Neurosurgical management of intractable pain

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Presentation transcript:

Neurosurgical management of intractable pain Mohammad.reza akrami M.D.

Pain Acute Chronic Nociceptive Neuropathic

Surgical treatment of intractable pain is not usually the first treatment option Medication Adjuvant therapy Simple nerve block Augmentative ablative

Patient selection for surgical pain therapies

Surgical procedures for trigeminal pain Surgical procedures for nontrigeminal pain

Neurosurgical pain therapies

Augmentative Stimulation Neuroaxial drug infusion Advantages……. safe,adjustable,reversibilty Disadvantages…….expensive ,need to maintenance,life expectancy >3 m

stimulation SCS Main indication is neuropathic pain in limbs FBSS CRPS

Stimulation PNS Cranial PHN Occipital neuralgia When pain is limited to specific nerve Cranial PHN Occipital neuralgia

stimulation DBS Target Thalamus PAG INDICATION TGN FBSS Cancer pains

stimulation MCS INDICATIONS TGN FBSS CANCER PAIN (3M+) MCS vs. DBS

neuroaxial drug infusion Intrathecal/epidural Intraventricular For below the neck pains For above the neck intraven. Effective in both nociceptive and neuropathic pain Expensive and need for maintenance

ablative The last choice 3 site for intervention Peripheral Cheap, less technique demanding ,no need for f/u, feasible in cancers Invasive ,irreversible 3 site for intervention Peripheral Spinal cord intracranial

Sympathectomy visceral pain in cancers limb pain in vasospastic dis Sympathectomy visceral pain in cancers limb pain in vasospastic dis. No good for nonmalignant pain

Neurectomy usually in non functionl limb or amputated limb

Neurectomy

Dorsal rhizotomy and ganglionectomy back, neck ,abdoman no good for functional limb

DREZ lesioning for trunk and limbs in cord inj pains trumatic avulsion of root

cordotomy Target :spinothalamic tract Excellent response 80% Open vs percutaneous No need for f/u Good for cancer

thalamotomy In all types of pain Steriotaxic RF SRS

Singolotomy The last choice When others ineffective Good for cancer pains

hypophysectomy Good relief of hormone responsive cancers pain Specific mechanism of pain relief is unknown Techinques SRS SURGERY