A Care-Level-Stratified Algorithm for Neuromodulation in Persistent Spinal Pain Syndrome Type 2: Critical Appraisal of Contemporary Evidence Adapted to Latin American Health Systems

@article{quintero2026carelevelstratified,
  title = {{A Care-Level-Stratified Algorithm for Neuromodulation in Persistent Spinal Pain Syndrome Type 2: Critical Appraisal of Contemporary Evidence Adapted to Latin American Health Systems}},
  author = {Juan J Valero Quintero and Héctor Aceituno and Francisco Rico-Fernández and José Vásconez-Fabre and Juan Lopéz-Urdaneta and Eugenio Cerezo-Prado and José Villamediana-Rodríguez and Jennifer Vela-Poveda and Luisana Maldonado-De Santiago and Anthuan Hazkour},
  journal = {Cureus},
  year = {2026},
  month = sep,
  doi = {10.7759/cureus.117149},
  url = {https://europepmc.org/article/PMC/PMC13718374},
  note = {CC BY},
}

TY  - JOUR
TI  - A Care-Level-Stratified Algorithm for Neuromodulation in Persistent Spinal Pain Syndrome Type 2: Critical Appraisal of Contemporary Evidence Adapted to Latin American Health Systems
AU  - Juan J Valero Quintero
AU  - Héctor Aceituno
AU  - Francisco Rico-Fernández
AU  - José Vásconez-Fabre
AU  - Juan Lopéz-Urdaneta
AU  - Eugenio Cerezo-Prado
AU  - José Villamediana-Rodríguez
AU  - Jennifer Vela-Poveda
AU  - Luisana Maldonado-De Santiago
AU  - Anthuan Hazkour
PY  - 2026
DA  - 2026/09/29
JO  - Cureus
DO  - 10.7759/cureus.117149
UR  - https://europepmc.org/article/PMC/PMC13718374
AB  - Persistent spinal pain syndrome type 2 (PSPS-T2), the mechanism-based successor to failed back surgery syndrome (FBSS) and a recognized International Classification of Diseases 11th Revision (ICD-11) entity, affects 10%-40% of patients after spinal surgery and is among the most refractory conditions in pain medicine. The past decade has produced a technological expansion in neuromodulation, with next-generation modalities (10-kHz high-frequency stimulation (HF10; Nevro Corp., Redwood City, CA), burst stimulation (Abbott, Plano, TX), differential target multiplexed (DTM) stimulation (Medtronic, Minneapolis, MN), evoked compound action potential-controlled closed-loop stimulation (ECAP-CL; Saluda Medical, Artarmon, Australia), dorsal root ganglion stimulation (DRG-S; Abbott, Plano, TX), and restorative neurostimulation (ReActiv8; Mainstay Medical, Dublin, Ireland)) each supported by randomized controlled trials (RCTs). We conducted a narrative review designed to meet the Scale for the Assessment of Narrative Review Articles (SANRA) quality criteria, searching five databases (January 2020 to April 2026) to critically appraise this evidence, including negative results and methodological controversies, and to propose a mechanism-directed treatment algorithm stratified by level of care and adapted to the heterogeneous resource landscape of Latin American health systems. Pivotal trials report responder rates of approximately 74%-78% at 12-36 months, with superiority over conventional stimulation; however, these estimates derive from trials that differ in population, comparator, and follow-up, and several enrolled populations only partially overlapping with PSPS-T2 (e.g., complex regional pain syndrome or non-surgical mechanical low back pain). The single independent, placebo-controlled crossover trial (of burst stimulation) found no benefit on its primary disability outcome, underscoring the field's near-total reliance on manufacturer-sponsored studies. On this basis, we propose a three-tier algorithm (primary, secondary, and tertiary care) that rests on Oxford Centre for Evidence-Based Medicine (OCEBM) level 1-2 evidence for individual modality efficacy and on expert consensus (OCEBM level 5) for the stratification itself. The algorithm is intended as a pragmatic, resource-sensitive decision-support scaffold requiring local adaptation and prospective regional validation. Equitable access to neuromodulation across Latin America remains a first-order ethical and health-policy priority.
SN  - 2168-8184
ER  -