In 1991 Tsubokawa and colleagues first published their landmark results from a series in which epidural motor cortex stimulation (MCS) was used in the treatment of eight patients with central and neuropathic pain. In ensuing studies authors have elaborated on the indications, technique, hypotheical mechanisms, and beneficial results of this treatment. Epidural MCS is effective for trigeminal neuropathy, lateral medullary and thalamic infarction, anesthesia dolorosa, postherpetic neuralgia, spinal cord injury, and limb stump pain. Postoperative outcomes are better when patients present with only mild or absent motor weakness in the region of pain and when there is pain in the trigeminal region. It is hypothesized that MCS is effective because it increases regional cerebral blood flow in the ipsilateral ventrolateral thalamus in which corticothalamic connections from the motor and premotor areas predominate. The extent of pain alleviation also correlates with the increase of blood flow in the cingulate gyrus. This suggests that stimulation reduces the suffering experienced by a patient with chronic pain. Procedure-related morbidity has included epidural hematoma, subdural effusion, gradual diminution of benefit, and painful stimulation. Although of concern, treatment-induced chronic seizure disorders have not occurred as a complication or in animal models of chronic cortical stimulation. Stimulation-induced pain relief occurs within minutes. There are no associated paresthesias or muscle contractions that confirm function. Pain relief may last for hours after electrical stimulation is discontinued. Motor cortex stimulation is an established therapy for the treatment of complex central and neuropathic pain syndromes that have proved refractory to medical treatment.