1. 2026;29;17-36Selecting Neuromodulation Devices For Chronic Pain Conditions: A Narrative Review
   Narrative Review
   Sayed Wahezi, MD, Alan D. Kaye, MD, PhD, Ugur Yener, MD, Corey Hunter, MD, Tony K. George, DO, Marom Bikson, PhD, Moorice Caparo, MD, Miles Day, MD, Yashar Eshraghi, MD, Andrew Kaufman, MD, Haijun Zhang, MD, Daniel Pak, MD, Scott Pritzlaff, MD, Hatice Begum Cifti, MD, Naum Shaparin, MD, Michael Schatman, PhD, Scott Lempka, PhD, and Laxmaiah Manchikanti, MD.

BACKGROUND: Neuromodulation is a rapidly advancing field in pain medicine, providing targeted, reversible interventions for patients with chronic pain unresponsive to conventional therapies. Advances in waveform technology, device design, and stimulation strategies have shifted neuromodulation from a last-resort approach to a core element of multidisciplinary pain management. Despite its growing adoption, variability in training, terminology, and clinical implementation underscores the need for consensus-driven frameworks to ensure safety, efficacy, and uniformity across practice settings.

OBJECTIVES: This review aims to define current and emerging concepts in neuromodulation, summarize the supporting evidence, and offer clinicians an evidence-informed framework for individualized application in chronic pain management.

STUDY DESIGN: Narrative review.

METHODS: We conducted a comprehensive synthesis of neuromodulation strategies spanning spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRGS), peripheral nerve stimulation (PNS), motor cortex stimulation (MCS), deep brain stimulation (DBS), and targeted drug delivery (TDD). The review integrates data from published studies and reviews to cover emerging concepts, classifications, indications, technological advancements, device features, clinical applications, and practical guidance for patient-specific decision-making.

RESULTS: Over the past decade, neuromodulation use has expanded significantly, driven by technological and mechanistic innovations. Peripheral nerve stimulation (PNS) has become increasingly precise for focal neuropathic pain, demonstrating efficacy in migraine, hemiplegic shoulder pain, persistent spinal pain syndrome, post-amputation neuropathic pain, trigeminal neuralgia, plexus injuries, and multifidus dysfunction. SCS remains a mainstay for widespread neuropathic pain, including CRPS, painful diabetic neuropathy, and post-surgical syndromes, with innovations such as 10-kHz high-frequency and burst stimulation offering paresthesia-free analgesia and improved patient satisfaction. DRGS provides targeted relief for localized neuropathic pain, including post-herniorrhaphy and post-thoracotomy syndromes, with more predictable outcomes. Neurophysiological refinements, including differential target multiplexed (DTM) stimulation and closed-loop systems with evoked compound action potential (ECAP) feedback, enable real-time spinal control and consistent analgesia. Multiphase and surround-inhibition paradigms further enhance segmental coverage, energy efficiency, and rapid analgesic onset. TDD has evolved into a precise adjunctive therapy, with programmable pumps delivering morphine, baclofen, and ziconotide safely, minimizing systemic exposure while allowing individualized dosing. Collectively, these innovations support precision-guided, personalized neuromodulation with durable efficacy and improved patient-centered outcomes across diverse chronic pain conditions.

LIMITATIONS: Heterogeneity in published evidence and the lack of large-scale, head-to-head randomized trials for certain waveforms and technologies limit the conclusions of this review.

CONCLUSIONS: Neuromodulation continues to advance at the intersection of neuroscience, bioengineering, and clinical practice. Harmonizing definitions, classifications, and education will guide future innovation and help ensure that neuromodulation fulfills its promise of safe, effective, and equitable patient care.