Neuromodulation of pain

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Neuromodulation is a burgeoning and exciting field that offers potential for innovative applications in medicine. The International Neuromodulation Society defines neuromodulation as electrical or chemical alteration of signal transmission within the nervous system by using implanted devices to affect improvement in symptoms and render optimal functioning to improve quality of life (Sakas et al. , 2007). Currently, spinal cord stimulation (SCS) leads the way as the most common application of neuromodulation, predominantly in cases of complex regional pain syndrome (CRPS) and failed back surgery syndrome (FBSS). Motor cortex stimulation (MCS) and peripheral nerve stimulation (PNS) have also been used for treatment of intractable pain syndromes. Historically, even deep brain stimulation (DBS) has been employed for pain despite its most established application in current treatment of movement disorders such as Parkinson’s disease (PD). Neuromodulation of pain in palliative care, though not advocated previously because of cost and questionable efficacy with disease progression, may provide significant relief to many patients, especially as survival expectancy increases. This population typically has diminished organ reserve and particular vulnerability to drug-drug interactions from the exorbitant number of medications prescribed to manage conditions as well as the associated side effects from these medications. Thus, using a different modality of treatment such as an electrical stimulation device may be quite beneficial. Here, we explore the pre-clinical and clinical data that support the potential use of neuromodulation in palliation. We discuss the major modalities of stimulation (DBS, MCS, SCS, and PNS), examine their current uses, and assess the noted effects on refractory debilitating symptoms which may benefit people at the end of life. In addition, we outline the current limitations to widespread application of neuromodulation in palliative medicine.