Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0018
P. Hunt, Patrick J. Karas, A. Viswanathan, S. Sheth
Chronic pain is a common and often debilitating condition. This pain can be intractable to pharmacologic treatment, thereby necessitating non-pharmacologic approaches. Here we review anterior cingulotomy as a surgical solution to intractable chronic pain, from assessment and planning through the procedure and aftercare. Ablating tissue within the anterior cingulate cortex may allow for the amelioration of the affective aspect of chronic pain. This is especially beneficial to patients with significant psychiatric components to their pain, patients who are unfit for neuromodulatory implants, and patients with terminal diagnoses. Anterior cingulotomy is irreversible and is less commonly used than reversible neuromodulatory approaches. However, anterior cingulotomy remains an important option for patients suffering from intractable chronic pain.
{"title":"Cingulotomy for Intractable Pain","authors":"P. Hunt, Patrick J. Karas, A. Viswanathan, S. Sheth","doi":"10.1093/MED/9780190887674.003.0018","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0018","url":null,"abstract":"Chronic pain is a common and often debilitating condition. This pain can be intractable to pharmacologic treatment, thereby necessitating non-pharmacologic approaches. Here we review anterior cingulotomy as a surgical solution to intractable chronic pain, from assessment and planning through the procedure and aftercare. Ablating tissue within the anterior cingulate cortex may allow for the amelioration of the affective aspect of chronic pain. This is especially beneficial to patients with significant psychiatric components to their pain, patients who are unfit for neuromodulatory implants, and patients with terminal diagnoses. Anterior cingulotomy is irreversible and is less commonly used than reversible neuromodulatory approaches. However, anterior cingulotomy remains an important option for patients suffering from intractable chronic pain.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"176 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128343376","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0019
N. Field, J. Pilitsis
Motor cortex stimulation is a surgical treatment for medically refractory trigeminal neuropathic pain, a syndrome often caused by nerve injury due to trauma, dental work, or previous surgery for trigeminal neuralgia. Preoperative planning includes pain assessment scales, psychological clearance, and functional magnetic resonance imaging (fMRI) to map the motor cortex. The patient undergoes a craniotomy with trial placement of an epidural electrode array, assisted by neuronavigation, phase reversal monitoring, and somatosensory evoked potential recordings. Less commonly, the electrodes are placed in the subdural space. Postoperative seizure is the most common complication, additionally there are risks for infection and hemorrhage. Programming of the device is performed and the patient undergoes permanent implantation of the system if they achieve a greater than 50% reduction in their pain. Further research is necessary to determine which patients will have the best response to therapy.
{"title":"Trigeminal Neuropathic Pain","authors":"N. Field, J. Pilitsis","doi":"10.1093/MED/9780190887674.003.0019","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0019","url":null,"abstract":"Motor cortex stimulation is a surgical treatment for medically refractory trigeminal neuropathic pain, a syndrome often caused by nerve injury due to trauma, dental work, or previous surgery for trigeminal neuralgia. Preoperative planning includes pain assessment scales, psychological clearance, and functional magnetic resonance imaging (fMRI) to map the motor cortex. The patient undergoes a craniotomy with trial placement of an epidural electrode array, assisted by neuronavigation, phase reversal monitoring, and somatosensory evoked potential recordings. Less commonly, the electrodes are placed in the subdural space. Postoperative seizure is the most common complication, additionally there are risks for infection and hemorrhage. Programming of the device is performed and the patient undergoes permanent implantation of the system if they achieve a greater than 50% reduction in their pain. Further research is necessary to determine which patients will have the best response to therapy.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"9 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128184195","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0011
O. Sagher
The treatment of spinal cord injury pain is one of the most challenging clinical problems in pain neurosurgery. It represents a type of deafferentation pain that resists most treatment modalities. And while ablative neurosurgical procedures have largely been abandoned in the treatment of deafferentation pain, it still plays an important role in transitional zone pain. This chapter outlines the essential clinical features of transitional zone pain following spinal cord injury and describes the use of dorsal root entry zone lesioning (DREZ) in its management. The decision-making process involved in offering this procedure is nuanced, and this chapter provides key considerations important in counseling patients prior to surgery.
{"title":"Spinal Cord Injury Transitional Zone Pain","authors":"O. Sagher","doi":"10.1093/MED/9780190887674.003.0011","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0011","url":null,"abstract":"The treatment of spinal cord injury pain is one of the most challenging clinical problems in pain neurosurgery. It represents a type of deafferentation pain that resists most treatment modalities. And while ablative neurosurgical procedures have largely been abandoned in the treatment of deafferentation pain, it still plays an important role in transitional zone pain. This chapter outlines the essential clinical features of transitional zone pain following spinal cord injury and describes the use of dorsal root entry zone lesioning (DREZ) in its management. The decision-making process involved in offering this procedure is nuanced, and this chapter provides key considerations important in counseling patients prior to surgery.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"46 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117312842","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}
Pub Date : 2019-07-01DOI: 10.1093/med/9780190887674.003.0007
R. Weiner
Patients with occipital neuralgia typically complain of intractable, posterior headaches. Prior attempts to treat this condition have traditionally consisted of various strategies to decompress or cut the greater occipital nerve. Some have even advocated the ablation of ganglia or cervical roots that give rise to the occipital nerve. However, such treatments are highly invasive, irreversible, and fraught with failure and complications. Modern strategies employing subcutaneous stimulation of the occipital nerve using linear stimulation arrays are quite effective and lower in invasiveness and risk. This chapter discusses the clinical hallmarks of occipital neuralgia and the technique by which these subcutaneous electrodes are implanted and utilized.
{"title":"Occipital Neuralgia","authors":"R. Weiner","doi":"10.1093/med/9780190887674.003.0007","DOIUrl":"https://doi.org/10.1093/med/9780190887674.003.0007","url":null,"abstract":"Patients with occipital neuralgia typically complain of intractable, posterior headaches. Prior attempts to treat this condition have traditionally consisted of various strategies to decompress or cut the greater occipital nerve. Some have even advocated the ablation of ganglia or cervical roots that give rise to the occipital nerve. However, such treatments are highly invasive, irreversible, and fraught with failure and complications. Modern strategies employing subcutaneous stimulation of the occipital nerve using linear stimulation arrays are quite effective and lower in invasiveness and risk. This chapter discusses the clinical hallmarks of occipital neuralgia and the technique by which these subcutaneous electrodes are implanted and utilized.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117223859","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0012
B. Gill, F. Khan, C. Winfree
Failed back surgery syndrome (FBSS), or post-laminectomy syndrome, is a form of chronic lumbar radiculopathy characterized by persistent pain following spinal surgery. When medical management for FBSS fails, three surgical options remain: revision lumbar surgery, spinal cord stimulation (SCS), or intrathecal infusion pump placement. If faced with neurological deficits and correlative compressive lesions, revision lumbar surgery is often indicated. But in the absence of such complications, surgeons and their patients can explore the two latter options. Thus, this chapter will implement a case study to navigate the decision making involved when choosing either SCS or intrathecal infusion pump placement.
{"title":"Chronic Lumbar Radiculopathy","authors":"B. Gill, F. Khan, C. Winfree","doi":"10.1093/MED/9780190887674.003.0012","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0012","url":null,"abstract":"Failed back surgery syndrome (FBSS), or post-laminectomy syndrome, is a form of chronic lumbar radiculopathy characterized by persistent pain following spinal surgery. When medical management for FBSS fails, three surgical options remain: revision lumbar surgery, spinal cord stimulation (SCS), or intrathecal infusion pump placement. If faced with neurological deficits and correlative compressive lesions, revision lumbar surgery is often indicated. But in the absence of such complications, surgeons and their patients can explore the two latter options. Thus, this chapter will implement a case study to navigate the decision making involved when choosing either SCS or intrathecal infusion pump placement.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"27 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123875231","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0013
Sebastian Rubino, Shelby Sabourin, J. Pilitsis
Vertebral metastases often lead to a complex pain syndrome that consists of both nociceptive and neuropathic pain. Multimodal medical management often includes paracetamol, non-steroidal anti-inflammatory agents, bisphosphonates, opioids, antidepressants, anti-epileptics, and neuroleptics. Surgical treatment to address oncologic burden and spinal instability, radiation therapy, and vertebroplasty or kyphoplasty may be indicated for some patients. However, often times patients with advanced malignancies are not able to safely undergo surgery and have medication-refractory oncologic pain. For these patients and for patients unwilling to undergo large oncologic or spinal stabilization surgeries, intrathecal drug therapy (IDT) serves as a safe and effective adjunct in the management of cancer-related pain.
{"title":"Intrathecal Drug Therapy for Painful Vertebral Metastases","authors":"Sebastian Rubino, Shelby Sabourin, J. Pilitsis","doi":"10.1093/MED/9780190887674.003.0013","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0013","url":null,"abstract":"Vertebral metastases often lead to a complex pain syndrome that consists of both nociceptive and neuropathic pain. Multimodal medical management often includes paracetamol, non-steroidal anti-inflammatory agents, bisphosphonates, opioids, antidepressants, anti-epileptics, and neuroleptics. Surgical treatment to address oncologic burden and spinal instability, radiation therapy, and vertebroplasty or kyphoplasty may be indicated for some patients. However, often times patients with advanced malignancies are not able to safely undergo surgery and have medication-refractory oncologic pain. For these patients and for patients unwilling to undergo large oncologic or spinal stabilization surgeries, intrathecal drug therapy (IDT) serves as a safe and effective adjunct in the management of cancer-related pain.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"67 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125181654","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0005
M. Behbahani, N. Chaudhry, K. Slavin
Trigeminal neuropathic pain (TNP) involves pain isolated to the distribution of one or more branches of the trigeminal nerve following unintentional injury to that nerve. It is important to distinguish this facial pain syndrome from trigeminal neuralgia, as the treatment is quite different. The diagnosis is typically clinical, although local anesthetic blocks may aid in the diagnosis. Psychological testing is often performed preoperatively. Like other neuropathic pain syndromes, TNP may be treated with peripheral nerve stimulation. This chapter discusses a typical presentation of TNP, as well as the evaluation and management process, including placement of subcutaneous electrodes and connection to an internal pulse generator.
{"title":"Trigeminal Neuropathic Pain","authors":"M. Behbahani, N. Chaudhry, K. Slavin","doi":"10.1093/MED/9780190887674.003.0005","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0005","url":null,"abstract":"Trigeminal neuropathic pain (TNP) involves pain isolated to the distribution of one or more branches of the trigeminal nerve following unintentional injury to that nerve. It is important to distinguish this facial pain syndrome from trigeminal neuralgia, as the treatment is quite different. The diagnosis is typically clinical, although local anesthetic blocks may aid in the diagnosis. Psychological testing is often performed preoperatively. Like other neuropathic pain syndromes, TNP may be treated with peripheral nerve stimulation. This chapter discusses a typical presentation of TNP, as well as the evaluation and management process, including placement of subcutaneous electrodes and connection to an internal pulse generator.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131380098","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0002
K. Raygor, Anthony T. Lee, E. Chang
Treatment of trigeminal neuralgia (TN) in the elderly is accomplished using both medical and surgical approaches. Medical therapies are similar to those used in younger patients, but drug-drug interactions are more common in the elderly. Oxcarbazepine is one drug that has fewer side effects due to its bypassing of the cytochrome P-450 metabolic pathway. Surgical options are used for medically refractory TN; the only non-ablative procedure—microvascular decompression (MVD)—provides the most durable pain freedom but may be deferred in patients deemed to be high risk. Both outcomes and complications are similar in young and elderly patients undergoing MVD. In those deemed unsafe for MVD, ablative procedures including stereotactic radiosurgery (SRS) and various percutaneous procedures can be offered. Future studies directly comparing outcomes after MVD and SRS in the elderly with large, prospectively collected databases would help guide management strategies in elderly patients with medically refractory TN.
{"title":"Idiopathic Trigeminal Neuralgia in the Elderly","authors":"K. Raygor, Anthony T. Lee, E. Chang","doi":"10.1093/MED/9780190887674.003.0002","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0002","url":null,"abstract":"Treatment of trigeminal neuralgia (TN) in the elderly is accomplished using both medical and surgical approaches. Medical therapies are similar to those used in younger patients, but drug-drug interactions are more common in the elderly. Oxcarbazepine is one drug that has fewer side effects due to its bypassing of the cytochrome P-450 metabolic pathway. Surgical options are used for medically refractory TN; the only non-ablative procedure—microvascular decompression (MVD)—provides the most durable pain freedom but may be deferred in patients deemed to be high risk. Both outcomes and complications are similar in young and elderly patients undergoing MVD. In those deemed unsafe for MVD, ablative procedures including stereotactic radiosurgery (SRS) and various percutaneous procedures can be offered. Future studies directly comparing outcomes after MVD and SRS in the elderly with large, prospectively collected databases would help guide management strategies in elderly patients with medically refractory TN.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"36 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116991350","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0014
A. Viswanathan
The management of medically refractory cancer pain is a complex, multi-disciplinary effort. When optimal medical management has failed, neuroablative and neuromodulatory efforts can be used. While neuromodulation is an attractive option due its minimally invasive nature, neuroablation offers the advantage of high efficacy and the lack of maintenance or upkeep requirements. Punctate midline myelotomy is an ablative procedure targeting the ascending visceral pain pathway in the dorsal columns. The procedure can be performed through an open approach creating a mechanical lesion, or percutaneously via either a mechanical lesion or radiofrequency ablation. Careful attention to the spinal cord midline during lesion creation and attention to surgical technique, including an excellent fascial closure, can minimize potential complications.
{"title":"Pelvic/Visceral Cancer Pain","authors":"A. Viswanathan","doi":"10.1093/MED/9780190887674.003.0014","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0014","url":null,"abstract":"The management of medically refractory cancer pain is a complex, multi-disciplinary effort. When optimal medical management has failed, neuroablative and neuromodulatory efforts can be used. While neuromodulation is an attractive option due its minimally invasive nature, neuroablation offers the advantage of high efficacy and the lack of maintenance or upkeep requirements. Punctate midline myelotomy is an ablative procedure targeting the ascending visceral pain pathway in the dorsal columns. The procedure can be performed through an open approach creating a mechanical lesion, or percutaneously via either a mechanical lesion or radiofrequency ablation. Careful attention to the spinal cord midline during lesion creation and attention to surgical technique, including an excellent fascial closure, can minimize potential complications.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130380609","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}
Pub Date : 2019-07-01DOI: 10.1093/MED/9780190887674.003.0015
E. Levin
Diabetic neuropathy may cause numbness and burning pain in a distal, symmetric distribution, typically involving the hands and feet. Management is with improved glucose control and treatment with tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, and anti-epileptics. Surgical treatment is reserved for those patients with severe symptoms, with significantly impaired quality of life, for whom medications have not provided significant relief. There is evidence that spinal cord stimulation can provide a significant reduction in pain. A temporary trial of stimulation should be performed prior to permanent implantation. Leads may be placed in the epidural space percutaneously or via laminectomy and are connected to an internal pulse generator. Complications are typically device related. Treatment of device infection may require device removal.
{"title":"Painful Diabetic Neuropathy","authors":"E. Levin","doi":"10.1093/MED/9780190887674.003.0015","DOIUrl":"https://doi.org/10.1093/MED/9780190887674.003.0015","url":null,"abstract":"Diabetic neuropathy may cause numbness and burning pain in a distal, symmetric distribution, typically involving the hands and feet. Management is with improved glucose control and treatment with tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, and anti-epileptics. Surgical treatment is reserved for those patients with severe symptoms, with significantly impaired quality of life, for whom medications have not provided significant relief. There is evidence that spinal cord stimulation can provide a significant reduction in pain. A temporary trial of stimulation should be performed prior to permanent implantation. Leads may be placed in the epidural space percutaneously or via laminectomy and are connected to an internal pulse generator. Complications are typically device related. Treatment of device infection may require device removal.","PeriodicalId":372220,"journal":{"name":"Pain Neurosurgery","volume":"2 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117034036","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}
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