Management of Chronic Low Back Pain

Rationale for Determination

The American Society of Anesthesiologists (ASA) guidelines acknowledge that subcutaneous peripheral nerve stimulation can provide pain relief for peripheral nerve injuries, but do not specifically endorse its use for chronic low back pain or postlaminectomy syndrome 1
The 2025 clinical practice guideline for non-cancer chronic spine pain issued strong recommendations against interventional procedures for chronic spine pain, including nerve stimulation techniques, as they lack sufficient evidence of effectiveness 2
While spinal cord stimulation may be considered for persistent radicular pain that has not responded to other therapies, peripheral nerve field stimulation has not received the same level of endorsement in major guidelines 3, 4
Evidence-based guidelines recommend a multimodal approach to chronic low back pain management, including non-pharmacologic therapies such as exercise therapy, cognitive-behavioral therapy, and interdisciplinary rehabilitation 5, 6
Pharmacologic options including acetaminophen, NSAIDs, and carefully monitored use of other medications are also recommended 7

For patients with persistent radicular pain who have not responded to conservative therapies, spinal cord stimulation is an established option 4, 1
Adding a second neuromodulation device when the patient already has a functioning spinal cord stimulator introduces additional risks without clear evidence of incremental benefit 1

The patient's pain flare-up occurred when she ran out of pain medication, suggesting that medication management rather than an additional implanted device might be more appropriate 8

The American College of Physicians and American Pain Society recommend nonpharmacologic therapies, including exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation for chronic low back pain management 9, 10
The American College of Physicians and American Pain Society suggest intensive interdisciplinary rehabilitation for patients not responding to initial therapies 9, 11
The American College of Physicians recommends against the use of transcutaneous electrical nerve stimulation (TENS) for chronic low back pain, citing insufficient evidence 12, 10

The American College of Physicians and American Pain Society recommend optimized pharmacologic management, including a trial of duloxetine, for neuropathic pain component 9, 12
The American Society of Anesthesiologists acknowledges the potential benefit of cognitive-behavioral therapy for chronic pain management 13, 9, 10
The American College of Physicians recommends structured exercise therapy with individual tailoring, supervision, stretching, and strengthening for chronic low back pain management 9, 10