Chronic pain affects millions of individuals worldwide, substantially impairing quality of life and functional capacity. It may originate from a wide range of pathological conditions, including peripheral nerve disorders such as complex regional pain syndrome and primary pain syndromes, including neuropathic pain and fibromyalgia (Zolezzi et al., 2022). Over recent decades, multiple medical and surgical strategies have been developed to manage chronic pain. Nevertheless, a significant proportion of patients fail to achieve adequate symptom control with first-line therapies. In these cases, advanced neuromodulatory interventions commonly referred to as second-line approaches are required. Among these, spinal cord stimulation (SCS) represents a well-established technique that delivers electrical impulses to specific spinal segments to modulate nociceptive transmission (Gupta et al., 2022). SCS exerts its therapeutic effect through neuromodulation of ascending pain pathways, altering the excitability of afferent neurons and modifying the perception of pain. Depending on the etiology and distribution of pain, stimulation may be applied either at the segmental spinal level or at the cervicomedullary junction (CMJ) (Li et al., 2022). Cervical SCS is generally indicated for conditions such as brachial plexus injury, complex regional pain syndrome, degenerative disc disease, failed neck surgery syndrome, chronic radiculopathy, and post-herpetic neuralgia (PHN). Conversely, CMJ SCS is primarily utilized in refractory craniofacial pain syndromes, including trigeminal deafferentation pain, trigeminal neuropathic pain, and occipital neuralgia (Texakalidis et al., 2019). The neuroanatomical rationale for CMJ SCS lies in its influence on the spinal trigeminal tract and nucleus, particularly the caudal spinal nucleus (SpC), which contains second-order neurons responsible for relaying nociceptive and thermal information from the ipsilateral face. Sensory neurons within the trigeminal ganglion (TG) provide afferent innervation to the face, scalp, and associated sensory structures such as the teeth, sinuses, dura mater, cornea, and temporomandibular joint (TMJ) (Mills et al., 2021; Kim et al., 2024). Nociceptive stimuli arising in the orofacial region are transmitted by TG neurons to the SpC, which also receives convergent afferents from cranial nerves VII, IX, and X. Despite growing interest in neuromodulatory interventions, the role of SCS applied at the CMJ level in managing facial pain remains largely underexplored (Middleton et al., 2021). Notably, Tomycz et al. (2011) reported one of the first successful applications of CMJ stimulation for head and facial pain, demonstrating significant clinical improvement (Tomycz et al., 2011). However, the precise neurophysiological mechanisms underlying this therapeutic approach remain incompletely understood. In this context, we report a case illustrating the successful application of 10 kHz high-frequency spinal cord stimulation (HFSCS) targeting the CMJ in a patient with right-sided cranial trigeminal neuropathy.

The extended duration of follow-up represents a major strength of the present case report, as long-term data on neuromodulation for refractory trigeminal neuropathic pain remain scarce in the literature. Chronic neuropathic pain is a dynamic condition, and sustained observation over several years is essential to assess durability of analgesic benefit, stability of functional improvement, and the emergence of delayed adverse events (Isagulyan et al., 2023; Rauck et al., 2023; Caylor et al., 2019). Nevertheless, some methodological limitations must be acknowledged. Follow-up assessments were not conducted at predefined intervals, and standardized outcome measures were applied retrospectively. Consequently, psychometric instruments such as the SF-36, BDI-II, and MoCA should be interpreted with caution, as their longitudinal variability may be influenced by multiple confounding factors, including emotional state, disease chronicity, and long-term pharmacological exposure (Caylor et al., 2019). Despite these limitations, the magnitude and consistency of clinical improvement observed after implantation strongly support the clinical relevance of the intervention. Improvements in health-related quality of life and affective symptoms exceeded published minimal clinically important differences for the SF-36 and BDI-II in several domains, indicating a meaningful benefit beyond statistical fluctuation (Petersen et al., 2023; Patel et al., 2023). In contrast, changes in cognitive performance assessed by the MoCA were more modest and variable over time. This finding is consistent with previous evidence suggesting that cognitive scores in patients with chronic pain may fluctuate as a function of pain burden, mood, sleep quality, and medication effects, rather than reflecting a direct neuromodulatory impact on cognition itself (Mills et al., 2021; Caylor et al., 2019). Taken together, the longitudinal psychometric profile supports a sustained global benefit of high-frequency spinal cord stimulation, while highlighting the inherent complexity of long-term outcome assessment in chronic pain populations (Kapural et al., 2016; Malik et al., 2024). The contribution of concomitant pregabalin therapy to the observed clinical outcomes also warrants careful discussion. Pregabalin is a first-line pharmacological agent for neuropathic pain and has demonstrated efficacy across a range of peripheral and central neuropathic conditions (Joosten and Franken, 2020). In the present case, pregabalin was introduced to manage a residual dull, background pain component that became apparent after resolution of the paroxysmal electric shock–like attacks. This phenomenon is not uncommon in trigeminal neuropathic pain, where distinct pain generators may coexist and become unmasked following suppression of the dominant paroxysmal component. However, several observations support the conclusion that high-frequency spinal cord stimulation represented the primary driver of sustained analgesia (Zuidema et al., 2023). Most notably, recurrence of severe pain occurred exclusively during periods of stimulation interruption caused by complete battery depletion, and pain intensity rapidly returned to baseline levels (NRS = 10) despite continuation of the pharmacological regimen. Restoration of stimulation resulted in immediate and complete pain relief without any adjustment of pregabalin dosage. This tight temporal coupling between stimulation status and pain control provides strong causal evidence for the central role of continuous high-frequency neuromodulation, consistent with previous reports demonstrating the dependence of analgesic efficacy on uninterrupted stimulation in long-term HFSCS therapy (Petersen et al., 2023; Patel et al., 2023; Provenzano et al., 2023). Accordingly, pregabalin should be regarded as an adjunctive component of a multimodal treatment strategy rather than the principal determinant of outcome (Piacentino et al., 2025; Alvarez et al., 2025; González-González et al., 2025). This distinction is clinically relevant, as it underscores the importance of device maintenance, patient education regarding charging habits, and structured long-term follow-up to prevent inadvertent therapy interruption (Sillevis et al., 2025; Jones and Rosenow, 2020; Maric et al., 2025). From a broader perspective, this case supports the concept that high-frequency spinal cord stimulation at the cervicomedullary junction can provide durable and causally robust analgesia in carefully selected patients with refractory trigeminal neuropathic pain, even when conventional tonic SCS has failed.

This updated case report demonstrates the sustained long-term efficacy of high-frequency spinal cord stimulation (HFSCS) at the cervicomedullary junction (CMJ) for the treatment of neuropathic pain secondary to trigeminal nerve injury that was unresponsive to both tonic SCS and conventional medical management. The findings highlight the potential of CMJ-targeted HFSCS as a durable and safe neuromodulatory option for patients with refractory trigeminal neuropathic pain. Future prospective and randomized controlled studies are warranted to further validate these observations, assess their impact on patient quality of life, and evaluate the cost–benefit balance of this approach from a public health perspective.