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Shoraka O, Syed M, Mandloi S, Thalheimer S, Kashani SN, Heller JE, Mohamed FB, Sharan AD, Talekar KS, Matias CM, Harrop JS, Krisa L, Alizadeh M. Periaqueductal gray connectivity in spinal cord injury-induced neuropathic pain. J Neuroimaging 2024. [PMID: 39252511 DOI: 10.1111/jon.13237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 08/28/2024] [Accepted: 08/28/2024] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND AND PURPOSE Neuropathic pain (NP) is a debilitating condition following spinal cord injury (SCI). The role of periaqueductal gray (PAG) in NP development following SCI remains underexplored. Using resting-state functional MRI (rsfMRI), our study aimed to demonstrate the alterations in functional connectivity (FC) of PAG in NP following SCI. METHODS Ten SCI patients (SCI + NP, n = 7, and SCI - NP, n = 3), alongside 10 healthy controls (HCs), were enrolled. rsfMRI was conducted followed by seed-to-voxel analysis using PAG as the seed region and then group-based analysis comprising three groups (SCI + NP, SCI - NP, and HC). Age and gender were considered as confounding variables. RESULTS Compared to HCs, SCI + NP demonstrated decreased FC between PAG and right insula, right frontal orbital cortex, right pallidum, dorsal raphe nucleus (DRN), red nuclei (RN), substantia nigra (SN), and ventral posterolateral (VPL) thalamic nuclei. Compared to SCI - NP, SCI + NP demonstrated increased FC between PAG and posterior cingulate cortex (PCC), hippocampus, cerebellar vermis lobules IV and V, and thalamic structures (posterior and lateral pulvinar, the mediodorsal nuclei, and the ventral lateral nuclei). Additionally, decreased FC between the PAG and VPL, geniculate bodies, intralaminar nuclei of thalamus, DRN, RN, SN, and prefrontal cortex was observed in this comparison. CONCLUSIONS Altered FC between PAG and right anterior insula, VPL, DRN, RN, SN, cerebellar vermis lobules IV and V, frontal cortex, and PCC was associated with NP sequelae of SCI. Additionally, SCI was independently associated with decreased FC between PAG and right posterior insula, cerebellar lobules IV and V, and cerebellar vermis lobules III, IV, and V.
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Affiliation(s)
- Omid Shoraka
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mashaal Syed
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Shreya Mandloi
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sara Thalheimer
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sara Naghizadeh Kashani
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joshua E Heller
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Feroze B Mohamed
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashwini D Sharan
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kiran S Talekar
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Caio M Matias
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James S Harrop
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Laura Krisa
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mahdi Alizadeh
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Huang Y, Sadeghzadeh S, Li AHY, Schonfeld E, Ramayya AG, Buch VP. Rates and Predictors of Pain Reduction With Intracranial Stimulation for Intractable Pain Disorders. Neurosurgery 2024:00006123-990000000-01186. [PMID: 38836613 DOI: 10.1227/neu.0000000000003006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/01/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intracranial modulation paradigms, namely deep brain stimulation (DBS) and motor cortex stimulation (MCS), have been used to treat intractable pain disorders. However, treatment efficacy remains heterogeneous, and factors associated with pain reduction are not completely understood. METHODS We performed an individual patient review of pain outcomes (visual analog scale, quality-of-life measures, complications, pulse generator implant rate, cessation of stimulation) after implantation of DBS or MCS devices. We evaluated 663 patients from 36 study groups and stratified outcomes by pain etiology and implantation targets. RESULTS Included studies comprised primarily retrospective cohort studies. MCS patients had a similar externalized trial success rate compared with DBS patients (86% vs 81%; P = .16), whereas patients with peripheral pain had a higher trial success rate compared with patients with central pain (88% vs 79%; P = .004). Complication rates were similar for MCS and DBS patients (12% vs 15%; P = .79). Patients with peripheral pain had lower likelihood of device cessation compared with those with central pain (5.7% vs 10%; P = .03). Of all implanted patients, mean pain reduction at last follow-up was 45.8% (95% CI: 40.3-51.2) with a 31.2% (95% CI: 12.4-50.1) improvement in quality of life. No difference was seen between MCS patients (43.8%; 95% CI: 36.7-58.2) and DBS patients (48.6%; 95% CI: 39.2-58) or central (41.5%; 95% CI: 34.8-48.2) and peripheral (46.7%; 95% CI: 38.9-54.5) etiologies. Multivariate analysis identified the anterior cingulate cortex target to be associated with worse pain reduction, while postherpetic neuralgia was a positive prognostic factor. CONCLUSION Both DBS and MCS have similar efficacy and complication rates in the treatment of intractable pain. Patients with central pain disorders tended to have lower trial success and higher rates of device cessation. Additional prognostic factors include anterior cingulate cortex targeting and postherpetic neuralgia diagnosis. These findings underscore intracranial neurostimulation as an important modality for treatment of intractable pain disorders.
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Affiliation(s)
- Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alice Huai-Yu Li
- Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ethan Schonfeld
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ashwin G Ramayya
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vivek P Buch
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
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Wang D, Lu Y, Han Y, Zhang X, Dong S, Zhang H, Wang G, Wang G, Wang JJ. The Influence of Etiology and Stimulation Target on the Outcome of Deep Brain Stimulation for Chronic Neuropathic Pain: A Systematic Review and Meta-Analysis. Neuromodulation 2024; 27:83-94. [PMID: 36697341 DOI: 10.1016/j.neurom.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/12/2022] [Accepted: 12/01/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) to treat chronic neuropathic pain has shown variable outcomes. Variations in pain etiologies and DBS targets are considered the main contributing factors, which are, however, underexplored owing to a paucity of patient data in individual studies. An updated meta-analysis to quantitatively assess the influence of these factors on the outcome of DBS for chronic neuropathic pain is warranted, especially considering that the anterior cingulate cortex (ACC) has emerged recently as a new DBS target. MATERIALS AND METHODS A comprehensive literature review was performed in PubMed, Embase, and Cochrane data bases to identify studies reporting quantitative outcomes of DBS for chronic neuropathic pain. Pain and quality of life (QoL) outcomes, grouped by etiology and DBS target, were extracted and analyzed (α = 0.05). RESULTS Twenty-five studies were included for analysis. Patients with peripheral neuropathic pain (PNP) had a significantly greater initial stimulation success rate than did patients with central neuropathic pain (CNP). Both patients with CNP and patients with PNP with definitive implant, regardless of targets, gained significant follow-up pain reduction. Patients with PNP had greater long-term pain relief than did patients with CNP. Patients with CNP with ACC DBS gained less long-term pain relief than did those with conventional targets. Significant short-term QoL improvement was reported in selected patients with CNP after ACC DBS. However, selective reporting bias was expected, and the improvement decreased in the long term. CONCLUSIONS Although DBS to treat chronic neuropathic pain is generally effective, patients with PNP are the preferred population over patients with CNP. Current data suggest that ACC DBS deserves further investigation as a potential way to treat the affective component of chronic neuropathic pain.
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Affiliation(s)
- Dengyu Wang
- School of Medicine, Tsinghua University, Beijing, China; Institute for Precision Medicine, Tsinghua University, Beijing, China
| | - Yang Lu
- Institute for Precision Medicine, Tsinghua University, Beijing, China; Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Han
- School of Medicine, Tsinghua University, Beijing, China; Institute for Precision Medicine, Tsinghua University, Beijing, China
| | - Xiaolei Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Sheng Dong
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Huifang Zhang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Guoqin Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - James Jin Wang
- Institute for Precision Medicine, Tsinghua University, Beijing, China; Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
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Mandat V, Zdunek PR, Krolicki B, Szalecki K, Koziara HM, Ciecierski K, Mandat TS. Periaqueductal/periventricular gray deep brain stimulation for the treatment of neuropathic facial pain. Front Neurol 2023; 14:1239092. [PMID: 38020618 PMCID: PMC10660684 DOI: 10.3389/fneur.2023.1239092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background The Periaqueductal gray (PAG) and the periventricular gray (PVG) are the anatomical targets for deep brain stimulation (DBS) to treat severe, refractory neuropathic pain. Methods Seven (four female and three male) patients were qualified for PAG/PVG DBS because of neuropathic facial pain. Frame-based unilateral implantations of DBS were conducted according to indirect planning of the PAG/PVG, contralateral to reported pain (3389, Activa SC 37603, Medtronic). The efficacy of PAG/PVG DBS on pain was measured with Numeric Pain Rating Scale (NRS) and Neuropathic Pain Symptom Inventory (NPSI) before surgery and 3, 12, and 24 months after surgery. Results The mean age of the group at the implantation was 43.7 years (range: 28-62; SD: 12.13). The mean duration of pain varied from 2 to 12 years (mean: 7.3; SD: 4.11). Five patients suffered from left-sided facial pain and two suffered right-sided facial pain. The etiology of pain among four patients was connected to ischemic brain stroke and in one patient to cerebral hemorrhagic stroke. Patients did not suffer from any other chronic medical condition The beginnings of ailments among two patients were related to craniofacial injury. NRS decreased by 54% at the 3 months follow-up. The efficacy of the treatment measured with mean NRS decreased at one-year follow-up to 48% and to 45% at 24 months follow-up. The efficacy of the treatment measured with NPSI decreased from 0.27 to 0.17 at 2 years follow-up (mean reduction by 38%). The most significant improvement was recorded in the first section of NPSI (Q1: burning- reduced by 53%). The records of the last section (number five) of the NPSI (paresthesia/dysesthesia- Q11/Q12) have shown aggravation of those symptoms by 10% at the two-years follow-up. No surgery- or hardware-related complications were reported in the group. Transient adverse effects related to the stimulation were eliminated during the programming sessions. Conclusion PAG/PVG DBS is an effective and safe method of treatment of medically refractory neuropathic facial pain. The effectiveness of the treatment tends to decrease at 2 years follow-up. The clinical symptoms which tend to respond the best is burning pain. Symptoms like paresthesia and dysesthesia might increase after DBS treatment, even without active stimulation.
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Affiliation(s)
- Victor Mandat
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
- Department of Biology, University of Toronto, Toronto, ON, Canada
| | - Pawel R. Zdunek
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Bartosz Krolicki
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Krzysztof Szalecki
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Henryk M. Koziara
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Konrad Ciecierski
- Research and Academic Computer Network Organization (NASK), Warsaw, Poland
| | - Tomasz S. Mandat
- Department of Neurosurgery, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Motzkin JC, Kanungo I, D’Esposito M, Shirvalkar P. Network targets for therapeutic brain stimulation: towards personalized therapy for pain. FRONTIERS IN PAIN RESEARCH 2023; 4:1156108. [PMID: 37363755 PMCID: PMC10286871 DOI: 10.3389/fpain.2023.1156108] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Precision neuromodulation of central brain circuits is a promising emerging therapeutic modality for a variety of neuropsychiatric disorders. Reliably identifying in whom, where, and in what context to provide brain stimulation for optimal pain relief are fundamental challenges limiting the widespread implementation of central neuromodulation treatments for chronic pain. Current approaches to brain stimulation target empirically derived regions of interest to the disorder or targets with strong connections to these regions. However, complex, multidimensional experiences like chronic pain are more closely linked to patterns of coordinated activity across distributed large-scale functional networks. Recent advances in precision network neuroscience indicate that these networks are highly variable in their neuroanatomical organization across individuals. Here we review accumulating evidence that variable central representations of pain will likely pose a major barrier to implementation of population-derived analgesic brain stimulation targets. We propose network-level estimates as a more valid, robust, and reliable way to stratify personalized candidate regions. Finally, we review key background, methods, and implications for developing network topology-informed brain stimulation targets for chronic pain.
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Affiliation(s)
- Julian C. Motzkin
- Departments of Neurology and Anesthesia and Perioperative Care (Pain Management), University of California, San Francisco, San Francisco, CA, United States
| | - Ishan Kanungo
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Mark D’Esposito
- Department of Psychology, University of California, Berkeley, Berkeley, CA, United States
| | - Prasad Shirvalkar
- Departments of Neurology and Anesthesia and Perioperative Care (Pain Management), University of California, San Francisco, San Francisco, CA, United States
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
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6
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Zhang Q, Hu S, Talay R, Xiao Z, Rosenberg D, Liu Y, Sun G, Li A, Caravan B, Singh A, Gould JD, Chen ZS, Wang J. A prototype closed-loop brain-machine interface for the study and treatment of pain. Nat Biomed Eng 2023; 7:533-545. [PMID: 34155354 PMCID: PMC9516430 DOI: 10.1038/s41551-021-00736-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/22/2021] [Indexed: 12/25/2022]
Abstract
Chronic pain is characterized by discrete pain episodes of unpredictable frequency and duration. This hinders the study of pain mechanisms and contributes to the use of pharmacological treatments associated with side effects, addiction and drug tolerance. Here, we show that a closed-loop brain-machine interface (BMI) can modulate sensory-affective experiences in real time in freely behaving rats by coupling neural codes for nociception directly with therapeutic cortical stimulation. The BMI decodes the onset of nociception via a state-space model on the basis of the analysis of online-sorted spikes recorded from the anterior cingulate cortex (which is critical for pain processing) and couples real-time pain detection with optogenetic activation of the prelimbic prefrontal cortex (which exerts top-down nociceptive regulation). In rats, the BMI effectively inhibited sensory and affective behaviours caused by acute mechanical or thermal pain, and by chronic inflammatory or neuropathic pain. The approach provides a blueprint for demand-based neuromodulation to treat sensory-affective disorders, and could be further leveraged for nociceptive control and to study pain mechanisms.
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Affiliation(s)
- Qiaosheng Zhang
- Department of Anesthesiology, Perioperative Care and Pain, New York University School of Medicine, New York, NY, USA
| | - Sile Hu
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Robert Talay
- Department of Anesthesiology, Perioperative Care and Pain, New York University School of Medicine, New York, NY, USA
| | - Zhengdong Xiao
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - David Rosenberg
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Yaling Liu
- Department of Anesthesiology, Perioperative Care and Pain, New York University School of Medicine, New York, NY, USA
| | - Guanghao Sun
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Anna Li
- Department of Anesthesiology, Perioperative Care and Pain, New York University School of Medicine, New York, NY, USA
| | - Bassir Caravan
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA
| | - Amrita Singh
- Department of Anesthesiology, Perioperative Care and Pain, New York University School of Medicine, New York, NY, USA
| | - Jonathan D Gould
- College of Arts and Sciences, New York University, New York, NY, USA
| | - Zhe S Chen
- Department of Psychiatry, New York University School of Medicine, New York, NY, USA.
- Department of Neuroscience & Physiology, New York University School of Medicine, New York, NY, USA.
- Neuroscience Institute, New York University School of Medicine, New York, NY, USA.
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain, New York University School of Medicine, New York, NY, USA.
- Department of Neuroscience & Physiology, New York University School of Medicine, New York, NY, USA.
- Neuroscience Institute, New York University School of Medicine, New York, NY, USA.
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Pagano RL, Dale CS, Campos ACP, Hamani C. Translational aspects of deep brain stimulation for chronic pain. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2023; 3:1084701. [PMID: 36713643 PMCID: PMC9874335 DOI: 10.3389/fpain.2022.1084701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023]
Abstract
The use of deep brain stimulation (DBS) for the treatment of chronic pain was one of the first applications of this technique in functional neurosurgery. Established brain targets in the clinic include the periaqueductal (PAG)/periventricular gray matter (PVG) and sensory thalamic nuclei. More recently, the anterior cingulum (ACC) and the ventral striatum/anterior limb of the internal capsule (VS/ALIC) have been investigated for the treatment of emotional components of pain. In the clinic, most studies showed a response in 20%-70% of patients. In various applications of DBS, animal models either provided the rationale for the development of clinical trials or were utilized as a tool to study potential mechanisms of stimulation responses. Despite the complex nature of pain and the fact that animal models cannot reliably reflect the subjective nature of this condition, multiple preparations have emerged over the years. Overall, DBS was shown to produce an antinociceptive effect in rodents when delivered to targets known to induce analgesic effects in humans, suggesting a good predictive validity. Compared to the relatively high number of clinical trials in the field, however, the number of animal studies has been somewhat limited. Additional investigation using modern neuroscience techniques could unravel the mechanisms and neurocircuitry involved in the analgesic effects of DBS and help to optimize this therapy.
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Affiliation(s)
- Rosana L. Pagano
- Laboratory of Neuroscience, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Camila S. Dale
- Laboratory of Neuromodulation and Experimental Pain, Department of Anatomy, University of São Paulo, São Paulo, Brazil
| | | | - Clement Hamani
- Sunnybrook Research Institute, Hurvitz Brain Sciences Centre, Toronto, ON, Canada,Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada,Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada,Correspondence: Clement Hamani
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8
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Keller D, Tsuda MC, Usdin TB, Dobolyi A. Behavioural actions of tuberoinfundibular peptide 39 (parathyroid hormone 2). J Neuroendocrinol 2022; 34:e13130. [PMID: 35499975 PMCID: PMC9515240 DOI: 10.1111/jne.13130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 12/31/2022]
Abstract
Tuberoinfundibular peptide of 39 residues (TIP39) acts via its endogenous class B G-protein coupled receptorthe parathyroid hormone 2 receptor (PTH2R). Hence, it is also known as parathyroid hormone 2. The peptide is expressed in the brain by a small number of neurons with a highly restricted distribution, which in turn project to a large number of brain regions that contain PTH2R. This peptide neuromodulator system has been extensively investigated over the past 20 years including its behavioural actions, such as its role in the control of nociception, fear and fear incubation, anxiety and depression-like behaviours, and maternal and social behaviours. It also influences thermoregulation and potentially auditory responses. TIP39 probably exerts direct effect on the neuronal networks controlling these behaviours based on the localization of PTH2R and local TIP39 actions. In addition, TIP39 also affects the secretion of several hypothalamic hormones providing the basis for indirect behavioural actions. Recently developed experimental tools have stimulated further behavioural investigations, and novel results obtained are discussed in this review.
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Affiliation(s)
- Dávid Keller
- ELKH‐ELTE Laboratory of Molecular and Systems Neurobiology, Eötvös Loránd Research Network and Eötvös Loránd UniversityBudapestHungary
- Laboratory of Neuromorphology, Department of Anatomy, Histology and EmbryologySemmelweis UniversityBudapestHungary
| | - Mumeko C. Tsuda
- Preclinical Behavior and Modeling Core, Uniformed Services UniversityBethesdaMarylandUSA
| | - Ted B. Usdin
- Systems Neuroscience Imaging Resource, National Institute of Mental Health, NIHBethesdaMarylandUSA
| | - Arpád Dobolyi
- ELKH‐ELTE Laboratory of Molecular and Systems Neurobiology, Eötvös Loránd Research Network and Eötvös Loránd UniversityBudapestHungary
- Department of Physiology and NeurobiologyEötvös Loránd UniversityBudapestHungary
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9
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Chung M, Huh R. Neuromodulation for trigeminal neuralgia. J Korean Neurosurg Soc 2022; 65:640-651. [PMID: 35574582 PMCID: PMC9452392 DOI: 10.3340/jkns.2022.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/16/2022] [Indexed: 11/27/2022] Open
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10
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Xu R, Xie ME, Jackson CM. Trigeminal Neuralgia: Current Approaches and Emerging Interventions. J Pain Res 2021; 14:3437-3463. [PMID: 34764686 PMCID: PMC8572857 DOI: 10.2147/jpr.s331036] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 09/13/2021] [Indexed: 12/22/2022] Open
Abstract
Trigeminal neuralgia (TN) has been described in the literature as one of the most debilitating presentations of orofacial pain. This review summarizes over 150 years of collective clinical experience in the medical and surgical treatment of TN. Fundamentally, TN remains a clinical diagnosis that must be distinguished from other types of trigeminal neuropathic pain and/or facial pain associated with other neuralgias or headache syndromes. What is increasingly clear is that there is no catch-all medical or surgical intervention that is effective for all patients with trigeminal neuralgia, likely reflective of the fact that TN is likely a heterogenous group of disorders that jointly manifests in facial pain. The first-line treatment for TN remains anticonvulsant medical therapy. Patients who fail this have a range of surgical options available to them. In general, microvascular decompression is a safe and effective procedure with immediate and durable outcomes. Patients who are unable to tolerate general anesthesia or whose medical comorbidities preclude a suboccipital craniectomy may benefit from percutaneous methodologies including glycerol or radiofrequency ablation, or both. For patients with bleeding diathesis due to blood thinning medications who are ineligible for invasive procedures, or for those who are unwilling to undergo open surgical procedures, radiosurgery may be an excellent option-provided the patient understands that maximum pain relief will take on the order of months to achieve. Finally, peripheral neurectomies continue to provide an inexpensive and resource-sparing alternative to pain relief for patients in locations with limited economic and medical resources. Ultimately, elucidation of the molecular mechanisms underlying trigeminal neuralgia will pave the way for novel, more effective and less invasive therapies.
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Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael E Xie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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Liu Y, Xu H, Sun G, Vemulapalli B, Jee HJ, Zhang Q, Wang J. Frequency Dependent Electrical Stimulation of PFC and ACC for Acute Pain Treatment in Rats. FRONTIERS IN PAIN RESEARCH 2021; 2:728045. [PMID: 35295497 PMCID: PMC8915567 DOI: 10.3389/fpain.2021.728045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/02/2021] [Indexed: 11/13/2022] Open
Abstract
As pain consists of both sensory and affective components, its management by pharmaceutical agents remains difficult. Alternative forms of neuromodulation, such as electrical stimulation, have been studied in recent years as potential pain treatment options. Although electrical stimulation of the brain has shown promise, more research into stimulation frequency and targets is required to support its clinical applications. Here, we studied the effect that stimulation frequency has on pain modulation in the prefrontal cortex (PFC) and the anterior cingulate cortex (ACC) in acute pain models in rats. We found that low-frequency stimulation in the prelimbic region of the PFC (PL-PFC) provides reduction of sensory and affective pain components. Meanwhile, high-frequency stimulation of the ACC, a region involved in processing pain affect, reduces pain aversive behaviors. Our results demonstrate that frequency-dependent neuromodulation of the PFC or ACC has the potential for pain modulation.
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Affiliation(s)
- Yaling Liu
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, United States
| | - Helen Xu
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, United States
| | - Guanghao Sun
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, United States
- Interdisciplinary Pain Research Program, New York University Langone Health, New York, NY, United States
- Department of Psychiatry, New York University School of Medicine, New York, NY, United States
| | - Bharat Vemulapalli
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, United States
| | - Hyun Jung Jee
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, United States
| | - Qiaosheng Zhang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, United States
- Interdisciplinary Pain Research Program, New York University Langone Health, New York, NY, United States
- *Correspondence: Qiaosheng Zhang
| | - Jing Wang
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, United States
- Interdisciplinary Pain Research Program, New York University Langone Health, New York, NY, United States
- Department of Neuroscience & Physiology, New York University School of Medicine, New York, NY, United States
- Neuroscience Institute, New York University School of Medicine, New York, NY, United States
- Jing Wang
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12
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Frizon LA, Yamamoto EA, Nagel SJ, Simonson MT, Hogue O, Machado AG. Deep Brain Stimulation for Pain in the Modern Era: A Systematic Review. Neurosurgery 2020; 86:191-202. [PMID: 30799493 DOI: 10.1093/neuros/nyy552] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 01/25/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) has been considered for patients with intractable pain syndromes since the 1950s. Although there is substantial experience reported in the literature, the indications are contested, especially in the United States where it remains off-label. Historically, the sensory-discriminative pain pathways were targeted. More recently, modulation of the affective sphere of pain has emerged as a plausible alternative. OBJECTIVE To systematically review the literature from studies that used contemporary DBS technology. Our aim is to summarize the current evidence of this therapy. METHODS A systematic search was conducted in the MEDLINE, EMBASE, and Cochrane libraries through July 2017 to review all studies using the current DBS technology primarily for pain treatment. Study characteristics including patient demographics, surgical technique, outcomes, and complications were collected. RESULTS Twenty-two articles were included in this review. In total, 228 patients were implanted with a definitive DBS system for pain. The most common targets used were periaqueductal/periventricular gray matter region, ventral posterior lateral/posterior medial thalamus, or both. Poststroke pain, phantom limb pain, and brachial plexus injury were the most common specific indications for DBS. Outcomes varied between studies and across chronic pain diagnoses. Two different groups of investigators targeting the affective sphere of pain have demonstrated improvements in quality of life measures without significant reductions in pain scores. CONCLUSION DBS outcomes for chronic pain are heterogeneous thus far. Future studies may focus on specific pain diagnosis rather than multiple syndromes and consider randomized placebo-controlled designs. DBS targeting the affective sphere of pain seems promising and deserves further investigation.
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Affiliation(s)
- Leonardo A Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Erin A Yamamoto
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Olivia Hogue
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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13
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Abstract
Pain is a salient and complex sensory experience with important affective and cognitive dimensions. The current definition of pain relies on subjective reports in both humans and experimental animals. Such definition lacks basic mechanistic insights and can lead to a high degree of variability. Research on biomarkers for pain has previously focused on genetic analysis. However, recent advances in human neuroimaging and research in animal models have begun to show the promise of a circuit-based neural signature for pain. At the treatment level, pharmacological therapy for pain remains limited. Neuromodulation has emerged as a specific form of treatment without the systemic side effects of pharmacotherapies. In this review, we will discuss some of the current neuromodulatory modalities for pain, research on newer targets, as well as emerging possibility for an integrated brain-computer interface approach for pain management.
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14
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Peyron R, Fauchon C. Functional imaging of pain. Rev Neurol (Paris) 2018; 175:38-45. [PMID: 30318262 DOI: 10.1016/j.neurol.2018.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 12/12/2022]
Abstract
Brain functional imaging has been applied to the study of pain since 1991. Then, a plethora of studies around the world looking at pain sensations and their brain correlates was published. Four kinds of studies can be distinguished: i) A first set investigated brain responses to noxious heat stimulations (above the pain threshold) relative to an equivalent warm innocuous stimulation (below the pain threshold). The aim of these studies was to identify the pattern of brain regions involved in the nociceptive processes and they may be considered as descriptive studies rather than explanative studies. Their value was to list for the first time every brain structure that might be playing a role. ii) Secondly, several experimental investigations have explored brain activations when subjects are confronted with unpleasant situations such as seeing or imagining other people in pain (e.g. empathy for pain). Obviously, feeling pain and representing others suffering share a common brain network, indicating that a large part of the regions showing intensity changes are not specific to nociception. iii) The third set of imaging studies is aimed at investigating the functional and structural brain abnormalities that may account for clinical pain states. Unfortunately, a relatively small number of studies provide clear findings that do not allow drawing convincing and generalized conclusions. iv) The last set of studies focused on the modulation of pain experience in humans. Several research groups conducted projects on different factors known to alter pain perception and their associated brain processes with the objective of identifying one or more key regions capable of controlling the pain sensation. In the same vein, investigations have been performed around pain therapies. From the clinician's point of view, it may be seen as complementary to assess pain and analgesic processes. All these aspects of pain research with functional imaging are considered below, including attempts to understand the functional significance of each of the observed activations. v) A special focus will be dedicated to new sophisticated approaches, vi) applied to neuroimaging (e.g. graph theory). These promising techniques and recent electrophysiological investigations bring additional information to our understanding of pain/analgesic processes, particularly for temporal dynamics and connectivity between brain regions.
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Affiliation(s)
- R Peyron
- Centre stéphanois de la douleur, CHU de Saint-Etienne & INSERM U1028, Université Jean Monnet, CRNL-Lyon, 10, rue de la Marandière, 42270 Saint-Priest en Jarez, France.
| | - C Fauchon
- Centre stéphanois de la douleur, CHU de Saint-Etienne & INSERM U1028, Université Jean Monnet, CRNL-Lyon, 10, rue de la Marandière, 42270 Saint-Priest en Jarez, France
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15
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Strand J, Stinson C, Bellinger LL, Peng Y, Kramer PR. G i protein functions in thalamic neurons to decrease orofacial nociceptive response. Brain Res 2018; 1694:63-72. [PMID: 29763576 PMCID: PMC6026072 DOI: 10.1016/j.brainres.2018.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/27/2018] [Accepted: 05/12/2018] [Indexed: 01/01/2023]
Abstract
Orofacial pain includes neuronal pathways that project from the trigeminal nucleus to and through the thalamus. What role the ventroposterior thalamic complex (VP) has on orofacial pain transmission is not understood. To begin to address this question an inhibitory G protein (Gi) designer receptor exclusively activated by a designer drug (DREADD) was transfected in cells of the VP using adeno-associated virus isotype 8. Virus infected cells were identified by a fluorescent tag and immunostaining. Cells were silenced after injecting the designer drug clozapine-n-oxide, which binds the designer receptor activating Gi. Facial rubbing and local field potentials (LFP) in the VP were then recorded in awake, free moving Sprague Dawley rats after formalin injection of the masseter muscle to induce nociception. Formalin injection significantly increased LFP and the nociceptive behavioral response. Activation of DREADD Gi with clozapine-n-oxide significantly reduced LFP in the VP and reduced the orofacial nociceptive response. Because DREADD silencing can result from Gi-coupled inwardly-rectifying potassium channels (GIRK), the GIRK channel blocker tertiapin-Q was injected. Injection of GIRK blocker resulted in an increase in the nociceptive response and increased LFP activity. Immunostaining of the VP for glutamate vesicular transporter (VGLUT2) and gamma-aminobutyric acid vesicular transporter (VGAT) indicated a majority of the virally transfected cells were excitatory (VGLUT2 positive) and a minority were inhibitory (VGAT positive). We conclude first, that inhibition of the excitatory neurons within the VP reduced electrical activity and the orofacial nociceptive response and that the effect on excitatory neurons overwhelmed any change resulting from inhibitor neurons. Second, inhibition of LFP and nociception was due, in part, to GIRK activation.
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Affiliation(s)
- Jennifer Strand
- Department of Psychology, University of Texas at Arlington, Arlington, TX 76019, United States
| | - Crystal Stinson
- Texas A&M University College of Dentistry, Dallas, TX 75246, United States
| | - Larry L Bellinger
- Texas A&M University College of Dentistry, Dallas, TX 75246, United States
| | - Yuan Peng
- Department of Psychology, University of Texas at Arlington, Arlington, TX 76019, United States
| | - Phillip R Kramer
- Texas A&M University College of Dentistry, Dallas, TX 75246, United States.
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16
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Ward M, Mammis A. Deep Brain Stimulation for the Treatment of Dejerine-Roussy Syndrome. Stereotact Funct Neurosurg 2017; 95:298-306. [PMID: 28848107 DOI: 10.1159/000479526] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 07/11/2017] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Max Ward
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
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17
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Abejón D, Rueda P, Vallejo R. Threshold Evolution as an Analysis of the Different Pulse Frequencies in Rechargeable Systems for Spinal Cord Stimulation. Neuromodulation 2016; 19:276-82. [PMID: 26857220 DOI: 10.1111/ner.12401] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 12/26/2015] [Accepted: 12/27/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pulse frequency (Fc) is one of the most important parameters in neurostimulation, with Pulse Amplitude (Pw) and Amplitude (I). Up to certain Fc, increasing the number of pulses will generate action potentials in neighboring neural structures and may facilitate deeper penetration of the electromagnetic fields. In addition, changes in frequency modify the patient's sensation with stimulation. MATERIALS/METHODS Fifty patients previously implanted with rechargeable current control spinal cord stimulation. With pulse width fixed at 300 μsec, we stimulated at 26 different Fc values between 40 and 1200 Hz and determine the influence of these changes on different stimulation thresholds: perception threshold (Tp ), therapeutic perception (Tt), and discomfort threshold (Td). Simultaneously, paresthesia coverage of the painful area and patient's sensation and satisfaction related to the quality of stimulation were recorded. RESULTS Pulse Fc is inversely proportional to stimulation thresholds and this influence is statistically significant (p < 0.05). As Pulse Fc increased from 40 to 1200 Hz, the mean threshold decreases from 7.25 to 1.38 mA (Tp ), 8.17 to 1.63 (Tt ), and 9.20 to 1.85 (Td). Significant differences for Tp and Tt began at 750 Hz (Tp , Tt ) and at 650 Hz for Td. No significant influence was found regarding paresthesia coverage. As expected, Fc affects significantly patient's sensation and satisfaction. DISCUSSION Changes in Fc affect the quality of paresthesias. Within the evaluated parameters higher frequencies are inversely proportional to stimulation thresholds and Tt. It seems that Fc is a vital parameter to achieve therapeutic success. CONCLUSIONS Changes in Fc is a useful parameter to modulate the patient's sensory perception. Fc can be successfully used to adjust the quality of the paresthesias and to modify patient's subjective sensation. We showed that as the frequency increases, the patient's satisfaction with the perceived sensation decreases, suggesting that higher Fc may need to be set up at subthreshold amplitude to achieve positive response.
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Affiliation(s)
- David Abejón
- Head of Pain Unit, Hospital Universitario Quirón Madrid, Madrid, Spain
| | | | - Ricardo Vallejo
- Director of Research Millennium Pain Center, IL, USA.,Biology Department, Illinois State University, Normal, IL, USA.,Wesleyan University, Bloomington, IL, USA
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18
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Liang Y, Zhang J, Xie T, Cho EYP, Hu D, Liu B, Xiao L, Sha O. Hospitalized pain patients have recently doubled: a retrospective case series study in Shenzhen Nanshan People's Hospital of China. Int J Neurosci 2015; 126:812-818. [PMID: 26268306 DOI: 10.3109/00207454.2015.1073728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To study the characteristics of hospitalized pain patients in Shenzhen with the aim of identifying some of the social, economic and therapeutic aspects of pain management in China. METHODS A retrospective study was designed to collect the information of 3061 hospitalized pain patients in 2003, 2007 and 2011. Their demographic characteristics, diagnoses of pain types, hospitalization, therapeutic effect, economic cost and payment types were analyzed. RESULTS The number of female patients significantly increased with time. The patient's average age increased from 41.3 in 2003 to 49.7 years old in 2011. The most common diagnosis of pain was lumbar intervertebral disc herniation. The total hospitalization days of each patient per year significantly decreased from 15.7 days in 2003 to 10.4 days in 2011. However, the hospitalization cost for each patient was almost doubled. CONCLUSION The hospitalized pain patients and their economic burdens have almost been doubled in the recent four years.
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Affiliation(s)
- Yilin Liang
- a 1 Department of Preclinical Medicine, School of Medicine , Shenzhen University , Shenzhen , Guangdong , China
| | - Jian Zhang
- a 1 Department of Preclinical Medicine, School of Medicine , Shenzhen University , Shenzhen , Guangdong , China
| | - Tianshun Xie
- a 1 Department of Preclinical Medicine, School of Medicine , Shenzhen University , Shenzhen , Guangdong , China
| | - Eric Yu Pang Cho
- b 2 School of Biomedical Sciences, Faculty of Medicine , The Chinese University of Hong Kong , Shatin , Hong Kong
| | - Dongsheng Hu
- a 1 Department of Preclinical Medicine, School of Medicine , Shenzhen University , Shenzhen , Guangdong , China
| | - Baohua Liu
- a 1 Department of Preclinical Medicine, School of Medicine , Shenzhen University , Shenzhen , Guangdong , China
| | - Lizu Xiao
- c 3 Department of Pain Medicine , Shenzhen Nanshan People's Hospital , Shenzhen , Guangdong , China
| | - Ou Sha
- a 1 Department of Preclinical Medicine, School of Medicine , Shenzhen University , Shenzhen , Guangdong , China
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19
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Gee LE, Chen N, Ramirez-Zamora A, Shin DS, Pilitsis JG. The effects of subthalamic deep brain stimulation on mechanical and thermal thresholds in 6OHDA-lesioned rats. Eur J Neurosci 2015; 42:2061-9. [PMID: 26082992 DOI: 10.1111/ejn.12992] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/08/2015] [Accepted: 06/11/2015] [Indexed: 12/21/2022]
Abstract
Chronic pain is a major complaint for up to 85% of Parkinson's disease patients; however, it often not identified as a symptom of Parkinson's disease. Adequate treatment of motor symptoms often provides analgesic effects in Parkinson's patients but how this occurs remains unclear. Studies have shown both Parkinson's patients and 6-hydroxydopamine-lesioned rats exhibit decreased sensory thresholds. In humans, some show improvements in these deficits after subthalamic deep brain stimulation, while others report no change. Differing methods of testing and response criteria may explain these varying results. We examined this effect in 6-hydroxydopamine-lesioned rats. Sprague-Dawley rats were unilaterally implanted with subthalamic stimulating electrodes in the lesioned right hemisphere and sensory thresholds were tested using von Frey, tail-flick and hot-plate tests. Tests were done during and off subthalamic stimulation at 50 and 150 Hz to assess its effects on sensory thresholds. The 6-hydroxydopamine-lesioned animals exhibited lower mechanical (left paw, P < 0.01) and thermal thresholds than shams (hot plate, P < 0.05). Both 50 and 150 Hz increased mechanical (left paw; P < 0.01) and thermal thresholds in 6-hydroxydopamine-lesioned rats (hot-plate test: 150 Hz, P < 0.05, 50 Hz, P < 0.01). Interestingly, during von Frey testing, low-frequency stimulation provided a more robust improvement in some 6OHDA lesioned rats, while in others, the magnitude of improvement on high-frequency stimulation was greater. This study shows that subthalamic deep brain stimulation improves mechanical allodynia and thermal hyperalgesia in 6-hydroxydopamine-lesioned animals at both high and low frequencies. Furthermore, we suggest considering using low-frequency stimulation when treating Parkinson's patients where pain remains the predominant complaint.
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Affiliation(s)
- Lucy E Gee
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, AMC Neurosurgery Group, Albany Medical Center, 47 New Scotland Ave, MC 10, Physicians Pavilion, 1st Floor, Albany, NY, 12208, USA
| | - Nita Chen
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA
| | | | - Damian S Shin
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA
| | - Julie G Pilitsis
- Center for Neuroscience and Neuropharmacology, Albany Medical College, Albany, NY, USA.,Department of Neurosurgery, AMC Neurosurgery Group, Albany Medical Center, 47 New Scotland Ave, MC 10, Physicians Pavilion, 1st Floor, Albany, NY, 12208, USA
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20
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Boccard SGJ, Pereira EAC, Aziz TZ. Deep brain stimulation for chronic pain. J Clin Neurosci 2015; 22:1537-43. [PMID: 26122383 DOI: 10.1016/j.jocn.2015.04.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/11/2015] [Indexed: 11/29/2022]
Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention popularised in movement disorders such as Parkinson's disease, and also reported to improve symptoms of epilepsy, Tourette's syndrome, obsessive compulsive disorders and cluster headache. Since the 1950s, DBS has been used as a treatment to relieve intractable pain of several aetiologies including post stroke pain, phantom limb pain, facial pain and brachial plexus avulsion. Several patient series have shown benefits in stimulating various brain areas, including the sensory thalamus (ventral posterior lateral and medial), the periaqueductal and periventricular grey, or, more recently, the anterior cingulate cortex. However, this technique remains "off label" in the USA as it does not have Federal Drug Administration approval. Consequently, only a small number of surgeons report DBS for pain using current technology and techniques and few regions approve it. Randomised, blinded and controlled clinical trials that may use novel trial methodologies are desirable to evaluate the efficacy of DBS in patients who are refractory to other therapies. New imaging techniques, including tractography, may help optimise electrode placement and clinical outcome.
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Affiliation(s)
- Sandra G J Boccard
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
| | - Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Tipu Z Aziz
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
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21
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Keifer OP, Riley JP, Boulis NM. Deep brain stimulation for chronic pain: intracranial targets, clinical outcomes, and trial design considerations. Neurosurg Clin N Am 2015; 25:671-92. [PMID: 25240656 DOI: 10.1016/j.nec.2014.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
For over half a century, neurosurgeons have attempted to treat pain from a diversity of causes using acute and chronic intracranial stimulation. Targets of stimulation have included the sensory thalamus, periventricular and periaqueductal gray, the septum, the internal capsule, the motor cortex, posterior hypothalamus, and more recently, the anterior cingulate cortex. The current work focuses on presenting and evaluating the evidence for the efficacy of these targets in a historical context while also highlighting the major challenges to having a double-blind placebo-controlled clinical trial. Considerations for pain research in general and use of intracranial targets specifically are included.
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Affiliation(s)
- Orion Paul Keifer
- MD/PhD Program, School of Medicine, Emory University, Suite 375-B, 1648 Pierce Drive, Atlanta, GA 30322, USA
| | - Jonathan P Riley
- Department of Neurosurgery, Emory University, 1365-B Clifton Road Northeast, Suite 2200, Atlanta, GA 30322, USA
| | - Nicholas M Boulis
- Department of Neurosurgery, Emory University, 1365-B Clifton Road Northeast, Suite 2200, Atlanta, GA 30322, USA.
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22
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Pereira EAC, Boccard SG, Aziz TZ. Deep brain stimulation for pain: distinguishing dorsolateral somesthetic and ventromedial affective targets. Neurosurgery 2015; 61 Suppl 1:175-81. [PMID: 25032548 DOI: 10.1227/neu.0000000000000397] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Erlick A C Pereira
- *Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, United Kingdom; ‡Department of Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Portugal
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23
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24
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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.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, OX3 9DU, UK,
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25
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26
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Canavero S, Bonicalzi V. Central pain syndrome: elucidation of genesis and treatment. Expert Rev Neurother 2014; 7:1485-97. [DOI: 10.1586/14737175.7.11.1485] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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28
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Pereira EAC, Green AL, Nandi D, Aziz TZ. Deep brain stimulation: indications and evidence. Expert Rev Med Devices 2014; 4:591-603. [PMID: 17850194 DOI: 10.1586/17434440.4.5.591] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Deep brain stimulation is a minimally invasive targeted neurosurgical intervention that enables structures deep in the brain to be stimulated electrically by an implanted pacemaker. It has become the treatment of choice for Parkinson's disease, refractory to, or complicated by, drug therapy. Its efficacy has been demonstrated robustly by randomized, controlled clinical trials, with multiple novel brain targets having been discovered in the last 20 years. Multifarious clinical indications for deep brain stimulation now exist, including dystonia and tremor in movement disorders; depression, obsessive-compulsive disorder and Tourette's syndrome in psychiatry; epilepsy, cluster headache and chronic pain, including pain from stroke, amputation, trigeminal neuralgia and multiple sclerosis. Current research argues for novel indications, including hypertension and orthostatic hypotension. The development, principles, indications and effectiveness of the technique are reviewed here. While deep brain stimulation is a standard and widely accepted treatment for Parkinson's disease after 20 years of experience, in chronic pain it remains restricted to a handful of experienced, specialist centers willing to publish outcomes despite its use for over 50 years. Reasons are reviewed and novel approaches to appraising clinical evidence in functional neurosurgery are suggested.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery, Nuffield Department of Surgery and Department of Neurological Surgery, The West Wing, The John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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29
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Wu D, Wang S, Stein JF, Aziz TZ, Green AL. Reciprocal interactions between the human thalamus and periaqueductal gray may be important for pain perception. Exp Brain Res 2013; 232:527-34. [PMID: 24217977 DOI: 10.1007/s00221-013-3761-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 10/29/2013] [Indexed: 12/18/2022]
Abstract
Pain perception can be altered by activity in the periaqueductal gray (PAG). The PAG can decrease the incoming nociceptive signals at the level of the spinal dorsal horn, but it is not clear whether the PAG can also affect the sensory thalamus, ventral posterolateral and ventral posteromedial thalamic nuclei, to modulate pain. However, the PAG and the thalamus have direct connections with each other; so we postulated that the PAG may also modulate pain by inhibiting the sensory nuclei in the thalamus, and that these may also reciprocally influence the PAG. Here, by analyzing the local field potentials recorded from the sensory thalamus and the PAG in chronic pain patients with deep brain stimulation electrodes, we show that PAG stimulation inhibited the sensory thalamus with decreasing thalamic delta, theta, alpha and beta power, and sensory thalamus stimulation excited the PAG with increasing PAG delta and theta power. We demonstrate that the PAG and the sensory thalamus interact reciprocally at short latency, which may be related to pain modulation.
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Affiliation(s)
- Dali Wu
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX3 9DU, UK,
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Wang N, Shi M, Wang JY, Luo F. Brain-network mechanisms underlying the divergent effects of depression on spontaneous versus evoked pain in rats: a multiple single-unit study. Exp Neurol 2013; 250:165-75. [PMID: 24100021 DOI: 10.1016/j.expneurol.2013.09.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 09/18/2013] [Accepted: 09/24/2013] [Indexed: 12/23/2022]
Abstract
Studies have reported divergent behavioral effects of depression on spontaneous vs. stimulus-evoked pain. However, the underlying neurobiological mechanisms are still unclear. The present study used a depression model of unpredictable chronic mild stress (UCMS) and pain models for spontaneous pain (i.e., the formalin test) and acute evoked pain (i.e., noxious thermal stimulation) in rats. The activity of neurons within thalamo-cortical circuits in the lateral and medial pain pathways was recorded by a multiple-channel recording technique, and behaviors were observed simultaneously. The results confirmed our previous findings that rats exposed to UCMS tended to exhibit decreased pain sensitivity to experimental stimuli but increased behavioral responses to ongoing pain. Based on the analysis of single-unit responses, the results demonstrated that the processing of spontaneous vs. evoked pain in a depressive-like state was altered in the opposite direction (activation vs. inhibition). The ensemble encoding analysis revealed that exposure to UCMS gave rise to enhanced inter-regional functional connectivity in spontaneous pain processing, but did not influence that of evoked pain. In addition, different brain activation patterns underlying the processing of spontaneous vs. evoked pain were observed. These findings revealed that the distinct response patterns of neurons within the pain-related brain circuits, especially in the affective pain pathway, mediate the divergent effects of depression on spontaneous vs. evoked pain. This is also the first report on the electrophysiology of depression models that provides direct evidence that the effect of depression on spontaneous and evoked pain may involve different brain mechanisms.
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Affiliation(s)
- Ning Wang
- Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, Beijing 100101, China
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Deppe M, Müller D, Kugel H, Ruck T, Wiendl H, Meuth SG. DTI detects water diffusion abnormalities in the thalamus that correlate with an extremity pain episode in a patient with multiple sclerosis. NEUROIMAGE-CLINICAL 2013; 2:258-62. [PMID: 24179780 PMCID: PMC3778262 DOI: 10.1016/j.nicl.2013.01.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 01/15/2013] [Accepted: 01/17/2013] [Indexed: 12/13/2022]
Abstract
Background Various types of multiple sclerosis (MS) related pain have been discussed. One concept is that deafferentation secondary to lesions in the spino-thalamo-cortical network can cause central pain. However, this hypothesis is somehow limited by a lack of a robust association between pain episodes and sites of lesion location. Objective We tested the hypothesis that temporary tissue alterations in the thalamus that are not detectable by conventional magnetic resonance imaging (T1w, FLAIR) can potentially explain a focal, paroxysmal central pain episode of a patient with MS. For microstructural tissue assessment we employed ten longitudinal diffusion tensor imaging (DTI) examinations. Results We could demonstrate an abnormal, unilateral temporary increase of the fractional anisotropy (FA) in the thalamus contralateral to the affected body side. Before the pain episode and after pain relief the FA reached completely normal values as seen in identically investigated age and gender matched 100 healthy control subjects. Conclusion These findings suggest that: i.) frequently applied and quantitatively evaluated DTI could be used as a sensitive imaging technique for detection of pathological processes associated with MS not detectable with conventional imaging strategies, ii.) temporary pathological processes in the “normal-appearing” thalamus may explain waxing and waning symptoms like episodes of central pain, and iii.) cross-sectional case examinations on (MS) patients with central pain should be performed to investigate how often thalamic alterations occur together with central pain.
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Affiliation(s)
- Michael Deppe
- Department of Neurology, Westfälische Wilhelms University, Münster, Germany
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Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention whose efficacy, safety, and utility have been shown in the treatment of movement disorders. For the treatment of chronic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated during the past decade using current standards of neuroimaging and stimulator technology. We summarize the history, science, selection, assessment, surgery, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and, latterly, the rostral anterior cingulate cortex (Cg24) in 100 patients treated now at two centers (John Radcliffe Hospital, Oxford, UK, and Hospital de São João, Porto, Portugal) over 12 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 considered for whole-body 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.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, UK
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Pereira EA, Wang S, Peachey T, Lu G, Shlugman D, Stein JF, Aziz TZ, Green AL. Elevated gamma band power in humans receiving naloxone suggests dorsal periaqueductal and periventricular gray deep brain stimulation produced analgesia is opioid mediated. Exp Neurol 2013; 239:248-55. [DOI: 10.1016/j.expneurol.2012.10.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/03/2012] [Accepted: 10/24/2012] [Indexed: 11/29/2022]
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Monsalve GA. Motor cortex stimulation for facial chronic neuropathic pain: A review of the literature. Surg Neurol Int 2012; 3:S290-311. [PMID: 23230534 PMCID: PMC3514920 DOI: 10.4103/2152-7806.103023] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Accepted: 09/11/2012] [Indexed: 11/05/2022] Open
Abstract
Background: Facial chronic neuropathic pain (FCNP) is a disabling clinical entity, its incidence is increasing within the chronic pain population. There is indication for neuromodulation when conservative treatment fails. Motor cortex stimulation (MCS) has emerged as an alternative in the advanced management of these patients. The aim of this work is to review the worldwide literature on MCS for FCNP. Methods: A PubMed search from 1990 to 2012 was conducted using established MeSH words. A total of 126 relevant articles on MCS focused on chronic pain were selected and analysed. Series of cases were divided in (1) series focused on MCS for FCNP, and (2) MCS series of FCNP mixed with other chronic pain entities. Results: A total of 118 patients have been trialed for MCS for FCNP, 100 (84.7%) pursued permanent implantation of the system, and 84% of them had good pain control at the end of the study. Male: female ratio was about 1:2 in the whole group of studies; mean age was 58 years (range, 28–83), and mean pain duration was 7 years (range, 0.6–25). Four randomized controlled studies have been reported, all of them not focused on MCS for FCNP. The most common complication was seizure followed by wound infection. Preoperative evaluation, surgical techniques, and final settings varied among the series. Conclusion: MCS for FNCP is a safe and efficacious treatment option when previous managements have failed; however, there is still lack of strong evidence (larger randomized controlled multicentre studies) that MCS can be offered in a regular basis to FNCP patients.
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Machado AG, Baker KB, Plow E, Malone DA. Cerebral stimulation for the affective component of neuropathic pain. Neuromodulation 2012; 16:514-8. [PMID: 23094938 DOI: 10.1111/j.1525-1403.2012.00517.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 07/30/2012] [Accepted: 08/30/2012] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To review the current state of cerebral stimulation for neuropathic pain and to propose that cerebral stimulation should aim also at the affective sphere of chronic pain rather than solely focusing on the primary sensory-discriminative sphere. METHODS The past and current goals of cerebral stimulation are reviewed as well as its limitations. A novel deep brain stimulation approach is proposed to evaluate this conceptual shift from somatosensory to affective sphere of pain targeting. APPROACH Thalamic and other central pain syndromes are typically intractable to current treatment methods, including cerebral neuromodulation of somatosensory pathways, leading to long-term distress and disability. Our modern understanding of chronic pain pathophysiology is based largely on the neuromatrix theory, where cognitive, affective, and sensory-discriminative spheres contribute equally to the overall pain experience. During the last decade, the safety and feasibility of chronic stimulation of neural pathways related to mood and affect has been explored with promising results. Here, we propose a novel approach to modulate the affective sphere of chronic pain by targeting similar networks in patients with treatment-refractory central pain. Our primary goal is not to produce (or measure) analgesia, but rather to modulate the affective burden of chronic pain. DISCUSSION Cerebral neuromodulation for neuropathic pain has had limited efficacy thus far. Shifting our aim to neural networks related to the affective sphere of pain may allow us to reduce pain conditioning and pain-related disability. Our ultimate goal is to promote rehabilitation from chronic pain-social and occupational.
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Affiliation(s)
- Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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Green AL, Shad A, Watson R, Nandi D, Yianni J, Aziz TZ. N-of-1 Trials for Assessing the Efficacy of Deep Brain Stimulation in Neuropathic Pain. Neuromodulation 2012; 7:76-81. [PMID: 22151187 DOI: 10.1111/j.1094-7159.2004.04010.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The objective of this study is to determine the usefulness of single-patient, randomised, controlled trials (N-of-1 trials) in assessing the efficacy of deep brain stimulation (DBS) in neuropathic pain. Seven patients with various causes of intractable neuropathic pain underwent insertion of deep brain stimulating electrodes into the periventricular gray area or ventroposterolateral nucleus of the thalamus. Preoperatively, pain was measured using Visual Analog Scales (VAS) and the McGill Pain Questionnaire (MPQ). At 6 months, these pain assessments were repeated. At this point all patients were entered into a N-of-1 trial with the DBS on and off. Data were analyzed using the Wilcoxon and Student t-tests. Following placement of the deep brain stimulator, VAS scores were significantly reduced in six of seven patients. McGill Pain Scores (MPS) showed pain reduction in four of seven. The results of the N-of-1 trials were most similar to the MPQ scores and showed that three of seven patients could accurately predict whether the DBS was on or off. In the N-of-1 trials, the time between changing the DBS from on to off (or vice versa) had an effect on the results and probably underestimated the efficacy. We conclude that N-of-1 trials are a useful tool for assessing DBS efficacy.
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Mallory GW, Abulseoud O, Hwang SC, Gorman DA, Stead SM, Klassen BT, Sandroni P, Watson JC, Lee KH. The nucleus accumbens as a potential target for central poststroke pain. Mayo Clin Proc 2012; 87:1025-31. [PMID: 22980165 PMCID: PMC3498057 DOI: 10.1016/j.mayocp.2012.02.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 02/09/2012] [Indexed: 12/21/2022]
Abstract
Although deep brain stimulation (DBS) has been found to be efficacious for some chronic pain syndromes, its usefulness in patients with central poststroke pain (CPSP) has been disappointing. The most common DBS targets for pain are the periventricular gray region (PVG) and the ventralis caudalis of the thalamus. Despite the limited success of DBS for CPSP, few alternative targets have been explored. The nucleus accumbens (NAC), a limbic structure within the ventral striatum that is involved in reward and pain processing, has emerged as an effective target for psychiatric disease. There is also evidence that it may be an effective target for pain. We describe a 72-year-old woman with a large right hemisphere infarct who subsequently experienced refractory left hemibody pain. She underwent placement of 3 electrodes in the right PVG, ventralis caudalis of the thalamus, and NAC. Individual stimulation of the NAC and PVG provided substantial improvement in pain rating. The patient underwent implantation of permanent electrodes in both targets, and combined stimulation has provided sustained pain relief at nearly 1 year after the procedure. These results suggest that the NAC may be an effective DBS target for CPSP.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Kendall H. Lee
- Department of Neurosurgery, Mayo Clinic, Rochester, MN
- Correspondence: Address to Kendall H. Lee, MD, PhD, Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN 55901
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Nguyen JP, Nizard J, Keravel Y, Lefaucheur JP. Invasive brain stimulation for the treatment of neuropathic pain. Nat Rev Neurol 2011; 7:699-709. [DOI: 10.1038/nrneurol.2011.138] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Yamada K, Akazawa K, Yuen S, Goto M, Matsushima S, Takahata A, Nakagawa M, Mineura K, Nishimura T. MR imaging of ventral thalamic nuclei. AJNR Am J Neuroradiol 2009; 31:732-5. [PMID: 19926703 DOI: 10.3174/ajnr.a1870] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Vim and VPL are important target regions of the thalamus for DBS. Our aim was to clarify the anatomic locations of the ventral thalamic nuclei, including the Vim and VPL, on MR imaging. MATERIALS AND METHODS Ten healthy adult volunteers underwent MR imaging by using a 1.5T whole-body scanner. The subjects included 5 men and 5 women, ranging in age from 23 to 38 years, with a mean age of 28 years. The subjects were imaged with STIR sequences (TR/TE/TI = 3200 ms/15 ms/120 ms) and DTI with a single-shot echo-planar imaging technique (TR/TE = 6000 ms/88 ms, b-value = 2000 s/mm(2)). Tractography of the CTC and spinothalamic pathway was used to identify the thalamic nuclei. Tractography of the PT was used as a reference, and the results were superimposed on the STIR image, FA map, and color-coded vector map. RESULTS The Vim, VPL, and PT were all in close contact at the level through the ventral thalamus. The Vim was bounded laterally by the PT and medially by the IML. The VPL was bounded anteriorly by the Vim, laterally by the internal capsule, and medially by the IML. The posterior boundary of the VPL was defined by a band of low FA that divided the VPL from the pulvinar. CONCLUSIONS The ventral thalamic nuclei can be identified on MR imaging by using reference structures such as the PT and the IML.
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Affiliation(s)
- K Yamada
- Departments of Radiology, Kyoto Prefectural University of Medicine, Japan.
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Analgesia in conjunction with normalisation of thermal sensation following deep brain stimulation for central post-stroke pain. Pain 2009; 147:299-304. [PMID: 19833434 PMCID: PMC2789248 DOI: 10.1016/j.pain.2009.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Revised: 09/08/2009] [Accepted: 09/10/2009] [Indexed: 11/22/2022]
Abstract
The aetiology of central post-stroke pain (CPSP) is poorly understood and such pains are often refractory to treatment. We report the case of a 56-year-old man, who, following a temporo-parietal infarct, suffered from debilitating and refractory hemi-body cold dysaesthesia and severe tactile allodynia. This was associated with thermal and tactile hypoaesthesia and hypoalgesia on his affected side. Implantation of a deep brain stimulating electrode in his periventricular gray (PVG) region produced an improvement in his pain that was associated with a striking normalisation of his deficits in somatosensory perception. This improvement in pain and thermal sensibility was reversed as stimulation became less effective, because of increased electrode impedance. Therefore, we postulate that the analgesic benefit may have occurred as a consequence of the normalisation of somatosensory function and we discuss these findings in relation to the theories of central pain generation and the potential to engage useful plasticity in central circuits.
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Abstract
Deep brain stimulation (DBS) has been used to treat various neurological and psychiatric disorders. Over the years, the most suitable surgical candidates and targets for some of these conditions have been characterized and the benefits of DBS well demonstrated in double-blinded randomized trials. This review will discuss some of the areas of current investigation and potential new applications of DBS.
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Affiliation(s)
- Nasir Raza Awan
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Canada
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42
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Motor cortex and deep brain stimulation for the treatment of intractable neuropathic face pain. Curr Neurol Neurosci Rep 2009; 9:120-6. [PMID: 19268035 DOI: 10.1007/s11910-009-0020-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Intractable neuropathic face pain is a syndrome of unremitting severe pain that stems from abnormal nociceptive processing at various levels of the trigeminal system. Treatment of this debilitating condition has long presented a challenge for physicians due to its refractoriness to standard pharmacologic therapies. With few viable treatments, surgical procedures such as motor cortex stimulation (MCS) and deep brain stimulation (DBS) provide additional options. This article reviews the current literature and practices regarding patient selection criteria, potential mechanisms of action, surgical technique, and outcome of patients with neuropathic face pain treated with MCS and DBS.
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Green AL, Wang S, Stein JF, Pereira EAC, Kringelbach ML, Liu X, Brittain JS, Aziz TZ. Neural signatures in patients with neuropathic pain. Neurology 2009; 72:569-71. [PMID: 19204269 DOI: 10.1212/01.wnl.0000342122.25498.8b] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- A L Green
- Department of Physiology, Anatomy & Genetics, University of Oxford, UK.
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Abnormal thalamocortical dynamics may be altered by deep brain stimulation: using magnetoencephalography to study phantom limb pain. J Clin Neurosci 2008; 16:32-6. [PMID: 19019684 DOI: 10.1016/j.jocn.2008.03.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 03/03/2008] [Accepted: 03/12/2008] [Indexed: 11/24/2022]
Abstract
Deep brain stimulation (DBS) is used to alleviate chronic pain. Using magnetoencephalography (MEG) to study the mechanisms of DBS for pain is difficult because of the artefact caused by the stimulator. We were able to record activity over the occipital lobe of a patient using DBS for phantom limb pain during presentation of a visual stimulus. This demonstrates that MEG can be used to study patients undergoing DBS provided control stimuli are used to check the reliability of the data. We then asked the patient to rate his pain during and off DBS. Correlations were found between these ratings and power in theta (6-9) and beta bands (12-30). Further, there was a tendency for frequencies under 25 Hz to correlate with each other after a period off stimulation compared with immediately after DBS. The results are interpreted as reflecting abnormal thalamocortical dynamics, previously implicated in painful syndromes.
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Abstract
The concept of fetal pain is becoming more and more relevant since the possibilities for invasive intrauterine treatment are increasing. However, there is much debate as to whether the fetus is mature enough to be able to perceive pain. But what is ‘pain’? One cannot determine whether a fetus feels pain unless one has a conception of what pain is. There is a difference in opinion about what pain really is and that is also the difficulty in studies on fetal pain: we cannot simply ask the fetus whether or not it feels pain. We can only give indirect evidence of possible harmful effects of stressful stimuli on the developing fetus. In this review we will first explore the meaning of ‘pain’. We will then discuss fetal anatomic, neurophysiologic and behavioural development and the responses which are thought to be required to experience pain. Finally, we discuss some ethical considerations and suggestions on fetal anaesthesia.
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48
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Abstract
Deep-brain stimulation (DBS) is a clinical intervention that has provided remarkable therapeutic benefits for otherwise treatment-resistant movement and affective disorders. The resulting direct causal manipulation of both local and distributed brain networks is not only clinically helpful but can also help to provide novel fundamental insights into brain function. In particular, DBS can be used in conjunction with methods such as local field potentials and magnetoencephalography to map the underlying mechanisms of normal and abnormal oscillatory synchronization in the brain. The precise mechanisms of action for DBS remain uncertain but here we present an overview of the clinical efficacy of DBS, its neural mechanisms and potential future applications.
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Affiliation(s)
- Morten L Kringelbach
- University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK and, University of Aarhus, Centre for Functionally Integrative Neuroscience (CFIN), Aarhus University Hospital, Århus Sygehus Nørrebrogade 44 Building 30, 8000 Århus C, Denmark
| | - Sarah LF Owen
- University of Oxford, Department of Physiology, Anatomy & Genetics, Parks Road, Oxford, OX1 3PT, UK
| | - Tipu Z Aziz
- University of Oxford, Department of Physiology, Anatomy & Genetics, Parks Road, Oxford, OX1 3PT, UK and, John Radcliffe Hospital, Nuffield Department of Surgery, Oxford, UK
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Abstract
Pain in the developing fetus is controversial because of the difficulty in measuring and interpreting pain during gestation. It has received increased attention lately because of recently introduced legislation that would require consideration of fetal pain during intentional termination of pregnancy. During development, sensory fibers are abundant by 20 weeks; a functional spinal reflex is present by 19 weeks; connections to the thalamus are present by 20 weeks; and connections to subplate neurons are present by 17 weeks with intensive differentiation by 25 weeks. These cells are important developmentally, but decline as a result of natural apoptosis. Mature thalamocortical projections are not present until 29 to 30 weeks, which has led many to believe the fetus does not experience emotional "pain" until then. Pain requires both nociception and emotional reaction or interpretation. Nociception causes physiologic stress, which in turn causes increases in catecholamines, cortisol, and other stress hormones. Physiological stress is different from the emotional pain felt by the more mature fetus or infant, and this stress is mitigated by pain medication such as opiates. The plasticity of the developing brain makes it vulnerable to the stressors that cause long-term developmental changes, ultimately leading to adverse neurological outcomes. Whereas evidence for conscious pain perception is indirect, evidence for the subconscious incorporation of pain into neurological development and plasticity is incontrovertible. Scientific data, not religious or political conviction, should guide the desperately needed research in this field. In the meantime, it seems prudent to avoid pain during gestation.
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Affiliation(s)
- Curtis L Lowery
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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Abstract
BACKGROUND Deep brain stimulation (DBS) for the treatment of neurologic diseases has markedly increased in popularity over the past 15 years. This review primarily focuses on movement disorder applications and efficacy of DBS, but also briefly reviews other promising new and old uses of DBS. REVIEW SUMMARY A multidisciplinary team consisting of a movement disorders neurologist, a functional neurosurgeon, and a neuropsychologist optimally selects patients for DBS. Patients must be significantly disabled despite optimal medical therapy and be cognitively healthy without significant psychiatric disorders. Although this surgery is elective, it should not be withheld until the patient suffers marked loss of quality of life. Patients must have support from caregivers and postoperatively multiple DBS programming visits may be required. DBS of the subthalamic nucleus (STN) and the globus pallidus pars interna (GPi) significantly improves motor performance, activities of daily living, and quality of life in advanced Parkinson disease. In addition, STN DBS allows for marked reductions of antiparkinson medication. Stimulation of the ventralis intermedius nucleus of the thalamus is an effective treatment for essential tremor with sustained long-term effects. The GPi may be the preferred site of stimulation for dystonia with movement scores typically improved by 75% in patients with primary dystonia. CONCLUSIONS DBS is an effective surgical treatment for movement disorders with sustained long-term benefits. Further research is ongoing to better understand the mechanism of DBS, refine the hardware to improve efficacy and reduce adverse effects, and identify additional applications and new anatomic targets.
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Affiliation(s)
- Drew S Kern
- College of Medicine, University of Vermont, Burlington, Vermont, USA
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