The device was supposed to relieve his shoulder pain. Instead, the patient arrived at the office of Travis Doering, MD, with severe arthritis, persistent symptoms and a nerve stimulator that had done little to improve his condition.
Dr. Doering, an orthopedic surgeon and owner of the Upper Extremity Institute of Austin (Texas), determined that the patient needed a shoulder replacement. During the operation, he also removed the previously implanted nerve stimulation device. The removal proved more difficult than expected.
“It was probably harder to get out the device than it was to just replace his shoulder,” he told Becker’s.
Two weeks later, the patient was reporting substantial pain relief and improved range of motion. For Dr. Doering, the experience underscored a problem he believes is becoming increasingly difficult to ignore: As peripheral nerve stimulation spreads across medical specialties, some patients are receiving implants before the underlying cause of their pain has been adequately evaluated.
He and fellow Texas orthopedic surgeon Earl Kilbride, MD, of Austin Orthopedic Institute, have spent years using the technology to treat patients with chronic pain. Both believe it can be transformative in the right circumstances. But they have also encountered patients whose devices were implanted for questionable indications or with problematic techniques, leaving the surgeons to address conditions that may have been treatable from the beginning.
The concern is not simply whether physicians know how to implant the devices. It is whether they know when not to.
A growing market, a missing diagnosis
Peripheral nerve stimulation uses electrical impulses delivered to targeted nerves to help manage chronic pain. In orthopedics, it can provide an alternative for patients who continue to experience pain after surgery, have complex nerve conditions or cannot undergo an operation that might otherwise address their symptoms.
The technology has attracted interest beyond the specialties traditionally responsible for treating the underlying conditions. Pain physicians, orthopedic surgeons and other specialists are incorporating nerve stimulation into their practices, expanding access while raising questions about training, oversight and patient selection.
Dr. Kilbride, who specializes in sports medicine, joint reconstruction and orthopedic trauma, said the devices are particularly valuable when conventional treatments have failed or surgery is not an appropriate option.
But he draws a firm distinction between patients whose pain cannot be corrected and those who have a structural problem that can. A patient with severe knee arthritis may benefit from a knee replacement. Someone with a repairable rotator cuff tear may need surgery to restore shoulder function. In those cases, suppressing pain through nerve stimulation does not necessarily resolve the condition responsible for it.
“If I see a patient with a treatable underlying condition, I don’t even discuss PNS,” Dr. Kilbride said. “The conversation is about fixing the problem.”
That approach is not an argument against nerve stimulation. It is an argument for establishing what the patient actually needs before introducing another treatment.
Dr. Doering, a hand, upper-extremity and peripheral nerve surgeon, said the distinction becomes especially important when pain is accompanied by mechanical dysfunction. Consider a patient with knee instability caused by ligament damage. A nerve stimulator might reduce pain, but it cannot restore the stability of the joint. Leaving that instability unaddressed could allow further damage to develop.
The same challenge arises after joint replacement. A patient with a painful knee or hip implant might be referred for nerve stimulation when the actual problem involves instability or another potentially correctable complication. A physician focused on pain relief may see an opportunity to manage symptoms. An orthopedic surgeon familiar with the mechanics of the joint may see an opportunity to correct the problem.
“If all you have is a hammer and that hammer is the PNS, everything looks like a nail,” Dr. Doering said.
The hidden cost of the wrong procedure
The consequences can extend well beyond an unsuccessful implant.
In the shoulder case Dr. Doering described, the patient endured continued pain and impaired function before ultimately undergoing the replacement he needed. Removing the nerve stimulator added complexity to the operation. For the patient, that meant additional treatment and time spent living with a condition that had not been resolved.
For the healthcare system, the surgeons see the potential for unnecessary spending as more devices are implanted without sufficiently comprehensive evaluations.
Peripheral nerve stimulation involves device, procedural and follow-up costs. When it is used for a condition that could have been addressed through another intervention, those expenses may be incurred without eliminating the need for subsequent treatment.
Dr. Doering also raised concerns about the financial implications for Medicare and other government-funded insurance programs. Implanting costly nerve stimulators as an initial treatment, rather than first addressing potentially correctable conditions, could drive up healthcare spending without resolving the underlying problem.
The issue is especially consequential as adoption grows. Dr. Kilbride recalled that when he and Dr. Doering began performing peripheral nerve stimulation approximately five years ago, relatively few orthopedic surgeons were offering the procedure. Both have since watched interest expand.
Yet greater access does not automatically produce better care. If the procedure becomes an early intervention rather than an option considered after appropriate diagnostic evaluation, the surgeons worry that more patients could undergo implantation without first exploring treatments that address the source of their symptoms.
Dr. Kilbride said some physicians can begin performing the procedure after relatively brief training and adjustments to their surgical privileges. He believes more extensive education and oversight are needed.
The technical steps, both surgeons emphasized, are only part of the challenge. “The insertion and the placement of the device is not the hard part,” Dr. Doering said. The harder work happens before the patient enters the procedure room: establishing the diagnosis, weighing alternatives and deciding whether stimulation is appropriate at all.
The screening requirement surgeons want to rethink
One of the clearest examples of what the surgeons consider misplaced oversight involves preprocedural evaluations. Certain commercial insurance policies require psychological screening before peripheral nerve stimulation, an approach the surgeons said was influenced by standards developed for spinal cord stimulation.
Drs. Doering and Kilbride question why patients may be required to undergo that assessment without necessarily receiving an evaluation from a specialist who treats the anatomical condition causing their pain.
Dr. Kilbride pointed to the contrast with major orthopedic operations.
“We can replace someone’s entire knee or shoulder without requiring a psychological evaluation,” Dr. Kilbride said. “But to place a single wire around their knee, we need one.”
Their proposal is to incorporate a condition-specific specialist assessment into the approval process. A patient seeking nerve stimulation for shoulder pain, for example, could undergo an orthopedic evaluation to determine whether arthritis, a rotator cuff injury or another structural problem warrants treatment. Someone with a neurological condition could receive input from a neurologist or neurosurgeon.
The surgeons are not suggesting that psychological considerations have no place in chronic pain care. Rather, they argue that such screening cannot substitute for identifying the underlying medical problem. A patient can be psychologically prepared for an implanted device and still be a poor candidate for that particular treatment.
Dr. Doering said a specialist evaluation could help confirm the indication and establish whether a better alternative exists. Dr. Kilbride suggested that, depending on the circumstances, even a consultation between physicians might be sufficient to identify an overlooked treatment option.
The goal, they said, is not to create an orthopedic monopoly over nerve stimulation.
“We’re not saying these procedures should be limited to orthopedic surgeons,” Dr. Doering said. Instead, they want physicians with relevant diagnostic expertise involved before an implant is placed.
Who should be allowed to implant?
The debate comes as medicine reexamines who should be qualified to perform emerging minimally invasive procedures.
On Oct. 2, the American Society of Pain and Neuroscience called for a national credential tying physicians’ procedural privileges to demonstrated competence rather than specialty training alone. The society warned that minimally invasive spine techniques are advancing faster than traditional training programs can adapt.
Its proposed framework would assess physicians across seven competency domains, including anatomy, patient selection and complication management, with requirements scaled to procedural risk.
Although the proposal focuses on spine procedures, it reflects the same tension emerging in nerve stimulation: How can medicine expand access to new treatments without compromising patient safety?
Dr. Kilbride believes nerve stimulation requires more rigorous training and oversight than a weekend course. But technical proficiency addresses only part of the problem. A physician may know how to implant a device without recognizing an unstable joint or failed reconstruction that requires a different intervention.
For hospitals and ASCs, that distinction raises questions about credentialing, procedural privileges and when specialist consultation should be required. For insurers, it raises another: Are existing coverage requirements doing enough to ensure patients receive the right treatment?
The next test is proving value
Neither surgeon wants to slow innovation. Both see peripheral nerve stimulation as a valuable option for patients who have exhausted conventional treatments or cannot safely undergo surgery.
Dr. Doering described one patient with an entrapped saphenous nerve following ligament reconstruction who had already undergone two operations. He was considering nerve stimulation alongside further surgical exploration, the kind of complex case where he believes the technology has a meaningful role.
Dr. Kilbride expects adoption to continue growing, but said that expansion must be accompanied by stronger outcomes data across specialties.
“We need to continue to collect our data,” he said, “and show numbers that these things are working, they are safe, and patients are really getting benefit from them.”
For Drs. Doering and Kilbride, the future of nerve stimulation depends as much on restraint as innovation. The technology may offer relief when other treatments fall short, but its growing accessibility makes careful patient selection increasingly important.
The patient whose shoulder ultimately needed replacing illustrates the stakes: A device can be implanted successfully, yet still delay the treatment a patient actually needs.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
