Integrating the Central Sensitization Inventory (CSI) into Neuropelveological Practice: A Systematic Review of Endometriosis and Overlapping Pelvic Pain Syndromes

Background: The surgical management of chronic pelvic pain (CPP), particularly in endometriosis, often focuses on lesion excision or nerve decompression. However, persistent pain frequently occurs despite “anatomical perfection,” suggesting central nervous system involvement. Neuropelveology faces a “surgical paradox” when dealing with central sensitization (CS), where peripheral interventions fail to address a systemic nociplastic state. Methods: This systematic review followed PRISMA guidelines and was registered in PROSPERO (CRD420261335008). A search across PubMed, Embase, and Cochrane (2010–2026) identified 71 relevant studies involving over 12,000 participants. Results: CS prevalence in the endometriosis population ranges from 11.3% to 58.2%, rising to 74.8% in specialized tertiary referral centers. The Central Sensitization Inventory (CSI) is a robust predictor of surgical failure; every one-point increase in preoperative CSI raises the risk of persistent pain (OR 1.02, p = 0.02). Objective markers, such as the collapse of Conditioned Pain Modulation (CPM), confirm that “high-sensitizers” (CSI ≥ 40) suffer from a systemic “software” failure of pain inhibition. Conclusions: We propose a paradigm shift in neuropelveology. In patients with high CSI scores (≥40), functional neuromodulation—specifically the LION procedure—should be prioritized over traditional nerve decompression to address the nociplastic nature of the pain.