Tiefe Hirnstimulation und motorische Kortexstimulation bei der Behandlung chronischer, neuropathischer Schmerzen

Neuropathic pain represents a complex clinical entity which remains a major therapeutic challenge, despite conservative and pharmacological treatment. Neuromodulation procedures, including deep brain stimulation (DBS), and motor cortex stimulation (MCS) have been explored for these patients. This study analyses four cases of pharmaco-resistant neuropathic pain treated with both thalamic DBS and MCS, and evaluates the potential of the synergistic effects of both treatments.

This singe-centre retrospective study includes patients with refractory chronic neuropathic pain treated between 2007 and 2022. Patients underwent implantation of DBS leads in the centromedian-parafascicular nucleus, and the ventral posterolateral or the ventral posteromedial nuclei. For MCS, using neuronavigation, an epidural quadripolar paddle lead was placed. Preoperative assessments included imaging, pain evaluation, and cognitive assessments. Inclusion criteria were medically refractory chronic neuropathic pain with a defined cause, while exclusion criteria were patients with low average pain scores and comorbidities.

Four patients underwent both DBS and MCS treatment at a mean age of 37 years. The mean pain duration was 8.2 years. The first two cases had a trial of MCS and upon insufficient response additional DBS electrodes were implanted. The remaining two patients had first DBS electrode implanted with temporary pain relief and underwent afterwards MCS test stimulation. At a mean follow-up of 68.8 months, there were variable improvements of pain intensity, with two patients achieving ≥50% improvement on average at the last follow-up. One patient experienced a sustained improvement with the combination of MCS and DBS.

Combined DBS and MCS may offer a viable treatment option for selected patients with refractory neuropathic pain, with some patients achieving significant pain reduction. However, the variable response rates suggest the need for careful patient selection and larger studies to better define the optimal sequencing and combination of these neuromodulation techniques.