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Robert B. King

that recurrent pain and similar patterns of decreased sensory deficit following rhizotomy occurred in patients receiving L-dopa in the early postoperative period. The third was the recognition that recurrent pain and virtually identical reduction of sensory deficits appeared in these patients over a period of many months following rhizotomy. The fourth observation was the demonstration that serotonin is essential as a neurotransmitter in the inhibitory system descending from the raphé nuclei to the dorsal horn of the spinal cord for both stimulation-produced and

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Contemporary concepts of pain surgery

JNSPG 75th Anniversary Invited Review Article

Kim J. Burchiel and Ahmed M. Raslan

T he past 50 years have produced a litany of advances in the field of pain surgery. Our goal in this review is to highlight the successes and failures of this period, and to project our expectations for future innovation and improvement in this subspecialty of neurosurgery. In its most classical definition, pain is the organism’s sensation of tissue injury, or impending tissue injury. Of course, pain as experienced by our patients is a complex biopsychosocial phenomenon. Recognizing that this subject is far more complex than this brief review will allow, this

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D. Andries Bosch

R ecent evidence from pain research 3, 5 suggests that only cancer pain should be treated by surgery, as it is morphine-sensitive and because neuropathic sequelae are more acceptable when life expectancy is short. Among various ablative surgical procedures, stereotactic rostral mesencephalotomy remains one of the few that have stood the test of time. 2, 4, 11, 12, 14, 20 The indications, however, are very specific: 6, 21, 30 only pain caused by cancers of the head and neck, or lateralized pain in the extremities are susceptible to this approach. According

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Richard D. Penn and Judith A. Paice

N eurosurgical procedures are often the last resort for patients suffering from intractable cancer pain. Unfortunately, many of these operations have limited effectiveness and are inappropriately invasive for debilitated patients. Furthermore, the pain is frequently midline or bilateral, and burning or boring in character — the most difficult to manage surgically. The discovery of opiate receptors in the spinal cord and the subsequent demonstration that pain could be relieved by epidural or intrathecal spinal morphine has suggested a new alternative. Chronic

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Christopher R. Honey, A. Jon Stoessl, Joseph K. C. Tsui, Michael Schulzer, and Donald B. Calne

P ain has long been recognized as a feature of Parkinson's disease (PD). 3, 22 Recent reviews have again focused attention on the alarmingly high prevalence of pain in patients with PD. 9, 11, 16, 20, 21 The percentage of patients suffering pain attributable to their PD has been estimated to be between 15% and 46%. 8, 11, 23 With the increased popularity of the pallidotomy procedure have come anecdotal comments on its ability to reduce pain. Laitinen and colleagues 12 reported that 63% of their patients had some degree of “dystonia/pain” before pallidotomy

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Haring J. W. Nauta, Elena Hewitt, Karin N. Westlund, and William D. Willis Jr.

C lassic anatomical teaching holds that the somatic pain pathways ascend crossed in the anterolateral quadrant of the spinal cord, whereas the pathway for “epicritic” sensory modalities ascends uncrossed in the posterior columns. It comes as a surprise, therefore, to learn that recent evidence obtained in experimental animal studies 1–3, 10 shows there is a major visceral pain pathway that ascends in the midline of the posterior column ( Fig. 1 ). The cell bodies of origin of this “new” pathway lie in the spinal gray matter dorsal to the central canal near

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Robert B. King

E xploring neural processes essential to the perception of pain has continued for a century. Specificity theorists argue that pain, a primary sensation, has its own specialized peripheral receptors and central neural pathways committed exclusively to pain discrimination. Pattern theorists argue that pain results from intense stimulation of any sensory receptor. Many now combine portions of both notions and consider models of pain sensations and their reactions. The affective-motivational systems in pain have been stressed by others who suggest that the

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Dorsal column stimulation for control of pain

Preliminary report on 30 patients

Blaine S. Nashold Jr. and Harry Friedman

T he application of surface electrodes to the dorsal columns of the spinal cord has been used by Shealy, et al., 6 and Sweet and Wepsic 7 in the treatment of intractable pain. The rationale for dorsal column stimulation (DCS) has been the “gate theory” of pain proposed by Melzack and Wall. 3 Stimulation of large diameter myelinated peripheral cutaneous fibers or of their extensions into the dorsal columns will inhibit some of the activity produced in dorsal horns by stimulation of small myelinated or unmyelinated fibers. We have carried out the

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John B. Mullen and Wesley A. Cook Jr.

I n the initial postoperative period, patients who have undergone lumbar hemilaminectomy will often suffer a considerable amount of back pain requiring narcotic analgesics. Many will also require urethral catheterization for urinary retention. These problems are generally accentuated in patients with exploration for recurrent herniated disc. In an attempt to alleviate these problems, we have developed a technique using a local anesthetic intraoperatively. The results have been quite successful. Technique We have been using Marcaine (bupivacaine) as an

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Ian M. Turnbull, Ralph Shulman, and W. Barrie Woodhurst

S ensory pathway injury may cause chronic pain. One may distinguish between pain caused by an active disease, such as sarcoma of the thigh, and pain resulting from nerve damage on the basis that pain due to noxious stimulation can usually be relieved for months or years by transection of a sensory pathway central to the lesion, while pain caused by partial or complete deafferentation, here called “neuropathic pain” so as to include the pain of perineural fibrosis, seldom responds to such a surgical approach. An electrode in the thalamic sensory relay nucleus