Is sacral neuromodulation (SNM) approved for the treatment of low back pain?

Sacral Neuromodulation for Low Back Pain: Current Approval Status

Sacral neuromodulation (SNM) is not FDA-approved or formally indicated for the treatment of low back pain. 1, 2

Regulatory Status and Approved Indications for SNM

Sacral neuromodulation is currently approved and used primarily for:

• Urological and pelvic disorders including:
  • Overactive bladder syndrome
  • Non-obstructive urinary retention
  • Fecal incontinence
  • Certain types of pelvic pain associated with bladder disorders 1, 2

The American Urological Association guidelines specifically state that SNM is "not currently FDA-approved for IC/BPS treatment; however, many patients meet the frequency/urgency indication for which sacral neuromodulation is approved." The guidelines further caution that "the procedure is indicated for frequency/urgency symptoms and is much less effective and potentially ineffective for pain." 1

Evidence for Neuromodulation in Pain Management

Spinal Cord Stimulation vs. Sacral Neuromodulation

• Spinal Cord Stimulation (SCS) is the primary neuromodulation technique used for chronic pain conditions, including:

  • Failed back surgery syndrome
  • Complex regional pain syndrome
  • Peripheral neuropathic pain 2, 3

• Sacral Neuromodulation (SNM) has been studied for:

  • Chronic pelvic pain 4, 5, 6
  • Interstitial cystitis/bladder pain syndrome 1
  • But not specifically for isolated low back pain

Evidence for SNM in Pain Management

The evidence for SNM in pain management is limited and primarily focused on pelvic pain:

• A 2023 systematic review found that SNM can reduce chronic pelvic pain with a weighted mean difference in pain scores of -4.64 on a 10-point scale, but this was specific to pelvic pain, not low back pain 4

• A 2018 case series of 52 patients reported improvement in perineal pain with SNM, but did not address low back pain specifically 5

• A 2011 review found insufficient evidence to determine the role of SNM in chronic pelvic pain treatment 6

Current Recommendations for Low Back Pain Management

For low back pain, the evidence supports other neuromodulation techniques:

• Spinal cord stimulation (SCS) has been studied specifically for low back pain, though a 2023 Cochrane review concluded that "data in this review do not support the use of SCS to manage low back pain outside a clinical trial" 7

• The American College of Physicians and American Pain Society guidelines for low back pain do not include sacral neuromodulation among recommended treatments 1

Clinical Implications

When considering neuromodulation for pain:

• The primary symptom location should guide technique selection:

  • Widespread pain or pain in limbs/trunk → Consider SCS
  • Pelvic-specific symptoms with bladder/bowel dysfunction → Consider SNM 2

• For low back pain specifically, SCS would be the more appropriate neuromodulation technique to consider, though evidence for its efficacy is mixed 7

Conclusion

While sacral neuromodulation has established efficacy for urological and certain pelvic disorders, it is not approved or indicated for the treatment of low back pain. Clinicians should be aware that using SNM for low back pain would be an off-label application with limited supporting evidence.