INTRODUCTION:Neuropathic pain is a debilitating and often treatment-resistant condition with significant personal and societal burden. As conventional pharmacologic options frequently fall short, there is a growing need for targeted, durable solutions. AREAS COVERED:Dorsal root ganglion (DRG) stimulation has emerged as a promising neuromodulation technique offering anatomically targeted therapy for focal neuropathic syndromes. This review examines the anatomical underpinnings, mechanisms of action, clinical evidence, technological innovations, procedural techniques, and safety considerations associated with DRG stimulation, while highlighting current challenges and future directions in expanding its role within modern pain management. Literature was searched in PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane CENTRAL from 2010 through 2024. This narrative review synthesizes the anatomic rationale, mechanistic hypotheses, clinical evidence by indication, procedural technique, safety considerations, and emerging technological developments in DRG stimulation. EXPERT OPINION:DRG stimulation represents a significant advancement in interventional pain medicine. With its dermatomal targeting and clinical efficacy in anatomically discrete pain syndromes, it can be considered as a option in appropriately selected patients. Continued innovation, real-world outcome data, and improved access will be key to realizing its full therapeutic potential.
BACKGROUND CONTEXT:Mechanical chronic low back pain (CLBP) associated with lumbar multifidus muscle dysfunction is a major cause of long-term disability. Available nonoperative and interventional treatments often provide limited and transient benefit. Restorative neurostimulation is intended to activate the lumbar multifidus to restore neuromuscular control and address the underlying pathophysiology of mechanical CLBP. PURPOSE:The purpose of this extension of the original randomized controlled trial was to track outcomes in a crossover group for the subsequent treatment year. Participants in the original treatment group were also followed for an additional year, allowing long-term clinical follow-up. STUDY DESIGN/SETTING:RESTORE is a postmarket, multicenter, open-label randomized controlled trial performed at 25 clinical sites in the United States. PATIENT SAMPLE:A total of 203 participants were randomized 1:1 to restorative neurostimulation or optimal medical management. At the completion of the randomized phase, 80/96 (83%) eligible control participants elected to cross over to restorative neurostimulation treatment. These participants and the original treatment group were followed for an additional year. OUTCOME MEASURES:Oswestry Disability Index (ODI), back pain (Numerical Rating Scale [NRS]), and health-related quality of life (EuroQol 5-Dimension 5-Level [EQ-5D-5L]) were assessed at 18 and 24 months postrandomization. Outcomes included responder rates based on minimal clinically important change thresholds, pain remission, composite responder definitions, work ability, subject global impression of change, opioid use, and number needed to treat. METHODS:This prespecified delayed-start crossover analysis included a nonrandomized comparison of outcomes between early and delayed-start treatment groups, with within-group analyses serving as the primary basis for inference regarding crossover efficacy. Longitudinal outcomes for the treatment group were analyzed using mixed models for repeated measures. Crossover group outcomes were analyzed using completer analyses. RESULTS:The treatment group improvements were sustained through 24 months, with mean changes from baseline of -24.6±17.1 in ODI, -4.2±2.4 in NRS, and +0.189±0.163 in EQ-5D-5L (all p<.001). After crossover, participants demonstrated significant improvements after 1 year of active therapy, with mean changes from baseline of -21.1±14.8 in ODI, -3.8±2.2 in NRS, and +0.191±0.144 in EQ-5D-5L (all p<.001), comparable in magnitude to those observed in the treatment group at the same timepoint. At 12 months, responder rates in the treatment group were 70% for ODI ≥15 point improvement, 53% for ≥50% NRS reduction, 52% for NRS remission, and 72% for the composite endpoint, compared with 17%, 6%, 6%, and 12% in the control group, respectively; after crossover, corresponding responder rates at 12 months of active therapy were 64%, 61%, 60%, and 73%, consistent in magnitude with those observed in the treatment group at the equivalent timepoint of therapy. Corresponding numbers needed to treat ranged from 1.7 to 2.2 and remained similarly low when the crossover outcomes were compared with control. CONCLUSIONS:These findings reinforce the role of restorative neurostimulation as an effective therapeutic option for patients with multifidus dysfunction-related CLBP who have exhausted conservative care and suggest that earlier intervention may reduce prolonged disability and loss of quality of life.
INTRODUCTION:Sacroiliac joint (SIJ) disease is a common source of low back and buttock pain and is often linked to prior lumbar fusion, pregnancy, trauma, or repetitive loading. Because conservative measures such as injections and radiofrequency can be short-lived, interest has shifted toward minimally invasive SIJ fusion. AREAS COVERED:This review summarizes SIJ diagnosis, workup, and patient selection for fusion, and focuses on posterior allograft fixation, including procedural steps, postoperative care, outcomes, complications, and limitations. EXPERT OPINION/COMMENTARY:Modern SIJ fusion first gained momentum with lateral transfixing implants. Additional developments included the method of lateral oblique placement, with a theory of being higher in the sacrum to avoid the neural structures and arterial supply to the gluteal muscles. Posterior intra-articular allograft fixation (LinQ; PainTEQ) may reduce exposure to major vessels and nerves, can be performed in office or outpatient settings, and may be easier to adopt because access and imaging resemble SIJ injection. Available studies suggest meaningful pain and functional improvement. We view posterior intra-articular allograft fixation as appealing for osteoporosis, where transfixing implants are less desirable, and we recommend registry data plus randomized trials to refine selection and comparative effectiveness.
Craniofacial and corneal neuropathic pain are disabling conditions characterized by persistent pain that is frequently refractory to conventional pharmacologic and interventional therapies. These disorders arise from complex interactions between peripheral nerve injury, neuroinflammation, and maladaptive central sensitization within trigeminal pathways, features that span neuropathic and nociplastic pain mechanisms as defined by the International Association for the Study of Pain, thus emphasizing the need for mechanism-based, patient-stratified treatment strategies. Regenerative medicine offers a paradigm shift from symptom suppression toward structural nerve repair and functional restoration. This narrative review examines the pathophysiological mechanisms underlying craniofacial and corneal neuropathic pain and critically evaluates emerging regenerative therapies, including autologous biologics (autologous serum tears and platelet-rich plasma), mesenchymal stem cells and their derivatives, exosomes and extracellular vesicles, and neurotrophic peptides. Particular emphasis is placed on corneal neuropathic pain as a translational model, given the cornea’s dense sensory innervation and the ability to non-invasively quantify nerve regeneration using in vivo confocal microscopy as an objective biomarker of treatment response. Clinical evidence across regenerative modalities varies by indication: cenegermin has demonstrated robust efficacy and regulatory approval for neurotrophic keratitis, while platelet-rich plasma shows growing evidence in temporomandibular disorders, myofascial pain, and occipital neuralgia. Cell-based and cell-free therapies demonstrate strong preclinical promise but remain limited by heterogeneous protocols and a paucity of large-scale randomized trials. Key barriers to translation include regulatory uncertainty, lack of standardized outcome measures, and workforce and implementation challenges. Advancing regenerative therapies for craniofacial and corneal neuropathic pain will require rigorous clinical trials, biomarker-driven patient selection, and multidisciplinary collaboration. Sex as a biological variable remains underexplored across all regenerative modalities and represents a priority for future research.
Traditional spinal cord stimulation (SCS) trials often span several days, increasing the risks of infection, equipment failure, lead migration, and complications for patients on anticoagulant/antiplatelet therapy. Optimal SCS trial durations have not been established, although shorter durations are recommended for patients at high risk. Evoked compound action potential (ECAP)-controlled closed-loop (CL) SCS provides objective, real-time confirmation of neural activation at therapeutic dose levels, enabling immediate assessment of SCS treatment response. We evaluated the long-term response up to 12 months for patients undergoing ECAP-controlled CL-SCS trial evaluations where leads were removed on the same day of the trial procedure (day 0). Fifteen patients who met predefined day 0 responder criteria underwent a day 0 trial using ECAP-controlled CL-SCS at a single center in the ECAP Study. Outcomes and ECAP-based neural metrics were assessed at day 0, 3 months, and 12 months. All 15 (100.0
