Neuromodulative Pain Therapy
The term "neuromodulative pain therapy" is used to describe a range of minimally invasive neurosurgical techniques that involve the stimulation of nerve cells to achieve pain suppression or altered pain perception.
These techniques are a supplement, and sometimes an alternative, to drug-based pain therapies. Typical areas of application are so-called "neuropathic pain". This is pain caused by damage to nerve tissue. Such pain can occur after nerve damage in accidents, after operations, but also in advanced diabetes mellitus, multiple sclerosis or CRPS ( complex regional pain syndrome / Sudeck's disease). Similarly, neuromodulative techniques are used for mixed pain syndromes. This includes pain after multiple spinal interventions (failed back surgery syndrome), when a mechanically correctable cause has been ruled out or further surgical intervention is deemed unreasonably risky.
Neuromodulatory techniques primarily include epidural spinal cord stimulation ( SCS , Spinal Cord Stimulation) , posterior root ganglion stimulation ( DRG , Dorsal Root Ganglion Stimulation), subcutaneous field stimulation, and peripheral nerve stimulation.
Common to all techniques is the use of small electrodes in conjunction with a pulse generator implanted in the subcutaneous fatty tissue, similar to a pacemaker.
Epidural spinal cord stimulation represents the most commonly used form of therapy.
Depending on the pain syndrome, one or more electrodes are placed on the spinal cord via a hollow needle and light electrical currents are delivered. A number of different stimulation methods allow adaptation to the individual patient. All neuropathic forms of pain below the head are suitable. Before deciding on a permanent therapy, a so-called test stimulation is usually performed to understand whether satisfactory pain relief can be achieved for the individual patient. The exact neuronal mechanisms are still the subject of research at the Clinic for Stereotactic Neurosurgery.
Root ganglion stimulation (DRG) is based on similar principles as spinal cord stimulation (SCS), but is more suitable for sharply circumscribed pain syndromes. A typical application is pain following inguinal hernia surgery. Complex regional pain syndromes or strictly monoradicular pain after intervertebral disc surgery can also benefit from this form of treatment..
Occipital nerve stimulation (ONS) is suitable for alleviating certain chronic forms of headache (cluster headache, trigeminal autonomic headache, occipital neuralgia ).
Different forms of neuromodulation, e.g. stimulation of the 1st and 2nd branch of the facial nerve (peripheral nerve stimulation), can be used in the context of post-zoster neuralgia, or in trigeminal neuropathy.
Subcutaneous field stimulation is used for the treatment of circumscribed pain zones, e.g. scar pain after surgery (e.g.: post -thoracotomy pain ).
In rare cases, e.g. in so-called central pain syndromes (e.g. pain after strokes), deep brain stimulation can be considered. Testing of this stimulation is recommended in principle before permanent use.
Motor cortex stimulation is another technique, especially if other methods are unsuccessful. A flat electrode is attached over the so-called motor cortex (the representation of movement control on the surface of the brain) and, similar to deep brain stimulation, is initially treated with an external pulse generator. If the test stimulation is successful, the stimulation system is permanently attached.
Which neuromodulatory technique is used for the individual patient should be determined by an expert appropriately familiar with all techniques. Factors such as pain type, age of the patient, handling of the controls, MRI approval, comfort of wearing and programming, as well as the possibility of using different forms of stimulation, all come into play..
Unlike drug therapies, neuromodulation is not known to have any organ-damaging side effects. This advantage is particularly important because many chronic pain disorders are lifelong complaints, so that organ-sparing procedures are to be aimed for therapeutically. On the other hand, the risks of a surgical intervention are low. A reduction in medication is possible in many cases, but is not the primary goal. The latter consists in the desired improvement of the general quality of life through pain relief. The pain-relieving effects of neuromodulative procedures are based on different mechanisms of action than those of drug therapies. Neuromodulation thus represents a meaningful and evidence-based extension of pain therapy measures.