Chronic pain can result from a wide range of underlying causes and be severely debilitating. While many types of pain can be managed by identifying the underlying cause and trying to correct it surgically or by a combination of physical therapy, rehabilitation and oral medications, sometimes these treatments are not enough. In those cases, there may be some neurosurgical procedures that may be performed to achieve some control over your pain.
Spinal Cord Stimulation
Spinal cord stimulation (SCS) is a neuromodulation technique that is used to treat neuropathic and sympathetically mediated chronic pain. SCS involves percutaneous or surgical implantation of electrodes in the epidural space, with power supplied by an implanted battery. Usually, a trial of this type of stimulation is performed before deciding to proceed with a permanent implant. A successful trial is a good indicator of the potential benefits of a permanently implanted device.
Indications for SCS include:
- Intractable back and radicular pain
- Complex regional pain syndrome
- Painful peripheral vascular disease
- Intractable Angina
- Visceral Abdominal Pain
- Perineal Pain
- Painful Diabetic Neuropathy
Peripheral Nerve Stimulation
In some cases of focal peripheral pain (such as occipital neuralgia or unilateral knee or shoulder pain), special electrodes can be placed near the involved nerves and stimulated with the same devices used for spinal cord stimulation. Such peripheral nerve stimulation can be beneficial in the appropriately selected patient. Usually, a trial of this type of stimulation is performed before deciding to proceed with a permanent implant. A successful trial is a good indicator of the potential benefits of a permanently implanted device.
The indications for peripheral nerve stimulation are evolving but there are reports of success in:
- Distal nerve injuries resulting in neuropathic pain
- Shoulder Pain
- Knee pain
- Occipital Neuralgia
- Atypical facial pain
Intrathecal Pain Medication Pumps
In some situations, patients experience adequate management of their pain with oral medication but over time require higher doses to achieve adequate symptom control. When a patient experiences significant medication-related side effects (such as gastroparesis or severe constipation) from oral medications, they may be good candidates for an intrathecal pain pump. When delivered intrathecally, most medications can be delivered at much lower doses and with a significantly reduced side effect profile as a result.
Another circumstance where intrathecal pumps can be considered is when enteric delivery of medications will become challenging (e.g., in gastrointestinal malignancies). In this case, it may make sense for the treatment team to implant an intrathecal medication pump early in the treatment course. Given the reversible nature of these procedures, the pump could be removed at the end of successful treatment.
Palliative Pain Procedures
Cordotomy
Anterolateral cordotomy is a neurosurgical procedure in which a probe is inserted under image-guidance into the spinothalamic tract at the level of C1-C2. This procedure can be effective for relieving unilateral, somatic pain.
Midline Myelotomy
Midline myelotomy is a neurosurgical procedure that involves destruction of the midline posterior dorsal column pathway that transmits visceral pain. It can be used to relieve intractable visceral pain related to abdominal or pelvic cancer.
Dorsal root entry zone lesioning procedure
When peripheral nerves are avulsed from the spinal cord (such as in many traumatic brachial plexus injures or spinal cord injury), patients can develop significant deafferentation pain. Other patients that can benefit from this surgery are those with cancer-related pain that affects the nerves or the brachial plexus. The procedure involves creation of a small lesion in the area where the nerves enter (or used to enter) the spinal cord and can afford almost 70% of patients with significant pain relief.
Trigeminal Neuralgia
Treatment options include:
- Microvascular decompression
- Radiofrequency ablation or balloon compression
- Gamma knife radiosurgery
Atypical Facial Pain
Treatment options may include peripheral nerve stimulation