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How I Do It: Restorative Neuromodulation for Chronic Low Back Pain

Nov 9, 2025, 18:38 by Joseph Liao, MD, and Michael S. Leong, MD

Cite as: Liao J, Leong MS. How I do it: restorative neuromodulation for chronic low back pain. ASRA Pain Medicine News 2025;50. https://doi.org/10.52211/asra110125.016.

How I Do It

Introduction

Chronic axial low back pain (LBP) is a prevalent and disabling condition worldwide.1 In a subset of patients, dysfunction or atrophy of the lumbar multifidi muscles contributes to persistent pain and/or segmental instability.2 The lumbar multifidi are essential for spinal stabilization, movement control, proprioception, nociception, core stability, and protection against lumbar injury.3-5 Dysfunction may be primary or secondary to chronic lumbar spondylosis, inactivity, deconditioning, prior denervation procedures, or surgical instrumentation.

Restorative neuromodulation of the lumbar multifidi is a specialized form of peripheral nerve stimulation designed to re-educate and re-engage low back musculature, thereby improving neuromuscular function and reducing pain.6 This is achieved via stimulation of the L2 dorsal ramus medial branches to re-engage the lumbar chain.

Conventional LBP treatments—physical therapy, medications, steroid injections, and radiofrequency ablation—are primarily palliative. Surgical options range from neuromodulation (spinal cord stimulation, dorsal root ganglion stimulation) to fusion procedures. Restorative peripheral nerve stimulation offers a rehabilitative approach that may reduce the need for repeat interventions or surgeries.

Currently, an implantable restorative neuromodulation system targeting lumbar multifidus dysfunction has been approved by the FDA.2 Unlike other peripheral nerve or spinal cord stimulator systems that use sensory stimulation to decrease the perception of pain, this system specifically uses motor stimulation to promote neuromuscular re-education and functional rehabilitation.2

This article describes our technique for bilateral lead placement and internal pulse generator (IPG) implantation under fluoroscopic guidance, with intraoperative motor testing to ensure optimal placement.

Procedural Goal

Activate the lumbar multifidus network by stimulating the L2 dorsal ramus medial branches using bilateral leads secured to the L2–3 intertransversarii muscles.

Table 1. Characteristics of Ideal Candidates for Restorative Neuromodulation for Chronic Low Back Pain
Ideal Candidate
≥ 6 months of axial LBP
MRI evidence of multifidus atrophy or dysfunction
Failure of conservative management (eg, physical therapy, medications)
No untreated radicular pain
Psychological suitability for neuromodulation
Positive provocative physical exam findings:
  • Multifidus Toe Touch Test – motor control dysfunction
  • Prone Instability Test – painful dynamic instability
  • Multifidus Lift Test – multifidus activation dysfunction
Figure 1. Provocative physical exam findings and magnetic resonance imaging findings associated with multifidus dysfunction.
Image obtained from Mainstay Medical

Anesthetic and Positioning Considerations

The procedure is performed under monitored anesthesia care or general anesthesia. Intraoperatively, multifidus muscle contraction is tested. If paralytics were used for general anesthesia, then reversal agents for neuromuscular blockers should be available. Preoperative antibiotics must be given routinely as there are incisions involved.

The patient should be in the prone position with one or two pillows or a positioning device under the abdomen to reduce lumbar lordosis. The arms should be untucked and placed in “superman” position to optimize the lateral view on fluoroscopy.

Table 2: Recommended Equipment for Implantation of Restorative Neuromodulation System
Recommended Tools
Imaging
  • Fluoroscopy
Local anesthetics
  • Lidocaine 1% with 1:100,000 epinephrine
  • Bupivacaine 0.5% with 1:200,000 epinephrine
Intraoperative tools
  • 25 or 22G spinal needles x2
  • #11 scalpel; #10 or #15 scalpel
  • Electrocautery
  • Suction
Device kit
  • Guide needles x2
  • Introducer sheaths x2
  • Dilators x2
  • Leads x2
  • Internal pulse generator (IPG)
Irrigation
  • 500ml preservative-free saline ± antibiotics
Closure
  • 2-0 deep fascial sutures
  • 4-0 subcuticular sutures
  • Topical skin adhesive
  • Sterile dressings

 

Table 3: Optimal Imaging Views to Facilitate Safe Implantation with Reliable Landmarks
Fluoroscopic Views
True Poster-Anterior (PA) View
  • Centered at L3–L4
  • Spinous process (SP) midline at L3
  • Alignment of L3 superior endplate (SEP)
  • Identification of L3 transverse process (TP)-superior articular process (SAP) junction
True Lateral View
  • Centered at L2–L3
  • Identification of L2–3 neural foramen
  • Visualization of the inferior dorsal L2 body
Ipsilateral Oblique View (optional)
  • Useful for navigating around existing hardware (~5°)

Step-by-Step Technique

  1. Obtain PA view centered at L3, visualizing L2 and L4.
  2. Place marker 22G or 25G spinal needles bilaterally at L3 TP–SAP junction; confirm tip at superior TP border on the lateral view.
Figures 2 and 3. PA and lateral views of marker spinal needles at L3 TP-SAP junction.
  1. Infiltrate L3–L4 interlaminar space; make 2–4 cm vertical midline incision just cephalad to L4 SP with cutdown to spinous process.
  2. Create a 3–4 cm diameter inferolateral tension-relief loop pocket via finger dissection towards the anticipated IPG site.
  3. In PA view, introduce guide needle just off midline from the superior L4 SP border towards the ipsilateral L3 TP–SAP junction marker; in lateral view, advance anteriorly to TP to traverse L2–L3 intertransversarii (~45°).
Figures 4 and 5. Red circle = entry point of guide needle just off midline of superior L4 SP border in PA view. Green circles = trajectory from L3 superior TP to L2 dorsal inferior vertebral body in the lateral view.

  1. In the lateral view, advance the guidewire towards the inferior dorsal L2 body; adjust depth if resistance is encountered. Prior to removing the guide needle and exchanging for the introducer sheath/dilator, use a #11 scalpel to make a stab incision along the guide needle trajectory adjacent to the L4 SP to create room for the introducer sheath/dilator.
  2. Advance introducer sheath/dilator over guidewire past TP; remove guidewire/dilator.
Figure 6. Introducer sheath/dilator advanced over the guidewire towards the L2 dorsal inferior vertebral body in the lateral view.
  1. Insert lead anterior to TP; retract introducer sheath to deploy lead and confirm tine engagement around intertransversarii via push–pull test under low-dose live fluoroscopy in lateral and AP view.
Figure 7. Introducer sheath retracted with lead overlying the anterior L3 TP and deployed in the L2-3 intertransversarii.
  1. Repeat on the contralateral side.
  2. Test impedances and motor responses; reverse paralytics if needed.
  3. Create an IPG pocket; tunnel leads from the inferolateral tension-relief loop pocket to the IPG pocket; test impedances and motor responses again with the IPG in the IPG pocket.
  4. Form tension-relief loops without sharp bends or significant friction points; tuck the loop into the tension-relief loop pocket.
Figure 8. Final position of bilateral leads with tension-relief loop in situ.
  1. Irrigate, close with layered sutures, and apply adhesives and dressing.

Post-operative Care

This is typically a same-day, outpatient surgical procedure. Postoperative antibiotics are usually recommended per Neurostimulation Appropriateness Consensus Committee guidelines.7

Best practices require a 1-week postoperative follow-up for a routine wound check, followed by a 2-week postoperative check when the device is turned on. The device is turned on at the 2-week postoperative appointment to optimize soft tissue recovery before activation of the multifidi muscles. The device company facilitates the programming to optimize muscular contraction at a duration and frequency tailored to individual patients.2,6

Recommended activity precautions focus on limiting rigorous activities that may result in lead migration, such as repetitive bending, lifting, and twisting, during the first 4 to 6 weeks. Furthermore, preventing moisture from entering the incision sites will reduce the risk of infection.

Outcomes

Longitudinal targeted multifidi activation via stimulation of the L2 medial branch nerves promotes neuromuscular re-education and rehabilitation of the lumbar spine. Restorative neuromodulation through this methodology decreases disability, increases functionality, and reduces chronic low back pain.

Joseph Liao, MD, is a clinical assistant professor in the department of anesthesiology in the pain management division at Stanford University in California.
Michael S. Leong, MD, is a clinical professor in the department of anesthesiology in the pain management division at Stanford University in California.

References

  1. Lucas JW, Connor EM, Bose J. Back, Lower limb, and upper limb pain among U.S. adults, NCHS Data Brief, No. 415, National Center for Health Statistics, 2021. https://doi.org/10.15620/cdc:107894
  2. Gilligan C, Volschenk W, Russo M, et al. Five-Year longitudinal follow-up of restorative neurostimulation shows durability of effectiveness in patients with refractory chronic low back pain associated with multifidus muscle dysfunction. Neuromodulation 2024;27(5):930-43. https://doi.org/10.1016/j.neurom.2024.01.006
  3. Ward SR, Eng CM, Gottschalk LJ, et al. The architectural design of the lumbar multifidus muscle supports its role as stabilizer. J Biomech 2006; 39:S101.
  4. Kim C, Gottschalk C, Eng SW, et al. The multifidus muscle is the strongest stabilizer of the lumbar spine. Spine J 2007;7(5):76S.
  5. Rosatelli AL, Ravichandiran K, Agur AM. Three-Dimensional study of the musculotendinous architecture of lumbar multifidus and its functional implications. Clin Anat 2008;21(6):539-46.https://doi.org/10.1002/ca.20659
  6. Gilligan C, Volschenk W, Russo M, et al. Long-Term outcomes of restorative neurostimulation in patients with refractory chronic low back pain secondary to multifidus dysfunction: two-year results of the ReActiv8-B pivotal trial. Neuromodulation 2023;26(1):87-97. https://doi.org/10.1016/j.neurom.2021.10.011
  7. Deer TR, Russo MA, Grider JS, et al. The Neurostimulation Appropriateness Consensus Committee (NACC): recommendations for surgical technique for spinal cord stimulation. Neuromodulation 2022;25(1):1-34. https://doi.org/10.1016/j.neurom.2021.10.015
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