For Physicians
Who to refer, and when
Neuromodulation outcomes are largely determined before the first lead is placed. This page sets out the selection reasoning so referrals arrive at the right time, with the right documentation, for the right phenotype.
What You'll Learn
Approx. 10 min min read- Identify the pain phenotypes with the strongest response signal
- Match presentation to target — dorsal column, DRG or peripheral nerve
- Recognise the modifiable factors that should be addressed before referral
- Know what documentation makes authorisation straightforward
The selection problem
Technology has advanced faster than selection has.
Waveforms, closed-loop control and lead design have all improved substantially over the last decade. Selection criteria, by contrast, have changed relatively little, and remain the largest single determinant of whether a given patient benefits. A well-selected patient on a decade-old platform generally does better than a poorly-selected patient on the newest one.
The practical implication for referral is that the useful question is not whether a patient has failed enough treatment to justify a trial. It is whether their pain has the characteristics that neuromodulation actually addresses.
Phenotype First
Four questions that sort most referrals
Is the pain neuropathic?
Burning, electric, lancinating quality; allodynia or hyperalgesia; a distribution that follows neural rather than musculoskeletal anatomy. This remains the strongest predictor of response.
Is it focal or diffuse?
Focal pain confined to a single dermatome or a distal limb region is DRG territory. Broad multi-dermatomal or axial pain is dorsal column territory. Getting this wrong is a common reason for a failed trial.
How long has it been present?
Response rates decline with pain duration. Referral after two years does better than referral after ten. 'Last resort' framing systematically delays referral past the point of best benefit.
Is there a correctable structural lesion?
Progressive neurological deficit, significant instability or a surgically correctable compressive lesion should be addressed before neuromodulation is considered, not after.
Target Selection
Matching presentation to target
The initial branch point, before any question of manufacturer or waveform.
| Presentation | Usual target | Rationale |
|---|---|---|
| Persistent spinal pain syndrome, back and leg | Dorsal column (SCS) | Broad coverage across multiple dermatomes; the population with the deepest evidence base |
| Non-surgical refractory back pain | Dorsal column (SCS) | Specific FDA indications now exist; consider before further imaging-led escalation |
| Focal CRPS of a foot, knee or hand | Dorsal root ganglion | Stable, position-independent focal coverage of a single dermatome — the ACCURATE population |
| Groin, pelvic or post-herniorrhaphy pain | Dorsal root ganglion | Regions that are notoriously difficult to cover reliably from the dorsal columns |
| Painful diabetic neuropathy of the feet | Dorsal column (SCS) | Supported by randomised data; bilateral distal coverage is achievable |
| Post-amputation or post-surgical mononeuropathy | Peripheral nerve | A single identifiable nerve; a temporary 60-day system may be sufficient |
| Mechanical low back pain with multifidus dysfunction | Medial branch (restorative) | A different mechanism entirely — restoring motor control rather than masking pain signalling |
Most failed trials are not device failures. They are target failures — the right therapy aimed at the wrong structure.
Before Referral
Modifiable factors worth addressing first
None of these are absolute contraindications. All of them measurably reduce the odds of a good outcome if left unaddressed.
Infection risk
Active smoking and poorly controlled diabetes
Both raise surgical site infection risk and impair healing. HbA1c and smoking status should be documented; smoking cessation support before referral is genuinely worthwhile.
Psychiatric
Untreated depression, anxiety or catastrophising
These blunt response to any pain therapy. Identifying and treating them improves outcomes; they are not grounds for exclusion, but they should not be discovered at the psychological evaluation.
Pharmacology
High-dose opioid therapy
Very high morphine-equivalent doses are associated with poorer trial outcomes. A tapering plan initiated before referral improves both the trial result and the interpretation of it.
Anticoagulation
Antithrombotic management
Epidural haematoma is the rare complication with the worst consequences. Document the agent, indication and prescriber so a management plan can be agreed in advance.
Expectations
The expectation of cure
A patient expecting elimination of pain will report a successful trial as a failure. Framing the goal as meaningful relief plus functional gain before referral changes how the trial is experienced.
Sleep
Untreated sleep disorder
Sleep fragmentation amplifies pain and confounds trial interpretation. Screening for obstructive sleep apnoea is worth doing in this population.
Referral Packet
What to send with the referral
A complete packet typically removes several weeks from the authorisation timeline.
- Recent advanced imaging of the relevant region, with the images not only the report
- Operative reports for any prior spine surgery, with levels and dates
- Documented conservative care with dates and outcomesPhysical therapy, medication trials, injections, ablation — payers require a defined period of documented failure.
- Current medication list including anticoagulants and morphine-equivalent dose
- Relevant comorbidities: HbA1c, smoking status, immunosuppression, prior infections
- Any prior psychological evaluation
- A clear statement of the pain distribution and qualityThis is what determines target selection, and it is the item most often missing.
Refer urgently, not routinely, for these
Progressive motor deficit, new bowel or bladder dysfunction, saddle anaesthesia, suspected infection, or suspected malignancy require urgent surgical or oncological assessment rather than a neuromodulation referral. Neuromodulation treats pain; it does not treat the lesion causing it.
Common Questions
Common referral questions
Planning a referral
Discuss the referral with a qualified neuromodulation clinician in your region. Record-transfer and consultation procedures vary by practice and location.