Abstract
Central neuropathic pain (CNP) is a significant problem after spinal cord injury (SCI). Pharmacological and non-pharmacological approaches may reduce the severity, but relief is rarely substantial. While deep brain stimulation (DBS) has been used to treat various chronic pain types, the technique has rarely been used to attenuate CNP after SCI. Here we present the case of a 54-year-old female with incomplete paraplegia who had severe CNP in the lower limbs and buttock areas since her injury 30 years prior. She was treated with bilateral DBS of the midbrain periaqueductal gray (PAG). The effects of this stimulation on CNP characteristics, severity and pain-related sensory function were evaluated using the International SCI Pain Basic Data Set (ISCIPBDS), Neuropathic Pain Symptom Inventory (NPSI), Multidimensional Pain Inventory and Quantitative Sensory Testing before and periodically after initiation of DBS. After starting DBS treatment, weekly CNP severity ratings rapidly decreased from severe to minimal, paralleled by a substantial reduction in size of the painful area, reduced pain impact and reversal of pain-related neurological abnormalities, i.e., dynamic-mechanical and cold allodynia. She discontinued pain medication on study week 24. The improvement has been consistent. The present study expands on previous findings by providing in-depth assessments of symptoms and signs associated with CNP. The results of this study suggest that activation of endogenous pain inhibitory systems linked to the PAG can eliminate CNP in some people with SCI. More research is needed to better-select appropriate candidates for this type of therapy. We discuss the implications of these findings for understanding the brainstem’s control of chronic pain and for future progress in using analgesic DBS in the central gray.
Highlights
Persistent neuropathic pain is a common and serious consequence of spinal cord injury (SCI) that is especially refractory to both pharmacological and non-pharmacological treatments (Siddall et al, 2003; Vranken, 2009; Finnerup et al, 2014)
Electrical stimulation of specific brain structures with the purpose of relieving chronic pain has been used for a long time but the reported efficacy for central neuropathic pain (CNP) is relatively low and difficult to predict
We provide a more detailed analysis focusing on the CNP below the level of injury evaluating a broader set of pain characteristics, somatosensory function and psychosocial impact conducted at intervals over a 52-week period
Summary
Persistent neuropathic pain is a common and serious consequence of spinal cord injury (SCI) that is especially refractory to both pharmacological and non-pharmacological treatments (Siddall et al, 2003; Vranken, 2009; Finnerup et al, 2014). Because deep brain stimulation (DBS) is an invasive procedure, its use for SCI pain is rare and currently restricted to severe cases refractory to non-invasive therapies. In order to be accepted as a therapy for chronic pain, success rates need to improve This will require, inter alia, a better understanding of CNP mechanisms along with improved patient selection. The optimization of stimulation parameters and the time-course of daily changes in general pain intensity over a 42-week period were previously reported for this subject and one other with SCI-related chronic pain (Hentall et al, 2016). We provide a more detailed analysis focusing on the CNP below the level of injury evaluating a broader set of pain characteristics, somatosensory function and psychosocial impact conducted at intervals over a 52-week period. The work was performed under an Investigative Device Exemption of the U.S Food and Drug Administration (IDE G120202), and Clinical Trials.gov (NCT02006433)
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