Objective: To illustrate an example of an improvement in chronic pain, following bilateral subthalamic nuclei (STN) deep brain stimulation (DBS) surgery in a Parkinson’s disease (PD) patient.

Background: Over 50% of patients with PD can have chronic pain, which can significantly reduce quality of life. Musculoskeletal pain is the most common source of pain in PD and may be experienced as rigidity, cramps, shoulder disturbances, spinal or hand/foot deformities, dystonic pain, or non-radicular back pain. Other sources of pain to consider include neuropathic pain (peripheral or central), or pain related to akathisia, restless legs syndrome, or depression.

Methods: A 45-year-old man with PD presented with intermittent left upper extremity rest tremor. Approximately one year after symptom onset he developed constant pain in his entire left upper extremity which gradually worsened over time. Pain worsened over time and was exacerbated by tremor. He initially deferred dopaminergic therapy but after approximately five years of disease he began carbidopa/levodopa (25/100 mg) 1 tab PO TID. Carbidopa/levodopa completely alleviated both his left upper extremity tremor and pain. Over the next several years, he gradually developed motor fluctuations and dyskinesia. His “OFF” periods were associated with bothersome tremor and pain, and his “ON” periods were associated with prominent neck dyskinesia and left arm dyskinesia, both of which also caused significant pain. His medication regimen now included carbidopa/levodopa 25-100 mg tablets (5 tabs/day) and amantadine 100 mg TID. Dyskinesia was only minimally reduced by amantadine. Eventually, his maximum levodopa equivalent daily dose was 800 mg per day. After 15 years of PD, he underwent bilateral STN-DBS implantation with the goal of reducing prominent motor fluctuations and dyskinesia.

Results: Bilateral STN-DBS implantation resulted in significant improvement in motor fluctuations, dyskinesia, neck and left arm pain.

Conclusions: STN-DBS can have a secondary beneficial effect on levodopa-responsive pain. STN-DBS may produce its anti-nociceptive effect by raising the threshold of pain and by modulating analgesia systems in the anterior cingulate cortex and periaqueductal gray, thereby altering descending pain pathways within the spinal cord.

References: 1. Pellaprat J, Ory-Magne F, Canivet C, Simonetta-Moreau M, Lotterie JA, Radji F, et al. Deep brain stimulation of the subthalamic nucleus improves pain in Parkinson’s disease. Parkinsonism Relat Disord 2014;20:662-664. 2. Beiske AG, Loge JH, Ronningen A, Svensson E. Pain in Parkinson’s disease: Prevalence and characteristics. Pain 2009;141:173-177.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/improvement-of-levodopa-responsive-chronic-pain-after-stn-dbs-in-parkinsons-disease/