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Mehnert J, Tinnermann A, Basedau H, May A. Functional representation of trigeminal nociceptive input in the human periaqueductal gray. SCIENCE ADVANCES 2024; 10:eadj8213. [PMID: 38507498 PMCID: PMC10954197 DOI: 10.1126/sciadv.adj8213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 02/13/2024] [Indexed: 03/22/2024]
Abstract
The periaqueductal gray (PAG) is located in the mesencephalon in the upper brainstem and, as part of the descending pain modulation, is considered a crucial structure for pain control. Its modulatory effect on painful sensation is often seen as a systemic function affecting the whole body similarly. However, recent animal data suggest some kind of somatotopy in the PAG. This would make the PAG capable of dermatome-specific analgesic function. We electrically stimulated the three peripheral dermatomes of the trigemino-cervical complex and the greater occipital nerve in 61 humans during optimized brainstem functional magnetic resonance imaging. We provide evidence for a fine-grained and highly specific somatotopic representation of nociceptive input in the PAG in humans and a functional connectivity between the individual representations of the peripheral nerves in the PAG and the brainstem nuclei of these nerves. Our data suggest that the downstream antinociceptive properties of the PAG may be rather specific down to the level of individual dermatomes.
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Affiliation(s)
| | | | - Hauke Basedau
- Department of Systems Neuroscience, University Medical Center Eppendorf, 20146 Hamburg, Germany
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2
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Qassim H, Zhao Y, Ströbel A, Regensburger M, Buchfelder M, de Oliveira DS, Del Vecchio A, Kinfe T. Deep Brain Stimulation for Chronic Facial Pain: An Individual Participant Data (IPD) Meta-Analysis. Brain Sci 2023; 13:brainsci13030492. [PMID: 36979302 PMCID: PMC10046035 DOI: 10.3390/brainsci13030492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/27/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Despite available, advanced pharmacological and behavioral therapies, refractory chronic facial pain of different origins still poses a therapeutic challenge. In circumstances where there is insufficient responsiveness to pharmacological/behavioral therapies, deep brain stimulation should be considered as a potential effective treatment option. We performed an individual participant data (IPD) meta-analysis including searches on PubMed, Embase, and the Cochrane Library (2000–2022). The primary endpoint was the change in pain intensity (visual analogue scale; VAS) at a defined time-point of ≤3 months post-DBS. In addition, correlation and regression analyses were performed to identify predictive markers (age, duration of pain, frequency, amplitude, intensity, contact configuration, and the DBS target). A total of seven trials consisting of 54 screened patients met the inclusion criteria. DBS significantly reduced the pain levels after 3 months without being related to a specific DBS target, age, contact configuration, stimulation intensity, frequency, amplitude, or chronic pain duration. Adverse events were an infection or lead fracture (19%), stimulation-induced side effects (7%), and three deaths (unrelated to DBS—from cancer progression or a second stroke). Although comparable long-term data are lacking, the current published data indicate that DBS (thalamic and PVG/PAG) effectively suppresses facial pain in the short-term. However, the low-quality evidence, reporting bias, and placebo effects must be considered in future randomized-controlled DBS trials for facial pain.
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Affiliation(s)
- Hebatallah Qassim
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Yining Zhao
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Armin Ströbel
- Center for Clinical Studies (CCS), Medical Faculty, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Martin Regensburger
- Division of Molecular Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Daniela Souza de Oliveira
- Department of Artificial Intelligence in Biomedical Engineering (AIBE), Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Alessandro Del Vecchio
- Department of Artificial Intelligence in Biomedical Engineering (AIBE), Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Thomas Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, 91054 Erlangen, Germany
- Correspondence:
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Szikszay TM, Lévénez JLM, Adamczyk WM, Carvalho GF, Luedtke K. Offset analgesia is increased intra-orally. J Oral Rehabil 2022; 49:993-1001. [PMID: 35841379 DOI: 10.1111/joor.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/27/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Offset analgesia (OA) is commonly used to quantify endogenous pain inhibition. However, the potential role of afferent inputs and the subsequent peripheral factors from different body areas on the underlying mechanisms are still unclear. OBJECTIVES The aim of this cross-sectional study was to compare the magnitude of OA in four different body areas representing a) glabrous and non-glabrous skin, b) trigeminal and extra-trigeminal areas, and c) intra- and extra-oral tissue. METHODS OA was assessed at the oral mucosa of the lower lip, at the skin of the cheek, the forearm and the palm of the hand in 32 healthy and pain-free participants. OA testing included two trials: (1) a constant trial (30 seconds of constant heat stimulation at an individualized temperature of Pain50 (pain intensity of 50 out of 100)), and (2) an offset trial (10 seconds of individualized Pain50 , followed by 5 seconds at Pain50 +1°C and 15 seconds at Pain50 ). Participants continuously rated their pain during each trial with a computerized visual analog scale. RESULTS A significant OA response was recorded at the oral mucosa (p<0.001, d=1.24), the cheek (p<0.001, d=0.84) and the forearm (p<0.001, d=1.04), but not at the palm (p=0.19, d=0.24). Significant differences were shown for OA recorded at the cheek versus the mucosa (p=0.02), and between palm and mucosa (p=0.007), but not between the remaining areas (p>0.05). CONCLUSION This study suggests that intra-oral endogenous pain inhibition assessed with OA is enhanced and supports the role of peripheral mechanisms contributing to the OA response.
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Affiliation(s)
- T M Szikszay
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
| | - J L M Lévénez
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
| | - W M Adamczyk
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany.,Laboratory of Pain Research, Institute of Physiotherapy and Health Sciences, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - G F Carvalho
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
| | - K Luedtke
- Institute of Health Sciences, Department of Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), Universität zu Lübeck, Lübeck, Germany
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4
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Deep Brain Stimulation for Chronic Pain. Neurosurg Clin N Am 2022; 33:311-321. [DOI: 10.1016/j.nec.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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5
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Ben-Haim S, Mirzadeh Z, Rosenberg WS. Deep brain stimulation for intractable neuropathic facial pain. Neurosurg Focus 2019; 45:E15. [PMID: 30064325 DOI: 10.3171/2018.5.focus18160] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is a well-established, evidence-based therapy with FDA approval for Parkinson's disease and essential tremor. Despite the early successful use of DBS to target the sensory thalamus for intractable facial pain, subsequent studies pursuing various chronic pain syndromes reported variable efficacy, keeping DBS for pain as an investigational and "off-label" use. The authors report promising results for a contemporary series of patients with intractable facial pain who were treated with DBS. METHODS Pain outcomes for 7 consecutive patients with unilateral, intractable facial pain undergoing DBS of the ventral posteromedial nucleus of the thalamus (VPM) and the periaqueductal gray (PAG) were retrospectively reviewed. Pain was assessed preoperatively and at multiple postoperative time points using the visual analog scale (VAS), the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2), and the Pain Disability Index (PDI). RESULTS VAS scores significantly decreased from a mean ± SD of 9.0 ± 1.3 preoperatively to 2.6 ± 1.5 at 1 year postoperatively (p = 0.001). PDI scores decreased from a mean total of 48.5 to 28.5 (p = 0.01). SF-MPQ-2 scores decreased from a mean of 4.6 to 2.4 (p = 0.03). Notably, several patients did not experience maximum improvement until 6-9 months postoperatively, correlating with repeated programming adjustments. CONCLUSIONS DBS of the VPM and PAG is a potential therapeutic option for patients suffering from severe, intractable facial pain refractory to other interventions. Improved efficacy may be observed over time with close follow-up and active DBS programming adjustments.
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Affiliation(s)
- Sharona Ben-Haim
- 1Department of Neurosurgery, University of California, San Diego, California
| | - Zaman Mirzadeh
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
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Kuehn E, Dinse J, Jakobsen E, Long X, Schäfer A, Bazin PL, Villringer A, Sereno MI, Margulies DS. Body Topography Parcellates Human Sensory and Motor Cortex. Cereb Cortex 2018; 27:3790-3805. [PMID: 28184419 PMCID: PMC6248394 DOI: 10.1093/cercor/bhx026] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Indexed: 12/25/2022] Open
Abstract
The cytoarchitectonic map as proposed by Brodmann currently dominates models of human sensorimotor cortical structure, function, and plasticity. According to this model, primary motor cortex, area 4, and primary somatosensory cortex, area 3b, are homogenous areas, with the major division lying between the two. Accumulating empirical and theoretical evidence, however, has begun to question the validity of the Brodmann map for various cortical areas. Here, we combined in vivo cortical myelin mapping with functional connectivity analyses and topographic mapping techniques to reassess the validity of the Brodmann map in human primary sensorimotor cortex. We provide empirical evidence that area 4 and area 3b are not homogenous, but are subdivided into distinct cortical fields, each representing a major body part (the hand and the face). Myelin reductions at the hand-face borders are cortical layer-specific, and coincide with intrinsic functional connectivity borders as defined using large-scale resting state analyses. Our data extend the Brodmann model in human sensorimotor cortex and suggest that body parts are an important organizing principle, similar to the distinction between sensory and motor processing.
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Affiliation(s)
- Esther Kuehn
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig 04103, Germany.,Department of Psychology and Language Sciences, University College London, London WC1H 0DG, UK.,Center for Behavioral Brain Sciences Magdeburg, Magdeburg 39106, Germany.,Aging and Cognition Research Group, DZNE, Magdeburg 39106, Germany
| | - Juliane Dinse
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig 04103, Germany.,Faculty of Computer Science, Otto-von-Guericke University, Magdeburg 39106, Germany
| | - Estrid Jakobsen
- Max Planck Research Group for Neuroanatomy & Connectivity, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig04103, Germany
| | - Xiangyu Long
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig04103, Germany
| | - Andreas Schäfer
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig04103, Germany
| | - Pierre-Louis Bazin
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig 04103, Germany.,Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig 04103, Germany
| | - Arno Villringer
- Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig04103, Germany
| | - Martin I Sereno
- Department of Psychology and Language Sciences, University College London, LondonWC1H 0DG, UK
| | - Daniel S Margulies
- Max Planck Research Group for Neuroanatomy & Connectivity, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig04103, Germany
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Surgical Neurostimulation for Spinal Cord Injury. Brain Sci 2017; 7:brainsci7020018. [PMID: 28208601 PMCID: PMC5332961 DOI: 10.3390/brainsci7020018] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 01/07/2023] Open
Abstract
Traumatic spinal cord injury (SCI) is a devastating neurological condition characterized by a constellation of symptoms including paralysis, paraesthesia, pain, cardiovascular, bladder, bowel and sexual dysfunction. Current treatment for SCI involves acute resuscitation, aggressive rehabilitation and symptomatic treatment for complications. Despite the progress in scientific understanding, regenerative therapies are lacking. In this review, we outline the current state and future potential of invasive and non-invasive neuromodulation strategies including deep brain stimulation (DBS), spinal cord stimulation (SCS), motor cortex stimulation (MCS), transcutaneous direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in the context of SCI. We consider the ability of these therapies to address pain, sensorimotor symptoms and autonomic dysregulation associated with SCI. In addition to the potential to make important contributions to SCI treatment, neuromodulation has the added ability to contribute to our understanding of spinal cord neurobiology and the pathophysiology of SCI.
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Barbaresi P, Mensà E. Connections from the rat dorsal column nuclei (DCN) to the periaqueductal gray matter (PAG). Neurosci Res 2016; 109:35-47. [PMID: 26902642 DOI: 10.1016/j.neures.2016.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 11/30/2022]
Abstract
Electrical stimulation of the dorsal columns (DCs; spinal cord stimulation; SCS) has been proposed to treat chronic neuropathic pain. SCS may activate a dual mechanism that would affect both the spinal cord and supraspinal levels. Stimulation of DCs or DC nuclei (DCN) in animals where neuropathic pain has been induced causes activation of brainstem centers including the periaqueductal gray (PAG), which is involved in the endogenous pain suppression system. Biotinylated dextran-amine (BDA) was iontophoretically injected into the DCN to analyze the ascending projection directed to the PAG. Separate injections into the gracile nucleus (GrN) and the cuneate nucleus (CunN) showed BDA-positive fibers terminating in different regions of the contralateral PAG. GrN-PAG afferents terminated in the caudal and middle portions of PAG-l, whereas CunN-PAG fibers terminated in the middle and rostral portions of PAG-l. Based on the DCN somatotopic map, the GrN sends information to the PAG from the contralateral hindlimb and the tail and the CunN from the contralateral forelimb, shoulder, neck and ear. This somatotopic organization is consistent with earlier electrophysiological and PAG stimulation studies. These fibers could form part of the DCs-brainstem-spinal cord loop, which may be involved in the inhibitory effects of SCS on neuropathic pain.
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Affiliation(s)
- Paolo Barbaresi
- Department of Experimental and Clinical Medicine, Section of Neuroscience and Cell Biology, Marche Polytechnic University, Via Tronto 10/A, Torrette di Ancona, I-60020 Ancona, Italy.
| | - Emanuela Mensà
- Department of Experimental and Clinical Medicine, Section of Neuroscience and Cell Biology, Marche Polytechnic University, Via Tronto 10/A, Torrette di Ancona, I-60020 Ancona, Italy
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Coulombe MA, Erpelding N, Kucyi A, Davis KD. Intrinsic functional connectivity of periaqueductal gray subregions in humans. Hum Brain Mapp 2016; 37:1514-30. [PMID: 26821847 DOI: 10.1002/hbm.23117] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 12/08/2015] [Accepted: 01/03/2016] [Indexed: 12/19/2022] Open
Abstract
The periaqueductal gray matter (PAG) is a key brain region of the descending pain modulation pathway. It is also involved in cardiovascular functions, anxiety, and fear; however, little is known about PAG subdivisions in humans. The aims of this study were to use resting-state fMRI-based functional connectivity (FC) to parcellate the human PAG and to determine FC of its subregions. To do this, we acquired resting-state fMRI scans from 79 healthy subjects and (1) used a data-driven method to parcellate the PAG, (2) used predefined seeds in PAG subregions to evaluate PAG FC to the whole brain, and (3) examined sex differences in PAG FC. We found that clustering of the left and right PAG yielded similar patterns of caudal, middle, and rostral subdivisions in the coronal plane, and dorsal and ventral subdivisions in the sagittal plane. FC analysis of predefined subregions revealed that the ventolateral(VL)-PAG was supfunctionally connected to brain regions associated with descending pain modulation (anterior cingulate cortex (ACC), upper pons/medulla), whereas the lateral (L) and dorsolateral (DL) subregions were connected with brain regions implicated in executive functions (prefrontal cortex, striatum, hippocampus). We also found sex differences in FC including areas implicated in pain, salience, and analgesia including the ACC and the insula in women, and the MCC, parahippocampal gyrus, and the temporal pole in men. The organization of the human PAG thus provides a framework to understand the circuitry underlying the broad range of responses to pain and its modulation in men and women.
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Affiliation(s)
- Marie-Andree Coulombe
- Division of Brain, Imaging & Behaviour Systems, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Nathalie Erpelding
- Division of Brain, Imaging & Behaviour Systems, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Aaron Kucyi
- Division of Brain, Imaging & Behaviour Systems, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Canada.,Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Karen Deborah Davis
- Division of Brain, Imaging & Behaviour Systems, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Canada.,Institute of Medical Science, University of Toronto, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
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10
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Boccard SGJ, Fernandes HM, Jbabdi S, Van Hartevelt TJ, Kringelbach ML, Quaghebeur G, Moir L, Mancebo VP, Pereira EAC, Fitzgerald JJ, Green AL, Stein J, Aziz TZ. Tractography Study of Deep Brain Stimulation of the Anterior Cingulate Cortex in Chronic Pain: Key to Improve the Targeting. World Neurosurg 2015; 86:361-70.e1-3. [PMID: 26344354 DOI: 10.1016/j.wneu.2015.08.065] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the anterior cingulate cortex (ACC) is a new treatment for alleviating intractable neuropathic pain. However, it fails to help some patients. The large size of the ACC and the intersubject variability make it difficult to determine the optimal site to position DBS electrodes. The aim of this work was therefore to compare the ACC connectivity of patients with successful versus unsuccessful DBS outcomes to help guide future electrode placement. METHODS Diffusion magnetic resonance imaging (dMRI) and probabilistic tractography were performed preoperatively in 8 chronic pain patients (age 53.4 ± 6.1 years, 2 females) with ACC DBS, of whom 6 had successful (SO) and 2 unsuccessful outcomes (UOs) during a period of trialing. RESULTS The number of patients was too small to demonstrate any statistically significant differences. Nevertheless, we observed differences between patients with successful and unsuccessful outcomes in the fiber tract projections emanating from the volume of activated tissue around the electrodes. A strong connectivity to the precuneus area seems to predict unsuccessful outcomes in our patients (UO: 160n/SO: 27n), with (n), the number of streamlines per nonzero voxel. On the other hand, connectivity to the thalamus and brainstem through the medial forebrain bundle (MFB) was only observed in SO patients. CONCLUSIONS These findings could help improve presurgical planning by optimizing electrode placement, to selectively target the tracts that help to relieve patients' pain and to avoid those leading to unwanted effects.
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Affiliation(s)
- Sandra G J Boccard
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom.
| | - Henrique M Fernandes
- Department of Psychiatry, University of Oxford, United Kingdom; CFIN/MindLab, Aarhus University, Aarhus, Denmark
| | - Saad Jbabdi
- Centre for Functional MRI of the Brain (FMRIB), University of Oxford, United Kingdom
| | - Tim J Van Hartevelt
- Department of Psychiatry, University of Oxford, United Kingdom; CFIN/MindLab, Aarhus University, Aarhus, Denmark
| | - Morten L Kringelbach
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom; Department of Psychiatry, University of Oxford, United Kingdom; CFIN/MindLab, Aarhus University, Aarhus, Denmark
| | | | - Liz Moir
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - Victor Piqueras Mancebo
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - James J Fitzgerald
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - Alexander L Green
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
| | - John Stein
- Department of Physiology, Anatomy, & Genetics, University of Oxford, United Kingdom
| | - Tipu Z Aziz
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery, University of Oxford, United Kingdom
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Boccard SGJ, Pereira EAC, Aziz TZ. Deep brain stimulation for chronic pain. J Clin Neurosci 2015; 22:1537-43. [PMID: 26122383 DOI: 10.1016/j.jocn.2015.04.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/11/2015] [Indexed: 11/29/2022]
Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention popularised in movement disorders such as Parkinson's disease, and also reported to improve symptoms of epilepsy, Tourette's syndrome, obsessive compulsive disorders and cluster headache. Since the 1950s, DBS has been used as a treatment to relieve intractable pain of several aetiologies including post stroke pain, phantom limb pain, facial pain and brachial plexus avulsion. Several patient series have shown benefits in stimulating various brain areas, including the sensory thalamus (ventral posterior lateral and medial), the periaqueductal and periventricular grey, or, more recently, the anterior cingulate cortex. However, this technique remains "off label" in the USA as it does not have Federal Drug Administration approval. Consequently, only a small number of surgeons report DBS for pain using current technology and techniques and few regions approve it. Randomised, blinded and controlled clinical trials that may use novel trial methodologies are desirable to evaluate the efficacy of DBS in patients who are refractory to other therapies. New imaging techniques, including tractography, may help optimise electrode placement and clinical outcome.
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Affiliation(s)
- Sandra G J Boccard
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
| | - Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Tipu Z Aziz
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, Level 6, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
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12
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Jerath R, Crawford MW, Jensen M. Etiology of phantom limb syndrome: Insights from a 3D default space consciousness model. Med Hypotheses 2015; 85:153-9. [PMID: 26003829 DOI: 10.1016/j.mehy.2015.04.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 04/15/2015] [Accepted: 04/23/2015] [Indexed: 11/18/2022]
Abstract
In this article, we examine phantom limb syndrome to gain insights into how the brain functions as the mind and how consciousness arises. We further explore our previously proposed consciousness model in which consciousness and body schema arise when information from throughout the body is processed by corticothalamic feedback loops and integrated by the thalamus. The parietal lobe spatially maps visual and non-visual information and the thalamus integrates and recreates this processed sensory information within a three-dimensional space termed the "3D default space." We propose that phantom limb syndrome and phantom limb pain arise when the afferent signaling from the amputated limb is lost but the neural circuits remain intact. In addition, integration of conflicting sensory information within the default 3D space and the loss of inhibitory afferent feedback to efferent motor activity from the amputated limb may underlie phantom limb pain.
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Affiliation(s)
| | | | - Mike Jensen
- Graduate Program in Medical Illustration, Georgia Regents University, Augusta, GA, USA
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13
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Pereira EAC, Boccard SG, Aziz TZ. Deep brain stimulation for pain: distinguishing dorsolateral somesthetic and ventromedial affective targets. Neurosurgery 2015; 61 Suppl 1:175-81. [PMID: 25032548 DOI: 10.1227/neu.0000000000000397] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Erlick A C Pereira
- *Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, United Kingdom; ‡Department of Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Portugal
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Abstract
Deep brain stimulation (DBS) is a neurosurgical intervention the efficacy, safety, and utility of which are established in the treatment of Parkinson's disease. For the treatment of chronic, neuropathic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated with current standards of neuroimaging and stimulator technology over the last decade . We summarize the history, science, selection, assessment, surgery, programming, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and latterly rostral anterior cingulate cortex (Cg24) in 113 patients treated at 2 centers (John Radcliffe, Oxford, UK, and Hospital de São João, Porto, Portugal) over 13 years. Several experienced centers continue DBS for chronic pain, with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS under general anesthesia considered for whole or hemibody pain, or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Department of Neurological Surgery and Nuffield Department of Surgical Sciences, Oxford University, John Radcliffe Hospital, Oxford, OX3 9DU, UK,
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