July 21, 2023
Mayo Clinic is committed to addressing chronic neurological pain. Neurosurgeons have expertise with an array of advanced interventions, including neurostimulation and lesioning procedures, to treat people with complex pain.
"Chronic pain is underdiagnosed and undertreated, and it basically sucks the joy out of life. Patients often have gone through the wringer trying to get the help they need."
Nonopioid medication can provide relief. Patients also might respond to nerve blocks or steroid injections. But these treatments aren't always effective for individuals with cancer-related pain or severe neuropathic pain syndromes.
Mayo Clinic uses a multidisciplinary approach to identify the source of an individual's pain and optimal treatment. "As a team, our specialists are able to put our heads together and come up with a very patient-centric, precision medicine approach to handling these very complex cases," Dr. Ali says.
Identifying the cause of life-altering pain
Chronic neurological pain can upend lives. "It affects the ability to work, to interact socially and to do whatever activities people love to do," Dr. Ali says. "The ramifications of not being able to work can include losing insurance coverage or not being able to afford a mortgage."
Chronic pain can also affect neural circuitry over time. "That can then lead to mood disorders," Dr. Ali says. "If the pain is severe enough, patients can be suicidal."
Interest in surgical intervention has grown in the wake of the opioid crisis. "Surgical experts can benefit a huge population of patients by offering nonopioid therapies to manage chronic pain," Dr. Ali says. "Not every patient will be a candidate for surgical intervention. The success of therapy depends largely on patient selection and setting appropriate expectations."
At Mayo Clinic, treatment starts with identifying the source of pain. "Our biggest challenge as clinicians specializing in complex pain is making the correct diagnosis — figuring out what part of the pain pathway is involved," Dr. Ali says.
The process starts with a detailed clinical history. "We ask about the inciting event for the pain and build from there," Dr. Ali says. "Our interventional pain colleagues can perform nerve blocks that temporarily interrupt the pain circuitry, which is very helpful in reaching a diagnosis."
Choosing the optimal intervention
Cancer-related pain can occur at the site of a primary malignancy or be distant and diffuse. Lesioning procedures selectively damage the nerve fibers associated with pain.
"Lesioning carries a little bit higher surgical risk compared with that of other interventions. Also, the nerve circuit rewires itself so the pain tends to come back over time," Dr. Ali says. "We typically perform lesioning for patients with cancer pain and limited life expectancy, to allow them to enjoy time with loved ones and maintain their dignity at end of life. For patients with a reasonable life expectancy, we prefer to offer some form of neuromodulation to help with their pain — the benefit of which is sustained long-term."
Neuropathic pain syndromes can occur anywhere in the body. Various types of neuromodulation therapies can address these syndromes, depending on where pain originates.
The options include:
- Peripheral nerve stimulation for peripheral nerve pain.
- Dorsal root ganglion stimulation for focal pain, such as pain due to an injury.
- Dorsal column stimulation for indications such as complex regional pain syndrome and continued pain after spinal surgery. "We also have expanded our use to patients who have never had spinal surgery but experience pain in the back or extremities," Dr. Ali says.
- Deep brain stimulation (DBS) of the thalamus or brainstem nuclei. "DBS of certain brainstem nuclei helps release endorphins that take away the suffering component of pain. DBS of the thalamus affects the processing of pain sensation," Dr. Ali says.
- Motor cortex stimulation for post-stroke pain, atypical facial pain and central neuropathic pain.
- Stimulation of the cingulate cortex. "It disconnects suffering from the sensation of pain. Patients continue to experience pain, but they stop being bothered by it," Dr. Ali says.
Pain rehabilitation
Mayo Clinic has a Pain Rehabilitation Center that provides an intensive, three-week program for adults. The treatment team includes specialists in pain medicine, physical therapy, psychology, occupational therapy and biofeedback.
Planning is underway for studies of combined therapies to treat chronic neuropathic pain. "Chronic pain is a lifelong issue," Dr. Ali says. "Our job is to do whatever we can to ease that suffering and bring the pain down to a tolerable level."
For more information
Pain Rehabilitation Center. Mayo Clinic.
Refer a patient to Mayo Clinic.