Neurostimulation therapy is indicated for neuropathic pain that is refractory to medical treatment, and includes stimulation of the dorsal spinal cord, deep brain structures, and the precentral motor cortex. Spinal cord stimulation is validated in the treatment of selected types of chronic pain syndromes, such as failed back surgery syndrome. Deep brain stimulation (DBS) has shown promise as a treatment for peripheral neuropathic pain and phantom limb pain. Compared with DBS, motor cortex stimulation (MCS) is currently more frequently used, mainly because it is more easily performed, and has a wider range of indications (including central poststroke pain). Controlled trials have demonstrated the efficacy of MCS in the treatment of various types of neuropathic pain, although these trials included a limited number of patients and need to be confirmed by large, controlled, multicenter studies. Despite technical progress in neurosurgical navigation, results from studies of MCS are variable, and validated criteria for selecting good candidates for implantation are lacking. However, the evidence in favor of MCS is sufficient to include it in the range of therapeutic options for refractory neuropathic pain. In this Review, the respective efficacies and mechanisms of action of DBS and MCS are discussed.

Repetitive transcranial magnetic stimulation (rTMS) has been proposed to treat neuropathic pain but the quality of evidence remains low. We aimed to assess the efficacy and safety of neuronavigated rTMS to the motor cortex (M1) or dorsolateral prefrontal cortex (DLPFC) in neuropathic pain over 25 weeks. We did a randomised double-blind, placebo-controlled trial at four outpatient clinics in France. Patients aged 18–75 years with peripheral neuropathic pain were randomly assigned in a 1:1 ratio to M1 or DLPFC-rTMS and re-randomised in a 2:1 ratio to active or sham rTMS (10 Hz, 3000 pulses/session, 15 sessions over 22 weeks). Patients and investigators were blind to treatment allocation. The primary endpoint was the comparison between active M1-rTMS, active DLPCF-rTMS and sham-rTMS for the change over the course of 25 weeks (group by time interaction) in average pain intensity (from 0 no pain to 10 maximal pain) on the Brief Pain Inventory (BPI), using a mixed model repeated measures analysis in patients who received at least one rTMS session (modified ITT population). Secondary outcomes included other measures of pain intensity and relief, sensory and affective dimensions of pain, quality of pain, self reported pain intensity and fatigue (patients diary), patient and clinician global impression of change (PGIC, CGIC), quality of life, sleep, mood and catastrophizing. This study is registered with ClinicalTrials.gov NCT02010281. A total of 152 patients were randomised and 149 received treatment (49 for M1; 52 for DLPFC; 48 for sham). M1-rTMS reduced pain intensity versus sham-rTMS (estimate for group x session interaction: -0.048 ± 0.02; 95% CI: -0.09 to -0.01; p = 0.01). DLPFC-rTMS was not better than sham (estimate: -0.003 ± 0.01; 95% CI:-0.04 to 0.03, p = 0.9). M1-rRMS, but not DLPFC-rTMS, was also superior to sham-rTMS on pain relief, sensory dimenson of pain, self reported pain intensity and fatigue, PGIC and CGIC. There were no effect on quality of pain, mood, sleep and quality of life as all groups improved similarly over time. Headache was the most common side effect and occurred in 17 (34.7%), 23 (44.2%) and 13 (27.1%) patients from M1, DLPFC and sham groups respectively (p = 0.2). Our results support the clinical relevance of M1-rTMS, but not of DLPFC-rTMS, for peripheral neuropathic pain with an excellent safety profile.

No abstract

No abstract

These two first cases suggest that motor cortex stimulation constitutes a new treatment for refractory pelvic and perineal pain, and should be considered after failure of conventional neuromodulation techniques, especially spinal cord stimulation.

Purpose The COVID-19 pandemic and the extended lockdown are associated with numerous changes in behavior and lifestyles. The objective was to assess the impact of the first lockdown on LBP course among chronic LBP patients. Methods Descriptive and analytical, cross-sectional, multicenter study, conducted by questionnaire from mid-May to end of June 2020 among patients treated for chronic LBP in 6 French and 1 Swiss center. Collected data concerned changes in LBP intensity during lockdown, lockdown experience, physical activity (PA) practice and sedentary lifestyle prior and during lockdown, recourse to care, consumption of psychoactive substances for LBP, and professional activity and its conditions during lockdown. Results 360 participants (58.6% women, 52.1 ± 13.4 years) were included of which 65% were active (63% keep on working of which 54% teleworked). LBP got worse in 41.1%, mean VAS went from 49.5 ± 21.6 before to 53.5 ± 22.4 during lockdown (p < 0.001) and needed increase of treatment by 29% but very few people increased their consumption psychoactive substances for analgesia. Half of participants had well-experienced lockdown. Findings revealed a significant decrease in PA and increase of sedentary during lockdown (p < 0.0001). Good experience of lockdown was associated with LBP improvement (OR = 0.6 [0.3–0.9]) and decrease of PA with LBP worsening (OR = 1.9 [1.1–3.2]). Teleworking was also associated with LBP worsening. Gender, age, or BMI did not influence LBP course. Conclusion These findings indicate that chronic LBP people suffered from increase in self-perceived LBP during lockdown and help to better understand the factors associated with their condition.

No abstract

No abstract