Deep Brain Stimulation for Intractable Pain: A 15-Year Experience

Kumar, Krishna; Toth, Cory; Nath, Rahul K.

doi:10.1097/00006123-199704000-00015

Cited by 364 publications

(207 citation statements)

References 36 publications

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“…This is in good agreement with calculations, based on Eq. [1], indicating that the induced voltage should not exceed 4 mV on the small-bore MR scanner for the chosen experimental setup. The induced voltage for the clinical MR scanner with its weaker gradients is even lower (U Ͻ 0.5 mV).…”

Section: Voltagementioning

confidence: 99%

See 1 more Smart Citation

Active deep brain stimulation during MRI: A feasibility study

Georgi¹,

Stippich²,

Tronnier³

et al. 2004

Magnetic Resonance in Med

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The goal of this study was to evaluate the feasibility of active deep brain stimulation (DBS) during the application of standard clinical sequences for functional MRI (fMRI) in phantom measurements. During active DBS, we investigated induced voltage, temperature at the electrode tips and lead, forces on the electrode and lead, consequences of defective leads and loose connections, proper operation of the neurostimulator, and image quality. Sequences for diffusion-and perfusion-weighted imaging, fMRI, and morphologic MRI were used. The DBS electrode and lead were placed in a NaCl solution-filled phantom. Over the past decade, deep brain stimulation (DBS) has become an established technique in the neurosurgical treatment of patients suffering from medically intractable, chronic pain, Parkinson's disease, or seizures. However, about 30% of the patients in whom electrodes were implanted did not improve clinically (1,2).MRI examinations to map activity, perfusion, and cellular integrity in the human brain (e.g., fMRI, perfusionweighted imaging, and diffusion-weighted imaging) have become an integral part of clinical radiodiagnostics. If these techniques were also feasible in patients undergoing DBS, they could be used as powerful tools to distinguish between responders and nonresponders to DBS, and to investigate possible causes of treatment success or failure (3). During fMRI, a periodic switching between active and inactive DBS can serve as a stimulation paradigm to map brain activity and assess therapeutic effects.Recent studies (3-7) have suggested that in patients undergoing examination with inactive or disconnected implanted neurostimulators, MRI does not appear to be hazardous because the induced voltage is in the range of a few volts. Given the high frequency of the sinusoidal induced voltage, it was assumed that an action potential could not be evoked in neurons. The temperature increase at the electrodes and the implanted pulse generator (IPG) did not exceed 3.7°C for commonly used positioning and specific absorption rate (SAR) values (4). When the stimulators were switched off during imaging, they worked properly after they were switched on again. Imaging was not affected by the electrodes, except for an MR signal loss near the electrode due to susceptibility artifacts.The results obtained with inactive IPGs and disconnected electrodes cannot be applied to the setup required for fMRI, where the electrodes are connected to an active extracorporeal pulse generator that is switched on and off during the examination. The aim of this study was to investigate the feasibility of fMRI techniques using such an experimental setup. We focused on the question of whether the safety and feasibility of MRI are influenced by 1) the sequences used for the examinations (i.e., diffusionweighted spin-echo EPI, T* 2 gradient-echo EPI for perfusion MRI, and BOLD imaging); 2) the periodic switching (on/off) of the pulse generator during measurements; and 3) the localization of the pulse generator outside the scanning room. THEOR...

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Section: Voltagementioning

confidence: 99%

“…However, about 30% of the patients in whom electrodes were implanted did not improve clinically (1,2).…”

mentioning

confidence: 99%

Active deep brain stimulation during MRI: A feasibility study

Georgi¹,

Stippich²,

Tronnier³

et al. 2004

Magnetic Resonance in Med

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show abstract

“…To address this predicament, alongside improving case selection, further challenges are to identify predictors of long-term efficacy and to investigate the putative phenomenon of tolerance. Progressive increases of stimulus amplitude or insertion of a second electrode have proven unhelpful [184]. Our experience [79], and that of others [195], is that tolerance is often overcome by subtle alterations of pulse width by 30-90 μs or frequency by 5-15 Hz, or both, and by either cycling stimulation or having stimulation breaks-periods off DBS lasting from days to months as required.…”

Section: Discussionmentioning

confidence: 99%

Neuropathic Pain and Deep Brain Stimulation

Pereira

Aziz

2014

Neurotherapeutics

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Deep brain stimulation (DBS) is a neurosurgical intervention the efficacy, safety, and utility of which are established in the treatment of Parkinson's disease. For the treatment of chronic, neuropathic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated with current standards of neuroimaging and stimulator technology over the last decade . We summarize the history, science, selection, assessment, surgery, programming, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and latterly rostral anterior cingulate cortex (Cg24) in 113 patients treated at 2 centers (John Radcliffe, Oxford, UK, and Hospital de São João, Porto, Portugal) over 13 years. Several experienced centers continue DBS for chronic pain, with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS under general anesthesia considered for whole or hemibody pain, or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.

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“…16 Others reported that deep brain stimulation was non-effective in 3 patients with central pain after SCI. 19 A more rational treatment of central neuropathic pain following SCI should be derived from an increased understanding of the pathophysiology underlying this pain syndrome.…”

Section: Neuropathic Painmentioning

confidence: 99%

Pathophysiological mechanisms of central neuropathic pain after spinal cord injury

Eide¹

1998

Spinal Cord

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After spinal cord injury (SCI), between 10% and 20% of the patients may develop central neuropathic pain. This type of chronic pain usually is a very bothersome sequel and represents a major therapeutic challenge since conventional medical and surgical pain therapies generally are ine ective. This review focuses on recent advances in the understanding of the pathophysiology of this pain syndrome. Important clinical features of central neuropathic pain after SCI include loss of sensations mediated by spinothalamic pathways combined with development of abnormal pain perception (spontaneous continuous pain and abnormally evoked pain). Up-regulation of neuronal activity leading to spontaneous and evoked neuronal hyperactivity/hyperexcitability, may be the neurophysiological substrate for development of abnormal pain perception. This paper describes some neurochemical changes that may be important for the induction and maintenance of neuronal hyperactivity and abnormal pain perception: Increased excitatory glutaminergic activity involving N-methyl-D-aspartate (NMDA) receptor activation, may trigger the intracellular cascade reaction leading to upregulation of neuronal activity/excitability. Changes in voltage-sensitive Na + channels may contribute to changes in nerve membrane excitability. Other important mechanisms may be loss of endogenous inhibition, including reduced g-amino-butyric acid (GABA)ergic, opioid and monoaminergic inhibition. These various mechanisms may provide new targets for treatment of a pain syndrome that traditionally has been so di cult to handle.

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Deep Brain Stimulation for Intractable Pain: A 15-Year Experience

Abstract: DBS in selected patients provides long-term effective pain control with few side effects or complications.

Cited by 364 publications

References 36 publications

Active deep brain stimulation during MRI: A feasibility study

Active deep brain stimulation during MRI: A feasibility study

Neuropathic Pain and Deep Brain Stimulation

Pathophysiological mechanisms of central neuropathic pain after spinal cord injury

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