1
|
Allam AK, Larkin Michael MB, Shofty B, Viswanathan A. Ablation Procedures. Neurosurg Clin N Am 2022; 33:339-344. [PMID: 35718404 DOI: 10.1016/j.nec.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although ablation has a limited role in the management of chronic noncancer pain, ablation continues to help patients with treatment of refractory cancer-related pain. Interdisciplinary treatment involving supportive care, pain medicine, oncology, and neurosurgery is critical to optimizing the timing and outcome of neurosurgical ablative options for pain management. In this review, 3 targets for ablative surgery-the spinothalamic tract, the dorsal column's visceral pain pathway, and the anterior cingulate cortex-are discussed with a focus on patient selection and key aspects of surgical technique.
Collapse
Affiliation(s)
- Anthony Kaspa Allam
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA
| | - M Benjamin Larkin Michael
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA
| | - Ben Shofty
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA
| | - Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX 77030, USA.
| |
Collapse
|
2
|
Desai MJ, Safriel Y. MRI for in vivo Analysis of Ablation Zones Formed by Cooled Radiofrequency Neurotomy to Treat Chronic Joint Pain Across Multiple Axial Spine Sites. J Pain Res 2022; 15:423-430. [PMID: 35177931 PMCID: PMC8843798 DOI: 10.2147/jpr.s342795] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/18/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose Radiofrequency (RF) ablation is the targeted damage of neural tissues to disrupt pain transmission in sensory nerves using thermal energy generated in situ by an RF probe. The present study aims to evaluate the utility of magnetic resonance imaging (MRI) for in vivo quantitative assessment of ablation zones in human subjects following cooled radiofrequency neurotomy for chronic pain at spinal facet or sacroiliac joints. Ablation zone size and shape have been shown in animal models to be influenced by size and type of RF probe – with cooled RF probes typically forming larger, more spherical ablation zones. To date, MRI of RF ablation zones in humans has been limited to two single retrospective case reports. Patients and Methods A prospective, open-label pilot study of MRI for evaluation of cooled radiofrequency ablation zones following standard of care procedures in adult outpatients was conducted. Adult subjects (n=13) received monopolar cooled RF (CRF) ablation (COOLIEF™, Avanos Medical) of sensory nerves at spinal facet or sacroiliac joints, followed by an MRI 2–7 days after the procedure. MRI data were acquired using both Short Tau Inversion Recovery (STIR) and contrast-enhanced T1-weighted (T1C) protocols. T1C MRI was used to calculate 3-dimensional ellipsoid ablation zone volumes (V), where well-defined regions of signal hyperintensity were used to identify three orthogonal diameters (T, D, L) and apply the formula V=π/6×T×D×L. Results Among 13 patients, 96 CRF ablation zones were created at 4 different anatomic sites (sacroiliac, lumbar, thoracic and cervical). CRF ablation zone morphology varied by anatomical location and structural features of surrounding tissues. In some cases, proximity to bone and striations of surrounding musculature obscured ablation zone borders. The volumes of 75 of the 96 ablation zones were measurable from MRI, with values (mean±SD) ranging from 0.4679 (±0.29) cm3 to 2.735 (±2.62) cm3 for the cervical and thoracic sites, respectively. Conclusion In vivo T1C MRI analysis of cooled RF ablation zones at spinal facet and sacroiliac joints demonstrated variable effects of local tissues on ablation zone morphology. Placement of the CRFA probe very close to bone alters the ablation zone in a negative way, causing non-spherical and incomplete lesioning. These new data may serve to inform practicing physicians about optimal cooled RF probe placement in clinical procedures.
Collapse
Affiliation(s)
- Mehul J Desai
- International Spine, Pain & Performance Center, Washington, DC, USA
- Department of Anesthesiology and Critical Care, George Washington University, School of Medicine & Health Sciences, Washington, DC, USA
- Correspondence: Mehul J Desai, International Spine, Pain & Performance Center, Washington, DC, 20006, USA, Tel +1 202 808 8295, Email
| | - Yair Safriel
- Pharmascan, Wilmington, DE, USA
- University of South Florida Affiliated Programs, Clearwater, FL, USA
| |
Collapse
|
3
|
Gurbani SS, Brandman DM, Reeves C, Boulis NM, Weinberg BD. Percutaneous trigeminal tractotomy for trigeminal neuralgia: Postoperative MRI findings. J Neuroimaging 2021; 32:57-62. [PMID: 34468049 DOI: 10.1111/jon.12925] [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: 06/24/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Percutaneous trigeminal tractotomy is an ablative procedure that can be used to treat trigeminal neuralgia in patients who have failed prior pharmacologic and surgical treatments. Using perioperative computed tomography (CT) guidance, ablation of the descending spinal trigeminal nucleus and trigeminal tract can be performed precisely to mitigate damage to surrounding structures. These patients are subsequently followed with postoperative imaging and clinical visits to assess long-term pain relief. METHODS In this report, we present a series of four patients with trigeminal neuralgia who were had refractory disease after prior medical and surgical interventions. These patients underwent CT-guided percutaneous trigeminal tractotomy for pain relief. The patients underwent postoperative MRI and were followed for up to 6 months for long-term clinical outcomes. RESULTS For intraoperative CT, we find that preprocedure lumbar contrast injection enables better visualization of the cord during placement of the ablation probe. On postoperative imaging, we find that all four patients have hyperintense lesions on T2-weighted MRI that correspond with the location of the trigeminal nucleus and tract. Three patients had short-term pain relief, one of which continued to have long-term relief. CONCLUSION Intraoperative CT and postoperative MRI serve as useful modalities for confirming localization, evaluating complications, and can be used as a metric for quality control.
Collapse
Affiliation(s)
- Saumya S Gurbani
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | - David M Brandman
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Christopher Reeves
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
| | | | - Brent D Weinberg
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Vargas MI, Boto J, Dammann P, Lovblad KO. High-Resolution Hybrid Imaging Could Improve Cordotomy Lesions and Outcomes. AJNR Am J Neuroradiol 2017; 38:E78. [PMID: 28572148 DOI: 10.3174/ajnr.a5269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - J Boto
- Division of Neuroradiology, DISIM
| | | | - K-O Lovblad
- Division of Neuroradiology, DISIM Geneva University Hospital Geneva, Switzerland
| |
Collapse
|