Deep Brain Stimulation Improves the Symptoms and Sensory Signs of Persistent Central Neuropathic Pain from Spinal Cord Injury: A Case Report

Abstract

Central neuropathic pain (CNP) is a significant problem after spinal cord injury (SCI). Pharmacological and non-pharmacological approaches may reduce the severity, but relief is rarely substantial. While deep brain stimulation (DBS) has been used to treat various chronic pain types, the technique has rarely been used to attenuate CNP after SCI. Here we present the case of a 54-year-old female with incomplete paraplegia who had severe CNP in the lower limbs and buttock areas since her injury 30 years prior. She was treated with bilateral DBS of the midbrain periaqueductal gray (PAG). The effects of this stimulation on CNP characteristics, severity and pain-related sensory function were evaluated using the International SCI Pain Basic Data Set (ISCIPBDS), Neuropathic Pain Symptom Inventory (NPSI), Multidimensional Pain Inventory and Quantitative Sensory Testing before and periodically after initiation of DBS. After starting DBS treatment, weekly CNP severity ratings rapidly decreased from severe to minimal, paralleled by a substantial reduction in size of the painful area, reduced pain impact and reversal of pain-related neurological abnormalities, i.e., dynamic-mechanical and cold allodynia. She discontinued pain medication on study week 24. The improvement has been consistent. The present study expands on previous findings by providing in-depth assessments of symptoms and signs associated with CNP. The results of this study suggest that activation of endogenous pain inhibitory systems linked to the PAG can eliminate CNP in some people with SCI. More research is needed to better-select appropriate candidates for this type of therapy. We discuss the implications of these findings for understanding the brainstem’s control of chronic pain and for future progress in using analgesic DBS in the central gray.

Microstructural plasticity in nociceptive pathways after spinal cord injury

“… 35 Direct stimulation of the PAG has successfully been trialled as a treatment option for NP including pain following SCI. 36 Thus, it is anticipated that molecular changes in the PAG could compromise descending inhibition of nociceptive processing and subsequently increase the spinal gain of incoming information. Our study is the first to provide evidence for NP-related changes in PAG microstructure in humans, underscoring the clinical relevance of these changes for NP following SCI.…”

Effects of botulinum toxin A on endometriosis‑associated pain and its related mechanism

“…Previous studies have reported that NE and M-EK have analgesic effects. Injection of NE and/or opioid agonists into the spinal dorsal horn can achieve analgesic effects ( 25 , 26 ). Microencapsulated PC12 cells can be transplanted into the subarachnoid space of rats, and as a source of microcellular pump, can continuously produce NE and M-EK, and may have a notable analgesic effect in a chronic neurogenic animal model ( 23 , 27 ).…”

Cellular Changes in Injured Rat Spinal Cord Following Electrical Brainstem Stimulation

“…Raphe neurons also secrete several neuropeptides, including galanin, substance P, and thyrotropin-release hormone, that are potentially protective after SCI [32,33]. The relation of NRM LFS to other stimulation targets used for the management of neurotrauma (vagal nerve, periaqueductal grey, spinal cord), for which the modulation of autonomic function is a commonly proposed mechanism, is unclear [6,8,14,16,17,19,35]. However, given the established reciprocal connections between these targets, it is likely that diverse overlapping processes are elicited with each stimulation target [14,26,32].…”

“…However, since some degree of functional improvement occurs naturally in the weeks following injury, it is possible that the sequelae of SCI may be overcome to some extent by interventions that enhance endogenous beneficial processes [2,6,7]. Chronic low-frequency electrical stimulation (LFS) of various brain and spinal targets has long been known to influence the perception of chronic pain in select patients [8,9,10]. However, more recently, LFS of several of these targets and their inputs has received attention for its ability to improve functional outcomes in laboratory and clinical models of SCI [6,11,12,13,14,15].…”