The Neuromodulation Appropriateness Consensus Committee (NACC) has released the first comprehensive guidance on best practices for neurostimulation for chronic pain.
The guidelines, four peer-reviewed articles totaling 101 pages that were authored by about 60 international experts, were published in the journal Neuromodulation (2014;17:515-615) and cover the following general areas: appropriate use of neurostimulation of the spinal cord and peripheral nervous system; stimulation of the intracranial and extracranial space and head; avoidance and treatment of complications of neurostimulation therapies; and new and evolving neurostimulation therapies.
“There was such variability in practice around the world and in the United States as well. We really felt we needed to look at the literature, look at what seemed to be the most effective and safe therapies, and give guidance to our colleagues based on what the literature said. In addition, we filled in the gaps with the consensus of opinions of experts who were well published,” said Timothy R. Deer, MD, medical director, Center for Pain Relief, in Charleston, W.Va., and chairman of the NACC.
The guidance was “absolutely needed,” according to Nicholas Scott, MD, an interventional pain physician at Arizona Pain Associates, in Scottsdale, who was not involved in developing the guidance. “It’s important to have guidelines that physicians can use for best practices, as these can lead to decreased complications and improved patient outcomes related to this valuable modality for pain control.”
When he was asked if there was anything lacking in the guidance, Dr. Scott answered, “No, they covered quite a bit of ground. There’s nothing glaring that I see as lacking in the guidance.”
Dr. Deer, who is also a clinical professor of anesthesiology at West Virginia University, in Morgantown, cited three recommendations that the NACC made that are different from current practice. The first was best practices in infection control. According to a survey of infection control practices soon to be published, Dr. Deer said, “Some doctors weren’t using any prophylactic antibiotics. We learned that people were doing various things with their preps and their irrigation techniques. In this guidance, we give best practices to avoid infection. While that sounds like it may be simple, if you look at the survey of what people do, people are doing a lot of things, many of which probably aren’t the best things for the patient.”
Dr. Scott agreed that the infection control guidance was needed. “I think the recommendations related to infection control are very important. We obviously want to make patients better; you know the Hippocratic Oath, ‘first, do no harm,’ is something that I take very seriously and I think most physicians take very seriously. So, you don’t want to have a negative outcome when you’re trying to do pain relief.”
The second and third NACC recommendations deal with handling bleeding and medications that affect bleeding, and the proper training required to get credentialed for these procedures.
The NACC guidance will be regularly updated, probably beginning in summer 2015, to include new data on existing devices and for the introduction of new devices.
—George Ochoa
