Louis Whitworth1, Julius Fernández2, Claudio Feler2
The control of chronic intractable pain has been a challenge to neurosurgeons for decades. Over the last 30 years there has been a shift in treatment paradigms from ablation to neuroaugmentation therapies. Surgical ablative treatments have in common the risk of motor system deficits and delayed deafferentation pain. In recent years, electrical stimulation and intrathecal drug delivery have become the favored interventional treatments for chronic benign pain syndromes. The use of electrical stimulation on the human brain to modulate pain dates back to the 1950s. Paramount to obtaining a good outcome with deep brain stimulation (DBS) is the proper selection of a patient and a correct target. In contemporary times, selection of patients for DBS procedures should be limited to those who experience neuropathic pain syndromes and more specifically complain of constant, steady burning or aching pain. These patients must first be considered for stimulation at other sites, such as spinal cord, nerve root, or peripheral nerve. Patients who have had trials with one of these other targets may have failed to respond for a variety of reasons. If the failure has been due to an inability to produce an overlap of paresthesia on the pain segment, the patient may be considered a candidate for DBS. Other reasons for failure of the previously attempted targets are likely to predict failure of DBS as well.
{"title":"Deep Brain Stimulation for Chronic Pain","authors":"Louis Whitworth1, Julius Fernández2, Claudio Feler2","doi":"10.1055/s-2004-835707","DOIUrl":"https://doi.org/10.1055/s-2004-835707","url":null,"abstract":"The control of chronic intractable pain has been a challenge to neurosurgeons for decades. Over the last 30 years there has been a shift in treatment paradigms from ablation to neuroaugmentation therapies. Surgical ablative treatments have in common the risk of motor system deficits and delayed deafferentation pain. In recent years, electrical stimulation and intrathecal drug delivery have become the favored interventional treatments for chronic benign pain syndromes. The use of electrical stimulation on the human brain to modulate pain dates back to the 1950s. Paramount to obtaining a good outcome with deep brain stimulation (DBS) is the proper selection of a patient and a correct target. In contemporary times, selection of patients for DBS procedures should be limited to those who experience neuropathic pain syndromes and more specifically complain of constant, steady burning or aching pain. These patients must first be considered for stimulation at other sites, such as spinal cord, nerve root, or peripheral nerve. Patients who have had trials with one of these other targets may have failed to respond for a variety of reasons. If the failure has been due to an inability to produce an overlap of paresthesia on the pain segment, the patient may be considered a candidate for DBS. Other reasons for failure of the previously attempted targets are likely to predict failure of DBS as well.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"41 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114307142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Early surgical observations during microvascular decompression (MVD) procedures have contributed to our knowledge and theories regarding the pathophysiology of trigeminal neuralgia. This procedure represents the only therapy that directly addresses the presumed etiology of the disease and is associated with the longest duration of pain relief. Once thought to represent a major operation with significant risks and rate of mortality, MVD is now performed routinely and safely worldwide because of advances in anesthesia, monitoring, and microsurgical technique. Modern imaging now provides accurate pre-operative assessment of the trigeminal nerve, which should increase surgical success rates and limit failures or complications.
{"title":"Trigeminal Neuralgia: Microvascular Decompression","authors":"W. Elias1, Kim Burchiel2","doi":"10.1055/s-2004-835704","DOIUrl":"https://doi.org/10.1055/s-2004-835704","url":null,"abstract":"Early surgical observations during microvascular decompression (MVD) procedures have contributed to our knowledge and theories regarding the pathophysiology of trigeminal neuralgia. This procedure represents the only therapy that directly addresses the presumed etiology of the disease and is associated with the longest duration of pain relief. Once thought to represent a major operation with significant risks and rate of mortality, MVD is now performed routinely and safely worldwide because of advances in anesthesia, monitoring, and microsurgical technique. Modern imaging now provides accurate pre-operative assessment of the trigeminal nerve, which should increase surgical success rates and limit failures or complications.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"42 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123322643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The dorsal root entry zone (and dorsal horn)—which is the first important level of modulation for pain sensation—can be a neurosurgical target to treat resistant pain. Lesioning techniques include microsurgical coagulation, radiofrequency thermocoagulation, laser beam or ultrasound lesion maker. Indications are (1) malignant pain in patients with long life expectancy and cancer that is limited in extent (such as in Pancoast-Tobias syndrome); (2) persistent neuropathic pain that is due to (a) brachial plexus injuries, especially those with avulsion, (b) spinal cord lesions (predominantly in the conus medullaris), especially the pain corresponding to segmental lesions (pain below the lesion is not favorably influenced), (c) segmental pain caused by lesions in the cauda equina, (d) peripheral nerve injuries, amputation, or herpes zoster, when the predominant component of pain is of the paroxysmal type and/or corresponds to provoked allodynia or hyperalgesia; and (3) disabling hyperspastic states with pain.
{"title":"Surgery in the Dorsal Root Entry Zone for Pain","authors":"Marc Sindou1, Patrick Mertens1","doi":"10.1055/s-2004-835710","DOIUrl":"https://doi.org/10.1055/s-2004-835710","url":null,"abstract":"The dorsal root entry zone (and dorsal horn)—which is the first important level of modulation for pain sensation—can be a neurosurgical target to treat resistant pain. Lesioning techniques include microsurgical coagulation, radiofrequency thermocoagulation, laser beam or ultrasound lesion maker. Indications are (1) malignant pain in patients with long life expectancy and cancer that is limited in extent (such as in Pancoast-Tobias syndrome); (2) persistent neuropathic pain that is due to (a) brachial plexus injuries, especially those with avulsion, (b) spinal cord lesions (predominantly in the conus medullaris), especially the pain corresponding to segmental lesions (pain below the lesion is not favorably influenced), (c) segmental pain caused by lesions in the cauda equina, (d) peripheral nerve injuries, amputation, or herpes zoster, when the predominant component of pain is of the paroxysmal type and/or corresponds to provoked allodynia or hyperalgesia; and (3) disabling hyperspastic states with pain.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"35 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128843250","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In medical practice, each time span has a dogma of that period. Now, in the science and technology age, one particular dogma is very extensively accepted and used in pain practice. There is a general belief in neurosurgical practice that lesioning of the pain conducting system is accepted as ablative and dangerous. This idea is a dogma and it is wrong. In modern times, modern stereotactic pain surgery is performed in three important steps. First, morphology and localization of the pain conducting pathways are demonstrated with special imaging techniques; the surgeon approaches the target percutaneously by a specially designed needle electrode system. Second, the function of the target and surrounding structures can be defined by stimulation just after the target is totally, partially, or selectively destroyed by radiofrequency lesion. Third, lesioning of the system is controlled at every step of the procedure. These procedures are applied with morphological real-time demonstration, physiological evaluation of the target, and, finally, controlled lesioning. In this way, this surgery is performed safely and effectively. In this paper, I describe the techniques of this method based on a 17-year experience with three different stereotactic destructive procedures: CT-guided percutaneous cordotomy, trigeminal trac-totomy, and extralemniscal myelotomy.
{"title":"Percutaneous Cordotomy, Tractotomy, and Midline Myelotomy: Minimally Invasive Stereotactic Pain Procedures","authors":"Yucel Kanpolat1","doi":"10.1055/s-2004-835709","DOIUrl":"https://doi.org/10.1055/s-2004-835709","url":null,"abstract":"In medical practice, each time span has a dogma of that period. Now, in the science and technology age, one particular dogma is very extensively accepted and used in pain practice. There is a general belief in neurosurgical practice that lesioning of the pain conducting system is accepted as ablative and dangerous. This idea is a dogma and it is wrong. In modern times, modern stereotactic pain surgery is performed in three important steps. First, morphology and localization of the pain conducting pathways are demonstrated with special imaging techniques; the surgeon approaches the target percutaneously by a specially designed needle electrode system. Second, the function of the target and surrounding structures can be defined by stimulation just after the target is totally, partially, or selectively destroyed by radiofrequency lesion. Third, lesioning of the system is controlled at every step of the procedure. These procedures are applied with morphological real-time demonstration, physiological evaluation of the target, and, finally, controlled lesioning. In this way, this surgery is performed safely and effectively. In this paper, I describe the techniques of this method based on a 17-year experience with three different stereotactic destructive procedures: CT-guided percutaneous cordotomy, trigeminal trac-totomy, and extralemniscal myelotomy.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"92 3 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116298791","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Douglas Kondziolka1 , 2 , 3, L. Lunsford1 , 2 , 3, John Flickinger1 , 2 , 3
Although medical therapy is of benefit to many patients with trigeminal neuralgia, surgical management is often performed for patients with medically refractory pain. Gamma knife radiosurgery has been advocated as a minimally invasive alternative surgical approach to microvascular decompression or percutaneous surgeries. In this article, we review the safety and efficacy of this technique and discuss potential ways to improve on results.
{"title":"Trigeminal Neuralgia Radiosurgery","authors":"Douglas Kondziolka1 , 2 , 3, L. Lunsford1 , 2 , 3, John Flickinger1 , 2 , 3","doi":"10.1055/s-2004-835703","DOIUrl":"https://doi.org/10.1055/s-2004-835703","url":null,"abstract":"Although medical therapy is of benefit to many patients with trigeminal neuralgia, surgical management is often performed for patients with medically refractory pain. Gamma knife radiosurgery has been advocated as a minimally invasive alternative surgical approach to microvascular decompression or percutaneous surgeries. In this article, we review the safety and efficacy of this technique and discuss potential ways to improve on results.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"9 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126916198","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This article reviews the current knowledge and clinical applications of spinal cord stimulation for chronic pain management. It also covers basic neurophysiology, implantation techniques, indications, and complications.
{"title":"Spinal Cord Stimulation for Chronic Pain Management","authors":"Giancarlo Barolat1, Ashwini Sharan1","doi":"10.1055/s-2004-835705","DOIUrl":"https://doi.org/10.1055/s-2004-835705","url":null,"abstract":"This article reviews the current knowledge and clinical applications of spinal cord stimulation for chronic pain management. It also covers basic neurophysiology, implantation techniques, indications, and complications.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"43 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115576807","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Intracranial stereotactic procedures in the central nervous system for the treatment of medically refractory chronic pain have evolved over the years. Neuroablative lesions have become a rare treatment for chronic pain, primarily because of the advent of more effective pharmacotherapy and intrathecal drug delivery. Lesion generation has the advantage of being less costly and having none of the hardware-related side effects of deep brain stimulation but the disadvantage of not being modifiable or reversible when the lesion has been generated. Although neuroablative procedures typically result in short-lived pain relief and the possibility of deafferentation pain, these procedures are still useful in certain clinical settings. The indications, methods employed, and outcome for these procedures are covered in this article.
{"title":"Stereotactic Ablative Procedures for Pain Relief","authors":"Aviva Abosch1, Andres Lozano2","doi":"10.1055/s-2004-835708","DOIUrl":"https://doi.org/10.1055/s-2004-835708","url":null,"abstract":"Intracranial stereotactic procedures in the central nervous system for the treatment of medically refractory chronic pain have evolved over the years. Neuroablative lesions have become a rare treatment for chronic pain, primarily because of the advent of more effective pharmacotherapy and intrathecal drug delivery. Lesion generation has the advantage of being less costly and having none of the hardware-related side effects of deep brain stimulation but the disadvantage of not being modifiable or reversible when the lesion has been generated. Although neuroablative procedures typically result in short-lived pain relief and the possibility of deafferentation pain, these procedures are still useful in certain clinical settings. The indications, methods employed, and outcome for these procedures are covered in this article.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"95 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124288477","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Percutaneous destructive procedures include radiofrequency rhizotomy, glycerol rhizotomy, and trigeminal balloon compression. These procedures are best offered to patients who cannot undergo microvascular decompression or gamma knife radiosurgery or who fail the latter procedures. They are especially utilized in elderly patients in poor medical condition and in the treatment of trigeminal neuralgia associated with multiple sclerosis. All percutaneous destructive procedures cause injury to trigeminal rootlets. Under fluoroscopic guidance, a needle is inserted into the foramen ovale. In radiofrequency rhizotomy, an electrode that can deliver radiofrequency energy is advanced behind the ganglion into the painful trigeminal rootlets, causing thermal destruction of especially small myelinated fibers. In glycerol rhizotomy, glycerol in injected into the trigeminal cistern causing chemical injury to various trigeminal rootlets. In balloon compression, a #4 fogarty balloon is advanced into the porus trigeminus. When inflated, the balloon compresses the trigeminal rootlets against the dura, causing a mechanical injury to especially the large myelinated fibers. All percutaneous destructive procedures achieve a high rate of immediate initial pain relief and are associated with various rates of pain recurrence. Significant dysesthesia is the main potential complication that should be avoided by meticulous attention to details.
{"title":"Trigeminal Neuralgia: Percutaneous Procedures","authors":"Jamal Taha1 , 2","doi":"10.1055/s-2004-835702","DOIUrl":"https://doi.org/10.1055/s-2004-835702","url":null,"abstract":"Percutaneous destructive procedures include radiofrequency rhizotomy, glycerol rhizotomy, and trigeminal balloon compression. These procedures are best offered to patients who cannot undergo microvascular decompression or gamma knife radiosurgery or who fail the latter procedures. They are especially utilized in elderly patients in poor medical condition and in the treatment of trigeminal neuralgia associated with multiple sclerosis. All percutaneous destructive procedures cause injury to trigeminal rootlets. Under fluoroscopic guidance, a needle is inserted into the foramen ovale. In radiofrequency rhizotomy, an electrode that can deliver radiofrequency energy is advanced behind the ganglion into the painful trigeminal rootlets, causing thermal destruction of especially small myelinated fibers. In glycerol rhizotomy, glycerol in injected into the trigeminal cistern causing chemical injury to various trigeminal rootlets. In balloon compression, a #4 fogarty balloon is advanced into the porus trigeminus. When inflated, the balloon compresses the trigeminal rootlets against the dura, causing a mechanical injury to especially the large myelinated fibers. All percutaneous destructive procedures achieve a high rate of immediate initial pain relief and are associated with various rates of pain recurrence. Significant dysesthesia is the main potential complication that should be avoided by meticulous attention to details.","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"206 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122589987","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Pain Management for the Neurosurgeon: Part 2","authors":"Kim Burchiel1","doi":"10.1055/s-2004-835701","DOIUrl":"https://doi.org/10.1055/s-2004-835701","url":null,"abstract":"","PeriodicalId":287382,"journal":{"name":"Seminars in Neurosurgery","volume":"137 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2004-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115182436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：