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Burst vs Tonic Spinal Cord Stimulation for Chronic Neuropathic Pain: A Systematic Review and Meta-Analysis of
Majed Aldehri1, Ibrahim Serag2, Mohamed M Elgohary3
1Anatomy Department, College of Medicine, King Khalid University, Abha, Saudi Arabia.
Background:
Spinal cord stimulation (SCS) is an established therapy for refractory neuropathic pain; however, conventional tonic stimulation has limitations, including paresthesia dependence and variable long-term efficacy. Burst SCS has emerged as a novel paradigm designed to provide paresthesia-free analgesia and enhanced modulation of both sensory and affective pain pathways. This systematic review and meta-analysis aimed to compare the efficacy of burst and tonic SCS, focusing on pain intensity and quality of life.
Materials And Methods:
A systematic search of PubMed, Web of Science, and Scopus was conducted from inception to March 2026. Randomized controlled trials and cohort studies comparing burst and tonic SCS in adults with chronic neuropathic pain were included. Primary outcomes were pain intensity measured using the visual analog scale (VAS) across general, trunk, and limb domains, and quality of life. Secondary outcomes included improvement in general pain, Oswestry Disability Index (ODI), and patient satisfaction and preference. Data were pooled using a random-effects model (DerSimonian and Laird). Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale, and certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Results:
Overall, 17 studies comprising 669 participants were included. Burst SCS showed significant reductions in pain compared with tonic SCS across all VAS domains: general pain (mean difference [MD] -1.31, 95% CI -1.78 to -0.83), trunk pain (MD -1.88, 95% CI -3.19 to -0.57), and limb pain (MD -1.52, 95% CI -2.75 to -0.28). Heterogeneity was high across analyses (I2 = 88%-98%), but sensitivity analyses confirmed consistent direction of effect. No significant differences were observed in quality of life (MD 4.31, 95% CI -1.93 to 10.54) or ODI scores. Burst SCS was associated with greater relief of general pain and higher patient preference. GRADE assessment indicated moderate certainty for pain outcomes and low certainty for quality of life.
Conclusions:
Burst SCS was associated with statistically significant reductions in pain compared with conventional tonic stimulation and was generally preferred by patients. However, the magnitude of the pooled benefit for the primary pain outcome may not reach commonly accepted minimum clinically important difference thresholds, and evidence regarding improvements in quality of life and functional outcomes remains limited. Further adequately powered comparative studies are needed to better define the clinical significance of these findings.
