SciELO - Scientific Electronic Library Online

 
vol.54 issue1Digital EEG with brain mapping in Alzheimer's dementia and Parkinson's disease: a prospective controlled studyStereotactic surgery for intracranial lesions: diagnosis and treatment author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.54 no.1 São Paulo Mar. 1996

http://dx.doi.org/10.1590/S0004-282X1996000100010 

Risk factors for unpleasant paresthesiae induced by paresthesiae - producing deep brain stimulation

 

Fatores de risco para parestesia dolorosa induzida por estimulação cerebral profuda em sítios produtores de parestesia

 

 

Osvaldo Vilela Filho

M.D.;Director, Instituto do Cérebro, Instituto Ortopédico de Goiânia (INCER-IOG); Head, Division of Stereotactic and Functional Neurosurgery, INCER-IOG; Attending Neurosurgeon, Division of Neurosurgery, Hospital das Clínicas and Researcher, Department of Physiology and Pharmacology, Institute of Biological Sciences, Universidade Federal de Goiás; Ex-Fellow, Division of Neurosurgery, Toronto Hospital; Department of Surgery, University of Toronto. Paper prepared at the Division of Stereotactic and Functional Neurosurgery, INCER-IOG, Division of Neurosurgery, Hospital das Clínicas, Universidade Federal de Goiás and Division of Neurosurgery, Toronto Hospital, University of Toronto

 

 


ABSTRACT

Paresthesiae-producing deep brain stimulation (stimulation of ventrocaudal nucleus - VC, medial lemniscus - ML or internal capsule - IC) is one of the few procedures to treat the steady element of neural injury pain (NIP) currently available. Reviewing the first 60 patients with NIP submitted to deep brain stimulation (DBS) from 1978 to 1991 at the Division of Neurosurgery, Toronto Hospital, University of Toronto, we observed that 6 patients complained of unpleasant paresthesiae with paresthesiae-producing DBS, preventing permanent electrode implantation in all of them. Such patients accounted for 15% of the failures (6 out of 40 failures) in our series. In an attempt to improve patient selection, we reviewed our patients considering a number of parameters in order to determine risk factors for unpleasant paresthesiae elicited by paresthesiae-producing DBS. The results showed that this response happenned only in patients with brain central pain complaining of evoked pain, secondary to a supratentorial lesion. Age, sex, duration of pain, quality of the steady pain, size of the causative lesion and site (VC,ML,IC) and type (micro or macroelectrode) of surgical exploration were not important factors. Unpleasant paresthesiae in response to dorsal column stimulation, restricted thalamic lesion on computed tomography and the occurrence of associated intermittent pain were considered major risk factors in this subset of patients and the presence of cold allodynia or hyperpathia in isolation and the absence of sensory loss were considered minor risk factors. It is our hope that the criteria here established will improve patient selection and so, the overall results of DBS.

Key words:pain, analgesia, deep brain stimulation, electrical stimulation, paresthesiae, stereotaxis, thalamus, thalamic nuclei, medial lemniscus, internal capsule.


RESUMO

A estimulação cerebral profunda (ECP) de sítios cuja estimulação elicita parestesia (núcleo talâmico ventrocaudal - VC, lemnisco medial - LM e cápsula interna - CI) é um dos poucos métodos atualmente disponíveis para o tratamento do elemento constante da dor por injúria neural (DIN). Revendo os primeiros 60 pacientes com DIN submetidos à ECP na Division of Neurosurgery, Toronto Hospital, University of Toronto, no período 1978/ 1991, observamos que 6 destes pacientes apresentaram parestesia dolorosa à estimulação de VC/LM/ CI, prevenindo a definitiva implantação do sistema em todos eles e totalizando 15% (6 dentre 40) das falhas em nossa série. Em uma tentativa de se melhorar a seleção de pacientes para a ECP e, com isto, seus resultados globais, revimos nossos casos, considerando uma série de parâmetros, de modo a determinar os fatores de risco para parestesia dolorosa. Os resultados mostraram que esta resposta à estimulação de VC/LM/CI é exclusiva de pacientes com dor central cerebral, secundária a lesão supratentorial, apresentando dor evocada como parte do quadro doloroso. Nem todos os pacientes com estas características, porém, apresentavam parestesia dolorosa.
O estudo comparativo destes dois subgrupos (dor central cerebral + dor evocada + parestesia dolorosa e dor central cerebral + dor evocada + parestesia dolorosa) permitiu definir que: 1. Parestesia dolorosa à estimulação da coluna dorsal da medula espinhal, lesão restrita ao tálamo à tomografia computorizada e dor intermitente como parte do quadro doloroso são fatores de risco maiores para parestesia dolorosa à estimulação de VC / LM / Cl; 2. Alodínia ao frio ou hiperpatia isoladamente e ausência de deficit sensitivo ao exame neurológico são fatores de risco menores; e 3. Idade, sexo, duração da dor, qualidade da dor constante, dimensões da lesão causal e sítio (VC, LM ou Cl) ou tipo (macro ou microeletrodo) da exploração cirúrgica não parecem ser fatores de risco relevantes. O autor sugere também os prováveis mecanismos fisiopatológicos envolvidos na gênese da parestesia dolorosa à estimulação de VC / LM / Cl.

Palavras-chave:dor, analgesia, estimulação cerebral profunda, estimulação elétrica, parestesia. estereotaxia, tálamo, núcleos talâmicos, lemnisco mediai, cápsula interna.


 

 

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

 

 

Acknowledgements - The author would like to express his gratitude to Dr. Ronald R. Tasker and Dr. Herbert Almeida O. e Souza for their critical review of this paper.

 

REFERENCES

1. Gorecki J, Hirayama T, Dostrovsky JO, Tasker RR, Lenz FA. Thalamic stimulation and recording in patients with deafferentation and central pain. Stereotact Funct Neurosurg 1989; 52:219-226.         [ Links ]

2. Tasker RR. Identification of pain processing systems by electrical stimulation of the brain. Human Neurobiol 1982; 1:261-272.         [ Links ]

3. Tasker RR, Dostrovsky JO. Deafferentation and central pain. In Wall PD, Melzack R (eds). Textbook of pain. Ed 2. Edinburgh: Churchill Livingstone, 1989:154-180.         [ Links ]

4. Tasker RR, Gorecki J, Lenz FA, Hirayama T, Dostrovsky JO. Thalamic microelectrode recording and microstimulation in central and deafferentation pain. Appl Neurophysiol 1987; 50:414-417.         [ Links ]

5. Tasker RR, Organ LW, Hawrylyshyn PA. The spinothalamic pathway. In Tasker RR, Organ LW, Hawrylyshyn PA (eds). The thalamus and midbrain of man: a physiological atlas using electrical stimulation. Springfield: Thomas, 1982:154-172.         [ Links ]

6. Tasker RR, Tsuda T, Hawrylyshyn P. Clinical neurophysiological investigation of deafferentation pain. In Bonica JJ (ed). Advances in pain research and therapy. New York: Raven Press, 1983:713-738.         [ Links ]

7. Tasker RR, Vilela O Filho. Deep brain stimulation for the control of untreatable pain. In Youmans JR (ed). Neurological surgery. Ed 4. Philadelphia: Saunders, 1996:3512-3527.         [ Links ]

8. Tsubokawa T, Katayama Y, Yamamoto T, Hirayama T, Koyamá S. Treatment of thalamic pain by chronic motor cortex stimulation. Pace 1991; 14:131-134.         [ Links ]

9. Vilela O Filho. Thalamic ventrobasal stimulation for pain relief: probable mechanisms, pathways and neurotransmitters. Arq Neuropsiquiatr 1994; 52:578-584.         [ Links ]

10. Vilela O Filho, Tasker RR. Pathways involved in thalamic ventrobasal stimulation for pain relief: evidence against the hypothesis VB stimulation ® rostroventral medulla excitation ® dorsal horn inhibition. Arq Neuropsiquiatr 1994; 52:386-391.         [ Links ]

 

 

Aceite:30-novembro-1995.

 

 

Dr. Osvaldo Vilela Filho - Instituto do Cérebro, Instituto Ortopédico de Goiânia - Rua T-27, 819 - Setor Bueno - 74210-030 - Goiânia - GO - BRASIL - FAX: 062 2855130.

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License