Clinical Policy Bulletin: Dorsal Column Stimulation

A. Failed back surgery syndrome with low back pain and significant radicular pain; or B. Complex regional pain syndrome (also known as reflex sympathetic dystrophy); or C. Inoperable chronic ischemic limb pain secondary to peripheral vascular disease; or D. Last resort treatment of moderate to severe (5 or more on a 10-point VAS scale) chronic neuropathic pain of certain origins (i.e., lumbosacral arachnoiditis and radiculopathies, phantom limb/stump pain, peripheral neuropathy, post-herpetic neuralgia, intercostal neuralgia, cauda equina injury, incomplete spinal cord injury, or plexopathy) that is refractory to 12 or more months of standard therapy (including non-steroidal anti-inflammatory drugs, tricyclic antidepressants, and anticonvulsants).