{'fraction_non_alphanumeric': 0.01791713325867861, 'fraction_numerical': 0.0014930944382232176, 'mean_word_length': 5.4891041162227605, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Differentiating the Leaves From the Branches in the Tree of Neuromodulation: The State of Peripheral Nerve Field Stimulation

Within this issue of Neuromodulation, two articles focus on the subcutaneous placement of stimulating electrodes to activate unnamed peripheral nervous system targets for the treatment of intractable pain (1,2); two such articles appeared in our last issue as well (3,4). While the practice of what has become known by some as subcutaneous or peripheral field stimulation has grown tremendously over the past decade, there exists significant controversy concerning the taxonomy, anatomic rationale, techniques, longterm efficacy, and proper reimbursement strategies for these procedures. This controversy is more than simply of academic interest; our patients deserve to understand what to expect from these procedures, our field needs to know if and how best to perform them and those who fund healthcare demand to better understand the potential risks, benefits, and long-term efficacy of these potentially costly procedures. What is clear is that an increasingly large percentage of coaxial neurostimulation electrodes are being used for this unproven application. This results in part from the frustration of health-care providers with the poor outcome of traditional neurostimulation devices for specific recalcitrant chronic pain states, such as joint pain and axial back or neck pain. This also results from the relative ease and limited complications of this technique. Less clear is whether the performance of these procedures is to some extent reimbursement-driven, as trials are often performed in the office setting and quirks in the reimbursement for office-based neuromodulation procedures result in their extraordinarily high reimbursement relative to other sites of service. Further clear is that there is relatively little impetus on the part of industry to perform the high-quality, randomized controlled trials necessary to demonstrate long-term efficacy and outcomes, in that their products are already being sold in large numbers for this application. Such studies are expensive and both timeand personnel resourceconsuming. Furthermore, while positive data could lead to explicit approval by the U.S. Food and Drug Administration (FDA), with resultant reimbursement provided by the Centers for Medicare Services and other third party carriers leading to improved physician acceptance and growth of the procedure, negative data could lead to abandonment of the procedure. As product is already being sold for these applications on a large scale, in sum, I believe that industry is disincentivized to provide leadership in this area.