Pre-treatment brain white matter integrity associated with neuropathic pain relief and changes in temporal summation of pain following ketamine

Neuropathic pain (NP) is a prevalent condition often associated with heightened pain responsiveness suggestive of central sensitization. Neuroimaging biomarkers of treatment outcomes may help develop personalised treatment strategies, but white matter (WM) properties have been under-explored for this purpose. Here we assessed whether WM pathways of the default mode network (DMN: medial prefrontal cortex (mPFC), posterior cingulate cortex (PCC), precuneus (PCu)) and descending pain modulation system (periaqueductal gray (PAG)) are associated with ketamine analgesia and attenuated temporal summation of pain (TSP, reflecting central sensitization) in NP. We used a fixel-based analysis (FBA) of diffusion weighted imaging data to evaluate WM microstructure (fiber density, FD) and macrostructure (fiber bundle cross-section) within the DMN and mPFC-PAG pathways in 70 individuals who underwent MRI and TSP testing; 35 with NP who underwent ketamine treatment and 35 age- and sex-matched pain-free individuals. Individuals with NP were assessed before and 1-month after treatment; those with ≥30% pain relief were considered responders (n=18), or otherwise as non-responders (n=17). We found that WM structure within the DMN and mPFC-PAG pathways did not differentiate responders from non-responders. However, pre-treatment FD in the anterior limb of the internal capsule correlated with pain relief (r=0.48). Moreover, pre-treatment FD in the DMN (left mPFC-PCu/PCC; r=0.52) and mPFC-PAG (r=0.42) negatively correlated with changes in TSP. This suggests that WM microstructure in the DMN and mPFC-PAG pathway is associated with the degree to which ketamine reduces central sensitization. Thus, fixel metrics of WM structure may hold promise to predict ketamine NP treatment outcomes. PERSPECTIVE: We used advanced fixel-based analyses of MRI diffusion-weighted imaging data to identify pre-treatment white matter microstructure associated with ketamine outcomes including analgesia and markers of attenuated central sensitization. Exploring associations between brain structure and treatment outcomes could contribute to a personalized approach to treatment for individuals with neuropathic pain.