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).
    Spine and Spinal Cord
    • 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;
    • 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

Source

References