DEEP BRAIN STIMULATION FOR REFRACTORY CHRONIC PAIN: CLINICAL TARGETS, INDICATIONS, AND EMERGING STRATEGIES

L. Al-Husinat¹, S. Azzam¹, S. Al Sharie², A.A. Alomari³, A. Baydoun⁴, H.B. Yaseen⁵, G. Varrassi⁶ | ¹Department of General Surgery and Anesthesia, Faculty of Medicine, Yarmouk University, Irbid, Jordan; ²Laboratory of Science and Translation in Critical Illness, Vanderbilt University Medical Center, Nashville, TN, USA; ³Section of Neurosurgery, Department of Special Surgery, Faculty of Medicine, Mutah University, Alkarak, Jordan; ⁴Unit of Anesthesia, Intensive Care and Pain Therapy, Sant’Andrea University Hospital, Rome, Italy; ⁵Department of Anesthesia and Intensive care unit, Ministry of Health Educational Hospitals, Amman, Jordan; ⁶Fondazione Paolo Procacci, Rome, Italy

Background and Aims. Chronic pain remains a major unmet clinical challenge, particularly in patients who are refractory to pharmacological, interventional, and neuromodulatory therapies. Deep brain stimulation (DBS) has re-emerged as a potential option for select chronic pain syndromes, targeting both sensory-discriminative and affective-emotional pain circuits. This paper aims to synthesize current clinical evidence on DBS for chronic pain, focusing on therapeutic targets, pain indications, treatment outcomes, and emerging strategies relevant to pain medicine practice.
Methods. A narrative review of clinical and translational studies evaluating DBS for chronic pain was performed. Evidence was analyzed according to pain etiology, neuroanatomical target, stimulation strategy, and reported clinical outcomes.
Results. DBS demonstrates the most consistent benefit in neuropathic and mixed pain syndromes, including cluster headache, phantom limb pain, and failed back surgery syndrome. Stimulation of the periaqueductal/periventricular gray (PAG/PVG) and sensory thalamus is associated with meaningful pain reduction in a substantial proportion of patients, while limbic targets such as the anterior cingulate cortex and ventral striatum primarily modulate the affective dimensions of pain. The clinical response varies greatly and is affected by the choice of patients, the type of pain, the accuracy of lead placement, and the stimulation parameters. New methods, such as dual-target stimulation, advanced imaging-guided targeting, and combination neuromodulation therapies, look like they could help improve results.
Conclusions. DBS represents a viable therapeutic option for carefully selected patients with refractory chronic pain, particularly those with neuropathic components. While its use remains off-label in many regions, advances in targeting strategies and patient phenotyping may enhance efficacy and expand its role within multidisciplinary pain management.