Long-term Outcomes of Deep Brain Stimulation for Neuropathic Pain

1Department of Physiology, Anatomy and Genetics, University of Oxford, UK 2Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, UK 3 Nuffield Department of Neurosciences, University of Oxford, UK.
Neurosurgery (Impact Factor: 3.62). 11/2012; 72(2). DOI: 10.1227/NEU.0b013e31827b97d6
Source: PubMed


BACKGROUND:: Deep brain stimulation (DBS) to treat neuropathic pain refractory to pharmacotherapy has reported variable outcomes, and gained UK but not USA regulatory approval. OBJECTIVE:: To prospectively assess long-term efficacy of DBS for chronic neuropathic pain in a single center case series. METHODS:: Patient reported outcome measures were collated before and after surgery, using a visual analog score (VAS), Short Form 36 quality of life survey (SF-36), McGill pain questionnaire (MPQ), and EuroQol-5D questionnaires (EQ-5D; Health state). RESULTS:: 197 patients were referred over twelve years, of whom 85 received DBS for various etiologies: 9 amputees, 7 brachial plexus injuries, 31 after stroke, 13 with spinal pathology, 15 with head and face pain, and 10 miscellaneous. Mean age at surgery was 52 years and mean follow-up 19.6 months. Contralateral DBS targeted the periventricular gray area (PVG; n=33), the ventral posterior nuclei of the thalamus (VPL/VPM; n=15), or both targets (n=37). Almost seventy percent (69.4%) of patients retained implants 6 months after surgery. 39 of 59 (66%) of those implanted gained benefit and efficacy varied by etiology, improving outcomes in 89% after amputation and 70% after stroke. In this cohort, sustained >30% improvements in VAS, MPQ, SF-36, and EQ-5D were observed in 15 patients with >42 months follow-up, with several outcome measures improving from those assessed at one year. CONCLUSION:: DBS for pain has long-term efficacy for select etiologies. Clinical trials retaining patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.

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    • "Studies on deep brain stimulation for chronic pain in humans increased in the last years, thanks to the efficacy reported in various aetiologies including phantom limb pain[5,6], brachial plexus injury[7,8], central poststroke pain[7,9], face pain[10,11], spinal injuries or failed back surgery syndrome[7,8]. DBS targets for pain are the septal region[12], the sensory thalamus (VPL and VPM)[6,7], the periventricular grey (PVG) and periaqueductal grey (PAG)[13], the internal capsule, the posterior hypothalamus, the nucleus accumbens[9]and the anterior cingulate cortex (ACC)[8]. Sensory thalamic stimulation is mainly used with varying effectiveness in several chronic pain syndromes with the VPM particularly targeted in facial pain. "

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    ABSTRACT: Background: Somatosensory homunculi have been demonstrated in primary somatosensory cortex and ventral posterior thalamus but not periaqueductal and periventricular grey matter (PAVG), a therapeutic target for deep brain stimulation (DBS) in chronic pain. Aims: The study is an investigation of somatotopic representation in PAVG and assessment for a somatosensory homunculus. Methods: Five human subjects were investigated using electrical somatosensory stimulation and deep brain macroelectrode recording. DBS were implanted in the contralateral PAVG. Cutaneous arm, leg and face regions were stimulated while event-related potentials were recorded from deep brain electrodes. Electrode contact positions were mapped using MRI and brain atlas information. Results: Monopolar P1 somatosensory evoked potential amplitudes were highest and onset latencies shortest in contralateral caudal PAVG with facial stimulation and rostral with leg stimulation, in agreement with reported subjective sensation during intra-operative electrode advancement. Conclusions: A rostrocaudally inverted somatosensory homunculus exists in the human PAVG region. Objective human evidence of PAVG somatotopy increases understanding of a brainstem region important to pain and autonomic control that is a clinical target for both pharmacological and neurosurgical therapies. Such knowledge may assist DBS target localisation for neuropathic pain syndromes related to particular body regions like brachial plexopathies, anaesthesia dolorosa and phantom limb pain.
    No preview · Article · Jun 2013 · Stereotactic and Functional Neurosurgery
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    ABSTRACT: The periaqueductal/periventricular grey area (PAG/PVG) is a midbrain nucleus with an important role in pain signalling and autonomic control. We present the case of an initially hypertensive man who developed a presumed neurodegenerative disorder over a decade, characterised by progressive right-sided chronic pain, extra-pyramidal symptoms and autonomic dysfunction including postural hypotension, sleep apnoea, and bladder instability. He underwent a variety of treatments for his symptoms, including deep brain stimulation (DBS) of the PAG/PVG. 24-h blood pressure monitoring was carried out 1 and 5 years after implantation. Although the DBS initially produced a significant reduction in blood pressure, the effect was significantly reversed when the same tests were repeated 5 years after surgery. This may imply a functional involvement of the PAG/PVG in the neurodegenerative process.
    No preview · Article · Jun 2013 · Clinical Autonomic Research
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