Deep Brain Stimulation for Pain in the Modern Era: A Systematic Review

Abstract

BACKGROUND Deep brain stimulation (DBS) has been considered for patients with intractable pain syndromes since the 1950s. Although there is substantial experience reported in the literature, the indications are contested, especially in the United States where it remains off-label. Historically, the sensory-discriminative pain pathways were targeted. More recently, modulation of the affective sphere of pain has emerged as a plausible alternative. OBJECTIVE To systematically review the literature from studies that used contemporary DBS technology. Our aim is to summarize the current evidence of this therapy. METHODS A systematic search was conducted in the MEDLINE, EMBASE, and Cochrane libraries through July 2017 to review all studies using the current DBS technology primarily for pain treatment. Study characteristics including patient demographics, surgical technique, outcomes, and complications were collected. RESULTS Twenty-two articles were included in this review. In total, 228 patients were implanted with a definitive DBS system for pain. The most common targets used were periaqueductal/periventricular gray matter region, ventral posterior lateral/posterior medial thalamus, or both. Poststroke pain, phantom limb pain, and brachial plexus injury were the most common specific indications for DBS. Outcomes varied between studies and across chronic pain diagnoses. Two different groups of investigators targeting the affective sphere of pain have demonstrated improvements in quality of life measures without significant reductions in pain scores. CONCLUSION DBS outcomes for chronic pain are heterogeneous thus far. Future studies may focus on specific pain diagnosis rather than multiple syndromes and consider randomized placebo-controlled designs. DBS targeting the affective sphere of pain seems promising and deserves further investigation.

Current and future directions of deep brain stimulation for neurological and psychiatric disorders

“…Other targets include the CMPfc, VS/ALIC, and the posterior hypothalmus. 35 There have also been studies with combined PAG/PVG and VPL/VPM stimulation in which investigators had inconclusive results. In addition to DBS, there has also been interest in using motor cortex stimulation to treat both poststroke and non-poststroke pain (facial neuropathic pain, phantom limb pain, postherpetic neuralgia, brachial plexus avulsion, Wallenberg syndrome, complex regional pain syndrome, multiple sclerosis-derived pain, spinal cord injury pain, and posttraumatic brain injury pain).…”

Clinical applications of neurochemical and electrophysiological measurements for closed-loop neurostimulation

“…Subsequent studies have been performed, with mixed results. 46 In a successful study by Boccard et al, a mean pain reduction of 46% occurred after 1 year with PAG/PVG and/or VPL/VPM (vT) stimulation in 74 patients. 48 Another study by Boccard et al targeting the ACC found a 43.4% reduction after 1 year in 22 patients.…”

“…Since the initial trials of DBS for pain, numerous studies for a myriad of pain indications have been performed. 46 The most common DBS targets identified in these studies include the periaqueductal gray (PAG) and periventricular gray matter (PVG) region; the ventral thalamus (vT), which includes the ventral posterolateral nucleus (VPL) and ventral posteromedial nucleus (VPM); the anterior cingulate cortex (ACC); and the ventral striatum (VS) and anterior limb of the internal capsule (ALIC). The first multicenter randomized controlled trial of DBS for pain enrolled over 200 patients with a variety of chronic pain indications.…”

Chronic wireless streaming of invasive neural recordings at home for circuit discovery and adaptive stimulation

“…While continuous neurostimulation is now employed in many conditions, it may induce adverse effects such as hypophonia 11 or dyskinesia 12 in PD, mania in OCD 48 , or seizures from cingulate stimulation for pain 43 . Efficacy of continuous stimulation may also suffer from waning effectiveness, such as in chronic pain 49 . If stimulation were only delivered contingent on the relevant patterns of abnormal circuit activity, it could respond to changing brain needs and reduce adverse effects 15,19 .…”