Chronic pain, defined as pain that persists or recurs for more than 3 months, is one of the leading causes of disability worldwide, significantly impacting quality of life, work productivity, and healthcare systems. The World Health Organization (WHO) recently recognized chronic pain as a standalone disease category in the ICD-11, emphasizing its significance beyond just a symptom. To date, chronic pain affects over 50 million adults in the United States, with nearly 20 million experiencing high-impact chronic pain.
Discussions around treating chronic pain, as well as revolutionizing individual therapeutic selection, was a major focal point at the 2025 Peripheral Nerve Society (PNS) Annual Meeting, held earlier this year in Vienna, Austria. Following the meeting, NeurologyLive® reached out to Nester Tomycz, MD, director of neurosurgical pain division at Allegheny Health Network, to discuss a few related topics around ways to treat chronic pain, especially as more novel neurosurgical approaches come into play.
Tomycz, who also serves as director of Stereotactic/Functional Neurosurgery, detailed his clinical path into pain medicine and the evolving use of neuromodulation strategies such as spinal cord and peripheral nerve stimulation. In the interview, he outlined how technological improvements in implant hardware and software are enhancing patient outcomes and access, especially in cancer-related and neuropathic pain. In addition, he spoke on the consideration for opioid-free options, as well as the need for scalable approaches and cross-specialty collaboration to expand the reach of neurosurgerical pain care.
NeurologyLive: How did you get involved with pain medicine?
Nester Tomycz, MD: I’m a neurosurgeon, and I trained under a neurosurgeon who did a lot of pain management. So, during my training, I did a lot of chronic pain management from the surgical side of things and was really excited about the technological advancements in surgery for chronic pain. I do a lot of spinal cord stimulation, peripheral nerve stimulation, dorsal root ganglion stimulation, and I also do deep brain stimulation.
I think having seen the opioid epidemic kind of develop during my training led me to start studying deep brain stimulation for opioid addiction, and I implanted a patient a couple years ago. So we’re studying that indication, which is still emerging. But I see many patients who are trying to come off opioids for multiple reasons, and that’s when I look toward electrical implants—different stimulators—to try to help them.
There’s been a lot of advances in the last five years, especially in software. The hardware continues to improve, but there’s been a lot more on the software side. So just like the AI explosion in other fields, I think in medicine, the software, the deep learning algorithms, and big-number data are really starting to affect the programming and how smart these devices are getting. That’s exciting. We have a lot more tools than I did when I was in training. I finished training in 2012, and the field has really exploded. There are a lot more companies involved, a lot more technologies.
Chronic pain is such a massive problem—it’s estimated to affect upwards of 100 million people in the country, depending on how you define it. Traditionally, I was seeing mainly patients who had back pain or leg pain after prior back surgery, but now I’m treating patients with abdominal pain, pelvic pain, chemotherapy pain, and different neuropathies.
One of my main interests has been cancer pain. It’s a great thing that people are living longer with cancer as treatments have improved, but we’re now seeing some of the sequelae of nerve damage from the treatment of cancer. We’re seeing patients who’ve survived their cancer, but treatment left them with nerve damage and chronic pain. So we’re developing treatments like spinal cord stimulation and would really like to study those treatments as well.
We have a very high-volume neuromodulation pain center here. I work closely with other neurosurgeons who are also interested in pain—Dr. Devan, Dr. Patterson, Dr. Flannery, Dr. Monica. There’s a big group of us that do chronic pain and neuromodulation neurosurgery. Pain management and neurosurgeons are working together. We also work closely with behavioral health experts, so we’ve developed an integrated Chronic Pain Center here at Allegheny, which is pretty exciting.
We’re all under one wing now—under neurosciences—which is new. Before, pain was kind of under anesthesia, but now the pain divisions have melded together with neurosciences. That’s exciting. There’s really no place in western Pennsylvania—and very few in the country—where neurosurgeons and pain management are integrated in the same health system. We have a shared mission to advance interventional pain and pain options for patients.
How do you decide which neurosurgical approach is right for which patient?
The first question I ask is: is there something fixable? As a neurosurgeon, I’m looking for a structural fix. If there’s a herniated disc or a pinched nerve that correlates with the pain, that’s where we recommend structural surgery.
But we often see patients who don’t have something amenable to an easy fix. Maybe they’re elderly, with severe spinal deformity, and the structural fix might be a 12-hour surgery. That’s too invasive. If non-surgical care hasn’t helped and surgery is too aggressive, neuromodulation—like spinal cord stimulation—can be a middle ground. It’s not fixing the problem per se, but it’s a palliative option that can reduce pain.
The patient’s goals are a big factor. Some want to come off opioids. Some want to avoid invasive surgery. In some cases, the damage—like nerve damage from chemotherapy, trauma, or radiation—is not repairable. We can repair nerves to some extent in 2025, but not completely. Once the nervous system is damaged, it often leads to chronic pain.
Medications for nerve pain aren’t great. Even neuropathic meds are still limited, and opioids aren’t effective either. Plus, some patients can’t take meds because of their jobs—bus drivers, pilots, etc.—so they need med-free treatments.
Not everyone can be “fixed.” Sometimes you have to say: yes, there’s a surgical fix, but it’s not reasonable at this point in your life. That’s part of the art of medicine—knowing when not to offer a fix. If we do something too invasive and the outcome is poor, that reflects badly on surgery as a whole. So, the challenge is finding what’s reasonable, what patients can tolerate, and what’s likely to lead to good outcomes.
Are there new clinical pathways or ways of evolving how neurosurgeons treat pain?
We’re trying to develop more streamlined pathways for patients. We feel that the earlier we get involved, the better the outcomes. A lot of times, we don’t see patients until it’s very late in the game. And they’re frustrated—especially with things like diabetic neuropathy—because they weren’t aware earlier that surgeries even existed for their condition.
There are meds for diabetic neuropathy, but many patients stop taking them within a year because of side effects. That leaves them with ongoing pain and morbidity. We implant stimulators for that, and we’re trying to access those patients sooner—so it doesn’t become a “last resort” therapy.
The longer chronic pain goes on, the harder it is to treat. It wears people down—physically, emotionally, functionally. We’ve even discussed intervening before pain becomes chronic, like immediately post-surgery when we know pain will be a problem.
Cancer pain is another example. We often don’t get involved until the end of life, but we know from the beginning that pain is going to be part of the story. So, we want to start that discussion much earlier.
That said, there are hurdles: insurance approvals, psychological evaluations, and device trial requirements. These are expensive interventions, so there’s a process we have to go through. These devices often pay for themselves over time—patients use fewer meds, fewer injections, fewer ER visits—but the upfront cost is high.
Can you elaborate on chemotherapy-induced neuropathy care and how it’s being managed?
I’m not a chemotherapy expert, so I can’t speak to specific agents, but I’ve seen many patients with severe chemotherapy neuropathy. And a lot of them have done really well with spinal cord stimulators.
There’s no medication specifically for chemotherapy neuropathy. They typically prescribe the same meds used for diabetic neuropathy—but it’s a different kind of pain. In my experience, it’s often more severe and more debilitating.
Early referral to a neurosurgeon familiar with stimulation is important. These stimulators don’t just reduce pain. They may also improve blood flow and sometimes even function.
One issue that held us back in the past was MRI compatibility. The old stimulators weren’t MRI-safe, which made oncologists wary. But now, with newer models, we can do full-body MRIs. That’s a huge improvement and removes a major barrier.
How do you see the broader field of interventional pain evolving, especially in light of the opioid crisis?
Anyone with chronic pain not doing well on meds should at least consider interventional options. There’s been a massive explosion in nerve stimulation and related technologies.
A lot of patients don’t know these options exist until they find us. Others are hesitant—they think they won’t get insurance approval or that they aren’t candidates. But I’ve done over 1,000 implants in the last 12 years, and I’ve seen so many different types of pain conditions respond to electrical stimulation.
Opioids, especially in young people, carry major risks. If someone’s on escalating opioids, they really should be thinking about how to come off them. The field of pain medicine has changed. We’re much more cautious with opioids now, but it’s still a huge issue.
You can’t just tell someone to stop opioids when they’re in pain. You have to give them something else—an alternative. And these implants are one of those tools. Reducing opioid use may be even more impactful than lowering pain scores.
We’re not necessarily curing pain. People still have chronic pain. But if we can reduce it to the point where they no longer need opioids, that’s a major win—for fertility, for organ health, for immune function. Helping someone come off opioids is huge, and it’s one of the most important goals we focus on.
Transcript edited for clarity. Click here for more PNS 2025 coverage.