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Targeting the Affective Component of Chronic Pain: A Case Series of Deep Brain Stimulation of the Anterior Cingulate Cortex

Boccard, Sandra G.J. PhD*,‡; Fitzgerald, James J. PhD*,‡; Pereira, Erlick A.C. MD; Moir, Liz RGN; Van Hartevelt, Tim J. MSc§; Kringelbach, Morten L. DPhil§; Green, Alexander L. MD; Aziz, Tipu Z. FMedSci

Neurosurgery:
doi: 10.1227/NEU.0000000000000321
Research-Human-Clinical Studies
Abstract

BACKGROUND: Deep brain stimulation (DBS) has shown considerable promise for relieving nociceptive and neuropathic symptoms of refractory chronic pain. Nevertheless, for some patients, standard DBS for pain remains poorly efficacious. Pain is a multidimensional experience with an affective component: the unpleasantness. The anterior cingulate cortex (ACC) is a structure involved in this affective component, and targeting it may relieve patients’ pain.

OBJECTIVE: To describe the first case series of ACC DBS to relieve the affective component of chronic neuropathic pain.

METHODS: Sixteen patients (13 male and 3 female patients) with neuropathic pain underwent bilateral ACC DBS. The mean age at surgery was 48.7 years (range, 33-63 years). Patient-reported outcome measures were collected before and after surgery using a Visual Analog Scale, SF-36 quality of life survey, McGill Pain Questionnaire, and EQ-5D (EQ-5D and EQ-5D Health State) questionnaires.

RESULTS: Fifteen patients (93.3%) transitioned from externalized to fully internalized systems. Eleven patients had data to be analyzed with a mean follow-up of 13.2 months. Post-surgery, the Visual Analog Scale score dropped below 4 for 5 of the patients, with 1 patient free of pain. Highly significant improvement on the EQ-5D was observed (mean, +20.3%; range, +0%-+83%; P = .008). Moreover, statistically significant improvements were observed for the physical functioning and bodily pain domains of the SF-36 quality-of-life survey: mean, +64.7% (range, −8.9%-+276%; P = .015) and mean +39.0% (range, −33.8%-+159%; P = .050), respectively.

CONCLUSION: Affective ACC DBS can relieve chronic neuropathic pain refractory to pharmacotherapy and restore quality of life.

ABBREVIATIONS: ACC, anterior cingulate cortex

DBS, deep brain stimulation

PAG, periventricular/periaqueductal gray area

VP, ventral posterior medial and lateral nuclei of the sensory thalamus

Author Information

Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Departments of Clinical Neuroscience and Surgery;

§Department of Psychiatry, University of Oxford, United Kingdom

Correspondence: Sandra G.J. Boccard-Binet, PhD, Department of Neurosurgery, Level 6, West Wing, John Radcliffe Hospital, Oxford, OX3 9DU, UK. E-mail: sandra.boccard@ndcn.ox.ac.uk

* These authors contributed to the manuscript equally.

Received September 17, 2013

Accepted February 02, 2014

Copyright © by the Congress of Neurological Surgeons