Epidural spinal cord stimulation (SCS) is a neuromodulatory, reversible procedure for the treatment of selected chronic pain conditions, primarily neuropathic in nature. The updated German S3 guideline provides evidence-based recommendations for the use of SCS and dorsal root ganglion stimulation (DRG-S). Key innovations include recent technical advances and increased integration into multimodal pain management. The guideline aims to enhance the care of patients with chronic pain by offering rational, scientifically substantiated recommendations. A systematic literature review was conducted, including meta-analyses and randomized controlled trials, with relevant case reports also taken into account. Publications were evaluated by topic, including fundamentals, indications, methods, complications, quality management, and psychosocial aspects. Recommendations are based on established evidence classifications. Major updates include strong evidence in favor of SCS for diabetic polyneuropathy. For other neuropathies, smaller studies indicate positive effects. SCS is considered the most effective therapy for chronic, postoperative back and leg pain. Additionally, SCS receives a strong recommendation for peripheral arterial occlusive disease (Fontaine stages IIb and III). For complex regional pain syndrome (CRPS), DRG‑S demonstrates superiority over SCS and is preferentially recommended. The guideline addresses all professional groups involved in the care of pain patients and offers practical guidance for therapeutic decision-making in the management of chronic pain.

Die Behandlung neuropathischer Schmerzen nach Plexusausriss, Schlaganfall („central post stroke pain“, CPSP) oder Trigeminusneuropathien (TNP) ist durch peripher durchgeführte Neuromodulationsmethoden nicht möglich. Nichtinvasive Neuromodulationsverfahren wirken nur temporär. Dauerhaft implantierte Elektroden subkortikal (tiefe Hirnstimulation, THS) oder über dem motorischen Cortex (Motorkortexstimulation, MCS) können bei ca. 50–70

BACKGROUND:Dorsal root ganglion stimulation (DRGS) has become established as a specialized neuromodulation technique for focal neuropathic pain syndromes, such as complex regional pain syndrome (CRPS), peripheral nerve injuries as well as groin and knee pain. It enables targeted segmental coverage, selective stimulation of hard to reach dermatomal areas and improves daily functioning and treatment adherence. OBJECTIVE:The aim of this work is to present the current evidence on DRGS, analyze its clinical fields of application and evaluate its effectiveness, safety, quality of care, and economic aspects. MATERIAL AND METHODS:A review of the relevant literature was conducted, including randomized controlled trials (RCTs), reviews, cohort studies and clinically significant case reports. Key outcomes assessed included pain reduction, function, quality of life, patient selection, technique, adverse events and the cost-benefit ratio. RESULTS:The results of RCTs confirm response rates ≥ 50% and a pain reduction >80% in CRPS and similar pain conditions. Observational studies confirm sustained effects, improved quality of life and reduced medication dependency. The infection rates range between 2-5%. The electrodes for DRGS can be placed with high precision. Advantages include low stimulation amplitudes, high energy efficiency and stable therapeutic effects. CONCLUSION:The DRGS is an evidence-based, selective treatment option with high therapeutic potential for focal neuropathic pain. It offers high response rates, functional improvements and a favorable safety profile. Technical innovations and expanded indications further enhance the clinical utility. Critical factors remain careful patient selection, structured follow-up and further studies on long-term efficacy and cost-effectiveness.

BACKGROUND:Treatment of central neuropathic pain, such as pain after plexus avulsion, stroke or cerebral hemorrhage (central post-stroke pain; CPSP) or trigeminal neuropathies, is generally not possible with neuromodulation methods that are carried out further peripherally. Non-invasive neuromodulation methods only have a temporary effect. Permanently implanted electrodes subcortically (deep brain stimulation; DBS) or epi- or subdurally over the motor cortex ("motor cortex stimulation", MCS) can lead to pain relief in about 50-70% of patients with central neuropathic pain. OBJECTIVES:To present the main indications for DBS and MCS according to the literature. MATERIAL AND METHODS:Both procedures, DBS and MCS, are not approved for the treatment of chronic pain, but decades of clinical experiences exist. The results of meaningful studies and clinical series are presented on the basis of a literature search and recommendations for specific indications are developed. RESULTS:Patients with CPSP benefit significantly more from MCS than from DBS, and better results are also achieved with MCS in patients with neuropathic pain after spinal cord injury. Patients with pain after plexus avulsion or phantom pain can be treated better with DBS. The best results are achieved with both procedures in patients with trigeminal neuropathy. We prefer MCS as it is less invasive. The results from both stimulation therapies for postherpetic neuralgia are disappointing. CONCLUSIONS:DBS and MCS can be used to treat chronic neuropathic pain when conservative or less invasive measures have failed. Depending on the cause and localization of the pain, DBS or MCS may have better long-term results. However, neither procedure is a "stand-alone" therapy; they are additive and must be accompanied by medication and behavioral therapy.

Die epidurale Rückenmarkstimulation („spinal cord stimulation“ [SCS]) ist ein reversibles Neuromodulationsverfahren zur Behandlung ausgewählter chronischer, in erster Linie neuropathischer Schmerzen. Die aktualisierte deutsche S3-Leitlinie gibt evidenzbasierte Empfehlungen für den Einsatz der SCS und der Spinalganglienstimulation („dorsal root ganglion stimulation“ [DRG-S]). Neu sind technische Fortschritte und die stärkere Einbindung in die multimodale Schmerztherapie. Die Leitlinie dient dazu, die Versorgung von Menschen mit chronischen Schmerzen durch rationale, wissenschaftlich fundierte Empfehlungen zu verbessern. Es erfolgte eine systematische Literaturrecherche mit Auswertung von Metaanalysen und randomisierten, kontrollierten Studien, wobei einzelne relevante Fallberichte ebenfalls berücksichtigt wurden. Thematisch wurden die Publikationen nach Grundlagen, Indikationen, Methoden, Komplikationen, Qualitätsmanagement und psychosozialem Verlauf ausgewertet. Die Empfehlungen beruhen auf etablierten Evidenzklassifikationen. Wesentliche Neuerungen: Für die diabetische Polyneuropathie besteht gute Evidenz zugunsten der SCS. Für andere Neuropathien zeigen kleinere Studien positive Effekte. SCS gilt als effektivste Therapie bei chronischen postoperativen Rücken- und Beinschmerzen. Auch bei der peripheren arteriellen Verschlusskrankheit (Stadium 2b und 3) erhält die SCS eine starke Empfehlung. In der Behandlung des komplexen regionalen Schmerzsyndroms ist die DRG‑S der SCS überlegen und wird bevorzugt empfohlen. Die Leitlinie richtet sich an alle Berufsgruppen, die an der Versorgung von Schmerzpatienten beteiligt sind, und bietet eine praxisnahe Orientierung für Therapieentscheidungen in der chronischen Schmerzbehandlung.

Differential target multiplexed spinal cord stimulation (DTM SCS) is a stimulation paradigm for chronic pain management that aims to modulate neuron-glial interactions. In parallel, closed-loop SCS systems using evoked compound action potential (ECAP) sensing have been introduced to adjust stimulation output in response to measured neural activation. Although clinical evidence for DTM SCS has expanded, data remain limited for patients with Persistent Spinal Pain Syndrome Type 2 (PSPS-T2), particularly regarding ECAP-controlled closed-loop DTM SCS and its implementation in routine European practice. ENDLESS aims to investigate the feasibility, safety, and longitudinal clinical outcomes associated with open-loop and closed-loop DTM SCS in patients with PSPS-T2 through a longitudinal European multicentre cohort study. ENDLESS is a prospective multicentre cohort study including at least 200 patients, with follow-up until 12 months after implantable pulse generator activation. Outcomes will be assessed at baseline and at 1, 6 and 12 months after DTM SCS initiation. The primary effectiveness endpoint is pain intensity, measured using the Visual Analogue Scale through ecological momentary assessment. Secondary effectiveness outcomes include pain intensity with and without medication use, negative affect, disability, health-related quality of life, pain medication use, clinical holistic responder status, patient impression of change, work status, pain catastrophising, symptoms of anxiety and depression, patient unwanted stimulation awareness and patient expectations. In a subset of patients, sleep, activity patterns and RR-intervals will be assessed using actigraphy. Device-derived outcomes will include time spent in different body postures, technical implantable pulse generator details, battery consumption, stimulation parameters, programming information and ECAP-related data when closed-loop DTM SCS is used. Technical issues, adverse events, serious adverse events and the proportion of successful DTM SCS trial periods will also be documented. Longitudinal mixed models will be used to evaluate changes in effectiveness outcomes over time.Trial registration numberClinicalTrials.gov identifier NCT07211308.

Die Dorsalganglienstimulation (Dorsal-root-ganglion-Stimulation [DRGS]) hat sich als spezialisierte Technik der Neuromodulation bei fokalen neuropathischen Schmerzsyndromen wie dem komplexen regionalen Schmerzsyndrom („complex regional pain syndrome“ [CRPS]), peripheren Nervenläsionen sowie Leisten- und Knieschmerzen etabliert. Die DRGS ermöglicht eine gezielte Segmentabdeckung und selektive Stimulation schwer erreichbarer Dermatomareale. Sie verbessert Alltagsfunktion und Therapieadhärenz. Ziel ist die Darstellung der aktuellen Evidenz zur DRGS, ihrer klinischen Anwendungsbereiche sowie der Bewertung von Wirksamkeit, Sicherheit, Versorgungsqualität und ökonomischen Aspekten. Analysiert wurde die einschlägige Literatur, darunter randomisierte, kontrollierte Studien (RCT), Reviews, Kohortenstudien und praxisnahe Erfahrungsberichte. Bewertet wurden Schmerzreduktion, Funktion, Lebensqualität, Patientenselektion, Technik, Nebenwirkungen und das Kosten-Nutzen-Verhältnis. RCT belegen bei CRPS und ähnlichen Schmerzen Ansprechraten ≥ 50

Biallelic KIF1C variants are associated with a spectrum of neurological phenotypes, including spasticity, cerebellar ataxia, chorea, and dystonia. Most reported patients involve single-nucleotide variants, whereas copy number variants (CNVs) have been described only once in the PubMed-listed literature. The therapeutic potential of deep-brain stimulation (DBS) in KIF1C-related disease has not yet been evaluated. We report a patient presenting with spasticity, ataxia, dystonia, and head tremor, in whom prior exome sequencing was inconclusive. A multi-omics approach was applied, including optical genome mapping (OGM), genome sequencing, and transcriptome sequencing. The clinical effect of DBS was assessed. OGM revealed a homozygous KIF1C Exon 17–18 deletion, retrospectively detectable in exome and genome data but initially missed by sequence analysis. Transcriptome sequencing demonstrated significantly reduced KIF1C expression and absence of normally spliced transcripts around those exons, consistent with a loss-of-function mechanism. DBS led to partial clinical improvement, with notable reduction of dystonia and head tremor. Structural variants may be an underrecognized cause of complex movement disorders involving spasticity, ataxia, and dystonia. Diagnostic methods specifically targeting structural variation, such as OGM or CNV analysis of short-read data, can be essential for diagnosis. Transcriptome data add valuable functional insight. This report also suggests that DBS may offer symptomatic benefit in KIF1C-associated disease, particularly for dystonic signs.

Background The prevalence in diabetic sensorimotor polyneuropathy (DSPN) is around 30% in patients with diabetes, while up to half of those with DSPN develop neuropathic pain. Painful DSPN is associated with an increased risk of mortality and reduced quality of life. Analgesic pharmacotherapy, including combinations, may be limited in efficacy and associated with adverse drug reactions. Methods A multidisciplinary group of seven experts developed consensus recommendations on the value of spinal cord stimulation for refractory painful DSPN based on systematic reviews, current guidelines, randomized controlled trials (RCTs), and cohort studies. Results Chronic neuropathic pain is considered refractory or resistant to treatment if adequate pain relief is not achieved despite analgesic combination therapy in line with guidelines. Several RCTs with a treatment duration of up to 2 years and meta-analyses have consistently shown that additional epidural spinal cord stimulation (SCS) leads to a clinically relevant, long-term pain reduction compared to conventional analgesic pharmacotherapy in participants with refractory painful DSPN. This benefit is accompanied by an improvement in sleep and quality of life as well as functionality with a favorable safety profile and low discontinuation rates of SCS. Therefore, after a maximum of 9 months of refractory multimodal analgesic therapy for painful DSPN, patients should be referred to a specialized center to assess the indication for the use of SCS. Conclusion With a high level of evidence and expert consensus, SCS is recommended as an integral part of the treatment of painful DSPN refractory to pharmacotherapy.

BACKGROUND:Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established therapy in advanced Parkinson's disease (PD) improving motor and non-motor signs including sleep. The mechanisms of sleep improvement are insufficiently understood. OBJECTIVES:The objective was to identify stimulation-dependent effects on the sleep-wake cycle and circadian clock regulation. METHODS:Fourteen PD patients who underwent STN DBS (PD-DBS) were assessed before as well as 6 and 12 months post-surgery. As control groups, 18 PD patients under best medical treatment (PD-CON) and 25 healthy controls (H-CON) were also enrolled. Wrist actigraphy to measure sleep and sleep questionnaires, such as the PD Sleep Scale (PDSS), were applied and the expression of clock genes in peripheral blood was measured. Electrode placement in the STN was localized, and the local impact of STN DBS was estimated. RESULTS:STN DBS improved daytime sleepiness 12 months post-surgery (P = 0.006) which was correlated with limbic VTA (r = 0.737, P = 0.006). PDSS scores decreased 6 months post-surgery (P = 0.050) and were positively associated with activation of the motor part of the STN (r = 0.582, P = 0.037). Time in bed increased after surgery and was also positively correlated with the activation of the motor part of the STN (r = 0.941, P = 0.005). There were no changes in clock gene expression between groups and over time (all P ≥ 0.323). CONCLUSIONS:Sleep and daytime sleepiness are improved after STN DBS in PD. Different STN sub-proportions contribute to these improvements. The changes in sleep appear not be driven by changes in clock gene expression.

Die Prävalenz der diabetischen sensomotorischen Polyneuropathie (DSPN) liegt bei ca. 30% der Patienten mit Diabetes, während bis zur Hälfte von denen mit DSPN neuropathische Schmerzen entwickeln. Die schmerzhafte DSPN geht mit erhöhtem Mortalitätsrisiko und eingeschränkter Lebensqualität einher. Die analgetische Pharmakotherapie einschließlich Kombinationen kann in ihrer Wirksamkeit begrenzt sein und mit unerwünschten Arzneimittelwirkungen einhergehen. Eine multidisziplinäre Gruppe von sieben Experten entwickelte in mehreren Diskussionsrunden Consensus-Empfehlungen zum Stellenwert der Rückenmarkstimulation bei therapierefraktärer schmerzhafter DSPN basierend auf systematischen Reviews, aktuellen Leitlinien sowie randomisierten kontrollierten Studien (RCTs) und Kohortenstudien. Chronisch neuropathischer Schmerz wird als therapierefraktär angesehen, wenn trotz leitliniengerechter analgetischer Kombinationstherapie keine ausreichende Schmerzlinderung erreicht wird. Mehrere RCTs mit einer Behandlungsdauer bis zu 2 Jahren sowie Meta-Analysen konnten übereinstimmend zeigen, dass die zusätzliche epidurale Rückenmarkstimulation (spinal cord stimulation: SCS) im Vergleich zur konventionellen analgetischen Pharmakotherapie bei Teilnehmern mit therapierefraktärer schmerzhafter DSPN zu einem klinisch relevanten, langfristig anhaltendem Schmerzrückgang führt. Dieser geht einher mit einer Verbesserung der Schlaf- und Lebensqualität sowie Funktionalität bei günstigem Sicherheitsprofil und geringen Abbruchraten der SCS. Nach spätestens 9 Monaten einer refraktären multimodalen analgetischen Therapie bei schmerzhafter DSPN soll daher eine Vorstellung der Patienten in einem spezialisierten Zentrum zwecks Indikationsprüfung bzw. -stellung zum Einsatz der SCS erfolgen. Die SCS wird bei hohem Evidenzgrad und Expertenkonsens als integraler Bestandteil der Behandlung der therapierefraktären schmerzhaften DSPN empfohlen.

Background Pallidal deep brain stimulation (GPi-DBS) has been considered as an effective treatment option for medication-refractory Huntington's disease (HD). Objectives To identify stimulation-dependent effects on motor symptoms and to determine if these alterations are associated with the local impact of DBS on different pallidal parcellations. Methods We prospectively evaluated the effects of bilateral GPi-DBS within one year in 5 HD patients. We evaluated the effects of GPi-DBS on choreatic symptoms and UHDRS. Electrode placement in the pallidum was localized, and the local impact of DBS was estimated. Results The chorea subscore (p < 0.001) and UHDRS total motor score was significantly reduced postoperatively (p = 0.019). Pallidal DBS did not improve other motor symptoms. Activation of the lateral GPi/GPe was associated with improvement in choreatic symptoms (p = 0.048; r = 0.90). Conclusions Our findings indicate that stimulation of the lateral GPi has a stable effect on choreatic symptoms. The modulation of the electrical field is relevant for motor outcome.

Intrathecal baclofen therapy (ITB) is an approved treatment option for patients with severe spasticity and is performed for more than 40 years. In this retrospective analysis of a period from March 2012 until December 2019, the clinical data of patients under 18 years of age, which got an ITB via an implanted pump device, were evaluated.

Body weight gain in combination with metabolic alterations has been observed after deep brain stimulation (DBS) of subthalamic nucleus (STN) in patients with Parkinson’s disease (PD), which potentially counteracts the positive effects of motor improvement. We aimed to identify stimulation-dependent effects on motor activities, body weight, body composition, energy metabolism, and metabolic blood parameters and to determine if these alterations are associated with the local impact of DBS on different STN parcellations. We assessed 14 PD patients who underwent STN DBS (PD-DBS) before as well as 6- and 12-months post-surgery. For control purposes, 18 PD patients under best medical treatment (PD-CON) and 25 healthy controls (H-CON) were also enrolled. Wrist actigraphy, body composition, hormones, and energy expenditure measurements were applied. Electrode placement in the STN was localized, and the local impact of STN DBS was estimated. We found that STN DBS improved motor function by ~ 40% (DBS ON, Med ON). Weight and fat mass increased by ~ 3 kg and ~ 3% in PD-DBS (all P ≤ 0.005). fT3 ( P = 0.001) and insulin levels ( P = 0.048) increased solely in PD-DBS, whereas growth hormone levels ( P = 0.001), daily physical activity, and VO 2 during walking were decreased in PD-DBS (all P ≤ 0.002). DBS of the limbic part of the STN was associated with changes in weight and body composition, sedentary activity, insulin levels (all P ≤ 0.040; all r ≥ 0.56), and inversely related to HOMA-IR ( P = 0.033; r = − 0.62). Daily physical activity is decreased after STN DBS, which can contribute to weight gain and an unfavorable metabolic profile. We recommend actigraphy devices to provide feedback on daily activities to achieve pre-defined activity goals.