Neuromodulation: Overview

Abstract
Introduction: Chronic low back pain is one of the most common causes of absence from work. This not only has economic consequences but also affects the mental health of patients. Furthermore, returning to work is one of the main concerns of patients with chronic pain. Spinal cord stimulation (SCS) has shown its effectiveness in pain reduction and quality of life in many studies. Work-related outcomes have often been neglected or only marginally documented.

Objective: The aim of this study is to examine specific work-related data of the patients before and after surgery and to assess the influence of SCS on the ability to work with a review of the literature.

Materials and methods: This is a single-center retrospective study with prospective data collection. All patients were operated on by the same surgeon at the University Hospital Bern between October 2018 and October 2022. Data were collected during postoperative follow-up and by telephone call. In addition, a literature search was conducted to identify previous research on this topic.

Results: Of the 26 patients included in this study, 18 were on disability leave before SCS whereas eight were still working. After SCS, five of the 18 patients on disability leave were able to return to work within a mean period of 58.3 weeks with a standard deviation of 33.59 after surgery, with a workload of ≥20%. Two of these patients transitioned to a new profession. This corresponds to a return-to-work (RTW) rate of 27.8% for patients previously unemployed in our study. Among the eight patients who were employed before SCS, all were able to resume work. Those who had been working full-time (n = 4) maintained their full workload, whereas the four patients who had previously reduced their workload were able to sustain or even slightly increase their employment percentage.

Conclusion: Our study shows a positive impact of SCS on the patients' work ability with an RTW rate of 27.8%. The findings not only indicate a favorable influence on patients' health and well-being but also create positive economic implications.

Abstract
Objectives: The Neuromodulation Society of Australia and New Zealand (NSANZ) developed evidence-based best practice guidelines for spinal cord stimulation (SCS) in chronic pain management. The primary objective was to provide clear guidance to support evidence-informed care across Australia and New Zealand, with a focus on patient selection, procedural techniques, and complication management.

Materials and methods: A systematic literature review was conducted using Medline, EMBASE, Trip Pro, and Google Scholar, covering publications from 2010 to July 2024. A total of 283 studies and relevant clinical guidelines were included on the basis of level 1B evidence or strong expert consensus, consistent with the Grading of Recommendations Assessment, Development, and Evaluation criteria. Clinical questions were developed using the Population, Intervention, Comparison, and Outcome framework, and a Delphi process was used to achieve consensus among NSANZ board members.

Results: The guidelines provide comprehensive recommendations on patient selection, preparation, procedural techniques, postimplantation care, and complication management. Additional guidance is included on training standards, quality improvement processes, and the importance of multidisciplinary collaboration. Key recommendations emphasize optimizing patient selection, enhancing procedural safety, and improving treatment outcomes.

Conclusions: These guidelines offer practical, evidence-informed recommendations for the safe and effective use of SCS in chronic pain management. By promoting consistency, transparency, and collaborative care, they aim to guide clinical decision-making and support the delivery of evidence-informed neuromodulation services across Australia and New Zealand.

Abstract
Background: Managing focal neuropathic pain poses significant challenges. Neuromodulation therapies, particularly dorsal root ganglion stimulation (DRG-S), have shown promise in many cases. However, frequent issues with system durability, necessitating revisions, and the complexity of these revisions due to associated difficulties and the limitations in complex cases with difficult access to the epidural space or foramen have prompted practitioners to seek more durable and long-lasting alternatives. Spinal nerve stimulation through an extraforaminal approach offers a promising solution for patients who have exhausted conventional pain therapies or are unsuitable candidates for DRG-S.

Materials and methods: This is a single-center, retrospective data analysis in 73 patients with neuropathic pain who underwent spinal nerve stimulation (SNS) using our facility's novel extraforaminal approach from January 2019 to December 2024. The collected data included patient-reported outcomes. We also reviewed any adverse events, complications, or procedure-related issues.

Results: Initially, extraforaminal SNS was primarily considered for patients with a history of failed DRG-S. Since 2021, however, this approach has become the primary treatment for focal neuropathic pain at our institution. Of the 73 patients trialed, 75% achieved >50% pain relief, causing permanent implantation in 53 patients. Patient satisfaction remained high, with 38 of 42 patients currently implanted reporting satisfaction in a 2024 follow-up survey. Remarkably, >80% of patients implanted in 2019 and 2020 reported sustained satisfaction five and four years after implantation, respectively. No intraoperative complications or serious adverse events were documented during the trial or after implantation, surgical revisions, or explantation.

Conclusion: The extraforaminal SNS approach has shown safety and durability as a treatment for patients with refractory neuropathic pain. With long-term patient satisfaction and a favorable safety profile, it offers a promising alternative to traditional neuromodulation techniques, particularly in complex cases in which DRG-S may be challenging or contraindicated.