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: 2.87). 01/2013; 32(1). DOI: 10.1002/nau.22269
Source: PubMed


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.
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.
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.
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. 32: 53–57, 2013.

Download full-text


Available from: Julien Nizard, May 06, 2015
  • Source
    • "André-Obadia et al. [17] also showed that rTMS was more effective in reducing pain when applied at 20 Hz than at 1 Hz, and Saitoh et al. [18] found that 10 Hz rTMS was more effective than 5 Hz rTMS, while 1 Hz rTMS had no significant effects. A study of low-frequency rTMS over somatosensory areas has been performed in patients suffering from chronic pancreatitis [19]; whereas high-frequency rTMS over motor cortex was applied to treat pelvic pain due to rectal adenocarcinoma [15] and another for noncancer pelvic pain [13]. Finally, it should be noted that therapeutic applications of rTMS in pain syndromes are limited by the short duration of the induced effects, but prolonged pain relief can be obtained by repeating rTMS sessions everyday for several weeks [20]. "

    Full-text · Article · Jan 2015
  • [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.
    No preview · Article · Sep 2013
  • [Show abstract] [Hide abstract]
    ABSTRACT: Motor cortex stimulation produces significant relief of symptoms in many forms of refractory chronic pain disorders.
    No preview · Article · Oct 2014 · Neurosurgery Clinics of North America
Show more