Curr Pain Headache Rep (2015) 19: 27 DOI 10.1007/s11916-015-0504-1
ANESTHETIC TECHNIQUES IN PAIN MANAGEMENT (D WANG, SECTION EDITOR)
Deep Brain Stimulation for Chronic Pain Steven M. Falowski 1
Published online: 7 June 2015 # Springer Science+Business Media New York 2015
Abstract Deep brain stimulation (DBS) is a commonly performed procedure and has been used for the treatment of chronic pain since the early 1970s. A review of the literature was performed utilizing the PubMed database evaluating the use of DBS in the treatment of various pain syndromes. Literature over the last 30 years was included with a focus on those articles in the last 10 years dealing with pain conditions with the highest success as well as the targets utilized for treatment. DBS carries favorable results for the treatment of chronic pain, especially when other methods have not been successful such as medications, conservative measures, and extracranial procedures. Various chronic pain conditions reported in the literature respond to DBS including failed back surgery syndrome (FBSS), phantom limb pain, and peripheral neuropathic pain with a higher response rate for those with nociceptive pain compared to neuropathic pain. Cephaligias have promising results, with cluster headaches carrying the best success rates. DBS plays a role in the treatment of chronic pain conditions. Although considered investigational in the USA, it carries promising success rates in a recalcitrant patient population.
Keywords Pain management . Deep brain stimulation . Chronic pain . Phantom limb pain
This article is part of the Topical Collection on Anesthetic Techniques in Pain Management * Steven M. Falowski [email protected] 1
St. Luke’s University Health Network, Bethlehem, PA, USA
Introduction Deep brain stimulation (DBS) has become a commonly performed procedure by neurosurgeons. It involves delivering electrical current through implanted electrodes in the intracranial space at subcortical targets. DBS is the most frequently utilized neurosurgical procedure for movement disorders such as Parkinson’s disease (PD), dystonia, and essential tremor (ET). In addition, new applications such as obsessive compulsive disorder, Tourette’s syndrome, depression, cluster headache (CH), and epilepsy are increasingly being investigated. DBS has been used for the treatment of chronic pain since the early 1970s [1, 2]. It was initially approved by the Food and Drug Administration (FDA) for this indication following a multicenter study, but this approval was ultimately retracted with the FDA requesting further trials to determine efficacy and safety [1]. The allure of DBS stems from its less invasive approach as compared to other neurosurgical procedures and being generally well tolerated. It carries a low risk profile compared to other neurosurgical procedures. Being under the umbrella of neuromodulation, it is an adjustable procedure that is reversible compared to the previous ablative procedures of creating lesions in the brain. DBS has been used effectively to treat chronic painful conditions, with reports documenting success for multiple targets, including the ventrocaudalis thalamic nucleus, globus pallidus, subthalamic nuclei, ventral striatum, and periventricular (PVG) and periaqueductal grey (PAG) matter. The use of DBS in pain has been evaluated in several studies with various targets being utilized depending on pain patterns. The use of PAG/PVG stimulation has come into favor by many authors in the treatment of nociceptive pain and ventroposterolateral/ventroposteromedial (VPL/VPM) stimulation for those with neuropathic pain [3]. However, it should
27 Page 2 of 4
be noted that one of the difficulties is that patients have different types of pain syndromes which may be non-discreet, as well as combined. This is commonly seen in failed back surgery syndrome (FBSS) patients who may have both nociceptive low back pain and neuropathic leg pain.
Surgical Technique Surgical technique starts with initial patient evaluation, includes patient preparation, and continues until the postoperative period. Patients typically present the morning of the procedure to undergo frame placement and can then undergo a stereotactic MRI or can obtain a stereotactic CT head which is merged with an MRI obtained prior to surgery. Surgery is generally performed utilizing intravenous sedation with local anesthesia for the incisions. Stereotactic coordinates are used to localize targets. The electrodes are placed using microelectrode recordings (MER) and macro-stimulation to Bdefine^ the target nucleus and identify the optimal location for final lead placement. Intraoperative physiologic stimulation combined with the recordings is utilized to determine final placement of the permanent electrodes [4, 5]. These electrodes are then externalized to undergo trial stimulation. Connection and implantation of the IPG are routinely done 1 week after DBS implantation under general anesthesia if the trial period is successful. See Fig. 1.
Deep Brain Stimulation Indications and success with DBS for pain syndromes vary and have been observed in syndromes from facial neuropathic pain to failed back surgery syndrome (FBSS). DBS has also been utilized for pain after amputation, brachial plexus injury,
Fig. 1 Lateral skull X-ray of implanted bilateral deep brain stimulators
Curr Pain Headache Rep (2015) 19: 27
stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury [6•]. Proper target selection and surgical planning within the brain for placement of the lead are paramount in the treatment of these painful conditions [1]. Bittar et al. performed a metaanalysis of DBS for pain relief and demonstrated that the longterm pain alleviation rate was highest with DBS of the PVG/ PAG or the PVG/PAG plus sensory thalamus/internal capsule [2]. Long-term success was attained in those with intractable low back pain (FBSS), as well as those patients with phantom limb pain and neuropathies. Interestingly, DBS was more effective for nociceptive than deafferentation pain. Hamani et al. performed a retrospective analysis of 21 patients treated for neuropathic pain with a third of those patients responding positively to DBS and obtaining long-term benefit. The targets included the ventrocaudalis thalamic nucleus, as well as the periaqueductal and periventricular grey matter [1]. Those patients who had an insertional effect had a trend towards a successful stimulation trial. Levy et al. performed a review of the literature and found a range of success from 47 to 60 % with up to 80 months follow-up in the use of DBS for chronic pain [3]. The literature continues to evolve when looking at DBS as an intervention for these indications with Parmar et al. describing overall efficacy for refractory pain in both nociceptive pain (61 %) and phantom limb pain (71 %) [7]. Postamputation phantom limb pain (PAPLP) has been known to be a very difficult problem to treat with medication management or neurostimulation. DBS for PAPLP has shown mixed results. Bittar showed some limited success in a few patients, but durability was not established [8]. However, Owen et al. looked at 38 patients implanted with DBS and found that those patients with phantom limb/post-brachial plexus injury pain and anesthesia dolorosa obtained the highest relief [9]. DBS of the PVG alone was associated with the highest degree of pain alleviation, with a mean improvement of 59 %. Of important note is post-stroke pain responds in 70 % of patients [9]. Various reports in the literature have shown that DBS can be used in the treatment of other painful conditions including postherpetic-induced trigeminal nerve pain [10]. Targets utilized include the periventricular/periaqueductal grey region and/or the ventroposteromedial nucleus of the thalamus with statistically significant improvement in pain scores (VAS and McGill’s) as well as health-related quality of life (SF-36v2). Leone et al. published two studies and found that DBS was an effective treatment for cluster headaches and targeted the ipsilateral posterior inferior hypothalamus [11, 12]. An overall efficacy rate for primary headache disorders was reported as 65 % [13]. A more recent trend has looked at combination therapies as a treatment modality. Combination spinal cord stimulation
Curr Pain Headache Rep (2015) 19: 27
(SCS) and DBS of the PVG has been reported with great results for the treatment of FBSS. Utilizing variable stimulation parameters both separately and in conjunction, the SCS was able to treat the neuropathic leg pain, while the DBS was able to cover the nociceptive back pain [14]. Vagal nerve stimulation has been described to treat cluster headaches in combination with DBS, as well as supraorbital stimulation being utilized with DBS for the treatment of cluster headaches [13]. Although the majority of research surrounding DBS for chronic pain revolves around improved pain intensity, there is an important aspect pertaining to the mood and neuropsychological component. Grey et al. reported that in addition to improvement in pain, DBS leads to improved mood, anxiety, and quality of life. This can lead to an improved emotional well-being of the patients suffering from chronic pain [15]. This carries significant importance as one considers its role in maintaining long-term efficacy with these interventions.
Complications Operative complications can range from serious lifethreatening issues, such as hemorrhage, to more benign entities such as device malfunction. These may occur at any step in the DBS procedure or post-operative period [16, 17]. Multiple studies have looked at the potential complications with DBS and have demonstrated its low risk profile. The most serious complication of DBS would include an intracranial hemorrhage with reports demonstrating an incidence of 1.9 to 4.1 % of cases, as well as a permanent neurological deficit with reports ranging from 2.0 to 3.4 % [3, 18•, 19••]. Another complication reported with DBS is the risk of infection, which is seen with any surgical procedure. This is reported with an incidence of 3.3 to 13.3 %. Falowski et al. reported a decreased infection rate of 1.9 % by describing techniques of isolating the implant from the incision [18•]. Complication rates have improved over time given improved technology and improved surgical skills. Minor complications include transient headache (51.5 % of cases), diplopia after periaqueductal or periventricular grey (PAG/PVG) stimulation (14.2 %), nausea (10.6 %), vertical gaze palsies (9.9 %), blurred vision (9.2 %), horizontal nystagmus (4.3 %), and persistent oscillopsia (3.5 %) [20]. The risk of death with DBS remains rare.
Page 3 of 4 27
chronic pain. DBS has been used for the treatment of chronic pain since the early 1970s, being initially approved by the Food and Drug Administration (FDA), but after this, approval was ultimately retracted since it had fallen out of favor. It is because of this that DBS for chronic pain is considered investigational in the USA. Multicenter controlled trials are lacking and the present research has demonstrated variable results. A review of the literature, however, does demonstrate that it carries favorable results for various indications and can be used when other methods have not been successful such as medications, conservative measures, and extracranial procedures. There has been some growing interest for a return in the treatment of chronic pain with DBS. This is largely in part due to the success seen for movement disorders, improved safety with lower complication rates, and a growing experience with improved efficacy for specific indications. Diagnosis, patient selection, and target are critical in the outcome of DBS in the treatment of chronic pain. We know that success rates can vary based on these variables. It is important to realize that many of the patients undergoing these treatment modalities have failed medication, conservative measures, and surgical interventions which lends itself to lower success rates with most interventions and limited treatment options. In this subset of patients, it is hard to find a treatment modality that can claim the success rates that DBS does. Proper indications for DBS based on this literature review are several nociceptive and neuropathic pain conditions including FBSS, phantom limb pain, and peripheral neuropathic pain. It has also demonstrated a higher response rate for those with nociceptive pain compared to neuropathic pain. Cephaligias have promising results, with cluster headaches carrying the best success rates. DBS will continue to play a role in the treatment of chronic pain conditions. Few modalities can claim similar success rates in this recalcitrant patient population. This intervention can be considered as treatment for those patients who have failed medication and conservative measures. DBS should be weighed in the treatment paradigm that involves other interventions such as SCS, peripheral nerve stimulation, intrathecal therapy, and motor cortex stimulation. Lastly, combination therapies are building interest and should be explored with further research.
Compliance with Ethics Guidelines
Discussion DBS has become a standard of care for movement disorders and is therefore an established and well-accepted treatment method in treating Parkinson’s disease, tremor, and dystonia. However, it has not become a mainstay in the treatment of
Conflict of Interest Steven M. Falowski declares no potential conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by the author.
27 Page 4 of 4
References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.
2.
3.
4.
5. 6.•
7.
8. 9.
10.
Hamani C, Schwalb JM, Rezai AR, et al. Deep brain stimulation for chronic neuropathic pain: long-term outcome and the incidence of insertional effect. Pain. 2006;125(1–2):188–96. Bittar RG, Kar-Purkayastha I, Owen SL, Bear RE, Green A, Wang S, et al. Deep brain stimulation for pain relief: a meta-analysis. J Clin Neurosci. 2005;12(5):515–9. Levy RM, Lamb S, Adams JE. Treatment of chronic pain by deep brain stimulation: long term follow-up and review of the literature. Neurosurgery. 1987;21:885–93. Kumar K, Toth C, Nath RK. Deep brain stimulation for intractable pain: a 15-year experience. Neurosurgery. 1997;40:736– 46. Turnbull IM, Shulman R, Woodhurst WB. Thalamic stimulation for neuropathic pain. J Neurosurg. 1980;52:486–93. Levy RM, Deer T, Henderson J. Intracranial neurostimulation for pain control: a review. Pain Physician. 2010;13:157–65. This is a thorough review of various indications and results for DBS in the treatment of chronic pain as well as an evaluation of the procedure. It also looks at other treatment modalities of the Intracranial space including Motor Cortex Stimulation. Parmar VK, Gee L, Smith H, Pilitsis JG. Supraspinal stimulation for the treatment of refractory pain. Clin Neurol Neurosurg. 2014;123:155–63. Bittar RG, Otero S, Carter H, Aziz TZ. Deep brain stimulation for phantom limb pain. J Clin Neurosci. 2005;12(4):399–404. Owen SL, Green AL, Nandi DD, Bittar RG, Wang S, Aziz TZ. Deep brain stimulation for neuropathic pain. Acta Neurochir Suppl. 2007;97(Pt 2):111–6. Green AL, Nandi D, Armstrong G, Carter H, Aziz T. Post-herpetic trigeminal neuralgia treated with deep brain stimulation. J Clin Neurosci. 2003;10(4):512–4.
Curr Pain Headache Rep (2015) 19: 27 11.
Leone M, May A, Franzini A, et al. Deep brain stimulation for intractable chronic cluster headache: proposals for patient selection. Cephalalgia. 2004;24(11):934–7. 12. Leone M, Franzini A, Broggi G, Bussone G. Hypothalamic deep brain stimulation for intractable chronic cluster headache: a 3-year follow-up. Neurol Sci. 2003;24:S143–5. 13. Jenkins B, Tepper S. Neurostimulation for primary headache disorders: part 2, review of central neurostimulators for primary headache, overall therapeutic efficacy, safety, cost, patient selection, and future research in headache neuromodulation. Headache. 2011;51: 1408–18. 14. Chodakiewitz Y, Bicalho G, Chodakiewitz J. Multi-target neurostimulation for adequate long term relief of neuropathic and nociceptive chronic pain components. Surg Neurol Int. 2013;4: 170–5. 15. Gray A, Pounds-Cornish E, Eccles F, Aziz T, Green A, Scott R. Deep brain stimulation as a treatment for neuropathic pain: a longitudinal study addressing neuropsychological outcomes. J Pain. 2014;15(3):283–92. 16. Voges J, Waerzeggers Y, Maarouf M, et al. Deep-brain stimulation: long-term analysis of complications caused by hardware and surgery- experiences from a single centre. J Neurol Neurosurg Psychiatry. 2006;77:868–72. 17. Beric A, Kelly PJ, Rezai A, et al. Complications of deep brain stimulation surgery. Stereotact Funct Neurosurg. 2001;77:73–8. 18.• Falowski S, Cher-Ooi Y, Smith A, Verhargen L, Bakay R. An evaluation of hardware and surgical complications with deep brain stimulation based on diagnosis and lead location. Stereotact Funct Neurosurg. 2012;90:173–80. This is an evaluation of the surgical and hardware complications with a review on surgical technique and technical nuances to decrease the risk of adverse events. 19.•• Deer T, Mekhail N, Peterson E, Krames E, Staats P, Pope J, et al. The appropriate use of neurostimulation: stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation. 2014;17:551–70. Guidelines that have been released by the Neuromodulation Appropriate Consensus Committee (NACC) on all areas of Neuromodulation. 20. Kumar K, Wyant GM, Nath R. Deep brain stimulation for control of intractable pain in humans, present and future: a ten-year follow-up. Neurosurgery. 1990;26:774–82.
ANESTHETIC TECHNIQUES IN PAIN MANAGEMENT (D WANG, SECTION EDITOR)
Deep Brain Stimulation for Chronic Pain Steven M. Falowski 1
Published online: 7 June 2015 # Springer Science+Business Media New York 2015
Abstract Deep brain stimulation (DBS) is a commonly performed procedure and has been used for the treatment of chronic pain since the early 1970s. A review of the literature was performed utilizing the PubMed database evaluating the use of DBS in the treatment of various pain syndromes. Literature over the last 30 years was included with a focus on those articles in the last 10 years dealing with pain conditions with the highest success as well as the targets utilized for treatment. DBS carries favorable results for the treatment of chronic pain, especially when other methods have not been successful such as medications, conservative measures, and extracranial procedures. Various chronic pain conditions reported in the literature respond to DBS including failed back surgery syndrome (FBSS), phantom limb pain, and peripheral neuropathic pain with a higher response rate for those with nociceptive pain compared to neuropathic pain. Cephaligias have promising results, with cluster headaches carrying the best success rates. DBS plays a role in the treatment of chronic pain conditions. Although considered investigational in the USA, it carries promising success rates in a recalcitrant patient population.
Keywords Pain management . Deep brain stimulation . Chronic pain . Phantom limb pain
This article is part of the Topical Collection on Anesthetic Techniques in Pain Management * Steven M. Falowski [email protected] 1
St. Luke’s University Health Network, Bethlehem, PA, USA
Introduction Deep brain stimulation (DBS) has become a commonly performed procedure by neurosurgeons. It involves delivering electrical current through implanted electrodes in the intracranial space at subcortical targets. DBS is the most frequently utilized neurosurgical procedure for movement disorders such as Parkinson’s disease (PD), dystonia, and essential tremor (ET). In addition, new applications such as obsessive compulsive disorder, Tourette’s syndrome, depression, cluster headache (CH), and epilepsy are increasingly being investigated. DBS has been used for the treatment of chronic pain since the early 1970s [1, 2]. It was initially approved by the Food and Drug Administration (FDA) for this indication following a multicenter study, but this approval was ultimately retracted with the FDA requesting further trials to determine efficacy and safety [1]. The allure of DBS stems from its less invasive approach as compared to other neurosurgical procedures and being generally well tolerated. It carries a low risk profile compared to other neurosurgical procedures. Being under the umbrella of neuromodulation, it is an adjustable procedure that is reversible compared to the previous ablative procedures of creating lesions in the brain. DBS has been used effectively to treat chronic painful conditions, with reports documenting success for multiple targets, including the ventrocaudalis thalamic nucleus, globus pallidus, subthalamic nuclei, ventral striatum, and periventricular (PVG) and periaqueductal grey (PAG) matter. The use of DBS in pain has been evaluated in several studies with various targets being utilized depending on pain patterns. The use of PAG/PVG stimulation has come into favor by many authors in the treatment of nociceptive pain and ventroposterolateral/ventroposteromedial (VPL/VPM) stimulation for those with neuropathic pain [3]. However, it should
27 Page 2 of 4
be noted that one of the difficulties is that patients have different types of pain syndromes which may be non-discreet, as well as combined. This is commonly seen in failed back surgery syndrome (FBSS) patients who may have both nociceptive low back pain and neuropathic leg pain.
Surgical Technique Surgical technique starts with initial patient evaluation, includes patient preparation, and continues until the postoperative period. Patients typically present the morning of the procedure to undergo frame placement and can then undergo a stereotactic MRI or can obtain a stereotactic CT head which is merged with an MRI obtained prior to surgery. Surgery is generally performed utilizing intravenous sedation with local anesthesia for the incisions. Stereotactic coordinates are used to localize targets. The electrodes are placed using microelectrode recordings (MER) and macro-stimulation to Bdefine^ the target nucleus and identify the optimal location for final lead placement. Intraoperative physiologic stimulation combined with the recordings is utilized to determine final placement of the permanent electrodes [4, 5]. These electrodes are then externalized to undergo trial stimulation. Connection and implantation of the IPG are routinely done 1 week after DBS implantation under general anesthesia if the trial period is successful. See Fig. 1.
Deep Brain Stimulation Indications and success with DBS for pain syndromes vary and have been observed in syndromes from facial neuropathic pain to failed back surgery syndrome (FBSS). DBS has also been utilized for pain after amputation, brachial plexus injury,
Fig. 1 Lateral skull X-ray of implanted bilateral deep brain stimulators
Curr Pain Headache Rep (2015) 19: 27
stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury [6•]. Proper target selection and surgical planning within the brain for placement of the lead are paramount in the treatment of these painful conditions [1]. Bittar et al. performed a metaanalysis of DBS for pain relief and demonstrated that the longterm pain alleviation rate was highest with DBS of the PVG/ PAG or the PVG/PAG plus sensory thalamus/internal capsule [2]. Long-term success was attained in those with intractable low back pain (FBSS), as well as those patients with phantom limb pain and neuropathies. Interestingly, DBS was more effective for nociceptive than deafferentation pain. Hamani et al. performed a retrospective analysis of 21 patients treated for neuropathic pain with a third of those patients responding positively to DBS and obtaining long-term benefit. The targets included the ventrocaudalis thalamic nucleus, as well as the periaqueductal and periventricular grey matter [1]. Those patients who had an insertional effect had a trend towards a successful stimulation trial. Levy et al. performed a review of the literature and found a range of success from 47 to 60 % with up to 80 months follow-up in the use of DBS for chronic pain [3]. The literature continues to evolve when looking at DBS as an intervention for these indications with Parmar et al. describing overall efficacy for refractory pain in both nociceptive pain (61 %) and phantom limb pain (71 %) [7]. Postamputation phantom limb pain (PAPLP) has been known to be a very difficult problem to treat with medication management or neurostimulation. DBS for PAPLP has shown mixed results. Bittar showed some limited success in a few patients, but durability was not established [8]. However, Owen et al. looked at 38 patients implanted with DBS and found that those patients with phantom limb/post-brachial plexus injury pain and anesthesia dolorosa obtained the highest relief [9]. DBS of the PVG alone was associated with the highest degree of pain alleviation, with a mean improvement of 59 %. Of important note is post-stroke pain responds in 70 % of patients [9]. Various reports in the literature have shown that DBS can be used in the treatment of other painful conditions including postherpetic-induced trigeminal nerve pain [10]. Targets utilized include the periventricular/periaqueductal grey region and/or the ventroposteromedial nucleus of the thalamus with statistically significant improvement in pain scores (VAS and McGill’s) as well as health-related quality of life (SF-36v2). Leone et al. published two studies and found that DBS was an effective treatment for cluster headaches and targeted the ipsilateral posterior inferior hypothalamus [11, 12]. An overall efficacy rate for primary headache disorders was reported as 65 % [13]. A more recent trend has looked at combination therapies as a treatment modality. Combination spinal cord stimulation
Curr Pain Headache Rep (2015) 19: 27
(SCS) and DBS of the PVG has been reported with great results for the treatment of FBSS. Utilizing variable stimulation parameters both separately and in conjunction, the SCS was able to treat the neuropathic leg pain, while the DBS was able to cover the nociceptive back pain [14]. Vagal nerve stimulation has been described to treat cluster headaches in combination with DBS, as well as supraorbital stimulation being utilized with DBS for the treatment of cluster headaches [13]. Although the majority of research surrounding DBS for chronic pain revolves around improved pain intensity, there is an important aspect pertaining to the mood and neuropsychological component. Grey et al. reported that in addition to improvement in pain, DBS leads to improved mood, anxiety, and quality of life. This can lead to an improved emotional well-being of the patients suffering from chronic pain [15]. This carries significant importance as one considers its role in maintaining long-term efficacy with these interventions.
Complications Operative complications can range from serious lifethreatening issues, such as hemorrhage, to more benign entities such as device malfunction. These may occur at any step in the DBS procedure or post-operative period [16, 17]. Multiple studies have looked at the potential complications with DBS and have demonstrated its low risk profile. The most serious complication of DBS would include an intracranial hemorrhage with reports demonstrating an incidence of 1.9 to 4.1 % of cases, as well as a permanent neurological deficit with reports ranging from 2.0 to 3.4 % [3, 18•, 19••]. Another complication reported with DBS is the risk of infection, which is seen with any surgical procedure. This is reported with an incidence of 3.3 to 13.3 %. Falowski et al. reported a decreased infection rate of 1.9 % by describing techniques of isolating the implant from the incision [18•]. Complication rates have improved over time given improved technology and improved surgical skills. Minor complications include transient headache (51.5 % of cases), diplopia after periaqueductal or periventricular grey (PAG/PVG) stimulation (14.2 %), nausea (10.6 %), vertical gaze palsies (9.9 %), blurred vision (9.2 %), horizontal nystagmus (4.3 %), and persistent oscillopsia (3.5 %) [20]. The risk of death with DBS remains rare.
Page 3 of 4 27
chronic pain. DBS has been used for the treatment of chronic pain since the early 1970s, being initially approved by the Food and Drug Administration (FDA), but after this, approval was ultimately retracted since it had fallen out of favor. It is because of this that DBS for chronic pain is considered investigational in the USA. Multicenter controlled trials are lacking and the present research has demonstrated variable results. A review of the literature, however, does demonstrate that it carries favorable results for various indications and can be used when other methods have not been successful such as medications, conservative measures, and extracranial procedures. There has been some growing interest for a return in the treatment of chronic pain with DBS. This is largely in part due to the success seen for movement disorders, improved safety with lower complication rates, and a growing experience with improved efficacy for specific indications. Diagnosis, patient selection, and target are critical in the outcome of DBS in the treatment of chronic pain. We know that success rates can vary based on these variables. It is important to realize that many of the patients undergoing these treatment modalities have failed medication, conservative measures, and surgical interventions which lends itself to lower success rates with most interventions and limited treatment options. In this subset of patients, it is hard to find a treatment modality that can claim the success rates that DBS does. Proper indications for DBS based on this literature review are several nociceptive and neuropathic pain conditions including FBSS, phantom limb pain, and peripheral neuropathic pain. It has also demonstrated a higher response rate for those with nociceptive pain compared to neuropathic pain. Cephaligias have promising results, with cluster headaches carrying the best success rates. DBS will continue to play a role in the treatment of chronic pain conditions. Few modalities can claim similar success rates in this recalcitrant patient population. This intervention can be considered as treatment for those patients who have failed medication and conservative measures. DBS should be weighed in the treatment paradigm that involves other interventions such as SCS, peripheral nerve stimulation, intrathecal therapy, and motor cortex stimulation. Lastly, combination therapies are building interest and should be explored with further research.
Compliance with Ethics Guidelines
Discussion DBS has become a standard of care for movement disorders and is therefore an established and well-accepted treatment method in treating Parkinson’s disease, tremor, and dystonia. However, it has not become a mainstay in the treatment of
Conflict of Interest Steven M. Falowski declares no potential conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by the author.
27 Page 4 of 4
References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.
2.
3.
4.
5. 6.•
7.
8. 9.
10.
Hamani C, Schwalb JM, Rezai AR, et al. Deep brain stimulation for chronic neuropathic pain: long-term outcome and the incidence of insertional effect. Pain. 2006;125(1–2):188–96. Bittar RG, Kar-Purkayastha I, Owen SL, Bear RE, Green A, Wang S, et al. Deep brain stimulation for pain relief: a meta-analysis. J Clin Neurosci. 2005;12(5):515–9. Levy RM, Lamb S, Adams JE. Treatment of chronic pain by deep brain stimulation: long term follow-up and review of the literature. Neurosurgery. 1987;21:885–93. Kumar K, Toth C, Nath RK. Deep brain stimulation for intractable pain: a 15-year experience. Neurosurgery. 1997;40:736– 46. Turnbull IM, Shulman R, Woodhurst WB. Thalamic stimulation for neuropathic pain. J Neurosurg. 1980;52:486–93. Levy RM, Deer T, Henderson J. Intracranial neurostimulation for pain control: a review. Pain Physician. 2010;13:157–65. This is a thorough review of various indications and results for DBS in the treatment of chronic pain as well as an evaluation of the procedure. It also looks at other treatment modalities of the Intracranial space including Motor Cortex Stimulation. Parmar VK, Gee L, Smith H, Pilitsis JG. Supraspinal stimulation for the treatment of refractory pain. Clin Neurol Neurosurg. 2014;123:155–63. Bittar RG, Otero S, Carter H, Aziz TZ. Deep brain stimulation for phantom limb pain. J Clin Neurosci. 2005;12(4):399–404. Owen SL, Green AL, Nandi DD, Bittar RG, Wang S, Aziz TZ. Deep brain stimulation for neuropathic pain. Acta Neurochir Suppl. 2007;97(Pt 2):111–6. Green AL, Nandi D, Armstrong G, Carter H, Aziz T. Post-herpetic trigeminal neuralgia treated with deep brain stimulation. J Clin Neurosci. 2003;10(4):512–4.
Curr Pain Headache Rep (2015) 19: 27 11.
Leone M, May A, Franzini A, et al. Deep brain stimulation for intractable chronic cluster headache: proposals for patient selection. Cephalalgia. 2004;24(11):934–7. 12. Leone M, Franzini A, Broggi G, Bussone G. Hypothalamic deep brain stimulation for intractable chronic cluster headache: a 3-year follow-up. Neurol Sci. 2003;24:S143–5. 13. Jenkins B, Tepper S. Neurostimulation for primary headache disorders: part 2, review of central neurostimulators for primary headache, overall therapeutic efficacy, safety, cost, patient selection, and future research in headache neuromodulation. Headache. 2011;51: 1408–18. 14. Chodakiewitz Y, Bicalho G, Chodakiewitz J. Multi-target neurostimulation for adequate long term relief of neuropathic and nociceptive chronic pain components. Surg Neurol Int. 2013;4: 170–5. 15. Gray A, Pounds-Cornish E, Eccles F, Aziz T, Green A, Scott R. Deep brain stimulation as a treatment for neuropathic pain: a longitudinal study addressing neuropsychological outcomes. J Pain. 2014;15(3):283–92. 16. Voges J, Waerzeggers Y, Maarouf M, et al. Deep-brain stimulation: long-term analysis of complications caused by hardware and surgery- experiences from a single centre. J Neurol Neurosurg Psychiatry. 2006;77:868–72. 17. Beric A, Kelly PJ, Rezai A, et al. Complications of deep brain stimulation surgery. Stereotact Funct Neurosurg. 2001;77:73–8. 18.• Falowski S, Cher-Ooi Y, Smith A, Verhargen L, Bakay R. An evaluation of hardware and surgical complications with deep brain stimulation based on diagnosis and lead location. Stereotact Funct Neurosurg. 2012;90:173–80. This is an evaluation of the surgical and hardware complications with a review on surgical technique and technical nuances to decrease the risk of adverse events. 19.•• Deer T, Mekhail N, Peterson E, Krames E, Staats P, Pope J, et al. The appropriate use of neurostimulation: stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation. 2014;17:551–70. Guidelines that have been released by the Neuromodulation Appropriate Consensus Committee (NACC) on all areas of Neuromodulation. 20. Kumar K, Wyant GM, Nath R. Deep brain stimulation for control of intractable pain in humans, present and future: a ten-year follow-up. Neurosurgery. 1990;26:774–82.
