT (included in 2002 review)

 
Summary of findings for the main comparison.

Lumbar sympathectomy using radiofrequency lesioning compared with phenol ablation for complex regional pain syndrome

Patient or population: adults with complex regional pain syndrome type 1 (lower limb)

Settings: hospital

Intervention: sympathectomy using radiofrequency lesioning

Comparison: sympathectomy using phenol ablation

OutcomeProbable outcome with interventionProbable outcome with comparatorNNT or NNH and/or relative effect (95% CI)No of participantsQuality of the evidence
(GRADE)
Comments

At least 50% reduction in pain or equivalentNo dataNo data

At least 30% reduction in painNo dataNo data

Proportion below 30/100 mm on VASGroup average pain score fell from 9/10 to 4.5/10 within < 7 days and remained fairly stable for 4 monthsGroup average pain score fell from 8/10 to 4/10 within < 7 days and remained fairly stable for 4 monthsNot calculated19Very lowLow number of events.

One participant excluded from efficacy analysis

Patient Global Impression of Change: much or very much improvedNo dataNo data

Adverse event withdrawals1 in 100 in 10Not calculated20Very lowLow number of events

Serious adverse events1 in 100 in 10Not calculated20Very lowLow number of events

DeathNoneNone

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 NNT: number needed to treat for an additional beneficial outcome: NNH: number needed to treat for an additional harmful outcome; RR: risk ratio; VAS: visual analogue scale