Surgical treatment of pain


 * We usually affect chronic pain in malignant tumors, indications for benign reasons are rarer.
 * We indicate patients who have a chance of longer survival and are in good general condition (to manage the operation).
 * It is the method of choice always after palliative RT and the application of strong analgesics.
 * The general effort is to make performance as simple as possible.

Spinal epidural and intrathecal application of morphine

 * The advantage is a lower dose of morphine, it does not burden the patient much. Insert a catheter there and apply it.

Spinal epidural stimulation

 * It blocks the transmission of information about spinal cord pain and does not lead to irreversible changes or addiction.
 * It is suitable for benign causes of pain, we put the stimulator under the skin. The disadvantage is the price.

Surgical methods

 * Pain pathway - main fibers - A and C (A leads sharp localized pain, C dull, burning).Spinal column curvature.png
 * They switch in the posterior corners of the spinal cord, where the response is modulated (gating, etc…).
 * Then the 2nd N intersects and runs as a tractus spinothalamicus lateralis.
 * Peripheral nerve disruption - by surgery or alcoholization.
 * It is a completely inappropriate method, in addition to failure, it can also add to the pain of denervation.


 * Spinal cord procedures - the open way, mainly microsurgically.
 * Dorsal root entry zone coagulation (DREZ = dorsal root entry zone):
 * damage in the posterior corners of the spinal cord;
 * suitable for deafferentation pain perceiving as burning or jerky;
 * plexus avulsion, after amputations.
 * Spinothalamic chordotomy (tractotomy):
 * interruption of the lateral spinothalamic tract;
 * the result is unilateral analgesia (contralateral) - suitable for unilateral pain.
 * Mediolongitudinal myelotomy (commissural):
 * longitudinal intersection of the spinal cord in the midline, interrupts the crossing of the pain pathway (crossing of the secondary fibers, most often in area C);
 * analgesia occurs below the lesion site - for bilateral pain.
 * Brain procedures - little is done.
 * Psychosurgery - bilateral cingulotomy.

Causalgia

 * Algic syndrome, rarely caused by a partial injury to the peripheral nerve.
 * Three symptoms - burning pain, autonomic nerve dysfunction and trophic changes.
 * It most often occurs after injuries to the median, ulnar and sciatic.
 * When large nerves are affected - we deal with microsurgical reconstruction of the nerve.

Sudeck's osteodystrophy

 * Severe pain, vasomotor disorders (edema, cyanosis, trophic disorder), eventually osteoporosis;
 * Therapy – sympathectomy

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