Network-Guided Neuromodulation and Mechanism-Based Surgical Approaches in Refractory Neuropathic Pain
DOI:
https://doi.org/10.64784/143Keywords:
neuropathic pain, refractory pain, spinal cord stimulation, dorsal root ganglion stimulation, burst stimulation, high-frequency stimulation, neuromodulation, motor cortex stimulation, deep brain stimulation, trigeminal neuralgia, neurosurgery, chronic pain managementAbstract
Refractory neuropathic pain remains one of the most challenging conditions in neurosurgical and pain medicine practice. Defined as pain arising from a lesion or disease of the somatosensory system, it frequently persists despite optimized pharmacological management and significantly impairs quality of life. This review analyzes current evidence on neuromodulation and selected surgical strategies for refractory neuropathic pain, integrating diagnostic frameworks, mechanistic insights, technological evolution, and long-term clinical outcomes. Spinal cord stimulation (SCS) emerges as the most extensively validated modality, supported by comparative trials in failed back surgery syndrome and reinforced by durability data. Advances such as burst stimulation, high-frequency (10 kHz) paradigms, and dorsal root ganglion targeting reflect a shift toward phenotype-driven and precision neuromodulation. Peripheral nerve stimulation and intracranial techniques, including motor cortex stimulation and deep brain stimulation, maintain defined roles in focal and central pain syndromes. Mechanism-based surgical interventions, exemplified by trigeminal neuralgia treatment, remain essential when structural pathology is identified. Across modalities, standardized patient selection, consensus-based appropriateness criteria, and structured follow-up are critical determinants of sustained benefit and safety. Contemporary management of refractory neuropathic pain is therefore best understood as a mechanism-guided, network-oriented, and internationally adaptable therapeutic continuum.
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