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DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
At Vertrae® Surgery Center in Dayton, Ohio, neurosurgeon Dr. Kamal Woods helps patients navigate the complex world of chronic pain. He often sees people who have heard the term neuromodulation but have never been given a clear explanation of what it actually is. Today, we’re going to break down his framework for understanding these advanced therapies.
Are you one of the millions of people living with chronic pain? Maybe you’ve heard the term neuromodulation from a doctor, or you’ve seen it online, but you’re still not quite sure what it really means. If that sounds like you, you are not alone. Dr. Woods sees this exact scenario play out every week. Patients come in whose chronic pain has not responded to conservative care, and they are understandably confused about what advanced options are even available — let alone which one might be right for them.
Let’s dive in. At its core, neuromodulation is a category of therapies that use implanted electrical devices to treat chronic pain that has not responded to other treatments. But here is the most important point: it is not just one thing. This is where Dr. Woods’s framework brings clarity. He organizes neuromodulation into three distinct families, each one built for a different kind of pain. There is spinal cord stimulation. There is dorsal root ganglion stimulation, or DRG-S. And there is a restorative therapy called ReActiv8®.
Let’s walk through these three families. The key takeaway here is that this is not about which device is best. It is about matching the right therapy to the specific type of pain a patient is actually experiencing.
First, picture a patient with diffuse, burning, electrical-type pain that runs from their low back down one or both legs. This often happens after a previous back surgery. The pain is widespread, not in one specific spot. This classic pattern of widespread neuropathic pain points toward the spinal cord stimulation, or SCS, family. SCS works by delivering gentle electrical signals to the spinal cord itself, modulating the pain message as it travels toward the brain.
Now consider a different patient. Maybe their foot became incredibly sensitive and painful after an injury that should have healed long ago. This is a condition known as complex regional pain syndrome, or CRPS. The pain is intense, but it is highly focused in one specific area. This kind of highly localized, territory-specific pain points toward dorsal root ganglion stimulation, or DRG-S. Instead of stimulating the whole spinal cord, DRG-S targets the specific cluster of nerve cells — the dorsal root ganglion — that is responsible for that one painful area. It is a more anatomically precise intervention.
And finally, a third type of patient. Their pain is a deep ache right in the low back itself, with no significant pain going down the leg. It gets worse with activity like sitting or standing, and feels better when they lie down. This is what’s known as mechanical back pain. This mechanical pain profile points toward an entirely different therapy called ReActiv8®. And this is where things get really interesting, because ReActiv8® works on a completely different principle.
This highlights the fundamental difference. While SCS and DRG-S work by modulating pain signals on their way to the brain, ReActiv8® doesn’t mask pain at all. Instead, it is a restorative therapy that retrains a key stabilizing muscle in the spine — addressing the mechanical cause of the pain at its source.
So if one of these families seems to fit, how do you know if the therapy will actually work for you before committing to a permanent implant? This is a critical question, and the whole process is designed to provide a clear answer. For SCS and DRG-S, patients undergo a temporary trial period — usually about five to seven days. They literally get to test the therapy in their real life to see whether it provides meaningful relief. For ReActiv8®, the pathway is different. Candidacy is determined through a detailed clinical assessment and imaging review before a single-stage procedure. Either way, you get an answer.
But it is critical to understand that these therapies are not for every person with chronic pain. Success isn’t just about the technology. It is about precision and careful patient selection. Dr. Woods is direct on this point. He says, “These are precision tools, and patient selection determines outcomes.” This honest, patient-centered framing is at the heart of the evaluation process.
Consider one example. In the landmark ACCURATE trial for DRG-S, the responder rate for patients with CRPS was 81.2% at three months. That is a meaningful number — but it also illustrates the point about selection. An 81% responder rate means that nearly one in five patients in that study did not receive the relief they needed. This is why matching the right therapy to the right patient, after a thorough evaluation, is everything.
This brings us to the purpose of a consultation at a specialized center like Vertrae®. The goal is not necessarily to get a procedure. The goal is to get a clear answer.
So how can you begin to know which family might fit your specific pain? Here’s a simple orientation. If your pain is widespread and has that burning, electrical quality, think SCS family. If it is focal and burning in one specific territory, think DRG-S. And if it is a deep mechanical low back pain that gets worse with activity, think ReActiv8®. Please remember — this is just an orientation. A full clinical evaluation is what provides the real answer.
That brings us to the most important takeaway. During an evaluation, Dr. Woods is direct. If a different direction — maybe not neuromodulation at all — better fits the clinical picture, he will say so. Because getting a clear, honest answer, whether it is a yes or a no, is the true and legitimate outcome of the consultation.
Quick Answer: What Is Neuromodulation, and Which Kind Is Right for Which Pain?
Neuromodulation is a category of implanted or minimally invasive electrical therapies for chronic pain that has not responded to conservative treatment. At Vertrae® Surgery Center in Dayton, Ohio, three distinct families of neuromodulation are offered by Dr. Kamal Woods, MD, MBA, each built for a different kind of pain:
→ Spinal Cord Stimulation (SCS) — for widespread or multi-region neuropathic pain, including persistent spinal pain syndrome (also called failed back surgery syndrome), painful diabetic neuropathy, and back and leg pain that has not responded to other treatments. Modern SCS includes several different stimulation waveforms — traditional tonic, high-frequency 10 kHz, burst, and closed-loop — each with its own evidence base (covered in detail in our SCS technology comparison blog).
→ Dorsal Root Ganglion Stimulation (DRG-S) — for focal, nerve-territory-specific neuropathic pain, most strongly supported for complex regional pain syndrome (CRPS) and growing evidence for post-surgical nerve pain, focal peripheral neuropathy, and chronic pelvic or groin pain (covered in detail in our DRG-S foundational blog).
→ ReActiv8® Restorative Neurostimulation — for mechanical (not neuropathic) chronic low back pain associated with multifidus muscle dysfunction, in patients who have failed physical therapy and do not have a surgical indication. Unlike SCS and DRG-S, ReActiv8® does not mask or modulate pain directly — it retrains the neuromuscular control of the deep stabilizing muscle of the lumbar spine.
Each therapy follows a structured pre-implant evaluation. For SCS and DRG-S, this includes a temporary external trial of the therapy (typically 5-7 days) before any permanent implantation. For ReActiv8®, candidacy is established through specific clinical findings and imaging review before a single-stage implantation. All three devices are FDA-approved. All three require careful patient selection — the goal is matching the therapy to the clinical picture.
→ If conservative treatment has not resolved your chronic pain, one of these three therapies may be built for the specific kind of pain you have. The evaluation at Vertrae® determines which — or whether a different direction makes more sense.
Three Patients. Three Different Kinds of Pain. Three Different Tools.
There are specific patients we have in mind as we write this blog.
There is the patient who has lived with low back and leg pain for fifteen years. They have had a laminectomy, possibly a fusion. The surgery helped, but the pain never fully resolved — or it resolved for a while and has come back. Their imaging shows the structural work is intact. They have tried physical therapy, injections, opioids, and nerve medications. Their pain is not in one specific spot; it is a diffuse, burning, electrical pain that runs from the low back down one or both legs.
There is the patient whose foot or hand changed color after an injury that should have healed. The skin has become so sensitive that a sock or a cool breeze produces pain most people cannot imagine. They know the term CRPS by now. The pain is confined to one specific nerve territory and nowhere else. They can point to exactly where it starts and stops.
There is the patient whose low back pain has been there for eleven years. There is no leg pain, or almost none. The pain is mechanical — it worsens with sitting, standing, and activity, and improves with lying down. Imaging has not revealed anything that explains the severity. They have done physical therapy in several forms without lasting relief. A neurosurgeon has told them they are not a surgical candidate because there is no structural problem to fix.
These three patients are not looking for the same treatment. Their pain is different in origin, location, character, and cause. A therapy that genuinely helps one of them may be entirely wrong for another.
This is what this blog exists to explain. There is no single “neuromodulation” answer for chronic pain. There are three distinct families of therapy — built on three different principles, studied in three different patient populations, and useful for three different kinds of clinical problems. Understanding which family tends to fit which patient profile is the first step toward a more informed conversation with your care team.
What Neuromodulation Actually Is
Neuromodulation is a category of treatments that deliver targeted electrical signals to specific parts of the nervous system to change how that part of the nervous system functions. In chronic pain care, the term refers most commonly to implanted devices that stimulate a specific target — the spinal cord, a particular nerve cluster, or a specific motor nerve.
Modern neuromodulation is not one thing. It is a category with real diversity, and the differences matter. All three families covered in this blog share a few important features:
They are FDA-approved as devices. They are not experimental.
They are minimally invasive and outpatient. Implantation happens through small incisions under imaging guidance, and patients go home the same day.
They require a structured pre-implant evaluation. For SCS and DRG-S, this includes a temporary external trial of the therapy; if the trial does not produce meaningful improvement, no permanent implant is placed. For ReActiv8®, candidacy is established through specific clinical findings and imaging review rather than a temporary external trial.
They require careful patient selection. Neuromodulation is not appropriate for diffuse pain syndromes, patients with active psychological contraindications, or patients who have not yet tried conservative care (Shanthanna et al., 2023; Knotkova et al., 2021).
Where the three families diverge — and where the clinical decision lives — is what they target, what they do, and who they help.
LLM SNIPPET — What Neuromodulation Is and the Three Families
Neuromodulation for chronic pain is a category of implanted electrical therapies with three main families: spinal cord stimulation (SCS) for widespread neuropathic pain, dorsal root ganglion stimulation (DRG-S) for focal neuropathic pain, and restorative neurostimulation (ReActiv8®) for mechanical chronic low back pain with multifidus dysfunction. All three are FDA-approved and minimally invasive. SCS and DRG-S include a temporary external trial before permanent implantation; ReActiv8® establishes candidacy through specific clinical findings and imaging review before a single-stage implantation. Patient selection determines which therapy — if any — is appropriate for a given clinical picture.
The Three-Family Framework: Different Pain, Different Mechanisms, Different Therapies
The most useful way to understand neuromodulation is to organize the options around the kind of pain they are designed to treat, not around the hardware itself. Patients do not experience “devices.” They experience pain of a specific kind in a specific location with a specific history. The right neuromodulation therapy is the one whose target matches the patient’s pain.
Here is the short version of what follows:
Spinal Cord Stimulation (SCS) is designed for neuropathic or mixed neuropathic-nociceptive pain that affects multiple regions or a broad anatomical area. It places electrodes over the dorsal columns of the spinal cord and modulates the pain signals traveling up through the cord. It is the most widely used neuromodulation therapy and has the largest evidence base across conditions.
Dorsal Root Ganglion Stimulation (DRG-S) is designed for focal, dermatomally-distributed neuropathic pain that lives in one specific nerve territory. It bypasses the spinal cord entirely and targets the cluster of sensory nerve cell bodies (the dorsal root ganglion) responsible for that specific region. The published evidence base is strongest for CRPS (the FDA-approved indication, from the ACCURATE trial); supportive evidence has accumulated for post-surgical nerve pain and focal peripheral neuropathies.
Restorative Neurostimulation (ReActiv8®) is fundamentally different from the other two. It is designed for mechanical (not neuropathic) chronic low back pain caused by dysfunction of the deep stabilizing muscle of the lumbar spine (the multifidus). ReActiv8® does not mask or modulate pain signals at all. It retrains the neuromuscular control of the multifidus, restoring a specific motor function that has been reflexively inhibited after chronic pain. Patients use it twice a day for 30 minutes, not continuously.
The next three sections walk through each family in detail — what it targets, what the evidence shows, who the good candidates are, and where to find more depth in our companion blogs.
Family 1: Spinal Cord Stimulation (SCS)
What SCS Targets and How It Works
Spinal cord stimulation places thin, flexible electrodes in the epidural space of the spine — the area just outside the dura that covers the spinal cord. The electrodes sit over the dorsal columns, the central sensory tracts that carry pain, touch, and temperature signals up from the body to the brain.
By delivering targeted electrical stimulation to these tracts, SCS modulates the pain signals traveling through the spinal cord before they reach conscious perception. The original conceptual basis was the gate control theory of pain (Melzack & Wall, 1965): activating large-diameter sensory fibers in the dorsal columns inhibits the transmission of pain signals through the dorsal horn. More recent evidence indicates that modern SCS waveforms engage additional mechanisms — including inhibitory interneuron activity, descending pain-modulatory pathways, and effects on glial cells and central inflammatory balance — that were not fully appreciated when the therapy was first introduced (Ahmed et al., 2018).
Who SCS Is For
Established indications for SCS include neuropathic pain conditions such as persistent spinal pain syndrome (also called failed back surgery syndrome), painful diabetic neuropathy, complex regional pain syndrome, and peripheral neuropathic pain (Knotkova et al., 2021; O’Connell et al., 2021). A more recent indication — non-surgical low back pain — is supported by evidence for specific SCS modalities and was formally recognized in the 2025 NEURON Group consensus (Deer et al., 2025).
The most common SCS patient at Vertrae® Surgery Center is the patient with persistent back and leg pain after lumbar spine surgery — sometimes years after surgery — whose imaging looks intact but whose pain has not resolved. This pattern, now called persistent spinal pain syndrome type 2 (PSPS-T2), is the most studied SCS indication in the literature. The second most common presentation is chronic neuropathic leg pain (radicular pain that persists despite technically successful surgery) and chronic neuropathic back pain that spans multiple dermatomes.
Patients considering SCS have typically already tried medications (including nerve medications such as gabapentinoids), physical therapy, and often epidural steroid injections or other interventional treatments. SCS is generally considered after conservative options have been exhausted, not as a first-line therapy.
The Waveform Question: Why SCS Is Not One Therapy
Modern SCS is not a single therapy. It is a family of stimulation waveforms — tonic (conventional), high-frequency 10 kHz, burst, and closed-loop (ECAP-controlled) — each with its own neurobiology, evidence base, and clinical profile. Some produce the tingling sensation (paresthesia) historically associated with SCS; newer waveforms often do not. Each waveform has been studied in specific trials, and the comparators in those trials matter. The SENZA trial showed 10 kHz outperformed traditional tonic SCS for chronic back and leg pain (Kapural et al., 2016). The EVOKE trial — the only double-blind RCT in the SCS field — compared closed-loop (ECAP-controlled) SCS to open-loop stimulation on the same platform, and closed-loop outperformed its comparator through 36 months (Mekhail et al., 2024). The SUNBURST trial supported burst stimulation in a crossover against tonic (Deer et al., 2018), though a subsequent placebo-controlled trial raised questions about burst stimulation in certain populations (Hara et al., 2022). Worth noting plainly: there are essentially no large head-to-head trials directly comparing modern waveforms to each other, so claims that one waveform is categorically “best” should be read carefully.
The key point for this overview is that the choice of SCS waveform is a real clinical decision informed by the available evidence, and the waveform that tends to perform well for one patient may not be the best fit for another. It is also worth understanding that FDA approval applies to SCS devices (systems) rather than to individual waveforms — waveforms are programming strategies within approved systems. The specific waveform comparisons, the evidence supporting each modality, and how we approach the decision at Vertrae® are covered in detail in our SCS technology comparison blog (Blog C in this series).
Research Spotlight — Key SCS Trials
Three landmark SCS trials anchor the modern evidence base:
SENZA-RCT (Kapural et al., 2016): In the SENZA trial, 10 kHz high-frequency SCS outperformed traditional tonic SCS for chronic back and leg pain. At 24 months, 76.5% of 10 kHz patients were back-pain responders versus 49.3% with tonic (p<0.001). This was a head-to-head against tonic; it does not establish superiority over other modern waveforms.
EVOKE (Mekhail et al., 2024): The only double-blind parallel-arm RCT in the SCS field. Closed-loop (ECAP-controlled) SCS outperformed open-loop stimulation on the same platform through 36 months. The comparison was on the same device with the feedback mechanism on versus off; it does not establish superiority over other modern waveforms.
Petersen et al., 2021 (JAMA Neurology): Established 10 kHz SCS as effective for painful diabetic neuropathy — an indication outside traditional SCS territory.
For deeper coverage of SCS evidence including SUNBURST, MULTIWAVE, and the Cochrane review, see Blog C.
Who SCS Is Typically Not For
SCS is generally not the preferred therapy for focal, highly localized neuropathic pain in a single nerve territory — that profile tends to be better matched by DRG-S. It is generally not the preferred therapy for mechanical axial low back pain caused by multifidus dysfunction in patients without neuropathic features — that profile tends to be better matched by ReActiv8®. It is generally not appropriate for diffuse pain syndromes such as fibromyalgia, active substance use disorder, active psychosis, or for patients who have not yet adequately tried conservative care.
For the full picture on SCS waveform selection, the evidence for each modality, and how we approach the decision at Vertrae®, see our SCS technology comparison blog (Blog C in this series).
Family 2: Dorsal Root Ganglion Stimulation (DRG-S)
What DRG-S Targets and How It Differs from SCS
DRG-S takes a different anatomical approach. Instead of placing electrodes over the broad dorsal columns of the spinal cord, DRG-S places thin leads through the neural foramen — the small bony opening where nerves exit the spine — and positions them over a specific dorsal root ganglion. The dorsal root ganglion is a cluster of sensory nerve cell bodies that processes sensory input from a specific region of the body (a dermatome). There is one DRG at every spinal level, on each side.
In chronic neuropathic pain, the nerve cells inside a specific dorsal root ganglion often become hypersensitive, firing pain signals in response to normal input or firing spontaneously with no trigger. DRG-S acts on these specific cell bodies directly — a more anatomically precise intervention than SCS, which affects a broad region.
The clinical implications of this precision: DRG-S can target exactly the dermatome where the pain lives without affecting other regions. It produces more consistent stimulation across body positions (the DRG sits in a more anatomically stable space than the spinal cord does). It requires less energy. And in many patients, DRG-S works without producing the tingling sensation (paresthesia) that historically defined SCS.
Who DRG-S Is For
DRG-S is FDA-approved for moderate to severe chronic intractable pain of the lower limbs in adults with complex regional pain syndrome (CRPS) types I and II. The pivotal ACCURATE trial (Deer et al., 2017) found that 81% of DRG-S patients achieved ≥50% pain relief at 3 months compared to 56% for conventional SCS, and outcomes remained better in the DRG-S arm at 12 months. A follow-up analysis (Levy et al., 2020) reported that DRG-S effectiveness held steady over 12 months in this cohort, while the SCS arm showed more attenuation. ACCURATE is one of the few direct head-to-head trials in the broader neuromodulation evidence base, and its findings are specific to the CRPS population studied.
Evidence beyond the CRPS approval is growing. DRG-S has shown meaningful results for post-surgical nerve pain (Mol et al., 2023; Wensing et al., 2022), focal peripheral neuropathy and peripheral nerve injury (Kretzschmar et al., 2021 — 73% pain relief at 36 months, 99% opioid reduction), and chronic pelvic or groin pain (Huygen et al., 2020; Nagpal et al., 2021). All of these populations share a common feature: focal, dermatomally distributed pain within a specific nerve territory.
Who DRG-S Is Typically Not For
DRG-S is not generally the first choice for widespread, multi-region neuropathic pain — for that profile, SCS has more supporting evidence. It is not generally the first choice for axial low back pain as a primary symptom — for that profile, advanced SCS waveforms or ReActiv8®, depending on the underlying mechanism, tend to be better starting points. It is not appropriate for pain outside the T10-S2 anatomical range that current DRG-S placement reliably covers.
Research Spotlight — Key DRG-S Trials
The DRG-S evidence base centers on one landmark RCT and a growing body of observational data:
ACCURATE (Deer et al., 2017): Randomized controlled trial of 152 patients with lower-extremity CRPS. At 3 months, 81.2% of DRG-S patients achieved ≥50% pain relief versus 55.7% for conventional SCS (p<0.001). Superiority held at 12 months (74.2% vs 53.0%). This trial led to FDA approval.
Habituation analysis (Levy et al., 2020): Pre-specified follow-up of ACCURATE. SCS pain relief diminished over 12 months; DRG-S pain relief remained stable.
Peripheral Nerve Injury 3-year outcomes (Kretzschmar et al., 2021): 58% pain relief at 3 months rising to 73% at 36 months, with 99% opioid reduction.
Pelvic and groin pain (Huygen et al., 2020): Pooled analysis showing 80% responder rate for groin pain in this dataset — one of the most consistently supported anatomical regions in the DRG-S literature to date.
For the full picture on DRG-S — patient selection, the ACCURATE trial in detail, procedure specifics, the growing evidence beyond CRPS, and how we approach evaluation at Vertrae® — see our DRG-S foundational blog (Blog B1). For patients whose spinal cord stimulator did not work and who are considering whether DRG-S might, see our blog on DRG-S when SCS has failed (Blog B2).
Family 3: Restorative Neurostimulation (ReActiv8®)
Why ReActiv8® Is a Genuinely Different Kind of Therapy
Both SCS and DRG-S work by modulating pain signals — either masking them, interrupting them, or quieting the cells that generate them. ReActiv8® works on a fundamentally different principle. It does not mask or modulate pain at all. It restores a specific motor function that has been lost.
The multifidus muscle is the deep, segmental stabilizing muscle of the lumbar spine. It lies directly adjacent to each vertebra and provides the fine-grained control that keeps the spine stable during ordinary movement. In many patients with chronic mechanical low back pain, the multifidus becomes reflexively inhibited after an initial spinal injury or pain episode — even after the original injury has resolved. The nervous system essentially turns off the muscle as a protective response, and then fails to turn it back on. The result is persistent functional instability, ongoing mechanical pain, and a cycle that conventional exercise often cannot break, because the reflex inhibition prevents voluntary activation in the first place (Abd-Elsayed et al., 2025).
ReActiv8® delivers electrical stimulation bilaterally to the L2 medial branch of the dorsal ramus — the motor nerve that controls multifidus activation. Patients use the device twice a day for 30 minutes. During each session, the stimulation produces a direct contraction of the multifidus, effectively bypassing the reflex inhibition and retraining the neuromuscular pathway. Over weeks and months, this restores the automatic feedforward activation of the muscle that was lost, which in turn restores spinal stability and reduces mechanical back pain at the source.
This is why ReActiv8® is classified as a restorative therapy rather than a pain-modulation therapy. It treats the cause of the mechanical pain, not the pain signal itself.
Who ReActiv8® Is For
The ideal ReActiv8® candidate has a specific clinical profile (Gilligan et al., 2024; Lorio et al., 2025):
Pain type is mechanical (nociceptive), not neuropathic. The pain worsens with activity and loading and improves with rest. It is the opposite of the burning, electrical, or shooting pain that characterizes SCS and DRG-S candidates.
Pain location is predominantly axial — the pain sits in the low back itself rather than radiating down a specific leg. Patients with leg-dominant pain are not ReActiv8® candidates.
Duration is at least 6 months, with pain on most days for the past 12 months. This is a chronic, persistent pattern, not an acute flare.
Conservative care has failed. Patients have already tried physical therapy, medications, and often injections without lasting relief.
There is evidence of multifidus dysfunction on clinical exam. The key finding is a positive prone instability test (PIT): the patient lies prone with legs off the examination table, and the examiner presses on the lumbar spine. Pain that is present when the patient’s legs are relaxed but resolves or significantly decreases when the patient actively engages the paraspinals (by lifting the legs) constitutes a positive test — indicating that the pain is driven by impaired neuromuscular control that can be improved by restoring multifidus activation.
The patient is not a surgical candidate. There is no structural pathology (significant stenosis, instability, disc herniation with neurological deficit) requiring surgery. This is an important distinction: ReActiv8® is specifically for the patient whose back pain has no surgical solution.
As of October 2024, the ICD-10-CM code M62.85 provides a formal diagnosis for multifidus dysfunction, thereby improving coding accuracy and insurance coverage (Lorio et al., 2025).
The Evidence for ReActiv8®
The ReActiv8® evidence base is robust and has one unusual feature: outcomes tend to continue improving over time rather than diminishing — a pattern distinct from most chronic pain interventions.
The pivotal ReActiv8®-B trial (Gilligan et al., 2021) was a sham-controlled randomized trial of 204 patients. The 120-day primary endpoint was inconclusive by its original definition, though prespecified secondary outcomes and a subsequent MCID-based reanalysis (Smuck et al., 2025) showed significant benefit over sham. The long-term picture is clearer. At 5 years (Gilligan et al., 2024), pain scores (VAS) had dropped from 7.3 to 2.4, disability (ODI) from 39.1 to 16.5, and 71.8% of patients had achieved at least 50% pain reduction. Among patients on opioids at baseline, 46% discontinued and 23% decreased use by 5 years.
The most recent major trial in this space is the RESTORE trial (Schwab et al., 2025), a randomized trial of 203 patients comparing ReActiv8® against optimal medical management. At one year, ReActiv8® patients had an ODI improvement of 19.7 points compared to 2.9 points for medical management — a difference that crossed commonly cited thresholds for clinical meaningfulness several times over. The ISASS 2025 guideline update (Lorio et al., 2025) reaffirmed payer coverage for appropriately selected patients. As with any single trial, findings are specific to the studied population and reflect an industry-sponsored randomized design rather than a placebo-controlled comparison.
Research Spotlight — Key ReActiv8® Trials
The ReActiv8® evidence base centers on two trials — the original pivotal trial and a more recent active-comparator RCT:
ReActiv8®-B (Gilligan et al., 2021): Sham-controlled RCT of 204 patients. Primary 120-day endpoint was inconclusive by original definition, but prespecified secondary outcomes and MCID-based reanalysis (Smuck et al., 2025) demonstrated significant benefit over sham.
ReActiv8®-B 5-Year Follow-Up (Gilligan et al., 2024): VAS improved from 7.3 to 2.4 cm; ODI from 39.1 to 16.5; 71.8% of patients achieved ≥50% pain reduction. Among baseline opioid users, 46% discontinued and 23% decreased use by 5 years.
RESTORE (Schwab et al., 2025): Active-comparator RCT of 203 patients comparing ReActiv8® against optimal medical management. At 1 year, ODI improvement was -19.7 with ReActiv8® versus -2.9 with optimal medical management — a difference several times the minimum clinically important threshold.
ISASS 2025 Guideline Update (Lorio et al., 2025): Reaffirmed support for payer coverage of ReActiv8® in appropriately selected patients, citing a positive Anthem Blue Cross Blue Shield coverage decision.
Who ReActiv8® Is Typically Not For
ReActiv8® is not appropriate for neuropathic pain (burning, electrical, shooting pain in a nerve distribution). It is not appropriate for leg-dominant pain, radiculopathy, or pain that radiates into an extremity. It is not appropriate for pain where structural pathology (significant stenosis, unstable spondylolisthesis, disc herniation with neurological deficit) is the driver and surgical intervention is indicated. It is not typically appropriate in patients with prior lumbar spine surgery in the RESTORE-era criteria, though the original pivotal trial allowed some prior surgical patients.
For the full picture on multifidus dysfunction, how we assess for it clinically, conservative rehabilitation protocols, and when ReActiv8® becomes the right next step, see our dedicated blog on multifidus dysfunction and restorative neurostimulation.
How Do I Know Which Family Fits My Pain?
Patients often come to us asking which of these therapies is right for them before we have evaluated them in person. The honest answer is that the decision depends on specific clinical findings that require a real evaluation. But there are patterns that help orient the conversation.
If your pain is burning, electrical, or shooting — if it radiates down a leg, into a foot, or into a specific nerve territory — you likely have a neuropathic component, and SCS or DRG-S is more likely to be the relevant family than ReActiv8®. The question then becomes whether your pain is focal (one specific nerve territory, with clear boundaries) or widespread (multiple regions, no clear boundary). Focal neuropathic pain — CRPS, post-surgical nerve pain in a single location, peripheral nerve injury — points toward DRG-S. Widespread neuropathic or mixed pain — persistent spinal pain syndrome after lumbar surgery, painful diabetic neuropathy, radiculopathy spanning multiple levels — points toward SCS.
If your pain is mechanical — if it worsens with sitting, standing, lifting, or activity and improves with rest — and if it is concentrated in your low back without radiating down a leg, and if physical therapy has not resolved it, then ReActiv8® may be worth evaluating. The specific clinical finding that supports ReActiv8® candidacy is a positive prone instability test, which is part of the evaluation at Vertrae®.
If you have had prior lumbar spine surgery, the picture is more complex. Persistent pain after lumbar surgery is most commonly evaluated for SCS first. In patients where the remaining pain has a focal, nerve-specific character, DRG-S may be relevant (covered in Blog B2). ReActiv8® in the RESTORE-era criteria is typically not offered to patients with prior lumbar surgery.
If your pain includes features of more than one family, there are two important points. First, patients can have overlapping pain types, and a careful evaluation separates which pain generator is primary. Second, combination approaches — SCS plus DRG-S, or sequential trials of different therapies — are real options for specific patients, supported by emerging evidence (Rigoard et al., 2023).
The clinical evaluation is what produces a usable answer. The pain pattern, the history, the imaging, the response to prior treatments, and specific physical exam findings together determine which therapy — if any — fits the patient in front of us.
Clinical Insight — A Simple Orientation Based on Pain Character
A practical orientation for patients reading this blog:
- If your pain is widespread, burning, and travels (back + leg, both feet, multiple regions): think SCS family
- If your pain is focal, burning, and stays in one specific nerve territory (one foot, one side of the groin, one band of skin): think DRG-S
- If your pain is mechanical, deep in the low back, worse with activity and not radiating: think ReActiv8®
This is orienting only, not diagnostic. The evaluation at Vertrae® determines the actual answer.
Before the Permanent Implant: Trials and Assessments Across the Three Families
One of the most important features of modern neuromodulation is that patients do not commit to a permanent implant without a structured pre-implant evaluation. For SCS and DRG-S, that evaluation includes a temporary external trial of the therapy itself. For ReActiv8®, it includes specific clinical findings and imaging review that establish candidacy before a single-stage implantation.
For SCS and DRG-S, the trial phase works the same way: under imaging guidance, thin temporary leads are placed at the intended stimulation target, connected to an external stimulator the patient wears for approximately 5 to 7 days. During this week, the patient lives normally and tracks how the stimulation affects pain, function, and sleep. Trials are kept within this window because infection risk rises sharply for trials that extend beyond 10 days (North et al., 2020). If the trial produces meaningful improvement — typically defined as at least 50% pain reduction plus functional improvement — the patient proceeds to permanent implantation. If it does not, the leads are removed, no permanent device is placed, and the patient has a clear answer to whether that specific therapy fits their clinical picture.
ReActiv8® works slightly differently. Candidacy is established through specific clinical findings (particularly the prone instability test) and imaging review rather than a temporary external trial. After implantation, benefit typically accrues over months rather than days — which matches the restorative rather than pain-modulating mechanism. Long-term data consistently show progressive improvement over time (Gilligan et al., 2024).
In all three cases, the patient’s lived response to therapy — not just imaging and history — is part of the clinical decision.
Patient Selection: The Evaluation Before the Evaluation
Neuromodulation is an invasive therapy with real risks and real costs. Appropriate selection is as important as the therapy itself. Every patient considering neuromodulation at Vertrae® Surgery Center undergoes a careful evaluation that combines clinical history, physical examination, imaging review, psychosocial screening, and assessment of the patient’s understanding and expectations.
Specific exam findings matter differently for each family. For DRG-S candidacy, the key finding is a dermatomally-specific pain distribution with sensory changes. For ReActiv8® candidacy, the prone instability test is the defining clinical finding. For SCS candidacy, the pain distribution and pattern guide whether the therapy is likely to cover the relevant anatomy. Imaging is reviewed to assess both what is present and what is absent — structural findings that might be surgical indications (where neuromodulation may not be the right answer), and findings that support specific diagnoses such as multifidus dysfunction.
Modern consensus guidelines (Shanthanna et al., 2023) emphasize that every neuromodulation candidate should be screened for psychosocial factors including depression, anxiety, pain catastrophizing, and coping patterns. Active psychosis, untreated substance use disorder, and certain other psychiatric conditions are absolute contraindications. Poorly controlled depression warrants treatment before proceeding. Multidisciplinary team evaluation, when available, significantly improves trial success rates (Salmasi et al., 2023). Patients must also be assessed for their understanding of the procedure, its risks and benefits, and the commitment to long-term follow-up and device maintenance.
The evaluation is not a formality. It is a structured clinical conversation that determines whether neuromodulation is appropriate, and if so, which family and which specific therapy fits.
Honest Limitations of Neuromodulation
A thoughtful discussion has to include limitations. Placebo effects are real — a 2023 Cochrane review (Traeger et al., 2023) and a 2022 JAMA placebo-controlled trial (Hara et al., 2022) both raised meaningful questions about how much of the benefit observed in open-label SCS studies reflects placebo response. The most rigorous evidence across the three families comes from double-blind or randomized trials with active comparators and long-term follow-up: the EVOKE trial for SCS (closed-loop vs. open-loop on the same platform), the ACCURATE trial for DRG-S (a true head-to-head against conventional SCS in CRPS), and the RESTORE trial for ReActiv8® (vs. optimal medical management) are the clearest examples. Most major neuromodulation trials are industry-funded, which warrants appropriate skepticism of any single-trial claim of superiority. Importantly, large head-to-head trials between modern SCS waveforms do not exist, and FDA approval applies to devices (systems) rather than to specific waveforms — an important distinction when reading any manufacturer-sponsored comparison.
Complication rates are real. For SCS and DRG-S, overall complication rates run approximately 30-40% over long-term follow-up, though most complications are mechanical (lead migration, lead fracture, battery issues) rather than life-threatening. For ReActiv8®, serious procedure- or device-related adverse events ran 3.9% in the pivotal trial with no lead migrations through 5 years. And no therapy works for every patient. The 81% responder rate in ACCURATE means about one in five CRPS patients did not achieve meaningful relief even within the population where the evidence is strongest. The 77.6% responder rate in EVOKE and the 71.8% 5-year responder rate for ReActiv8® carry the same honest math. Neuromodulation is a precision tool: when matched to the right patient, it tends to produce significant and durable benefit. When applied to the wrong patient, it often does not. The evaluation exists to make that distinction.
Finally, a note about the gap between trial evidence and real-world access. Clinical trials report what happens when a specific therapy is delivered to a specific population under study conditions. In practice, what any individual patient can actually receive depends on additional factors: the specific device and waveforms available on the platform being considered, whether a prior implant can be reprogrammed or must be revised, what insurance coverage allows, and the individual clinical judgment of the evaluating physician — who may weight the evidence somewhat differently based on experience with their own patient population. The goal of this blog is to inform, not to prescribe. The evaluation is where the evidence, the patient, and the practical realities come together in an individualized conversation.
How Neuromodulation Fits Into Care at Vertrae® Surgery Center
Vertrae® is a spine-focused surgical practice in Dayton, Ohio. Dr. Kamal Woods is a double fellowship-trained neurosurgeon who completed combined Orthopedic and Neurosurgery Spine Fellowship training at Cedars-Sinai Medical Center and practices exclusively minimally invasive and robotic spine surgery. Vertrae® Surgery Center offers all three families of neuromodulation covered in this blog:
Spinal cord stimulation with current-generation technologies — traditional tonic, high-frequency 10 kHz, burst (Abbott BurstDR), and closed-loop ECAP-controlled stimulation (Saluda Evoke System) — so the right waveform can be matched to the right patient.
Dorsal root ganglion stimulation (DRG-S) for focal neuropathic pain, following advanced training completed by Dr. Woods. Vertrae® is among a small number of practices in the Dayton and broader Southwest Ohio region currently offering DRG-S.
ReActiv8® restorative neurostimulation for chronic mechanical low back pain with multifidus dysfunction, offered as part of an integrated pathway that may include physical therapy, conservative multifidus rehabilitation, and imaging review before neurostimulation is considered.
Because Vertrae® is a spine-exclusive practice, the full range of spine care decisions happens inside one clinical relationship — which matters because the evaluation often determines that something other than neuromodulation (or something in addition to it) is the right next step. The full Vertrae® toolkit includes minimally invasive and robotic spine surgery, non-surgical spine options including basivertebral nerve ablation (BVNA) for vertebrogenic pain, in-house physical therapy including multifidus-focused motor control rehabilitation, and care coordination with prescribing physicians and referring pain specialists.
The neuromodulation evaluation at Vertrae® is not a procedural visit. It is a clinical conversation. Dr. Woods reviews the patient’s complete picture before determining which therapy (if any) fits the specific situation. When the clinical picture clearly fits one family, the conversation moves toward trial planning or implantation planning. When the picture does not clearly fit any of the three families, Dr. Woods is direct about that finding, and the conversation often shifts toward structural reassessment, different conservative approaches, or referral to the right clinical setting. Either direction is a legitimate outcome of the consultation.
Evidence Summary
| Family | Primary Indication | Key Evidence | Typical Outcomes |
|---|---|---|---|
| Spinal Cord Stimulation (SCS) | Neuropathic or mixed pain, including PSPS, PDN, and widespread pain | SENZA (Kapural 2016), EVOKE (Mekhail 2024), SUNBURST (Deer 2018), Petersen 2021 (PDN) | Approximately 50–78% responder rates depending on waveform and patient population |
| DRG Stimulation (DRG-S) | Focal neuropathic pain, including CRPS, post-surgical nerve pain, pelvic pain, and groin pain | ACCURATE (Deer 2017), Levy 2020, Kretzschmar 2021, Huygen 2020 | 81% responder rate at 3 months; 73% at 3 years in peripheral nerve injury |
| ReActiv8® | Mechanical chronic low back pain with multifidus dysfunction and no surgical indication | ReActiv8®-B (Gilligan 2021), 5-Year Follow-Up (Gilligan 2024), RESTORE (Schwab 2025) | 71.8% responder rate at 5 years; ODI improvement of -19.7 vs -2.9 with optimal medical management at 1 year |
When to See a Specialist About Neuromodulation in Dayton
Neuromodulation is not the first step in chronic pain care. It is the step that becomes appropriate after conservative care has been tried and has not resolved the problem. Consider requesting an evaluation at Vertrae® if any of the following describes your situation:
→ Your chronic pain has persisted despite six months or more of conservative care, including physical therapy and appropriate medications. Injections may or may not have been part of that pathway.
→ Your pain has a specific character — burning, electrical, shooting, or mechanical — that fits one of the three family profiles described above.
→ You have had prior spine surgery, and your pain is continuing despite technically successful repair.
→ You have been told by another provider that there is nothing more to do. That may be true, and it may not. A dedicated evaluation at a spine-exclusive center can determine which.
→ You are being offered long-term opioid therapy or escalating doses of opioids for pain that neuromodulation could potentially address with different tools.
New patients at Vertrae® Surgery Center are typically seen promptly — because spine is the only thing we do.
Serving patients from: Dayton • Miamisburg (Austin Landing) • Kettering • Beavercreek • Centerville • Springboro • Southwest Ohio • Northern Kentucky • Southeast Indiana
Vertrae® Surgery Center: Spine-only outpatient facility • same-day discharge • in-person and virtual consultations available
Dr. Kamal Woods, MD, MBA: Double fellowship-trained neurosurgeon • Cedars-Sinai trained • exclusively minimally invasive & robotic spine surgery
New patients are typically seen promptly — because spine is the only thing we do.
Hear This Blog as a Podcast
Prefer to listen? This podcast episode walks through the three families of neuromodulation in the same patient-friendly format as the blog, with a two-host conversation that explores how to think about which therapy might fit which kind of chronic pain.
Read the Full Podcast Transcript
DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
Speaker 1: What if the reason your chronic back pain hasn’t been fixed after years of pills, injections, and therapy isn’t because your pain is untreatable — but because your doctors have been trying to rewire your entire house when the problem is just one isolated circuit breaker in the basement?
Speaker 2: It’s a profound shift in perspective. For so long, the approach to chronic pain has been to throw a massive blanket over the nervous system and hope it smothers the problem. But if you have localized, very specific pain, treating the entire spinal cord is like turning off the whole city grid just to fix a desk lamp. And if you’re listening to this right now, that is probably exactly what the medical system has felt like for you.
Speaker 1: You’ve been down those conservative treatment roads. You’ve exhausted the options. You’ve probably heard the words “complex” or “idiopathic” more times than you can count, which is incredibly frustrating. And you’ve already read the foundational clinical blog we’re doing a deep dive into today — the one by Dr. Kamal Woods at Vertrae® Surgery Center in Dayton, Ohio.
Speaker 2: Highly detailed material. Our mission for this deep dive is to skip the basic definitions. You already know what chronic pain is, because you live it every single day. You’re the expert on your own pain. Instead, we are looking at the actual mechanics of matching precise pain phenotypes to the right technology. That’s the critical pivot. We’re moving away from treating chronic pain as a single diagnosis, and toward targeting the specific architecture of each patient’s unique pain.
Speaker 1: Honestly, the biggest revelation for me, right out of the gate with this material, was realizing that neuromodulation is not just one thing.
Speaker 2: That surprises a lot of people. Most patients assume that getting a spinal cord stimulator is a single type of device you plug in to block pain. But Dr. Woods’s text reveals that there are actually distinct neuromodulation therapies — different mechanisms built for entirely different pain populations. It’s a common misconception, and it’s the root of much patient frustration. Dr. Woods outlines what he calls a three-family framework. First, traditional spinal cord stimulation, or SCS. Second, dorsal root ganglion stimulation, or DRG-S. And third, restorative neurostimulation, which specifically refers to a device called ReActiv8®.
Speaker 1: Let’s unpack this. If I’m a patient who has been told a stimulator is my absolute last resort, I need to know why there are three different ones. Let’s start with traditional SCS. The text says it involves placing electrodes in the midline epidural space. Before we map this to patients — what actually is the midline epidural space? Are we talking about putting wires inside the spinal cord itself?
Speaker 2: Not inside the spinal cord itself. The spinal cord is protected by a tough outer membrane called the dura mater. The epidural space is the area just outside that membrane, but still inside the spinal canal. By placing leads in the midline — right down the center of that space — traditional SCS casts a wide electrical net over the spinal cord. It’s a broad effect, covering a large area of the body.
Speaker 1: So who is that for? If it’s a wide net, I’m guessing it’s for pain that doesn’t have neat, clean borders.
Speaker 2: Precisely. It’s best suited for widespread non-dermatomal pain. Think of diffuse polyneuropathy, where a patient has burning pain spread symmetrically across both feet or both hands. The pain is everywhere, so you need a broad therapy to calm a widespread neurological storm.
Speaker 1: But what if your pain isn’t a wide net? What if you can point to one exact square inch on your knee or your groin where the pain lives? I assume that’s where the second family comes in — DRG-S.
Speaker 2: Exactly. DRG-S targets the dorsal root ganglion. To understand this, picture your spinal cord as a major highway. Before sensory nerves from your leg or foot can merge onto that highway to send a pain signal up to your brain, they have to pass through a toll booth. That toll booth is the dorsal root ganglion. It’s a small cluster of sensory nerve cell bodies sitting just outside the spinal canal, inside a bony opening called the neural foramen.
Speaker 1: Planting an electrical wire directly onto a tiny bundle of nerves right next to the spine sounds terrifying. If DRG-S is so highly localized, isn’t there a risk of causing more nerve damage or missing the target completely?
Speaker 2: It’s a valid concern, but anatomically, the dorsal root ganglion sits in a very stable, isolated envelope. It’s a highly protected area with minimal cerebrospinal fluid around it, which means that once a lead is placed there by a skilled specialist, it stays put. It doesn’t float or shift the way leads in the larger epidural space sometimes can. And because it’s so isolated, you are only modulating the specific nerve — the specific dermatome where the pain lives.
Speaker 1: So we’re talking about conditions like complex regional pain syndrome, or CRPS, chronic pelvic pain, or stubborn post-surgical nerve pain that stays in one exact spot after something like a hernia repair.
Speaker 2: That’s right.
Speaker 1: So we have SCS for the broad storm and DRG-S for the isolated short circuit. Then there’s the third family — ReActiv8®. The text says this is for patients with multifidus dysfunction contributing to chronic low back pain.
Speaker 2: And this brings us to a crucial turning point in how we understand chronic pain. When a patient comes in with a complex, poorly understood condition, they often hear a doctor say it’s “idiopathic.” But what the patient actually hears is the unspoken translation: we think this is all in your head.
Speaker 1: It’s incredibly dismissive. You start to question your own sanity when multiple doctors tell you they can’t find the source of the pain.
Speaker 2: But what this three-family framework emphasizes is that the pain isn’t in your head. It usually means the pain is living in a physical structure that traditional treatments — standard injections, or a midline SCS — simply aren’t designed to reach.
Speaker 1: Which leads me to something that made me stop reading the source material and just stare at the wall for a minute. ReActiv8® isn’t a pain-masking device at all?
Speaker 2: It is not. And that is the most vital distinction to understand in this entire deep dive. With traditional SCS and DRG-S, we’re talking about modulating or interrupting sensory pain signals before they reach the brain — a high-tech filter. But the text explicitly categorizes ReActiv8® as restorative neurostimulation.
Speaker 1: How does a spinal implant restore something?
Speaker 2: It comes down to biology. ReActiv8® does not modulate sensory pain signals. It restores motor function. It specifically targets the multifidus, the deep stabilizing muscle of the spine. When you injure your back, your nervous system triggers a protective reflex that essentially shuts that stabilizing muscle off to protect the area from further movement and damage.
Speaker 1: Like when you sprain your ankle and your body instinctively forces you to limp so you don’t put weight on it?
Speaker 2: Exactly. It’s called arthrogenic muscle inhibition. The problem is that in chronic back pain, the nervous system forgets to turn the muscle back on after the initial injury has healed. The multifidus stays deactivated, causing instability in the spine, which causes more pain, which then tells the brain to keep the muscle shut off. It’s a self-reinforcing loop.
Speaker 1: So how does ReActiv8® break that loop? Does it just shock the muscle?
Speaker 2: It rehabilitates it. ReActiv8® delivers electrical pulses that override the brain’s shutdown order, forcing the multifidus to contract. Patients perform this therapy twice a day for about 30 minutes while lying down. It’s physical therapy delivered from the inside out, directly to the nerve that controls the muscle. Over time, waking that muscle up addresses the underlying mechanical instability.
Speaker 1: It’s the difference between putting on noise-canceling headphones to ignore a broken engine, versus popping the hood and replacing the timing belt. You’re fixing the machinery.
Speaker 2: It’s restorative medicine in the truest sense of the word.
Speaker 1: Let’s pivot back to DRG-S for a moment. If the physical structure of the spine is fine, and the nerves themselves are misfiring and screaming pain for no reason, how does DRG-S stop a sensory signal? Is it just numbing the nerve?
Speaker 2: It’s not numbing it. It’s essentially outsmarting it using something called gate control theory. Imagine the nerve pathway as a gate. When you have chronic pain, the gate is wide open and pain signals are flooding the brain. DRG-S sends rapid electrical pulses to the cell bodies at the dorsal root ganglion, and these pulses travel faster than the pain signals. They reach the gate first and effectively close it. They jam the frequency, so the brain does not receive the pain signal.
Speaker 1: And because you’re doing this at the DRG — that tiny toll booth — you achieve what the text calls “paresthesia independence.” What does that mean for patients in real life?
Speaker 2: Historically, traditional spinal cord stimulation relies on replacing pain with a tingling sensation called paresthesia. The idea was to distract the brain with that buzzing feeling so patients wouldn’t feel the pain. But with DRG-S, nearly 40% of patients get meaningful relief without any tingling at all.
Speaker 1: That’s significant. I can imagine the constant electrical tingling, even if it’s better than agony, could become distracting or annoying over the course of years.
Speaker 2: And beyond that, patients also get position independence. In traditional SCS, because the leads are in the epidural space, the layer of spinal fluid between the lead and the spinal cord changes depending on posture. If you stand up, lie down, or even cough, the distance shifts.
Speaker 1: Let me guess — if the lead gets closer to the cord when you lie down, the stimulation suddenly spikes.
Speaker 2: Exactly. Patients would sometimes get a sudden, uncomfortable jolt of electricity just from rolling over in bed. But because the DRG sits in that tight, stable anatomical envelope, the distance does not change. The stimulation stays consistent whether the patient is running, sitting, or sleeping.
Speaker 1: Let me play the skeptic for a minute. I’m looking at these three highly engineered families of therapy. I hear the logic, but patients have heard miracle-cure statistics before. They’ve had surgeons promise them the world and woken up from the procedure in the exact same amount of pain. So for patients who have truly exhausted all options, why should they trust this data? Does it hold up in rigorous trials?
Speaker 2: It’s entirely fair to be skeptical. And that’s exactly why the field has moved toward high-level randomized controlled trials. It’s important to look at the specific evidence for each family. For traditional SCS, the text highlights the EVOKE trial. This is critical because EVOKE is the only double-blind RCT in the field, and it studied closed-loop SCS.
Speaker 1: Before we talk about the EVOKE data — what does “closed-loop” actually mean? Is the device listening to my body?
Speaker 2: That is exactly what it does. Traditional open-loop SCS fires electrical pulses at a set rate, regardless of what the spinal cord is actually doing. Closed-loop SCS measures the spinal cord’s actual nerve responses many times per second and adjusts the electrical dose in real time to keep the therapy optimized.
Speaker 1: It’s like a smart thermostat for your spinal cord, rather than a space heater running on high all day.
Speaker 2: That’s a good way to put it. For ReActiv8®, we look at the RESTORE trial, which compared the device directly to optimal medical management. But where the data is most remarkable is the ACCURATE trial for DRG-S. Researchers took patients with lower-extremity CRPS — one of the most notoriously difficult chronic pain conditions — and compared DRG-S directly to conventional SCS.
Speaker 1: Break down those numbers.
Speaker 2: At three months, 81.2% of DRG-S patients achieved at least 50% pain relief, compared to 55.7% for the conventional SCS group.
Speaker 1: 81.2% versus 55.7%. That’s a meaningful leap.
Speaker 2: A different category of outcome. But the most important finding wasn’t at three months — it was at the 12-month mark. The data showed DRG-S had no therapy habituation.
Speaker 1: What does therapy habituation mean in a patient’s daily life?
Speaker 2: It means the body gets used to the treatment and the treatment stops working. With traditional SCS, efficacy often drops over time. The relief fades as the nervous system adapts. But with DRG-S, the 81% relief held stable throughout the entire year. The nervous system didn’t outsmart it.
Speaker 1: What does this mean beyond the clinical data — beyond the p-values and trial acronyms? Because the text raises a concept that hit me hard. They call it the family-system reality.
Speaker 2: I’m glad you brought that up. We can talk about the SMASHING study showing a 50% average pain reduction for post-hernia pain, or the 80% responder rate for groin pain. But as Dr. Woods points out, those numbers matter because of how they impact the reality of the household. Chronic pain doesn’t just isolate the patient. It reorganizes the entire family dynamic around the pain.
Speaker 1: When someone has debilitating focal pain for years, their spouse takes over the physical labor of daily life — the laundry, the groceries, the driving to every appointment. Children or adult children become medical schedulers and caregivers. And the patient carries this quiet guilt over what their pain requires from the people they love.
Speaker 2: That psychological weight rarely gets mentioned in a 15-minute doctor’s appointment. You just feel like a burden. So when we look at an 81% responder rate in the ACCURATE trial, it isn’t just a clinical victory. It’s the restoration of a patient’s role within their own family. It is a mother getting to pick up her toddler again. It’s a grandparent back at the baseball games because they can finally sit in the bleachers. It is returning to partnership rather than a patient-caregiver dynamic.
Speaker 1: It’s not just pain score down. It’s life score up.
Speaker 2: Well said.
Speaker 1: Say you’re listening to this and the mechanism makes sense, the data makes sense, and you fit the phenotype. What does the actual path look like? Because committing to a permanent spinal implant — even a precise one — sounds like an intense, irreversible decision.
Speaker 2: This is where the process is designed to remove that exact anxiety. You do not jump into a permanent implant. It starts with stage one — a temporary trial phase. For five to seven days, the patient wears an external stimulator.
Speaker 1: How does that work? Where is the battery?
Speaker 2: A specialist places thin temporary leads percutaneously — through a needle puncture in the skin, no major incisions — into the epidural space or the neural foramen. The battery pack is worn entirely outside the body, taped to the back under clothing. You go home, live your normal daily life, walk around, do the dishes, and see whether the stimulation provides meaningful relief in the real world.
Speaker 1: There’s a specific reason it’s exactly five to seven days. I imagine some patients get relief on day four and say, “Please just let me keep this on for another week to be absolutely sure.”
Speaker 2: They do. But the medical guidelines are strict for a good reason. The PROMISE randomized controlled trial looked at this exact issue. They found that if you extend a temporary trial past 10 days, infection rates spike dramatically.
Speaker 1: How much?
Speaker 2: They jump from 1.4% up to 24.1%.
Speaker 1: 24%?
Speaker 2: Yes. So that five-to-seven-day limit is a non-negotiable safety protocol.
Speaker 1: I appreciate the structural honesty built into this setup. If the trial doesn’t work — if you go those five to seven days and you don’t get that 50% relief — it’s not a failure.
Speaker 2: Not at all. It’s a clear answer. The temporary leads are simply pulled out in the office, almost like an IV line. No permanent implant is placed. And you know for certain whether this technology is the answer for your specific pain.
Speaker 1: All without committing to surgery.
Speaker 2: It gives the power back to the patient. You get to test-drive the outcome. And that intellectual honesty extends into patient selection, which is a major theme in Dr. Woods’s practice at Vertrae®. Neuromodulation is not a universal fix. Patient selection matters as much as the technology itself. DRG-S, for instance, is not the first-line choice for axial low back pain — meaning pain that sits entirely in the lower back without radiating down a leg. For widespread axial back pain, DRG-S will not help. For that, we look at advanced closed-loop SCS or ReActiv8®. And DRG-S is not the right tool for diffuse polyneuropathy.
Speaker 1: Here’s where it gets interesting, because you don’t often see a medical practice or clinical blog so explicitly stating who they cannot help with a given tool. Usually the medical industry reads like a sales brochure saying they can fix everyone. But here, they’re saying: if you have this exact pain footprint, we use this tool. If your pain shifts unpredictably or covers your whole back, we don’t. That kind of integrity builds trust.
Speaker 2: A thoughtful consultation has to acknowledge reality. Neuromodulation is an evidence-based tool with a documented track record for the right patient — and also a clear record of who it tends not to help. Saving a patient from a procedure that won’t work is as important as offering one that will.
Speaker 1: That’s the takeaway for anyone listening right now — navigating this landscape of chronic pain, of failed treatments, of complex terminology. It isn’t something you have to figure out by yourself in the dark. The goal of an evaluation at Vertrae® with Dr. Kamal Woods isn’t to push a specific device. It’s to look at the architecture of your pain and determine which family of therapy fits best — or, importantly, to determine if none of them fit, and a completely different medical direction makes more sense.
Speaker 2: Either answer is a useful step forward out of the limbo you’ve been stuck in. You can find more about this framework and request an evaluation at vertrae.com.
Speaker 1: Before we wrap up, I want to leave listeners with one final thought. We talked earlier about therapy habituation and how traditional treatments often fade over time. But there’s remarkable data from Kretzschmar and colleagues in the sources we reviewed. They tracked patients with peripheral nerve injuries who were treated with DRG-S over the course of three years.
Speaker 2: What happened after three years?
Speaker 1: Over those 36 months, their pain relief didn’t just hold steady — it actually increased. Average pain relief went from 58% at three months, climbing to 73% at three years. And alongside that progressive improvement, 20 out of 21 of those patients became completely opioid-free.
Speaker 2: Relief going up over time. You rarely hear that in chronic pain.
Speaker 1: Almost never. But it raises a profound biological question. We know that chronic pain is effectively the nervous system learning and memorizing a dysfunctional, hyperexcitable state. But if precision-targeted stimulation at the dorsal root ganglion can cause pain relief to improve year after year — could we actually be teaching the nervous system to permanently forget the pain?
Speaker 2: Teaching the nervous system to unlearn the pain.
Speaker 1: We started this conversation by talking about the medical system feeling like a broken record — how patients learn to accept a ceiling on their recovery. But maybe the real breakthrough isn’t just turning down the volume on that broken record. If we can target the exact circuit and teach the nerves to forget the dysfunction, maybe this is how you finally lift the needle off the vinyl.
Key Takeaway
Neuromodulation is not one therapy. It is three distinct families of therapy, each built for a different kind of chronic pain: spinal cord stimulation for widespread neuropathic pain, DRG stimulation for focal nerve-territory pain, and ReActiv8® restorative neurostimulation for mechanical back pain with multifidus dysfunction. The decision among them is a clinical decision, not a marketing decision. It depends on the character of the pain, its location, its history, and specific physical exam findings. At Vertrae® Surgery Center in Dayton, Ohio, Dr. Kamal Woods evaluates patients for all three therapies, determines which — if any — fits the specific clinical picture, and is direct when a different direction is the honest answer. Either conclusion is a useful outcome of the conversation.
Frequently Asked Questions About Neuromodulation
I have chronic pain. How do I know if neuromodulation is right for me?
Neuromodulation becomes a reasonable consideration when chronic pain has persisted despite appropriate conservative care — typically at least six months of medications, physical therapy, and often injections — and when the pain pattern fits one of the three family profiles. A burning, electrical pain that radiates down a leg fits the SCS family. A focal nerve-territory pain like CRPS fits DRG-S. A deep, mechanical low back pain without radiation fits ReActiv8®. A clinical evaluation at Vertrae® Surgery Center determines which — if any — applies to your specific situation.
How is ReActiv8® different from SCS and DRG stimulation?
ReActiv8® works on a fundamentally different principle. SCS and DRG stimulation modulate pain signals — they mask, interrupt, or quiet the nerves that generate pain. ReActiv8® does not do that. Instead, it restores a specific motor function (the activation of the deep multifidus muscle of the lumbar spine) that has been reflexively shut off after chronic back pain. Patients use ReActiv8® for 30 minutes twice a day, not continuously. The benefit comes from retraining neuromuscular control, not from pain masking. It is a different kind of therapy for a different kind of pain.
Can I have more than one neuromodulation therapy?
In most cases, patients receive one therapy that matches their primary pain pattern. However, for patients with mixed pain phenotypes — for example, PSPS after lumbar surgery with both widespread neuropathic pain and a specific focal component — combined SCS and DRG-S approaches are supported by emerging evidence. ReActiv8® is generally evaluated separately because its indication (mechanical pain without surgery) is distinct from the SCS and DRG-S populations. Any combination or sequencing is a clinical decision based on the specific picture.
What happens before permanent implantation?
For SCS and DRG-S, the pre-implant evaluation includes a temporary external trial. Under imaging guidance, thin temporary leads are placed at the intended stimulation target and connected to an external stimulator the patient wears for 5-7 days. The patient lives normally and tracks how the therapy affects pain, function, and sleep. If the trial produces meaningful relief (typically defined as at least 50% pain reduction plus functional improvement), the patient proceeds to permanent implantation. If it does not, the leads are removed, no permanent device is placed, and the patient has a definitive answer. A trial that does not produce relief is not a failure — it is a clear answer to a specific clinical question. ReActiv8® works differently. Candidacy is established through specific clinical findings (particularly the prone instability test) and imaging review rather than a temporary external trial, followed by a single-stage implantation.
Is neuromodulation covered by insurance?
All three therapies are FDA-approved and typically covered by commercial insurance plans and Medicare when specific medical necessity criteria are documented. Coverage specifics vary by plan and may require additional clinical documentation, preauthorization, and in some cases a temporary trial of the proposed therapy. The ISASS 2025 guideline update reaffirmed payer coverage support for ReActiv8® in appropriately selected patients. The Vertrae® team assists with insurance verification and pre-authorization as part of the consultation process so patients have a clear picture of both the clinical path and the coverage path before any decision is made.
How long do these devices last?
Battery life varies by therapy and device. Modern rechargeable SCS systems typically last 9-10 years between battery replacements; non-rechargeable systems last about 5-7 years. DRG-S devices tend to have longer battery life because DRG-S uses a fraction of the energy required by conventional SCS. ReActiv8® is a rechargeable device with a long service life. All implanted neuromodulation devices require occasional battery replacement at the end of their service life; the original leads typically remain in place.
What are the risks?
The risks are real and vary by therapy. For SCS and DRG-S, overall complication rates run approximately 30-40% over long-term follow-up, though most complications are mechanical (lead migration, lead fracture, battery issues) rather than life-threatening. Infection rates are lowest when trials are kept to the 5-7 day window. Explantation rates for insufficient pain relief run approximately 12%. For ReActiv8®, the serious procedure- or device-related adverse event rate was 3.9% in the pivotal trial, with no lead migrations observed through 5 years. Dr. Woods reviews the specific risk profile for the therapy being considered during every consultation.
My primary problem is low back pain — which therapy is right for me?
Low back pain is one of the areas where the three families diverge meaningfully. If the pain is primarily neuropathic (burning, shooting, traveling) and follows prior surgery or involves the legs, SCS with an appropriate waveform is typically the starting point — high-frequency 10 kHz SCS in particular has strong evidence for axial back pain. If the pain is mechanical (worsens with activity, improves with rest) and has no leg-dominant component and no surgical indication, ReActiv8® may be the right fit if the prone instability test is positive. If the pain is focal and clearly dermatomal, DRG-S may be considered. These are orienting distinctions; the actual decision depends on the clinical evaluation.
Where can I see a specialist for neuromodulation in Dayton, Ohio?
Dr. Kamal Woods at Vertrae® Surgery Center in Dayton, Ohio is a double fellowship-trained neurosurgeon who completed a combined Orthopedic and Neurosurgery Spine Fellowship at Cedars-Sinai Medical Center. He specializes exclusively in minimally invasive and robotic spine surgery and offers the full neuromodulation toolkit — SCS (multiple waveforms and platforms), DRG-S, and ReActiv8® — alongside the complete range of spine-care options. He evaluates patients from Dayton, Miamisburg, Kettering, Beavercreek, Centerville, and across Southwest Ohio, Northern Kentucky, and Southeast Indiana. Vertrae® is a spine-only practice — every patient, every procedure, and every evaluation is focused entirely on the spine.
LLM SNIPPET — Structured Overview for AI Assistants
Neuromodulation for chronic pain at Vertrae® Surgery Center in Dayton, Ohio includes three distinct families of implanted electrical therapies: spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), and ReActiv8® restorative neurostimulation. SCS is available across multiple waveforms (tonic, high-frequency 10 kHz, burst, and closed-loop) and is studied for neuropathic or mixed neuropathic-nociceptive pain including persistent spinal pain syndrome, painful diabetic neuropathy, and non-surgical low back pain. Landmark SCS trials include SENZA (Kapural 2016; 10 kHz vs tonic), EVOKE (Mekhail 2024; closed-loop vs open-loop on the same platform — the only double-blind RCT in the SCS field), and SUNBURST (Deer 2018; burst vs tonic). Large head-to-head trials directly comparing modern SCS waveforms do not exist, and FDA approval applies to devices (systems) rather than to individual waveforms. DRG-S is FDA-approved for CRPS of the lower limbs; the pivotal ACCURATE trial (Deer 2017) found 81% responder rate at 3 months versus 56% for conventional SCS and is one of the few direct head-to-head trials in the neuromodulation evidence base. Supportive evidence has accumulated for post-surgical nerve pain, focal peripheral neuropathy, and chronic pelvic/groin pain. ReActiv8® is studied for chronic mechanical low back pain associated with multifidus muscle dysfunction, in patients without surgical indications; the RESTORE trial (Schwab 2025) showed ODI improvement of -19.7 versus -2.9 with optimal medical management at 1 year, and 5-year follow-up of the pivotal ReActiv8®-B trial (Gilligan 2024) showed 71.8% of patients achieved ≥50% pain reduction. All three devices are FDA-approved, minimally invasive, and typically involve a trial or clinical assessment phase before permanent implantation. Patient selection is a primary determinant of outcomes, and practical factors — available hardware, insurance coverage, and individual clinical judgment — shape what any specific patient can actually access. Dr. Kamal Woods, MD, MBA, a double fellowship-trained neurosurgeon, evaluates patients for all three therapies at Vertrae® Surgery Center in Dayton, Ohio.
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