Introduction: Despite tremendous advances in drug and physical therapy, chronic pain treatment remains challenging in a considerable proportion of individuals. It is not uncommon, especially in pain syndromes in a chronic state, for up to 20% of patients to be insufficiently analgesic leading to enormous economical as well as psychosocial consequences for affected individuals. When conventional therapies fail, modulation of the lateral and medial thalamic pain networks using reversible deep brain stimulation (DBS) or targeted irreversible thalamotomy by Gamma Knife Radiosurgery (GKRS), Radiofrequency ablation (RFA) or Magnetic Resonance (MR)-guided Focus Ultrasound (MRgFUS) appear to be considerable treatment options. Materials and Methods: We performed a literature search for clinical trials targeting the sensory and affective thalamic circuits relevant for pain processing. We performed searches on PubMed, Ovid MEDLINE, and Scopus. Furthermore, a manual library search was performed using the terms “chronic pain”, “thalamotomy”, “deep brain stimulation”, “ventral-postero-lateral nucleus of the thalamus”, “centrum-median parafascicular nucleus of the thalamus”, “affective thalamic pain transmission”, “somatosensory thalamic pain processing”, and “anterior cingulate cortex”. Results: We identified human studies on the modulation of the somatosensory and affective thalamic nuclei for four different stereotactic-guided procedures, namely DBS, GKRS, RFA, MRgFUS. Specifically, we identified a total number of 320 patients that has been treated with thalamaic DBS. Furthermore, DBS of the anterior cingulate cortex (ACC) revealed 5 human studies with a total of 54 implanted chronic pain patients. GKRS was performed in a total of 60 patients, while MRgFUS has been applied to a relatively low number of patients. Conclusions: While in contrast, the CmPf lacks such kind of topography indicating that both, VPL and CmPf, decrease pain levels by sensory and attentional modulation. DBS targeting the VPL evokes paraesthesia in the affected pain region of the body, while CmPf and ACC evokes similar DBS responses. Chronic pain stimulated in the CmPf or ACC reported unchanged pain levels, however, attention and emotional (affective distancing to chronic pain stimuli was observed in these cohorts of DBS patients (Fig. 1a). However, the available data is of heterogeneous and preliminary nature, hindering effective comparable analysis. Currently, there is no evidence in favour or against any stereotactic approach, hence, we advocate to establish recommendations and guidelines covering advantages and disadvantages of each approach, including such parameters as invasiveness, risk-benefit ratio, reversibility and responsiveness.
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