Ethics, economics, and patient-centered outcomes of spinal cord stimulation

With the widespread integration of spinal cord stimulation (SCS) into clinical practice, understanding its ethical, economic, and patient-centered implications has become increasingly important. This review critically examines recent evidence across these domains to illuminate challenges and opportunities for advancing transparent, ethical, patient-centered, and value-based neuromodulation practice.

Recent analyses reveal persistent challenges with bias, conflicts of interest, and selective outcome reporting in neuromodulation research. Studies demonstrate significant disparities in access to SCS across racial and socioeconomic groups and highlight new ethical considerations associated with artificial intelligence-enabled and informed treatment in neuromodulation. Contemporary randomized trials support clinically meaningful improvements in pain, functionality, psychological outcomes, and other patient-centered outcomes, although durability remains inconsistent because of the potential for therapy habituation or adverse events. Despite high initial upfront costs, evaluations of SCS cost-effectiveness across healthcare systems generally favor SCS over conventional medical management when assessed over multiyear periods, with differential economic benefits observed based on the type of waveform and type of national healthcare system.

While current evidence supports the clinical and long-term economic benefits of SCS in defined clinical contexts and indications, gaps in research transparency, equitable access to care, economic considerations, and durability of effectiveness persist.