Is the implantation of neuroelectrodes medically necessary for low back pain?

Neuroelectrode Implantation for Chronic Low Back Pain: Not Medically Necessary

The implantation of neuroelectrodes for unspecified low back pain is not medically necessary and should not be performed. Current evidence demonstrates that neurostimulation devices lack proven efficacy for chronic low back pain and carry substantial surgical risks without corresponding benefits to morbidity, mortality, or quality of life.

Evidence Against Neurostimulation for Low Back Pain

Guideline Recommendations

• The 2025 clinical practice guideline for non-cancer chronic spine pain issued strong recommendations against interventional procedures for chronic spine pain, including nerve stimulation techniques, as they lack sufficient evidence of effectiveness 1

• The American College of Physicians and American Pain Society guidelines do not endorse neurostimulation for chronic low back pain, instead recommending nonpharmacologic therapies including exercise, spinal manipulation, and cognitive-behavioral therapy 2

• Transcutaneous electrical nerve stimulation (TENS) has been specifically recommended against for chronic low back pain due to insufficient evidence of benefit 2

Research Evidence on Spinal Cord Stimulation

• A 2023 Cochrane systematic review found moderate-certainty evidence that spinal cord stimulation probably does not improve back pain, function, or quality of life compared with placebo at 6 months 3

• At 6 months, pain scores with SCS were only 4 points better on a 0-100 scale (95% CI: 8.2 better to 0.2 worse) compared to placebo - a clinically insignificant difference 3

• Function improved by only 1.3 points on a 0-100 scale (95% CI: 3.9 better to 1.3 worse) with SCS versus placebo 3

• The Cochrane review concluded that "data do not support the use of SCS to manage low back pain outside a clinical trial" 3

Substantial Surgical Risks

Documented Complications

• 31% of patients receiving SCS required revision surgery at 24 months 3

• Serious adverse events include infections, neurological damage, and lead migration requiring repeated surgery 3

• 18% of participants experienced adverse events and 8% required revision surgery in placebo-controlled trials 3

Risk-Benefit Analysis

• The surgical risks and costs of neurostimulation are not justified by the lack of sustained clinical benefits 3

• Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention 3

Evidence-Based Alternative Approaches

First-Line Nonpharmacologic Therapies

• Exercise therapy with individual tailoring, supervision, stretching, and strengthening shows fair to good evidence for chronic low back pain 2

• Spinal manipulation has demonstrated effectiveness for chronic low back pain 2

• Cognitive-behavioral therapy and progressive relaxation are recommended interventions 2, 1

• Intensive interdisciplinary rehabilitation combining physical, vocational, and behavioral components is recommended for patients not responding to initial therapies 2, 1

Pharmacologic Management

• Optimized medication management should be pursued before considering invasive procedures 1

• For neuropathic pain components, a trial of duloxetine is recommended 1

• NSAIDs and acetaminophen remain appropriate pharmacologic options 1

Injection Therapies (Limited Role)

• Lumbar epidural injections, facet injections, or trigger point injections may provide temporary symptomatic relief only in selected patients 2

• Facet injections are not recommended as long-term treatment for chronic low back pain 2

• These injection therapies are not recommended for long-term relief 2

Clinical Decision Algorithm

1. Confirm diagnosis: Ensure no red flags requiring urgent intervention (cauda equina syndrome, infection, fracture) 2

2. Implement evidence-based conservative care:

   • Structured exercise program with supervision 2, 1
   • Consider spinal manipulation 2
   • Add cognitive-behavioral therapy if psychosocial factors present 2, 1

3. Optimize pharmacologic management: Trial appropriate medications including NSAIDs and duloxetine for neuropathic components 1

4. Consider intensive interdisciplinary rehabilitation if initial therapies fail 2, 1

5. Avoid neurostimulation devices: Current evidence does not support their use outside clinical trials 1, 3

Critical Pitfalls to Avoid

• Do not proceed with neurostimulation based solely on patient request or failure of conservative therapy - the evidence does not support efficacy even in refractory cases 1, 3

• Avoid the misconception that "something must be done" surgically for chronic pain - invasive procedures without proven benefit cause harm 3

• Do not rely on older literature or anecdotal reports suggesting benefit - the highest quality recent evidence (2023 Cochrane review and 2025 guidelines) clearly demonstrates lack of efficacy 1, 3

• Recognize that the 31% revision surgery rate represents a substantial burden of morbidity that is not justified by the minimal and non-sustained benefits 3