neurologic disorders
Treatment of Pain
Neuromodulation
Stimulation of neural tissues may decrease pain, presumably by activating endogenous pain modulatory pathways. Evidence supports treatment of certain types of Neuropathic Pain (eg, failed back surgery syndrome with chronic leg pain after spine surgery, Electrical stimulation (TENS) uses low current at low-frequency oscillation to help manage pain. Advances in electrical stimulation paradigms have improved the efficacy and applicability of neuromodulation techniques. Use of neuromodulation techniques in pain management has increased significantly. With the shift to limit use of opioids for nonterminal pain, neuromodulation techniques are now considered earlier as treatment options for neuropathic pain. Advances in neuromodulation techniques and technologies include High-frequency stimulation Dorsal root ganglion stimulation Burst spinal cord stimulation waveforms Small flexible peripheral nerve stimulators Improved MRI compatibility, which has greatly expanded the clinical situations in which neuromodulation can be used High-frequency stimulation is efficacious for neuropathic limb pain. Efficacy is similar to that of traditional neuromodulation techniques, but evidence suggests that it may also be efficacious for axial spine pain, which is not effectively treated with traditional neuromodulation techniques. Dorsal root ganglion stimulation is a more focused neuromodulation treatment; it targets localized neuropathic pain within limited dermatomes. Peripheral nerve stimulation is being increasingly used to treat intractable neuropathic pain when a single peripheral nerve is involved (eg, postherniorrhaphy pain syndrome, some headache syndromes such as occipital neuralgia, meralgia paresthetica [pain in the outer part of the thigh due to compression of the lateral femoral cutaneous nerve]). It has also been used to stimulate branches of the axillary nerve to treat hemiplegic shoulder pain after stroke. Proof-of-concept studies have reported that peripheral nerve stimulation may be useful in treating postoperative pain during the first several weeks after total knee replacement, anterior cruciate ligament surgery, and foot surgery. Peripheral nerve stimulation involves inserting small, thin, flexible electrode leads percutaneously next to the affected nerve, often using ultrasound guidance. The leads are connected to a stimulator, which is fixed to the skin adjacent to the leads with a replaceable adhesive. Pain in certain areas cannot be treated with peripheral nerve stimulation because the stimulator would interfere with moving or sitting. Stimulation of brain structures (deep brain stimulation, motor cortex stimulation) has been used for refractory neuropathic pain syndromes, but evidence is limited. 