Is spinal cord stimulation (SCS) effective for treating low back pain?

Spinal Cord Stimulation for Low Back Pain

Spinal cord stimulation (SCS) should not be used as a first-line treatment for low back pain but may be considered in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies. 1

Efficacy of SCS for Different Types of Low Back Pain

For Radicular Pain

• SCS is primarily indicated for persistent radicular pain (pain that radiates down the legs) rather than axial low back pain alone 1
• The American Society of Anesthesiologists (ASA) recommends SCS for patients with radicular pain who have failed other treatment modalities 1
• A spinal cord stimulation trial should always be performed before considering permanent implantation 1

For Axial Low Back Pain (Non-radicular)

• Current evidence does not strongly support SCS for isolated axial low back pain
• A 2023 Cochrane review found that SCS probably does not improve back pain, function, or quality of life compared to placebo at 6 months (moderate-certainty evidence) 2
• The Cochrane review concluded that "data does not support the use of SCS to manage low back pain outside a clinical trial" 2

Patient Selection for SCS

SCS may be considered for:

1. Patients with persistent radicular pain who have not responded to other therapies 1
2. Selected patients with:
   • Complex regional pain syndrome (CRPS)
   • Peripheral neuropathic pain
   • Peripheral vascular disease
   • Postherpetic neuralgia 1

Treatment Algorithm for Low Back Pain

1. First-line treatments (0-8 weeks):

   • Physical therapy with focus on active interventions 3
   • NSAIDs for short-term use 3
   • Heat therapy 3
   • Continued activity as tolerated 3

2. Second-line treatments (if inadequate response after 8-12 weeks):

   • Cognitive behavioral therapy 3
   • Epidural steroid injections (for radicular pain) 1
   • Biofeedback and relaxation training 3

3. Third-line treatments (if inadequate response to above):

   • Consider SCS trial for patients with persistent radicular pain 1
   • Proceed to permanent implantation only if trial shows >50% pain reduction 4

Evidence for SCS Effectiveness

Positive Evidence

• A 2022 multicenter RCT found that 10-kHz SCS was effective for "nonsurgical refractory back pain" with 80.9% of patients achieving ≥50% pain relief at 3 months compared to 1.3% in the conventional medical management group 4
• A 2025 systematic review reported that newer SCS approaches (high frequency, differential target multiplexed, and multiphase SCS) demonstrated improved efficacy over traditional SCS for pain relief and functionality 5

Negative Evidence

• The 2023 Cochrane review found that SCS probably does not provide sustained clinical benefits that would outweigh the costs and risks of this surgical intervention 2
• At 6 months, SCS showed minimal improvement in pain (4 points better on a 100-point scale) and function (1.3 points better on a 100-point scale) compared to placebo 2

Potential Complications and Risks

• Dural puncture
• Insertion-site infections
• Neurological damage
• Lead migration requiring repeated surgery 1, 2
• In one study, 31% of SCS recipients required revision surgery at 24 months 2

Important Considerations Before SCS Implementation

• Shared decision-making regarding SCS should include specific discussion of potential complications 1
• SCS should be part of a multimodal approach rather than used in isolation 1
• A trial of stimulation is mandatory before permanent implantation 1
• The high cost and invasive nature of SCS must be weighed against potential benefits 2

Newer SCS Technologies

• High-frequency (10 kHz) SCS has shown promising results in some studies 4, 6
• Combination approaches using SCS with peripheral nerve field stimulation may be more effective than either modality alone for patients with both back and leg pain 7

Despite some promising recent research, current guidelines and the most comprehensive systematic review (Cochrane) do not support routine use of SCS for axial low back pain. SCS should be reserved for carefully selected patients with radicular pain who have failed other treatment modalities.