Neuropathic Pain and Deep Brain Stimulation

Abstract

Deep brain stimulation (DBS) is a neurosurgical intervention the efficacy, safety, and utility of which are established in the treatment of Parkinson's disease. For the treatment of chronic, neuropathic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated with current standards of neuroimaging and stimulator technology over the last decade . We summarize the history, science, selection, assessment, surgery, programming, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and latterly rostral anterior cingulate cortex (Cg24) in 113 patients treated at 2 centers (John Radcliffe, Oxford, UK, and Hospital de São João, Porto, Portugal) over 13 years. Several experienced centers continue DBS for chronic pain, with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS under general anesthesia considered for whole or hemibody pain, or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.

The Promising Role of Neuromodulation in Improving Ischemic Stroke Recovery

“…A review examining DBS with motor and sensory cortical stimulation examines all recent prospective studies examining long-term outcomes in patients and advocate that DBS is superior to motor cortical stimulation for refractory pain syndromes and may be more appropriate than sensory cortical stimulation for certain pain etiologies, including phantom pain after amputation [45]. In regards to pain after stroke, DBS reveals greatest efficacy for stroke patients complaining of burning hyperaesthesia [18].…”

Role of radiology in central nervous system stimulation

“…Targets now include the thalamus, internal capsule, periaqueductal grey matter and cingulate gyrus for treating chronic pain syndromes. [16][17][18] Over recent years, the use of DBS for chronic pain has expanded to include indications such as peripheral nerve injuries, plexopathies and amputation pain, stroke and neurological disease such as multiple sclerosis. [16][17][18][19] During intraoperative use of DBS to guide lesioning surgery for epilepsy and movement disorders in the 1950s-70s, it was noted that there was an improvement in dyskinesia and Parkinsonian tremor.…”

“…[16][17][18] Over recent years, the use of DBS for chronic pain has expanded to include indications such as peripheral nerve injuries, plexopathies and amputation pain, stroke and neurological disease such as multiple sclerosis. [16][17][18][19] During intraoperative use of DBS to guide lesioning surgery for epilepsy and movement disorders in the 1950s-70s, it was noted that there was an improvement in dyskinesia and Parkinsonian tremor. 9,20,21 Despite this, the success of Parkinson's medical therapy and the already established lesioning surgery meant the introduction of therapeutic use of DBS for these conditions was delayed until the late 1980s.…”

Nonpharmacological Therapies for Neurologic Devices

“…Its use in movement disorders is reviewed in this issue by Larson [1]. With the success of DBS in treating movement disorders, the possibility of taking on other disorders is now in sight, and clinical studies in various phases of development are underway in a number of disorders, including depression (Morishita et al [2]), obsessive compulsive disorder (Lapidus et al [3]), pain (Pereira and Aziz [4]), epilepsy (Laxpati et al [5]) , and even disorders of memory and cognition (Sankar et al [6]). There is also the realization that other peripheral targets may be useful.…”