Effects of neuromodulation techniques on neuropathic pain: a systematic review and network meta-analysis

Although neuromodulation is widely used for neuropathic pain (NP), high-quality comparative evidence on the analgesic effects of different techniques is lacking for most NP subtypes, except for well-defined conditions such as complex regional pain syndrome (CRPS). This gap leaves clinicians with limited guidance on optimal technique selection in most clinical scenarios. PubMed, Embase, Cochrane Library, Web of Science, and Scopus were systematically searched from inception to July 1, 2025. Randomized controlled trials (RCTs) employing neuromodulation techniques for the treatment of NP were included. Two reviewers independently extracted data, and the Cochrane Risk of Bias 2 tool was used to assess bias. Network meta-analysis was based on Bayesian models and implemented in R 4.2.3 and Stata. The Confidence in Network Meta-Analysis (CINeMA) program is based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to evaluate the level of evidence in the results. The conclusions are based on the evidence from the network meta-analysis (NMA) using a partially contextualised framework. 115 RCTs evaluating 19 neuromodulations were included. LF-SCS was identified as the neuromodulation with substantial evidence for neuropathic pain, supported by moderate certainty. PNS, HF-SCS, RFT, DRGS, b-PRF, and Hv-PRF showed favorable analgesic effects, although the certainty of evidence was low. Non-invasive transcranial neuromodulation techniques demonstrated limited analgesic benefits with low certainty evidence, suggesting that further studies are needed. Overall, this review provides a comparative overview of the efficacy and evidence certainty of various neuromodulation techniques, offering a basis for future research and clinical decision-making.