Multicentre, double-blind, randomised, sham-controlled trial of 10 khz high-frequency spinal cord stimulation for chronic neuropathic low back pain (MODULATE-LBP): a trial protocol

Adnan Al-Kaisy, Jonathan Royds, Stefano Palmisani, David Pang, Samuel Wesley, Rod S Taylor, Andrew Cook, Sam Eldabe, Lance McCracken, Rui Duarte, Jeremy Fairbank, Adnan Al-Kaisy, Jonathan Royds, Stefano Palmisani, David Pang, Samuel Wesley, Rod S Taylor, Andrew Cook, Sam Eldabe, Lance McCracken, Rui Duarte, Jeremy Fairbank

Abstract

Introduction: Chronic neuropathic low back pain (CNLBP) is a debilitating condition in which established medical treatments seldom alleviate symptoms. Evidence demonstrates that high-frequency 10 kHz spinal cord stimulation (SCS) reduces pain and improves health-related quality of life in patients with failed back surgery syndrome (FBSS), but evidence of this effect is limited in individuals with CNLBP who have not had surgery. The aim of this multicentre randomised trial is to assess the clinical and cost-effectiveness of 10 kHz SCS for this population.

Methods: This is a multicentre, double-blind, randomised, sham-controlled trial with a parallel economic evaluation. A total of 96 patients with CNLBP who have not had spinal surgery will be implanted with an epidural lead and a sham lead outside the epidural space without a screening trial. Patients will be randomised 1:1 to 10 kHz SCS plus usual care (intervention group) or to sham 10 kHz SCS plus usual care (control group) after receiving the full implant. The SCS devices will be programmed identically using a cathodal cascade. Participants will use their handheld programmer to alter the intensity of the stimulation as per routine practice. The primary outcome will be a 7-day daily pain diary. Secondary outcomes include the Oswestry Disability Index, complications, EQ-5D-5 L, and health and social care costs. Outcomes will be assessed at baseline (pre-randomisation) and at 1 month, 3 months and 6 months after device activation. The primary analyses will compare primary and secondary outcomes between groups at 6 months, while adjusting for baseline outcome scores. Incremental cost per quality-adjusted life year (QALY) will be calculated at 6 months and over the lifetime of the patient.

Discussion: The outcomes of this trial will inform clinical practice and healthcare policy on the role of high-frequency 10 kHz SCS for use in patients with CNLBP who have not had surgery.

Trial registration: Clinicaltrials.gov, NCT03470766. Registered on 20 March 2018.

Disclaimer: The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR had no role in the study design, writing of the manuscript or the decision to submit for publication.

Roles and responsibilities: AK, SP, DP, SW, RST, AC, SE, LM, RD and JF all contributed to the trial design and to securing trial funding. AK, JR, SP, DP, and SE are involved in the recruitment, the intervention and the follow-up. SW will perform data collection and analysis. RST will be responsible for the statistical analysis, and RD will be responsible for the health economic analysis. All authors read and approved the final manuscript.

Keywords: Spinal cord stimulation, Neuropathic pain, Chronic neuropathic low back pain, Neuromodulation.

Conflict of interest statement

AK has received receipt of honoraria from Nevro and is a stock shareholder in Micron Devices. DP has received travel expenses from Medtronic and Nevro outside the submitted work. SP reports grants and non-financial support from Saluda Medical, personal fees and non-financial support from Nevro outside the submitted work. RT is a paid consultant for Medtronic and Nevro. RD has received consultancy fees from Medtronic and Boston Scientific. SE, AC, LM, JR, and SW have no conflicts of interest.

Figures

Fig. 1
Fig. 1
Consort diagram of MODULATE-LBP trial
Fig. 2
Fig. 2
Anterior-posterior X-ray position of desired lead location and diagrammatic illustration of ‘cascade’
Fig. 3
Fig. 3
Position of epidural lead (1), sham lead (2) and implantable Pulse Generator
Fig. 4
Fig. 4
Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) diagram

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