Justin S. Cetas, Targol Saedi and Kim J. Burchiel
Nonmalignant pain has been treated in the past century with ablative, or more appropriately, destructive procedures. Although individual outcomes for these procedures have previously been described in the literature, to the authors' knowledge this is the first comprehensive and systematic review on this topic.
A US National Library of Medicine PubMed search was conducted for the following ablative procedures: cingulotomy, cordotomy, DREZ (also input as dorsal root entry zone), ganglionectomy, mesencephalotomy, myelotomy, neurotomy, rhizotomy, sympathectomy, thalamotomy, and tractotomy. Articles related to pain resulting from malignancy and those not in peer-reviewed journals were excluded. In reviewing pertinent articles, focus was placed on patient number, outcome, and follow-up.
A total of 146 articles was included in the review. The large majority of studies (131) constituted Class III evidence. Eleven Class I and 4 Class II studies were found, of which nearly all (13 of 15) evaluated radiofrequency rhizotomies for different pain origins, including lumbar facet syndrome, cervical facet pain, and Type I or typical trigeminal neuralgia. Overall, support for ablative procedures for nonmalignant pain is derived almost entirely from Class III evidence; despite a long history of use in neurosurgery, the evidence supporting destructive procedures for benign pain conditions remains limited.
Newly designed prospective standardized studies are required to define surgical indications and outcomes for these procedures, to provide more systematic review, and to advance the field.
Ahmed M. Raslan, Justin S. Cetas, Shirley McCartney and Kim J. Burchiel
Historically, destructive procedures for cancer pain were the main line of treatment therapy. However, the use of high-dose opioids has essentially replaced such procedures. Recognition of the limits of medical therapy to treat cancer pain effectively is growing, while conversely, in regions with limited access to pain medications, the importance of destructive surgical techniques is increasing. A critical evaluation of the evidence for destructive techniques is warranted, and the authors review current evidence underlying these procedures.
A US National Library of Medicine PubMed search for “ablation,” “DREZ,” “dorsal root entry zone,” “cingulotomy,” “cordotomy,” “ganglionectomy,” “mesencephalotomy,” “myelotomy,” “neurotomy,” “neurectomy,” “rhizotomy,” “sympathectomy,” “thalamotomy,” “tractotomy,” and “pain” was undertaken. The search was then limited to human studies, English-language literature, cancer pain, and reports with more than 1 patient.
One hundred twenty papers were identified and reviewed based on the selection criteria described. According to the Canadian and US task forces, classification of clinical research literature only “sympathectomy” was supported by Class I or II studies, with 2 Class I papers and 1 Class II paper identified for cancer pain. All other procedures were supported by Class III studies of variable quality. Cordotomy in particular was the most extensively studied and reviewed procedure. Given the large number of patients studied, consistent results, multiplicity of reports and, even though evidence quality for individual studies was relatively low, cumulative evidence suggests that cordotomy may play an important role in the treatment of cancer pain.
Destructive procedures for cancer pain may play more than a historic role in the management of cancer pain. Cumulative evidence from even the poorest quality studies suggests that some procedures, such as cordotomy, should be included in the armamentarium available to the neurosurgeon today. To renew appropriate interest in these procedures, evidence and studies that meets today's evidence-based research criteria are warranted.