Toward Closed-Loop PNS and the Translational Reality Check

Peripheral nerve stimulation has re-entered the mainstream of pain management, but the technology itself is evolving faster than the frameworks clinicians use to deploy it. New waveform paradigms-high-frequency, burst, and prepolarizing pulse trains-are being explored for their ability to selectively recruit specific fiber populations and modulate pain transmission through distinct mechanisms of action. Electrode and lead design is advancing alongside them: smaller form factors, wireless architectures, and multi-contact arrays are changing where and how peripheral nerves can be targeted. At the same time, computational modeling, machine learning-driven parameter optimization, and early closed-loop concepts are beginning to offer a path from empirical programming toward personalized stimulation "dosing." This panel brings together functional neurosurgeons, clinician-scientists, and interventional pain physicians to examine what is genuinely new in PNS and what it means for clinical practice. The session opens with a mechanistic foundation: how different waveforms and electrode configurations interact with peripheral nerve fiber types, and why understanding mechanism of action matters for selecting stimulation strategies. From there, faculty address four interconnected domains of innovation. First, advances in lead design and miniaturization-including wireless and injectable systems-and how they expand the anatomic targets accessible to PNS. Second, emerging waveform strategies and what preclinical and early clinical data reveal about fiber selectivity and therapeutic windows. Third, computational and AI-driven approaches to parameter optimization, including surrogate fiber models that can explore the stimulation parameter space more efficiently than trial-and-error programming. Fourth, the translational reality check: what closed-loop PNS could plausibly look like in the near term, what safety and validation checkpoints must be cleared, and what would count as clinically meaningful improvement versus incremental novelty. Each segment pairs engineering science with clinical translation, ensuring the discussion stays grounded in what matters to the practitioner and the patient. Moderated Q&A will close the session.