Percutaneous Cordotomy, Tractotomy, and Midline Myelotomy: Minimally Invasive Stereotactic Pain Procedures

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.