1
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Akbaş M, Dağıstan G. Effectiveness of CT-guided percutaneous cordotomy in intractable cancer pain: Experience in 14 patients. Pain Pract 2024; 24:296-302. [PMID: 37846871 DOI: 10.1111/papr.13307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
BACKGROUND Severe and treatment-resistant pain is a major issue for patients with cancer. Cordotomy is an effective approach for addressing severe cancer-related pain. It is based on blocking the transmission of pain by damaging the lateral spinothalamic tract. METHODS Computed tomography guided cordotomy was performed on 14 patients who did not respond to medical and interventional pain management methods. RESULTS Fourteen patients with cancer pain underwent CT-guided percutaneous cordotomy. Pain relief was reported in 86% of the patients. The visual analog scale values before and after cordotomy were compared and a significant difference was found (p = 0.0001). The improvement in the Karnofsky Performance Scale score of the patients was found to be statistically significant (p = 0.0001). CONCLUSION We believe that CT-guided cordotomy, performed by experienced hands in a team of experienced individuals and applied to the right patients, is an effective treatment. However, it is crucial to exercise extreme caution regarding potential side effects and serious complications during the cordotomy procedure.
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Affiliation(s)
- Mert Akbaş
- Division of Algology, Anesthesiology and Reanimation Department, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Gözde Dağıstan
- Division of Algology, Anesthesiology and Reanimation Department, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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2
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Adams JL, Goble G, Johnson A. Multidisciplinary Approaches: Cingulotomy in an Adult With Refractory Neuropathic Cancer-Related Pain. J Palliat Med 2023; 26:1297-1301. [PMID: 37192484 DOI: 10.1089/jpm.2022.0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Background: Oral medications, intravenous medications, and invasive interventions are effective means of neuropathic pain control. In patients with pain refractory to more conventional approaches, cingulum bundle ablation is an alternative treatment modality not routinely considered by providers. Case Description: A 42-year-old woman with history of cervical cancer in remission presented with intractable left lower extremity pain. Workup revealed radiation-induced left iliopsoas osteosarcoma complicated by deep venous occlusion and thrombosis. Her pain remained intractable to pharmacologic therapies and more invasive pain control interventions. A multidisciplinary decision was made to pursue bilateral subcortical cingulum bundle radiofrequency ablation. After a technically successful surgery, the patient exhibited improved pain control as evidenced by a decline in her numerical rating scale of pain and analgesic medication requirements. Conclusion: Cancer-related neuropathic pain often requires treatment with multiple modalities involving multidisciplinary teams. In select refractory cases, cingulum bundle ablation may be an effective alternative treatment modality.
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Affiliation(s)
- Jessica L Adams
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gretchen Goble
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amy Johnson
- Department of Palliative Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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3
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Allam AK, Larkin MB, Katlowitz KA, Shofty B, Viswanathan A. Case report: MR-guided laser induced thermal therapy for palliative cingulotomy. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 3:1028424. [PMID: 36387414 PMCID: PMC9663803 DOI: 10.3389/fpain.2022.1028424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/11/2022] [Indexed: 01/24/2023]
Abstract
In end-stage cancer, oncologic pain refractory to medical management significantly reduces patients' quality of life. In recent years, ablative surgery has seen a resurgence in treating diffuse and focal cancer pain in terminal patients. The anterior cingulate gyrus has been a key focus as it plays a role in the cognitive and emotional processing of pain. While radiofrequency ablation of the dorsal anterior cingulate is well described for treating cancer pain, MRI-guided laser-induced thermal therapy (LITT) is novel. Our paper describes a patient treated with an MRI-guided LITT therapy of the anterior cingulate gyrus for intractable debilitating pain secondary to terminal metastatic cancer.
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Affiliation(s)
- Anthony K. Allam
- School of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - M. Benjamin Larkin
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Kalman A. Katlowitz
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Ben Shofty
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States,Department of Neurosurgery, University of Texas, MD Anderson, Houston, TX, United States,Correspondence: Ashwin Viswanathan
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4
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Treister R, Honigman L, Berger A, Cohen B, Asaad I, Kuperman P, Tellem R, Hochberg U, Strauss I. Temporal Summation Predicts De Novo Contralateral Pain After Cordotomy in Patients With Refractory Cancer Pain. Neurosurgery 2022; 90:59-65. [PMID: 34982871 DOI: 10.1227/neu.0000000000001734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Percutaneous cervical cordotomy (PCC), which selectively interrupts ascending nociceptive pathways in the spinal cord, can mitigate severe refractory cancer pain. It has an impressive success rate, with most patients emerging pain-free. Aside from the usual complications of neurosurgical procedures, the risks of PCC include development of contralateral pain, which is less understood. OBJECTIVE To evaluate whether sensory and pain sensitivity, as measured by quantitative sensory testing (QST), are associated with PCC clinical outcomes. METHODS Fourteen palliative care cancer patients with severe chronic refractory pain limited mainly to one side of the body underwent comprehensive quantitative sensory testing assessment pre-PPC and post-PCC. They were also queried about maximal pain during the 24 h precordotomy (0-10 numerical pain scale). RESULTS All 14 patients reported reduced pain postcordotomy, with 7 reporting complete resolution. Four patients reported de novo contralateral pain. Reduced sensitivity in sensory and pain thresholds to heat and mechanical stimuli was recorded on the operated side (P = .028). Sensitivity to mechanical pressure increased on the unaffected side (P = .023), whereas other sensory thresholds were unchanged. The presurgical temporal summation values predicted postoperative contralateral pain (r = 0.582, P = .037). CONCLUSION The development of contralateral pain in patients postcordotomy for cancer pain might be due to central sensitization. Temporal summation could serve as a potential screening tool to identify those who are most likely at risk to develop contralateral pain. Analysis of PCC affords a unique opportunity to investigate how a specific lesion to the nociceptive system affects pain processes.
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Affiliation(s)
- Roi Treister
- Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Liat Honigman
- Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Assaf Berger
- Functional Neurosurgery Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ben Cohen
- Institute of Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Israa Asaad
- Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Pora Kuperman
- Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Rotem Tellem
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Palliative Medicine Care Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Uri Hochberg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ido Strauss
- Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Walker MR, Zhong J, Waspe AC, Piorkowska K, Nguyen LN, Anastakis DJ, Drake JM, Hodaie M. Peripheral Nerve Focused Ultrasound Lesioning-Visualization and Assessment Using Diffusion Weighted Imaging. Front Neurol 2021; 12:673060. [PMID: 34305786 PMCID: PMC8299784 DOI: 10.3389/fneur.2021.673060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/18/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Magnetic resonance-guided focused ultrasound (MRgFUS) is a non-invasive targeted tissue ablation technique that can be applied to the nervous system. Diffusion weighted imaging (DWI) can visualize and evaluate nervous system microstructure. Tractography algorithms can reconstruct fiber bundles which can be used for treatment navigation and diffusion tensor imaging (DTI) metrics permit the quantitative assessment of nerve microstructure in vivo. There is a need for imaging tools to aid in the visualization and quantitative assessment of treatment-related nerve changes in MRgFUS. We present a method of peripheral nerve tract reconstruction and use DTI metrics to evaluate the MRgFUS treatment effect. Materials and Methods: MRgFUS was applied bilaterally to the sciatic nerves in 6 piglets (12 nerves total). T1-weighted and diffusion images were acquired before and after treatment. Tensor-based and constrained spherical deconvolution (CSD) tractography algorithms were used to reconstruct the nerves. DTI metrics of fractional anisotropy (FA), and mean (MD), axial (AD), and radial diffusivities (RD) were measured to assess acute (<1-2 h) treatment effects. Temperature was measured in vivo via MR thermometry. Histological data was collected for lesion assessment. Results: The sciatic nerves were successfully reconstructed in all subjects. Tract disruption was observed after treatment using both CSD and tensor models. DTI metrics in the targeted nerve segments showed significantly decreased FA and increased MD, AD, and RD. Transducer output power was positively correlated with lesion volume and temperature and negatively correlated with MD, AD, and RD. No correlations were observed between FA and other measured parameters. Conclusions: DWI and tractography are effective tools for visualizing peripheral nerve segments for targeting in non-invasive surgical methods and for assessing the microstructural changes that occur following MRgFUS treatment.
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Affiliation(s)
- Matthew R Walker
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Jidan Zhong
- Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Adam C Waspe
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Karolina Piorkowska
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, ON, Canada
| | - Lananh N Nguyen
- Laboratory Medicine Program, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Dimitri J Anastakis
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Department of Surgery, Toronto Western Hospital, University Health Network and University of Toronto, Toronto, ON, Canada
| | - James M Drake
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, ON, Canada.,Department of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Mojgan Hodaie
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Division of Brain, Imaging & Behaviour, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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6
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Alhazmi LSS, Bawadood MAA, Aljohani AMS, Alzahrani AAR, Moshref L, Trabulsi N, Moshref R. Pain Management in Breast Cancer Patients: A Multidisciplinary Approach. Cureus 2021; 13:e15994. [PMID: 34336485 PMCID: PMC8318122 DOI: 10.7759/cureus.15994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2021] [Indexed: 12/05/2022] Open
Abstract
Pain is a significant problem and is one of the most invalidating symptoms in breast cancer (BC) patients that would negatively affect the functional status and the Quality of Life (QoL). Pain management in BC patients requires thorough patient evaluation and critical assessment of pain. The actual cause for the pain must be recognized, so management can be tailored to each patient. This review aims to discuss various treatment modalities employed for effectively managing pain in BC patients. Pharmacotherapy makes up the cornerstone of the management of pain in BC patients. Both opioid and non-opioid analgesics are utilized. The WHO recommends a method called “by the ladder” for managing pain in BC patients where analgesics are used in ascending order. In comprehensive pain management (CPM), non-pharmacologic therapies are gaining wide acceptance and popularity, including complementary and alternative medicine (CAM), procedural and psychosocial interventions. Procedural interventions are usually used in case of severe pain refractory to pharmacological therapy. Techniques, such as radiotherapy, neurectomy, and nerve blocks, are effective in managing cancer pain. However, CAM therapies in BC pain management need to be guided by enough scientific evidence, decision-making, and medical judgment of regulatory bodies. BC pain management is based on careful routine pain assessments and appropriate patient evaluation both physically and psychologically. Pain control is one of the methods to improve the QoL of BC patients. Both pharmacological and non-pharmacological therapies are accessible to patients today, but they should be used with caution to minimize toxicity and increase effectiveness. The use of any pain management intervention should be based on proper scientific evidence and collective medical judgment.
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Affiliation(s)
| | | | | | | | - Leena Moshref
- General Surgery, King Abdulaziz University, Jeddah, SAU
| | - Nora Trabulsi
- General Surgery, King Abdulaziz University, Jeddah, SAU
| | - Rana Moshref
- General Surgery, King Abdulaziz University, Jeddah, SAU
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7
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Krakauer EL, Kane K, Kwete X, Afshan G, Bazzett-Matabele L, Ruthnie Bien-Aimé DD, Borges LF, Byrne-Martelli S, Connor S, Correa R, Devi CRB, Diop M, Elmore SN, Gafer N, Goodman A, Grover S, Hasenburg A, Irwin K, Kamdar M, Kumar S, Nguyen Truong QX, Randall T, Rassouli M, Sessa C, Spence D, Trimble T, Varghese C, Fidarova E. Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering. JCO Glob Oncol 2021; 7:886-895. [PMID: 34115537 PMCID: PMC8457849 DOI: 10.1200/go.21.00027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/18/2021] [Accepted: 05/12/2021] [Indexed: 01/24/2023] Open
Abstract
The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.
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Affiliation(s)
- Eric L. Krakauer
- Division of Palliative Care & Geriatric Medicine, Massachusetts General Hospital, Boston, MA
- Departments of Medicine and of Global Health and Social Medicine, Harvard Medical School, Boston, MA
- Department of Palliative Care, University of Medicine & Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Khadidjatou Kane
- Division of Palliative Care & Geriatric Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Gauhar Afshan
- Department of Anaesthesiology, Aga Khan University Medical College, Karachi, Pakistan
| | - Lisa Bazzett-Matabele
- Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
- Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT
| | - Danta Dona Ruthnie Bien-Aimé
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
- Université Episcopale d'Haiti, Port-au-Prince, Haiti
- Faculté des Sciences Infirmières de Leogane, Léogâne, Haiti
| | - Lawrence F. Borges
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Sarah Byrne-Martelli
- Division of Palliative Care & Geriatric Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Raimundo Correa
- Gynecologic Oncology Unit & Palliative Care Service, Clínica Las Condes, Santiago, Chile
| | | | - Mamadou Diop
- Cancer Institute of Cheikh Anta Diop University, Dakar, Senegal
| | - Shekinah N. Elmore
- Department of Radiation Oncology University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nahla Gafer
- Radiation and Isotope Centre, Khartoum Oncology Hospital, Khartoum, Sudan
- Comboni College of Science and Technology, Khartoum, Sudan
| | - Annekathryn Goodman
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA
| | - Surbhi Grover
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Annette Hasenburg
- Department of Gynecology and Obstetrics, Johannes Gutenberg University Medical Center, Maine, Germany
| | - Kelly Irwin
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Mihir Kamdar
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Palliative Care and Geriatric Medicine, Department of Anesthesiology, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Suresh Kumar
- Institute of Palliative Medicine, Medical College, Kerala, India
| | - Quynh Xuan Nguyen Truong
- College of Public Health Science, Chulalongkorn University, Bangkok, Thailand
- School of Social Work, Boston College, Newton, MA
- University Medical Center of Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Tom Randall
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA
- Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA
| | - Maryam Rassouli
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Cristiana Sessa
- Department of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Dingle Spence
- Hope Institute Hospital, Kingston, Jamaica
- University of the West Indies, Kingston, Jamaica
| | | | - Cherian Varghese
- Department of Non-communicable Diseases, World Health Organization, Geneva, Switzerland
| | - Elena Fidarova
- Department of Non-communicable Diseases, World Health Organization, Geneva, Switzerland
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8
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Berger A, Artzi M, Aizenstein O, Gonen T, Tellem R, Hochberg U, Ben-Bashat D, Strauss I. Cervical Cordotomy for Intractable Pain: Do Postoperative Imaging Features Correlate with Pain Outcomes and Mirror Pain? AJNR Am J Neuroradiol 2021; 42:794-800. [PMID: 33632733 DOI: 10.3174/ajnr.a6999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/28/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Percutaneous cervical cordotomy offers relief of unilateral intractable oncologic pain. We aimed to find anatomic and postoperative imaging features that may correlate with clinical outcomes, including pain relief and postoperative contralateral pain. MATERIALS AND METHODS We prospectively followed 15 patients with cancer who underwent cervical cordotomy for intractable pain during 2018 and 2019 and underwent preoperative and up to 1-month postoperative cervical MR imaging. Lesion volume and diameter were measured on T2-weighted imaging and diffusion tensor imaging (DTI). Lesion mean diffusivity and fractional anisotropy values were extracted. Pain improvement up to 1 month after surgery was assessed by the Numeric Rating Scale and Brief Pain Inventory. RESULTS All patients reported pain relief from 8 (7-10) to 0 (0-4) immediately after surgery (P = .001), and 5 patients (33%) developed contralateral pain. The minimal percentages of the cord lesion volume required for pain relief were 10.0% on T2-weighted imaging and 6.2% on DTI. Smaller lesions on DWI correlated with pain improvement on the Brief Pain Inventory scale (r = 0.705, P = .023). Mean diffusivity and fractional anisotropy were significantly lower in the ablated tissue than contralateral nonlesioned tissue (P = .003 and P = .001, respectively), compatible with acute-phase tissue changes after injury. Minimal postoperative mean diffusivity values correlated with an improvement of Brief Pain Inventory severity scores (r = -0.821, P = .004). The average lesion mean diffusivity was lower among patients with postoperative contralateral pain (P = .037). CONCLUSIONS Although a minimal ablation size is required during cordotomy, larger lesions do not indicate better outcomes. DWI metrics changes represent tissue damage after ablation and may correlate with pain outcomes.
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Affiliation(s)
- A Berger
- From the Department of Neurosurgery (A.B., I.S.)
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
| | - M Artzi
- Sagol Brain Institute (M.A., T.G, D.B.-B.)
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
| | - O Aizenstein
- Department of Radiology (O.A.)
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
| | - T Gonen
- Sagol Brain Institute (M.A., T.G, D.B.-B.)
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
| | - R Tellem
- The Palliative Care Service (R.T.)
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
| | - U Hochberg
- Institute of Pain Medicine (U.H.)
- Division of Anesthesiology, Tel Aviv Medical Center (U.H.), Tel Aviv, Israel
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
| | - D Ben-Bashat
- Sagol Brain Institute (M.A., T.G, D.B.-B.)
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
| | - I Strauss
- From the Department of Neurosurgery (A.B., I.S.)
- Sackler School of Medicine (A.B., M.A., O.A., T.G., R.T., U.H., D.B.-B., I.S.), Tel Aviv University, Tel Aviv, Israel
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9
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Zomers PJW, Groeneweg G, Baart S, Huygen FJP. Percutaneous Cervical Cordotomy for the Treatment of Cancer Pain: A Prospective Case Series of 52 Patients with a Long-Term Follow-Up. Pain Pract 2021; 21:557-567. [PMID: 33350042 DOI: 10.1111/papr.12991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/19/2020] [Accepted: 12/15/2020] [Indexed: 01/07/2023]
Abstract
AIM The aim of this study is to describe the effects of percutaneous cervical cordotomy (PCC) on pain, opioid consumption, adverse events, and satisfaction in palliative care patients with cancer pain after PCC until end of life. METHODS This is a prospective observational case series of 58 PCCs in 52 consecutive patients. Indication for PCC was unilateral cancer pain with a maximum numeric rating scale (NRS) of pain above 5 despite maximal conservative treatment. The PCC was fluoroscopy guided. A radiofrequency lesion was made at 95°C for 20 seconds. The pain location and pain scores, analgesic medication, the cranial and caudal borders of dermatomes hypoesthetic for pin pricks, dysesthesia, urinary retention, Horner's syndrome, muscle strength, Karnofsky performance scale (KPS) score, patient satisfaction, hospital anxiety and distress score (HADS), and RAND 36 score were evaluated at 1 day; 1 and 6 weeks; and 3, 6, 9, 12 18, and 24 months after PCC, or until death if death occurred during the follow-up period. RESULTS Pain relief after PCC was intense (change in median maximum NRS from 9 to 0) and persistent. Median opioid use per day was 240 mg (145 to 565 mg) before PCC and 55 mg (0 to 120 mg) after PCC. The upper and lower borders of dermatomes hypoesthetic for pin pricks were stable over time. The most common side effects were short-term (< 1 week) neck pain (28%), dysesthesia (40%), and mild loss of muscle strength (11%). Approximately 83% of the patients were satisfied or very satisfied with the results of PCC 1 week after the procedure, and this percentage remained high in the long term. There was no significant change in the KPS score, HADS, and RAND 36 score. CONCLUSION Percutaneous cervical cordotomy is an effective treatment for unilateral cancer pain. The reduction in pain, reduction in opioid consumption, and hypoesthetic area remain stable until death.
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Affiliation(s)
- Paul J W Zomers
- Pain Department, Bravis Hospital, Roosendaal, The Netherlands
| | - George Groeneweg
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sara Baart
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank J P Huygen
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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10
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Viswanathan A, Vedantam A, Williams LA, Koyyalagunta D, Abdi S, Dougherty PM, Mendoza T, Bassett RL, Hou P, Bruera E. Percutaneous Cordotomy for Pain Palliation in Advanced Cancer: A Randomized Clinical Trial Study Protocol. Neurosurgery 2021; 87:394-402. [PMID: 32012217 DOI: 10.1093/neuros/nyz527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cancer pain, one of the most common symptoms for patients with advanced cancer, is often refractory to maximal medical therapy. A controlled clinical trial is needed to provide definitive evidence to support the use of ablative procedures such as cordotomy for patients with medically refractory cancer pain. OBJECTIVE To assess the efficacy of cordotomy for patients with unilateral advanced cancer pain using a controlled clinical trial study design. The secondary objectives are to define the patient experience of cordotomy for medically refractory cancer pain as well as to determine the utility of magnetic resonance imaging as a non-invasive biomarker for successful cordotomy. METHODS We will undertake a single-institution, double-blind, sham-controlled clinical trial of cordotomy in patients with refractory cancer pain. Patients in the cordotomy arm will undergo a percutaneous computed tomography-guided cordotomy at C1-C2, while patients in the control arm will undergo a similar procedure where the needle will not penetrate the thecal sac. The primary endpoint will be the reduction in pain intensity, as measured by the Edmonton Symptoms Assessment Scale. EXPECTED OUTCOMES We expect that patients randomized to cordotomy will have a significantly greater reduction in pain intensity than those patients randomized to the control surgical intervention. DISCUSSION This randomized clinical trial comparing cordotomy with a control intervention will provide the level of evidence necessary to determine whether cordotomy should be the standard of care intervention for patients with advanced cancer pain.
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Affiliation(s)
| | - Aditya Vedantam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Loretta A Williams
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Salahadin Abdi
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patrick M Dougherty
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tito Mendoza
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roland L Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ping Hou
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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11
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Affiliation(s)
- Arun Bhaskar
- 15th Floor, Imperial Healthcare at Charing Cross Hospital, Thames Path, Fulham Palace Rd, London W6 8RF
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12
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Mazzucchi E, Brinzeu A, Mertens P, Sindou M. Microsurgical DREZ lesions for the control of cancer-related pain. ACTA ACUST UNITED AC 2020; 3:V14. [PMID: 36285266 PMCID: PMC9542504 DOI: 10.3171/2020.7.focvid2033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
Pain in patients with cancer is a major problem, and sometimes it is necessary to surgically interrupt pain pathways to effectively control refractory pain. Surgical lesion of the dorsal root entry zone (DREZ) was first performed in 1972 for the treatment of pain related to a Pancoast-Tobias tumor. The rationale of DREZotomy is to preferentially interrupt the nociceptive inputs in the lateral part of the DREZ and the ventrolateral (excitatory) part of the dorsal horn. Microsurgical DREZotomy is one technique for DREZ lesioning that is suited for tailored control of pain in patients in good general condition who are experiencing pain in a well-defined territory. The video can be found here: https://youtu.be/JtLQDP7gYSQ
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Affiliation(s)
- Edoardo Mazzucchi
- 1Mater Olbia Hospital, Olbia, Italy
- 2Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; and
| | - Andrei Brinzeu
- 2Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; and
- 3Universitatea de Medicina si Farmacie Victor Babes, Timisoara, Romania
| | - Patrick Mertens
- 2Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; and
| | - Marc Sindou
- 2Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; and
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13
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Sapir Y, Korn A, Bitan-Talmor Y, Vendrov I, Berger A, Shofty B, Zegerman A, Strauss I. Intraoperative Neurophysiology for Optimization of Percutaneous Spinothalamic Cordotomy for Intractable Cancer Pain. Oper Neurosurg (Hagerstown) 2020; 19:E566-E572. [PMID: 32710768 DOI: 10.1093/ons/opaa209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/30/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Percutaneous ablation of the cervical spinothalamic tract (STT) remains a therapeutic remedy for intractable cancer pain. However, it is accompanied by the risk of collateral damage to essential spinal cord circuitry, including the corticospinal tract (CST). Recent studies describe threshold-based mapping of the CST with the objective of motor bundle preservation during intramedullary spinal cord and supratentorial surgery. OBJECTIVE To assess the possibility that application of spinal cord mapping using intraoperative neuromonitoring in percutaneous cordotomy procedures may aid in minimizing iatrogenic motor tract injury. METHODS We retrospectively reviewed the files of 11 patients who underwent percutaneous cervical cordotomy for intractable oncological pain. We performed quantitative electromyogram (EMG) recordings to stimulation of the ablation needle prior to the STT-ablative stage. We compared evoked motor and sensory electrical thresholds, and the electrical span between them as a reliable method to confirm safe electrode location inside the STT. RESULTS Quantified EMG data were collected in 11 patients suffering from intractable cancer pain. The threshold range for evoking motor activity was 0.3 to 1.2 V. Stimulation artifacts were detected from trapezius muscles even at the lowest stimulation intensity, while thenar muscles were found to be maximally sensitive and specific. The minimal stimulation intensity difference between the motor and the sensory threshold, set as "Δ-threshold," was 0.26 V, with no new motor deficit at 3 days or 1 month postoperatively. CONCLUSION Selective STT ablation is an effective procedure for treating intractable pain. It can be aided by quantitative evoked EMG recordings, with tailored parameters and thresholds.
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Affiliation(s)
| | - Akiva Korn
- Surgical Monitoring Services, Beit Shemesh, Israel.,Intraoperative Neurophysiological Monitoring Service, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Yifat Bitan-Talmor
- Surgical Monitoring Services, Beit Shemesh, Israel.,Intraoperative Neurophysiological Monitoring Service, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Irina Vendrov
- Intraoperative Neurophysiological Monitoring Service, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Assaf Berger
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ben Shofty
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Zegerman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Anesthesia and Critical Care, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ido Strauss
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Endo T, Tominaga T. Use of an endoscope for spinal intradural pathology. JOURNAL OF SPINE SURGERY (HONG KONG) 2020; 6:495-501. [PMID: 32656387 PMCID: PMC7340816 DOI: 10.21037/jss.2020.01.06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/24/2019] [Indexed: 05/29/2023]
Abstract
The endoscope has been increasingly used to treat various spinal diseases. However, the application of spinal endoscopy in an intradural lesion has been less common compared to that of an epidural counterpart. The authors reviewed existing literature describing spinal endoscopy as an aid in surgical treatment for intradural pathologies. Importantly, available literature indicated the safety and feasibility of spinal endoscopy for intradural lesions. Especially, an endoscope was utilized for intradural subarachnoid cystic lesions, tethered cord syndrome, extramedullary tumors, spinal arteriovenous malformations, and cordectomy for intractable pain. The results of this review should enhance further development and broaden application of an endoscope for various intradural pathologies.
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Affiliation(s)
- Toshiki Endo
- Department of Neurosurgery, Sendai Medical Center, Sendai, Miyagi, Japan
- Department of Neurosurgery, Tohoku University, Graduate school of Medicine, Sendai, Miyagi, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Sendai Medical Center, Sendai, Miyagi, Japan
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15
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Vedantam A, Hassan I, Kotrotsou A, Hassan A, Zinn PO, Viswanathan A, Colen RR. Magnetic Resonance-Based Radiomic Analysis of Radiofrequency Lesion Predicts Outcomes After Percutaneous Cordotomy: A Feasibility Study. Oper Neurosurg (Hagerstown) 2020; 18:721-727. [PMID: 31665446 DOI: 10.1093/ons/opz288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/19/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To date, there is limited data on evaluation of the cordotomy lesion and predicting clinical outcome. OBJECTIVE To evaluate the utility of magnetic resonance (MR)-based radiomic analysis to quantify microstructural changes created by the cordotomy lesion and predict outcome in patients undergoing percutaneous cordotomy for medically refractory cancer pain. METHODS This is a retrospective interpretation of prospectively acquired data in 10 patients (5 males, age range 43-76 yr) who underwent percutaneous computed tomography-guided high cervical cordotomy for medically refractory cancer pain between 2015 and 2016. All patients underwent magnetic resonance imaging (MRI) of the cordotomy lesion on postoperative day 1. After segmentation of T2-weighted images, 310 radiomic features were extracted. Pain outcomes were recorded on postoperative day 1 and day 7 using the visual analog scale. R software was used to build statistical models based on MRI radiomic features for prediction of pain outcomes. RESULTS A total of 20 relevant radiomic features were identified using the maximum relevance minimum redundanc method. Radiomics predicted postoperative day 1 pain scores with an accuracy of 90% (P = .046), 100% sensitivity, 75% specificity, 85.7% positive predictive value, and 100% negative predictive value. The radiomics model also predicted if the postoperative day 1 pain score was sustained on postoperative day 7 with an accuracy of 100% (P = .028), 100% sensitivity, 100% specificity, and 100% positive and negative predictive value. CONCLUSION MR-based radiomic analysis of the cordotomy lesion was predictive of pain outcomes at 1 wk after percutaneous cordotomy for intractable cancer pain.
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Affiliation(s)
- Aditya Vedantam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Islam Hassan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Aikaterini Kotrotsou
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ahmed Hassan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pascal O Zinn
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Cancer Biology, Division of Basic Science Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Rivka R Colen
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Cancer Systems Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Burchiel KJ, Raslan AM. Contemporary concepts of pain surgery. J Neurosurg 2020; 130:1039-1049. [PMID: 30933905 DOI: 10.3171/2019.1.jns181620] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 01/03/2019] [Indexed: 11/06/2022]
Abstract
Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice. This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned. For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management. While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis. Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge. Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.
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17
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Berger A, Hochberg U, Zegerman A, Tellem R, Strauss I. Neurosurgical ablative procedures for intractable cancer pain. J Neurosurg 2019; 133:144-151. [PMID: 31075782 DOI: 10.3171/2019.2.jns183159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cancer patients suffering from severe refractory pain may benefit from targeted ablative neurosurgical procedures aimed to disconnect pain pathways in the spinal cord or the brain. These patients often present with a plethora of medical problems requiring careful consideration before surgical interventions. The authors present their experience at an interdisciplinary clinic aimed to facilitate appropriate patient selection for neurosurgical procedures, and the outcome of these interventions. METHODS This study was a retrospective review of all patients who underwent neurosurgical interventions for cancer pain in the authors' hospital between March 2015 and April 2018. All patients had advanced metastatic cancer with limited life expectancy and suffered from intractable oncological pain. RESULTS Sixty patients underwent surgery during the study period. Forty-three patients with localized pain underwent disconnection of the spinal pain pathways: 34 percutaneous-cervical and 5 open-thoracic cordotomies, 2 stereotactic mesencephalotomies, and 2 midline myelotomies. Thirty-nine of 42 patients (93%) who completed these procedures had excellent immediate postoperative pain relief. At 1 month the improvement was maintained in 30/36 patients (83%) available for follow-up. There was 1 case of hemiparesis.Twenty patients with diffuse pain underwent stereotactic cingulotomy. Nineteen of these patients reported substantial pain relief immediately after the operation. At 1 month good pain relief was maintained in 13/17 patients (76%) available for follow-up, and good pain relief was also found at 3 months in 7/11 patients (64%). There was no major morbidity or mortality. CONCLUSIONS With careful patient selection and tailoring of the appropriate procedure to the patient's pain syndrome, the authors' experience indicates that neurosurgical procedures are safe and effective in alleviating suffering in patients with intractable cancer pain.
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Affiliation(s)
- Assaf Berger
- 1Department of Neurosurgery
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Hochberg
- 4Institute of Pain Medicine; and
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Zegerman
- 5Division of Anesthesiology, Tel Aviv Medical Center; and
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rotem Tellem
- 3The Palliative Care Service
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Strauss
- 1Department of Neurosurgery
- 2Neuromodulation Unit
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Viswanathan A, Vedantam A, Hess KR, Ochoa J, Dougherty PM, Reddy AS, Koyyalagunta D, Reddy S, Bruera E. Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial. Oncologist 2019; 24:e590-e596. [PMID: 30796153 DOI: 10.1634/theoncologist.2018-0570] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/10/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Up to 30% of patients with cancer continue to suffer from pain despite aggressive supportive care. The present study aimed to determine whether cordotomy can improve cancer pain refractory to interdisciplinary palliative care. MATERIALS AND METHODS In this randomized controlled trial, we recruited patients with refractory unilateral somatic pain, defined as a pain intensity (PI) ≥4, after more than three palliative care evaluations. Patients were randomized to percutaneous computed tomography-guided cordotomy or continued interdisciplinary palliative care. The primary outcome was 33% improvement in PI at 1 week after cordotomy or study enrollment as measured by the Edmonton Symptom Assessment Scale. RESULTS Sixteen patients were enrolled (nine female, median age 58 years). Six of seven patients (85.7%) randomized to cordotomy experienced >33% reduction in PI (median preprocedure PI = 7, range 6-10; 1 week after cordotomy median PI = 1, range 0-6; p = .022). Zero of nine patients randomized to palliative care achieved a 33% reduction in PI. Seven patients (77.8%) randomized to palliative care elected to undergo cordotomy after 1 week. All of these patients experienced >33% reduction in PI (median preprocedure PI = 8, range 4-10; 1 week after cordotomy median PI = 0, range 0-1; p = .022). No patients were withdrawn from the study because of adverse effects of the intervention. CONCLUSION These data support the use of cordotomy for pain refractory to optimal palliative care. The findings of this study justify a large-scale randomized controlled trial of percutaneous cordotomy. IMPLICATIONS FOR PRACTICE This prospective clinical trial was designed to determine the improvement in pain intensity in patients randomized to either undergo cordotomy or comprehensive palliative care for medically refractory cancer pain. This study shows that cordotomy is effective in reducing pain for medically refractory cancer pain, and these results can be used to design a large-scale comparative randomized controlled trial that could provide the evidence needed to include cordotomy as a treatment modality in the guidelines for cancer pain management.
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Affiliation(s)
- Ashwin Viswanathan
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aditya Vedantam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jewel Ochoa
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick M Dougherty
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila S Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Suresh Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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19
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Careskey H, Narang S. Interventional Anesthetic Methods for Pain in Hematology/Oncology Patients. Hematol Oncol Clin North Am 2019; 32:433-445. [PMID: 29729779 DOI: 10.1016/j.hoc.2018.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article reviews anesthetic interventional approaches to the management of pain in hematology and oncology patients. It includes a discussion of single interventions including peripheral nerve blocks, plexus injections, and sympathetic nerve neurolysis, and continuous infusion therapy through implantable devices, such as intrathecal pumps, epidural port-a-caths, and tunneled catheters. The primary objective is to inform members of hematology and oncology care teams regarding the variety of interventional options for patients with cancer-related pain for whom medical pain management methods have not been effective.
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Affiliation(s)
- Holly Careskey
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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20
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Sapio MR, Neubert JK, LaPaglia DM, Maric D, Keller JM, Raithel SJ, Rohrs EL, Anderson EM, Butman JA, Caudle RM, Brown DC, Heiss JD, Mannes AJ, Iadarola MJ. Pain control through selective chemo-axotomy of centrally projecting TRPV1+ sensory neurons. J Clin Invest 2018; 128:1657-1670. [PMID: 29408808 DOI: 10.1172/jci94331] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 02/01/2018] [Indexed: 11/17/2022] Open
Abstract
Agonists of the vanilloid receptor transient vanilloid potential 1 (TRPV1) are emerging as highly efficacious nonopioid analgesics in preclinical studies. These drugs selectively lesion TRPV1+ primary sensory afferents, which are responsible for the transmission of many noxious stimulus modalities. Resiniferatoxin (RTX) is a very potent and selective TRPV1 agonist and is a promising candidate for treating many types of pain. Recent work establishing intrathecal application of RTX for the treatment of pain resulting from advanced cancer has demonstrated profound analgesia in client-owned dogs with osteosarcoma. The present study uses transcriptomics and histochemistry to examine the molecular mechanism of RTX action in rats, in clinical canine subjects, and in 1 human subject with advanced cancer treated for pain using intrathecal RTX. In all 3 species, we observe a strong analgesic action, yet this was accompanied by limited transcriptional alterations at the level of the dorsal root ganglion. Functional and neuroanatomical studies demonstrated that intrathecal RTX largely spares susceptible neuronal perikarya, which remain active peripherally but unable to transmit signals to the spinal cord. The results demonstrate that central chemo-axotomy of the TRPV1+ afferents underlies RTX analgesia and refine the neurobiology underlying effective clinical use of TRPV1 agonists for pain control.
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Affiliation(s)
- Matthew R Sapio
- Clinical Center, Department of Perioperative Medicine, NIH, Bethesda, Maryland, USA
| | - John K Neubert
- Department of Orthodontics, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Danielle M LaPaglia
- Clinical Center, Department of Perioperative Medicine, NIH, Bethesda, Maryland, USA
| | - Dragan Maric
- Flow Cytometry Core Facility, NIH, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Jason M Keller
- Clinical Center, Department of Perioperative Medicine, NIH, Bethesda, Maryland, USA
| | - Stephen J Raithel
- Clinical Center, Department of Perioperative Medicine, NIH, Bethesda, Maryland, USA
| | - Eric L Rohrs
- Department of Orthodontics, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Ethan M Anderson
- Department of Oral and Maxillofacial Surgery, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - John A Butman
- Clinical Center, Radiology and Imaging Services, NIH, Bethesda, Maryland, USA
| | - Robert M Caudle
- Department of Oral and Maxillofacial Surgery, University of Florida College of Dentistry, Gainesville, Florida, USA
| | - Dorothy C Brown
- Veterinary Clinical Investigations Center, University of Pennsylvania, School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| | - John D Heiss
- Surgical Neurology Branch, NIH, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Andrew J Mannes
- Clinical Center, Department of Perioperative Medicine, NIH, Bethesda, Maryland, USA
| | - Michael J Iadarola
- Clinical Center, Department of Perioperative Medicine, NIH, Bethesda, Maryland, USA
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21
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Strauss I, Berger A, Arad M, Hochberg U, Tellem R. O-Arm-Guided Percutaneous Radiofrequency Cordotomy. Stereotact Funct Neurosurg 2018; 95:409-416. [DOI: 10.1159/000484614] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/18/2017] [Indexed: 12/11/2022]
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22
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Strauss I, Berger A, Ben Moshe S, Arad M, Hochberg U, Gonen T, Tellem R. Double Anterior Stereotactic Cingulotomy for Intractable Oncological Pain. Stereotact Funct Neurosurg 2018; 95:400-408. [PMID: 29316566 DOI: 10.1159/000484613] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Stereotactic anterior cingulotomy has been used in the treatment of patients suffering from refractory oncological pain due to its effects on pain perception. However, the optimal targets as well as suitable candidates and outcome measures have not been well defined. We report our initial experience in the ablation of 2 cingulotomy targets on each side and the use of the Brief Pain Inventory (BPI) as a perioperative assessment tool. METHODS A retrospective review of all patients who underwent stereotactic anterior cingulotomy in our Department between November 2015 and February 2017 was performed. All patients had advanced metastatic cancer with limited prognosis and suffered from intractable oncological pain. RESULTS Thirteen patients (10 women and 3 men) underwent 14 cingulotomy procedures. Their mean age was 54 ± 14 years. All patients reported substantial pain relief immediately after the operation. Out of the 6 preoperatively bedridden patients, 3 started ambulating shortly after. At the 1-month follow-up, the mean preoperative Visual Analogue Scale score decreased from 9 ± 0.9 to 4 ± 2.7 (p = 0.003). Mean BPI pain severity and interference scores decreased from levels of 29 ± 4 and 55 ± 12 to 16 ± 12 (p = 0.028) and 37 ± 15 (p = 0.043), respectively. During the 1- and 3-month follow-up visits, 9/11 patients (82%) and 5/7 patients (71%) available for follow-up reported substantial pain relief. No patient reported worsening of pain during the study period. Neuropsychological analyses of 6 patients showed stable cognitive functions with a mild nonsignificant decline in focused attention and executive functions. Adverse events included transient confusion or mild apathy in 5 patients (38%) lasting 1-4 weeks. CONCLUSIONS Our initial experience indicates that double stereotactic cingulotomy is safe and effective in alleviating refractory oncological pain.
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Affiliation(s)
- Ido Strauss
- Department of Neurosurgery, Division of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
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23
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Microstructural mechanisms of analgesia in percutaneous cervical cordotomy revealed by diffusion tensor imaging. J Clin Neurosci 2017; 45:311-314. [PMID: 28887076 DOI: 10.1016/j.jocn.2017.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 08/10/2017] [Indexed: 11/23/2022]
Abstract
The purpose of this study is to demonstrate the potential of diffusion tensor imaging (DTI) to reveal structural mechanisms underlying spinal ablative procedures, including percutaneous radiofrequency cordotomy (PRFC). PRFC is a surgical procedure that produces analgesia through focal ablation of the lateral spinothalamic tract (STT), thereby interrupting the flow of pain information from the periphery to the brain. To date, studies regarding mechanisms of analgesia after PRFC have been limited to postmortem cadaveric dissection and histology. However, with recent advances in DTI, the opportunity has arisen to study the STT non-invasively in vivo. In this technical note, an individual with successful pain relief following unilateral STT PRFC was examined using DTI, with the contralateral STT serving as an internal control. PRFC substantially reduced rostrocaudal directional DTI signal in the STT from the lesion in the cervical spinal cord through the pons and mesencephalon. Our findings confirm that focal ablation and anterograde degeneration accompany the analgesic effects of PRFC. In vivo imaging of the STT with DTI may contribute to surgical targeting for PRFC procedures, better understanding of the therapeutic and untoward effects of PRFC, and a deeper understanding of spinothalamic contributions to nociception.
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24
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Chai T, Suleiman ZA, Roldan CJ. Unilateral Lower Extremity Pain Due to Malignancy Managed With Cordotomy: A Case Report. PM R 2017; 10:442-445. [PMID: 28867666 DOI: 10.1016/j.pmrj.2017.08.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 08/09/2017] [Accepted: 08/19/2017] [Indexed: 11/17/2022]
Abstract
Cancer pain management is comprehensive, and it generally begins with pharmacotherapy in a step-wise approach per analgesic guidelines established decades ago by the World Health Organization. This analgesic ladder involves the prescribing of co-analgesics, adjuvants, and opioids, with each step depending on pain severity. Although the majority of cancer pain responds to this strategy, there exist patients who do not respond adequately or experience significant side effects or intolerance to pain medications. It is in these patients whom clinicians consider interventional approaches. One approach to manage unremitting unilateral malignant pain includes evaluation for cordotomy, which is an approach that has been effective in such cases. We present a patient with breast cancer metastatic to the pelvis, with associated severe pelvic and right lower limb pain. Due to progressive disease, her pain worsened despite aggressive opioid dose escalations. She ultimately underwent percutaneous left anterolateral cervical cordotomy for malignant right leg pain, resulting in complete resolution of leg pain. We propose that, in select patients with neoplasm-related pain, cordotomy may prove very effective. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Thomas Chai
- Pain Medicine, UT MD Anderson Cancer Center, 1400 Holcombe Blvd, Unit 409, Houston, TX 77030
- University of Ilorin, Ilorin, Nigeria
- Univeristy of Texas MD Anderson Cancer Center, Houston, TX
| | - Zakari A Suleiman
- Pain Medicine, UT MD Anderson Cancer Center, 1400 Holcombe Blvd, Unit 409, Houston, TX 77030
- University of Ilorin, Ilorin, Nigeria
- Univeristy of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos J Roldan
- Pain Medicine, UT MD Anderson Cancer Center, 1400 Holcombe Blvd, Unit 409, Houston, TX 77030
- University of Ilorin, Ilorin, Nigeria
- Univeristy of Texas MD Anderson Cancer Center, Houston, TX
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25
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Abstract
Pain is a significant burden for patients with cancer and is particularly prevalent among those with advanced cancer. Appropriate interventional cancer pain therapies complement conventional pain management by reducing the need for systemic opioid therapy and its associated toxicity; however, these therapies are often underutilized. This article reviews techniques, indications, complications, and outcomes of the most common interventional approaches for the management of cancer-related pain. These approaches include intrathecal drug delivery, vertebral augmentation, neurolysis of the celiac, superior hypogastric and ganglion impar plexus', image-guided tumor ablation, and other less commonly performed but potentially beneficial interventions.
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Affiliation(s)
- Jill E Sindt
- Department of Anesthesiology, University of Utah School of Medicine, 30 North 1900 East Room C3444, Salt Lake City, UT 84132, USA.
| | - Shane E Brogan
- Department of Anesthesiology, University of Utah School of Medicine, 30 North 1900 East Room C3444, Salt Lake City, UT 84132, USA
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Hochberg U, Elgueta MF, Perez J. Interventional Analgesic Management of Lung Cancer Pain. Front Oncol 2017; 7:17. [PMID: 28261561 PMCID: PMC5306685 DOI: 10.3389/fonc.2017.00017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/25/2017] [Indexed: 12/31/2022] Open
Abstract
Lung cancer is one of the four most prevalent cancers worldwide. Comprehensive patient care includes not only adherence to clinical guidelines to control and when possible cure the disease but also appropriate symptom control. Pain is one of the most prevalent symptoms in patients diagnosed with lung cancer; it can arise from local invasion of chest structures or metastatic disease invading bones, nerves, or other anatomical structures potentially painful. Pain can also be a consequence of therapeutic approaches like surgery, chemotherapy, or radiotherapy. Conventional medical management of cancer pain includes prescription of opioids and coadjuvants at doses sufficient to control the symptoms without causing severe drug effects. When an adequate pharmacological medical management fails to provide satisfactory analgesia or when it causes limiting side effects, interventional cancer pain techniques may be considered. Interventional pain management is devoted to the use of invasive techniques such as joint injections, nerve blocks and/or neurolysis, neuromodulation, and cement augmentation techniques to provide diagnosis and treatment of pain syndromes resistant to conventional medical management. Advantages of interventional approaches include better analgesic outcomes without experiencing drug-related side effects and potential for opioid reduction thus avoiding central side effects. This review will describe various pain syndromes frequently described in lung cancer patients and those interventional techniques potentially indicated for those cases.
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Affiliation(s)
- Uri Hochberg
- Cancer Pain Program, McGill University Health Centre , Montreal, QC , Canada
| | | | - Jordi Perez
- Cancer Pain Program, McGill University Health Centre, Montreal, QC, Canada; Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, QC, Canada
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27
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Shepherd TM, Hoch MJ, Cohen BA, Bruno MT, Fieremans E, Rosen G, Pacione D, Mogilner AY. Palliative CT-Guided Cordotomy for Medically Intractable Pain in Patients with Cancer. AJNR Am J Neuroradiol 2016; 38:387-390. [PMID: 27811129 DOI: 10.3174/ajnr.a4981] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/28/2016] [Indexed: 11/07/2022]
Abstract
Palliative cervical cordotomy can be performed via percutaneous radiofrequency ablation of the lateral C1-2 spinothalamic tract. This rare procedure can be safe, effective, and advantageous in mitigating medically intractable unilateral extremity pain for selected patients with end-stage cancer. This report reviews the indications, techniques, risks, and potential benefits of cordotomy. We describe our recent experience treating 3 patients with CT-guided C1-2 cordotomy and provide the first characterization of spinal cord diffusion MR imaging changes associated with successful cordotomy.
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Affiliation(s)
- T M Shepherd
- From the Department of Radiology (T.M.S., M.J.H., B.A.C., M.T.B., E.F.) .,Center for Advanced Imaging Innovation and Research (T.M.S., E.F.)
| | - M J Hoch
- From the Department of Radiology (T.M.S., M.J.H., B.A.C., M.T.B., E.F.)
| | - B A Cohen
- From the Department of Radiology (T.M.S., M.J.H., B.A.C., M.T.B., E.F.)
| | - M T Bruno
- From the Department of Radiology (T.M.S., M.J.H., B.A.C., M.T.B., E.F.)
| | - E Fieremans
- From the Department of Radiology (T.M.S., M.J.H., B.A.C., M.T.B., E.F.).,Center for Advanced Imaging Innovation and Research (T.M.S., E.F.)
| | - G Rosen
- Departments of Medicine (G.R.)
| | - D Pacione
- Neurosurgery (D.P., A.Y.M.), New York University, New York, New York
| | - A Y Mogilner
- Neurosurgery (D.P., A.Y.M.), New York University, New York, New York
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28
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Inserra A, Narciso A, Paolantonio G, Messina R, Crocoli A. Palliative care and pediatric surgical oncology. Semin Pediatr Surg 2016; 25:323-332. [PMID: 27955737 DOI: 10.1053/j.sempedsurg.2016.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Survival rate for childhood cancer has increased in recent years, reaching as high as 70% in developed countries compared with 54% for all cancers diagnosed in the 1980s. In the remaining 30%, progression or metastatic disease leads to death and in this framework palliative care has an outstanding role though not well settled in all its facets. In this landscape, surgery has a supportive actor role integrated with other welfare aspects from which are not severable. The definition of surgical palliation has moved from the ancient definition of noncurative surgery to a group of practices performed not to cure but to alleviate an organ dysfunction offering the best quality of life possible in all the aspects of life (pain, dysfunctions, caregivers, psychosocial, etc.). To emphasize this aspect a more modern definition has been introduced: palliative therapy in whose context is comprised not only the care assistance but also the plans of care since the onset of illness, teaching the matter to surgeons in training and share paths. Literature is very poor regarding surgical aspects specifically dedicated and all researches (PubMed, Google Scholar, and Cochrane) with various meshing terms result in a more oncologic and psychosocial effort.
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Affiliation(s)
- Alessandro Inserra
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy.
| | - Alessandra Narciso
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Guglielmo Paolantonio
- Interventional Radiology Unit, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Raffaella Messina
- Neurosurgery Unit, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
| | - Alessandro Crocoli
- General Pediatric and Thoracic Surgery, Bambino Gesù Children׳s Hospital-Research Institute, Rome, Italy
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29
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Ivanishvili Z, Pujara S, Honey CM, Chang S, Honey CR. Stereotactic mesencephalotomy for palliative care pain control: A case report, literature review and plea to rediscover this operation. Br J Neurosurg 2016; 30:444-7. [PMID: 26760110 DOI: 10.3109/02688697.2015.1133805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction Stereotactic mesencephalotomy is an ablative procedure which lesions the pain pathways (spinothalamic and trigeminothalamic tracts) at the midbrain level to treat medically refractory, nociceptive, contralateral pain. Sparsely reported in contemporary English language literature, this operation is at risk of being lost from the modern-day neurosurgical practice. Methods We present a case report and brief review of the literature on stereotactic mesencephalotomy. A 17-year-old girl with cervical cord glioblastoma and medically refractory unilateral head and neck pain was treated with contralateral stereotactic mesencephalotomy. The lesion was placed at the level of the inferior colliculus, half way between the lateral edge of the aqueduct and lateral border of the midbrain. Results The patient had no head and neck pain immediately after the procedure and remained pain-free for the remainder of her life (five months). She was weaned off her pre-operative narcotics and was able to leave hospital, meeting her palliative care goals. Conclusions Cancer-related unilateral head and neck nociceptive pain in the palliative care setting can be successfully treated with stereotactic mesencephalotomy. We believe that stereotactic mesencephalotomy is the treatment of choice for a small number of patients typified by our case. The authors make a plea to the palliative care and neurosurgical communities to rediscover this operation.
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Affiliation(s)
- Zurab Ivanishvili
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
| | - Shyam Pujara
- b Department of Neurosurgery, University of Leicester , Leicester , UK
| | - C Michael Honey
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
| | - Stephano Chang
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
| | - Christopher R Honey
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
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30
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Huisman M, Staruch RM, Ladouceur-Wodzak M, van den Bosch MA, Burns DK, Chhabra A, Chopra R. Non-Invasive Targeted Peripheral Nerve Ablation Using 3D MR Neurography and MRI-Guided High-Intensity Focused Ultrasound (MR-HIFU): Pilot Study in a Swine Model. PLoS One 2015; 10:e0144742. [PMID: 26659073 PMCID: PMC4682836 DOI: 10.1371/journal.pone.0144742] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 11/22/2015] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Ultrasound (US)-guided high intensity focused ultrasound (HIFU) has been proposed for noninvasive treatment of neuropathic pain and has been investigated in in-vivo studies. However, ultrasound has important limitations regarding treatment guidance and temperature monitoring. Magnetic resonance (MR)-imaging guidance may overcome these limitations and MR-guided HIFU (MR-HIFU) has been used successfully for other clinical indications. The primary purpose of this study was to evaluate the feasibility of utilizing 3D MR neurography to identify and guide ablation of peripheral nerves using a clinical MR-HIFU system. METHODS Volumetric MR-HIFU was used to induce lesions in the peripheral nerves of the lower limbs in three pigs. Diffusion-prep MR neurography and T1-weighted images were utilized to identify the target, plan treatment and immediate post-treatment evaluation. For each treatment, one 8 or 12 mm diameter treatment cell was used (sonication duration 20 s and 36 s, power 160-300 W). Peripheral nerves were extracted < 3 hours after treatment. Ablation dimensions were calculated from thermal maps, post-contrast MRI and macroscopy. Histological analysis included standard H&E staining, Masson's trichrome and toluidine blue staining. RESULTS All targeted peripheral nerves were identifiable on MR neurography and T1-weighted images and could be accurately ablated with a single exposure of focused ultrasound, with peak temperatures of 60.3 to 85.7°C. The lesion dimensions as measured on MR neurography were similar to the lesion dimensions as measured on CE-T1, thermal dose maps, and macroscopy. Histology indicated major hyperacute peripheral nerve damage, mostly confined to the location targeted for ablation. CONCLUSION Our preliminary results indicate that targeted peripheral nerve ablation is feasible with MR-HIFU. Diffusion-prep 3D MR neurography has potential for guiding therapy procedures where either nerve targeting or avoidance is desired, and may also have potential for post-treatment verification of thermal lesions without contrast injection.
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Affiliation(s)
- Merel Huisman
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States of America
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert M. Staruch
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States of America
- Clinical Sites Research Program, Philips Research North America, Briarcliff Manor, NY, United States of America
| | | | | | - Dennis K. Burns
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Rajiv Chopra
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States of America
- * E-mail:
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31
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Vayne-Bossert P, Afsharimani B, Good P, Gray P, Hardy J. Interventional options for the management of refractory cancer pain--what is the evidence? Support Care Cancer 2015; 24:1429-38. [PMID: 26660344 DOI: 10.1007/s00520-015-3047-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/29/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Pain is the most common symptom in cancer patients. Standard pain treatment according to the WHO three-step analgesic ladder provides effective pain management in approximately 70-90% of cancer patients. Refractory pain is defined as not responding to "standard" treatments. Interventional analgesic techniques can be used in an attempt to control refractory pain in patients in whom conventional analgesic strategies fail to provide effective pain relief or are intolerable due to severe adverse effects. This systematic review aims to provide the latest evidence on interventional refractory pain management in cancer patients. METHODS Systematic literature search in Cochrane, EMBASE and PubMed including reviews and randomised controlled trials (RCTs) and non-randomised controlled trials in the absence of reviews. RESULTS Neuraxial analgesia may play a role in refractory cancer pain management. Paravertebral blocks decrease the incidence of persistent post-surgical pain after breast cancer. Coeliac plexus blocks improve pain scores in refractory pancreatic cancer pain for up to 4 weeks after the intervention with fewer burdensome side effects as compared to opioids. Cordotomy has mainly been studied in mesothelioma, and the case series suggest possible benefit for pain at the expense of a relatively high risk of side effects. CONCLUSIONS Overall, very few RCTs have been conducted on interventional pain techniques. In reality, it is very difficult to undertake large controlled trials for a number of reasons. Therefore, today's best evidence for practice may be from large case series of comparable patients with careful response and toxicity evaluation and follow-up.
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Affiliation(s)
- Petra Vayne-Bossert
- Readaptation and Palliative Care, University Hospital of Geneva, Geneva, Switzerland.,Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia
| | - Banafsheh Afsharimani
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia
| | - Phillip Good
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia.,Palliative Care Services, St Vincent's Private Hospital Brisbane, Kangaroo Point, Australia
| | - Paul Gray
- School of Medicine, University of Queensland, St Lucia, Australia.,Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Australia
| | - Janet Hardy
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia. .,School of Medicine, University of Queensland, St Lucia, Australia.
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Higaki N, Yorozuya T, Nagaro T, Tsubota S, Fujii T, Fukunaga T, Moriyama M, Yoshikawa T. Usefulness of cordotomy in patients with cancer who experience bilateral pain: implications of increased pain and new pain. Neurosurgery 2015; 76:249-56; discussion 256; quiz 256-7. [PMID: 25603110 PMCID: PMC4337588 DOI: 10.1227/neu.0000000000000593] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: Although mirror pain occurs after cordotomy in patients experiencing unilateral pain via a referred pain mechanism, no studies have examined whether this pain mechanism operates in patients who have bilateral pain. OBJECTIVE: To assess the usefulness of cordotomy for bilateral pain from the viewpoint of increased pain or new pain caused by a referred pain mechanism. METHODS: Twenty-six patients who underwent percutaneous cordotomy through C1-C2 for severe bilateral cancer pain in the lumbosacral nerve region were enrolled. Pain was dominant on 1 side in 23 patients, and pain was equally severe on both sides in 3 patients. Unilateral cordotomy was performed for the dominant side of pain, and bilateral cordotomy was performed for 13 patients in whom pain on the nondominant side developed or remained severe after cordotomy. RESULTS: After unilateral cordotomy, 19 patients (73.1%) exhibited increased pain, which for 14 patients was as severe as the original dominant pain. After bilateral cordotomy, 7 patients (53.4%) exhibited new pain, which was located cephalad to the region rendered analgesic by cordotomy and was better controlled than the original pain. No pathological organic causes of new pain were found in any patient, and evidence of a referred pain mechanism was found in 3 patients after bilateral cordotomy. CONCLUSION: These results show that a referred pain mechanism causes increased or new pain after cordotomy in patients with bilateral pain. Nevertheless, cordotomy can still be indicated for patients with bilateral pain because postoperative pain is better controlled than the original pain.
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Affiliation(s)
- Nobuhiro Higaki
- *Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Ehime, Japan; ‡Department of Palliative Care Medicine, Matsuyama Bethel Hospital, Ehime, Japan; §Department of Anesthesiology, Uwajima City Hospital, Ehime, Japan; ¶Department of Palliative Care Medicine, Japanese Red Cross Society Himeji Hospital, Hyogo, Japan; ‖Pain Clinic Unit, Nakatani Hospital, Hyogo, Japan
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33
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Fonoff ET, Lopez WOC, de Oliveira YSA, Teixeira MJ. Microendoscopy-guided percutaneous cordotomy for intractable pain: case series of 24 patients. J Neurosurg 2015; 124:389-96. [PMID: 26230468 DOI: 10.3171/2014.12.jns141616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to show that microendoscopic guidance using a double-channel technique could be safely applied during percutaneous cordotomy and provides clear real-time visualization of the spinal cord and surrounding structures during the entire procedure. METHODS Twenty-four adult patients with intractable cancer pain were treated by microendoscopic-guided percutaneous radiofrequency (RF) cordotomy using the double-channel technique under local anesthesia. A percutaneous lateral puncture was performed initially under fluoroscopy guidance to localize the target. When the subarachnoid space was reached by the guiding cannula, the endoscope was inserted for visualization of the spinal cord and surrounding structures. After target visualization, a second needle was inserted to guide the RF electrode. Cordotomy was performed by a standard RF method. RESULTS The microendoscopic double-channel approach provided real-time visualization of the target in 91% of the cases. The other 9% of procedures were performed by the single-channel technique. Significant analgesia was achieved in over 90% of the cases. Two patients had transient ataxia that lasted for a few weeks until total recovery. CONCLUSIONS The use of percutaneous microendoscopic cordotomy with the double-channel technique is useful for specific manipulations of the spinal cord. It provides real-time visualization of the RF probe, thereby adding a degree of safety to the procedure.
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Affiliation(s)
- Erich Talamoni Fonoff
- Pain Center and Division of Functional Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Brazil; and
| | - William Omar Contreras Lopez
- Pain Center and Division of Functional Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Brazil; and.,Department of Stereotactic and Functional Neurosurgery, University Medical Center, Freiburg, Germany
| | | | - Manoel Jacobsen Teixeira
- Pain Center and Division of Functional Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Brazil; and
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Kim DR, Lee SW, Son BC. Stereotactic mesencephalotomy for cancer - related facial pain. J Korean Neurosurg Soc 2014; 56:71-4. [PMID: 25289131 PMCID: PMC4185326 DOI: 10.3340/jkns.2014.56.1.71] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 03/29/2014] [Accepted: 07/15/2014] [Indexed: 11/27/2022] Open
Abstract
Cancer-related facial pain refractory to pharmacologic management or nondestructive means is a major indication for destructive pain surgery. Stereotactic mesencephalotomy can be a valuable procedure in the management of cancer pain involving the upper extremities or the face, with the assistance of magnetic resonance imaging (MRI) and electrophysiologic mapping. A 72-year-old man presented with a 3-year history of intractable left-sided facial pain. When pharmacologic and nondestructive measures failed to provide pain alleviation, he was reexamined and diagnosed with inoperable hard palate cancer with intracranial extension. During the concurrent chemoradiation treatment, his cancer-related facial pain was aggravated and became medically intractable. After careful consideration, MRI-based stereotactic mesencephalotomy was performed at a point 5 mm behind the posterior commissure, 6 mm lateral to and 5 mm below the intercommissural plane using a 2-mm electrode, with the temperature of the electrode raised to 80℃ for 60 seconds. Up until now, the pain has been relatively well-controlled by intermittent intraventricular morphine injection and oral opioids, with the pain level remaining at visual analogue scale 4 or 5. Stereotactic mesencephalotomy with the use of high-resolution MRI and electrophysiologic localization is a valuable procedure in patients with cancer-related facial pain.
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Affiliation(s)
- Deok-Ryeong Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Sang-Won Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Chul Son
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. ; Catholic Neuroscience Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Bentley JN, Viswanathan A, Rosenberg WS, Patil PG. Treatment of medically refractory cancer pain with a combination of intrathecal neuromodulation and neurosurgical ablation: case series and literature review. PAIN MEDICINE 2014; 15:1488-95. [PMID: 24931480 DOI: 10.1111/pme.12481] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Up to 90% of patients with advanced cancer experience intractable pain. For these patients, oral analgesics are the mainstay of therapy, often augmented with intrathecal drug delivery. Neurosurgical ablative procedures have become less commonly used, though their efficacy has been well-established. Unfortunately, little is known about the safety of ablation in the context of previous neuromodulation. Therefore, the aim of this study is to present the results from a case series in which patients were treated successfully with a combination of intrathecal neuromodulation and neurosurgical ablation. DESIGN Retrospective case series and literature review. SETTING Three institutions with active cancer pain management programs in the United States. METHODS All patients who underwent both neuroablative and neuromodulatory procedures for cancer pain were surveyed using the visual analog scale prior to the first procedure, before and after a second procedure, and at long-term follow-up. Based on initial and subsequent presentation, patients underwent intrathecal morphine pump placement, cordotomy, or midline myelotomy. RESULTS Five patients (2 male, 3 female) with medically intractable pain (initial VAS = 10) were included in the series. Four subjects were initially treated with intrathecal analgesic neuromodulation, and 1 with midline myelotomy. Each patient experienced recurrence of pain (VAS ≥ 9) following the initial procedure, and was therefore treated with another modality (intrathecal, N = 1; midline myelotomy, N = 1; percutaneous radiofrequency cordotomy, N = 3), with significant long-term benefit (VAS 1-7). CONCLUSION In cancer patients with medically intractable pain, intrathecal neuromodulation and neurosurgical ablation together may allow for more effective control of cancer pain.
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Affiliation(s)
- J Nicole Bentley
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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36
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A palliative care intervention for pain refractory to a percutaneous cordotomy. Palliat Support Care 2014; 13:395-8. [DOI: 10.1017/s1478951514000157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractBackground:Intrathecal analgesia and radiofrequency techniques for tumor ablation are employed for palliation of symptoms. These interventions are efficacious in a select number of patients for controlling pain and improving quality of life. Careful selection of an appropriate candidate must be performed to prevent needless, invasive, and costly interventions, as interventional pain management alone will not treat total pain in cancer patients. We describe here a patient who experienced intractable pain and unsuccessfully underwent cordotomy but responded to the interdisciplinary (IDT) palliative care approach in an acute palliative care unit (APCU).Case:A middle-aged female with ovarian cancer metastatic to the left psoas muscle and the supraclavicular and retroperitoneal lymph nodes was admitted with severe left thigh and flank pain. She had been unsuccessfully treated with different opioid regimens, hypogastric nerve block, epidural steroid injection, and cordotomy. The palliative care team was consulted while awaiting placement of an intrathecal pump. The patient was subsequently transferred to the APCU for symptom management and transition to hospice. On admission, her morphine equivalent daily dose (MEDD) was 660 mg. Our IDT—composed of a physician, fellow, nurse practitioner, counselor, chaplain, social worker, and physical and occupational therapists—was able to identify several sources of distress that likely contributed to her expression of pain. Our IDT focused on frequent counseling, improving her function, provided medication education, discussed goals of care, and educated about hospice. She was discharged to hospice care with good pain control and an 85% reduction in her MEDD.Conclusion:An APCU approach involving an IDT alleviated the need for invasive interventions by diagnosing and treating the psychosocial, emotional, and spiritual distress contributing to the patient's total pain expression. Successful management must be reflective of rigorous assessment of the physical, psychological, spiritual, social, and practical aspects before consideration of more invasive treatments.
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Son BC, Yoon JH, Kim DR, Lee SW. Dorsal Rhizotomy for Pain from Neoplastic Lumbosacral Plexopathy in Advanced Pelvic Cancer. Stereotact Funct Neurosurg 2014; 92:109-16. [DOI: 10.1159/000360581] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 02/12/2014] [Indexed: 11/19/2022]
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38
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France BD, Lewis RA, Sharma ML, Poolman M. Cordotomy in mesothelioma-related pain: a systematic review. BMJ Support Palliat Care 2013; 4:19-29. [DOI: 10.1136/bmjspcare-2013-000508] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Viswanathan A, Bruera E. Cordotomy for treatment of cancer-related pain: patient selection and intervention timing. Neurosurg Focus 2013; 35:E6. [DOI: 10.3171/2013.6.focus13237] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Many neurosurgical interventions for the management of cancer-related pain have been tried, but their role in today's advanced supportive and palliative care is not well described. The authors discuss the current knowledge gaps that prevent successful integration of neurosurgical interventions and patients with cancer-related pain.
Two patients underwent percutaneous CT-guided cordotomy for refractory cancer-related pain: one patient had melanoma and the other had ovarian carcinoma. Both patients seemed to have unilateral, somatic, nociceptive cancer-related pain.
Cordotomy was effective for only 1 patient.
Percutaneous CT-guided cordotomy is a low-risk intervention that can benefit carefully selected patients with cancer-related pain. There is a clear need for prospective controlled studies to evaluate the effectiveness of cordotomy for patients receiving optimal medical treatment. A multidisciplinary study design could help to identify factors correlated with a positive outcome.
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Affiliation(s)
| | - Eduardo Bruera
- 2Palliative Care & Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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40
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41
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Collins KL, Patil PG. Flat-panel fluoroscopy O-arm-guided percutaneous radiofrequency cordotomy: a new technique for the treatment of unilateral cancer pain. Neurosurgery 2013; 72:27-34; discussion 34. [PMID: 23037818 DOI: 10.1227/neu.0b013e31827415e7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Percutaneous radiofrequency cordotomy (PRFC) involves controlled ablation of the anterolateral quadrant of the spinal cord, thereby relieving pain. Evolving from a morbid open surgery, the procedure has been modernized through the application of physiological target confirmation, well-regulated thermal ablation, and improved intraoperative imaging. OBJECTIVE To evaluate the utility in PRFC of a new high-resolution, portable flat-panel fluoroscopic imaging technology, the O-arm Imaging System. The O-arm allows traditional 2-dimensional fluoroscopy in addition to axial and 3-dimensional reconstructed computed tomography imaging. METHODS PRFC was performed using the O-arm Imaging System in 6 patients with unilateral cancer pain. RESULTS Patients experienced 90% to 100% initial pain relief, with 50% to 100% sustained pain relief at the time of death at 2 to 12 months. There were no complications. CONCLUSION Portable flat-panel fluoroscopy allows high-resolution, readily updated computed tomography and fluoroscopic image guidance during PRFC. Use of this new technology may assist neurosurgeons in providing an important analgesic intervention at centers possessing the imaging technology.
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Affiliation(s)
- Kelly L Collins
- Department of Neurosurgery, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan 48109-5338, USA
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Chronic opioid therapy and opioid tolerance: a new hypothesis. PAIN RESEARCH AND TREATMENT 2013; 2013:407504. [PMID: 23401765 PMCID: PMC3557641 DOI: 10.1155/2013/407504] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 12/23/2012] [Accepted: 12/27/2012] [Indexed: 11/17/2022]
Abstract
Opioids are efficacious and cost-effective analgesics, but tolerance limits their effectiveness. This paper does not present any new clinical or experimental data but demonstrates that there exist ascending sensory pathways that contain few opioid receptors. These pathways are located by brain PET scans and spinal cord autoradiography. These nonopioid ascending pathways include portions of the ventral spinal thalamic tract originating in Rexed layers VI-VIII, thalamocortical fibers that project to the primary somatosensory cortex (S1), and possibly a midline dorsal column visceral pathway. One hypothesis is that opioid tolerance and opioid-induced hyperalgesia may be caused by homeostatic upregulation during opioid exposure of nonopioid-dependent ascending pain pathways. Upregulation of sensory pathways is not a new concept and has been demonstrated in individuals impaired with deafness or blindness. A second hypothesis is that adjuvant nonopioid therapies may inhibit ascending nonopioid-dependent pathways and support the clinical observations that monotherapy with opioids usually fails. The uniqueness of opioid tolerance compared to tolerance associated with other central nervous system medications and lack of tolerance from excess hormone production is discussed. Experimental work that could prove or disprove the concepts as well as flaws in the concepts is discussed.
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Gadgil N, Viswanathan A. DREZotomy in the treatment of cancer pain: a review. Stereotact Funct Neurosurg 2012; 90:356-60. [PMID: 22922361 DOI: 10.1159/000341072] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 06/11/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cancer-related pain is a common problem that may be intractable by medical and neuromodulatory treatment. The dorsal root entry zone (DREZ) is a hyperactive focus in neuropathic pain syndromes, and DREZotomy has been used in selective cases of neuropathic cancer pain. OBJECTIVE The aim of this study was to describe the technique of spinal DREZotomy in the treatment of cancer pain and review the relevant published literature. METHODS A PubMed database search for 'DREZ', 'dorsal root entry zone' and 'cancer', and a search of the references of these manuscripts, was undertaken. RESULTS 14 papers were identified and reviewed that described a total of 123 patients with cancer pain or radiation-induced pain who have been treated with DREZotomy. Though heterogeneous, these studies reported an overall favorable outcome in carefully selected patients with topographically limited pain syndromes. CONCLUSION For patients with well-localized neuropathic cancer pain intractable to medical and first-line surgical management, DREZotomy is a viable treatment option. Further prospective studies are needed to evaluate the outcomes of this procedure.
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Affiliation(s)
- Nisha Gadgil
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
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Abstract
PURPOSE OF REVIEW Interventional techniques were the mainstay for cancer pain management before the WHO ladder and opioids were freely available. The three-step WHO ladder has its limitations, and cancer pain is often under treated. Advances in treatment options mean that cancer patients are living longer and pain interventions may have a role to play even early in the cancer diagnosis for better quality of analgesia. The role of high doses of opioids in pain management is also currently under scrutiny. RECENT FINDINGS Recent advances in intrathecal analgesia, radiofrequency techniques, both in tumour ablation and neurotomies, are being widely used for palliation. Vertebroplasty techniques have been used not only for pain relief, but also for stabilization. Improved imaging and thoracoscopic techniques have made coeliac plexus and splanchnic blockade safer and more efficacious. There has been recent interest in percutaneous cordotomy with newer techniques using computed tomography/MRI and endoscopy guidance. Percutaneous electrical nerve stimulation and 8% capsaicin patches have been successfully used for managing neuropathic pain in cancer. SUMMARY Interventions form an integral part in providing pain relief in complex cancer pains. Oncologists and palliative care physicians are to be educated on the usefulness and timing of interventions in the management of complex cancer pain.
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Blacklidge DK, Masadeh SB, Lyons MC, Miller JM. A preliminary review of the use of deep peroneal neurectomy for the treatment of painful midtarsal and tarsometatarsal arthritis. J Foot Ankle Surg 2012; 51:464-7. [PMID: 22425071 DOI: 10.1053/j.jfas.2012.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Indexed: 02/03/2023]
Abstract
This report describes a retrospective analysis of chart and radiographic data pertaining to 10 consecutive cases performed over a 30-month period, undertaken in an effort to evaluate the preliminary efficacy of denervation for pain relief in high-risk surgical candidates with midfoot and tarsometatarsal joint arthritis. Ten patients (13 feet) were treated, and objective and subjective assessments were obtained using an index of subjective patient satisfaction. Results revealed 9 (69.2%) feet from 7 (70%) patients had greater than 75% relief. Two (15.4%) feet from 2 (20%) patients had at least 50% improvement and 2 (15.4%) feet from 1 (10%) patient claimed no relief. Our results indicate that this method of treatment can be an effective way to relieve pain associated with arthrosis involving the midfoot and tarsometatarsal joints.
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:109-25. [DOI: 10.1097/spc.0b013e328350f70c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Taira T. Ablative neurosurgical procedure for pain after spinal cord injury. World Neurosurg 2011; 75:449-50. [PMID: 21600494 DOI: 10.1016/j.wneu.2010.12.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 12/23/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan.
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Abstract
Neurosurgical procedures to treat pain are mainly destructive and involve the spinal cord and occasionally the brain. Targets include the spinothalamic tract, the trigeminal tract nucleus, the midline ascending visceral pain pathway, the brainstem spinal lemniscus, the thalamus, and the cingulate gyrus. Since the introduction of intrathecal opioids, the need for neurosurgical destructive procedures has been in decline. In recent years, cordotomy, trigeminal tractotomy, and dorsal root entry zone (DREZ) operations are the neurosurgical procedures most often utilized to treat cancer pain. The addition of CT guidance to spinal cord pain pathway ablation was a major addition and refinement to the procedure. Here the authors review the latest techniques and recently published results for CT-guided cordotomy, CT-guided trigeminal tractotomy, and DREZ operations utilized to treat cancer pain.
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