Evidence-Based Clinical Practice Guidelines on Implantable Peripheral Nerve Stimulation for Chronic Pain: A Consensus Report From a Multispecialty Working Group of the North American Neuromodulation Society.

OBJECTIVES: Although the clinical use of peripheral nerve stimulation (PNS) has increased rapidly, regulatory labeling remains broad and non-indication-specific. We aimed to conduct a comprehensive evidence appraisal of implantable PNS for defined anatomical and indication-specific chronic pain conditions and to generate stratified recommendations informed by the quality, strength, and certainty of the evidence. MATERIALS AND METHODS: The North American Neuromodulation Society convened a multidisciplinary expert panel with conflict-of-interest governance. A systematic literature search of Ovid MEDLINE®, Embase, Cochrane CENTRAL, and Scopus was conducted through July 1, 2025, with an additional manual search conducted on July 30, 2026. Eligible studies evaluated implantable temporary or permanent PNS systems for any chronic pain indication. Primary outcomes included pain intensity and physical function. Studies were stratified by anatomical region (craniofacial and neck, upper extremity, lower extremity, truncal, and pelvic). Via a modified Delphi consensus approach, evidence was graded using United States Preventive Services Task Force recommendation grades and levels of certainty. RESULTS: Recommendation strength varied substantially by anatomical location and indication. Grade A recommendations were assigned to hemiplegic shoulder pain, lower extremity postamputation pain, nonsurgical axial low back pain, and low back pain associated with multifidus dysfunction, whereas grade B recommendations were assigned to cluster headache, facial herpes zoster-related neuralgia, occipital neuralgia, trigeminal neuropathic pain, shoulder osteoarthritis, chronic postsurgical knee pain, lower extremity mononeuropathy, cluneal neuralgia, and pudendal neuralgia. For several other nociplastic and visceral pain conditions, the evidence was insufficient or suggested a small net benefit. Functional outcomes were reported inconsistently across studies. Clinical and methodological heterogeneity were observed, and the durability of relief varied by indication and device type, limiting the certainty of evidence. CONCLUSIONS: This guideline provides neural target-specific and pain syndrome-specific recommendations to inform clinical practice and payer policy. Implantable PNS therapy may be offered to patients with specifically defined chronic pain conditions, as defined in this guideline, after conservative measures have failed to provide meaningful relief for at least three months. However, limited or uncertain benefit of PNS was observed for various nociplastic and visceral syndromes. Future research should prioritize neural target- and pain syndrome-specific randomized clinical trials, standardized multidimensional outcomes, phenotype-driven stratification, and long-term durability assessment to continue refining the role of PNS in chronic pain management.