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The role of neurosurgery in the treatment of chronic pain

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Neurosurgical training should formally incorporate chronic pain management, and future generations will need to direct the development of rational surgical intervention

Until the early 1980s, neurosurgical intervention for intractable pain consisted almost exclusively of targeted neuroablative procedures aimed at disrupting nociceptive pathways at some point between peripheral nerve and cortex.

Used predominantly in the treatment of malignant pain in the trunk, pelvis and lower limbs, the most successful of these — dorsal rhizotomy, spinothalamic cordotomy and myelotomy — were considered to demonstrate, invariably in non-randomised case series, good to excellent results in selected patients with nociceptive cancer pain. Pain relief would usually be maintained through a survival period of 9–12 months but there were risks of operative mortality, post-lesion dysaesthesia, and impaired motor, sensory and sphincter function. Generally confined to use in cancer patients with a life expectancy of less than 1 year and with more widespread use of opiates, hospice care and the development of intrathecal drug delivery, these operations became almost redundant.

Recent advances in image-guided percutaneous cordotomy, a new understanding of the pain pathways within the dorsal columns, and the introduction of minimally invasive punctate myelotomy have led to some resurgence both of cordotomy and myelotomy…