Percutaneous Computed Tomography-Guided Spinal Destructive Procedures for Pain Control:

Open and Percutaneous Trigeminal Nucleotractotomy: A Case Series and Literature Review

INTRODUCTION

Nucleotractotomy is an efficient surgical technique that provides a high pain relief rate for specific clinical indications. There are two main approaches for performing this operation: an open and percutaneous technique.

METHODS

In the Federal Center of Neurosurgery (Novosibirsk, Russia) from 2016 to 2022, 13 trigeminal nucleotractotomies (7 open and 6 percutaneous) were performed in 12 patients (5 women and 7 men). The indications for surgery were deafferentation pain and chronic drug-resistant pain syndrome caused by malignancy in the facial region. A neurological examination was done on each patient 1 day before the surgery, right after the surgery, and at the follow-up (examinations were done after 1, 6, and 12 months, or when the patient independently applied to our hospital). In the early postoperative period, patients underwent brain MRI.

RESULTS

The average pain intensity score before nucleotractotomy on the 11-point (0-10) visual analog scale (VAS) was 9.3. The effectiveness of open interventions was somewhat higher; the average VAS score in the early postoperative period for the open technique was 1.57, in the group of patients who underwent percutaneous nucleotractotomy were 2.66. Complete regression of the pain syndrome was achieved in 6 patients; in 5 patients, the pain in the face decreased by more than 50%. One case had an unsatisfactory outcome. In the open-surgery group in the early postoperative period, according to MRI, the average length of the visualized area of signal change was longer (21.5 mm, the average diameter was 3.75 mm) than in a percutaneous nucleotractotomy group (16 mm, the average diameter was 3.75 mm). During the postoperative period (average follow-up 40 months), the pain recurred in 3 patients (30%): 2 patients after percutaneous nucleotractotomy (3 and 18 months after surgery) and in 1 patient 4 months after the open surgery. The mean VAS score at the last follow-up was 2.6.

CONCLUSION

Trigeminal nucleotractotomy is an effective approach to the treatment of intractable facial pain. Our experience suggests this technique is highly effective in patients with drug-resistant pain caused by craniofacial tumors and deafferentation conditions after treating trigeminal neuralgia.

Percutaneous CT-guided trigeminal tractotomy-nucleotomy under general anesthesia for intractable craniofacial pain

OBJECTIVE

When used to treat craniofacial pain, CT-guided trigeminal tractotomy-nucleotomy (TR-NC) is usually performed with local anesthesia. Unfortunately, local anesthesia is insufficient for patients with such severe pain that they cannot tolerate the required head positioning while awake. This study aimed to contextualize previous findings associated with TR-NC performed under general anesthesia. The authors examined clinical and operative factors that could impact postoperative pain outcomes.

METHODS

This is a retrospective single-institution cohort study of patients who underwent a percutaneous CT-guided TR-NC under general anesthesia at a single institution between 2012 and 2019. Outcome data were analyzed.

RESULTS

Twenty-five patients underwent CT-guided TR-NC procedures under general anesthesia; 23 met the inclusion criteria and underwent a total of 31 procedures. The procedure success rate was 74% (23/31). Approximately 50% and 40% of procedures provided pain relief for at least 6 and 12 months, respectively. The median duration of pain relief was 153 days. Adverse events, all minor and transient, occurred following 6/31 (19%) of procedures. Patients with a body mass index > 25 were less likely to experience a successful TR-NC (p = 0.045). Higher electrode ablation temperatures (p = 0.033) and more medial entry trajectories relative to the midsagittal plane (p = 0.029) characterized successful procedures.

CONCLUSIONS

These results suggest that CT-guided TR-NC performed under general anesthesia is safe and effective. Postoperative outcomes were found to be associated with a number of clinical and operative factors. Such associations should be further explored and evaluated in the context of future, better-powered analyses.

CT-Guided Percutaneous Trigeminal Tractotomy-Nucleotomy for Intractable Craniofacial Pain

OBJECT

In this report, we aimed to analyze the outcome results of our patients who underwent percutaneous trigeminal tractotomy (TR) and nucleotomy (NC) procedures, which are defined as destructive procedures targeting the descending trigeminal tractus and nucleus caudalis of the spinal trigeminal nucleus, respectively, for intractable craniofacial pain.

METHODS

The medical records of a total of 12 patients who underwent a total of 14 computed tomography (CT)-guided TR-NC procedures at our clinics between 2005 and 2017 were retrospectively reviewed.

RESULTS

A significant increase in patients' performance status (p = 0.015) as well as a significant decrease in the VAS score (p < 0.001) were achieved. Grade I pain relief (VAS = 0, no pain) was established in 66.7% of the patients, whereas grade II pain relief was observed in the remaining patients. Two of the patients suffered from recurrent pain after the initial procedure. Both patients underwent a second trigeminal TR-NC procedure, and grade I pain relief was re-established. The mean VAS score at 3-month follow-up was 1.4 ± 1.1, whereas this score at 6-month follow-up was 2 ± 1.3. The trigeminal TR-NC procedure resulted in a significant decrease in patients' VAS scores at 3- and 6-month follow-up visits compared with preoperative VAS scores (p < 0.001). Transient ataxia was noted in only one patient (8.3%) early after the procedure.

CONCLUSIONS

The results presented in the current study support the efficacy of the percutaneous CT-guided trigeminal TR-NC procedure in the management of intractable facial pain in selected patients. The use of CT guidance allows direct visualization of the target area, thereby enhancing the safety and success of the procedure.

Destructive procedures for the treatment of nonmalignant pain: a structured literature review

OBJECT

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

An efficient BiCGstab solved impedance method for induced field evaluation with a hyperthermia applicator

This paper presents a stabilized Bi-conjugate gradient algorithm that can significantly improve the performance of the impedance method, which has been widely applied to model low-frequency field induction phenomena in voxel phantoms. The improved quasi-static impedance method offers remarkable computational advantages in terms of convergence performance and memory consumption over the conventional, stationary iterative method-based algorithm. The scheme has been validated against other numerical/analytical solutions on a lossy, multilayered sphere phantom with an ideal coil loop excitation. To further demonstrate the computational performance and application capability of the developed algorithm, the induced fields inside a whole body human phantom responding to hyperthermia device was evaluated. The simulation results show the numerical accuracy and superior performance of the method.

Management of chronic severe pain: spinal neuromodulatory and neuroablative approaches

The spinal cord is the target of many neurosurgical procedures used to treat pain. Compactness and well-defined tract separation in addition to well understood dermatomal cord organization make the spinal cord an ideal target for pain procedures. Moreover, the presence of opioid and other receptors involved in pain modulation at the level of the dorsal horn increases the suitability of the spinal cord. Neuromodulative approaches of the spinal cord are either electrical or pharmacological. Electrical spinal cord modulation is used on a large scale for various pain syndromes including; failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), neuropathic pain, angina, and ischemic limb pain. Intraspinal delivery of medications e.g. opioids is used to treat nociceptive and neuropathic pains due to malignant and cancer pain etiologies. Neuroablation of the spinal cord pain pathway is mainly used to treat cancer pain. Targets involved include; the spinothalamic tract, the midline dorsal column visceral pain pathway and the trigeminal tract in the upper spinal cord. Spinal neuroablation can also involve cellular elements such as with trigeminal nucleotomy and the dorsal root entry zone (DREZ) operation. The DREZ operation is indicated for phantom type pain and root avulsion injuries. Due to its reversible nature spinal neuromodulation prevails, and spinal neuroablation is performed in a few select cases.

Percutaneous Computed Tomography-Guided Transdiscal Low Cervical Cordotomy for Cancer Pain as a Method to Avoid Sleep Apnea

OBJECTIVE

Study of percutaneous computed tomography (CT)-guided transdiscal low cervical cordotomy undertaken to treat pain in cancer patients.

METHODS

At the Department of Neurosurgery, Ain Shams University, Cairo, Egypt, 8 cancer pain patients, with either impaired pulmonary function or a previous cordotomy on an opposite side (sleep apnea was a feared complication) that prevented the possibility of undergoing a C(1-2) cordotomy, underwent a percutaneous CT-guided transdiscal low cervical cordotomy (C(4-5) or C(5-6)) to treat cancer pain.

RESULTS

Seven patients experienced initial improvement. One patient re-experienced pain within 2 weeks and 1 patient experienced no pain relief. In 6 patients in whom the cordotomy procedure was completed, satisfactory or complete pain relief, throughout a 6-month follow-up period was reported. In contrast, in 2 patients in whom the cordotomy was not completed there was no persistent pain relief.

CONCLUSION

Percutaneous CT-guided cordotomy remains a successful procedure to control pain in cancer patients, and is an affordable viable option under circumstances where economic disadvantage is an overriding determinate.