The Future of Neurostimulation for Pain and Handicap Management

A lesion of the central or peripheral nervous system can induce pain and be the source of disability. These two entities must be considered as one and only. Regarding with pain management, medicine has been taking the wrong path for a long time, attempting to destroy any potential neural target which was suspicious of dysfunctioning. The last decades have been stamped by a substantial change in this vision of the future: claiming that destroying would help in any way to provide pain relief or to restore function has progressively been banished in favor of the growing passion to stimulate… “Neuromodulate”… the anatomical target, considered as the subject of dysfunction. Nowadays, a neurostimulation procedure is considered as the last option to treat chronic refractory pain. This technology requires a sophisticated environment including robot, microscope, neuronavigation system and even intraoperative patient cooperation. The most recent technological advances have propelled neurostimulation to new horizons: new indications, new anatomical targets, multimodal individually based neuromodulations. These new perspectives lead us to transpose some concepts from the pain world to the scope of functional restoration. Culturally forged by a true ambition of « solving the pain », the neurosurgeon is now fascinated to implant diaphragmatic stimulators to help pauci-relational patients to breathe. He is also dreaming of making possible a paraplegic patient to walk again. These phantasms convinced research teams to develop new implantable epidural spinal cord stimulators to reactivate some motor patterns at the spinal cord level, under the guidance of innovative sensing brain cortical interface. The future of neurostimulation techniques will combine the sense & stim capabilities of the most recent stimulation devices, and probably target different sites of « electrical delivery ». Scientists stay divided by their convictions but brain and spinal cord do not appear to be in competition in this race of being the best target of neurostimulation. We need complementary approaches, a full toolbox and to use the diversity of neural targets in order to attempt finding the winning combination. But beyond passion and enthusiasm, ethical considerations about Men-Machine hybridization should refrain us to only dive into technical considerations. The goal of this paper is to develop some of these aspects, trying to help bridging the gap and building the bridge between the future of neurostimulation and the management of handicap.