Introduction

Medical fields, as in other fields of scientific or intellectual endeavor, are advanced from an idea of necessity to reality only after those early adherents to the idea form associations to bring commonality of purpose to their association. As we shall see in this chapter, neuromodulation, ¹

1 Neuromodulation is defined by the INS as technology that acts directly upon nerves. It is the alteration—or modulation—of nerve activity by delivering electrical or pharmaceutical agents directly to a target area.

In this chapter, we start with the field of stereotactic and functional neurosurgery, because, for the most part, neurosurgery birthed the field of neuromodulation with the early advent of stereotactic techniques to localize therapies, including electricity to alter function in the brain. Dr. Slavin will discuss the beginnings of the World Society for Stereotactic and Functional Neurosurgery (WSSFN), which will be followed by short histories of the International Neuromodulation Society (INS) by Dr. Barolat and Mr. Simpson, because it was a few disgruntled, WSSFN, break-away neurosurgeons, in collaboration with a few neurologists and anesthesiologists, who founded the INS. The last section, but not certainly the least, will be a discussion on the history of the North American Neuromodulation Society (NANS) by Dr. Stanton-Hicks, a past president of NANS. NANS represents the largest chapter of the INS and the first national chapter of the INS.

Today, the INS is an interdisciplinary field with more than 2500 members, worldwide, and more than 25 international chapters, representing practitioners of neuromodulation within the four corners of our globe. The INS are made up of neuroscientists, biomedical engineers, members of relevant industry, and clinicians, possibly represented by physicians and health caregivers from every other medical specialty that exists. The INS has meetings and a journal, Neuromodulation , and both are active in disseminating basic and clinical information relevant to our field. Now, on to those histories.

Perspectives on the History of the Neuromodulations Societies: Societies for Stereotactic and Functional Neurosurgery

Konstantin V. Slavin

University of Illinois at Chicago, Chicago, IL, United States

Before neuromodulation practitioners had their own societies, before neuromodulation became available to nonsurgical specialists, before pain medicine had formed as a separate specialty, there was a time when neuromodulation was in an exclusive purview of neurosurgeons. And before that, the treatment of chronic pain, movement disorders, epilepsy, and other conditions that are now managed with neuromodulation was mainly based on targeted ablation of nervous tissue by neurosurgeons, the approach that is still used as a valuable alternative to neuromodulation. The entire field of surgical management of these so-called functional disorders was, and still is, a subspecialty of neurological surgery—functional neurosurgery. Surgical techniques of functional neurosurgeons have been traditionally based on precise anatomical and physiologic targeting, frequently in an anatomically normal brain and spinal cord, and the ability to maintain accuracy and precision was mainly associated with the stereotactic method, a principle of navigation in three-dimensional space, based on known external and internal landmarks.

It is not surprising, therefore, that the first professional society of functional neurosurgeons was called the Society for Research in Stereoencephalotomy before it evolved into the present-day Society for Stereotactic and Functional Neurosurgery (SSFN). The society was founded by the pioneers in functional neurosurgery, a neuroscientist, neurologist, and experimenter, Dr. Ernest Adolf Spiegel (1895–1985), and his former student and scientific collaborator, neurosurgeon, Dr. Henry T. Wycis (1911–72), the same people who modified the original Horsley–Clarkedxmk stereotactic apparatus, adapting it for human use and linking it with intraoperative skull radiographs. They published the first clinical report of stereotactic thalamotomy in the journal Science in October 1947. The first interventions were performed in 1946 with a goal “to reduce the emotional reactivity by a procedure, much less drastic than frontal lobotomy” ( ), but in 1948, the same stereotactic device was used by the same team of pioneers for stereotactic pallidotomy on a patient with Huntington chorea ( ).

To grow the young field of functional and stereotactic neurosurgery, it was important to exchange ideas and discuss clinical results—these were the goals of the First International Symposium on Stereoencephalotomy that was held at Temple University Medical Center in Philadelphia, PA, on October 11–12, 1961. The event is considered epic in its nature; although there were only a few dozens of participants; the papers presented covered a wide range of subjects, with multiple presentations focusing on the electrical stimulation of deep brain structures for a variety of clinical conditions (in hindsight, one may say that 1961 symposium was focusing, to some extent, on what we today would consider neuromodulation).

At the conclusion of this symposium, the society was officially born; Spiegel was elected its president, Traugott Reichert of Freiburg, Germany, was elected vice president, and Wycis was elected secretary-treasurer. Remarkably, the newborn society chose to make its official journal, the oldest dedicated neurosurgical journal in the world, Confinia Neurologica ( Borderlands of Neurology ), which was founded by E.A. Spiegel in 1938 and published by Karger in Basel, Switzerland.

The next two meetings of the society took place in Copenhagen/Vienna in August/September 1965 and in Madrid in April 1967 ( Tables 1.1 and 1.2 ). Soon, thereafter, an American branch of the International Society for Research in Stereoencephalotomy was formed at its inaugural meeting in Atlantic City, NJ, on October 13, 1968 ( Tables 1.3 and 1.4 ). An independent European branch of the Society was formed at the Fifth International Symposium on Stereoencephalotomy in Freiburg, hosted by Riechert in September 1970. From its inception, this branch was called the European Society for Stereotactic and Functional Neurosurgery (ESSFN) ( Tables 1.5 and 1.6 ). Not long after that, at the conclusion of the Sixth Symposium of the International Society for Research in Stereoencephalotomy, in Tokyo on October 12–13, 1973, the Society changed its name to the World Society for Stereotactic and Functional Neurosurgery (WSSFN) with its American branch becoming the American Society for Stereotactic and Functional Neurosurgery (ASSFN) ( ).

The relationship between the world society and continental societies remains cordial and friendly; all members of ASSFN and ESSFN automatically become members of WSSFN. Similar arrangements exist with several national and regional societies for stereotactic and functional neurosurgery in Asia and Latin America. Since their inception, the WSSFN, the ASSFN, and the ESSFN have had regular well-attended conferences. Initially, the WSSFN and ASSFN alternated their quadrennial meetings during odd years, and the ESSFN had its biennial meetings during even years. As the field expanded and the amount of new information exponentially increased, having 4 years’ hiatus between meetings became unreasonable. Therefore, ASSFN switched its conference schedule and moved its meetings to May/June of even years, while ESSFN moved its meetings to September/October of even years. The WSSFN added interim meetings to the odd years between its quadrennial congresses.

Proceedings of the conferences continue to be published in the society’s journal, which has changed its name twice. In 1975, the name switched from Confinia Neurologica to Applied Neurophysiology , and then in 1988 it became Stereotactic and Functional Neurosurgery . The publisher of the journal was also its cofounder. In 1938, it was the meeting of Prof. Ernest Spiegel and Heinz Karger that resulted in the birth of the journal. Almost 80 years later, the journal publisher, the Karger family, remains our loyal friend and supporter ( ).

Currently, Stereotactic and Functional Neurosurgery serves as the official organ of the WSSFN, the ASSFN, the ESSFN, and several national societies. Spiegel edited it between 1938 and 1975; after that, it was edited by Dr. Philip L. Gildenberg, who took over the editorship and kept the journal at its high level of professional recognition for 27 years until 2002 when he passed his post to Dr. David W. Roberts, who is editing it now. With these three editors, the journal has reached its current height and became a premiere publication for every facet of functional neurosurgery worldwide. Currently, the journal comes out in eight issues per year and maintains a healthy impact factor through a rigorous peer-review process and unbiased, merit-based acceptance. The majority of readers receive an electronic version of the journal, but having it as a society membership benefit has allowed the publisher to avoid establishing “processing” and “publication” fees for the authors.

During the past five decades, the field of stereotactic and functional neurosurgery has gone through “ups and downs,” but the continuous growth of the society was and is always present, and just as one would expect, the emphasis gradually shifted from all kinds of destructive interventions to electrical and chemical neuromodulation. But even now, when neuromodulation represents a big part of our clinical practice, the specialty of stereotactic and functional neurosurgery is much more than neuromodulation. Stereotactic technique is used for navigation during open surgical interventions, minimally invasive biopsies, catheter placements, diagnostic electrode insertions, and frame-based and frameless radiosurgery. The spectrum of functional interventions, in addition to neuromodulation, includes all kinds of decompressive, ablative, and respective surgeries, and the tools that are used for these purposes include mechanical instrumentation, radiofrequency probes, cryoprobes, lasers, focused beams of radiation and brachytherapy seeds, chemical agents, and, most recently, genetic vectors and focused ultrasound. And, if the first functional and stereotactic interventions were aimed, primarily, at patients with psychiatric conditions, current surgical indications include movement disorders, chronic pain, medically refractory epilepsy, disorders of memory, mood and cognition, as well as the rapidly growing fields of neuroprosthetics, neurorestoration, and surgical facilitation of neurorehabilitation. All this dictates new priorities for the professional societies in stereotactic and functional neurosurgery. In addition to ongoing efforts in basic and clinical research, the societies are now focusing on providing quality education, creating practice guidelines, developing clinical evidence, and establishing access to the available technology and expertise.

The societies for stereotactic and functional neurosurgery today are stronger than ever. As the number of indications, interventions, and modalities expands, the need for experts who can perform these interventions safely and efficiently becomes more obvious.

A Perspective on the History of the Neuromodulation Societies; The Early History of the International Neuromodulation Society

Giancarlo Barolat, MD

Barolat Neuroscience, Denver, CO, United States

Neuromodulation is defined by the International Neuromodulation Society (INS) as a field of science, medicine, and bioengineering that encompasses implantable and nonimplantable technologies, electrical or chemical, that impact on neural interfaces to improve life for humanity. Currently, the involved clinical specialists come from anesthesiology, neurosurgery, neurology, neurophysiology, cardiology, physical medicine and rehabilitation, otolaryngology, gastroenterology, urology, and orthopedics; however, this relatively new discipline of medicine will most likely encompass or influence most medical specialties.

The INS was founded in 1990, because of the increasing frustration felt by neurosurgeons involved with “functional neurosurgery” and the directions of the WSSFN. Until the mid-1980s, most of the neuroimplantation procedures were for pain management and were performed by neurosurgeons, with anesthesiologists making some inroads. These implantation procedures included epidural, dorsal column stimulation (now called spinal cord stimulation [SCS]), peripheral nerve stimulation (PNS), and stereotactic, deep brain stimulation (DBS).

In the 1970s and 1980s, the use of medications helped control much of Parkinson disease symptoms, which resulted in a marked decrease in the use of stereotactic procedures. In the mid-1980s, however, there was a radical shift in the use of stereotactic surgery; whereas, until then, most of the procedures were used for functional neurosurgery applications, in subsequent years, the majority of stereotactic procedures were performed for brain biopsy and irradiation of brain tumors. Thus, by the late 1980s, most of the meetings and publications of the Stereotactic and Functional Neurosurgery Societies (WSSFN, ASSFN, and ESSFN) were dedicated to reporting the success of stereotactic brain biopsies and treatments, while functional neurosurgery was relegated to a minor part of these meetings and activities.

In 1990, an active and courageous group of functional neurosurgeons, a neurologist, and a cardiologist decided, in Paris, to create a new society, inclusive of other disciplines that were related to neuromodulation. The founding members of the new International Neuromodulation Society (INS) were:

• •
  

  Lee Illis (neurology, UK, president, 1990–94),

  
  
• •
  

  Mario Meglio (neurosurgery, Italy),

  
  
• •
  

  Daniel Galley (cardiology, France)

  
  
• •
  

  J.U. Krainick (neurosurgery, Germany),

  
  
• •
  

  J.C. Sier (vascular surgery, the Netherlands) and

  
  
• •
  

  Michiel J. Staal (neurosurgery, the Netherlands).

The first official scientific meeting of this new society was held in Rome in 1992, which was organized by Mario Meglio. Further successful meetings, held every 2 years, were held in:

• •
  

  Gotenburg, Sweden, in 1994, hosted by Lars Augustinsson

  
  
• •
  

  Orlando, FL, USA, in 1996, hosted by Giancarlo Barolat

  
  
• •
  

  Lucerne, Switzerland, in 1998, hosted by Claus Naumann and Ross Davis, for the first combined meeting of INS with the International Functional Electrical Stimulation Society (IFESS)

  
  
• •
  

  San Francisco, CA, USA, in 2000 and hosted by Elliot Krames, combining three different world societies in one comprehensive multidisciplinary symposium

  
  
• •
  

  Madrid, Spain, in 2003, hosted by Enrique Reig with Elliot Krames as scientific chair

  
  
• •
  

  Rome, Italy, in 2005, hosted by Mario Meglio

  
  
• •
  

  The meeting in 2007 was held in Acapulco, Mexico, and was cohosted by the INS (Elliot Krames, president) and its largest country/regional chapter, the North American Neuromodulation Society (NANS; Joshua Prager, president)

  
  
• •
  

  Seoul, Korea, in 2009, cohosted by Lee Jyung-Kiu, president of the Korean chapter of the INS, and Elliot Krames (president) of the INS

  
  
• •
  

  London, England, in 2011, hosted by President Simon Thompson

  
  
• •
  

  Berlin, Germany, in 2013, hosted by the German chapter of the INS and chaired by the President, Simon Thompson

  
  
• •
  

  Montreal, Canada, in 2015, hosted by the Canadian Neuromodulation Society and chaired by President Timothy Deer

Initially, the society encountered substantial difficulties before gaining its identity. Even though it had been created as a multidisciplinary group, the INS was perceived to be in competition with the various pain societies, both internationally and nationally within each country (the preponderance of neuromodulation procedures performed at that time were SCS for pain control). Intense competition for funding of meetings and symposia also generated friction with other pain and neurosurgical societies. Because the INS membership was, by its very nature, multidisciplinary, great difficulties existed in bringing together its members of disparate interests. However, the use of neurostimulation for peripheral vascular disease and angina in Europe helped the society attract a substantial number of vascular specialists and cardiologists.

In 1994, I was elected by the board as the second president of the INS. Minutes after my nomination, the entire previous board resigned. I was left with the monumental task of reorganizing the society, from scratch.

In a very inspired move, I brought Elliot Krames, who had made a name for himself in the field of implantable drug delivery, onto the INS board. Elliot did not waste any time and immediately undertook the task of creating the journal Neuromodulation for the society. I remember that we were in a board meeting in Notwill, Switzerland, when Elliot challenged the group to become a real society with more than the board as members. He said that to be a real scientific society, we must have a journal to harness and disseminate relevant neuromodulation science and information. Surprisingly, this simple and truthful statement caused quite a discussion at that meeting, with some dissenters, but Elliot’s position was approved by the majority. The first issue of the journal was published in January 1998, and the journal has become the authoritative publication in this area. Tia Sofatzis was brought in during 1998 as managing editor of Neuromodulation and later became the society’s executive director as well.

In 1999, the International Society for Functional Electrical Stimulation (IFESS) started publishing their scientific papers in Neuromodulation , in a special section devoted to functional electrical stimulation (FES). In 2001, the IFESS agreed to adopt Neuromodulation as their official publication. This collaboration has fostered a healthy relationship between clinicians, engineers, and scientists involved in the restoration of neurologic function through implanted devices. In January 2007, the Journal was renamed Neuromodulation: Technology at the Neural Interface .

Formation of International Chapters

In 1994, a group of implantation specialists with interest in pain control from the United States and Canada convened in Atlanta, GA, to form the American Neuromodulation Society (ANS). While originating as an independent society, ANS, in 1995, became a chapter of the INS under the name of the North American Neuromodulation Society (NANS). Because Elliot and I were also members of the board of the INS, it was natural that we suggested to the board of NANS that it become the first chapter of the INS, and this, too, created quite a stir. Some in that first NANS board accused Elliot and I as being “foreign agents.” Better heads prevailed, and NANS did become the first chapter of the INS, with the Italian Neuromodulation Society becoming the second. Under each of the INS presidencies of Giancarlo Barolat, Brian Simpson, Mario Meglio, Elliot Krames, Simon Thompson, and Tim Deer, more international chapters have been created and include the:

• •
  

  Argentinian Neuromodulation Society

  
  
• •
  

  Australian Neuromodulation Society

  
  
• •
  

  Benelux Neuromodulation Society

  
  
• •
  

  Brazilian Neuromodulation Society

  
  
• •
  

  Canadian Neuromodulation Society

  
  
• •
  

  French Neuromodulation Society

  
  
• •
  

  German Neuromodulation Society

  
  
• •
  

  Italian Neuromodulation Society

  
  
• •
  

  Japanese Neuromodulation Society

  
  
• •
  

  Korean Neuromodulation Society

  
  
• •
  

  Neuromodulation Society of the United Kingdom and Ireland

  
  
• •
  

  Nordic Neuromodulation Society

  
  
• •
  

  North American Neuromodulation Society

  
  
• •
  

  Polish Neuromodulation Society

  
  
• •
  

  South African Neuromodulation Society

  
  
• •
  

  South East European Neuromodulation Society

  
  
• •
  

  South Eastern Europe Neuromodulation Society

  
  
• •
  

  Spanish Neuromodulation Society

  
  
• •
  

  Swiss Neuromodulation Society

  
  
• •
  

  Turkish Neuromodulation Society

  
  
• •
  

  UK and Irish Neuromodulation Society

A Perspective on the History of the International Neuromodulation Society

Brian Simpson

Cardiff, United Kingdom

My first exposure to therapeutic neuromodulation was in the late 1970s when I was working toward my MD thesis in the neurosurgical laboratory at The London (later Royal London) Hospital. Professor Sid Watkins, who was already implanting electrodes by then, would come to the laboratory to discuss stimulator issues with Dr. Tom Koeze. Tom was an American academic neurologist and polymath who Sid had brought over from New York to help establish an academic neurosurgical unit and to run the laboratory. During my clinical neurosurgical training in 1982, Tom and I started one of the first dedicated neurostimulation clinics. With his expertise in electronics, we built up considerable experience in troubleshooting, mainly for spinal cord stimulators (SCSs) ( ). The hardware, both external and implanted, was very unreliable in those days, and I soon became the department’s fixer-in-chief of broken leads, dislodged electrodes, and leaky connectors, of which there were many. With Tom’s encyclopedic knowledge and Sid Watkins’ wisdom and vision, I gained formative experience, both technically and clinically in neurostimulation.

At that time there was still considerable uncertainty about the therapy, and when I presented our series of 60 cases of SCS for pain at a conference of the Society of British Neurological Surgeons in 1989, one eminent colleague commented that some light had finally been shed on the question, “Who might actually benefit from a stimulator?” ( ).

Neuromodulation was not all about SCS at that time (for both pain and movement disorders – some extrapyramidal disorders did respond to some extent). By the time I moved from London to the University Hospital of Wales in Cardiff in 1988, my neuromodulation experience included, in addition to SCS, deep brain stimulation (DBS) for pain and for epilepsy; cerebellar stimulation for epilepsy, cerebral palsy, and other causes of dystonia; and sacral nerve root stimulation (SNS) for bladder and erectile control in paraplegics. The diversity of the indications for neuromodulation, beyond just pain, and of stimulation targets was already becoming increasingly apparent.

Neuromodulation encompassed and was used by multiple disciplines, but there was no society, journal, or other vehicle that could adequately accommodate its eclectic reach. Huge variations in practice existed, including case selection and outcomes, and this had threatened the very survival of neuromodulation. The literature was similarly disparate and lacking; when I published the first comprehensive critical review of the (very heterogeneous) literature on SCS, in 1994 ( ), it was no less than 27 years since the therapy had been introduced! DBS had been introduced even earlier, in the early 1950s. There was no cohesion in the field and no really appropriate forum for dissemination and discussion of experience or for the guidance of research and development in neuromodulation. What was needed was an international neuromodulation society…

A resolution to establish such a society, the International Neuromodulation Society (INS), was passed in Groningen, the Netherlands, in 1989. This was followed by a founders’ meeting of the INS in Paris on April 21, 1990, and the first international congress ensued, in Rome, in 1992. The first general assembly of the INS was held in Amsterdam on November 6, 1993. I have the noble distinction of being the only ordinary member who attended that “general” assembly! The board members seemed rather surprised to see me. The chairman and first INS president was Lee Illis, a neurologist from the United Kingdom who was responsible for much of the early work on SCS for multiple sclerosis (MS). The warming of the extremities that SCS induced in patients with MS led to its use for peripheral vascular disease (PVD). Two other members of that original board, Michiel Staal and Mario Meglio, subsequently became good friends and long-term colleagues of mine in the INS. The others, whom I did not get to know well, were Drs. Sier, Krainick, and Galley. After that auspicious general assembly, Mario very kindly bought me dinner and I remember our enthusiastic discussion of how the society and the field generally should grow. Dr. Sier, the secretary, had invited me to become a board member but, for reasons that are lost in the mists of time, this did not actually happen for another 2 years. The Swedish neurosurgeon and early board member, Lars Augustinsson, one of the first to perform SCS in significant numbers and to publish his results, resuscitated the invitation. I attended my first board meeting in Lucerne, Switzerland, in 1995 and continued to serve on the board for 15 years.

Being a board member entailed a good deal of travel and I remember the six-monthly meetings with a mixture of exasperation and pleasure. The exasperation was at the lengthy and sometimes heated discussions; in the early days the meetings usually extended right through Saturday and well into Sunday, but there was a lot to be done. The pleasure was from the comradeship between the board members, the progress we made, and some great venues for board meetings. These venues included a convent in Rome, arranged by Mario Meglio and a chateaux in Bordeaux, thanks to Yves Keravel.

Topics for discussion had a habit of recurring; even the name of the society, which had been agreed on, right back at the founders’ meeting, in 1990. There was support, led strongly by Elliot Krames, an anesthesiologist, pain physician, and friend, for keeping the title as the International Neuromodulation Society (INS), and Neuromodulation was also subsequently used for the title of the journal. Another recurring theme, indeed standing item, was the updating and refining of the society’s constitution, not the most popular item, but essential.

The board and the members owe a very large debt of gratitude to Tia Sofatzis, who took over the role of executive director from Sherri Kae Calkins fairly early on and continues to fulfil that vital role. Tia’s skillful, cheerful, and unflustered management of the society, including producing superb meeting papers and minutes, has been one of the cornerstones of the INS. Another is the journal, for which we must recognize Elliot Krame’s vision and dogged determination; it really was his baby, being the founding editor of the journal.

I felt extremely honored to be elected president of the INS (2000–03), following in the steps of Lee Illis and Giancarlo Barolat. I was fortunate to have great support from the board, especially Mike de Jongste (secretary), Bob Foreman (treasurer), Giancarlo (immediate past president), Elliot (editor-in-chief and general ambassador), and of course Tia.

Just like the dinner with Mario Meglio in 1993, I have a clear memory of an afternoon I spent with Giancarlo sipping beer in a Madrid square, discussing how we should take the INS forward, as I stepped into his shoes (metaphorically – we only had a couple of beers). We were in complete agreement that the two key issues were to continue to grow the membership and to further develop and formalize the infrastructure and processes. We agreed that the key to increasing the membership was through establishing and promoting national chapters. We already had the North American society (NANS) and the Italian society as chapter societies of the INS. I was delighted when the Neuromodulation Society of the United Kingdom and Ireland (NSUKI) (Simon Thomson was a driving force there) and the Benelux society were soon formed. It was an important and very welcome step when the long-established Japanese Neuromodulation Society agreed to become part of the INS. The policy has been gratifyingly successful, now with more than 20 chapters (and more in formation), representing every inhabited continent and about 30 countries. On one occasion, when NANS was facing a particularly difficult problem, Mike de Jongste and I flew from Europe to San Francisco to join their board meeting and offer help from the standpoint of the INS. It was a long way to go for one agenda item, but it demonstrated the value and strength of the federated society.

One of my less successful ambitions was to forge a close relationship between the INS and IFESS (International Functional Electrical Stimulation Society). Their members’ interests include the restoration of limb function after stroke and after spinal cord and nerve damage; restoration of impaired respiratory, bladder, bowel, and sexual function; and the development of neuroprostheses for the special senses. With the clinical bias of the INS and the basic science and engineering bias of IFESS, along with the overlapping applications and technology, the two societies seemed to complement one another, perfectly.

Things had started well when a successful joint meeting in Lucerne, Switzerland, in 1998, led to an official affiliation. The neurosurgeon Ross Davis, who was noted, among other things, for his work on cerebellar stimulation, was on the INS board and was able to represent IFESS, of which he was a past president. Through Ross, the IFESS board invited the INS to provide a member to join the board of IFESS in a reciprocal arrangement. I was selected and occupied that role from 2004 until 2011. We successfully held sessions in each other’s conferences and, at board level, the relationship was very cordial. However, it did not move forward in practical terms. One sticking-point was that, before the journal Neuromodulation became indexed, IFESS members were, understandably, reluctant to publish in it. They already had strong links with other (indexed) journals and their funding depended heavily on the impact factor of their (prolific) publications. Indeed, as with many relationships, finances created much of the stress, IFESS being relatively disadvantaged in this respect.

I really enjoyed the meetings of the IFESS board and even forgave them for a misunderstanding, in 2009, in Seoul, South Korea, where INS and IFESS were holding their conferences consecutively but many miles apart. Having missed a great INS social function in order to attend the IFESS board meeting, and after a very long and fraught taxi ride from one side of Seoul to the other, I arrived to find that they had forgotten to tell me that their board meeting had been rescheduled and that I had missed it! It was one of those situations where everyone thinks somebody else had taken care of it.

After some relatively shaky years, the collaboration had improved again; IFESS continues to contribute to INS conferences and vice versa, to the undoubted benefit of both societies, and now “FES” papers appear regularly in Neuromodulation . The mutual representation at board level was, however, consigned to history, in 2011. The relationship still appears healthy but perhaps more platonic than passionate.

In summary, witnessing much of the development of the INS “from the inside” has been a rewarding, educational, and absorbing experience for me, over many years. Through the efforts of a relatively small and slowly changing (and growing) group of motivated individuals, representing a range of backgrounds and experience, but with a common goal, the INS has developed beyond recognition. A small and informal group has metamorphosed into a large, professional, multidisciplinary organization. The INS is no longer dismissed as “just another pain society.” The diversity of neuromodulation is increasingly recognized as is the need for the therapy and the (belatedly growing) evidence of its efficacy, although there remains huge geopolitical variation in availability. It is a work-in-progress, and the INS has the central role.