Deep brain stimulation of the posterior limb of the internal capsule in the treatment of central poststroke neuropathic pain of the lower limb: case series with long-term follow-up and literature review

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OBJECTIVE

Central poststroke neuropathic pain is a debilitating syndrome that is often resistant to medical therapies. Surgical measures include motor cortex stimulation and deep brain stimulation (DBS), which have been used to relieve pain. The aim of this study was to retrospectively assess the safety and long-term efficacy of DBS of the posterior limb of the internal capsule for relieving central poststroke neuropathic pain and associated spasticity affecting the lower limb.

METHODS

Clinical and surgical data were retrospectively collected and analyzed in all patients who had undergone DBS of the posterior limb of the internal capsule to address central poststroke neuropathic pain refractory to conservative measures. In addition, long-term pain intensity and level of satisfaction gained from stimulation were assessed. Pain was evaluated using the visual analog scale (VAS). Information on gait improvement was obtained from medical records, neurological examination, and interview.

RESULTS

Four patients have undergone the procedure since 2001. No mortality or morbidity related to the surgery was recorded. In three patients, stimulation of the posterior limb of the internal capsule resulted in long-term pain relief; in a fourth patient, the procedure failed to produce any long-lasting positive effect. Two patients obtained a reduction in spasticity and improved motor capability. Before surgery, the mean VAS score was 9 (range 8–10). In the immediate postoperative period and within 1 week after the DBS system had been turned on, the mean VAS score was significantly lower at a mean of 3 (range 0–6). After a mean follow-up of 5.88 years, the mean VAS score was still reduced at 5.5 (range 3–8). The mean percentage of long-term pain reduction was 38.13%.

CONCLUSIONS

This series suggests that stimulation of the posterior limb of the internal capsule is safe and effective in treating patients with chronic neuropathic pain affecting the lower limb. The procedure may be a more targeted treatment method than motor cortex stimulation or other neuromodulation techniques in the subset of patients whose pain and spasticity are referred to the lower limbs.

ABBREVIATIONS CPSP = central poststroke neuropathic pain; DBS = deep brain stimulation; MCS = motor cortex stimulation; PLIC = posterior limb of the internal capsule; ST = sensory thalamus; VAS = visual analog scale.

Article Information

Correspondence Andrea Franzini: University of Virginia Health System, Charlottesville, VA. andrea.franzini1@hotmail.it.

INCLUDE WHEN CITING Published online August 16, 2019; DOI: 10.3171/2019.5.JNS19227.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    The lead electrode is positioned at the border between the lateral part of the thalamic somatosensory nucleus (ventral posterolateral nucleus [VPL], where the inferior limb is somatotopically represented) and the PLIC. This schematic shows the electrical field (pale gray ellipse) generated by the DBS electrode. This field includes the sensory nuclei of the thalamus (ventroposteromedial [VPM] and ventroposterolateral [VPL] thalamic nuclei) and the PLIC fibers, which modulate the H-reflex at the spinal cord level and mediate pain relief. AcPc = anterior commissure–posterior commissure; Cl = internal capsule; Cm = thalamic centromedian nucleus; Ret = thalamic reticular nucleus. Adapted by permission from Springer Nature Customer Service Centre GmbH: Springer Nature, Textbook of Stereotactic and Functional Neurosurgery by Lozano AM, Gildenberg PL, Tasker RR (eds), ©Springer-Verlag Berlin Heidelberg, 2009. https://link.springer.com/referenceworkentry/10.1007%2F978-3-540-69960-6_77.

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    Case 2. Axial (A), coronal (B), and sagittal (C) T1-weighted MR images showing the artifact of the DBS electrode in the PLIC.

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    Case 3. Preoperative axial T1-weighted MR image showing the location of the stroke (arrow) in the left thalamus.

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    A: Case 2. Postoperative axial T1-weighted MR image showing an artifact of the lead electrode in the PLIC. B: Case 3. Preoperative axial T2-weighted image overlaid with the postoperative CT scan, which shows the position of the lead electrode at the border between the sensory lateral thalamus and the PLIC. C: Case 4. Preoperative axial T1-weighted MR image overlaid with the postoperative CT scan, which again shows the position of the lead electrode at the border between the sensory lateral thalamus and the PLIC.

  • View in gallery

    Chart showing each patient’s pain intensity, as measured with the VAS, in a preoperative period (T1), immediately after the stimulator had been turned on (T2), and at a long-term follow-up (T3). Figure is available in color online only.

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