Chapter 10: Pain Medicine 2026

Published: 24/04/2026

10.9 Neuromodulation for chronic pain management

Dr Harry Soar, Dr Ashish Gulve

Why do this Quality Improvement Project

Neuromodulation represents an exciting and rapidly evolving field within pain medicine, offering transformative outcomes for patients with chronic pain conditions previously considered intractable. With robust clinical evidence demonstrating significant pain reduction, improved quality of life, and reduced healthcare utilisation, neuromodulation techniques are recognised as key therapies for carefully selected patients.1–4

The expanding evidence base shows strong efficacy, with many patients achieving significant pain reduction and substantial functional improvements. As the field advances with innovative technologies, there is a tremendous opportunity to provide meaningful relief to patients. Healthcare systems, hospitals, teams and clinicians have a responsibility to enable the equitable, safe and effective delivery of these treatments utilising quality improvement methodology.

Quality improvement in neuromodulation services enhances patient outcomes, supports reduction in complications and adverse events, promotes cost-effectiveness and resource utilisation, aiming for improved patient satisfaction and engagement. It helps in standardisation and best practice adoption, continuous audit and registry participation, and benchmarking against national and international standards. It is a regulatory requirement for funding and service accreditation and supports training and workforce development in this field.

Background

The evidence supporting neuromodulation continues to strengthen, with landmark studies demonstrating superior outcomes compared to conventional medical management and repeat surgery. Despite the strong evidence of benefit for a range of neuromodulation therapies, the implementation and access to these effective treatments remains inconsistent across the UK.

The field of neuromodulation is undergoing rapid advancements, driven by cutting-edge technologies and widened therapeutic applications. Current techniques encompass spinal cord stimulation (SCS), dorsal root ganglion stimulation, peripheral nerve stimulation (PNS), multifidus muscle stimulation, deep brain stimulation (DBS), and intrathecal drug delivery systems (IDDS). These evidence-based therapies offer hope for patients with chronic pain, providing substantial pain relief and functional restoration when conventional treatments have reached their limits.

Best Practice

Best practice in neuromodulation requires:

  • Adherence to NICE TA159 guidelines
  • Comprehensive multidisciplinary assessment including psychological evaluation
  • Appropriate neuromodulation technique selection based on pain type, location and patient factors
  • Appropriate selection of implanted hardware taking into consideration unique features and patient’s healthcare needs as well as cost-effectiveness
  • Suitable follow-up for device optimisation, programming, and medication reduction
  • On-call system for management of specialist issues arising out-of-hours
  • Robust data collection practices utilising the National Neuromodulation Registry (NNR)
  • Clear pathways for device salvage therapy and revision procedures

 

Suggested Data to Collect

NNR Completion

  • Every patient having a neuromodulation device implanted should have a complete dataset entered onto the National Neuromodulation Registry.6  These data can then be utilised to support improvement initiatives.

    NNR can provide organisation-level and physician-level data, benchmarked against national outcome data on pain relief, improvement in function as measured by PROMIS-29 questionnaire and change in the quality of life measured by EQ5D-5L as well as explant rates.

Infection Rates

  • Continuous monitoring of the rates of device infection according to neuromodulation technique (e.g. SCS, PNS, IDDS).7,8,9

Explant Rates

  • Record the number of explanted devices and categorise according to reason for explant.

Medication Reduction

  • Record the % of patients with ≥30% morphine equivalent reduction post implantation maintained at 24 months.
  • Reduction in anti-neuropathic medications such as gabapentinoids, tricyclic antidepressants and SNRIs post-implantation.

Appropriate referrals

  • Survey data of primary care clinicians and secondary care referrers on their awareness of neuromodulation therapies and indications.

Real Life Example project utilising QI methods

A neuromodulation centre identified poor NNR (Neuromodulation National Registry) completion rates as a key quality improvement opportunity. Initial audit revealed only 35% of patients had complete NNR data entry, limiting the ability to demonstrate outcomes and contribute to national evidence.

The QI project used the “Model for Improvement” methodology with Plan-Do-Study-Act (PDSA) cycles:

  • Plan: Undertake a multidisciplinary process mapping exercise to enable implementing, or reviewing a current, systematic NNR data collection processes and improve completion rates to >90%
  • Do: Introduce dedicated registry coordinator role, automated reminder systems, and standardised data collection templates integrated into clinical workflows.
  • Study: Monitor monthly NNR completion rates, data quality scores, and time to data entry
  • Act: Refine data collection processes, provide additional staff training, and establish sustainable long-term systems

Results showed dramatic improvement in NNR completion rates (35% to 92%), enhanced data quality, and reduced time from procedure to registry entry (average 45 days to 12 days). The improved registry participation strengthened the department's ability to demonstrate excellent clinical outcomes, support research activities, and contribute to national benchmarking initiatives.

References

1. Helm S, Shirsat N, Calodney A, et al. Peripheral Nerve Stimulation for Chronic Pain: A Systematic Review of Effectiveness and Safety. Pain Ther 2021; 10: 985–1002 

2. Gilligan C, Volschenk W, Russo M, et al. Five-Year Longitudinal Follow-Up of Restorative Neurostimulation Shows Durability of Effectiveness in Patients With Refractory Chronic Low Back Pain Associated With Multifidus Muscle Dysfunction. Neuromodulation: Technology at the Neural Interface 2024; 27: 930–43 

3. Huygen FJPM, Soulanis K, Rtveladze K, Kamra S, Schlueter M. Spinal Cord Stimulation vs Medical Management for Chronic Back and Leg Pain. JAMA Netw Open 2024; 7: e2444608 

4. Martin SC, Baranidharan G, Thomson S, et al. Spinal Cord Stimulation Improves Quality of Life for Patients With Chronic Pain—Data From the UK and Ireland National Neuromodulation Registry. Neuromodulation: Technology at the Neural Interface 2024; 27: 1406–18 

5. NICE. TA159: Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin [Internet]. https://www.nice.org.uk/guidance/ta159. 2008 [cited 2025 Jun 23]. Available from: https://www.nice.org.uk/guidance/ta159

6. NSUKI. National Neuromodulation Registry [Internet]. [cited 2025 Jun 23]. Available from: https://www.nsuki.com/nnr

7. British Pain Society. Spinal cord stimulation for the management of pain: recommendations for best clinical practice [Internet]. [cited 2025 Jun 23]. Available from: https://www.britishpainsociety.org/static/uploads/resources/files/book_…

8. Faculty of Pain Medicine. Guidance on Competencies for Intrathecal Drug Delivery [Internet]. [cited 2025 Jun 23]. Available from: https://fpm.ac.uk/sites/fpm/files/documents/2024-05/Intrathecal%20guida…

9. Faculty of Pain Medicine. Guidance on Competencies for Spinal Cord Stimulation [Internet]. [cited 2025 Jun 23]. Available from: https://fpm.ac.uk/sites/fpm/files/documents/2020-07/SCS%20competencies%…