Spinal cord stimulation is increasingly requested in chronic pain cases, including personal injury, workers’ compensation, disability, and independent medical examination settings. The technology can be helpful in properly selected patients, especially when chronic neuropathic pain is present and conservative treatment has failed. But spinal cord stimulation is not a general treatment for unexplained neck pain, nonspecific low back pain, intermittent nonanatomic “radicular” complaints, or psychologically complex pain presentations without a clear neuropathic pain diagnosis.
A common medicolegal scenario involves a claimant with disabling neck and low back pain after trauma or assault, no prior pain history, equivocal injections, partial response to radiofrequency ablation, psychological symptoms, a short spinal cord stimulator trial described as a “miracle,” and a recommendation for permanent implantation.
The central question is not whether the claimant has pain. The question is:
Is there a medically accepted indication for permanent spinal cord stimulator implantation, supported by objective diagnosis, neuropathic pain findings, adequate psychological screening, a valid trial, and durable functional goals?
In many cases, the answer is no.
What Is Spinal Cord Stimulation?
Spinal cord stimulation, or SCS, is a neuromodulation therapy in which electrodes are placed in the epidural space to deliver electrical stimulation to the spinal cord. The goal is to reduce pain signaling and improve function. Modern systems include traditional paresthesia-based stimulation and newer waveforms, including high-frequency, burst, and closed-loop systems.
SCS has been used for several chronic pain conditions, especially neuropathic pain states. The best-established historical indications include:
- Failed back surgery syndrome or persistent spinal pain syndrome after surgery
- Chronic radicular leg pain
- Complex regional pain syndrome
- Painful diabetic neuropathy
- Certain peripheral neuropathic pain syndromes
- Selected cases of refractory neuropathic pain after careful evaluation
The 2023 evidence-based consensus guidelines on patient selection and trial stimulation state that SCS has demonstrated effectiveness for neuropathic pain, while also emphasizing that some patients do not obtain adequate long-term relief and that patient selection remains critical. (rapm.bmj.com)
This is the starting point for IME analysis: SCS is primarily a therapy for selected chronic neuropathic pain conditions, not a nonspecific pain device.
SCS Requires a Diagnosis, Not Just Pain
A permanent spinal cord stimulator should not be justified by pain severity alone. The physician expert should identify the specific pain diagnosis being treated.
A request for SCS is stronger when the records document:
- Objective radiculopathy
- Peripheral neuropathy
- CRPS meeting accepted criteria
- Persistent neuropathic leg pain after spine surgery
- Incomplete spinal cord injury with neuropathic pain
- Plexopathy
- Post-herpetic neuralgia
- Phantom limb pain
- Other well-defined neuropathic pain syndrome
A request is weaker when the diagnosis is:
- Chronic nonspecific low back pain
- Chronic nonspecific neck pain
- Myofascial pain
- Intermittent nonanatomic radicular complaints
- Axial pain without objective neurologic findings
- Pain behavior without anatomic correlation
- Somatic symptom disorder or functional pain presentation
- Pain primarily driven by psychological trauma, PTSD, anxiety, or depression
A claimant may have disabling pain without meeting criteria for SCS. Medical necessity depends on diagnosis, not simply distress.
Neuropathic Pain Must Be Established
The term “radicular pain” is often used loosely. True radiculopathy or neuropathic pain should be supported by the clinical pattern, examination, imaging, and electrodiagnostic testing where appropriate.
Evidence supporting neuropathic pain may include:
- Dermatomal pain distribution
- Objective sensory loss in a nerve or root distribution
- Reflex asymmetry
- Myotomal weakness
- Positive tension signs consistent with the level
- EMG evidence of radiculopathy or neuropathy
- MRI showing nerve root compression matching symptoms
- Allodynia or hyperalgesia in a regional pattern, if CRPS is alleged
- Consistent documentation across providers
In contrast, intermittent nonanatomic “radicular” symptoms—pain that changes sides, varies in distribution, lacks objective deficits, and does not correlate with imaging—are weak support for SCS.
A useful medicolegal statement is:
“The records describe intermittent radiating symptoms, but the distribution is nonanatomic and not supported by objective neurologic deficit, electrodiagnostic abnormality, or imaging-confirmed nerve compression. Therefore, the record does not establish a neuropathic pain diagnosis sufficient to support SCS.”
Axial Neck and Back Pain Are Not Enough
Many chronic pain patients have axial neck or low back pain after trauma. Some have facet-mediated pain, disc degeneration, myofascial pain, or nonspecific spinal pain. These conditions can be disabling. But they are not automatically indications for SCS.
In the example scenario, the claimant had cervical radiofrequency neurotomy and reported substantial improvement at three months. That suggests the cervical pain may have had a facet-mediated or axial component responsive to denervation. It does not support SCS for neck pain.
Similarly, equivocal lumbar epidural steroid injections and facet injections do not establish neuropathic pain. If injections are inconsistent, transient, or poorly documented, they do not provide the diagnostic foundation for permanent implantable neuromodulation.
A report might state:
“The cervical pain improved after RFNA, which supports a non-SCS pain generator. The lumbar injections were equivocal and do not establish a consistent neuropathic pain syndrome. The record therefore lacks a clear indication for permanent SCS implantation.”
Psychological Screening Is Not a Formality
Psychological evaluation is a core part of SCS selection. It should not be treated as a rubber stamp.
Psychological factors can significantly affect SCS outcomes, including pain perception, expectations, adherence, device satisfaction, disability behavior, and risk of treatment failure. The 2023 evidence-based consensus guidelines include recommendations addressing psychosocial screening and note that patient selection is emphasized because some patients fail to obtain durable benefit. (rapm.bmj.com)
Important psychological considerations include:
- Major depression
- Anxiety disorder
- PTSD
- Somatic symptom disorder
- Catastrophizing
- Poor coping
- Substance use disorder
- Untreated trauma symptoms
- Unrealistic expectations
- Poor treatment adherence
- Litigation-related stressors
- Noncompliance with prior mental health care
A psychiatric or psychological “clearance” that fails to mention documented PTSD, anxiety, depression, noncompliance with therapy, or prior discharge for failure to attend sessions is incomplete.
A strong screening evaluation should usually include:
- Review of relevant mental health records
- Structured clinical interview
- Validated psychometric testing when appropriate
- Substance use screening
- Assessment of expectations
- Assessment of adherence risk
- Evaluation for somatic symptom features
- Discussion of litigation or compensation context where relevant
- Clear statement of risk factors and mitigation plan
A two-paragraph clearance letter without record review or testing may not be adequate.
PTSD, Anxiety, and Depression Do Not Automatically Exclude SCS
It is important not to overstate the point. PTSD, anxiety, or depression do not automatically disqualify every patient from SCS. Many chronic pain patients have comorbid mental health symptoms. The issue is whether those symptoms are severe, untreated, destabilizing, undisclosed, or likely to impair outcome.
In the described scenario, the concern is not merely that PTSD, anxiety, or depression existed. The concern is that:
- The claimant had documented mental health treatment.
- She reportedly attended only six therapy sessions.
- She was discharged for failure to comply or attend.
- The SCS psychological clearance did not address this history.
- The pain complaints were nonanatomic.
- The proposed implant followed a very short trial described in dramatic terms.
Those facts create selection concerns.
A defensible IME opinion might state:
“The documented PTSD, anxiety, depression, and discharge from therapy for nonattendance do not automatically exclude SCS. However, they are material risk factors that should have been addressed in an independent psychological evaluation before permanent implantation. The psychological clearance is incomplete if it did not review or discuss these records.”
The SCS Trial: Why Trial Quality Matters
Most SCS protocols require a temporary trial before permanent implantation. Trial duration varies, but many trials last several days. The goal is to determine whether stimulation produces meaningful benefit before committing to permanent implantation.
However, trial response is not a perfect predictor of long-term success. The 2023 consensus guidelines specifically note that the prognostic capabilities and deployment strategies of existing selection techniques, including SCS trialing, have been questioned. (rapm.bmj.com)
A two-day trial described as a “miracle” raises several questions:
- Was the trial long enough to assess typical activity?
- Was pain relief measured using validated scales?
- Was function measured, or only pain?
- Did the claimant reduce medication?
- Were sleep, walking, sitting, standing, and activity measured?
- Was stimulation coverage appropriate?
- Were placebo effects considered?
- Was there objective documentation of improved function?
- Was the claimant more active during the trial?
- Did psychological factors influence reporting?
- Was the trial performed during an unusually favorable short window?
A dramatic short-term response is not the same as durable benefit. Placebo response, expectation, novelty, attention, and regression to the mean can all influence trial results.
What Should Count as Trial Success?
Trial success should not be defined only by “50% pain relief.” Pain relief is relevant, but SCS is usually justified by improvement in function and quality of life.
Useful trial outcomes include:
- At least 50% pain reduction in the target neuropathic pain area
- Increased walking or standing tolerance
- Improved sitting tolerance
- Improved sleep
- Improved ability to perform daily activities
- Reduced medication use
- Reduced reliance on passive treatment
- Improved participation in rehabilitation
- Specific functional goals met
- Patient understanding of device limitations
- Absence of major adverse psychological or behavioral concerns
If the trial documentation says only “miracle” or “excellent relief,” that is insufficient for a strong medical necessity opinion.
SCS Is Not Risk-Free
Permanent SCS implantation is invasive. Complications and later procedures are not rare.
Potential complications include:
- Lead migration
- Lead fracture
- Infection
- Pain at implant site
- Loss of efficacy
- Hardware malfunction
- Need for revision surgery
- Dural puncture
- Epidural hematoma
- Neurologic injury, rare but serious
- Explantation
A comprehensive review of SCS complications describes hardware-related complications, biological complications, infection, dural puncture, epidural hematoma, and neurologic injury, emphasizing that prompt diagnosis of serious complications is important. (link.springer.com)
Long-term explantation is also a meaningful concern. A recent systematic review on SCS explantation noted that durability remains a concern and examined explantation rates and causes across the literature. (dovepress.com)
Therefore, the threshold for implantation should be higher than the threshold for a noninvasive treatment. The expected benefit must justify the risks.
Newer Waveforms and Expanding Indications
Newer SCS technologies have expanded claims for benefit, including high-frequency and burst stimulation. Some newer systems may be used for broader chronic pain indications, including nonsurgical refractory back pain in selected settings. However, medical-legal reviewers should be careful to distinguish regulatory approval, emerging evidence, guideline support, payer criteria, and case-specific appropriateness.
A 2025 systematic review of SCS guidelines and consensus statements concluded that existing guidelines strongly emphasize evidence-based practice, patient selection, and perioperative management, but noted gaps including long-term data on new waveforms, emerging indications, psychological evaluations, and holistic outcomes. (experts.arizona.edu)
This is important. Expanding technology does not eliminate the need for careful diagnosis and patient selection.
Assault-Related Pain and SCS
An assault can cause significant physical and psychological injury. Neck pain, back pain, PTSD, anxiety, depression, sleep disturbance, and chronic pain may follow. But SCS is not a treatment for assault-related distress. It is not a treatment for PTSD. It is not indicated merely because pain is disabling.
The expert should separate:
- Physical injuries from the assault
- Neuropathic pain diagnosis, if present
- Axial spine pain generators
- Psychological trauma
- Functional impairment
- Nonanatomic symptom reporting
- Treatment response
- Medical necessity for implantable neuromodulation
If the claimant’s primary problem is chronic axial pain with psychological comorbidity and nonanatomic intermittent symptoms, permanent SCS is difficult to justify without additional objective evidence.
Example IME Report Language
A physician expert might write:
“Spinal cord stimulation is generally considered for selected chronic neuropathic pain conditions, including persistent radicular pain after spine surgery, CRPS, painful diabetic neuropathy, and other well-defined refractory neuropathic pain states. The records in this case do not establish a consistent neuropathic pain diagnosis. The described radiating symptoms are intermittent and nonanatomic, and they are not supported by objective neurologic deficit, electrodiagnostic abnormality, or imaging-confirmed nerve compression.”
For psychological screening:
“The psychological clearance is incomplete because it does not address the documented history of PTSD, anxiety, depression, prior therapy, and discharge for nonattendance. These factors are material to SCS candidacy and should be evaluated by an independent psychologist using appropriate psychometric testing before permanent implantation is considered.”
For trial adequacy:
“The two-day SCS trial reportedly produced dramatic pain relief. However, the record does not document durable functional improvement, medication reduction, validated neuropathic pain assessment, or activity-based outcome measures. A short trial response alone does not establish medical necessity for permanent implantation.”
For medical necessity:
“Based on the available records and examination, permanent SCS implantation is not medically necessary because the claimant lacks a well-defined neuropathic pain indication, has unresolved psychological risk factors, and has insufficient objective documentation of trial-related functional benefit.”
How This Applies in Medicolegal Reporting
For physician experts, SCS reviews should be structured. A strong report should address:
- Diagnosis: What pain syndrome is being treated?
- Neuropathic basis: Is neuropathic pain objectively supported?
- Conservative care: What treatments were tried and with what outcomes?
- Psychological screening: Was it independent, complete, and informed by records?
- Trial details: Duration, pain relief, function, medication use, complications.
- Functional goals: What permanent implant is expected to improve.
- Risk-benefit analysis: Complications, revision, explantation, alternatives.
- Causation: Whether the need for SCS is related to the event in question.
- Guideline criteria: Whether accepted criteria are met.
- Alternative explanations: Axial pain, somatic symptoms, PTSD, deconditioning, nonanatomic symptoms.
The report should not reject SCS simply because the expert dislikes the procedure. It should reject or support SCS based on diagnosis, evidence, and patient selection.
Practical Implications for Attorneys, Adjusters, and Physician Experts
For attorneys and claims professionals, important questions include:
- What exact diagnosis justifies SCS?
- Is the pain neuropathic?
- Are symptoms anatomically consistent?
- Are EMG, MRI, and exam findings concordant?
- Has CRPS been diagnosed using accepted criteria?
- Is there failed back surgery syndrome or persistent spinal pain after surgery?
- Is there objective radiculopathy?
- Was psychological screening independent?
- Did the psychological evaluator review prior mental health records?
- Was psychometric testing performed?
- Was substance use screened?
- How long was the trial?
- Was benefit documented by function or only pain?
- Were medications reduced?
- What are the complication, revision, and explant risks?
- Are there less invasive alternatives?
For physician experts, the central question is not whether the claimant felt better for two days. The central question is whether the patient meets accepted criteria for permanent implantation.
Conclusion
Spinal cord stimulation can be appropriate for carefully selected patients with chronic neuropathic pain, CRPS, failed back surgery syndrome, painful diabetic neuropathy, and other refractory neuropathic pain conditions. But permanent implantation is not justified merely because a claimant has severe neck and low back pain, equivocal injections, psychological distress, or a dramatic short trial response.
In an IME setting, a two-day “miracle” trial should be scrutinized if the claimant lacks objective neuropathic pain findings, has intermittent nonanatomic symptoms, has unresolved PTSD/anxiety/depression, and received psychological clearance that failed to address prior noncompliance with therapy.
The central principle is clear: spinal cord stimulation requires a valid indication, objective diagnostic support, adequate psychological screening, meaningful functional improvement, and careful risk-benefit analysis. Pain severity alone is not enough.
References
- Shanthanna H, Eldabe S, Provenzano DA, et al. Evidence-based consensus guidelines on patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain. Regional Anesthesia & Pain Medicine. 2023;48:273-287. (rapm.bmj.com)
- Deer TR, et al. Spinal cord stimulation guidelines and consensus statements: systematic review. Neuromodulation. 2025. (pubmed.ncbi.nlm.nih.gov)
- Schmidt College of Medicine / University of Arizona. Spinal Cord Stimulation Guidelines and Consensus Statements: Systematic Review. 2025. (experts.arizona.edu)
- Sivanesan E, et al. Complications of spinal cord stimulators: a comprehensive review article. Current Pain and Headache Reports. 2023. (link.springer.com)
- Spinal Cord Stimulation Explantation and Chronic Pain: A Systematic Review and Technology Recommendations. Journal of Pain Research. 2025. (dovepress.com)
- Gheith R, Wortmann M, Najjar M, et al. Real-world outcomes of spinal cord stimulation: trial-to-implant ratio, long-term efficacy, and explantation risk factors. Journal of Pain Research. 2025. (pmc.ncbi.nlm.nih.gov)