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Pre-Motor Versus Motor Cerebral Cortex Neuromodulation for Chronic

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Pre-Motor Versus Motor Cerebral Cortex Neuromodulation for Chronic www.nature.com/scientificreports OPEN Pre‑motor versus motor cerebral cortex neuromodulation for chronic neuropathic pain Igor Lavrov1,2,3,7*, Timur Latypov4,5, Elvira Mukhametova3, Brian Lundstrom1, Paola Sandroni1, Kendall Lee6, Bryan Klassen1 & Matt Stead1 Electrical stimulation of the cerebral cortex (ESCC) has been used to treat intractable neuropathic pain for nearly two decades, however, no standardized approach for this technique has been developed. In order to optimize targeting and validate the efect of ESCC before placing the permanent grid, we introduced initial assessment with trial stimulation, using a temporary grid of subdural electrodes. In this retrospective study we evaluate the role of electrode location on cerebral cortex in control of neuropathic pain and the role of trial stimulation in target‑optimization for ESCC. Location of the temporary grid electrodes and location of permanent electrodes were evaluated in correlation with the long‑term efcacy of ESCC. The results of this study demonstrate that the long‑term efect of subdural pre‑motor cortex stimulation is at least the same or higher compare to efect of subdural motor or combined pre‑motor and motor cortex stimulation. These results also demonstrate that the initial trial stimulation helps to optimize permanent electrode positions in relation to the optimal functional target that is critical in cases when brain shift is expected. Proposed methodology and novel results open a new direction for development of neuromodulation techniques to control chronic neuropathic pain. Chronic pain is clinically identifed as a disabling syndrome, which is relatively frequent across the general population, afecting 8% of adults in the United States, with an incidence of about 18 million people per year 1. Te International Association for the Study of Pain (IASP) defnes chronic pain as pain experienced every day for 3 months over a period of 6 months or longer 2. Chronic pain can be related to variety of medical conditions and commonly leads to a complex sensory and emotional experience with variety of features. Perception of chronic pain depends on the context and meaning of the pain, the physical, psychological, and psychosocial state of the patient3. Te management of patients with chronic pain is considered to be one of the most difcult challenges in medicine4. Various chronic pain syndromes, such as post-stroke pain, trigeminal neuralgia, or phantom limb pain are highly resistant to pharmacological treatment 4. Neuromodulation techniques have been increasingly used either as a substitute for surgical treatment or in addition to pharmacological therapy. Several condi- tions, such as essential tremor, Parkinson’s disease, dystonia, and psychiatric disorders have been successfully controlled with neuromodulation therapy5. Stimulation of brain structures for the treatment of chronic pain, however, have led to variable outcomes. Several trials reported successful neuromodulation of ventral posterior lateral nucleus (VC, Ventralis Caudalis) of thalamus, periventricular grey, and periaqueductal grey deep brain stimulation (DBS) with mean relief more than 50%6,7. Motor Cortex Stimulation (MCS) was introduced by Tsubokawa in 1991 as a treatment approach for patients with intractable pain, in response to growing frustration with inadequate DBS efcacy in this patient population 8. Initial studies revealed that in contrast to stimulation of the of primary sensory cortex, which increases pain, stimulation of the motor cortex causes suppression of neuropathic pain8,9. Later MCS was found to be efective for various types of neuropathic pain (NP), such as trigeminal neuralgia, peripheral neuropathy, neuropathic pain afer spinal cord injury (SCI), and others 10,11. Over the last decade MCS has emerge as a promising alternative to pharmacological therapy and for patients with drug-resistant chronic pain syndromes5,12. Interestingly, until now, no standardized approach for MCS has been formed and there is no consensus regarding the surgical technique, electrode array implantation site, and 1Department of Neurology, Mayo Clinic, Rochester, MN, USA. 2Department of Biomedical Engineering, Mayo Clinic, Rochester, MN, USA. 3Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia. 4Division of Brain, Imaging, and Behaviour Systems Neuroscience, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada. 5Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada. 6Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA. 7Skolkovo Institute of Science and Technology, Moscow, Russia. *email: [email protected] Scientifc Reports | (2021) 11:12688 | https://doi.org/10.1038/s41598-021-91872-2 1 Vol.:(0123456789) www.nature.com/scientificreports/ Subject number Age Sex Main Diagnosis Coexisting diagnosis Pain duration (years) Medications Stroke, hyperlipidemia, history of Central post-stroke syndrome afecting depression and anxiety, obesity, Clonazepam, dronabinol, gabapentin, 1 66 m 15 lef arm and leg orthostatic hypotension, impaired venlafaxine fasting glucose Phantom limb pain (lef upper extrem- Amitriptyline, gabapentin, DREZ 2 45 m 5 ity) surgery 3 83 m Phantom pain (lef upper extremity) 58 Gabapentin, duloxetine, amitriptyline Lef facial pain with a anesthesia 4 61 m DM type 2, hypertension 21 Indomethacin, venlafaxine dolorosa and SUNCT 5 61 f Right upper facial pain 3.5 Hydrocodone, baclofen, gabapentin History of non-psychotic major Acetaminophen, lorazepam, oxcarbaz- 6 40 f Right trigeminal neuralgia V2,3 1.8 depression and anxiety, PTSD epine, promethazine Lef trigeminal neuralgia and subse- 7 55 f Anxiety secondary 3.3 Anastrozole, baclofen, diazepam quent anesthesia dolorosa Hydrocodone, cyclobenzaprine, lamo- 8 61 f Right trigeminal neuralgia 13.5 trigine, topiramate Chronic lef greater right lower face Oxycodone, gabapentin, lidocaine, 9 59 f Laminectomy and L4-5 fusion 2.5 and lef parietal scalp pain diclofenac, methadone Table 1. Summary of initial clinical fndings for patients in this study. DM diabetes mellitus, PTSD posttraumatic stress disorder, DREZ dorsal root entry zone. optimal stimulation parameters13. Te surgical technique, as well as target optimization varies between diferent centers with most of the institutions implanting epidural or subdural electrodes based on cortical anatomy or results of functional imaging. In order to identify cortical areas, which give the best clinical outcome with MCS and optimal initial stimulation settings, a trial stimulation was introduced at Mayo Clinic and was successfully used over last decade14,15. In this study we retrospectively evaluated the efect of ESCC in patients treated with the inclusion of a period of trial stimulation prior to permanent implant. Te electrode locations with correction for brain shif were correlated with clinical outcome. In all cases the temporary electrodes were placed in the subdural space for initial trial stimulation and, then, were replaced with permanent electrode arrays for subse- quent long-term stimulation. All procedures were performed of-label based on previously reported efcacy 14. Te outcome of motor and premotor cortex stimulation was analyzed and correlated with the position of the ‘most efective’ temporary electrode contacts and contacts on the permanent electrodes based on reconstruction of anatomical location. Results Medical records of nine subjects were acquired from Mayo Clinic database (Table 1) from patients who underwent cortical electrode implantation procedure to treat chronic pain (Fig. 1). Algorithm of the image processing and post-implantation brain shif correction described in meth- ods and outlined on Fig. 2. Trial stimulation. Retrospective review of programming records demonstrated that afer surgical implan- tation of the permanent grid, all subjects in this study (n = 9) reported a "honeymoon efect" with signifcant improvement in pain during the frst one to two days afer surgery without active stimulation. Because of ‘honey- moon efect’, trial stimulation was delayed until the pain level exceeded 5/10 on the Numeric Rating Scale (NRS). Parameters of stimulation (frequency, pulse width, and stimulation intensity) were adjusted individually during trail stimulation and permanent stimulation and varied depending on pain reduction and side-efects. Initial settings were: 40 Hz, 450 µsec, 0–4 V. In two cases, stimulation frequency was increased up to 100 Hz (subjects 4 and 9), when the initial settings did not improve pain. Trial stimulation was started on day 1 (n = 3), 2 (n = 1), 3 (n = 3), or day 4 (n = 1) afer temporary grid placement. In all subjects except one, the initial trial stimulation reduced the pain intensity in more than 50%, although one subject (subject 9) didn’t show reduction in pain and afer trial stimulation his pain level was 8/10, comparing with 9–10/10 at baseline before implantation. Te mean pain level by the end of the trial stimulation was 2.16 ± 2.39 (n = 9). Based on results of trial stimulation the areas of stimulation with the most efective pain control were identifed as a target for permanent grid place- ment (Fig. 1). Trial stimulation was also helpful in evaluation of potential side efects of ESCC, i.e. problems with speech, muscles spasm or twitches, focal seizures, and in some cases increased pain (Table 2). For all cases, the fnal target for implantation of permanent grid was adjusted based on results of the
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