Symposium on Malignant Disease
Neurosurgical Treatment of Pain Caused by Cancer Stephen R. Freidberg, M.D.
Pain can be a most useful symptom. It can be the warning sign that initiates the search for disease, and, certainly, the best treatment for the symptom is the treatment of the disease itself. All too frequently, however, when we deal with malignant disease, pain itself becomes the major problem. It causes or increases the patient's anxiety, it prevents sleep, and it starts the patient on the vicious cycle of increasing doses of narcotics with concomitant depression, anorexia, and lethargy. It is at this point that the symptom must be treated. Various surgical modalities and their indications will be discussed.
Peripheral Neurectomy In our experience, peripheral neurectomy (Fig. 1, 1) has rarely been useful except in the unusual circumstance when a specific peripheral nerve and little else is involved with tumor. If an attempt to relieve pain is made with multiple neurectomies, the pain will usually persist and the patient will be burdened with a distressingly numb and frequently dysesthetic limb. Occasionally intercostal neurectomy is useful for relief of pain of the chest wall due to invasion by tumor. This procedure can be performed under local anesthesia after a test with intercostal nerve block. Alcohol Rhizotomy (An Alcoholic Spinal) An alcohol rhizotomy is one application of peripheral neurectomy with limited, specific indications but which produces a high degree of success. Alcohol rhizotomy is useful in those patients with perineal or genital pain usually caused by recurrent carcinoma of the rectum or bladder and is best reserved for those patients without bladder function. Patients who have had extensive pelvic surgery have tenuous bladder function at best, and an alcohol rhizotomy will frequently remove whatever voluntary control remains. Perineal and genital numbness will be extremely uncomfortable to many patients. The major virtues of alcohol rhizotomy are the ease with which the procedure is performed and its low rate of morbidity. It is carried out in the radiology department in half an hour using minimal sedation. Medical Clinics of North America- Vo!. 59, No. 2, March 1975
481
482
STEPHEN
R. FREIDBERG
(POSTERIOR VIEW)
f3\ ........... \.:::Y Intercostal n.
T2···-----0
.-A~
Figure 1. Diagram of the nervous system showing sites of lesions. The numbers correspond to numbers in the text.
Commissural Myelotomy Commissural myelotomy has limited applicability (Fig. 1, 2). Used for the relief of bilateral pelvic pain, it is rarely performed now. The spinal cord is sectioned in the sagittal plane, dividing the spinothalamic fibers as they cross in the anterior commissures from the dorsal horn to the spinothalamic tract. There are many drawbacks to this operation. Even if the landmarks described by Sourek1o are used, it is difficult to be certain that the incision is at exactly the correct cord level. The danger of cord damage is, likewise, very real. In general, if the patient has midline or bilateral pain, bilateral cordotomy is preferred. Rhizotomy Rhizotomy (Fig. 1,3), like neurectomy, has very limited application and is rarely carried out. We have performed this operation for pain of the chest wall. Not only does this procedure require extensive surgery but the results are very disappointing. Two recent large series by Loese:r4 and by Onofrio and Campa6 demonstrated the unpredictable results from rhizotomy.
NEUROSURGICAL TREATMENT OF PAIN
483
Cordotomy Section of the spinothalamic tract in the spinal cord has been the mainstay of treatment of pain caused by cancer. The results are predictably good, and the operation can be performed with a low degree of morbidity and mortality. W& prefer to perform cordotomy percutaneously using a slight modification of the technique by Rosomoff et al. 9 (Fig. 1, 5). The cordotomy is carried out on a patient who is awake and cooperative by inserting a needle and electrode into the cord at the C 1-C 2 level. Beside the obvious advantages of avoiding general anesthesia and a prolonged period of recuperation, the ability to monitor the lesion carefully while it is being formed is of tremendous benefit. This is especially useful if the level required is C3 for pain of the brachial plexus. By careful movement of the electrode it is possible to enlarge the lesion to obtain this high level (Fig. 2) . . Electrical stimulation before and clinical monitoring during the making of the lesion has avoided significant hemiparesis in the past 2 years. We have now performed approximately 50 cordotomies. In the past 2 years our success rate has be~n 90 per cent. We have had two deaths directly related to percutaneo~s cordotomy; in both patients carcinoma affected the lung on the painful side. Interfering with lung function on the side of the cordotomy was,enough to cause death from respiratory failure, 4 and 8 days after opexation. There is still a place for open cordotomy (Fig. 1,4). Some patients will not tolerate the 1 to 2 hours required to perform percutaneous cordotomy under local anesthesia. For those who require bilateral cordotomy, high cervical percutaneous cordotomy is accomplished on one side and open high thoracic cordotomy on the other. Despite Rosomoff's 7,8 encouraging results with bilateral high cervical cordotomy, we have been reluctant to perform this procedure because of the danger of respiratory failure. Lin et al. 3 used a low cervical percutaneous technique that we plan to adopt in the future for the second side of a bilateral cordotomy in an attempt to keep the frequency of open cordotomy to a minimum. Medullary Tractomy Section of the descending tract of the trigeminal nerve in the lower medulla is an effective procedure for the relief of a painful unilateral lesion of the head and neck (Fig. 1, 6). We rarely perform this operation. It requires a posterior fossa craniectomy, and, as a rule, by the time the referring physician believes he has exhausted all other therapeutic modalities, the patient is no longer a suitable candidate for the operation. Cerebral Operations We occasionally perform bilateral medial prefrontalleukotomy (Fig. 1, 7) for the control of pain in those patients with a high level of anxiety and agitation and with a'lesion not amenable to other surgical treatment, that is, bilateral tumors of the head and neck. This does not inter-
484
STEPHEN
R.
FREIDBERG
Figure 2. Section through center of lesion at the level of C,. The patient survived two months after successful cordotomy for pain caused by infiltration of the brachial plexus with reticulum cell sarcoma. It was necessary to move the electrode three times to achieve an adequate level (X14.5).
fere with the appreciation of pain, as does cordotomy, but it reduces the apprehension that makes these lesions so terrible. Hypophysectomy Transsphenoidal or transfrontal hypophysectomy has been effective in reducing pain from osseous metastases in certain patients with carcinoma of the breast and of the prostate gland. The effect can be dramatic, with marked improvement in the level of pain and a feeling of well being noted within a few days after the surgical procedure. 1 Peripheral Nerve and Dorsal Column Stimulation In general, these newer modalities of pain relief have been disappointing in the treatment of pain secondary to malignant disease. We had hoped that there would be a place for electrical stimulation when bilateral cordotomy was necessary or when cordotomy had a high risk of respiratory insufficiency. We have performed this operation only once for malignant disease in a patient with rectal carcinoma. Good results were achieved for about a month, but bilateral cordotomy was subsequently performed. Disappointing results in the treatment of pain caused by carcinoma have been noted by others.5 It is not at all clear, at this time, why electrical stimulation is effective primarily in patients with pain from benign causes and why cordotomy has such limited use in these same patients.
NEUROSURGICAL TREATMENT OF PAIN
485
COMMENT This discussion has dealt with the technical options and indications for various procedures. We must, of course, always place the symptom in the context of the patient. He must be interviewed carefully and at length to be certain the definition of pain is the same to both the patient and the physician. It must be determined if the symptom, pain, is actually a rather mild ache that has been magnified by anxiety and depression. If so, cordotomy will never relieve the pain and the postcordotomy numbness, usually well tolerated, will rapidly become intolerable dysesthesia. The real problem could be a strong narcotic addiction. We have seen the occasional patient use one pretext after another to continue to obtain narcotics long after any reasonable need for them has passed. In general, the indications for surgery to relieve pain are more straightforward in patients with malignant disease than in those with benign disease, and the results of surgery are much more satisfactory. We must be careful, however, that, in our eagerness to relieve these unfortunate patients of their pain, we do not subject them to surgery that will be ineffective.
REFERENCES 1. Fager, C. A.: Selection of patients with metastatic breast cancer for hypophysectomy. Surg. Clin. N. Amer., 42:701-707 (June) 1962. 2. Freidberg, S. R., and Takaoka, Y.: Techniques of high cervical percutaneous cordotomy. Surg. Clin. N. Amer., 53:291-300 (April) 1973. 3. Lin, P. M., Gildenberg, P. L., and Polakoff, P. P.: An anterior approach to percutaneous lower cervical cordotomy. J. Neurosurg., 25:553-560 (Nov.) 1966. 4. Loeser, J. D.: Dorsal rhizotomy for the relief of chronic pain. J. Neurosurg., 36:745-750 (June) 1972. 5. Meeting, Northeast Dorsal Column Stimulator Study Group, New York, November 2, 1973, unpublished data. 6. Onofrio, B. M., and Campa, H. K.: Evaluation of rhizotomy. Review of 12 years' experience. J. Neurosurg., 36:751-755 (June) 1972. 7. Rosomoff, H. L.: Bilateral percutaneous cervical radiofrequency cordotomy. J. Neurosurg., 31 :41-46 (July) 1969. 8. Rosomoff, H. L., Krieger, A. J., and Kuperman, A. S.: Effects of percutaneous cervical cordotomy on pulmonary function. J. Neurosurg., 31 :620-627 (Dec.) 1969. 9. Rosomoff, H. L., Carroll, F., Brown, J., et al.: Percutaneous radiofrequency cervical cordotomy: technique. J. Neurosurg., 23:639-644 (Dec.) 1965. 10. Sourek, K.: Commissural myelotomy. J. Neurosurg., 31 :524-527 (Nov.) 1969.
Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215
Neurosurgical Treatment of Pain Caused by Cancer Stephen R. Freidberg, M.D.
Pain can be a most useful symptom. It can be the warning sign that initiates the search for disease, and, certainly, the best treatment for the symptom is the treatment of the disease itself. All too frequently, however, when we deal with malignant disease, pain itself becomes the major problem. It causes or increases the patient's anxiety, it prevents sleep, and it starts the patient on the vicious cycle of increasing doses of narcotics with concomitant depression, anorexia, and lethargy. It is at this point that the symptom must be treated. Various surgical modalities and their indications will be discussed.
Peripheral Neurectomy In our experience, peripheral neurectomy (Fig. 1, 1) has rarely been useful except in the unusual circumstance when a specific peripheral nerve and little else is involved with tumor. If an attempt to relieve pain is made with multiple neurectomies, the pain will usually persist and the patient will be burdened with a distressingly numb and frequently dysesthetic limb. Occasionally intercostal neurectomy is useful for relief of pain of the chest wall due to invasion by tumor. This procedure can be performed under local anesthesia after a test with intercostal nerve block. Alcohol Rhizotomy (An Alcoholic Spinal) An alcohol rhizotomy is one application of peripheral neurectomy with limited, specific indications but which produces a high degree of success. Alcohol rhizotomy is useful in those patients with perineal or genital pain usually caused by recurrent carcinoma of the rectum or bladder and is best reserved for those patients without bladder function. Patients who have had extensive pelvic surgery have tenuous bladder function at best, and an alcohol rhizotomy will frequently remove whatever voluntary control remains. Perineal and genital numbness will be extremely uncomfortable to many patients. The major virtues of alcohol rhizotomy are the ease with which the procedure is performed and its low rate of morbidity. It is carried out in the radiology department in half an hour using minimal sedation. Medical Clinics of North America- Vo!. 59, No. 2, March 1975
481
482
STEPHEN
R. FREIDBERG
(POSTERIOR VIEW)
f3\ ........... \.:::Y Intercostal n.
T2···-----0
.-A~
Figure 1. Diagram of the nervous system showing sites of lesions. The numbers correspond to numbers in the text.
Commissural Myelotomy Commissural myelotomy has limited applicability (Fig. 1, 2). Used for the relief of bilateral pelvic pain, it is rarely performed now. The spinal cord is sectioned in the sagittal plane, dividing the spinothalamic fibers as they cross in the anterior commissures from the dorsal horn to the spinothalamic tract. There are many drawbacks to this operation. Even if the landmarks described by Sourek1o are used, it is difficult to be certain that the incision is at exactly the correct cord level. The danger of cord damage is, likewise, very real. In general, if the patient has midline or bilateral pain, bilateral cordotomy is preferred. Rhizotomy Rhizotomy (Fig. 1,3), like neurectomy, has very limited application and is rarely carried out. We have performed this operation for pain of the chest wall. Not only does this procedure require extensive surgery but the results are very disappointing. Two recent large series by Loese:r4 and by Onofrio and Campa6 demonstrated the unpredictable results from rhizotomy.
NEUROSURGICAL TREATMENT OF PAIN
483
Cordotomy Section of the spinothalamic tract in the spinal cord has been the mainstay of treatment of pain caused by cancer. The results are predictably good, and the operation can be performed with a low degree of morbidity and mortality. W& prefer to perform cordotomy percutaneously using a slight modification of the technique by Rosomoff et al. 9 (Fig. 1, 5). The cordotomy is carried out on a patient who is awake and cooperative by inserting a needle and electrode into the cord at the C 1-C 2 level. Beside the obvious advantages of avoiding general anesthesia and a prolonged period of recuperation, the ability to monitor the lesion carefully while it is being formed is of tremendous benefit. This is especially useful if the level required is C3 for pain of the brachial plexus. By careful movement of the electrode it is possible to enlarge the lesion to obtain this high level (Fig. 2) . . Electrical stimulation before and clinical monitoring during the making of the lesion has avoided significant hemiparesis in the past 2 years. We have now performed approximately 50 cordotomies. In the past 2 years our success rate has be~n 90 per cent. We have had two deaths directly related to percutaneo~s cordotomy; in both patients carcinoma affected the lung on the painful side. Interfering with lung function on the side of the cordotomy was,enough to cause death from respiratory failure, 4 and 8 days after opexation. There is still a place for open cordotomy (Fig. 1,4). Some patients will not tolerate the 1 to 2 hours required to perform percutaneous cordotomy under local anesthesia. For those who require bilateral cordotomy, high cervical percutaneous cordotomy is accomplished on one side and open high thoracic cordotomy on the other. Despite Rosomoff's 7,8 encouraging results with bilateral high cervical cordotomy, we have been reluctant to perform this procedure because of the danger of respiratory failure. Lin et al. 3 used a low cervical percutaneous technique that we plan to adopt in the future for the second side of a bilateral cordotomy in an attempt to keep the frequency of open cordotomy to a minimum. Medullary Tractomy Section of the descending tract of the trigeminal nerve in the lower medulla is an effective procedure for the relief of a painful unilateral lesion of the head and neck (Fig. 1, 6). We rarely perform this operation. It requires a posterior fossa craniectomy, and, as a rule, by the time the referring physician believes he has exhausted all other therapeutic modalities, the patient is no longer a suitable candidate for the operation. Cerebral Operations We occasionally perform bilateral medial prefrontalleukotomy (Fig. 1, 7) for the control of pain in those patients with a high level of anxiety and agitation and with a'lesion not amenable to other surgical treatment, that is, bilateral tumors of the head and neck. This does not inter-
484
STEPHEN
R.
FREIDBERG
Figure 2. Section through center of lesion at the level of C,. The patient survived two months after successful cordotomy for pain caused by infiltration of the brachial plexus with reticulum cell sarcoma. It was necessary to move the electrode three times to achieve an adequate level (X14.5).
fere with the appreciation of pain, as does cordotomy, but it reduces the apprehension that makes these lesions so terrible. Hypophysectomy Transsphenoidal or transfrontal hypophysectomy has been effective in reducing pain from osseous metastases in certain patients with carcinoma of the breast and of the prostate gland. The effect can be dramatic, with marked improvement in the level of pain and a feeling of well being noted within a few days after the surgical procedure. 1 Peripheral Nerve and Dorsal Column Stimulation In general, these newer modalities of pain relief have been disappointing in the treatment of pain secondary to malignant disease. We had hoped that there would be a place for electrical stimulation when bilateral cordotomy was necessary or when cordotomy had a high risk of respiratory insufficiency. We have performed this operation only once for malignant disease in a patient with rectal carcinoma. Good results were achieved for about a month, but bilateral cordotomy was subsequently performed. Disappointing results in the treatment of pain caused by carcinoma have been noted by others.5 It is not at all clear, at this time, why electrical stimulation is effective primarily in patients with pain from benign causes and why cordotomy has such limited use in these same patients.
NEUROSURGICAL TREATMENT OF PAIN
485
COMMENT This discussion has dealt with the technical options and indications for various procedures. We must, of course, always place the symptom in the context of the patient. He must be interviewed carefully and at length to be certain the definition of pain is the same to both the patient and the physician. It must be determined if the symptom, pain, is actually a rather mild ache that has been magnified by anxiety and depression. If so, cordotomy will never relieve the pain and the postcordotomy numbness, usually well tolerated, will rapidly become intolerable dysesthesia. The real problem could be a strong narcotic addiction. We have seen the occasional patient use one pretext after another to continue to obtain narcotics long after any reasonable need for them has passed. In general, the indications for surgery to relieve pain are more straightforward in patients with malignant disease than in those with benign disease, and the results of surgery are much more satisfactory. We must be careful, however, that, in our eagerness to relieve these unfortunate patients of their pain, we do not subject them to surgery that will be ineffective.
REFERENCES 1. Fager, C. A.: Selection of patients with metastatic breast cancer for hypophysectomy. Surg. Clin. N. Amer., 42:701-707 (June) 1962. 2. Freidberg, S. R., and Takaoka, Y.: Techniques of high cervical percutaneous cordotomy. Surg. Clin. N. Amer., 53:291-300 (April) 1973. 3. Lin, P. M., Gildenberg, P. L., and Polakoff, P. P.: An anterior approach to percutaneous lower cervical cordotomy. J. Neurosurg., 25:553-560 (Nov.) 1966. 4. Loeser, J. D.: Dorsal rhizotomy for the relief of chronic pain. J. Neurosurg., 36:745-750 (June) 1972. 5. Meeting, Northeast Dorsal Column Stimulator Study Group, New York, November 2, 1973, unpublished data. 6. Onofrio, B. M., and Campa, H. K.: Evaluation of rhizotomy. Review of 12 years' experience. J. Neurosurg., 36:751-755 (June) 1972. 7. Rosomoff, H. L.: Bilateral percutaneous cervical radiofrequency cordotomy. J. Neurosurg., 31 :41-46 (July) 1969. 8. Rosomoff, H. L., Krieger, A. J., and Kuperman, A. S.: Effects of percutaneous cervical cordotomy on pulmonary function. J. Neurosurg., 31 :620-627 (Dec.) 1969. 9. Rosomoff, H. L., Carroll, F., Brown, J., et al.: Percutaneous radiofrequency cervical cordotomy: technique. J. Neurosurg., 23:639-644 (Dec.) 1965. 10. Sourek, K.: Commissural myelotomy. J. Neurosurg., 31 :524-527 (Nov.) 1969.
Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215
