• Giovanna Zambo Galafassi, Pedro Henrique Simm Pires de Aguiar, Renata Faria Simm, Paulo Roberto Franceschini, Marco Prist Filho, Jorge Roberto Pagura, and Pires de Aguiar Paulo Henrique PH Department of Neurosurgery, Santa Paula Hospital, São Paulo, Brazil; Department of Research and Innovation, Laboratory of Cellular and M.
• Graduation Medicine at Faculty of Medicine of ABC, Santo André, São Paulo, Brazil. Electronic address: giovannagalafassi@gmail.com.
• World Neurosurg. 2021 Feb 1; 146: 246-260.

BackgroundThe treatment of neuropathic pain (NP) continues to be controversial as well as an economic health issue and a challenge to health care. Neurosurgery can offer different methods of neuromodulation that may improve patients' condition, including deep brain stimulation (DBS), motor cortex stimulation (MCS), spinal cord stimulation (SCS), and posterior insula stimulation (PIS). There is no consensus of opinion as to the final effects of these procedures, which stimulation parameters to select, the correct timing, or how to select the patients who will best benefit from these procedures.ObjectiveTo review the evidence available regarding these 4 procedures and the management of NP.MethodsWe conducted a PubMed, Embase, and Cochrane Library database search from 1990 to 2020. The strategy of the search concentrated on the following keywords: "neuropathic pain," "chronic pain," "deep brain stimulation," "motor cortex stimulation," "spinal cord stimulation," "insula stimulation," and "neuromodulation." Studies that provided data regarding the immediate and long-term effectiveness of the procedure, anatomic stimulation target, percentage of pain control, and cause of the NP were included.ResultsThe most frequent causes of NP were phantom limb pain and central poststroke pain in the MCS group; central poststroke pain, phantom limb pain, and spinal cord injury (SCI) in the DBS group; and complex regional pain syndrome and failed back surgery syndrome in the SCS group. Pain improvement varied between 35% and 80% in the MCS group and 50% and 60% in the DBS group. In the SCS group, successful rates varied between 38% and 89%.ConclusionsThis systematic review highlights the literature supporting SCS, DBS, MCS, and PIS methods for the treatment of NP. We found consistent evidence supporting MCS, DBS, and SCS as possible treatments for NP; however, we were not able to define which procedure should be indicated for each cause. Furthermore, we did not find enough evidence to justify the routine use of PIS. We conclude that unanswered points need to be discussed in this controversial field and emphasize that new research must be developed to treat patients with NP, to improve their quality of life.Copyright © 2020 Elsevier Inc. All rights reserved.

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