A Care-Level-Stratified Algorithm for Neuromodulation in Persistent Spinal Pain Syndrome Type 2: Critical Appraisal of Contemporary Evidence Adapted to Latin American Health Systems

Persistent spinal pain syndrome type 2 (PSPS-T2), the mechanism-based successor to failed back surgery syndrome (FBSS) and a recognized International Classification of Diseases 11th Revision (ICD-11) entity, affects 10%-40% of patients after spinal surgery and is among the most refractory conditions in pain medicine.The past decade has produced a technological expansion in neuromodulation, with nextgeneration modalities (10-kHz high-frequency stimulation (HF10; Nevro Corp., Redwood City, CA), burst stimulation (Abbott, Plano, TX), differential target multiplexed (DTM) stimulation (Medtronic, Minneapolis, MN), evoked compound action potential-controlled closed-loop stimulation (ECAP-CL; Saluda Medical, Artarmon, Australia), dorsal root ganglion stimulation (DRG-S; Abbott, Plano, TX), and restorative neurostimulation (ReActiv8; Mainstay Medical, Dublin, Ireland)) each supported by randomized controlled trials (RCTs).We conducted a narrative review designed to meet the Scale for the Assessment of Narrative Review Articles (SANRA) quality criteria, searching five databases (January 2020 to April 2026) to critically appraise this evidence, including negative results and methodological controversies, and to propose a mechanism-directed treatment algorithm stratified by level of care and adapted to the heterogeneous resource landscape of Latin American health systems.Pivotal trials report responder rates of approximately 74%-78% at 12-36 months, with superiority over conventional stimulation; however, these estimates derive from trials that differ in population, comparator, and follow-up, and several enrolled populations only partially overlapping with PSPS-T2 (e.g., complex regional pain syndrome or non-surgical mechanical low back pain).The single independent, placebo-controlled crossover trial (of burst stimulation) found no benefit on its primary disability outcome, underscoring the field's near-total reliance on manufacturersponsored studies.On this basis, we propose a three-tier algorithm (primary, secondary, and tertiary care) that rests on Oxford Centre for Evidence-Based Medicine (OCEBM) level 1-2 evidence for individual modality efficacy and on expert consensus (OCEBM level 5) for the stratification itself.The algorithm is intended as a pragmatic, resource-sensitive decision-support scaffold requiring local adaptation and prospective regional validation.Equitable access to neuromodulation across Latin America remains a first-order ethical and health-policy priority.