Chronic Pain

Chronic pain is pain that persists beyond the normal time expected for an injury to heal, or pain caused by an ongoing condition affecting the nervous system itself. It is not a single diagnosis but a broad category covering many different conditions, patterns and causes, and most patients with chronic pain are managed successfully with medication, physical therapy, injections and pain-management programs, without any surgical involvement.

For a smaller group of patients whose pain has not responded adequately to appropriate conservative treatment, surgical neuromodulation or, in specific circumstances, an older lesioning procedure, may be considered. These are not first-line treatments, and they are appropriate only after thorough evaluation, usually involving a multidisciplinary pain team.

• Persistent spinal pain syndrome (including “failed back surgery syndrome”): ongoing back or leg pain following spinal surgery, or spinal pain that has not responded to surgery and other treatment
• Neuropathic pain: pain arising from damage or dysfunction of the nervous system itself, often described as burning, shooting or electric-shock-like
• Complex regional pain syndrome (CRPS): a condition causing severe, often disproportionate pain, usually in a limb, following an injury, together with changes in skin colour, temperature or swelling
• Severe facial pain: including trigeminal neuropathic pain and other facial pain conditions that have not responded to medication or other targeted treatments
• Cancer-related (oncologic) pain: severe pain caused by cancer or its treatment that has not been adequately controlled by medication, including opioids, at doses the patient can tolerate

The surgical approach depends heavily on the type, location and pattern of pain, and on the patient’s overall goals and circumstances:

• Spinal Cord Stimulation is the most commonly considered option for persistent spinal pain, neuropathic pain and CRPS affecting the trunk or limbs. It is adjustable and reversible, and a trial period is used before any permanent decision is made.
• Stereotactic Thalamotomy is a more specialized, lesioning-based option used in a much smaller number of patients with severe facial pain or cancer-related pain that has not responded to other treatments, particularly where a device-based option is not suitable or not practical.

• Detailed pain history, including location, pattern, triggers and previous treatments tried
• Neurological examination, and imaging where a structural or neurological cause needs to be identified or excluded
• Multidisciplinary pain team review, since psychological, functional and medical aspects of chronic pain are all relevant to treatment planning
• Psychological assessment, which is a standard and important part of evaluation before device-based neuromodulation
• For device-based options, a trial period before any permanent implant, as described on the Spinal Cord Stimulation page

Across all of these treatments, the realistic goal is meaningful pain reduction and improved function, being able to do more, sleep better, or rely less on medication, rather than complete elimination of pain. Treatment goals vary between patients, and individual results may differ.

Each treatment carries its own specific risks, described in full on its own page. In general terms, device-based neuromodulation (spinal cord stimulation) is adjustable and can be removed if it does not help, while lesioning procedures such as thalamotomy create a permanent change and cannot be reversed. Neither treatment is guaranteed to eliminate pain, and not every patient with chronic pain is a suitable candidate for either.