AA

Surgical Interventions for Post-SCI Pain

Mrs. Miller continues to suffer from severe pain despite a number of pharmacological treatments. She is desperate and states “just cut the nerves”. Her sister, a nurse, has been on the internet and has found a few testimonials of SCI patients whose pain was helped substantially after a surgical procedure. Both Mrs. Miller and her sister want to know if surgery would be an option.
Q26.  List the various surgical interventions available for the treatment of post-SCI pain.
1. Spinal Cord Stimulation
2. Destructive Neurosurgical Procedures
3. Dorsal Rhizotomy
4. Sympathectomy
5. Lateral Spinothalamic Tractotomy
6. Spinal Cordotomy
Table 2. Surgical Interventions for Post-SCI Pain

Treatment

Description/ Evidence

Spinal Cord Stimulation

 

Spinal cord stimulation has been used to treat intractable pain and may improve post-SCI pain. The procedure is both expensive and invasive. Epidural electrodes are inserted percutaneously over the posterior columns of the spinal cord to allow for spinal cord stimulation. During spinal cord stimulation, 22 patients reported parasthesias overlapping the painful area. 9 patients reported 50% pain relief and 3 patients experienced no pain relief (see figure 11a).

 

Destructive Neurosurgical Procedures

Destructive neurosurgical procedures work best on segmental and central dysesthetic pain (Nashold, 1991). Nashold (1991) notes that 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 (Nashold 1991); however, in many cases pain is either unresponsive or returns (see figure 11b).

 

Dorsal Rhizotomy

Dorsal rhizotomy is a procedure where the sensory roots are divided either intradurally or extradurally. According to Nashold (1991) 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, Nashold (1991) reported the Dorsal Root Entry Zone procedure was more likely to be successful in these patients (see figure 11c).

 

Sympathectomy

 

Sympathectomy is not recommended for pain following SCI (Nashold 1991). As mentioned previously, sympathetic blockade and sympathectomy have reportedly failed to relieve the central pain of SCI (White 1969; Melzack 1978; Friedman 1986) (see figure 11d).

 

Lateral Spinothalamic Tractotomy

 

Hazouri and Mueller (1950) described three selected cases of patients with intractable root pain, subsequent to severe trauma to the cauda equina which resulted in paraplegia (L2-4 lesions). All three patients demonstrated a distinct increase in the threshold for perception of pain and "an even more remarkable increase in the threshold for reaction to pain." 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 11a.
Surgical intervention available for the treatment of post-SCI pain – Spinal Cord Stimulation


Figure 11b.Surgical intervention available for the treatment of post-SCI pain – Destructive Neurosurgical Procedures.


Figure 11c.Surgical interventions available for the treatment of post-SCI pain – Dorsal Rhizotomy.


Figure 11d.Surgical interventions available for the treatment of post-SCI pain – Sympathectomy.