Neurosurgical ablative procedures for intractable cancer pain

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OBJECTIVE

Cancer 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.

METHODS

This 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.

RESULTS

Sixty 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.

CONCLUSIONS

With 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.

ABBREVIATIONS NRS = numeric rating scale; PCC = percutaneous cervical cordotomy; POD = postoperative day; STT = spinothalamic tract.

Article Information

Correspondence Ido Strauss: Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel. idos@tlvmc.gov.il.

INCLUDE WHEN CITING Published online May 10, 2019; DOI: 10.3171/2019.2.JNS183159.

A.B. and U.H. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Algorithm for selection of the appropriate procedure for the patient’s pain syndrome.

  • View in gallery

    Illustrative case showing a C1–2 percutaneous cordotomy. A: Axial myelographic CT image acquired using an O-arm, showing the tip of the electrode in the left anterolateral quadrant of the spinal cord at the C1–2 level. B: Postoperative axial T2-weighted image showing the radiofrequency lesion in the left anterolateral quadrant.

  • View in gallery

    Bar graph showing the percentage of cingulotomy and cordotomy patients with intractable pain preoperatively, and immediately (POD 1), 1 month, and 3 months postoperatively.

  • View in gallery

    MR images obtained 1 day after cingulotomy, showing bilateral double lesions in the dorsal anterior cingulate cortex. A: Coronal T2-weighted image. B: Sagittal T1-weighted image. C: Axial T1-weighted image.

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