Contemporary concepts of pain surgery

Abstract

Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice. This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned. For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management. While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis. Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge. Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.

Stereotactic Radiosurgery Hypophysectomy for Palliative Treatment of Refractory Cancer Pain: A Historical Review and Update

“…Since Hayashi et al last published their original series in 2002, there have only been two further published studies (39, 43). The rise of intrathecal opioid administration, though not without significant complication (i.e., infection, neurotoxicity, endocrinopathies, and device malfunction) has largely driven hypophysectomy for the treatment of refractory cancer pain out of favor (44,45). Radiosurgery hypophysectomy studies to date have been small, non-randomized, and prospective trials providing lowlevel evidence to support its use (8,38,39,43).…”

Deep Brain Stimulation of the Posterior Insula in Chronic Pain: A Theoretical Framework

“…Neurosurgeons have long attempted to prevent the suffering of patients with chronic pain by disrupting various structures along pain pathways, including peripheral nerves, dorsal roots, the spinothalamic pathway in the spinal cord, the midbrain, the thalamus, and the cingulate cortex, by lesioning, electrically stimulating, or perfusing with analgesic/anesthetic agents [ 2 ]. Initially, ablative surgeries such as cordotomy, midline myelotomy, thalamotomy, and cingulotomy have been carried out to disrupt ascending pain signals.…”

High-Frequency Alternating Current Block Using Macro-Sieve Electrodes: A Pilot Study

“…Chemical blockade using anesthetics, or pharmaceutical nerve stabilizers are usually used for treatment; however, due to adverse effects and issues with long-term dependency, alternative non-pharmacological approaches are increasingly being preferred [2,3]. Surgical nerve destruction provides a long-term alternative but is irreversible [4]. A high-frequency alternating current (HFAC) can induce a peripheral nerve conduction block that quickly reverses after the current is turned off.…”