Deep brain stimulation of the posterior limb of the internal capsule in the treatment of central poststroke neuropathic pain of the lower limb: case series with long-term follow-up and literature review

OBJECTIVECentral poststroke neuropathic pain is a debilitating syndrome that is often resistant to medical therapies. Surgical measures include motor cortex stimulation and deep brain stimulation (DBS), which have been used to relieve pain. The aim of this study was to retrospectively assess the safety and long-term efficacy of DBS of the posterior limb of the internal capsule for relieving central poststroke neuropathic pain and associated spasticity affecting the lower limb.METHODSClinical and surgical data were retrospectively collected and analyzed in all patients who had undergone DBS of the posterior limb of the internal capsule to address central poststroke neuropathic pain refractory to conservative measures. In addition, long-term pain intensity and level of satisfaction gained from stimulation were assessed. Pain was evaluated using the visual analog scale (VAS). Information on gait improvement was obtained from medical records, neurological examination, and interview.RESULTSFour patients have undergone the procedure since 2001. No mortality or morbidity related to the surgery was recorded. In three patients, stimulation of the posterior limb of the internal capsule resulted in long-term pain relief; in a fourth patient, the procedure failed to produce any long-lasting positive effect. Two patients obtained a reduction in spasticity and improved motor capability. Before surgery, the mean VAS score was 9 (range 8–10). In the immediate postoperative period and within 1 week after the DBS system had been turned on, the mean VAS score was significantly lower at a mean of 3 (range 0–6). After a mean follow-up of 5.88 years, the mean VAS score was still reduced at 5.5 (range 3–8). The mean percentage of long-term pain reduction was 38.13%.CONCLUSIONSThis series suggests that stimulation of the posterior limb of the internal capsule is safe and effective in treating patients with chronic neuropathic pain affecting the lower limb. The procedure may be a more targeted treatment method than motor cortex stimulation or other neuromodulation techniques in the subset of patients whose pain and spasticity are referred to the lower limbs.

Download Full-text

Treatment of Chronic Pain by Deep Brain Stimulation: Long Term Follow-up and Review of the Literature

Neurosurgery ◽

10.1227/00006123-198712000-00017 ◽

1987 ◽

Vol 21 (6) ◽

pp. 885-893 ◽

Cited By ~ 213

Author(s):

Robert M. Levy ◽

Sharon Lamb ◽

John E. Adams

Keyword(s):

Chronic Pain ◽

Deep Brain Stimulation ◽

Brain Stimulation ◽

Nociceptive Pain ◽

Long Term Follow Up ◽

The Mean ◽

Deep Brain ◽

Stimulation Of

Abstract Since the senior author's (J.E.A.) first report in 1972 of the use of deep brain stimulation (DBS) to control chronic pain, electrodes for DBS have been implanted in 141 patients. Of reported series, this one has the largest number of patients and the longest period of follow-up. The mean age of patients in this study was 51.2 years. The mean length of follow-up was 80 months. Patients had experienced pain for a mean period of 65 months before DBS was attempted; all patients had exhausted other medical and surgical therapies. For the purposes of this study, pain states were characterized as being either nociceptive or deafferentation in nature. Nociceptive pain was treated primarily by stimulation of the periaqueductal or periventricular gray, and deafferentation pain was treated primarily by stimulation of the sensory thalamus. Eighty-four patients were treated for deafferentation pain, which included the thalamic pain syndrome (25 cases), peripheral neuropathic pain (16 cases), anesthesia dolorosa (12 cases), paraplegia pain (11 cases), postcordotomy dyesthesia (5 cases), phantom limb pain (5 cases), thoracic neuralgia (4 cases), and miscellaneous pain states (6 cases). We treated 57 patients with nociceptive pain states. 51 for low back and skeletal pain and 6 for pain from the invasion of cancer. Initial relief of pain was obtained by 83 patients (59%). After the mean follow-up period of 80 months, 42 patients (31%) continued to obtain significant pain relief with DBS. Some pain states, particularly anesthesia dolorosa and paraplegia pain, did not seem to respond to DBS. Major complications of therapy included wound infection (12%) and intracranial hemorrhage (3.5%); there was one death in the series (0.7%). Erosion of hardware occurred in 10 patients (7%), and foreign body reaction occurred in 7 (5%). Technical problems most often encountered included migration of the implanted electrodes and equipment failure that led to leakage of current and ineffective stimulation. These complications have been largely eradicated by advances in the design and manufacture of hardware over the 14 years of the study. A review of studies in which long term follow-up of patients treated with DBS was reported, including this series, suggests that lasting relief of pain is obtained in 47% and 60% of patients with deafferentation and nociceptive pain, respectively. Thus, in a carefully selected and evaluated group of patients, DBS can be an effective treatment for chronic, intractable pain.

Download Full-text

Deep brain stimulation of the subcallosal cingulate gyrus in patients with treatment-resistant depression: A double-blinded randomized controlled study and long-term follow-up in eight patients

Journal of Affective Disorders ◽

10.1016/j.jad.2017.11.024 ◽

2018 ◽

Vol 227 ◽

pp. 521-529 ◽

Cited By ~ 18

Author(s):

Angela Merkl ◽

Sabine Aust ◽

Gerd-Helge Schneider ◽

Veerle Visser-Vandewalle ◽

Andreas Horn ◽

...

Keyword(s):

Controlled Study ◽

Treatment Resistant ◽

Randomized Controlled ◽

Long Term Follow Up ◽

Resistant Depression ◽

Double Blinded ◽

Deep Brain ◽

Stimulation Of

Download Full-text

Gamma Knife thalamotomy for treatment of essential tremor: long-term results

Journal of Neurosurgery ◽

10.3171/2009.10.jns09332 ◽

2010 ◽

Vol 112 (6) ◽

pp. 1311-1317 ◽

Cited By ~ 70

Author(s):

Ronald F. Young ◽

Francisco Li ◽

Sandra Vermeulen ◽

Robert Meier

Keyword(s):

Surgical Treatment ◽

Essential Tremor ◽

Gamma Knife ◽

Surgical Intervention ◽

Long Term Results ◽

The Mean ◽

Lost To Follow Up ◽

Deep Brain

Object The goal of this report was to describe the safety and effectiveness of nucleus ventralis intermedius (VIM) thalamotomy performed with the Leksell Gamma Knife (GK) for the treatment of essential tremor (ET). Methods One hundred seventy-two patients underwent a total of 214 VIM thalamotomy procedures with the Leksell GK between February 1994 and March 2007 for treatment of disabling ET. Eleven patients were lost to follow-up less than 1 year after the procedures, so that in this report the authors describe the results in 161 patients who underwent a total of 203 thalamotomies (119 unilateral and 42 bilateral). Results There were statistically significant decreases (p < 0.0001) in tremor scores for both writing and drawing. The mean postoperative follow-up duration for all patients was 44 ± 33 months. Fifty-four patients have been followed for more than 60 months posttreatment. There were 14 patients who suffered neurological side effects that were temporary (6) or permanent (8), which accounted for 6.9% of the 203 treatments. All complications were related to lesions that grew larger than expected. Conclusions A VIM thalamotomy with the Leksell GK offers a safe and effective alternative for surgical treatment of ET. It is particularly applicable to patients who are not ideal candidates for deep brain stimulation but can be offered to all patients who are considering surgical intervention for ET.

Download Full-text

Factors involved in long-term efficacy of deep brain stimulation of the thalamus for essential tremor

Journal of Neurosurgery ◽

10.3171/jns/2008/109/10/0640 ◽

2008 ◽

Vol 109 (4) ◽

pp. 640-646 ◽

Cited By ~ 75

Author(s):

Julie G. Pilitsis ◽

Leo Verhagen Metman ◽

John R. Toleikis ◽

Lindsay E. Hughes ◽

Sepehr B. Sani ◽

...

Keyword(s):

Essential Tremor ◽

Disease Progression ◽

Rating Scale ◽

Long Term Outcomes ◽

Intraoperative Fluoroscopy ◽

Duration Of Disease ◽

Deep Brain ◽

Stimulation Of

Object Although nucleus ventralis intermedius stimulation has been shown to be safe and efficacious in the treatment of essential tremor, there is a subset of patients who eventually lose benefit from their stimulation. Proposed causes for this phenomenon include tolerance, disease progression, and suboptimal location. The goal of this study was to assess the factors that may lead to both stimulation failure, defined as loss of meaningful tremor relief, and less satisfactory outcomes, defined as leads requiring voltages > 3.6 V for effective tremor control. Methods The authors present their clinical outcomes from 31 leads in 27 patients who had effective tremor control for > 1 year following nucleus ventralis intermedius stimulation. All patients postoperatively had a mean decrease in both the writing and drawing subscales of the Fahn-Tolosa-Marin Tremor Rating Scale (p < 0.001). Results After a mean follow-up of 40 months, 22 patients continued to have tremor control with stimulation. Four patients eventually lost efficacy of their stimulation at a mean of 39 months. There was no difference in age, duration of disease, or disease severity between the groups. Examination of perioperative factors revealed that suboptimal anteroposterior positioning as evidenced on intraoperative fluoroscopy occurred significantly more frequently in patients with stimulation failure (p = 0.018). In patients with less satisfactory outcomes, no difference was seen between group demographics. Fluoroscopy again revealed suboptimal positioning more frequently in these patients (p = 0.005). Conclusions This study provides further evidence that suboptimal lead position in combination with disease progression or tolerance may result in less satisfactory long-term outcomes.

Download Full-text

Long-term Outcomes of Deep Brain Stimulation for Neuropathic Pain

Neurosurgery ◽

10.1227/neu.0b013e31827b97d6 ◽

2012 ◽

Vol 72 (2) ◽

pp. 221-231 ◽

Cited By ~ 93

Author(s):

Sandra G.J. Boccard ◽

Erlick A.C. Pereira ◽

Liz Moir ◽

Tipu Z. Aziz ◽

Alexander L. Green

Keyword(s):

Quality Of Life ◽

Neuropathic Pain ◽

Short Form ◽

Case Series ◽

Mcgill Pain Questionnaire ◽

Euroqol 5D ◽

Deep Brain

Abstract BACKGROUND: Deep brain stimulation (DBS) to treat neuropathic pain refractory to pharmacotherapy has reported variable outcomes and has gained United Kingdom but not USA regulatory approval. OBJECTIVE: To prospectively assess long-term efficacy of DBS for chronic neuropathic pain in a single-center case series. METHODS: Patient reported outcome measures were collated before and after surgery, using a visual analog score, short-form 36-question quality-of-life survey, McGill pain questionnaire, and EuroQol-5D questionnaires (EQ-5D and health state). RESULTS: One hundred ninety-seven patients were referred over 12 years, of whom 85 received DBS for various etiologies: 9 amputees, 7 brachial plexus injuries, 31 after stroke, 13 with spinal pathology, 15 with head and face pain, and 10 miscellaneous. Mean age at surgery was 52 years, and mean follow-up was 19.6 months. Contralateral DBS targeted the periventricular gray area (n = 33), the ventral posterior nuclei of the thalamus (n = 15), or both targets (n = 37). Almost 70% (69.4%) of patients retained implants 6 months after surgery. Thirty-nine of 59 (66%) of those implanted gained benefit and efficacy varied by etiology, improving outcomes in 89% after amputation and 70% after stroke. In this cohort, >30% improvements sustained in visual analog score, McGill pain questionnaire, short-form 36-question quality-of-life survey, and EuroQol-5D questionnaire were observed in 15 patients with >42 months of follow-up, with several outcome measures improving from those assessed at 1 year. CONCLUSION: DBS for pain has long-term efficacy for select etiologies. Clinical trials retaining patients in long-term follow-up are desirable to confirm findings from prospectively assessed case series.

Download Full-text