Article

Motor cortex stimulation in refractory pelvic and perineal pain: Report of two successful cases

Service de Neurochirurgie, Centre Hospitalier Universitaire, Nantes, France.
Neurourology and Urodynamics (Impact Factor: 2.46). 01/2013; 32(1). DOI: 10.1002/nau.22269
Source: PubMed

ABSTRACT AIMS: In some patients, with refractory chronic pelvic and perineal pain, pain and quality of life are barely alleviated despite optimal medical treatment, infiltrations and surgical release of the pudendal nerve. The management of these patients is complex, especially after failure of neuromodulation techniques (spinal cord stimulation. S3 nerve root stimulation and direct stimulation of the pudendal nerve). We report the first two cases illustrating the value of motor cortex stimulation (MCS), in this new indication. METHODS: The history, decision-making process, intraoperative findings and results of this technique are presented. The perineal cortical area was identified by intraoperative motor evoked potentials in the external anal sphincter, confirming its location in the primary motor cortex between the inferior and superior limb positions. As predictive value of repetitive transcranial magnetic stimulation (rTMS) in the identification of responders to MCS for pain is now established, we performed pre-operative rTMS sessions for both patients. RESULTS: The first patient was a 74-years-old woman who reported an 11-year history of left lateral perineal pain. The second patient was a 45-year-old woman who reported a 4-year history of perineal pain following hysterectomy with ovariectomy. After respectively 40 months and 19 months of follow up, both patients reported an improvement of pain ranging from 40 to 50%. Time to onset of pain on sitting was markedly improved from a few minutes to 90 minutes, and largely contributing to improvement of activities of daily living and of quality of life. CONCLUSION: 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. Neurourol. Urodynam. © 2012 Wiley Periodicals, Inc.

Download full-text

Full-text

Available from: Julien Nizard, May 06, 2015
1 Follower
 · 
133 Views
  • Source
    • "E. Confirmation that the pelvic-motor and right posterior insula cluster had comparable sizes to regions in the structural atlas. of primary motor cortex for pain processing. For example, primary motor cortex appears to process nociceptive signals in parallel with primary sensory cortex (Frot et al., 2013), and there is emerging evidence that repetitive transcranial magnetic stimulation over motor cortex has analgesic effects (Lefaucheur et al., 2014), including in patients with chronic pelvic pain (Louppe et al., 2013). One hypothesis that would explain our findings is that functional connectivity is altered by changes in direct neural communication between right posterior insular cortex and motor cortex. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Brain network activity associated with altered motor control in individuals with chronic pain is not well understood. Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a debilitating condition in which previous studies have revealed altered resting pelvic floor muscle activity in men with CP/CPPS compared to healthy controls. We hypothesized that the brain networks controlling pelvic floor muscles would also show altered resting state function in men with CP/CPPS. Here we describe the results of the first test of this hypothesis focusing on the motor cortical regions, termed pelvic-motor, that can directly activate pelvic floor muscles. A group of men with CP/CPPS (N = 28), as well as group of age-matched healthy male controls (N = 27), had resting state functional magnetic resonance imaging scans as part of the Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network study. Brain maps of the functional connectivity of pelvic-motor were compared between groups. A significant group difference was observed in the functional connectivity between pelvic-motor and the right posterior insula. The effect size of this group difference was among the largest effect sizes in functional connectivity between all pairs of 165 anatomically-defined subregions of the brain. Interestingly, many of the atlas region pairs with large effect sizes also involved other subregions of the insular cortices. We conclude that functional connectivity between motor cortex and the posterior insula may be among the most important markers of altered brain function in men with CP/CPPS, and may represent changes in the integration of viscerosensory and motor processing.
    06/2015; 1225. DOI:10.1016/j.nicl.2015.05.013
  • [Show abstract] [Hide abstract]
    ABSTRACT: SUMMARY The treatment of chronic pelvic pain in both females and males is a challenge for pain clinicians. Standard therapies are multimodal in nature with use of behavioral, medical and procedural therapeutics. In recent years, our understanding of the neurobiology of this disorder has improved and novel approaches have focused on neuromodulatory options, novel pharmacology and complementary/alternative medicine options. This review briefly examines newly employed therapeutic options, while restating currently utilized options. The current state-of-the-art treatment includes focal therapies for identified pathologies and empiric trials of other options for care when precise sources of the chronic pelvic pain are ill defined.
    09/2013; 3(5):387-94. DOI:10.2217/pmt.13.40
  • [Show abstract] [Hide abstract]
    ABSTRACT: Motor cortex stimulation produces significant relief of symptoms in many forms of refractory chronic pain disorders.
    Neurosurgery Clinics of North America 10/2014; 25(4). DOI:10.1016/j.nec.2014.06.004 · 1.54 Impact Factor