’ Case Report

Short-term cervical spinal cord stimulation for

central post-stroke pain: a case report and
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literature review
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Xu Zhang, MDa, Xuebin Yan, MDa,*, Yuzhao Huang, MDc, Haocheng Zhou, MDa,b,*

Introduction: Post-stroke central pain is disabling yet ineffectively treated with routine medical intervention. In this study, the
authors presented an alternative neuromodulation therapy and conducted a brief narrative literature review to examine current
evidence of spinal cord stimulation treatment for central post-stroke pain
Case presentation: Here, the authors reported a case of severe post-stroke syndrome, who achieved satisfactory improvement of
pain symptom, as well as muscle rigidity with a novel neuromodulation therapy of short-term implantation of cervical spinal cord
stimulation.
Clinical discussion: It remains a great challenge in the management of post-stroke pain, which in turn significantly reduces the
quality of life and worsens the burden on the public health system. Spinal cord stimulation therapy is an emerging neuromodulation
approach to restore pathological pain status and functional impairment to provide a prospective insight into neuromodulation and
rehabilitation options in the management of post-stroke syndrome.
Conclusion: A potential role of spinal cord stimulation in the treatment of post-stroke pain is proposed in combined with traditional
medication or other neuromodulation strategies, to achieve better control of pain in the future.
Keywords: case report, cervical spinal cord stimulation, neuromodulation, post-stroke pain

Introduction
Central post-stroke pain (CPSP) is a neuropathic pain compli-
HIGHLIGHTS
cation associated with injury of somatosensory structures after • We provided our experience of a novel neuromodulation
cerebrovascular accidents[1], and is one of the most troublesome procedure for central post-stroke pain.
sequelae of stroke. In China, the incidence rate of CPSP has been • Short-term but not permanent implantation of spinal cord
estimated to range from 1 to 18%[2]. The total number of stroke stimulation successfully attenuated a severe case of post-
population will keep rising up to 150 million per year by 2025 in stroke pain.
Europe[3], of whom about 11–55% may unfortunately develop • We summarized current evidence for the application of
CPSP, especially for the aged[3–5]. spinal cord stimulation treatment for central post-
In general, CPSP occurs three to six months following cere- stroke pain.
brovascular attack[6], still, latent cases may present with pain
symptoms even several years after initial stroke with a minor
fraction[7,8]. Clinical manifestation of CPSP includes intractable pain in the affected limb and/or trunk[9], which is characterized
by burning, pinpricking, tearing, cutting, and occasionally
a
squeezing or feeling cold[5,10]. As a result, ongoing requirement of
Department of Pain, The Third Xiangya Hospital and Institute of Pain Medicine,
b
Hunan Key Laboratory of Brain Homeostasis and cDepartment of Orthopaedics,
pain intervention is essentially needed, and it significantly reduces
The Third Xiangya Hospital, Central South University, Changsha, Hunan, China the quality of life[11].
X.Z. and X.Y. contributed equally to this paper. The current therapeutic method for the management of CPSP
Sponsorships or competing interests that may be relevant to content are disclosed at remains limited and unsatisfactory, mainly due to its complex and
the end of this article. uncertain mechanism[8,12,13]. Despite traditional medication
*Corresponding authors. Address: Department of Pain, The Third Xiangya therapy, emerging invasive or non-invasive neuromodulation
Hospital and Institute of Pain Medicine, Central South University, Changsha, Hunan strategies may offer alternative options for control of CPSP,
Province, China. Tel.: +86 0731 8861 8815. E-mail: Yanxb999@126.com (X. Yan), including motor cortex stimulation, deep brain stimulation,
and Haocheng.zhou@csu.edu.cn (H. Zhou).
transcranial magnetic stimulation[14,15], and spinal cord stimu-
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. This is an
open access article distributed under the terms of the Creative Commons
lation (SCS) reported in this study. Of these, SCS may provide a
Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to lasting modulatory effect given its implantable design, as well as a
download, share, remix, transform, and buildup the work provided it is properly cited. relatively less invasive injury compared with deep brain
The work cannot be used commercially without permission from the journal. stimulation.
Annals of Medicine & Surgery (2024) 86:3184–3188 The purpose of SCS treatment is to interrupt the abnormal
Received 15 February 2024; Accepted 23 March 2024 nociceptive signal transmission conveyed in the ascending and
Published online 3 April 2024 descending neural pathway, which has proven to be effective in
http://dx.doi.org/10.1097/MS9.0000000000002025 the treatment of failed back surgery syndrome, complex regional

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 Zhang et al. Annals of Medicine & Surgery (2024)

pain syndrome, post-herpetic neuralgia, phantom limb pain, and This patient initially experienced mild and occasional pain,
diabetic peripheral neuropathy. However, it remains con- however, suffering a persistent deficiency of functional use of the
troversial about the SCS administration in CPSP, due to limited left side of the body. Functional improvement was then achieved
clinical data and inconsistent consensus about stimulation with a following rehabilitation program for several months that
parameters[16–18]. Here, we report a severe case of CPSP that was she was able to walk with crutches by herself. Unfortunately, pain
effectively attenuated by short-term implantation of cervical SCS, severity has become worsen in the last 1 year, regarding episodic
to provide a novel neuromodulation strategy in the management duration, frequency, as well as pain intensity (8/10, numerical
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of CPSP. In addition, we aim to evaluate the therapeutic efficacy rating scale), ongoing stabbing, burning pain that mainly affects
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the left upper extremity. Previous medication included non-ster-

of neuromodulation by reviewing previous publications of SCS in
oidal anti-inflammatory drugs and gabapentin (0.5 g, Tid) with
the field of CPSP[16,19–30].
limited relief of pain. The only way to achieve temporal pain relief
was to keep the left side upper extremity in an extension position
back and forth. In addition to symptomatic pain, this case pre-
Case report sented with decreased muscle strength (grade III) and enhanced
muscle tone on the left side of the body.
History and examination
A 60-year-old female patient presented at our pain clinics in June SCS treatment
2023, complaining of intermittent burning pain related to the left Due to unsatisfactory control of pain, the patient was recom-
head, face, and upper and lower limbs for three and a half years mended and consented to the neuromodulation therapy of short-
caused by thalamic haemorrhage of the right hemisphere. The term SCS implantation. The patient was placed in a prone posi-
magnetic resonance imaging of the brain confirmed the stroke tion with necessary sedative administration. An eight-contact
lesion (Fig. 1). cylindrical lead (NO.3873, Medtronic Inc) was percutaneously

Figure 1. Image data of the central post-stroke pain patient underwent short-term implantation of cervical SCS. Magnetic resonance imaging of T2 weighted
(A) fluid-attenuated inversion recovery and (B) propeller techniques in identification of the lesion site. (C, D) Intraoperative fluoroscopy of anterior-posterior and lateral
view for confirmation of the implantable site of SCS. SCS, spinal cord stimulation.

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 Zhang et al. Annals of Medicine & Surgery (2024) Annals of Medicine & Surgery

≥ 30% (63) ＜30% (43)

Clinical outcome pain

≥ 30% (12) ＜30% (7)

≥ 30% (7) ＜30% (3)

≥ 30% (8) ＜30% (4)

≥ 30%(5) ＜30% (1)

inserted into the epidural space at T5–6 level, and gradually
advanced cephalically under fluoroscopic guidance. We aimed to

relief (%)

＞80%
＞60%
place the top of the stimulation lead approaching the C1 level

50%
NR

NR
NR

NR
NR
(Fig. 1) according to the preoperative assessment of painful
regions, which should be optimally covered by SCS and con-
firmed with intraoperative sensory testing. This case reported a
sensation of paraesthesia covering the left side of the upper and

Follow-up
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(months)

0.5–108
12–100
36–149
lower extremity at a frequency of 40 Hz (pulse width: 450 μs).

24–63

6–62

NR
NR

NR

96
24
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6
6

6
Clinical outcome

C (67) T (98) L C (60) T (63) L (4)

C (6) T (15) L (1) C (3) T (10) L (1)

The stimulation programming was adjusted at least twice a day

C (25) T (35)
C (12) T (9)

C (1) T (1)
T (5) L (1)
according to the patient-reported pain sensation that was per-

IPG

NR

NR

NR

NR
C

C
T
formed by an experienced technician. Postoperative stimulation

Lead position
protocol was set at a 40 Hz frequency with a pulse width ranging
between 450 and 500 μs. The initial stimulation voltage was set 2.4

C (1) T (6) L (1)

C (13) T (12)
volts and gradually lowered to 0.8 volts before the removal of lead.

C (6) T (24)

C (1) T (1)

C (1) T (1)
Trial

(14)
After SCS implantation, about 75% reduction of pain severity was

NR

NR

NR
C

C
T
reported in this case in relation to the upper and lower limbs
compared with baseline. However, the patient still suffered mod-
erate to severe craniofacial pain, which cannot be covered by the

Hemo (15) Inf (3) Thalamus (8) Others (10) single (2) dual (16)

single (5) dual (11)

No. electrodes
cervical spinal cord stimulation. As a result, the patient underwent

others (44)
single

single

single
single

single
dual

dual

dual

dual
once trigeminal pulsed radiofrequency for the control of cranio-

NR

NR
facial pain, which achieved significant relief from trigeminal suf-
fering, and only mild and tolerable pain remained. We did not
observe any obvious complications in this case. At the last follow-

C, cervical; Co, coexistence; F, female; Hemo, haemorrhage; Inf, infarction; IPG, implantable pulse generator; L, lumbar; M, male; NR, not reported; T, thoracic.
Hemo (127) Inf Thalamus (71) Others (95)

Hemo (22) Inf (8) Thalamus (12) Others (18)

Hemo (18) Inf (4) Thalamus (11) Others (11)

Thalamus 3) Others (5)

up, the patient still reported significant pain relief in the craniofa-

Thalamus (45)
Thalamus (8)
cial and upper extremities 5 months after discharge. Unfortunately, Location

Thalamus
Thalamus

Thalamus

Thalamus
Other
recurrent and aggressive lower limb pain was reported in the last 2

NR
weeks, and we recommended further rehabilitation and pain
Stroke

management therapy if necessary. Changes in pain severity were

assessed with the numerical rating scale (numerical rating scale,
shown in Fig. 2). In general, the patient reported satisfactory
control of pain symptoms, as well as functional improvement. Hemo (7) Inf (1)
(38) Co (1)

Hemo
Hemo

Hemo
Type

NR

NR

NR

Co
Discussion Inf
Pain duration

42.0 (12–168)

Here, we report one case who received short-term SCS treatment

37.5 (6–156)
50.0 (6–168)
(22.8–81.3)
(months)

for CPSP, providing us with an alternative option for multimode (3–600)

44.5

108
NR
NR

NR
24
43
6

2
management of intractable neuropathic pain syndromes after cer-
ebrovascular attack. Previous reports of permanent SCS implan-
General information and clinical data of enroled researches

tation are mainly applied in those with thalamic strokes, and about
47.1 ± 14.8
Age (years)
63.4 ± 7.9

65.2 ± 7.3
61.4 ± 8.0
63.9 ± 8.5

63.8 ± 6.2

80% (9 out of 11) of studies examined its validation in haemor-

21–74

rhagic lesions (Table 1). In general, permanent implantation should

NR
73
74
85

67

71
Sex F/M
55⁄111

26/34
9⁄21
7⁄15
8⁄10
3/5
3/5

NR

NR
M

M
F
166 163 106
All Trial IPG

NR
10
19
12

56
6
6

1
1
3
1

1
Sample size

30
22
18

45

24
8
8
1
1
1

1
30
22
18

45

60
8
8
1
1
1

1
Feierabend et al. (2016)[26]
Yamamoto et al. (2016)[21]

Katayama et al. (2001)[16]

Simpson et al. (1991)[29]

Hosomi et al. (2022)[19]

Lopez et al. (2009)[23]

Tanei et al. (2019)[22]

Tanei et al. (2012)[24]

Tanei et al. (2023)[28]

Noori et al. (2018)[27]
Yozu et al. (2016)[25]
[20]

Xu et al. (2020)[30]
Aly et al. (2010)
Table 1

Figure 2. Therapeutic effect of short-term SCS treatment in pain severity.

Preoperative and postoperative assessment was conducted according to the
Study

painful regions. NRS, numerical rating scale; SCS, spinal cord stimulation.

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 Zhang et al. Annals of Medicine & Surgery (2024)

be considered for responders with pain relief of more than 50% of the written consent is available for review by the Editor-
treated with percutaneous trial electrodes in our centre, which is in-Chief of this journal on request.
consistent with previous findings that pain reduction during the
trial period is the strongest predictive factor for long-term successful
Source of funding
control of pain. Satisfactory control of symptomatic pain in the
upper extremity was achieved in this case; however, the patient and Not applicable.
her family refused the secondary procedure of permanent implan-
kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/20/2024

tation for the potential risk of long-term complication, nursing and

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cost issues. Overall, this patient still felt very satisfactory about pain
Author contribution
control at discharge, the main reason she came to our department X.Z., X.Y., Y.H., and H.Z. contributed all aspects of the
for help, and the analgesic effect was enduring up to almost half a manuscript, including acquiring patient consent, literature
year after the removal of the trial lead. review, drafting the original manuscript, editing and revision of
Despite duration, the implantation site is another key factor in the final version of manuscript. The final version of this manu-
SCS procedure, that placement of stimulation lead is designed script has been written, read, and approved by all authors. The
to be closed to the spinal cord segments corresponding to the material has not been published, either whole or in part, and is
painful regions (Table 1), and dual leads may be used for not under consideration for publication elsewhere.
optimal coverage of SCS in some cases with extensive pain
suffering[21,22,24,27]. In general, cervical implantation is mostly
applied; meanwhile, the therapeutic effect of cervical SCS is more Conflicts of interest disclosure
reliable at trial, as well as long-term follow when compared with Not applicable.
thoracic and lumbar segments[19].
Neural projection between the high cervical spinal cord and
trigeminal nerve system may provide the anatomic fundamentals Research registration unique identifying number
for the intrathecal drug delivery system in the management of (UIN)
orofacial pain[31–33]. However, severe craniofacial pain was Name of the registry: not applicable. Unique identifying number
barely attenuated by cervical SCS therapy in this case; thus, we or registration ID: not applicable. Hyperlink to your specific
recommended a distinct pattern of neuromodulation by intro- registration (must be publicly accessible and will be checked): not
ducing trigeminal ganglion pulsed radiofrequency. Surprisingly, applicable.
trigeminal ganglion neuromodulation provided effective relief of
craniofacial pain by decreasing numerical rating scale from 8 to 2,
and the pain relief maintained for over 20 weeks. We speculate Guarantor
that a distinct form of aetiology and functional mechanism
Haocheng Zhou.
between SCS and intrathecal drug delivery system may result in
an inconsistency of analgesic effect in patients with craniofacial
pain. Recently, we have provided one novel intrathecal strategy Availability of data and materials
to effectively attenuate the intrathecal cancer-related pain by
The original contributions presented in the study are included in
placing the intrathecal into the prepontine cisternal space[34–36],
the article, further inquiries can be directed to the corresponding
which can subsequently act on the facial pain-related cranial
author.
nerves (i.e. trigeminal nerve), and the brain stem structures
nearby corresponding to the supraspinal processing of pain sig-
nal. Given the circulation of cerebrospinal fluid, we assume that Provenance and peer review
further validation of this intrathecal therapy via prepontine cis-
Not applicable.
ternal routine may be considered for the management of CPSP.
In clinical practice, we propose that a multimode analgesic
strategy should be highlighted in the management of CPSP, not References
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