Spinal cord stimulation

1. Introduction

Version followed: NICE technology appraisal TA159 (October 2008, on NICE's static list since 2014); British Pain Society consensus Spinal cord stimulation for the management of pain: recommendations for best clinical practice (April 2009); the PiPiN Good practice guidelines for psychological assessment and intervention for pain neuromodulation services (2024, endorsed February and May 2024, described by its authors as pending stakeholder consultation); US regulatory position from FDA documents and reporting as cited. Status checked October 2026.

Spinal cord stimulation (SCS) is an implanted neuromodulation treatment for chronic pain, mainly neuropathic pain. Leads are placed in the epidural space and connected to an implanted pulse generator; the person controls the device with a handheld programmer. The implanting team (pain medicine consultant, spinal or neurosurgeon, specialist nurses, physiotherapist, psychologist) selects, trials, implants and programmes it. The psychotherapist does not deliver SCS and never advises on device settings. [source: BPS 2009; CUH patient information 2025]

Core idea of change, as the sources frame it: SCS is a pain management tool, not a cure. It will probably relieve only part of a person's pain and works only within a wider approach that includes self-management, pacing and psychological care. The psychological task is to help the person reach a realistic, informed decision, prepare for the trial and the implant, keep using self-management, and live well with ongoing pain afterwards. [source: BPS 2009; PiPiN 2024; CUH 2025]

This guide is written for a psychotherapist working alongside an implanting team, or seeing a client who is being considered for, trialling, or living with an SCS. Ketamine, psychedelic and other drug-assisted therapies are covered elsewhere (Domain VII). [synthesis]

Regulatory and guideline status (as of October 2026, per the sources named)

England and Wales (NICE TA159, published 22 October 2008). Recommended as a treatment option for adults with chronic neuropathic pain that has lasted at least 6 months despite appropriate conventional medical management, of at least 50 mm on a 0 to 100 mm visual analogue scale, and who have had a successful trial of stimulation as part of assessment by a specialist team experienced in SCS assessment and management, including ongoing monitoring and support. Assessment should be adapted for people with disabilities or communication difficulties. SCS for chronic pain of ischaemic origin is not recommended except in research; people already using it may continue until they and their specialist decide to stop. Where systems are equally suitable, the least costly should be chosen. NICE made one minor wording change in February 2014. The January 2014 review decision moved TA159 to the static list because new neuropathic-pain evidence supported the existing recommendation and ischaemic-pain evidence was not robust enough to change it. TA159 itself does not mention psychological assessment. [source: NICE TA159 patient summary; NICE TA159 update information; NICE TA159 GE decision paper 2014]
United States (FDA). SCS systems are approved through premarket approval (PMA). For example, Medtronic's labelling (PMA P840001/S469, approved 24 January 2022) indicates the system as an aid in managing chronic, intractable pain of the trunk and/or limbs, including failed back syndrome, radiculopathy, post-laminectomy pain and complex regional pain syndrome, and now diabetic peripheral neuropathy of the lower extremities. It is approved for patients aged 18 and over, and diathermy is listed as a contraindication. Nevro's Senza system received PMA for painful diabetic neuropathy in July 2021. [source: FDA SSED P840001/S469; Practical Neurology 2021] Device class is [uncertain]: PMA normally means Class III.
FDA letter to health care providers (3 September 2020). FDA reported that it had reviewed 107,728 medical device reports (MDRs) over four years, including 428 deaths in patients implanted between 2005 and 2020. Nearly a third of deaths with timing data occurred within 30 days of implant, and many of these patients had comorbidities. The most common patient problem code was inadequate pain relief. FDA said some unexpected-effect reports might mean implants were done without a trial. It reminded providers to follow labelling and run an adequate trial before permanent implant, discuss risks with patients, and give each patient an individual follow-up plan. FDA noted that MDRs often cannot establish that a device caused an event. [source: MedTech Dive report of the FDA letter, 4 September 2020] [uncertain] Later FDA communications are not drawn on here.
US coverage (Medicare). Noridian's prior-authorisation checklist (updated 7 October 2025) for Medicare LCD L35136 requires multidisciplinary team evaluation before implant, a psychological examination, documentation that the person has no active substance-misuse problem, documented education and an extensive risk–benefit discussion, failed earlier treatments, and, for permanent implant, a successful trial as defined in the LCD. Commercial insurers' criteria differ. [source: Noridian checklist 2025; ACC review 2016 on Aetna and Cigna policies]
Other jurisdictions. Australia and New Zealand guidance (ANZCA, the ANZ Neurostimulation Working Group, and ACC NZ) lists psychological exclusion or caution criteria (see section 4). [source: ACC review 2016] [uncertain] EMA/CE-marking, MHRA and BfArM status is not covered here.
Ages. NICE TA159 covers adults. The BPS says children should be assessed by a specialist paediatric pain team. The FDA labelling opened is for patients 18 and over. [source: NICE TA159; BPS 2009; FDA SSED P840001/S469]

2. Framework

The pathway below combines the sources. Local pathways vary, so ask the team for theirs. [source: BPS 2009; PiPiN 2024; CUH 2025] [synthesis for the ordering]

Referral and MDT assessment. Goal: to establish whether the pain type suits SCS and to assess physical, psychological and social functioning. The BPS says all candidates must be assessed in all three areas, and that a multidisciplinary pain team is the right setting. Psychology: one direct assessment, usually up to about an hour (CUH), in person, by phone or by video, held before any procedure including the trial (PiPiN). Family or friends may attend. Use professional interpreters, not relatives (PiPiN). Moving on: the MDT agrees that the person is suitable for a trial (PiPiN "green"), or needs preparation first ("amber"), or that SCS is not appropriate ("red", mostly medical criteria).
Prehabilitation (where indicated). Goal: to address treatable factors such as untreated distress, high catastrophising, unrealistic or passive expectations, phobias, trauma symptoms and reliance on medication or alcohol, and to build self-management. Format: written self-help material, structured individual therapy (e.g. CBT), an SCS-specific pain management programme, or joint psychology and physiotherapy sessions. The BPS says a pain management programme should preferably be completed before SCS where appropriate. Session numbers are not fixed in the sources. Moving on: MDT review with repeat outcome measures at the end of prehabilitation (PiPiN).
Informed consent and decision. Goal: the person understands the benefits, risks, limits, need for long-term care and likelihood of further surgery, and has had time to weigh them (BPS). The psychologist can support understanding using teach-back and written information (PiPiN).
Trial stimulation. Goal: to test pain relief, function and change in medication use through a temporary external system before a permanent implant (BPS). The same team should do the trial and the implant (BPS). FDA labelling and the 2020 letter stress an adequate trial. The BPS also notes that a trial's predictive value is uncertain and that implanting without a trial is accepted in some UK practice. Moving on: the team judges success against its criteria (NICE TA159 and Medicare require a successful trial). Repeat measures at the end of the trial (PiPiN).
Permanent implant and recovery. Carried out by the surgical team. Follow written post-operative advice.
Long-term follow-up. SCS needs ongoing surveillance and support: reprogramming, medication review, physical rehabilitation and psychological support from the implant team (BPS), with repeat measures at regular intervals (PiPiN). Battery replacement, revisions and transfer of care if the person moves are planned in. The PiPiN 2020 survey found that only 9 of 25 UK centres offered routine psychological follow-up after implant, so outside therapists often fill this gap. [source: PiPiN 2024]

3. Guiding principles

Assessment is formulation, not a test to pass. Explain this to the client and write your reports as needs-and-support formulations. [source: PiPiN 2024]
Psychological testing does not predict outcome. The BPS says qualitative psychological testing does not predict outcome, and the PiPiN guidelines call the predictor evidence limited and inconsistent. Use measures to plan care, not to gatekeep. [source: BPS 2009; PiPiN 2024]
Comorbidity is not automatic exclusion. Physical or psychological comorbidity alone does not rule out SCS, and depression may be a treatment target rather than a bar. Identify what is treatable. [source: BPS 2009; ACC 2016 citing Sparkes et al.]
SCS is one part of self-management. Seeing SCS as a cure is a stated reason for a person being "not yet ready". Keep pacing and coping skills going throughout. [source: CUH 2025; BPS 2009]
Partial relief is the likely outcome. Prepare clients that SCS will probably help only part of their pain, especially when pain is mixed. [source: BPS 2009]
Language matters. Avoid "last resort" framing, which can distress people and raise the stakes. [source: PiPiN 2024]
Stay in your lane on the device. Never comment on settings, programming or whether the device should be switched off. Route every device concern to the implant team. [source: BPS 2009 on team-held reprogramming] [synthesis]
Risk is assessed now and for the future. This includes how the person would cope if the trial or the device fails. [source: PiPiN 2024]
Share information within the team, transparently. Psychology letters are discussed with the patient before they go to the GP, and risk is shared when someone may be at risk of harm. [source: CUH 2025]
Long-term care. Psychological support continues beyond the trial and implant, because pain usually remains. [source: PiPiN 2024; BPS 2009]
Equity and access. Adapt assessment for disability or communication difficulties, and use professional interpreters. [source: NICE TA159; PiPiN 2024]
Name the evidence honestly. Describe NICE and FDA positions as published, and avoid overselling or dismissing SCS. [synthesis]

4. Intervention inventory

Part A describes how the treating team delivers SCS, at a descriptive level only. Part B covers the psychotherapist's own interventions. No stimulation parameters, lead positions or programming details are given anywhere in this guide.

A1. How SCS is delivered (team-delivered; for orientation)

Purpose: to let you explain the pathway accurately and spot gaps in a client's understanding.
Steps (as sources describe them): The team takes an up-to-date history and examination for the specific indication. The BPS lists good indications as neuropathic limb pain after spinal surgery, CRPS, peripheral neuropathic pain, pain from peripheral vascular disease, refractory angina and some brachial plexus injuries. Pre-operative work-up includes MRSA screening, and patient and surgeon agree where the generator will sit. A temporary trial with an external device usually comes first, then a permanent implant if the trial succeeds. The team provides programming, medication review, physical rehabilitation and psychological support over the long term, and plans for battery replacement (BPS gives a common range of 2 to 8 years; rechargeable systems exist) and revisions. Primary care receives written advice. [source: BPS 2009]
Who delivers: a multidisciplinary pain team with access to a competent spinal or neurosurgeon. The BPS expects implanters to maintain competence and says no consultant should run SCS without colleague support. [source: BPS 2009]
Watch for: a client who has been offered an implant with no MDT or psychological assessment, no trial, or no follow-up plan. Encourage them to ask the team about these points; the FDA 2020 letter and NICE TA159 both stress the trial and ongoing support. [source: MedTech Dive 2020; NICE TA159] [synthesis]

A2. Risks and adverse events as official sources state them

Purpose: to support informed consent conversations and to recognise problems worth passing on.
Content: The BPS says major complications are rare, minor complications common and mostly technical, with lead migration the most frequent. Neurological injury is rare and may be reversible if recognised and treated promptly. Other risks include dural puncture, infection (serious, usually needing removal of the whole system), lead breakage, disconnection or revision, and persistent backache after open surgical placement. [source: BPS 2009] Medtronic's FDA labelling lists allergic or immune reactions, infection, erosion or migration of components, CSF leak, loss of pain relief, haematoma or seroma (which can cause paralysis), persistent pain at the implant site, epidural haemorrhage or paralysis, chest-wall stimulation, uncomfortable jolting changes in stimulation, delayed spinal cord compression from reactive tissue (weeks to years after implant) and stimulation-related bowel or bladder symptoms. It also describes higher perioperative risk in people with diabetes. [source: FDA SSED P840001/S469] FDA's 2020 MDR review found inadequate pain relief to be the most frequently coded patient problem and charging problems the most common device problem. [source: MedTech Dive 2020]
Watch for: loss of relief can be a device or programming issue, not only a psychological one, so always route it to the team. [synthesis]

A3. Everyday safety information the team gives

Purpose: to reinforce what the team says, without adding to it.
Content: While stimulation is on, people should not drive, climb or operate dangerous machinery, because unexpected stimulation effects can distract or cause movement effects. They should carry device information, expect airport security alarms, and tell every clinician about the implant. MRI is restricted, needs specialist input and depends on the device's labelling. Shortwave, microwave and therapeutic-ultrasound diathermy are hazardous and are a labelled contraindication. A cardiac demand pacemaker is a relative contraindication. [source: BPS 2009; FDA SSED P840001/S469]
Example language (illustrative): "Your team's leaflet covers driving and scans. If you're not sure what applies to your device, that's a question for the implant nurse, not for me."
Watch for: clients who plan therapies that involve heat or electrical equipment (e.g. other physical therapies). Prompt them to check with the implant team first. [synthesis]

B1. Pre-implant psychological assessment

Purpose: to build a formulation that informs the MDT decision and the support plan. The BPS recommends assessment by a psychologist to explore beliefs, expectations and understanding. PiPiN sets out the content in detail. In the US, Medicare requires a psychological examination, and some insurers require a mental health provider's evaluation. [source: BPS 2009; PiPiN 2024; Noridian 2025; ACC 2016]
Who: in UK services this is a clinical psychologist within the MDT (PiPiN role specification: doctorate in clinical psychology or equivalent). A psychotherapist outside the team should not provide the formal suitability assessment unless commissioned and competent to do so. Instead, offer collateral information with the client's consent. [source: PiPiN 2024] [synthesis]
Steps:
1. Schedule the assessment before any procedure, including the trial, ideally after the client has seen the nurse or consultant, so you can check what they retained. [source: PiPiN 2024]
2. Explain the purpose: building a shared picture and support plan, not a pass-or-fail test. Agree what will be shared with the team, and have a clear route for clients who decline. [source: PiPiN 2024; CUH 2025]
3. Cover the following: the pain history and its impact on thoughts, feelings and daily activities; pain beliefs and behaviours; self-management, coping and social support; hopes and expectations of SCS; past pain treatments and psychological help; current and past mental health; stressful and significant emotional life events; substance and medication reliance; sleep; risk (to self, to others and from others); and capacity to consent. [source: PiPiN 2024; CUH 2025; ACC 2016]
4. Use validated, repeatable measures across the BPS pain management programme outcome domains (pain, physical activity, emotional wellbeing, quality of life, goal attainment). Instruments named in published reviews include HADS, BDI, PCS, PSEQ, MMPI-2-RF, PAI, DASS, SF-36 and ODI. Use licensed instruments under their terms; items are not reproduced here. Repeat measures at the start and end of prehabilitation, at the end of the trial, and at follow-up. [source: PiPiN 2024; ACC 2016]
5. Note the factors linked to poorer outcomes in some studies, so you can target them rather than exclude on them: depression (the most consistent link with disability outcomes), low self-efficacy, high catastrophising, poor sleep, emotional dysfunction and demoralisation, and litigation. [source: ACC 2016; PiPiN 2024]
Example language (illustrative): "This isn't an exam. It helps the team and you work out what support would give the stimulator the best chance of being useful in your life."
Watch for: fear that being honest about mood or substance use will "fail" the client. Name this directly. [synthesis]

B2. Formulation and MDT contribution

Purpose: to give the team a biopsychosocial formulation that says whether SCS is appropriate or could cause biopsychosocial harm, and what support is needed. [source: PiPiN 2024]
Steps: Summarise needs against PiPiN's traffic-light categories. Red (contraindications) are mostly medical, plus chronically high opioid use or illicit drug use without engagement in reduction plans. Amber (cautions) include untreated distress, suicidal ideation, health anxiety, high physiological arousal, high catastrophising without engagement, litigation, poor self-care, social isolation, unrealistic or passive expectations, limited understanding, and failure to engage. Green means stable or managed mental health, realistic expectations, clear understanding and active self-management. For each amber item, propose a specific support plan. Compare with criteria elsewhere, such as ANZCA and the ANZ Neurostimulation Working Group (active psychosis, major untreated mood disorder, active or untreated substance misuse, unstable social circumstances) and North et al. (unresolved major psychiatric comorbidity or secondary gain). Discuss your letter with the client before it goes to the GP. [source: PiPiN 2024; ACC 2016; CUH 2025]
Example language (illustrative): "I'll tell the team what support would help you get the most out of this, and I'll show you what I write before it goes." [synthesis]
Watch for: hierarchy and time pressure in MDTs that sideline psychological concerns. PiPiN names these as common problems and recommends regular MDT meetings and reflective practice. [source: PiPiN 2024]

B3. Psychoeducation and expectation work

Purpose: to move expectations from "cure" to "tool within self-management". [source: BPS 2009; CUH 2025]
Steps: (1) Ask what the client imagines life will look like 6 and 12 months after implant. (2) Using the team's information, explain that relief is often partial, that some pain may not respond, that long-term follow-up is needed and further surgery is likely, and that SCS sits alongside pacing and coping. (3) Turn hopes into concrete, function-based goals (activities, roles, sleep) rather than a pain score alone. (4) Cover pain neurophysiology at a lay level. (5) Point to support groups, which the BPS calls a useful resource. [source: BPS 2009; PiPiN 2024] [synthesis for steps 1 and 3]
Example language (illustrative): "If the stimulator took the edge off, what's the first thing you'd want to get back to? Let's make that the measure, not just the number."
Watch for: all-or-nothing hopes, and a rapid drop in self-management in anticipation of the device. Progress shows when goals are stated in terms of function and the client can describe partial relief as worthwhile. [synthesis]

B4. Supporting informed consent and shared decision-making

Purpose: to help the client weigh benefits and burdens over time, without pressure. The BPS requires written, understandable information, indication-specific evidence, unit-specific complication and outcome data, and time to decide. [source: BPS 2009; PiPiN 2024]
Steps: (1) Use teach-back: ask the client to explain in their own words what the trial and the implant involve, what the main risks are, and what follow-up means. (2) List the questions they still have for the team, such as the unit's own outcome data, MRI implications for their device, or what happens if the trial fails. (3) Explore values: what matters most, and what they would regret. (4) Respect a decision not to proceed. (5) Check capacity concerns with the team. [source: PiPiN 2024 for teach-back and capacity; BPS 2009 for information content] [synthesis for steps 3 and 4]
Example language (illustrative): "Can you walk me through what you understood from the nurse about the trial? Then we'll note anything to ask them."
Watch for: decisions driven by desperation or by "last resort" framing. Slow things down and name it. [source: PiPiN 2024 on language] [synthesis]

B5. Prehabilitation and chronic-pain psychological treatment alongside SCS

Purpose: to treat distress and build self-management before and alongside SCS. The BPS says individual therapy such as CBT may be offered before SCS when distress is significant, and that a pain management programme should preferably be completed first where appropriate. Sequential cognitive pain-management training plus SCS outperformed either alone in one study (Molloy et al. 2006, as cited). PiPiN also cites McCracken et al. (2015) on prehabilitation with psychosocial components. [source: BPS 2009; ACC 2016; PiPiN 2024]
Steps (topics PiPiN lists for prehabilitation): pain neurophysiology; fear-avoidance and self-efficacy; activity pacing (the BPS asks for pacing to be reviewed both before and after the procedure); mood management; reliance on medication or alcohol (explore motivation, and pass any medication question to the prescriber); needle and other phobias (graded preparation with the team's knowledge); trauma symptoms (stabilise and treat, with trauma-informed care, before surgery where possible); and crisis planning. Deliver these through evidence-based chronic-pain approaches (e.g. CBT for pain); the specific programme content is your choice and is [synthesis]. Repeat outcome measures at the end of prehabilitation and report them to the MDT. [source: PiPiN 2024; BPS 2009]
Example language (illustrative): "Pacing now isn't wasted effort. It's what helps you make use of whatever relief the stimulator gives."
Watch for: treating therapy as a hoop before surgery. Frame it as useful whether or not SCS goes ahead. [synthesis]

B6. Support during the trial phase

Purpose: to help the client evaluate the trial honestly on pain, function and medication, and to prepare for either outcome. [source: BPS 2009]
Steps: (1) Before the trial, agree two or three functional tasks and a simple daily diary the client will use. Check that this fits the team's own trial assessment, and do not replace it. (2) Plan activity during the trial with the team's restrictions in mind, avoiding overactivity on good days. (3) Prepare for disappointment: what will they tell themselves, and who will support them? (4) After the trial, debrief the experience and pass relevant observations to the team with consent. [synthesis, built on BPS 2009 trial aims and PiPiN 2024 repeat measures]
Example language (illustrative): "Whatever the trial shows, it's information, not a verdict on you."
Watch for: pressure to report success (from hope, cost or family), and acute low mood or hopelessness after a failed trial. Review risk (B9). [synthesis; PiPiN 2024 on future risk if the device fails]

B7. Post-implant integration and long-term psychological care

Purpose: to support rehabilitation, re-engagement and adjustment, because chronic pain usually persists. The BPS describes CBT aimed at reducing functional interference as an option alongside SCS, and continuing psychological support from the implant team. [source: BPS 2009; PiPiN 2024]
Steps: (1) Review pacing to prevent boom-and-bust after relief. (2) Rebuild valued activities and roles step by step. (3) Address changes in identity, relationships and work. (4) Work with expectation gaps as they arise. (5) Coordinate with the implant team's follow-up, and involve mental health teams when concurrent conditions are present, as the BPS advises. [source: BPS 2009] [synthesis for steps 1 to 4]
Example language (illustrative): "You've got more room now. Let's spend it carefully so the gains stick."
Watch for: progress shown by functional gains and stable or improving mood. PiPiN notes that mood may improve after successful surgery. [source: PiPiN 2024]

B8. Monitoring and passing on adverse effects and warning signs

Purpose: you may be the clinician who sees the client most often. Your role is to notice problems and route them, not to interpret or manage them. [synthesis]
Steps: (1) At each session, briefly check pain, function, sleep, mood and any device concerns. (2) Ask the client to contact the implant team promptly about loss of relief, uncomfortable or jolting stimulation, persistent pain at the implant site, or charging problems. (3) Tell them to seek urgent medical help for new weakness, numbness, loss of bladder or bowel control, or signs of infection (fever, wound redness or discharge). These map onto the labelled risks of infection, haematoma, compression and paralysis, and the BPS notes that neurological injury may be reversible if recognised promptly. (4) With consent, write to the team about any mood change, new distress, substance-use change or sleep deterioration. (5) In the US, adverse events can be reported to FDA MedWatch [synthesis; verify with the FDA MedWatch page]. [source: FDA SSED P840001/S469; BPS 2009; MedTech Dive 2020] [synthesis for the routing]
Example language (illustrative): "That sounds like something the implant team needs to hear today. Shall we call them together now?"
Watch for: psychologising a physical change ("it's just stress"). Route first, then explore. [synthesis]

B9. Mood, risk and crisis planning

Purpose: chronic pain carries elevated suicide risk. PiPiN asks for assessment of current and future risk, including the response if the device fails, and lists crisis planning as a prehabilitation topic. It notes cluster headache as particularly high-risk. [source: PiPiN 2024]
Steps: (1) Use standard suicide and self-harm risk assessment at baseline, after the trial, at implant, at any loss of relief, and around revision, explant or battery issues. (2) Co-write a safety plan: warning signs (including device failure or a refused implant), coping steps, supports, crisis lines and the implant team's contact details. (3) Lethal-means counselling: safe storage or limited supply of medicines, agreed with the prescriber. (4) Share risk with the team and GP in line with your confidentiality agreement; CUH notes that risk overrides routine confidentiality. [source: PiPiN 2024; CUH 2025] [synthesis for the plan's structure]
Example language (illustrative): "Let's plan now for how you'd get through it if the device stopped helping, so that moment doesn't catch you alone."
Watch for: hopelessness tied to SCS as the "final option". [source: PiPiN 2024 on language] [synthesis]

B10. Adherence and ambivalence conversations

Purpose: to explore ambivalence about proceeding, attending follow-up, charging or using the device, or doing self-management, without ever advising a device or medicine change. [synthesis]
Steps: Use reflective, motivational-style listening. Summarise the costs and benefits the client names. If they are thinking of switching off, asking for explant, or changing medicines, encourage them to raise it with the team or prescriber, and offer to help them prepare questions. [synthesis]
Example language (illustrative): "Part of you is fed up with it, part of you isn't ready to give it up. What would you want the team to know?"
Watch for: silent disengagement (missed follow-up, device left uncharged) and decisions made in a crisis. Working if the client raises doubts with the team rather than acting alone [synthesis].

B11. Collaborative care, referral and transitions

Purpose: to keep care joined up across the long course of SCS. [source: BPS 2009]
Steps: Suggest medical review for unexplained physical change, loss of relief, medication concerns or sleep collapse. Suggest a mental health team referral for severe or complex comorbidity. Agree consent for two-way information sharing. Support transfer of care if the client moves away, and be ready for battery replacement, revision or explant episodes, which may bring grief or anger. [source: BPS 2009 on long-term care and transfer] [synthesis]
Ending: End therapy when goals are met and a relapse plan exists, including how to re-access psychology through the implant team. [synthesis]
Example language (illustrative): "If you move, let's make sure your new pain team gets a summary, so you're not starting from scratch."
Watch for: gaps in care at transfer or after team changes, and clients falling between pain and mental-health services. Working if each professional knows who does what [synthesis].

5. Handling problems

"Just give me the stimulator" (assessment seen as a hurdle). Restate that the assessment is a formulation, not a test. Name the fear of being refused. Link prehabilitation to getting the most out of SCS. [source: PiPiN 2024] [synthesis]
Cure expectations that don't shift. Use the team's data on partial relief and set function-based goals. If expectations stay unrealistic, document this as an amber factor with a plan rather than a refusal, and let the MDT decide. [source: CUH 2025; PiPiN 2024; BPS 2009]
Untreated depression, anxiety or trauma symptoms. Treat them first or in parallel. Depression is a treatment target, not an automatic bar. Agree timing with the MDT. [source: ACC 2016; BPS 2009; PiPiN 2024]
Active substance misuse or high opioid reliance. Explore motivation and link the client to substance services and their prescriber. Medicare and several guidelines treat active substance misuse as a barrier, and PiPiN treats high opioid or illicit use without engagement in a reduction plan as red. Never advise on medicine changes. [source: Noridian 2025; PiPiN 2024; ACC 2016]
Litigation or compensation processes. Acknowledge the stress without judging. Note that PiPiN lists litigation as amber and associated with poorer outcomes. Focus on goals within the client's control. [source: PiPiN 2024]
Needle, surgical or medical phobia. Offer graded preparation and coping skills in coordination with the team, and seek consent for any exposure work. [source: PiPiN 2024 lists phobias] [synthesis for method]
Overwhelm from information. Break the information into parts, use teach-back and the written leaflets, invite a support person, and schedule a second conversation. [source: PiPiN 2024; CUH 2025] [synthesis]
Failed trial. Validate the loss, review risk, return to pain-management goals, and help the client ask the team about alternatives. [source: PiPiN 2024 on future risk] [synthesis]
Loss of relief after implant, or new symptoms. Route to the team first, urgently for neurological or infection signs (B8). Then work with the emotional impact. Do not assume a psychological cause. [source: BPS 2009; FDA SSED P840001/S469] [synthesis]
Boom-and-bust after successful relief. Revisit pacing, which the BPS asks to be reviewed after the procedure. [source: BPS 2009]
Non-attendance at follow-up, or not charging or using the device. Explore barriers non-judgementally and support the client to discuss them with the team. Never suggest switching the device on or off yourself. [synthesis]
Rupture: "You think it's all in my head." Repair by validating that the pain is real, explaining the biopsychosocial rationale the BPS uses (physical, psychological and social assessment for everyone), and owning any misattunement. [source: BPS 2009] [synthesis]
Disagreement with the MDT decision. Help the client understand the reasons and options, including a second opinion through their doctor. Do not take sides on medical suitability, which belongs with medical colleagues. [source: PiPiN 2024] [synthesis]
Information-sharing tensions. Agree in advance what goes to the team and GP, and explain the risk exception. [source: CUH 2025]
A client offered SCS with no psychological input or trial, or pressured by device representatives. Encourage questions about the trial, the team's outcome data and follow-up. FDA's 2020 letter stressed an adequate trial and individual follow-up plans. [source: MedTech Dive 2020; BPS 2009] [synthesis]
Children and young people. Refer to a specialist paediatric pain team, as the BPS advises. [source: BPS 2009]
Cognitive impairment. This is not an exclusion if there is a capable caregiver and adequate social support. Involve the caregiver in planning and safety information. [source: BPS 2009]

Sources

Sources:

Further reading (not drawn on; cited only as these sources report them) [uncertain]:

The FDA Letter to Health Care Providers, "Conduct a Trial Stimulation Period Before Implanting a Spinal Cord Stimulator" (September 2020). The FDA page failed to load; its content is taken from the MedTech Dive report.
Molloy et al. (2006), McCracken et al. (2015), Sparkes et al. (2010), Block et al. (2017), North et al. (2007), and Deer et al. (2014, Neuromodulation, Neuromodulation Appropriateness Consensus Committee), all cited via the ACC review, the PiPiN guidelines or the ASRA page.
Medicare LCD L35136 full text; EMA/CE, MHRA and BfArM device status.

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