Spinal cord stimulation protocols for modern pain management: from two-stage models to direct-to-implant strategies

The direct-to-implant (DTI) approach to spinal cord stimulation (SCS) represents an emerging paradigm in the treatment of chronic neuropathic pain. Unlike the conventional two-stage models, which include a preliminary trial phase, the DTI strategy involves immediate permanent implantation in carefully selected patients. This article explores the rationale, clinical outcomes, and practical implications of adopting a single-stage implantation model. Drawing on recent evidence from randomized trials, real-world studies, health economic analyses, and patient preference data, this perspective highlights how the DTI approach may achieve comparable long-term pain relief and functional improvement while minimizing procedural burden, infection risk, and healthcare costs. It also discusses the essential role of rigorous patient selection and intraoperative assessment in ensuring safe and effective use of this model. The literature discussed was identified through non-systematic searches of PubMed, Scopus, and Google Scholar (January 2010-May 2025). By focusing on the clinical and economic value of DTI, this article challenges the assumption that a trial phase is universally necessary and proposes a more flexible, evidence-informed strategy for SCS implantation. As healthcare systems increasingly emphasize patient-centered and cost-effective care, the DTI strategy emerges as a practical and efficient option for managing chronic pain in carefully selected patients.