Chronic pain represents a major global health burden with profound individual, social, and economic consequences. Epidemiologic data suggest that approximately one in five adults worldwide experience chronic pain, and nearly one in ten live with high-impact chronic pain that substantially limits daily functioning and quality of life.^[1] In the United States alone, chronic pain affects over 50 million adults and contributes to annual productivity losses exceeding 290 billion USD.^[1] The condition is frequently associated with psychological comorbidities, including depression and suicidal ideation, emphasizing the need for effective and sustainable treatment options.^[2]

Conventional medical management (CMM)—including pharmacologic therapy, physical rehabilitation, and behavioral interventions—remains the first-line approach. However, a significant proportion of patients continue to experience refractory pain despite these measures.^[3] For this subgroup, spinal cord stimulation (SCS) has emerged as a well-established neuromodulation therapy. Initially introduced in the 1960s, SCS was developed on the foundation of the gate control theory of pain modulation. The therapy involves the epidural implantation of electrodes that deliver controlled electrical impulses to the dorsal columns, thereby modulating nociceptive transmission.^[4]

Over the past decade, SCS technology has undergone substantial evolution. While early systems relied on conventional “tonic” stimulation at 40–80 Hz, recent advances have introduced alternative stimulation paradigms such as high-frequency (10 kHz), burst stimulation, closed-loop feedback, and differential target multiplexed (DTM) waveforms.^[4] These modalities have demonstrated improved pain relief, greater patient satisfaction, and reduced paresthesia compared with traditional tonic stimulation in multiple randomized clinical trials.^[5]

Nevertheless, despite growing evidence supporting SCS, systematic reviews and meta-analyses have questioned its long-term efficacy, citing heterogeneity in study design and limited inclusion of contemporary stimulation modalities. Furthermore, the variability in patient selection, waveform optimization, and long-term explantation rates remains insufficiently characterized.

To address these gaps, we present our 10-year institutional experience with SCS in patients with chronic pain, including persistent spinal pain syndrome (PSPS), complex regional pain syndrome (CRPS), and painful diabetic polyneuropathy (PDPN).

This study aims to evaluate the efficacy, safety, and durability of SCS across multiple stimulation modalities, while exploring predictors of clinical success and device retention. Our results are discussed in the context of emerging evidence and evolving neuromodulation technologies.

This 10-year institutional analysis confirms the sustained efficacy and safety of spinal cord stimulation (SCS) in the management of refractory chronic pain.^[6] Across a heterogeneous patient population—including persistent spinal pain syndrome, complex regional pain syndrome, and painful diabetic polyneuropathy—SCS provided substantial and durable reductions in pain intensity, improved functional status, enhanced quality of life, and significantly reduced opioid consumption. These findings align with the growing body of evidence supporting SCS as a cornerstone therapy for patients who fail conventional medical management. Earlier generations of SCS, predominantly based on tonic stimulation, demonstrated meaningful but sometimes inconsistent results when compared with medical therapy.^[7] The advent of novel stimulation paradigms, such as burst, high-frequency, and closed-loop feedback, has redefined expectations regarding the depth and durability of analgesia. The present findings corroborate recent randomized trials and meta-analyses showing superior efficacy of advanced waveforms over traditional tonic stimulation, particularly in maintaining long-term pain control and patient satisfaction.^[8] Previous systematic reviews, including the Cochrane analyses by O’Connell and Traeger, questioned the magnitude and consistency of SCS benefit due to heterogeneity in study design and limited inclusion of contemporary waveforms.^[9] In contrast, this decade-long dataset reflects real-world use of modern systems and supports their clinical relevance. The higher responder rates and lower explantation rates observed with high-frequency and closed-loop stimulation suggest that waveform optimization plays a critical role in sustaining therapeutic benefit and mitigating habituation over time.

Device explantation remains an important indicator of long-term therapy durability. The overall explantation rate of 8% in this study compares favorably with previously reported ranges (5%–38%), with loss of efficacy accounting for most removals. The probability of explantation was inversely related to the use of advanced waveforms, implying improved long-term stability and neuroadaptive modulation.^[10] The observed decline in explantation rates over the decade may also reflect advances in patient selection, surgical technique, and post-implant programming strategies. Habituation to stimulation remains one of the most discussed causes of declining efficacy, and experimental data suggest that the use of variable or multi-waveform delivery may mitigate this effect by preventing neural adaptation.^[11] Reports indicating that alternating or combining stimulation modes—such as cyclic switching between high-frequency and burst patterns—can restore lost efficacy support this hypothesis and highlight the need for flexible programming platforms capable of accommodating individualized waveform combinations.^[11]

Psychological comorbidities such as depression, anxiety, and catastrophizing have been consistently associated with poorer SCS outcomes and higher explantation rates.^[12] Although psychiatric screening is standard before implantation, its predictive validity remains imperfect. The present data underscore the importance of multidisciplinary pain management, including psychological optimization and behavioral support, to maximize response and minimize attrition. Integration of real-time emotional or behavioral monitoring into closed-loop systems may represent the next frontier of patient-centered neuromodulation. The clinical effectiveness observed in this cohort also has significant implications for healthcare systems and payers. While SCS implantation is associated with substantial upfront costs, these are often offset by reductions in analgesic use, hospitalizations, and productivity loss. Long-term durability and low explantation rates are therefore critical not only for patient outcomes but also for the economic sustainability of neuromodulation therapies.^[13] As device technologies continue to evolve, careful cost-benefit analyses will remain essential to ensure equitable access to advanced pain management.

This study has several limitations. Its retrospective design introduces potential selection bias, and follow-up data were not available for all patients beyond three years. Although the cohort was large and diverse, it represents a single tertiary center, which may limit generalizability. Psychological and socioeconomic variables were not systematically quantified, and stimulation programming strategies evolved over time, introducing potential confounding. Nevertheless, the consistency of results across etiologies and modalities reinforces the validity of these findings and supports the role of SCS as a durable and effective intervention for refractory chronic pain.