Medial Thalamotomy with the Leksell Gamma Knife for Treatment of Chronic Pain

Young, Ronald F.; Jacques, David; Rand, Robert W.; Copcutt, B. R.

doi:10.1007/978-3-7091-9371-6_22

Cited by 53 publications

(36 citation statements)

References 47 publications

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“…The thalamus has been of great interest as a target organ in stereotactic surgery for pain relief and in treatment of movement disorders [83, 181,202]. In fact, even as early as the second part of the nineteenth century, the living human thalamus was studied directly by a stereotactic approach and some atlases constructed using the intercommissural line (connecting the anterior and posterior commissures in relation to the third ventricle) [67].…”

Section: Resultsmentioning

confidence: 99%

Functional anatomy of thalamus and basal ganglia

Herrero

Barcia

Navarro

2002

Child's Nervous System

570

415

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THALAMUS: The human thalamus is a nuclear complex located in the diencephalon and comprising of four parts (the hypothalamus, the epythalamus, the ventral thalamus, and the dorsal thalamus). The thalamus is a relay centre subserving both sensory and motor mechanisms. Thalamic nuclei (50-60 nuclei) project to one or a few well-defined cortical areas. Multiple cortical areas receive afferents from a single thalamic nucleus and send back information to different thalamic nuclei. The corticofugal projection provides positive feedback to the "correct" input, while at the same time suppressing irrelevant information. Topographical organisation of the thalamic afferents and efferents is contralateral, and the lateralisation of the thalamic functions affects both sensory and motoric aspects. Symptoms of lesions located in the thalamus are closely related to the function of the areas involved. An infarction or haemorrhage thalamic lesion can develop somatosensory disturbances and/or central pain in the opposite hemibody, analgesic or purely algesic thalamic syndrome characterised by contralateral anaesthesia (or hypaesthesia), contralateral weakness, ataxia and, often, persistent spontaneous pain. BASAL GANGLIA: Basal ganglia form a major centre in the complex extrapyramidal motor system, as opposed to the pyramidal motor system (corticobulbar and corticospinal pathways). Basal ganglia are involved in many neuronal pathways having emotional, motivational, associative and cognitive functions as well. The striatum (caudate nucleus, putamen and nucleus accumbens) receive inputs from all cortical areas and, throughout the thalamus, project principally to frontal lobe areas (prefrontal, premotor and supplementary motor areas) which are concerned with motor planning. These circuits: (i) have an important regulatory influence on cortex, providing information for both automatic and voluntary motor responses to the pyramidal system; (ii) play a role in predicting future events, reinforcing wanted behaviour and suppressing unwanted behaviour, and (iii) are involved in shifting attentional sets and in both high-order processes of movement initiation and spatial working memory. Basal ganglia-thalamo-cortical circuits maintain somatotopic organisation of movement-related neurons throughout the circuit. These circuits reveal functional subdivisions of the oculomotor, prefrontal and cingulate circuits, which play an important role in attention, learning and potentiating behaviour-guiding rules. Involvement of the basal ganglia is related to involuntary and stereotyped movements or paucity of movements without involvement of voluntary motor functions, as in Parkinson's disease, Wilson's disease, progressive supranuclear palsy or Huntington's disease. The symptoms differ with the location of the lesion. The commonest disturbances in basal ganglia lesions are abulia (apathy with loss of initiative and of spontaneous thought and emotional responses) and dystonia, which become manifest as behavioural and motor disturbances, respectively.

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Section: Resultsmentioning

confidence: 99%

Functional anatomy of thalamus and basal ganglia

Herrero

Barcia

Navarro

2002

Child's Nervous System

570

415

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“…In 1968, Leksell [9] performed thalamotomy using GKS in 2 patients with cancer pain; the centromedian nucleus was targeted with a dose of 200-250 Gy maximally. Steiner et al [10] and Young [11,12] also treated intractable pain in a similar way. In a clinical study by Young et al [11], good response (150% pain reduction) was observed in 65% of the patients.…”

Section: Introductionmentioning

confidence: 90%

“…Steiner et al [10] and Young [11,12] also treated intractable pain in a similar way. In a clinical study by Young et al [11], good response (150% pain reduction) was observed in 65% of the patients. Buckland et al [13] tried to treat cancer pain using GKS to the pituitary gland with a dose of 200-250 Gy.…”

Section: Introductionmentioning

confidence: 90%

Role of Pituitary Radiosurgery for the Management of Intractable Pain and Potential Future Applications

Hayashi

Taira

Chernov

et al. 2003

Stereotact Funct Neurosurg

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Rationale: Two or three decades ago, cancer pain was treated by surgical/chemical hypophysectomy. In one report, the control of central pain (thalamic pain syndrome) was also approached with chemical hypophysectomy. Although in most of the patients these treatments resulted in a decrease in severe pain, concomitantly severe adverse effects (panhypopituitarism, diabetes insipidus and visual dysfunction) occurred in most patients. This historical evidence prompted us to perform Gamma Knife surgery (GKS) for this kind of intractable severe pain using a high irradiation dose to the pituitary stalk/gland. In the majority of patients, marked pain relief was achieved, surprisingly without any of the complications mentioned above. Materials and Methods: A prospective multicenter study was conducted to evaluate the efficacy and safety in patients treated in Prague, Hong Kong and Tokyo. Indications of this treatment were: (1) failure of other effective treatment approaches prior to GKS, (2) good general patient condition (Karnofsky performance status >40%), (3) response to morphine for pain control (cancer pain), and (4) no previous radiotherapy of brain metastases (GKS/conventional radiotherapy). Eight patients with severe cancer pain due to bone metastasis and 12 patients with post-stroke thalamic pain syndrome were treated with GKS. The target was the border between the pituitary stalk and gland. Maximum dose was 160 Gy for cancer pain and 140 Gy for central pain. Follow-up included 6 patients (>1 month) with cancer pain and 8 patients (> 6 months) with thalamic pain syndrome. Results: All patients (6/6) with cancer pain experienced significant pain reduction, and 87.5% (7/8) of the patients with thalamic pain had initially significant pain reduction. In some patients, pain reduction was delayed for several hours. Pain relief was noted within 7 days (median 2 days). No recurrence was observed in the patients with cancer pain. However, in 71.4% (5/7) of the patients with thalamic pain syndrome, disease recurred during the 6-month follow-up. Up to now, other complications have not been observed. Conclusion: Our clinical study protocol is only preliminary. Further clinical results on the management of thalamic pain are required to develop this treatment protocol. However, efficacy and safety have been shown in all our cases. In our opinion, this treatment has a potential to control severe pain, and GKS will play an important role in the management of intractable pain.

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“…Encouraged by some positive results, 70 Young 68 treated 41 patients with chronic pain related to structural spinal disorders or spinal cord injury, postherpetic neuralgia, stroke, and thalamic pain syndrome, or anesthesia dolorosa of the face. The treatment target was the medial thalamus, including the intralaminar nuclei, the lateral portions of the medial-dorsal nucleus, the centromedian nucleus, and the parafascicular nucleus.…”

Section: Chronic Pain and Thalamic Pain Syndromementioning

confidence: 99%

Stereotactic radiosurgery for functional disorders

Friehs

Park

Goldman

et al. 2007

FOC

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✓ Stereotactic radiosurgery (SRS) with the Gamma Knife and linear accelerator has revolutionized neurosurgery over the past 20 years. The most common indications for radiosurgery today are tumors and arteriovenous malformations of the brain. Functional indications such as treatment of movement disorders or intractable pain only contribute a small percentage of treated patients. Although SRS is the only noninvasive form of treatment for functional disorders, it also has some limitations: neurophysiological confirmation of the target structure is not possible, and one therefore must rely exclusively on anatomical targeting. Furthermore, lesion sizes may vary, and shielding adjacent radiosensitive neural structures may be difficult or impossible. The most common indication for functional SRS is the treatment of trigeminal neuralgia. Radiosurgical treatment for epilepsy and certain psychiatric illnesses is performed in several centers as part of strict research protocols, and radiosurgical pallidotomy or medial thalamotomy is no longer recommended due to the high risk of complications. Radiosurgical ventrolateral thalamotomy for the treatment of tremor in patients with Parkinson disease or multiple sclerosis, as well as in the treatment of essential tremor, may be indicated for a select group of patients with advanced age, significant medical conditions that preclude treatment with open surgery, or patients who must receive anticoagulation therapy. A promising new application of SRS is high-dose radiosurgery delivered to the pituitary stalk. This treatment has already been successfully performed in several centers around the world to treat severe pain in patients with end-stage cancer.

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Medial Thalamotomy with the Leksell Gamma Knife for Treatment of Chronic Pain

Cited by 53 publications

References 47 publications

Functional anatomy of thalamus and basal ganglia

Functional anatomy of thalamus and basal ganglia

Role of Pituitary Radiosurgery for the Management of Intractable Pain and Potential Future Applications

Stereotactic radiosurgery for functional disorders

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