Intractable pain of spinal cord origin: clinical features and implications for surgery

Abstract

The clinical features and types of pain affecting 127 patients with central pain caused by lesions in the spinal cord were studied and correlated with the results of surgical procedures performed on 103 of them. The surgical procedures consisted of percutaneous cordotomy in 39 cases, cordectomy in 12, dorsal root entry zone (DREZ) surgery in four, dorsal cord stimulation in 35, and brain stimulation in 13. The three most common types of pain in the 127 patients were characterized as: steady in 95% of cases, intermittent (usually shooting) in 31%, and evoked (allodynia, hyperpathia, or hyperesthesia) in 45%. Steady pain was usually causalgic (74.8%) or dysesthetic (27.6%). The only obvious clinical correlation with pain type was the association of intermittent pain with lesions at the T10-L2 vertebral level. Destructive surgery (cordotomy, DREZ surgery, or cordectomy) affected the three chief types of pain differently from treatment with cord or brain stimulation. Destructive surgery resulted in reduction of steady pain in 26% of affected cases, of intermittent pain in 89%, and of evoked pain in 84%, while stimulation resulted in pain reductions in 36%, 0%, and 16% of cases, respectively. The differential effect of destructive surgery on steady and intermittent pain is consistent with published experience. These observations suggest differing mechanisms for the three types of pain.

A proposed algorithm for the management of pain following spinal cord injury

“…These include deep brain stimulation 49,50 and motor cortex stimulation, 51 dorsal root entry zone lesions (for at-level neuropathic pain) [52][53][54] and surgical approaches such as cordotomy. 55 Psychosocial and environmental contributors The person with SCI undergoes a huge adjustment in relationships, lifestyle, vocation and self-image that need to be addressed and people with a severe SCI usually have significant psychological distress. 56 The superimposition of chronic pain is a major factor that interferes with expected rehabilitation and return to employment and function in domestic life.…”

Pain following spinal cord injury

“…107 Ablative procedures Various surgical procedures have been attempted to provide relief to patients with SCI and were strongly advocated for the control of persistent pain with reported success. 4,112 However it is now recognised that the success of these various procedures is often disappointing and does vary according to the nature of the pain 113 and ablative neurosurgical procedures need to be tailored to the type of pain syndrome if they are to be successful. 113 For below level neuropathic SCI pain, ablative surgery, including cordotomy, distal cordectomy and thalamotomy and intrathecal administration of agents such as phenol 114 and alcohol have a low chance of success.…”

Radiation-Induced Spinal Cord Anaplastic Astrocytoma Subsequent to Radiotherapy for Testicular Seminoma

“…7) Cordectomy is advocated as a reasonable alternative treatment for spinal malignant astrocytoma presenting with complete deficit below the lesion, 6,9,12) for the treatment of pain, spasticity, and posttraumatic syringomyelia. 10,20,22) The effects of cordectomy for spinal malignant astrocytoma with remaining function below the lesion are unknown. To perform cordectomy in such cases, the patients need to accept complete deficits below the lesion and decreased quality of life after cordectomy.…”