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Spinal Cord Stimulation: Comparing Traditional Low-frequency Tonic Waveforms to Novel High Frequency and Burst Stimulation for the Treatment of Chronic Low Back Pain


Purpose of Review

The purpose of the present investigation is to summarize supporting evidence for novel sub-perception spinal cord stimulation (SCS) therapy over traditional paresthesia inducing low-frequency waveforms for the treatment of chronic pain. The focus of this review is to summarize key studies comparing traditional low-frequency tonic waveforms to modern high frequency and burst stimulation for the treatment of patients with chronic intractable low back pain and/or leg pain.

Recent Findings

Several recent studies have demonstrated the benefit of novel SCS therapies over traditional low-frequency SCS for the treatment of patients with chronic low back and/or leg pain. SENZA-RTC showed that paresthesia-free high-frequency SCS was superior to low-frequency stimulation for treatment of chronic low back pain with leg pain. The SUNBURST crossover trial recently found that high-frequency burst stimulation was preferred over low-frequency tonic SCS with patients citing better pain relief and a preference for paresthesia-free SCS. The new ongoing EVOLVE workflow retrospective multicenter study uses technology that can deliver both low-dose and high-dose SCS. Further, the wavewriter technology addresses patient variability with its ability to layer sub-perception waveforms and paresthesia inducing low-frequency stimulation tailored to patient needs via an interactive feedback feature.


Neuromodulation for the treatment of chronic pain is rapidly evolving with technology at its forefront. Modern SCS systems use novel waveforms, frequencies, and stimulation modes to deliver paresthesia-free pain relief to patients suffering from chronic low back pain and/or leg pain with better results than traditional tonic low-frequency SCS. As the field advances, new studies are needed comparing new waveform and delivery systems to optimize patient selection and treatment response.

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Papers of particular interest, published recently, have been highlighted as: •• Of major importance

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Correspondence to Richard D. Urman.

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Conflict of Interest

Ariel Morales declares no conflict of interest. R. Jason Yong, MD MBA serves as a consultant for Nevro and Medtronic. Alan D. Kaye, MD PhD serves on the Speakers Bureau of Depomed and Merck. Richard D. Urman MD MBA received research funding from Medtronic, Merck, Mallinckrodt and an honorarium from 3M and Sandoz.

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Morales, A., Yong, R.J., Kaye, A.D. et al. Spinal Cord Stimulation: Comparing Traditional Low-frequency Tonic Waveforms to Novel High Frequency and Burst Stimulation for the Treatment of Chronic Low Back Pain. Curr Pain Headache Rep 23, 25 (2019).

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  • Waveform
  • Spinal cord stimulator
  • Back pain
  • Frequency
  • Outcomes