Motor cortex stimulation and pain surgery.

Neuropathic pain is considered a difficult to treat clinical conditionand related to a large variety of lesions in the peripheral and/orcentral nervous system.Only approximately one-third of patients reach satisfactory reliefwith antiepileptic and antidepressants, which are considered mainstaytreatments.Neurostimulation represent a major step forward in the treatment ofintractable chronic pain. Chronic spinal cord stimulation allowspain control of mainly secondary to incomplete peripheral nervedamage. Deep brain stimulation of the sensory thalamic nuclei hasbeen disappointing in the long term. Cortex motor stimulation wasproposed as one alternative. It is an image guided surgery, improvedby intra-operating electrophysiogical monitoring. The objectiveis to accurately locate the motor cortex target to be stimulatedaccording to pain topography.In some types of central pain, such as thalamic pain, motor cortexstimulation constitutes a first intention therapeutic alternative. Thesame holds true for chronic facial neuropathic pain. Other indicationsneed to be confirmed even when lasting efficacy has beenreported in indications such as plexus brachial avulsion, phantomlimb pain or post-paraplegic pain.Multicentric and randomized on/off studies are on the way