Sustained Pain Relief Without Implant: Exploring Durability of Spinal Cord Stimulation Trials

Spinal cord stimulation (SCS) has become an increasingly utilized option for patients with chronic neuropathic pain, particularly those with refractory symptoms following spine surgery. While its role as a bridge to permanent implantation is well established, emerging observations suggest that even short-term neuromodulation trials may have longer-lasting therapeutic effects than previously appreciated in select patients.

A case presented at the 2026 Association of Academic Physiatrists (AAP) National Meeting highlighted a patient with post-laminectomy syndrome who experienced sustained pain relief and functional improvement nearly one year after an SCS trial—despite not proceeding to permanent implantation. This atypical response raises important questions about the durability of neuromodulatory effects and the potential for longer-term neuroplastic changes following short-duration stimulation.

In a follow-up conversation with NeurologyLive^®, Alexander Shustorovich, DO, interventional pain medicine physician at Hackensack Meridian JFK Johnson Rehabilitation Institute, discussed the clinical features of the case, mechanistic considerations underlying prolonged analgesia, and practical guidance for neurologists on referral timing and integration of SCS into multidisciplinary pain care.

NeurologyLive: Regarding your presentation, provide an overview of the case and the key clinical takeaways for neurologists

Alexander Shustorovich, DO: The patient presented with refractory low back and radicular pain with a history of post-laminectomy pain syndrome (failed back surgery). She had failed all conservative treatment including PT, medications, epidural steroid injections, and ongoing yoga. The uniqueness of this case is that after SCS trial, she did not progress to SCS implant. She had a delayed follow up almost 1 year later noting significant pain relief and functional improvement that was sustained. No changes in the rest of her pain care was made. She stopped taking her medications and was maintaining function with yoga and healthful eating.

The key clinical takeaway for neurologists is that SCS represents a highly effective, durable intervention for appropriately selected patients with chronic neuropathic pain refractory to conservative management. The trial period serves as both a therapeutic predictor and patient education opportunity, with trial success strongly correlating with long-term outcomes.

For neurologists who may refer patients for neuromodulation, what were the defining clinical features that made this patient an appropriate candidate for spinal cord stimulation?

The patient had a qualifying diagnosis of failed back surgery/post-laminectomy pain syndrome that remained refractory to conservative treatment including PT, medications, epidural steroid injections, and ongoing home exercise program. She had a favorable psychological evaluation for the SCS trial. SCS represents a highly effective, durable intervention for appropriately selected patients with chronic neuropathic pain refractory to conservative management. The trial period serves as both a therapeutic predictor and patient education opportunity, with trial success strongly correlating with long-term outcomes

What stood out about the durability of response in this case, and how does it compare with what we typically expect from trial-to-implant outcomes?

Based on current evidence, successful SCS trials demonstrate exceptional durability, with 72-90% of patients achieving successful trial outcomes and 65-80% maintaining clinically meaningful pain relief at long-term follow-up. The trial-to-permanent implant conversion rate typically ranges from 72-94%, with the highest rates observed in well-selected patients with predominant neuropathic pain. After SCS trial, there can be durability for a few days after lead pull due to the neuromodulatory effects over the trial period, however, lasting benefit is not reported in the current literature.

From a mechanistic standpoint, how might spinal cord stimulation contribute to sustained analgesia in chronic neuropathic pain?

SCS produces sustained analgesia through multilevel neuromodulation involving spinal segmental inhibition, supraspinal descending modulation, and cortical reorganization. These complementary mechanisms explain why pain relief persists long after the initial trial period.

Spinal mechanisms: Beyond simple gate control theory, SCS promotes sustained release of inhibitory neurotransmitters including GABA, adenosine, and endocannabinoids in the dorsal horn. Animal studies demonstrate that GABA receptor blockade reverses SCS analgesia, confirming its critical role. Additionally, SCS reduces spinal microglial activation by decreasing colony-stimulating factor 1 (CSF1) levels, attenuating neuroinflammatory contributions to chronic pain.¹⁴

Supraspinal modulation: SCS activates descending inhibitory pathways from the rostral ventromedial medulla and periaqueductal gray, increasing norepenephrine, dopamine, and serotonin release in the spinal cord. This descending modulation provides tonic inhibition of nociceptive transmission that persists between stimulation sessions.

Cortical reorganization: Functional neuroimaging reveals that SCS differentially activates frontal gyrus, limbic structures, and thalamic regions involved in pain perception and emotional processing. Closed-loop systems that maintain consistent neural activation demonstrate superior engagement of these circuits, potentially explaining their enhanced durability. The sustained improvements in mood disturbance and quality of life observed in long-term studies suggest that SCS modulates the affective-motivational dimension of pain, not merely sensory intensity.

Neuroplasticity: The durability of SCS effects likely involves activity-dependent neuroplastic changes in pain processing circuits. Burst stimulation patterns that mimic endogenous neuronal firing may be particularly effective at inducing these adaptive changes, explaining why benefits persist and even improve over time in some patients.

Based on this case, what guidance would you offer neurologists regarding timing of referral and integration of spinal cord stimulation into comprehensive pain management?

Refer patients early after at least 6 months of conservative treatment with refractory chronic neuropathic pain to hopefully prevent central sensitization and wind-up of the patients' nervous system. Early intervention, including early consideration for SCS can provide patients significant pain relief, functional improvement, and improved quality of life.

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