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Robot-Guided Neuronavigated Repetitive Transcranial Magnetic Stimulation (rTMS) in Central Neuropathic Pain

  • Charles Quesada
    Correspondence
    Corresponding author Charles Quesada, PhD, Laboratoire Inserm U1028 ICD, Faculté de Médecine Jacques Lisfranc, 10 chemin de Marandière 42270 Saint-Priest en Jarez.
    Affiliations
    NEUROPAIN Team, Inserm U1028, Université Claude Bernard Lyon1 et Université Jean Monnet, Saint-Etienne, France

    Centre Stéphanois de la Douleur, Hôpital Nord, Centre Hospitalier Régional Universitaire de Saint-Etienne, France
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  • Benjamin Pommier
    Affiliations
    NEUROPAIN Team, Inserm U1028, Université Claude Bernard Lyon1 et Université Jean Monnet, Saint-Etienne, France

    Service de Neurochirurgie, Hôpital Nord, Centre Hospitalier Régional Universitaire de Saint-Etienne, Australia
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  • Camille Fauchon
    Affiliations
    NEUROPAIN Team, Inserm U1028, Université Claude Bernard Lyon1 et Université Jean Monnet, Saint-Etienne, France
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  • Claire Bradley
    Affiliations
    Queensland Brain Institute, The University of Queensland, Australia
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  • Christelle Créac’h
    Affiliations
    NEUROPAIN Team, Inserm U1028, Université Claude Bernard Lyon1 et Université Jean Monnet, Saint-Etienne, France

    Centre Stéphanois de la Douleur, Hôpital Nord, Centre Hospitalier Régional Universitaire de Saint-Etienne, France

    Service de Neurologie, Hôpital Nord, Centre Hospitalier Regional Universitaire de Saint-Etienne
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  • François Vassal
    Affiliations
    NEUROPAIN Team, Inserm U1028, Université Claude Bernard Lyon1 et Université Jean Monnet, Saint-Etienne, France

    Service de Neurochirurgie, Hôpital Nord, Centre Hospitalier Régional Universitaire de Saint-Etienne, Australia
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  • Roland Peyron
    Affiliations
    NEUROPAIN Team, Inserm U1028, Université Claude Bernard Lyon1 et Université Jean Monnet, Saint-Etienne, France

    Centre Stéphanois de la Douleur, Hôpital Nord, Centre Hospitalier Régional Universitaire de Saint-Etienne, France

    Service de Neurologie, Hôpital Nord, Centre Hospitalier Regional Universitaire de Saint-Etienne
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      Highlights

      • 20Hz-rTMS can be used safely in chronic neuropathic central pain.
      • An analgesic cumulative effect is taking place during the first 4-5 rTMS sessions.
      • Once installed, duration of the analgesic effect can be maintained over 2 weeks.
      • The analgesic effect is maintained after a year of treatment.

      Abstract

      Objectives

      To confirm and extend previous results involving repetitive transcranial magnetic stimulation (rTMS) aimed at alleviating refractory central neuropathic pain (CNP). To evaluate pain relief in detail and to assess ongoing benefits after one year of treatment.

      Design

      Prospective observational study.

      Setting

      University hospital. Outpatient settings.

      Participants

      Patients (N=80) with chronic central pain after brain or spinal cord injuries.

      Interventions

      High-frequency (20Hz) neuronavigated-rTMS sessions were applied on the primary motor cortex using a figure-of-eight coil positioned by a robotized arm. Patients received a minimum of 4 consecutive sessions, each separated by 3-4 weeks.

      Main Outcome Measures

      Percentage of pain relief (%R), duration of pain relief (DPR), numeric rating scale (NRS), neuropathic pain symptom inventory (NPSI), and pain relief score (PRS).

      Results

      Seventy-one patients completed the study. On average, after the first 4 sessions, %R was 28% and DPR was 11 days. Fifty-four patients (76%) were responders with a permissive threshold of ≥10%R and 61% (43 patients) with a stringent threshold ≥30%R. After 12 months of treatment (15 sessions) we observed a cumulative effect on %R (48%), DPR (20d), and on the prevailing NPSI sub-score (-28%). This effect reached significance after 4 sessions and was further maintained over 12 months. Across participants, more than 1000 rTMS sessions were delivered over 6 years without any adverse effect.

      Conclusion

      These results confirm that multiple rTMS sessions are both safe and have potential as a treatment for CNP. An ongoing randomized controlled trial will allow teasing out of this effect from placebo analgesia.

      Graphical abstract

      Keywords

      List of abbreviations:

      CNP (central neuropathic pain), DPR (duration of pain relief), gNPSI (Neuropathic Pain Symptom Inventory Global Score), LEP (laser evoked potential), M1 (primary motor cortex), MRI (magnetic resonance imaging), MCS (motor cortex stimulation), MEP (motor evoked potential), NPSI (Neuropathic Pain Symptom Inventory), NPSIss (Neuropathic Pain Symptom Inventory Prevailing Sub-Score), NRS (numeric rating scale), PRS (pain relief score), %R (percentage of pain relief), rTMS (repetitive transcranial magnetic stimulation), SEP (somatosensory evoked potential)
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