Functional Neurosurgical Strategies for Refractory Chronic Pain: A Network-Based Neuromodulation Perspective

Refractory chronic pain involving the central and peripheral nervous system represents a persistent clinical challenge despite advances in pharmacological and multidisciplinary management. In this context, neurosurgical and neuromodulatory strategies have gained increasing relevance as therapeutic approaches aimed at modulating dysfunctional pain-processing networks rather than producing irreversible neural damage. This review synthesizes current evidence on surgical and neuromodulatory interventions, including spinal cord stimulation, deep brain stimulation, peripheral nerve stimulation, and intrathecal drug delivery systems, with emphasis on their neurobiological foundations, therapeutic roles, and integration within contemporary pain management frameworks. The analyzed literature highlights a progressive shift toward functional and reversible interventions, supported by growing understanding of chronic pain as a network-based disorder. Differences in evidence maturity, anatomical targets, and clinical indications among modalities underscore the importance of individualized selection and multidisciplinary evaluation. International experiences, including contributions from Mexico, Colombia, and Ecuador, reflect the global applicability of neuromodulation principles across diverse healthcare settings. Overall, neurosurgical neuromodulation emerges as a key component of comprehensive chronic pain management, offering adaptable strategies aligned with evolving neurobiological models and clinical demands.