Invasive Neurostimulation in the Management of Chronic Neuropathic Pain Syndromes
Invasive Neurostimulation in the Management of Chronic Neuropathic Pain Syndromes
Historical Perspective
The analgesic effect of electricity has been exploited for thousands of years (electric fish, static electricity) but it has been controllable only since the introduction of the Leyden jar in 1745. Electro-acupuncture was introduced in 1823. Peripheral nerve stimulation was also developed in the 19th century, but its misuse (‘the golden age of medical electricity’) led to its ban in the US in 1910. The modern era of therapeutic neurostimulation was launched by the gate control theory of pain transmission,1 although deep brain stimulation (DBS) had already been used for pain control.2 It was also driven by the dawning awareness that damage to the nervous system, including therapeutic damage, could itself generate pain – neuropathic pain. The first human application of spinal cord stimulation (SCS) was in 1967.3
General Considerations
Physical treatments such as electrical neurostimulation have clear advantages over pharmacotherapy in terms of adverse side effects. Despite this and the fact that fewer than half of patients with chronic neuropathic pain obtain worthwhile long-term pain relief from drugs,4 implanted neurostimulators are regarded as a treatment of last resort. This is only partly due to the high initial cost involved; cost-effectiveness studies are consistently positive, with a crossover point in less than three years5 (probably a little later, but with greater long-term benefit, in the case of the more expensive recently introduced rechargeable systems).
The biggest hurdle facing the field is the issue of evidence. There is a large body of positive but uncontrolled published evidence and enormous unpublished positive experience, but very little ‘level one’ evidence. Not only does this provide the financially constrained healthcare commissioners and insurers with an excuse, but it is also relevant to the key factor of case selection.
There are remarkably few contraindications: the presence of an implanted cardiac defibrillator or a demand-type cardiac pacemaker, uncontrolled coagulopathy, sepsis and, to a variable extent, cognitive impairment.
- Melzack R, Wall PD, Pain mechanisms: a new theory, Science, 1965;150:971–9.
- Mazars GJ, Roge R, Mazars Y, Stimulation of the spinothalamic fasciculus and their bearing on the physiology of pain, Revue Neurologique, 1960;103:136–8.
- Shealy CN, Mortimer JT, Reswick JB, Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report, Anesth Analg, 1967;46:489–91.
- Attal N, et al., EFNS guidelines on pharmacological treatment of neuropathic pain, Eur J Neurol, 2006;13:1153–69.
- Taylor RS, et al., The cost effectiveness of spinal cord stimulation in the treatment of pain: a systematic review of the literature, J Pain Symptom Manage, 2004;27:370–78.
- Simpson BA, Spinal cord stimulation, Pain Reviews, 1994;1:199–230.
- North RB, Kidd DH, Farrokhi F, Piantadosi SA, Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial, Neurosurgery, 2005;56:98–107.
- Kumar K, Spinal cord stimulation versus conventional medical management: a multicentre randomised controlled trial of patients with failed back surgery syndrome (PROCESS study), Eur J Pain, 2006;10(Suppl. S1):s122.
- Jänig W, Baron R, Is CRPS I a neuropathic pain syndrome?, Pain, 2006;120:227–9.
- Kemler MA, et al., The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy: two years’ follow-up of the randomized controlled trial, Ann Neurol, 2004;55:13–18.
- Simpson BA, Meyerson BA, Linderoth B, Spinal cord and brain stimulation. In: McMahon SB, Koltzenburg M (eds), Wall and Melzack’s Textbook of Pain, 5th Edn, Elsevier, Churchill Livingstone, 2006:563–82.
- Sindou MP, et al., Predictive value of somatosensory evoked potentials for long-lasting pain relief after spinal cord stimulation: practical use for patient selection, Neurosurgery, 2003;52:1374–84.
- Hord ED, et al., The predictive value of sympathetic block for the success of spinal cord stimulation, Neurosurgery, 2003;53:626–33.
- Meyerson BA, Linderoth B, Mode of action of spinal cord stimulation in neuropathic pain, J Pain Symptom Manage, 2006;31(Suppl. 4S):s6–12.
- Tsubokawa T, et al., Chronic motor cortex stimulation in patients with thalamic pain, J Neurosurg, 1993;78:393–401.
- Katayama Y, et al., Motor cortex stimulation for post-stroke pain: comparison of spinal cord and thalamic stimulation, Stereotact Funct Neurosurg, 2001;77:183–6.
- Peyron R, et al., Electrical stimulation of precentral cortical area in the treatment of central pain: electrophysiological and PET study, Pain, 1995;62:275–86.
- Bittar RG, et al., Deep brain stimulation for pain relief: a metaanalysis, J Clin Neurosci, 2005;12:515–19.
- Franzini A, et al., Hypothalamic deep brain stimulation for the treatment of chronic cluster headaches: a series report, Neuromodulation, 2004;7:1–8.
- Wall PD, Sweet WH, Temporary abolition of pain in man, Science, 1967;155:108–9.
- Stanton-Hicks M, Transcutaneous and peripheral nerve stimulation. In: Simpson BA, ed., Electrical Stimulation and the Relief of Pain: Pain Research and Clinical Management Vol. 15, Elsevier, 2003:37–55.
- Bennett DS, Brookoff D, Sacral nerve root stimulation for interstitial cystitis. In: Simpson BA (ed.), Electrical Stimulation and the Relief of Pain: Pain Research and Clinical Management Vol. 15, Elsevier, 2003:57–77.
- Krames E, Editorial, Neuromodulation, 2007;10:1–3.
