[New paradigms in spinal cord stimulation (SCS): technology and clinical evidence]

Spinal cord stimulation (SCS) has developed from the classical tonic, paresthesia-based stimulation to an increasingly differentiated, personalized neuromodulation. New paradigms such as high-frequency SCS, burst stimulation, differential target multiplexed (DTM™) SCS, and closed-loops expand the therapeutic spectrum, particularly in chronic neuropathic back and leg pain. Today, paresthesia-free forms of stimulation, adaptive control systems, physiological feedback parameters, and data-based programming are at the forefront technologically. Clinical studies show appreciable pain reduction for many of these procedures, improved quality of life, and partial advantages compared with conventional SCS. At the same time, questions regarding long-term efficacy, patient selection, mechanisms of action, and cost-benefit relationship remain unanswered. Overall, the new SCS paradigms mark a shift away from the symptom-oriented electrostimulation to an individualized, neurophysiology-based pain therapy.

The aim of this review article is to present the current technological developments in SCS and critically assess the clinical evidence.

There follows a narrative literature review on conventional tonic SCS, 10-kHz high-frequency SCS, burst SCS, FAST™ (fast-acting subperception therapy), differential target multiplexed (DTM™) SCS, closed-loop SCS/electrically evoked compound action potentials(ECAPs)-guided SCS, as well as related precision tools such as dorsal root ganglion (DRG) stimulation.

New SCS paradigms enable paresthesia-free or adaptive therapy and address the limitations of conventional SCS, in particular in axial back pain, position-dependent stimulation, and patient-specific variability. The strongest evidence is available for 10-kHz SCS, ECAP-guided closed-loop-SCS, burst-SCS, DTM SCS, as well as DRG stimulation in selected neuropathic pain syndromes.

Modern SCS should not be considered as a single procedure but as a spectrum of technologically differing therapies. Strict indication criteria, multidisciplinary patient selection, and realistic evaluation of the available evidence remain crucial to clinical success.