Employing neuromodulation strategies to treat chronic pain has gained momentum in recent years, along with an expansion of the indications. These therapies are safe, reversible, and efficacious, improving both validated pain and functional measures. However, the trial procedure is not without risk and deserves a respectful assessment of the risks and the benefits associated with the therapy. Improving the outcomes, safety, and efficacy of employing neuromodulation is contingent on evaluating the evidence and expert opinion. This knowledge gap has been identified and addressed by the International Neuromodulation Society (INS).1
Convened by the INS, the Neuromodulation Appropriateness Consensus Committee (NACC) issued the first comprehensive peer-reviewed recommendations for appropriate use of neurostimulation in pain and ischemic disease in the August 2014 issue of Neuromodulation: Technology at the Neural Interface, the official journal of the INS.2–5 The major objective of this paper series was to create a living document, based on the best available evidence and expert opinion, which will be regularly updated to address the different applications, innovations, disease-specific indications, and patient selection criteria for the safe and appropriate use of neuromodulation.
Spinal cord stimulation has been in common clinical use since the 1980s and over 25,000 neurostimulators, sometimes described as a ‘pain pacemaker,’ are implanted worldwide each year to help reduce pain and restore function. Spinal cord stimulation for chronic back pain (failed back surgery syndrome) is the most common indication in the US. In Europe, peripheral nerve stimulation is also part of the physician’s armamentarium for intractable migraine, medication-resistant chronic angina pectoris, and chronic clinical leg ischemia.6 As device innovation continues to evolve, so to will the indications for neuromodulation therapies, expanding from the conventional use of spinal cord stimulation for failed back spinal surgeries and complex regional pain syndrome.
The comprehensive effort produced the current opinion as a consensus statement about available evidence on the use of neuromodulation to treat neuropathic pain, with an eye on future trends and indications. The guideline series describes the Appropriate Use of Neurostimulation of the Spinal Cord and Peripheral Nervous System for the Treatment of Chronic Pain and Ischemic Diseases; the Stimulation of the Intracranial and Extracranial Space and Head for Chronic Pain; a review and recommendation on the Avoidance and Treatment of Complications of Neurostimulation Therapies for the Treatment of Chronic Pain; and Neuromodulation New and Evolving Neurostimulation Therapies and Applicable Treatment for Chronic Pain and Selected Disease States.2–5