The American Society of Pain and Neuroscience has released comprehensive new guidelines that support the use of neurostimulation therapies for patients with nonsurgical low back pain, according to findings.

The guidelines—published in the Journal of Pain Research and developed by the NEURON project—represent the first evidence-based consensus that specifically addresses neurostimulation as a treatment option for patients with nonsurgical low back pain (NSLBP) who have failed conventional medical management but are not candidates for surgery.

High Level of Evidence Supports Several Approaches

The review identified and graded multiple randomized controlled trials that showed s for spinal cord stimulation (SCS) compared with conventional medical management (CMM) for NSLBP.  Several neurostimulation techniques received the highest recommendation levels.

"SCS is recommended for patients with NSLBP," according to the guidelines, with an "A" grade recommendation and high level of certainty for net benefit. Two specific SCS approaches received strong endorsements with "A" grade recommendations and high consensus: passive recharge burst SCS and differential targeted multiplexed SCS.

Other approaches that received support included 10,000 Hz stimulation therapy (A grade, moderate consensus) and closed-loop SCS (B grade, moderate consensus).

Defining Nonsurgical Low Back Pain

The guideline authors defined patients with NSLBP as those who "have failed to respond to CMM, have no history of spine surgery, and are not appropriate candidates for surgical intervention." CMM refers to "physical or occupational therapy, analgesic medications, nerve blocks, steroid injections, radiofrequency ablation and other validated treatments for lumbar pain."

Approximately 13.1% of the U.S. population has chronic low back pain (CLBP), and nearly one-third experiences moderate-to-severe pain intensity. The guidelines note that NSLBP "is a prevalent condition that is not limited to any specific demographic" and is associated with age. The highest incidence is in the third decade of life and increases in prevalence with age up to 85 years.

Economic Benefits Demonstrated

"A 2023 prospective, randomized controlled trial comparing SCS to CMM for NSLBP over 12 months found a 33% average reduction in health care utilization cost in the SCS arm as compared to CMM," the guideline authors wrote. "The cost-effectiveness of SCS was estimated to be achieved within 2.1 years."

Additionally, they noted that SCS has been found to reduce opioid consumption and pain-related procedures.

Alternative Neuromodulation Approaches

While SCS received the strongest recommendations, the guideline authors also reviewed evidence for dorsal root ganglion stimulation (DRG-S) and peripheral nerve stimulation (PNS) for NSLBP.

• DRG-S received a "C" grade recommendation with low certainty regarding net benefit but moderate consensus. T12, L2, and S1 were identified as target levels.

• PNS received a "B" grade recommendation with moderate certainty regarding net benefit and moderate consensus.

Addressing Psychological Evaluation

The guideline authors questioned the traditional requirement for psychological screening prior to neurostimulation, noting "a complete lack of consensus regarding what elements constitute a sound evaluation, by whom it should be provided, and even its efficacy for improving outcomes."

They highlighted concerns about the severe shortage of trained pain psychologists in the U.S. "Given the literature identifying the strong inverse relationship between delayed neuromodulation and favorable long-term outcomes, the relationship between insurance insistence on still unproven psychological evaluations prior to neuromodulation trials, the delays in treatment that result from such, and the impact on outcomes certainly merits empirical investigation."

Future Research Directions

The guideline authors identified several priorities for future research, including refining the definition of NSLBP, continuing level 1 studies comparing neurostimulation to conventional management, and exploring artificial intelligence applications that might optimize therapy delivery.

"The NEURON project is intended to be living guidance with regular updates on the evidence and best practices for topics in spine and nerve," the researchers concluded. "The use of neuromodulation for NSLBP is building, and evidence has now led to FDA labeling for forms of SCS."

Disclosures can be found in the published guidelines.