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McBenedict B, Hauwanga WN, Pires MP, Netto JGM, Petrus D, Kanchwala JA, Joshi R, Alurkar SRA, Chankseliani O, Mansoor Z, Subash S, Alphonse B, Abrahão A, Lima Pessôa B. Cingulotomy for Intractable Pain: A Systematic Review of an Underutilized Procedure. Cureus 2024; 16:e56746. [PMID: 38650773 PMCID: PMC11033963 DOI: 10.7759/cureus.56746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024] Open
Abstract
Pain management is a critical aspect of cancer treatment and palliative care, where pain can significantly impact quality of life. Chronic pain, which affects a significant number of people worldwide, remains a prevalent and challenging symptom for patients. While medications and psychosocial support systems play a role in pain management, surgical and radiological interventions, including cingulotomy, may be necessary for refractory cases. Cingulotomy, a neurosurgical procedure targeting the cingulate gyrus, aims to disrupt neural pathways associated with emotional processing and pain sensation, thereby reducing the affective component of pain. Although cingulotomy has shown promise in providing pain relief, particularly in patients refractory to traditional medical treatment, its use has declined in recent years due to advancements in non-destructive therapies and concerns about long-term efficacy and patient suitability. Modern stereotactic methods have enhanced the precision and safety of cingulotomy, reducing associated complications and mortality rates. Despite these advancements, questions remain regarding its long-term efficacy and suitability for patients with limited life expectancy, particularly those with cancer. A comprehensive systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, aimed at providing insights into the efficacy, potential benefits, and limitations of this neurosurgical procedure in managing intractable pain. An electronic search of PubMed, Embase, Scopus, and Web of Science was conducted with open database coverage dates. The review focused on outcomes such as pain intensity and quality of life. The inclusion criteria encompassed human studies of any age experiencing intractable cancer or non-cancer pain, with cingulotomy as the primary intervention. Various study designs were considered, including observational studies, clinical trials, and reviews focusing on pain and cingulotomy. Exclusion criteria included non-human studies, non-peer-reviewed articles, and studies unrelated to pain or cingulotomy. This review highlights the efficacy of stereotactic anterior cingulotomy in managing intractable pain, particularly when conventional treatments fail. Advanced MRI-guided techniques enhance precision, but challenges like cost and expertise persist. Studies included in this review showed significant pain relief with minimal adverse effects, although the optimal target remains debated. Neurocognitive risks exist, but outcomes are generally favorable. Expected adverse events include transient effects like urinary incontinence and confusion. Reoperation may be necessary for inadequate pain control, with a median pain relief duration of three months to a year. A double stereotactic cingulotomy appears to be safe and effective for refractory pain.
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Affiliation(s)
| | - Wilhelmina N Hauwanga
- Family Medicine, Faculty of Medicine, Federal University of the State of Rio de Janeiro, Rio de Janeiro, BRA
| | | | | | - Dulci Petrus
- Family Health, Directorate of Special Programs, Ministry of Health and Social Services, Namibia, Windhoek, NAM
| | | | - Rhea Joshi
- Medicine and Surgery, Tbilisi State Medical University, Tbilisi, GEO
| | | | | | - Zaeemah Mansoor
- Faculty of Health Sciences, Karachi Medical & Dental College, Karachi, PAK
| | - Sona Subash
- Medicine and Surgery, Tbilisi State Medical University, Tbilisi, GEO
| | - Berley Alphonse
- Internal Medicine, University Notre Dame of Haiti, Port-au-Prince, HTI
| | - Ana Abrahão
- Public Health, Universidade Federal Fluminense, Niterói, BRA
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Gabay S, Sapir Y, Korn A, Hochberg U, Tellem R, Zegerman A, Brogan SE, Rahimpour S, Shofty B, Strauss I. Optimization of Radiofrequency Needle Placement in Percutaneous Cordotomy Using Electromyography in the Deeply Sedated Patient. Oper Neurosurg (Hagerstown) 2024; 26:22-27. [PMID: 37747336 DOI: 10.1227/ons.0000000000000907] [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: 04/19/2023] [Accepted: 07/14/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cordotomy, the selective disconnection of the nociceptive fibers in the spinothalamic tract, is used to provide pain palliation to oncological patients suffering from intractable cancer-related pain. Cordotomies are commonly performed using a cervical (C1-2) percutaneous approach under imaging guidance and require patients' cooperation to functionally localize the spinothalamic tract. This can be challenging in patients suffering from extreme pain. It has recently been demonstrated that intraoperative neurophysiology monitoring by electromyography may aid in safe lesion positioning. The aim of this study was to evaluate the role of compound muscle action potential (CMAP) in deeply sedated patients undergoing percutaneous cervical cordotomy (PCC). METHODS A retrospective analysis was conducted of all patients who underwent percutaneous cordotomy while deeply sedated between January 2019 and November 2022 in 2 academic centers. The operative report, neuromonitoring logs, and clinical medical records were evaluated. RESULTS Eleven patients underwent PCC under deep sedation. In all patients, the final motor assessment prior to ablation was done using the electrophysiological criterion alone. The median threshold for evoking CMAP activity at the lesion site was 0.9 V ranging between 0.5 and 1.5 V (average 1 V ± 0.34 V SD). An immediate, substantial decrease in pain was observed in 9 patients. The median pain scores (Numeric Rating Scale) decreased from 10 preoperatively (range 8-10) to a median 0 (range 0-10) immediately after surgery. None of our patients developed motor deficits. CONCLUSION CMAP-guided PCC may be feasible in deeply sedated patients without added risk to postoperative motor function. This technique should be considered in a group of patients who are not able to undergo awake PCC.
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Affiliation(s)
- Segev Gabay
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv , Israel
| | - Yechiam Sapir
- Surgical Monitoring Services, Beit Shemesh , Israel
- Intraoperative Neurophysiological Monitoring Service, Tel Aviv Medical Center, Tel Aviv , Israel
| | - Akiva Korn
- Surgical Monitoring Services, Beit Shemesh , Israel
- Intraoperative Neurophysiological Monitoring Service, Tel Aviv Medical Center, Tel Aviv , Israel
| | - Uri Hochberg
- Institute of Pain Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv , Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv , Israel
| | - Rotem Tellem
- Palliative Care Service, Tel Aviv Sourasky Medical Center, Tel Aviv , Israel
| | - Alex Zegerman
- Division of Anesthesia, Tel Aviv Sourasky Medical Center, Tel Aviv , Israel
| | - Shane E Brogan
- Division of Pain Medicine, Department of Anesthesiology, University of Utah, Salt Lake City , Utah , USA
| | - Shervin Rahimpour
- Department of Neurosurgery, University of Utah, Salt Lake City , Utah , USA
| | - Ben Shofty
- Department of Neurosurgery, University of Utah, Salt Lake City , Utah , USA
| | - Ido Strauss
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv , Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv , Israel
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Sharon H, Agbaria Y, Brill S, de Santiago J, Hochberg U. Medical cannabis for refractory cancer-related pain in a specialised clinical service: a cross-sectional study. BMJ Support Palliat Care 2023:spcare-2023-004421. [PMID: 37973200 DOI: 10.1136/spcare-2023-004421] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Cancer-related pain management in advanced stages presents a significant challenge that often requires a multidisciplinary approach. Although advancements in pharmacological and interventional therapies, a considerable number of patients still suffer from refractory pain, leading to unmet clinical needs. This study shares our experience with medical cannabis (MC) as a potential therapy for this specific population of patients with cancer-related refractory pain. METHODS In a cross-sectional study, 252 consecutive refractory cancer-related pain patients (mean age=61.71, SD=14.02, 47.6% males) filled out detailed self-report questionnaires. Of these, 126 patients (55%) were treated with MC and 105 patients (45%) were not. RESULTS Most patients received pain management from their oncologist, not a pain specialist. MC was mainly started for pain relief, sleep difficulties and anorexia. About 70% of patients reported subjective improvement from MC, with almost 40% reporting a significant improvement in coping with their illness. Side effects were generally mild, with fatigue and dizziness being the most common (21.78% and 23.46%, respectively). No patient required dedicated medical care for side effects. Of non-users, 65% had tried MC before and stopped due to lack of effectiveness or side effects (39.7% and 34.6%, respectively). CONCLUSION Refractory cancer pain necessitates innovative approaches. This registry highlights that MC can effectively improve symptoms in non-responsive patients, with favourable safety profiles for this vulnerable population.
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Affiliation(s)
- Haggai Sharon
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel Aviv Sourasky Medical Center, Tel aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Yara Agbaria
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel Aviv Sourasky Medical Center, Tel aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Silviu Brill
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jesus de Santiago
- Department of Anesthesia and Chronic Pain Unit, Hospital Quirónsalud de Tenerife, Palmones, Spain
| | - Uri Hochberg
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Szylak R, Bhargava D, Pridgeon M, Srinivasaiah R, Vijayendra V, Osman-Farah J. Open Thoracic Cordotomy for Cancer Pain with Intraoperative Neuromonitoring: A Case Series and Critical Review of the Literature. World Neurosurg 2023; 179:e90-e101. [PMID: 37574190 DOI: 10.1016/j.wneu.2023.08.016] [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] [Received: 07/13/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Cordotomy is a viable option for patients with intractable cancer pain and limited survival. Open thoracic cordotomy is offered when patients are not candidates for percutaneous cordotomy. After the open procedure, traditionally performed purely based on anatomic landmarks, up to 22% of patients experience postoperative limb weakness. The objective of this study is to report our experience with neurophysiology-guided open cordotomy along with a critical review of the literature. METHODS Between 2019 and 2022, 5 open thoracic cordotomies were performed in our center. Intraoperative neurophysiologic monitoring was used in all cases to guide the lesion and standard single-level laminectomy or hemilaminectomy was performed for exposure. Outcome measures were retrospectively reviewed focusing on pain control and neurologic status. Existing literature on cordotomy was critically reviewed. RESULTS There was satisfactory pain relief with preservation of motor function in all 5 cases. Temperature sensation was preserved in all but 1 patient, who lost it after the previous ipsilateral percutaneous cordotomy (PCC). No procedural complications were experienced. We found that the neurophysiology monitoring lesion was guided anterior compared with what would have been lesioned on an anatomic basis. CONCLUSIONS Open thoracic cordotomy is a safe and effective procedure for intractable cancer-related pain. Technical advancements significantly reduced mortality and major morbidity of PCC. Our series suggests that neurophysiology monitoring alters the location of the lesion and may help better targeting of pain fibers within the spinothalamic tract and preserve other long tracts. The safety profile of open cordotomy with neurophysiology compares favorably with the PCC.
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Affiliation(s)
- Rafal Szylak
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom.
| | - Deepti Bhargava
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
| | - Michael Pridgeon
- Department of Neurophysiology, The Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
| | - Rajesha Srinivasaiah
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
| | - Vishwas Vijayendra
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
| | - Jibril Osman-Farah
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom
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Leclerc A, Di Palma C, Emery E. Open thoracic cordotomy for intractable cancer pain: a how I do it. Acta Neurochir (Wien) 2023; 165:2197-2200. [PMID: 37392278 DOI: 10.1007/s00701-023-05696-2] [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] [Received: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Some cancers of the lower extremity involve nerves and plexuses and can produce extreme drug-resistant noceptive pain. In these cases, open thoracic cordotomy can be proposed. METHOD This procedure involves disruption of the spinothalamic tract, which sustains nociceptive pathways. After placement in the prone position, selection of the side to be operated on (contralateral to the pain), and dura exposure, microsurgery is used to section the anterolateral spinal cord quadrant previously exposed by gently pulling on the dentate ligament. CONCLUSION Open thoracic cordotomy is a moderate invasive, safe, and effective option for the management of drug-resistant unilateral lower extremity cancer pain in well-selected patients.
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Affiliation(s)
- Arthur Leclerc
- Department of Neurosurgery, Service de Neurochirurgie, CHU de Caen, Avenue de La Côte de Nacre, 14000, Caen, France.
- UNICAEN, ISTCT/CERVOxy Group, UMR6030, GIP CYCERON, Normandy University, Caen, France.
| | - Camille Di Palma
- Department of Neurosurgery, Service de Neurochirurgie, CHU de Caen, Avenue de La Côte de Nacre, 14000, Caen, France
| | - Evelyne Emery
- Department of Neurosurgery, Service de Neurochirurgie, CHU de Caen, Avenue de La Côte de Nacre, 14000, Caen, France
- INSERM, UMR-S U1237, GIP Cyceron, Physiopathology and Imaging of Neurological Disorders (PhIND), 14000, Caen, France
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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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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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