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Surgical Interventions for Pain

Mr. A.H.’s wife has been looking up treatment options for his pain on the internet, and has asked the physician about what surgical options may be available to Mr. A.H. at this stage in his rehabilitation.
Q19. Describe the available surgical interventions for treatment of post-SCI pain.
1. Spinal Cord Stimulation (Table 4; Figure 4a).
2. Destructive Neurosurgical Procedures (Table 4; Figure 4b).
3. Dorsal Rhizotomy (Table 4).
4. Sympathectomy (Table 4; Figure 4c).
5. Lateral Spinothalamic Tractotomy (Table 4).
6. Spinal Cordotomy (Table 4; Figure 4d).
Table 4. Surgical treatments for pain post SCI

Treatment Description/Evidence
Spinal Cord Stimulation Spinal cord stimulation has been used to try to treat intractable pain and may improve post-SCI pain. The procedure is both expensive and invasive.
Destructive Neurosurgical Procedures Destructive neurosurgical procedures work best on segmental and central dysesthetic pain. Surgery for pain is best done earlier than later. The Dorsal Root Entry Zone (DREZ) procedure is reportedly the most successful procedure at the present time; however, in many cases pain is either unresponsive or returns.
Dorsal Rhizotomy

Dorsal rhizotomy is a procedure where the sensory roots are divided either intradurally or extradurally. A single one or two level root rhizotomy may be appropriate when the pain is localized as in those patients with paraparesis and single root pain. Moreover, the Dorsal Root Entry Zone (DREZ) procedure was more likely to be successful in these patients.

Sympathectomy

Sympathectomy is not recommended for pain following SCI. As mentioned previously, sympathetic blockade and sympathectomy have reportedly failed to relieve the central pain of SCI.

Lateral Spinothalamic Tractotomy

Three selected cases of patients with intractable root pain, subsequent to severe trauma to the cauda equina which resulted in paraplegia (L2-4 lesions) have been reported. Lateral spinothalamic tractotomy in all three of these patients resulted in complete relief from pain. Threshold studies subsequent to the tractotomy "revealed a striking return of perception and reaction thresholds to a normal range."

Spinal Cordotomy

This procedure can be performed openly or percutaneously. Anterior spinothalamic tracts subserving pain and temperature function are sectioned, often requiring a bilateral approach. Spinal cordotomy is an option but is rarely employed and there is little evidence that it works.

For more information please see: Surgical Interventions
 

 


Figure 4a. Spinal Cord Stimulation


Figure 4b.Destructive Neurosurgical Procedures


Figure 4c. Sympathectomy


Figure 4d.Spinal Cordotomy