Cancer pain continues to be a significant problem since the mid 1980s, despite the promulgation of the World Health Organization (WHO) (1) analgesic ladder. The statistics are daunting:
Pain is reported in 60-85 percent of those with advanced cancer (2).
One-third of patients enrolled in hospice reported pain at the last hospice care visit before death (3).
Regardless of length of stay, a consistent 5-7 percent of patients wanted more help with pain management (study of 106,500 hospice decedents) (4).
Pain not only adversely affects functional status and quality of life, but also survival (5,6).
Much of the focus on this problem has been on palliative radiation, intrathecal opioids and hospice. Neurosurgical ablative procedures, with a long and storied history in the treatment of cancer pain, provide an alternative. Although there has been a decrease over time in publications about ablative procedures for cancer pain (8), more recent guidelines from organizations such as the British Pain Society advocate for cordotomy and other neuroablative procedures (9).
Given the clinical need and the perceived lack of knowledge of these procedures within neurosurgery, a RedCAP-based survey was sent out to the AANS membership in 2016. Questions were asked about comfort level and techniques used for various procedures for both cancer and non-cancer pain, including dorsal root entry zone lesioning (DREZ), cordotomy, midline myelotomy, cingulotomy, capsulotomy, dorsal rhizotomy, dorsal root ganglionectomy (DRGectomy), sympathectomy, neurectomy, hypothalamotomy, hypophysectomy, thalamotomy and mesencephalic tractotomy. Procedures for trigeminal neuralgia were not addressed. Of the small group of respondents (N=22):
77 percent are under 50 years old;
55 percent received fellowship training in stereotactic, functional and/or pain neurosurgery;
In this self-selected group of respondents, the numbers of people who rated themselves as “very comfortable” ranged from 5-45 percent for the various procedures, with most in the 20 percent range. With respect to frequency of performing procedures, none had done more than 10 for any single one. Most had done five or less.
In addition, there was a fair amount of heterogeneity in approaches (Table 1). There was considerable interest in hands on training, with the greatest interest in DREZ and midline myelotomy. Most (68 percent) were interested in participating in a national neuroablation registry, and there was considerable interest (55 percent) in being contacted to serve as an instructor.
Neuroablation is clearly of interest to the neurosurgery community, as evidenced from this survey and the recent well-attended Pain Section Biennial Meeting in Chicago, in May 2017. However, it will take significant effort to get these techniques to patients who could benefit from them but can be done so by increasing the volumes at centers with experts as well as by disseminating these techniques to neurosurgeons unfamiliar with them. Once we have greater volumes, pooled data offer opportunities to determine optimal patient selection and best practices.
Acknowledgment: Thanks to Manpreet Kaur, MBA, MPH for implementing this survey and assisting with the table (below).
Table 1: Data on level of comfort, number of procedures done and techniques used among respondents who performed a procedure for pain within the last 12 months.
