PubMed · 4103597
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J L Seymour. 1971. Easing the pain.. https://pubmed.ncbi.nlm.nih.gov/4103597/
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In a multidisciplinary approach to the management of chronic pain, neurosurgical methods are an indispensable part of the therapeutic armamentarium. With the exception of percutaneous interventions for trigeminal neuralgia and facet joint syndromes, most ablative pain surgery procedures (neurotomy, rhizotomy, sympathectomy, etc.) have been replaced by neuromodulatory approaches such as electrical stimulation of the central nervous system (CNS). However, cordotomy is still a valuable operation for certain forms of cancer related pains (Pancoast's syndrome, breakthrough pain) which are relatively resistant to pharmacotherapy. Another example of ablative surgery is the dorsal root entry zone (DREZ) operation, which is generally the only treatment option for pain due to root avulsion and segmental pain in spinal cord injury. Spinal cord stimulation (SCS) has proven to be most useful for the management of pain following peripheral nerve injury (including complex regional pain syndromes) and rhizopathy. For these conditions which are otherwise often therapy resistant, SCS may produce substantial and long-lasting pain relief in 60-70% of the patients. Considering that such pains are common and the fact that SCS has been shown to be cost-effective, this treatment is no doubt at present underused. Complications and side-effects are very rare. SCS has also been found to be useful for pain in peripheral vascular disorders and angina pectoris. In the latter condition the overall results are favorable in about 80% of patients with a significant reduction of the frequency and severity of angina attacks and the need for nitrates. Stimulation of the motor cortex is a novel and promising treatment of central, post-stroke pain and painful trigeminal neuropathy.
Although myelotomy was first designed to treat somatic pain by interruption of the decussating fibers of the spinothalamic tract, it was soon recognized that pain relief may be obtained in a wider distribution than the dermatomes represented by the interrupted nerves. In 1970, Hitchcock described relief of pain throughout the body by stereotactic production of a single lesion in the middle of the spinal cord at the cervico-medullary junction, a procedure named extra-lemniscal myelotomy by Schvarcz several years later. This led me to the observation reported in 1984 that pelvic pain might be controlled by a non-stereotactic lesion at the thoraco-lumbar area, which appeared to be particularly effective against visceral pain of cancer, in a procedure termed limited myelotomy. In 2000, Kim recognized that thoracic pain might be treated by a similar lesion in the high thoracic area, and termed his procedure thoracic dorsal column midline myelotomy. Up to that time, all authors had considered that pain relief was the result of interruption of a multi-synaptic pathway just dorsal to or within the central canal, which had not yet been defined. However, Willis identified a new pathway in the ventromedial dorsal columns in the post mortem spinal cord provided to him by my coauthor, which he further documented by animal physiologic studies. Nauta, at that same institution, reintroduced limited myelotomy based on those anatomical findings, naming the procedure punctate myelotomy. It must be recognized that all of these procedures have involved interruption of the same pathway, even before it was defined anatomically, and all authors provided similar observations about relief of particularly visceral pain.
Surgical treatment of intractable visceral pain has always been a challenge. The relatively recent discovery of a specific visceral pain pathway brought a new insight to this matter. The authors describe a new technique to interrupt this pathway, the CT-guided percutaneous punctate midline myelotomy, successfully applied in two patients with intractable pelvic visceral pain. Due to its simplicity, safety and high effectiveness, it may become the treatment of choice for intractable visceral pain.