Case Report: Beyond chronicity: sustained multidimensional response to spinal cord stimulation three decades after traumatic spinal cord injury.

Introduction: Spinal cord stimulation (SCS) is an established treatment for refractory neuropathic pain conditions, yet evidence for its effectiveness in spinal cord injury (SCI)-related neuropathic pain, particularly after decades of persistent symptoms, remains limited. It remains unclear whether unusually prolonged pain chronicity and established neurological deficits affect the potential for a meaningful response to neuromodulation. Case presentation: We report a 60-year-old man with chronic incomplete SCI, bilateral spastic paraparesis markedly more pronounced on the left, and severe chronic neuropathic pain following a gunshot-related spinal injury sustained in 1991. Retained metallic fragments were located at T12-L1; however, a formal neurological level of injury and AIS grade could not be reliably reconstructed because a complete contemporaneous ISNCSCI examination was unavailable. The longstanding bilateral lower-extremity pain phenotype was clinically consistent with below-level SCI neuropathic pain, although formal classification was limited by the absence of an ISNCSCI-defined neurological level. After more than three decades of persistent pain refractory to multimodal conservative treatment, permanent SCS was performed with two epidural leads positioned at T8-T9. Stimulation was predominantly DTM-based, supplemented by individualized tonic programming and later activation of closed-loop stimulation. Pain intensity decreased from 8/10 at baseline to 3/10 at 12 months and 2/10 at 24 months. This sustained response was accompanied by improvements in self-reported disability, neuropathic pain features, self-rated health, and psychological well-being, together with sustained discontinuation of pain-directed pharmacological therapy. No neurological deterioration or device-related complications occurred during the 24-month follow-up. Conclusion: This case demonstrates that a clinically meaningful and sustained multidimensional response to SCS can occur despite more than three decades of SCI-related neuropathic pain and established neurological impairment. Given the limited and heterogeneous evidence for SCS in this population, interpret this finding as an individual clinical observation supporting further investigation of neuromodulation in patients with longstanding SCI-related neuropathic pain, rather than as generalizable evidence for patient selection.