Peripheral nerve stimulation (PNS) has emerged as a minimally invasive neuromodulation option for focal pain syndromes.3 While spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation are well established for specific indications of use, PNS occupies a narrower and continually developing clinical niche. Despite the development of minimally invasive percutaneous systems that can be placed to target peripheral nerves with ultrasound and fluoroscopic guidance, widespread adoption remains limited.

PNS delivers electrical stimulation to peripheral nerves to modulate afferent pain signaling. Unlike SCS or DRG, which provide broad regional vs lumbar dermatomal coverage, PNS is anatomically targeted to specific peripheral nerves to produce focal effects.7,10

Emerging evidence suggests that PNS neuromodulation occurs through interaction with neural pathways via effects on endogenous neurotransmission and interactions with the central nervous system which may affect neuroplasticity and pain perception.5,8,9

Peripheral nerve stimulation should be considered for chronic pain persisting greater than 3 months when more conservative management has been failed.10 The pain should be severe in nature and affect daily function. To be a candidate for this treatment, there should be no medically or surgically correctable etiology of pain. Additionally, all other conservative and less invasive treatments should have been attempted first, including physical therapy, interventional injections, and medications. Patients who benefit from PNS are typically not ideal candidates for SCS or DRG. PNS is best suited for patients with localized pain corresponding to one or two peripheral nerves.7,10

Diagnostic blocks are not considered to be requisite or predictors of response, however a trial with a temporary PNS system is performed prior to consideration for permanent PNS placement. Temporary PNS stimulators are implanted for a set period of time after which they are removed.10

Common targets for PNS include axillary and suprascapular nerves for shoulder pain; femoral and obturator nerves for hip pain; sciatic nerve or distal branches for lower extremity or phantom limb pain; occipital nerve for migraines, and multifidus stimulation via medial branch targeting can be used for chronic axial low back pain.1,2,6,7,10

A recent systematic review and meta-analysis suggest PNS efficacy although this is level III evidence with moderate certainty on the GRADE scale.3 Another systematic review of studies including outcomes put to 24 months suggests low certainty evidence based on the GRADE scale.4 However, the evidence base for PNS is evolving. Individual study limitations in evaluating for efficacy are due to small sample sizes, lack of equivalent control groups, short follow-up duration, study design, and heterogeneity within individual studies. The recently published RESET Trial (McCormick et al, 2026) is one of the largest randomized controlled trials so far with 230 patients enrolled and a focus on 60 days PNS for low back pain.2  The 230 patients with chronic low back pain were randomized to 60-day percutaneous PNS of the lumbar medial branches or physician-directed usual care with standard interventional management. At the primary clinical endpoint of 3 months, 55% of PNS recipients achieved ≥50% reduction in pain intensity compared with 26% in the usual care group. Pain reductions and functional improvements in the PNS group were sustained through 6 months. Generalizability to other PNS indications is limited by the trial’s exclusive focus on axial low back pain and the use of a temporary 60-day system rather than permanent implantation. 12 month results from the COMFORT trial evaluating PNS efficacy for low back, knee, shoulder, or foot/ankle pain (Hathaway et al, 2024) demonstrated 86-89% responder rate in the 61 patients remaining in the trial of the original 89 initially randomized some of whom crossed over into the treatment group.1  Small sample size and heterogeneity were significant limitations in this study.

PNS lead placement may be performed under ultrasound guidance, which allows direct visualization of the target nerve, surrounding vasculature, and soft tissue planes, and facilitates real-time adjustment of needle trajectory and lead position. For many peripheral nerve targets, ultrasound is preferred due to its precision and avoidance of radiation exposure. However, fluoroscopy remains appropriate, and is often preferred, when targeting nerves with consistent and predictable anatomic relationships to bony landmarks. Fluoroscopy may also be used in cases of challenging anatomy, body habitus, or poor ultrasound visualization. In practice, a combined ultrasound and fluoroscopic approach may be used to optimize both nerve localization and confirmation of final lead position.

Specific nerves that can be targeted via fluoroscopy due to predictable bony anatomic relationships include the suprascapular nerve, axillary nerve, cluneal nerves, occipital nerves, and genicular nerves.

Most temporary PNS procedures can be completed in 15–30 minutes. Permanent implants are more time-consuming but can typically be completed in under 30-60 minutes depending on proceduralist experience and anatomic complexity. Optimal lead placement typically involves positioning the lead parallel to the target nerve when feasible and maintaining an appropriate distance to achieve effective stimulation while minimizing discomfort. Placement across highly mobile joints is avoided to reduce the risk of lead migration or fracture.

Temporary PNS systems, typically deployed for approximately 60 days, offer a less invasive option and may provide sustained benefit after removal, making them particularly appealing for patients hesitant about permanent implantation or when long-term response is uncertain. Permanent systems require implantation of leads and an implantable pulse generator (IPG) and involve greater procedural complexity, including considerations for lead anchoring, tunneling, and generator placement.

Clinical decision-making regarding PNS is influenced by several factors, including uncertainty regarding long-term outcomes, patient perception of implantable devices, and barriers to access. Additional studies are needed to evaluate long-term outcomes beyond 12 months and to better correlate outcomes with specific pain diagnoses.

Patient perception plays a significant role in the broader adoption of PNS, particularly given the implantable nature of these systems and the limited availability of long-term outcome data. Most patients are unfamiliar with PNS and are often first introduced to the concept during a specialty consultation, which can contribute to uncertainty. Adverse events of concern with PNS systems may include lead breakage, lead migration, infection, and battery malfunction.3 The conceptual nature of neuromodulation, combined with the need for device implantation, variable long-term evidence, and potential risks represents a meaningful barrier to acceptance.

For patients who are otherwise appropriate candidates for PNS and interested in proceeding, insurance coverage remains a significant limitation. While Medicare provides defined coverage pathways, many commercial insurers continue to classify PNS as investigational. This disproportionately restricts access for younger, more active patients—those most likely to benefit from pain relief in terms of functional restoration and participation in daily activities.

Coding for PNS varies based on the type of system used. Pre-2024 CPT codes, which remain in active use, reflect the traditional two-component design of most PNS systems. Code 64555 is used for percutaneous lead implantation, and code 64590 describes pocket creation, tunneling, and placement of the implantable pulse generator (IPG).

In 2024, new codes were introduced to account for integrated systems in which the electrode array and neurostimulator are implanted as a single unit. CPT code 64596 describes implantation of an electrode array with an integrated neurostimulator. For integrated systems, add-on code +64597 is used for each additional implanted electrode array, and CPT 64598 is used for revision or removal of an integrated system.

It is important to note that the majority of PNS systems on the market are two-component systems; therefore, CPT 64555 and 64590 remain the more commonly used PNS codes.