Neurosurgical ablative procedures for intractable cancer pain

2020 ◽  
Vol 133 (1) ◽  
pp. 144-151
Author(s):  
Assaf Berger ◽  
Uri Hochberg ◽  
Alexander Zegerman ◽  
Rotem Tellem ◽  
Ido Strauss
Keyword(s):  
Pain Relief ◽  
Cancer Pain ◽  
Patient Selection ◽  
Metastatic Cancer ◽  
Careful Consideration ◽  
Neurosurgical Procedures ◽  
Pain Pathways ◽  
Good Pain Relief ◽  
Intractable Cancer Pain

OBJECTIVECancer patients suffering from severe refractory pain may benefit from targeted ablative neurosurgical procedures aimed to disconnect pain pathways in the spinal cord or the brain. These patients often present with a plethora of medical problems requiring careful consideration before surgical interventions. The authors present their experience at an interdisciplinary clinic aimed to facilitate appropriate patient selection for neurosurgical procedures, and the outcome of these interventions.METHODSThis study was a retrospective review of all patients who underwent neurosurgical interventions for cancer pain in the authors’ hospital between March 2015 and April 2018. All patients had advanced metastatic cancer with limited life expectancy and suffered from intractable oncological pain.RESULTSSixty patients underwent surgery during the study period. Forty-three patients with localized pain underwent disconnection of the spinal pain pathways: 34 percutaneous-cervical and 5 open-thoracic cordotomies, 2 stereotactic mesencephalotomies, and 2 midline myelotomies. Thirty-nine of 42 patients (93%) who completed these procedures had excellent immediate postoperative pain relief. At 1 month the improvement was maintained in 30/36 patients (83%) available for follow-up. There was 1 case of hemiparesis.Twenty patients with diffuse pain underwent stereotactic cingulotomy. Nineteen of these patients reported substantial pain relief immediately after the operation. At 1 month good pain relief was maintained in 13/17 patients (76%) available for follow-up, and good pain relief was also found at 3 months in 7/11 patients (64%). There was no major morbidity or mortality.CONCLUSIONSWith careful patient selection and tailoring of the appropriate procedure to the patient’s pain syndrome, the authors’ experience indicates that neurosurgical procedures are safe and effective in alleviating suffering in patients with intractable cancer pain.

Tailoring of neurosurgical ablative procedures in the management of refractory cancer pain

2020 ◽  
Vol 45 (9) ◽  
pp. 696-701
Author(s):  
Uri Hochberg ◽  
Asaf Berger ◽  
Miri Atias ◽  
Rotem Tellem ◽  
Ido Strauss
Keyword(s):  
Pain Relief ◽  
Cancer Pain ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Treatment Plan ◽  
Metastatic Cancer ◽  
Spinothalamic Tract ◽  
Pain Syndromes ◽  
Intractable Cancer Pain ◽  
Ablative Procedures

IntroductionNeurosurgical ablative procedures can offer immediate and effective pain relief for patients suffering from refractory cancer pain. However, choosing the appropriate procedure for each patient may not be straightforward and warrants an interdisciplinary approach. The purpose of the current study was to evaluate the outcome of patients with cancer who were carefully selected for neurosurgical intervention by a dedicated interdisciplinary team composed of a palliative physician and nurse practitioner, a pain specialist and a neurosurgeon.MethodsA retrospective review was carried out on all patients who underwent neurosurgical ablative procedures in our institute between March 2015 and September 2019. All patients had advanced metastatic cancer with unfavorable prognosis and suffered from intractable oncological pain. Each treatment plan was devised to address the patients’ specific pain syndromes.ResultsA total of 204 patients were examined by our service during the study period. Sixty-four patients with localized pain and nineteen patients with diffuse pain syndromes were selected for neurosurgical interventions, either targeted disconnection of the spinothalamic tract or stereotactic cingulotomy. Substantial pain relief was reported by both groups immediately (cordotomy: Numerical Rating Scale (NRS) 9 ≥1, p=0.001, cingulotomy: NRS 9 ≥2, p=0.001) and maintained along the next 3-month follow-up visits.ConclusionsAn interdisciplinary collaboration designated to provide neurosurgical ablative procedures among carefully selected patients could culminate in substantial relief of intractable cancer pain.Trial registration numberIR0354-17.

scholarly journals Radiofrequency Denervation of the Lumbar Zygapophysial Joints: 10-Year Prospective Clinical Audit

2007 ◽  
Vol 2;10 (3;2) ◽  
pp. 291-299
Author(s):  
Michael Gofeld
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Pain Relief ◽  
Patient Selection ◽  
Clinical Audit ◽  
Low Back ◽  
Zygapophysial Joint ◽  
Radiofrequency Neurotomy ◽  
Radiofrequency Denervation

Background: Evidence for the efficacy of zygapophysial joint nerve radiofrequency neurotomy has remained controversial. Two randomized controlled trials showed positive results, but two others demonstrated no benefit. One carefully performed prospective trial confirmed high efficacy and lasting pain relief after the procedure; however, selection criteria for this study were superfluous, which resulted in a small number of patients available for follow up. Objectives: A large clinical audit with routine patient selection and use of appropriate technique was undertaken to determine the effect of radiofrequency neurotomy of the lumbar facet joints for relief of chronic low back pain. Design: Prospective clinical audit for quality was conducted in the pain clinic affiliated with a tertiary care teaching hospital. Setting: An interventional pain management setting in Canada. Methods: All patients with low back pain of more than 6 months’ duration, with or without non-radicular radiation to the buttock, hip, and leg were included. From January 1991 to December 2000, eligible patients underwent standardized diagnostic work-up, which included a self-reported pain questionnaire, physical examination, review of imaging studies, and diagnostic blockades. Those with an appropriate response to comparative double diagnostic blocks underwent standardized radiofrequency denervation of the lumbar zygapophysial joints. Patients were asked to estimate total perceived pain reduction (on a scale from 0% to 100%) at 6 weeks and at 6, 12, and 24 months after the procedure. Results: Of the 209 patients, 174 completed the study, and 35 were lost to follow-up or did not provide complete data for assessment. Of the 174 patients with complete data, 55 (31.6%) experienced no benefit from the procedure. One hundred and nineteen patients (68.4%) had good (> 50%) to excellent (> 80%) pain relief lasting from 6 to 24 months. Conclusion: This large, prospective clinical audit indicates that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophysial joints provide long-term pain relief in a routine clinical setting. Key words: low back pain, lumbar zygapophysial joint, radiofrequency denervation, clinical audit

Pain management

2020 ◽  
pp. 629-633
Author(s):  
Marie Fallon
Keyword(s):  
Quality Of Life ◽  
Pain Management ◽  
Pain Relief ◽  
Adverse Effects ◽  
Cancer Pain ◽  
Daily Functioning ◽  
Opioid Analgesia ◽  
Patients With Cancer ◽  
Good Pain Relief

Pain occurs in more than 50% of patients with advanced disease, interferes with daily functioning and quality of life, and is very often undertreated. Patients can find it difficult to articulate the character of their pains, but it is important to determine whether it is somatic, neuropathic, or visceral since this has important implications for management. For most patients with cancer pain, a three-step approach combining simple or opioid analgesia (depending on severity) along with an adjuvant analgesic (depending on cause) will result in good pain relief, but the challenge is to achieve good pain relief without unacceptable adverse effects.

Treatment of Morton's neuroma as a nerve compression. The role for neurolysis

1992 ◽  
Vol 82 (8) ◽  
pp. 399-402 ◽  
Author(s):  
AL Dellon
Keyword(s):  
Pain Relief ◽  
Surgical Approach ◽  
Crush Injury ◽  
Digital Nerve ◽  
Custom Made ◽  
Athletic Activities ◽  
Good Pain Relief ◽  
The Common ◽  
The Mean

The almost universal surgical approach for the treatment of Morton's metatarsalgia is to resect the neuroma through a dorsal incision. Considering that the mechanism for the metatarsalgia is chronic repetitive compression of the common plantar digital nerve between the metatarsal heads, this report explores the use of neurolysis in five patients with 11 involved nerves. In surgery, the intermetatarsal ligament is divided, intrinsic fibrosis is released, and the epineurium is opened. The mean follow-up period is 33 months. Complete pain relief was achieved in four of the five patients, with the fifth patient, 13 years after a crush injury to the foot, achieving good pain relief. All five patients resumed their usual jobs and athletic activities. One patient wears sneakers instead of regular shoes. The patient with the crush injury wears custom-made shoes.

DREZ lesions for relief of pain related to spinal cord injury

1986 ◽  
Vol 65 (4) ◽  
pp. 465-479 ◽  
Author(s):  
Allan H. Friedman ◽  
Blaine S. Nashold
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Pain Relief ◽  
Intractable Pain ◽  
Content Type ◽  
Root Entry Zone ◽  
Pain Syndromes ◽  
Cord Injury ◽  
Good Pain Relief

✓ Fifty-six patients with intractable pain following a spinal cord injury were treated with dorsal root entry zone (DREZ) lesions. After a follow-up period ranging from 6 months to 6 years, 50% of patients had good pain relief. Certain pain syndromes tended to respond better to DREZ lesions than did others. Patients with pain extending caudally from the level of the injury and patients with unilateral pain were most likely to obtain pain relief from the procedure; diffuse pain and predominant sacral pain did not respond as well.

scholarly journals Computerized tomography-guided percutaneous extralemniscal myelotomy

1997 ◽  
Vol 2 (1) ◽  
pp. E7 ◽  
Author(s):  
Yücel Kanpolat ◽  
Ali Savas ◽  
Sükrü Çaglar ◽  
Serdar Akyar
Keyword(s):  
Pain Relief ◽  
Cancer Pain ◽  
Computerized Tomography ◽  
Intractable Pain ◽  
Lesion Volume ◽  
Neurophysiological Mechanism ◽  
Ct Guided ◽  
Cervicomedullary Junction ◽  
Total Pain ◽  
Intractable Cancer Pain

Extralemniscal myelotomy (ELM) is a procedure performed at the cervicomedullary junction of the spinal cord in which the central cord is lesioned to treat intractable pain. The neurophysiological mechanism of pain relief after ELM remains unclear. The authors present a series of 14 patients with intractable cancer pain who were managed by CT-guided, percutaneous ELM. In six of the cases (42.8%), total pain relief was achieved; partial satisfactory pain relief was attained in four cases (28.5%), and no pain control was achieved in four cases (28.5%). No complications due to ELM were observed. The authors believe that ELM is a safe and effective procedure in the management of intractable cancer pain for selected cases; computerized tomography guidance is an essential part of the procedure to achieve morphological localization of the target in the cervicomedullary junction. More research is needed to understand the neurophysiological mechanism of pain relief after ELM and to standardize the lesion volume.

scholarly journals Peripheral and Neuraxial Chemical Neurolysis for the Management of Intractable Lower Extremity Pain in a Patient with Terminal Cancer

2015 ◽  
Vol 18;4 (4;18) ◽  
pp. E651-E656 ◽  
Author(s):  
Mario De Pinto
Keyword(s):  
Pain Relief ◽  
Lower Extremity ◽  
Cancer Pain ◽  
Femoral Nerve ◽  
Stage Iv ◽  
Left Lower Extremity ◽  
Complete Pain Relief ◽  
Adequate Pain Relief ◽  
Patient Reported ◽  
Intractable Cancer Pain

We present the case of a 74-year-old man with Stage IV metastatic, multifocal, malignant fibrous histiocytoma (T2b, N1, M1, G4) invading the proximal area of the left lower extremity and resulting in intractable neuropathic pain along the distribution of the femoral nerve. He described the pain as being so severe to cause inability to ambulate without assistance or to sleep in a supine or prone position. After a spinal cord stimulation trial and a trial of intrathecal (IT) hydromorphone, both performed at an outside institution, had failed to achieve adequate pain relief, we decided to perform a femoral nerve chemical neurolysis with phenol under ultrasound (US) guidance. The intervention provided 6 months of almost complete pain relief. With the tumor spreading in girth distally and proximally to the scrotal and pelvic areas as well as to the lungs, and pain returning back to baseline, we proceeded with a second femoral nerve chemical neurolysis. Unfortunately we were not able to achieve adequate pain relief. Therefore we opted to proceed with a diagnostic injection of local anesthetic under fluoroscopic guidance at the left L2, L3, and L4 nerve roots level. This intervention provided 100% pain relief and was followed, a few days later, by chemical neurolysis with phenol 3%. The patient reported complete pain relief with the procedure and no sensory-motor related side effects or complications. He was able to enjoy the last 6 weeks of life with his wife and family, pain-free. With this report we add to the limited literature available regarding the management of intractable cancer pain with chemical neurolysis in and around the epidural space. Key words: Cancer, pain, chemical neurolysis, peripheral, neuraxial

Administration of Intraspinal Morphine Sulfate for the Treatment of Intractable Cancer Pain

Neurosurgery ◽  
1986 ◽  
Vol 18 (6) ◽  
pp. 740-747 ◽  
Author(s):  
Andrew G. Shetter ◽  
Mark N. Hadley ◽  
Elizabeth Wilkinson
Keyword(s):  
Drug Delivery ◽  
Pain Relief ◽  
Cancer Pain ◽  
Morphine Sulfate ◽  
Significant Difference ◽  
Spinal Catheter ◽  
Epidural Catheters ◽  
Intractable Cancer Pain ◽  
Preservative Free

Abstract A total of 24 patients with intractable cancer pain were evaluated as candidates for spinal morphine therapy. Temporary trials were carried out with bolus injections of preservative-free morphine sulfate via percutaneously inserted epidural catheters. Fourteen patients felt that pain relief was sufficient to warrant long term morphine application, and permanent drug delivery systems were implanted. These consisted of an Ommaya reservoir and an epidural spinal catheter in 6 patients and an Infusaid pump with either an epidural or subarachnoid spinal catheter in 8 patients. Pain relief with these systems was felt to be excellent in 7 patients, good in 4 patients, and fair in 3 patients. There was a statistically significant reduction in supplemental narcotic use between the pre- and postoperative periods (P < 0.001). Median survival after operation was 3.0 months (mean, 5.0 months), with a range of 1 to 23 months. Tolerance was seen in all patients regardless of the mode of drug delivery, but it occurred more quickly with bolus injections than with continuous infusion (statistically significant difference, P < 0.05). A persistent cerebrospinal fluid fistula developed in 1 patient; this required wound revision. No other serious complications or episodes of respiratory depression occurred. We conclude that intraspinal morphine sulfate is a beneficial treatment option for cancer patients in whom pain has become debilitating and unresponsive to oral or parenteral narcotic regimes.

The Predictive Value of Sympathetic Block for the Success of Spinal Cord Stimulation

Neurosurgery ◽  
2003 ◽  
Vol 53 (3) ◽  
pp. 626-633 ◽  
Author(s):  
E. Daniela Hord ◽  
Steven P. Cohen ◽  
G. Rees Cosgrove ◽  
Shihab U. Ahmed ◽  
Ricardo Vallejo ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Pain Relief ◽  
Complex Regional Pain Syndrome ◽  
Spinal Cord Stimulation ◽  
Predictive Value ◽  
Massachusetts General Hospital ◽  
Pain Syndrome ◽  
Walter Reed Army Medical ◽  
Good Pain Relief

Abstract OBJECTIVE The purpose of this study was to assess the predictive value of response to sympathetic blockade (SB) on the success rate of spinal cord stimulation (SCS) in patients with complex regional pain syndrome. METHODS We performed a retrospective study on 23 patients with complex regional pain syndrome who underwent both SB and subsequent SCS trials in the past 3 years at the Massachusetts General Hospital Pain Center, Boston, MA, and Walter Reed Army Medical Center, Washington, DC. Fifteen of these patients underwent permanent placement of an SCS device, and pain relief at 1- and 9-month follow-up was recorded. RESULTS Among the 23 patients included in the study, those having transient pain relief with SB were more likely to have a positive SCS trial: all 13 with positive SB had good pain relief during the trial, compared with only 3 of the 10 with negative SB (100% versus 30%, P < 0.001). Among the 10 patients with negative SB, 7 noted poor pain relief during the trial despite adequate coverage, and they did not undergo placement of a permanent device. Among the patients who underwent permanent placement of an SCS device, those who received good pain relief with SB were more likely to have greater than 50% pain relief at 1-month follow-up (100% versus 33%, P = 0.029) and 9-month follow-up (87.5% versus 33.3%, P = 0.15). CONCLUSION We conclude that patients with good response to SB before SCS are more likely to have a positive response during their SCS trial and long-term pain relief after placement of permanent SCS device.

Sign in / Sign up

Export Citation Format

Share Document