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Neurosurgical Treatment of Chronic Pain FUMIKAZU TAKEDA M.D

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Neurosurgical Treatment of Chronic Pain FUMIKAZU TAKEDA M.D Postgrad Med J: first published as 10.1136/pgmj.60.710.905 on 1 December 1984. Downloaded from Postgraduate Medical Journal (December 1984) 60, 905-913 Neurosurgical treatment of chronic pain FUMIKAZU TAKEDA M.D. Neurosurgery Clinic, Saitama Cancer Center 818 Komuro, Ina, Saitama 362, Japan Introduction Cordotomy Neurosurgery is not a first-choice treatment for Cordotomy-section of the spinothalamic tract in chronic pain. It is indicated when chronic pain is the anterolateral quadrant of the spinal cord-used insufficiently relieved by analgesics, or when medica- to be carried out through a laminectomy until Mullan tion is effective but causes unacceptable side effects. et al. (1963, 1965) introduced the percutaneous Neurosurgical procedures may be ablative or aug- technique. Cordotomy is the treatment of choice to mentative (stimulating). An ablative procedure inter- relieve somatic non-dysaesthetic pain of organic rupts pain pathways at one of various levels in the origin in C5 dermatome or below. The most common central nervous system (CNS). In contrast, an aug- candidates for cordotomy are cancer patients, though mentative procedure is non-destructive and is gener- cordotomy is also performed for pain of benign ally considered to activate the inhibitory system in origin (Lorenz, 1976). Lipton (1979) states that copyright. the CNS, thereby suppressing pain perception. percutaneous cervical cordotomy (PCC) is not suffi- There is, however, no neurosurgical procedure ciently used, in spite of its superiority over all other which affords permanent pain relief. This stems from types of pain-relieving procedures. There are two the fact that pain is not simply the result of popular varieties of PCC: High (C1-C2) through a stimulation of specific sensory fibres in the peripheral lateral approach and low (C5-C6) through an and central nervous systems. As discussed elsewhere, anterior approach (Lin, Gildenberg and Polakoff, there are two varieties of pain: nociceptive (somatic) 1966). Both provide excellent pain and thermal and dysaesthetic (deafferentation). Some neurosurgi- anaesthesia in the contralateral half of the body. cal procedures relieve both nociceptive and dysaesth- The technique has been described in detail by etic pain, while others relieve only one or other type. Lipton (1979, 1983). In high PCC, a guide needle is http://pmj.bmj.com/ Which procedure should be used in a specific case inserted in the lateral cervical region on the contrala- depends on many variables, including efficacy, indi- teral side to the pain. When the needle enters the cations for use, advantages and disadvantages, limi- subarachnoid space, a myelography is performed. It tations and complications. These differ with each allows the needle to be positioned approximately procedure. Familiarity with neuroanatomical and (Fig. 1). Then an electrode is introduced through the neurophysiological concepts of pain mediation and needle, and intraoperative physiological studies are perception, and with a range of techniques, together performed: measurement of impedance, electrical with the necessary equipment, are all required for the stimulation, etc. The latter induces cool or warm on October 4, 2021 by guest. Protected safe and effective use of neurosurgery in the treat- tingling in the contralateral halfofthe body when the ment of pain. electrode is properly placed within the spinothalamic It is still sometimes thought that medication is no tract. The site of tingling induced by electrical longer necessary after neurosurgery even if the stimulation delineates the area in which pain relief procedure has resulted in incomplete relief. This will develop after cordotomy. A radiofrequency misunderstanding must be corrected. The goal of coagulation lesion is then produced. A somato- pain treatment is always to provide a pain-free state topographic organization for the contralateral halfof and, if necessary, it should be achieved through a the body within the lateral spinothalamic tract at Cl multi-modality approach. level has been proposed by Tasker (1976a). The following discussion of several neurosurgical The C5-C6 PCC is performed by inserting an procedures is based both on my personal experiences electrode from the anterior cervical region through and on data reported in the literature. the disc space. Bilateral PCC is carried out on a Postgrad Med J: first published as 10.1136/pgmj.60.710.905 on 1 December 1984. Downloaded from 906 F. Takeda Anterior border of spinal cord'XM FIG. 1. C l-C2 lateral percutaneous cervical cordotomy. (From Lipton 1979: Relief of Pain in Clinical Practice, Blackwell Scientific Publications, courtesy of the author and publisher). patient with bilateral pain. Since it is associated with a small retromastoid craniectomy with supracerebel-copyright. more postoperative hazards than a unilateral cordo- lar exposure using a microsurgical technique. After tomy, Lipton (1979) suggests that high lateral PCC is dissection of the blood vessel from the nerve root, a performed on one side and low anterior PCC on the spongy pad is placed between the blood vessel and other side. the nerve. Since Jannetta (1967) popularized this Tasker (1976b) reports 96% incidence of immedi- procedure, it has become the most attractive surgical ate pain relief in 199 consecutive unilateral proce- treatment of tic douloureux. Pain can be relieved by dures, and a 66% incidence of bilateral relief follow- this treatment without loss of neural function (Jan- ing bilateral procedures. Lipton (1983) performed netta, 1977). Preoperative diagnosis is based on PCC 809 times on 701 patients and obtained com- clinical assessment as cerebral angiography often plete pain relief in 86% of the cases. The effects of a fails to show nerve compression. Intraoperative http://pmj.bmj.com/ cordotomy tend to wear off within two or three years detection of a tumour compressing the nerve root is (Lipton, 1983). not rare. Removal ofthe tumour results in pain relief. Motor paresis, disturbance of micturition, dysaes- Jannetta (1977) reports excellent results following thesia, ataxia and Homer's syndrome sometimes occur surgery in 200 patients with tic douloureux. In the temporarily after PCC. Respiratory failure, resulting first 100 patients, he found compression-distortion of from impairment of automatic respiratory failure the root entry zone of the trigeminal nerve by normal during sleep is the most serious potential complication blood vessels in 88 cases, by tumours in four cases, by after high PCC, as the reticulospinal tract may be arteriovenous malformations in two cases and by on October 4, 2021 by guest. Protected destroyed if the lesion in the spinothalamic tract multiple sclerosis plaque in six cases. Recurrent pain extends ventrally. Caution should be exercised when a is documented in nine cases out of 200. This usually unilateral cordotomy is performed on a patient with results from slippage of the pad or missing a second contralateral pulmonary dysfunction. vascular loop. Both situations can be corrected by further surgery. Trigeminal rhizotomy is indicated for multiple sclerosis plaque. Neurovascular decompression Postoperative complications, e.g., meningitis, cere- The most frequent pathological process in tic bellar infarction and haematoma, and hearing loss douloureux, or classical trigeminal neuralgia, is now occur less often with greater surgical experience. considered to be distortion of the trigeminal nerve by Glossopharyngeal neuralgia can also be relieved by cross-compression of blood vessels (Jannetta, 1967, neurovascular decompression (Laha and Jannetta, 1977). Neurovascular decompression is done through 1977). Postgrad Med J: first published as 10.1136/pgmj.60.710.905 on 1 December 1984. Downloaded from Neurosurgery for chronic pain 907 Cranial nerve rhizotomy correct position of the electrode is finally determined, the sensory root is destroyed with a radiofrequency Trigeminal rhizotomy current. As stated by Tew and Keller (1977), ophthalmolo- Sweet and Wepsic (1974) obtained relief of trige- gical complications and a significant mortality rate minal neuralgia in 91% out of 217 patients, with a following retrogasserian trigeminal rhizotomy using recurrence rate of 22% in 125 patients over the next a direct intracranial approach have encouraged the 2-5-6 years. Based on results from 400 patients, Tew, development of alternative procedures such as percu- van Loveren and Keller (1982) report that 61% taneous injection (Harris, 1940) and coagulation obtained excellent relief and 13% good relief, while (Kirschner, 1932). Sweet and Wepsic (1974) revised 5% have undesirable side effects, such as troublesome the percutaneous radiofrequency coagulation tech- dysaesthesia in the face, and 1% have no relief. Pain nique, preserving touch sensation in the zone ren- recurred in 20%o of the patients during a follow-up dered analgesic. Percutaneous radiofrequency rhizo- period which averaged 6 years. tomy of the trigeminal nerve is indicated, at present, The most serious complication is production of an for the alleviation of tic douloureux, mainly in anaesthetic cornea, which sometimes results in cor- elderly patients, because it can be carried out under neal scarring. Dysaesthesia in the analgesic region, local anaesthesia. It is also performed in the treat- masseter weakness and extraocular cranial nerve ment of some other types of chronic facial pain e.g., palsies are also reported (Tew et al., 1982). cancer pain, but it often fails to be effective against postherpetic
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