Most of the pain patients can be effectively controlled by general conventional treatments such as analgesic drugs and nerve blocks, but there is a significant proportion of chronic intractable pain that is ineffective by conventional treatments or relapses after short-term effective treatment, which can cause serious impact on the work, rest and daily life of patients. This kind of chronic intractable pain often can only rely on neurosurgical pain relief surgery to relieve pain eventually.
1. Indications for neurosurgical pain relief surgery
Neurosurgical pain relief surgery is mainly aimed at some of the chronic intractable pain that is not effectively treated by medication and seriously affects the work and daily life of patients with pain.
(1) Chronic pain with a large scope of involvement.
(2) Cancer pain with an expected survival period of more than 6 months.
(3) Central pain caused by central nervous system lesions or dysfunction, such as pain after spinal cord injury and cerebrovascular disease.
(4) Pain after brachial plexus injury, phantom limb pain, amputation pain.
(5) Chronic pain combined with obvious mental, personality and mood changes.
(6) Those who have serious drug toxicities or cannot tolerate analgesic drug treatment for a long period of time.
(7) Other chronic pain that seriously affects the patient’s quality of life.
Neurosurgical pain relief surgery is a kind of surgery to improve function. The ideal neurosurgical pain relief surgery should have the following characteristics.
(1) High specificity, the surgery only targets nociception, without affecting other sensory functions and motor functions.
②Less invasive, with basically no damage and destruction to the surrounding normal tissues and structures.
③High safety, no serious complications or new pains will arise.
④Long effectiveness, the pain relief effect should be exact and lasting, and the pain is not easy to recur.
2.Commonly used neurosurgical procedures
Destruction of the posterior spinal cord root into the medullary area
Indications
① Pain after avulsion injury of the brachial plexus or pain after avulsion injury of the lumbar plexus.
②Central pain after spinal cord injury or paraplegia.
③Stump pain or phantom limb pain after amputation.
④Neuralgia after herpes zoster.
⑤ certain cancer pain, pain due to spinal cord cavitation and other intractable pain
⑥Trigeminal neuralgia or head and facial pain can also be considered for trigeminal nerve DREZ dissection at the level of the brainstem.
Posterior median punctal dissection of the spinal cord
Indications
It is mainly indicated for cancerous visceral pain caused by various pelvic and abdominal organ tumors, and can also be used to treat intractable visceral pain caused by other causes such as chronic inflammation, radiation therapy, chemotherapy, etc. PMM is usually performed in the T7 to T8 segments of the spine for pelvic pain, T4 to T5 segments for lower abdominal pain, and T2 to T3 segments for upper abdominal pain. PMM is generally contraindicated for thoracic pain because the corresponding spinal cord segment is in the high cervical medulla, and serious complications such as respiratory distress may occur with the procedure.
Spinal cord electrical stimulation
Indications
(i) Intractable pain caused by sympathetic dysfunction and peripheral vascular lesions.
②A wide range of shoulder and back pain, low back pain and peripheral neuropathic pain.
③Partial phantom limb pain and pain after spinal cord injury.
Midbrain conduction bundle disruption
Indications
It is suitable for a wide range of intractable pain in the trunk or head and face, with the contralateral midbrain spinal thalamus bundle for trunk pain and the contralateral midbrain trigeminal thalamus bundle for head and face pain.
Thalamic nucleus destruction
Indications
For a wide range of chronic intractable pain, the contralateral VPL for trunk and extremity pain and the contralateral VPM for head and facial pain, the contralateral thalamic occipital nucleus can be destroyed for unilateral pain and the bilateral thalamic occipital nucleus can be destroyed for bilateral pain or pain in the midline. As for the inner medullary plate nucleus, it is usually destroyed bilaterally at the same time.
Anterior cingulate disruption
Indications
For the treatment of intractable pain with obvious mental and emotional abnormalities such as anxiety, depression, fear, obsessive-compulsive ideas or behaviors.
Deep brain electrical stimulation
Indications
For a wide range of intractable injury-receptive pain and neuropathic pain, injury-receptive pain is usually stimulated by PVG or PAG, and neuropathic pain is often stimulated by VPL or VPM.
Motor cortex electrical stimulation
Indications
For all kinds of central pain, de-afferent pain, phantom limb pain and other neuropathic pain.