Long-Term Chronic Stimulation of Internal Capsule in Poststroke Pain and Spasticity

Background/Objectives: Both motor cortex stimulation (MCS) and deep brain stimulation (DBS) of the ventralis caudalis (Vc) thalamus have been shown to be effective in chronic neuropathic pain, and the modulation of thalamic and thalamocortical activity is regarded as a possible mechanism. Although Vc DBS and MCS have a common analgesic mechanism, the application of MCS and DBS is still considered empirical, and there is no consensus on which method is better. Methods: We performed a simultaneous trial of thalamic Vc DBS and MCS in 9 patients with chronic neuropathic pain and investigated the results of the stimulation trial and long-term pain relief. Results: Of the 9 patients initially implanted with both DBS and MCS electrodes, 8 (89%) had a successful trial; 6 of these 8 patients (75%) responded to MCS, and the remaining 2 responded to Vc DBS. During the long-term follow-up, the mean numeric rating scale score decreased significantly (p < 0.05). The percentages of pain relief in the chronic MCS group and the chronic DBS group were 37.9 ± 16.5 and 37.5%, respectively, and there was no statistically significant difference (p = 0.157). Conclusion: Considering the initial success rate and the less invasive nature of epidural MCS compared with DBS, we think that MCS would be a more reasonable initial means of treatment for chronic intractable neuropathic pain.

Section: Discussionmentioning

confidence: 99%

Simultaneous Trial of Deep Brain and Motor Cortex Stimulation in Chronic Intractable Neuropathic Pain

Son

Kim

et al. 2014

“…By far the oldest treatment targets in DRS patients are the ventral posterior medial/ventral posterior lateral thalamic nuclei (VPM/VPL) and the periaqueductal/periventricular gray matter (PAG/PVG) [34,38,41,42,52,53]. We have identified 5 additional targets within the literature for consideration: the ventral capsular/ventral stratal region (VC/VS) [3], the centromedian thalamic nucleus (CM) [37], the nucleus ventrocaudalis parvocellularis internis (Vc) [35], the ACC, and the posterior limb of the internal capsule (PLIC) [52,54]. …”

Section: Methodsmentioning

confidence: 99%

“…Stimulation of the PLIC is thought to inhibit nociceptive neurons in the sensory thalamus and inhibit neuronal activity in the VPL, leading to increased pain relief [54,78]. To date, there are 16 definitively described cases of implantation into the PLIC, with 1 occurring in conjunction with a VPL electrode [52,54,55,58,63,79]. Results were considered positive, with 8 out of 15 patients achieving “success”.…”

Section: Methodsmentioning

confidence: 99%

“…Unfortunately, 7 of the successful implants had no VAS quantification, making it impossible to determine what degree of pain relief was considered successful [55,63]. In this light, there exist only 2 reliable accounts of PLIC stimulation, totaling 5 patients [52,54]. Kumar et al [52] implanted 4 patients with PLIC electrodes as the sensory thalamus lacked the necessary volume for placement.…”

Section: Methodsmentioning

confidence: 99%

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Deep Brain Stimulation for the Treatment of Dejerine-Roussy Syndrome

Ward

Mammis²

2017

Background/Aims: Patients who suffer from Dejerine-Roussy syndrome commonly experience severe poststroke hemibody pain which has historically been attributed to thalamic lesions. Despite pharmacological treatment, a significant proportion of the population is resistant to traditional therapy. Deep brain stimulation is often appropriate for the treatment of resistant populations. In this review we aim to summarize the targets that are used to treat Dejerine-Roussy syndrome and provide insight into their clinical efficacy. Methods: In reviewing the literature, we defined stimulation success as achievement of a minimum of 50% pain relief. Results: Contemporary targets for deep brain stimulation are the ventral posterior medial/ventral posterior lateral thalamic nuclei, periaqueductal/periventricular gray matter, the ventral striatum/anterior limb of the internal capsule, left centromedian thalamic nuclei, the nucleus ventrocaudalis parvocellularis internis, and the posterior limb of the internal capsule. Conclusions: Due to technological advancements in deep brain stimulation, its therapeutic effects must be reevaluated. Despite a lack of controlled evidence, deep brain stimulation has been effectively used as a therapeutic in clinical pain management. Further clinical investigation is needed to definitively evaluate the therapeutic efficacy of deep brain stimulation in treating the drug-resistant patient population.

“…Alteration of the functionality or connectivity of the spinothalamocortical tract (STC) is discussed as part of its pathogenesis [2,3]. Successful pain relief has been reported by deep brain stimulation (DBS) of either the thalamus itself or the posterior limb of the internal capsule (PLIC) [4,5,6,7], an area in which the STC is located on its way from thalamus to postcentral cortex. Alternatively, motor cortex stimulation has been investigated for pain relief [8,9].…”

Section: Introductionmentioning

confidence: 99%

Tractography-Guided Stimulation of Somatosensory Fibers for Thalamic Pain Relief

Hunsche

Sauner

Runge

et al. 2013

Background: The spinothalamocortical tract (STC) is seen as a neural tract responsible for or involved in the generation or transmission of thalamic pain. Either the thalamus itself or the posterior limb of the internal capsule (PLIC) are targets for deep brain stimulation (DBS) in patients with thalamic pain, but due to its low contrast, conventional MRI cannot visualize the STC directly. Objectives: To show the feasibility of integrating diffusion tensor imaging-based tractography into the stereotactic treatment planning for identification of an object-oriented lead trajectory that allows STC-DBS with multiple electrode contacts. Methods: Diffusion tensor imaging was performed in 4 patients with thalamic pain. The STC was modeled and integrated into the stereotactic treatment planning for DBS. DBS-lead implantation was done according to trajectory planning along the modeled STC at the level of the PLIC. Results: After implantation, electrode stimulation was possible over a length of more than 20 mm with a tractography-based trajectory along the PLIC part of the STC. After a follow-up of 12 months, pain relief of more than 40% was achieved in 3 of 4 patients with rating on a visual analogue scale. In 1 patient, stimulation failed to reach any long-lasting positive effects. Conclusions: Integrating tractography data into stereotactic planning of DBS in thalamic pain is technically feasible. It can be used to identify a lead trajectory that allows for multiple contact stimulation along the STC at the level of the PLIC. Due to long-lasting positive stimulation effect, tractography-guided stimulation of sensory fibers seems to be beneficial for thalamic pain relief.