Chronic Neuropathic Pain,
Neurosurgical Treatment Options

What is neuropathic pain?

Pain that originates within the nervous system itself—not simply from tissue injury or inflammation.

Neuropathic pain is caused by damage or dysfunction within the nervous system— the brain, spinal cord, or peripheral nerves. It is not the result of a simple inflammatory process, fracture, or soft-tissue injury (such as arthritis or muscle strain), but rather an alteration in how sensory signals are processed and interpreted as pain.

Patients often describe it as burning, “electric,” stabbing, tingling, or deep and heavy. It may be constant, intermittent, or paroxysmal. In many cases it is accompanied by allodynia, where normally harmless stimuli (such as clothing touching the skin) become intensely painful.

A key feature of neuropathic pain is that it may persist even after the original injury has healed—because the nervous system has become “sensitized” and continues to generate pain signals without any protective purpose.

How common is it and who is affected?

Neuropathic pain can arise in a wide range of conditions—from nerve injuries to stroke and cancer-related disease.

Neuropathic pain is not a single diagnosis, but a pattern of pain that may occur in many different clinical settings, including:

• after injury to a peripheral nerve or plexus (e.g., brachial plexus injury)
• following spinal cord or nerve root injury
• after amputation (phantom limb pain)
• in multiple sclerosis
• after stroke (central post-stroke pain)
• in advanced cancer with invasion of neural structures or viscera

Prevalence varies depending on the underlying condition, but in many chronic neurological or oncologic diseases, a significant proportion of patients develop neuropathic pain that profoundly affects daily functioning, sleep, mood, and social life.

How does it present in everyday life?

Patients with neuropathic pain rarely complain of purely “mechanical pain with movement.” Instead, they experience continuous or unpredictable episodes, often without an obvious trigger, such as:

• burning or icy sensations in areas of the trunk or limbs
• sudden electric shocks or lancinating pain
• numbness combined with severe pain in the same distribution
• intense pain triggered by light touch (clothing, bedsheets, shower water)
• sleep disturbance, chronic irritability, fatigue, and difficulty concentrating

Family members may not see any visible cause (wound, swelling, surgical scar), which can unfortunately lead to doubt or misunderstanding. From a medical standpoint, neuropathic pain is a real neurological condition, not an exaggerated response.

Why does it occur – what happens in the nervous system?

From the site of injury to pain perception in the brain, the pain pathway may malfunction at multiple levels.

Neuropathic pain develops when injury such as trauma, inflammation, infarction, or demyelination affects structures responsible for transmitting or processing pain signals:

• peripheral nerves and ganglia (e.g., brachial plexus, nerve root lesions)
• the spinal cord (especially the anterolateral/spinothalamic pathways)
• the thalamus, cerebral cortex, and limbic system structures (e.g., cingulate gyrus)

After injury, neurons may become hyperexcitable and fire spontaneously or in response to minimal stimuli. At the same time, inhibitory pain-control mechanisms may weaken. The result is a self-perpetuating cycle in which pain signals sustain themselves.

The more centrally located the lesion (closer to the brain), the more challenging treatment becomes— which is why central pain syndromes and post-thalamic or cortical pain are among the most difficult forms of neuropathic pain to manage.

How is diagnosis and comprehensive evaluation performed?

A combination of detailed history, neurological examination, and targeted imaging studies.

There is no single “magic test” for neuropathic pain. Diagnosis is based on:

• Detailed history: onset, context (injury, surgery, stroke, disease), progression, aggravating and relieving factors.
• Neurological examination: assessment of sensation, strength, reflexes, and coordination.
• Imaging studies: MRI and CT of the brain and/or spinal cord, correlated with prior surgical findings.
• Electrophysiological testing when indicated: EMG, nerve conduction studies, evoked potentials.

Additional evaluation includes:

• impact on daily life (sleep, work, self-care)
• current medications and treatment-related side effects
• psychological burden, anxiety, depression, and family context

At Neuroknife, this assessment is typically multidisciplinary, involving neurologists, pain specialists, oncologists, and psychological support, ensuring a complete picture before considering invasive options.

How does it differ from “typical” nociceptive pain or other causes?

Neuropathic, nociceptive, or mixed—accurate classification guides appropriate treatment.

Pain is broadly classified into:

• Nociceptive pain: resulting from tissue injury or inflammation.
• Neuropathic pain: resulting from injury to the nervous system itself.
• Mixed pain: a combination of both mechanisms.

Nociceptive pain is typically proportional to the stimulus and serves a protective function. In neuropathic pain:

• pain may be disproportionate to any stimulus
• it may persist without an identifiable trigger
• it is often accompanied by sensory disturbances (numbness, hypersensitivity, allodynia)

It must also be distinguished from other conditions such as:

• degenerative spine disease with mechanical pain
• musculoskeletal disorders, arthritis, fibromyalgia
• purely psychogenic pain syndromes

Multiple pain mechanisms may coexist in the same patient—hence the need for individualized therapy.

When is conservative treatment sufficient?

Medications, rehabilitation, and psychological support form the foundation before any invasive intervention.

For the vast majority of patients, the first—and often primary—treatment pillar is conservative management, which includes:

• medications specifically targeting neuropathic pain (antiepileptics, antidepressants, etc.)
• careful dose titration and combination therapy under specialist supervision
• physical therapy, occupational therapy, and rehabilitation
• psychological or psychiatric support when indicated
• adjunctive techniques (TENS, acupuncture, etc.)

Neurosurgical intervention is considered when:

• multiple conservative strategies have been adequately attempted and
• pain remains refractory and disabling, or
• medication side effects become intolerable

In many patients, optimized conservative therapy provides satisfactory control without the need for surgery, and therefore always represents the first step.

When do we consider neurosurgical intervention?

Highly specialized options for carefully selected patients—not for every pain condition.

Neurosurgical interventions for neuropathic pain are reserved for a small subset of patients in whom:

• pain is severe, persistent, and disabling despite maximal conservative therapy
• the pain mechanism is clearly neuropathic and anatomically localized
• there is a realistic interventional target within the nervous system (e.g., plexus, spinal cord, thalamus)
• the patient is fully informed and consents to both benefits and limitations

At Neuroknife, each case is reviewed in a multidisciplinary conference, balancing potential benefit, risks, alternatives, and overall patient condition— particularly in oncologic settings.

Neuromodulation vs neuroablative techniques – what is the difference?

Stimulation versus lesioning: two distinct philosophies in pain control.

Neurosurgical pain treatments fall into two broad categories:

• Neuromodulatory (stimulation-based) techniques: implantation of systems that modulate neural activity, such as spinal cord stimulation, deep brain stimulation (DBS), or motor cortex stimulation. These approaches are adjustable and reversible.
• Neuroablative (lesion-based) techniques: targeted lesions in specific neural pathways to interrupt or modify pain transmission.

This page focuses primarily on ablative techniques, which still play an important role in:

• traumatic brachial plexus injuries (DREZ procedures)
• refractory unilateral cancer pain (cordotomy, myelotomy)
• central pain syndromes following stroke or thalamocortical injury (cingulotomy, CL thalamotomy)

The choice between stimulation and lesioning depends on diagnosis, prognosis, anatomy, and patient-specific therapeutic priorities.

What are the main ablative procedures for neuropathic pain?

From DREZ procedures at the spinal cord level to cingulotomy and targeted thalamotomy.

DREZ (Dorsal Root Entry Zone) – Pain after plexus or spinal cord injury

DREZ targets the area where sensory nerve roots enter the spinal cord. Highly focal lesions are created in hyperactive gray matter that has become dysfunctional after peripheral deafferentation, such as in brachial plexus injuries or spinal cord trauma.

Following microsurgical exposure and use of specialized electrodes or microsurgical techniques, a series of small lesions are created along the affected segment. In carefully selected patients, this procedure can provide long-term pain relief.

Cordotomy – Unilateral cancer-related pain

Cordotomy targets the spinothalamic tract in the anterolateral spinal cord, which transmits pain from the contralateral side of the body. It is most commonly used for unilateral, refractory cancer pain (e.g., Pancoast tumors, unilateral thoracic or abdominal pain).

The procedure can be performed percutaneously, under CT or fluoroscopic guidance, with the patient in controlled wakefulness to confirm effectiveness. The goal is rapid and meaningful relief in patients with limited life expectancy, where pain dominates daily life.

Myelotomy – Central visceral cancer pain

Myelotomy is primarily aimed at relieving visceral cancer pain of the abdomen or pelvis (e.g., advanced pancreatic cancer, gynecologic malignancies) when all other measures have failed.

Through a posterior midline approach to the spinal cord, lesions are created in regions where visceral pain fibers converge or cross (anterior commissure, posterior columns).

Cingulotomy – When pain carries a strong emotional burden

The cingulate gyrus is part of the limbic system and plays a key role in the emotional perception of pain—how distressing the pain feels to the patient. Bilateral cingulotomy does not block pain signals themselves, but aims to reduce the emotional suffering associated with chronic, medication-resistant pain.

It may benefit extremely severe and refractory pain syndromes or advanced oncologic cases when all other options have failed. This is a highly specialized stereotactic procedure with strict indications.

Central Lateral Thalamotomy

The thalamus is the primary sensory relay station of the brain. In selected severe chronic neuropathic pain syndromes—particularly after central lesions—targeted lesioning of thalamic nuclei (such as the central lateral nucleus) aims to reduce abnormal paroxysmal discharges.

These procedures remain highly specialized and are performed only in strictly selected cases, typically within expert pain centers such as Neuroknife.

Outcomes, limitations & risks of ablative procedures

Not “miracle cures,” but potentially life-changing when all other options have failed.

In carefully selected patients, ablative procedures may provide:

• substantial reduction in pain intensity
• decreased need for high-dose opioids and their associated side effects
• improvement in sleep, mobility, and independence

However, these procedures are irreversible and carry potential risks:

• sensory disturbances (numbness, dysesthesia)
• motor deficits (weakness, instability, rarely paralysis)
• bladder or bowel dysfunction (particularly after myelotomy)
• cognitive or emotional changes (especially after central procedures such as cingulotomy)
• general neurosurgical risks (bleeding, infection, seizures)

For this reason, such interventions are considered only when:

• less invasive options have been exhausted, and
• the patient has a clear and realistic understanding of potential benefits and limitations.

What should I expect after successful treatment?

From decision-making to recovery, your relationship with the pain team remains ongoing.

After an ablative procedure for neuropathic pain, the course depends on the type and level of intervention. In general:

• hospitalization is usually limited to a few days, with close neurological monitoring
• medications are reassessed and often gradually reduced under supervision
• a rehabilitation or physical therapy program may follow, depending on the procedure
• treatment effectiveness is evaluated over time, not immediately

At Neuroknife, we believe that decisions regarding neurosurgical treatment of chronic pain must be made with full transparency and close collaboration between the patient, family, and treating physicians.