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Techniques in Neurosurgery & Neurology

Deep Brain Stimulation for Management of Refractory Cranial Neuralgias: A Literature Review

Serge Rasskazoff*

Consultant Neurosurgeon King Salman Specialist Hospital, Hail Health Cluster, Kingdom of Saudi Arabia

*Corresponding author:Serge Rasskazoff, Consultant Neurosurgeon King Salman Specialist Hospital, Hail Health Cluster, Kingdom of Saudi Arabia

Submission: July 02, 2024;Published: August 28, 2024

DOI: 10.31031/TNN.2024.05.000624

ISSN 2637-7748
Volume5 Issue5

Abstract

Deep Brain Stimulation [DBS] is a neuromodulatory approach of treatment brain diseases by inserting electrodes intracranially for delivering electrical impulses to targeted brain deep nuclei and structures. This method of neurostimulation is well established and evidence based for management of patients with movement disorders and approved by Food and Drag Agency of USA. After initial introduction of DBS as a feasible treatment option for patient with intractable neuropathic pain conditions, this electrical stimulation modality has gained widespread acceptance in modern management of movement disorders. Recently, Neuromodulation Appropriateness Consensus Committee, an expert panel of the International Neuromodulation Society, found that the evidence to support the use of DBS therapy for facial pain is limited and a current clinical use of intracranial stimulation for facial pain management should be seen as investigational. Several recent studies have demonstrated the benefit of DBS in controlling medically resistant facial pain conditions. With progress of understanding of neural circuitry involved in pain processing and advances in electrostimulation technology, DBS therapy appears to be clinically reasonable option for patients with various cranial neuralgias, however, no consensus exists yet as to what is optimal treatment target and nosology of facial pain. The intention of this narrative review is to critically reassess current evidence of DBS efficacy for management of patient with cranial neuralgias.

Keywords: Deep brain stimulation; Cranial neuralgias; Facial pain; Cranial neuralgias; Bilateral facial

Introduction

Deep Brain Stimulation (DBS) is a form of electro-neuromodulation invasive therapeutic modality by surgically implantation of intracranial electrodes into subcortical deep brain structures for use of electrical impulses to alter function of targeted brain structures. DBS has been extensively evaluated as a therapeutic option for management of patients with movement disorders and is currently used as a standard evidence-based treatment option. However initially exploration of DBS in the 1950’s was used for intractable pain syndromes treatment and in fact has been considered as a method of choice for management chronic resistant pain conditions. However, due to poorly conducted clinical trials in USA the DBS was not approved by FDA as a mode of treatment for patients with various chronic neuropathic pain. The Task Force of European Federation of Neurological Societies published guidelines on neurostimulation therapy for neuropathic pain, showing a weak positive evidence for DBS use in facial pain (long term success is 38% for trigeminopathic facial pain and 36% for post-herpetic neuralgia) and concluded that DBS should be restricted to supraspecialist neurosurgical centers actively practicing DBS application for management refractory pain disorders, collecting and studying treatment outcome and publishing their results [1]. National Institute for Health and Clinical Excellence (NICE) made the recommendation for the safety and efficacy of DBS treatment for refractory chronic pain syndromes without specific information on facial pain [2]. Based on expert opinion and patient-reported outcomes the NICE approves the DBS application in patient with intractable face pain. However, current published surgical treatment algorithm of face pains does not include DBS therapy as a surgical procedure option [3]. Neuromodulation Appropriateness Consensus Committee (NACC), the expert panel of the International Neuromodulation Society, after evaluation of current literature and clinical experience found that the evidence of current use of intracranial stimulation for face pain should be seen as investigational [4]. Therefore, at the moment the evidence-based clinical guidelines that may help to determine which patient with chronic refractory face pain is surgical candidate for DBS trial are absent. Despite available publications in clinical literature on DBS application for face pain management there is no consensus regarding patient selection for this treatment option. The purpose of the present review is to summarize the current evidence on DBS efficacy as method of neuromodulation therapy and to provide the information to support clinical decision-making for clinicians treating patients with intractable cranial neuralgias.

Methods

An electronic search was performed manually by author from PubMed of all available articles published in English language from all countries. The following keywords were selected: “DBS”, “deep brain stimulation”, “face pain”, “cranial neuralgias”, “efficacy”. Only reports of patients with DBS implanted electrodes for control of chronic refractory face pain were included. During the data collection, articles reporting DBS for central post-stroke pain were excluded due to fact that facial pain was being as a part of hemi body pain. All bibliographies of obtained publications were additionally searched for any relevant reference. Additional historical references from the bibliographies of indexed publication and reviews has been researched also. The institutions from which the patients originated was recorded to avoid duplicating patient data when several publications from the same group were published. In case of multiple papers from the same center data was extracted from article with larges sample and longest outcome. The variables collected included patient demography, study publication date, first author, institution, city, country, type of publication, sample size, cranial neuralgia diagnosis, side and trigeminal branch of facial pain, previous surgical and interventional pain management treatments, DBS targets, duration of follow up and reported pain control outcomes. Electrode type, use of microelectrode intraoperative recordings, number of trials, failures and reported complications were not collected. In case of any missing data no attempt to contact corresponding authors to obtain the missing items was made. The data extraction form was completed by the same reviewer. Author in an unblinded, standardized manner, using a pre-constructed spreadsheet extracted data from identified published reports and all relevant information is summarized. Changes in pain score and response rates were considered as primary outcome of interest.

Relief from pain was assessed by 10-point pain scales used by investigators. Few publications provided incomplete information since DBS neuromodulation for face pain control was a part of bigger study on DBS application for chronic pain of various parts of human body. The efficacy of DBS was assessed on face pain of different nosology based on the third edition of the International Classification on Headache Disorders (only Part 13 Painful lesions of the cranial nerves and other facial pain) [5]. Changes in pain severity between pre- and post-DBS therapy in each diagnostic category according to ICH-3 were analyzed. Technical and surgical aspects of DBS techniques, coordinates of DBS targets, mechanism of action, safety and complications, history of DBS for chronic intractable face pain, patient selection and indications for treatment are well described elsewhere [6,7]. This narrative review provides a brief clinical summary of published evidence for different facial pain syndromes and has been structured according to the diagnoses of ICHD 3. Statistical Analysis. Due to the heterogeneous data quality and structure of the publications, the aggregate data analysis was not performed.

Result

The current literature on DBS neurostimulation in the treatment of chronic refractory facial pain is collected (Table 1). Twenty-six publications from 1980 till 2023 years were reviewed, most of them were case reports or small retrospective case series; half of the articles were part of bigger study on chronic pain of various locations and not exclusively on painful face syndromes; many of them did not provide data for individual patient. All reports represent non-blinding and non-randomized, singlearm uncontrolled studies. Data for a longer follow-up period were limited. All articles were from developed countries and all centers reporting their results were academic medical institutions: Belgium-1, Canada-5, Germany-5, Italy -1, Japan -2, Poland-1, Spain-1, Switzerland-2, UK-2, USA-4 centers. Literature search identified a total number of patients with refractory facial pain who underwent DBS neuromodulation was 175 with the biggest number of patients was collected in University Hospital Zurich from Switzerland -55. Only few centers are providing reports continuously over time with a majority of other institutions never publishing new articles on this topic again [30-32].

Table 1:Published literature on DBS for treatment of facial pain.


Trigeminal Neuralgia (Table 2)

Description: A disorder characterized by recurrent unilateral brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of the trigeminal nerve and triggered by innocuous stimuli. Only 3 patients with recurrent and persistent face pain due unclassified trigeminal neuralgia who underwent DBS implantation in sensory thalamus and periventricular gray matter reported in 2 publications; in two of them achieved mean pain reduction of 50% [33,34].

Table 2:Trigeminal neuralgia.


Trigeminal neuralgia attributed to multiple sclerosis (Table 3): Description: Trigeminal neuralgia caused by a multiple sclerosis plaque or plaques in the pons or trigeminal nerve root entry zone, and associated with other symptoms and/or clinical signs or laboratory findings of MS. A group from Italy studied DBS modality for the treatment of paroxysmal trigeminal pain in 5 patients (3 males and 2 females age ranging from 49 to 65 years) with long history of multiple sclerosis by stimulating posterior hypothalamic as a stereotactic target. Patient follow-up period was from 11 to 51 months after permanent implantation of DBS devices. Pain outcome was measured by reduction on Barrow Pain Scale. Provided evidence showed controversial efficacy results since face pain arising from the first trigeminal branch was controlled at follow up, however, all patients experienced recurrence of pain in the second and third trigeminal branches and two of them required repeated thermorhizotomies for pain control.

Table 3:Trigeminal Neuralgia attributed to multiple sclerosis.


Trigeminal post-herpetic neuralgia (Table 4): Description: Unilateral facial pain persisting or recurring for at least 3 months in the distribution(s) of one or more branches of the trigeminal nerve, with variable sensory changes, caused by herpes zoster. Forty-six patients with trigeminal post-herpetic neuralgia underwent DBS implantation surgery of various brain targets and collectively reported by 9 authors. Pain control outcome ranged from a clear failure to complete pain control, with half of patients achieving at least 50% pain relief during long term follow up. In 2 patients 100% of pain relief was achieved.

Table 4:Trigeminal post-herpetic neuralgia.


Painful post-traumatic trigeminal neuropathy (Table 5): Description: Unilateral or bilateral facial pain or oral pain following and caused by trauma to the trigeminal nerve(s), with other symptoms and/or clinical signs of trigeminal nerve dysfunction. Pain duration ranges widely from paroxysmal to constant and may be mixed. The traumatic event may be mechanical, chemical, thermal or caused by radiation. Neuroablative procedures for trigeminal neuralgia, aimed at the trigeminal ganglion or nerve root, may result in neuropathic pain involving one or more trigeminal divisions; this should be considered as post-traumatic and coded here. Burchiel proposed a patient-oriented classification scheme for facial pains commonly encountered in neurosurgical practice [35]. He defined Trigeminal Neuropathic Pain (TNP) as result from unintentional injury to the fifth cranial nerve from trauma or surgery, whereas Trigeminal Differentiation Pain (TDP) results from injury to the trigeminal nerve by a lesioning procedure in an intentional attempt to treat trigeminal neuralgia. Most likely the difference between TNP and TDP is not trauma intention per se but the injury to naïve, healthy or diseased, abnormal trigeminal nerve. Patients with painful post-traumatic trigeminal neuropathy are most prevalent DBS group in literature. Out 96 patients in this group 71 satisfy criteria of TDP (anesthesia dolorosa) and 25 patients fall into TNP cohort. Only in 2 patients DBS target was posterior hypothalamus with the rest of the patients targets for implantable electric stimulation were different nuclei of sensory thalamus and/or periaqueductal gray matter. Pain reduction of more than 50% was achieved in 53% and 72% of TDP and TNP patients respectfully. DBS neurostimulation of the posterior hypothalamus completely failed to control facial pain in patients with TNP diagnoses. One patient with intractable left facial pain and severe hyperkinesia of the left arm which was developed after ablation lesioning by previous surgical treatment was successfully treated by implantation of stimulating electrode through a single stereotactic trajectory controlling both pain in face and involuntary arm moments. Another patient underwent successful DBS targeting ventroposteromedial thalamic nucleus after 10 years of VPM thalamotomy.

Table 5:Painful post-traumatic trigeminal neuropathy.


Painful trigeminal neuropathy attributed to other disorder (Table 6): Description: Unilateral or bilateral facial or oral pain in the distribution(s) of one or more branches of the trigeminal nerve, caused by a disorder other than those described above, with other symptoms and/or clinical signs of trigeminal nerve dysfunction. This is a very rare nosology and only 2 cases have been published in literature. One is case of Parkinson’s disease patient who developed intractable facial pain with allodynia as a result of long-term levodopa replacement therapy, which was alleviated by subthalamic nucleus deep brain stimulation. Another patient presented with a 2 years’ history of progressive left-sided facial pain secondary to Lyme’s disease contracted during field work. Patient was treated with single electrode dual target surgery (Centromedian Intra- Laminar Parafascicular Complex (CMPF) and periaqueductal grey and periventricular grey (PAG/PVG)). At 3 years’ outcome results revealed only minimal symptoms in patient with full return to her daily living activities using gabapentin therapy 1.8g daily.

Table 6:Painful trigeminal neuropathy attributed to other disorders.


Persistent Idiopathic Facial Pain (PIFP) (Table 7): Description:

Persistent facial and/or oral pain, with varying presentations but recurring daily for more than two hours/day over more than three months, in the absence of clinical neurological deficit. It is most often depicted as dull, nagging or aching, either deep or superficial. PIFP may originate from a minor operation or injury to the face, maxillae, teeth or gum, but persists after healing of the initial noxious event without any demonstrable local cause. Thalamic and/or periaqueductal grey stimulation provided significant pain relief in half of eleven PIFP patients. Neurostimulation of posterior hypothalamus of PIFP patient was absolutely unsuccessful.

Table 7:Persistent Idiopathic Facial Pain (PIFP).


Study Limitation

The principal limitation of this study is that only small case series and case reports were available for data extraction and analysis with a relatively small number of participants. Evidence supporting the efficacy of DBS which has been collected makes the dataset subject to limited interpretation. The significant heterogeneity among the investigated patients was observed in collected dataset. The primary source of this heterogeneity is the fact that DBS was used for the treatment of chronic facial pain in variety of cranial neuralgias diagnoses. Moreover, variation in the stimulation brain targets and parameters, difference among old and modern electrode design, and the specifics surgical implantations setting, and trial period contribute to the increased heterogeneity. These shortcomings of data quality do not diminish the value of published results or positive clinical experiences of face pain control in patients. Variable published results of DBS for control of resistant face pain do not mean that the treatment is ineffective; however, they reveal the need of change new data acquisition and quality of publishing in order to gain meaningful information for clinical use. In the future any study on DBS for facial pain should require cranial neuralgia diagnosis according to 3rd edition of HIS classification by neurologist with specialized training in headache and face pain as an entry criterion in order to improve quality of research data in this area.

Discussion

Cranial neuralgias such as primary and secondary trigeminal neuralgia, post-traumatic trigeminal neuropathy, trigeminal postherpetic neuralgia and persistent idiopathic facial pain syndrome are characterized by severe, disabling, typically unilateral, burning or stabbing pain. An estimated 100 per million people in the United States suffer from these disorders, and for those patients with refractory course, the impact on their quality of life can be extremely debilitating [36]. Despite being available, wideaccepted by clinicians medical and surgical treatment, intractable and therapy cranial neuralgias of different origins still poses a management challenge in patients with therapy refractory facial pain syndromes. In circumstances where there is insufficient responsiveness to pharmacological/ surgical therapies, invasive neuromodulation option, including DBS, should have considered as a potential effective treatment option.

After the introduction of human stereotactic surgery in early 1950s and in parallel to ablative surgery clinical use of brain electrical stimulation was developed. Application of DBS as a tool for control of severe pain conditions preceded it used for management of movement disorder, since refractory chronic pain was among the first studied indications for brain stimulation over 50 years ago [37]. Now deep brain stimulation is an established, FDA approved, neurosurgical technique for treatment of movement disorders and currently, it is estimated that 160,000 DBS implant procedures have been performed worldwide. The first modern use of DBS in the US occurred in early 1970’s for the treatment of facial pain in patients with cranial neuralgias [38]. The exact mechanism by which DBS exerts its action on underlying pathophysiology of facial pain is still not clear. One of research hypothesis is that electrical stimulation modulates abnormal circuits toward a more physiological state [39].

DBS treatment for face pain is based on plausible physiological hypotheses and data from experiments in laboratory animals and clinical research of human subjects. The results of those experiments conducted in the 1950s and 1960s led pioneers of functional neurosurgery to stimulate the ventral posterolateral and posteromedial sensory thalamic nuclei and/or PAG and PVG in patient with chronic intractable face pain. It has been postulated that PAG stimulation is better suited to nociceptive pain, whereas sensory thalamic targets are more effective in neuropathic pain [40,41]. Both opioid and non-opioid mechanisms seem to be involved in DBS-induced analgesia. Contemporary and older case series publications on DBS application for resistant facial pain control have been restricted to only handful academic superspecialized, dedicated neurosurgical centers, located in North America, Western Europe and Japan, using this technology to relief suffering of patients with vast chronic pain conditions. There are around 2000 patients with chronic pain syndromes who underwent placement DBS system (188 patients with intractable face pain) and nearly 100 patients with cluster headache. Several factors explain this geographical and economic inequality for this method: 1) DBS is expensive neuromodulation therapy requiring significant capital investment in stereotactic and navigation equipment; high cost of implantables (IPG and electrodes) 2) existence of experienced, well-trained and qualified chronic pain multidisciplinary team for patient selection, assessment and long-term monitoring and adjustment stimulations programs. This pose an ethical issue of DBS significant financial and organizational costs and its availability to all classes of society. The expensive DBS hardware costs, high surgical and hospital fees along with lack of clinician expertise in area of functional neurosurgery for management intractable pain conditions are the issues which limiting widespread adoption of this invasive neuromodulation modalities in the developing world.

The main targets of DBS for face pain control are sensory thalamus and periventricular and periaqueductal gray matter. Selection of deep brain stimulation targets is usually based on the surgeon’s judgment, his previous operative experience with DBS targets for chronic pain control and the patient symptoms and diagnosis of face pain condition. The published data suggest that posterior hypothalamus should not be used as DBS target for management of the painful lesions of the cranial nerves due to that the pathophysiological mechanisms of neuropathic trigeminal pain do not involve the hypothalamus, since acute hypothalamic stimulation in ongoing cluster headache attacks remain ineffective. The rigorous evaluation of published literature showed significant limitations in the quality of reported data. There was a wide range in age, gender, etiology, mean durations of pain, interval between onset of pain and treatment with DBS, previous invasive interventional pain modalities, deep brain sites stimulated, and duration follow up. Additionally, the lack of standardized outcomes and outcomes measures used to contribute to heterogeneity of data and the growing inability to compare study results.

Multiple reports of the same patient cohort frequently did not track individual cases through the series of publications. Deep brain stimulation yielded mixed results in different face pain syndromes: best results were achieved in patient with painful posttraumatic neuropathy, while patients with trigeminal neuralgia, trigeminal post-herpetic neuralgia and persistent idiopathic facial pain had less benefit. Findings of this study are in line with data from a meta-analysis of individual participant data of patients that were treated with DBS for chronic facial pain with total of seven DBS reported small trials consisting of 54 screened patients: DBS provide facial pain control in safe manner across different neurostimulation targets without clear superiority of specific brain nuclei, and in many patients a combination of different DBS targets were used [42]. No statistical results can be derived since results seem to vary dramatically in clinical practice and therefore, data has to be interpreted in the light of what evidence is available. The therapeutic efficacy of DBS in some of patients could be maintained long-term with over 50% pain improvement at 4-year follow-up and more, although DBS does not reduce pain in all patients with successful trials.

Analysis of available DBS data on cranial neuralgias management showed serious lack of consistency and heterogeneity in face pain diagnoses. The assignment of diagnoses or face pain was inconsistent among medical institutions and sometimes among reports of the same center. Evidence supporting application of DBS for pain control of various facial painful diagnoses is based solely on case reports and uncontrolled retrospective small studies and therefore there is a difficult challenge to interpret and to draw conclusion from current dataset. Prospective randomized, doubleblinded clinical trials are often cited as highest-grade clinical evidence. In reality, several attempts of conducting the largescales clinical DBS pain trials had obvious problems: insufficient organizational and financial support, institutional review board approval, registration requirements for clinical trials, inadequate time, lack of control groups due to ethical concerns about potential patient harm. These factors are relevant to functional neurosurgeons as limited time and resources to support meaningful outcome research are commonplace in cash-strapped health care system. The blanket call for double-blinding and randomization of clinical trials in DBS for cranial neuralgias may be untenable due to the cost of DBS therapy and the rarity of patients with refractory facial pain. Modern innovations in DBS pain surgery were started by investigator practicing functional pain neurosurgery where outcome are almost always reported as case reports or retrospective case series. Those published opinions suffer from various forms of bias. The latter may be the highest achievable today grade of clinical evidence in an experience and skill-based specialty such as functional neurosurgery. Instead to relay on population statistics used in randomized control clinical trials, it is more appropriate to use DBS patient registry to obtain high-quality systemic data from more patients with long term follow-up.

The DBS registry is an organized method of collecting data as a systematic multicenter investigation to assess treatment efficacy based on study protocol, which should be developed by specialist in face pain management and functional neurosurgeons utilizing DBS surgery in daily practice. A minimal data set on clinical status, DBS targets, complication and outcome must be reported by each participating center by using an on-line Case Report Form as documentation method. Diagnosis of facial pain condition should be done and reported according to the criteria of the International Headache Society, a classification which intended to provide a systematic framework to better diagnose and treat face pain conditions. Patients must receive all appropriate ICHD diagnoses, meaning some patients will have more than one diagnosis (e.g. anesthesia dolorosa is trigeminal neuralgia and trigeminal posttraumatic neuropathy). Clinicians performing DBS for all patients with facial pain in experienced centers should collect data of the 2-year, 5-year and 10-year actuarial pain-free rates similar to studies on efficacy of open surgical and interventional pain management treatments of patients with trigeminal neuralgia. Development of DBS registry should be based on the general principles for registry planning, governance, data collection, quality assurance, human subjects and data protections and sharing established by a panel of authors from International Headache Society [43]. Analysis of published results has been difficult to compare treatment efficacy of between different centers due to lack of standardized outcomes. That lack of standardized outcomes and outcomes measures used to contribute to heterogeneity of data and leads the growing inability to arrive to clinical meaningful conclusion. Recently consensus meeting has been held under auspices of the Trigeminal Neuralgia Association UK and Rosetrees Trust to define the core outcome set for trigeminal neuralgia clinical trials [44]. The TN Core Outcome set (TRINCOS) agreement was reached during consensus meeting on 10 outcomes across six domains (pain, side effects, social impact, quality of life, global improvement, and satisfaction with treatment). TRINCOS is providing researchers not only with the “what to measure” information but also with “how to measure” details.

TRINCOS criteria may be applied to other cranial neuralgias. The establishing of DBS registry by professional medical societies would lead to ultimate improvement of the management of patients with intractable cranial neuralgias by providing systemic evidence into disease classification and heterogeneity, longitudinal outcomes and their predictors, treatment efficacy and safety and quality of care. Clinical DBS investigators can collect “big data” from such professional society registry to evaluate bigger cohorts than individual medical centers and may lead to recommendations based on current best evidence. Modern clinical decision-making is guided by evidence-based medicine standards formulated as practice guidelines. Determination that a requested surgical intervention (DBS) is not supported by evidence-based medicine is only helpful if an alternative treatment can be recommended with strong evidence-based medicine support. Therefore, until arrival of high-quality evidence from professional society registries, clinical practitioners should use a very low quality of evidence with high confidence obtained from published clinical experience. Practice of medicine is often defined as an ‘art based on science’.

The art of medicine should be a clinical practice by customizing treatment for a particular patient utilizing best available level of clinical evidence in circumstances when there is no data from prospective randomized controlled studies available. Customizing a treatment plan to individual patient may require expert opinion and common sense, both are considered Level V clinical evidence. The lack of information on outcomes fails to provide patients with adequate answers about the prognosis of the treatment options available and just adds to the misuse of research results. However, Level V evidence, little or no systematic empirical evidence is not absence of clinical evidence. It is representing a grade D practice recommendation, where clinicians should consider all options in their decision making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role [45]. Everyone has access to the current literature and this literature review could guide clinician treating patient suffering from refractory and intractable cranial neuralgias when to consider DBS surgery as a management option.

Conclusion

The DBS application as the treatment of refractory cranial neuralgias should be considered clinically established and justified to use such implantable neuromodulation technique in clinical practice. Results of recent studies at various centers have made progress in confirming DBS validity as a legitimate technology for management severe facial pain patients with cranial neuralgias. The DBS is effective therapeutic modality in clinical settings when used in appropriately selected patients, however, this invasive neuromodulation method should be only used in few centers with dedicated research program for pain disorders neuromodulation and strong DBS clinical practice and expertise. Its reversibility and safety profile during chronic continuous invasive electrostimulation made this technology ethically acceptable in those otherwise untreatable patients whose intractable facial pain achieved pain relief after this neuromodulation technique. DBS is the most expensive and invasive option of electrical stimulation approaches and should be reserved for extremely difficult-to-treat patients. Improvement of quality data reporting in future DBS studies and establishment a web-based data collection center under auspices of World Society for Stereotactic and Functional Neurosurgery, International Neuromodulation Society and International Headache Society could provide real-world contemporary data on clinical DBS efficacy and help to guide the practitioners regarding the procedural effectiveness and long-term outcome and the patient’s expectations.

The author concluded that DBS could be performed safely and successfully for medically refractory facial pain in carefully selected patients with following indications:
a) Painful post-traumatic trigeminal neuropathy-DBS as first choice for TDP and second choice for TNP if a trial of peripheral nerve stimulation of trigeminal nerve branch is unsuccessful.
b) Trigeminal neuralgia and Trigeminal post-herpetic neuralgia-DBS should be used as, last option therapy when other invasive neuromodulation approaches are failed.
c) DBS is a first choice of neuromodulation treatment using single electrode with dual target in patients with face pain and movement disorder.
d) DBS should be considered a rescue treatment in patients who underwent previous thalamotomy for face pain control and developed a tolerance.
e) Hypothalamus nuclei should not be used as the neurostimulation targets for DBS therapy of cranial neuralgias.

References

  1. Cruccu G, Aziz TZ, Larrea LG, Hansson P, Jensen TS, et al. (2007) EFNS guidelines on neurostimulation therapy for neuropathic pain. Eur J Neurol 14(9): 952-970.
  2. (2011) Deep brain stimulation for refractory chronic pain syndromes (excluding headache). National institute for health and clinical excellence, pp. 1-7.
  3. Slavin KV, Nersesyan H, Colpan ME, Munavar N (2007) Current algorithm for the surgical treatment of facial pain. Head and Face Medicine 3: 30.
  4. Deer TR, Mekhail N, Petersen E, Krames E,  Staats P, et al. (2014) The appropriate use of neurostimulation: Stimulation of the intracranial and extracranial space and head for chronic pain. Neuromodulation Appropriateness Consensus Committee Neuromodulation 17(6): 551-570.
  5. (2018) Headache classification committee of the International Headache Society (IHS): The international classification of headache disorders, 3rd Cephalalgia 38(1): 1-211.
  6. Boccard SG, Pereira EA, Moir L, Aziz TZ, Green AL, et al. (2013) Long-term outcomes of deep brain stimulation for neuropathic pain. Neurosurgery 72(2): 221-230.
  7. Frizon LA, Yamamoto EA, Nagel SJ, Simonson MT, Hogue O, et al. (2020) Deep brain stimulation for pain in the modern era: A systematic review. Neurosurgery 86(2): 191-202.
  8. Turnbull IM, Shulman R, Woodhurst WB (1980) Thalamic stimulation for neuropathic pain. J Neurosurg 52(4): 486-493.
  9. Roldan P, Broseta J, Salorio JLB (1982) Appl Neurophysiol 45: 112-113.
  10. Dieckmann G, Witzmann A (1982) Inial and long-term results of deep brain stimulation for chronic intractable pain. Appl Neurophysiol 45(1-2): 167-172.
  11. Hosobuchi Y (1986) Subcortical electrical stimulation for control of intractable pain in humans. Report of 122 cases (1970-1984). J Neurosurg 64(4): 543-553.
  12. Gybels J, Kupers R, Nuttin B (1993) Therapeutic stereotactic procedures on the thalamus for pain. Acta Neurochir 124(1): 19-22.
  13. Siegfried J (1991) Therapeutical neurostimulation-indications reconsidered. Acta Neurochirurgica 52: 112-117.
  14. Kumar K, Toth C, Nath R (1997) Deep brain stimulation for intractable pain: A 15-year experience. Neurosurgery 40(4): 736-747.
  15. Taira T, Kawamura H, Takakura K (1998) Posterior occipital approach in deep brain stimulation for both pain and involuntary movement. A case report. Stereotact Funct Neurosurg 70(1): 52-56.
  16. Marchand S, Kupers RC, Bushnell MC, Duncan GH (2003) Analgesic and placebo effect of thalamic stimulation. Pain 105(3): 481-488.
  17. Constantoyannis C, Kumar A, Stoessl AJ, Honey CR (2004) Tremor induced by thalamic deep brain stimulation in patients with complex regional facial pain. Mov Disord 19(8): 933-936.
  18. Green AL, Nandi D, Armstrong G, Carter H, Aziz T, et al. (2003) Post-herpetic trigeminal neuralgia treated with deep brain stimulation. J of Clin Neurosci 10(4): 512-514.
  19. Green AL, Owen SLF, Davies P, Moir L, Aziz TZ, et al. (2005) Deep brain stimulation for neuropathic cephalalgia. Cephalalgia 26(5): 561-567.
  20. Hamani C, Schwalb JM, Rezai AR, Dostrovsky JO, Davis KD, et al. (2006) Deep brain stimulation for chronic neuropathic pain: Long-term outcome and the incidence of insertional effect. Pain 125(1-2): 188-196.
  21. Rasche D, Rinaldi PC, Young RF, Tronnier VM (2006) Deep brain stimulation for the treatment of various chronic pain syndromes. Neurosurg Focus 21(6): E8.
  22. Franzini A, Marras C, Tringali G, Leone M, Ferroli P, et al. (2007) Chronic high frequency stimulation of the posteromedial hypothalamus in facial pain syndromes and behavior disorders. Acta Neurochir Suppl 97(2): 399-406.
  23. Samura K, Miyagi Y, Morioka N, Murakami N, Yoshida F, et al. (2008) Intractable facial pain in advanced parkinson’s disease alleviated by subthalamic nucleous stimulation. J Neurol Neurosurg Psychiatry 79(12): 1410-1411.
  24. Coenen VA, Kieselbach K, Mader I, Reinacher PC (2015) Diffusion tensor Magnetic Resonance Imaging (DTI) tractography-guided deep brain stimulation in neuropathic pain. Acta Neurochir 157(4): 739-741.
  25. Cordella R, Franzini A, Mantia LL, Marras C, Erbetta A, et al. (2009) Hypothalamic stimulation for trigeminal neuralgia in multiple sclerosis patients: Efficacy on the paroxysmal ophthalmic pain. Multiple Sclerosis 15(11): 1322-1328.
  26. Levine AB, MacDougall KW (2016) New-onset stutter after electrode insertion in the ventrocaudalis nucleus for face pain. World Neurosurg 90: 703.e7-703.e10
  27. Yamgoue Y, Pralong E, Levivier M, Bloch J (2016) Deep brain stimulation of the Ventroposteromedial (VPM) thalamus 10 years after VPM thalamotomy to treat a recurrent facial pain. Stereotact Funct Neurosurg 94(2): 118-122.
  28. Williams HPS, Javed S, Pickering AE, Patel NK (2016) Characterizing the analgesic effect of different targets for deep brain stimulation in trigeminal anaesthesia dolorosa. Stereotact Funct Neurosurg 94(3): 174-181.
  29. Hollingworth M, Williams HPS, Pickering AE, Barua N, Patel NK (2017) Single electrode deep brain stimulation with dual targeting at dual frequency for the treatment of chronic pain: A Case Series and Review Of The Literature. Brain Sci 7(1): 9.
  30. Haim SB, Mirzadeh Z, Rosenberg WS (2018) Deep brain stimulation for intractable neuropathic facial pain. Neurosurg Focus 45(2): E15.
  31. Kashanian A, Cesare JATD, Rohatgi P, Albano L, Krahl SE, et al. (2020) Case series: Deep brain stimulation for facial pain. Oper Neurosurg 19(5): 510-517.
  32. Abdallat M, Saryyeva A, Blahak C, Wolf ME, Weigel R, et al. (2021) Centromedian-parafascicular and somatosensory thalamic deep brain stimulation for treatment of chronic neuropathic pain: A contemporary series of 40 patients. Biomedecines 9(7): 731.
  33. Saway BF, Webb T, Weber A, Triano M, Barley J, et al. (2023) Functional MRI-guided motor cortex and deep brain stimulation for intractable facial pain: A novel, personalized approach in 1 patient. Operative Neurosurgery 24(1): 103-110.
  34. Mandat V, Zdunek PR, Krolicki B, Szalecki K, Koziara HM, et al. (2023) Periaqueductal/periventricular gray deep brain stimulation for the treatment of neuropathic facial pain. Frot Neurol 14: 1239092.
  35. Burchiel KJ (2003) A new classification for facial pain. Neurosurgery 53(5): 1164-1167.
  36. Manzoni GC, Torelli P (2005) Epidemiology of typical and atypical craniofacial neuralgias. Nerol Sci 26 (suppl 2): s65-s67.
  37. Adams JE, Hosobuchi Y, Fields HL (1974) Stimulation of internal capsule for relief of chronic pain. J Neurosurg 41(6): 740-744.
  38. Hosobuchi Y, Adams JE, Rutkin B (1973) Chronic thalamic stimulation of the control of facial anesthesia dolorosa. Arch Neurol 29(3): 158-161.
  39. Dostrovsky JO, Lozano AM (2002) Mechanisms of deep brain stimulation. Mov Disord 17 (Suppl 3): S63-S68.
  40. Gybels J (2001) Thalamic stimulation in neuropathic pain: 27 years later. Acta Neurol Belg 101(1): 65-71.
  41. Weigel R, Krauss JK (2004) Center median-parafascicular complex and pain control. Review from a neurosurgical perspective. Stereotact Funct Neurosurg 82(2-3): 115-126.
  42. Qassim H, Zhao Y, Strobel A, Regensburger M, Buchfelder M, et al. (2023) Deep brain stimulation for chronic facial pain: An Individual Participant Data (IPD) meta-analysis. Brain Sci 13(3): 492.
  43. Schwedt TJ, Tassorelli C, Silberstein SD, Szperka CL, Kurth T, et al. (2022) Guidelines of the international headcahe society for clinic-based headache registries, 1st (edn), Cephalalgia 42(11-12): 1099-1115.
  44. Nova CV, Riordain RN, Baker SR, Zakrzewska JM (2023) An international delphi survey and consensus meeting to define the core outcome set for trigeminal neuralgia trials. Eur J Pain 27(1): 86-98.
  45. Burns PB, Rohrich RJ, Chung KC (2011) The level of evidence and their role in evidence-based medicine. Plast Reconstr Surg 128(1): 305-310.

© 2024 Serge Rasskazoff. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.

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