Lost Arts: Teaching the Neurosurgical Management of Pain
Surgical intervention for the treatment of severe, chronic pain has been used successfully for centuries. With patients living longer and surviving cancer, chronic pain is skyrocketing. Techniques have evolved considerably over the years to become increasingly more precise, more effective and less invasive. Surgical options have progressed from effective, ablative procedures towards innovative, neuromodulation techniques and have become accessible through a variety of progressively more refined surgical methods. In this era of pain medication, however, certain neurosurgical techniques aimed at treating chronic, refractory pain are less utilized; some are at risk of extinction. Lack of education during training is a key factor.
Endangered Techniques and Procedures
Ablative procedures are currently at greatest risk of being forgotten, particularly those aimed at treating refractory cancer-related pain. Techniques like cervical cordotomy, midline myelotomy and dorsal root entry zone lesioning in the spine and nucleus caudalis are not frequently used, despite increasing safety and proven efficacy for their specific indications. Many of these surgical approaches are not practiced because of lack of education and/or misconceptions surrounding their safety profile. For example, most neurosurgeons envision cervical cordotomy as an aggressive, open spinal procedure from antiquity, fraught with complications. In reality, this technique, in its present form, is an effective and percutaneous outpatient procedure, most often performed under CT guidance. Today, most patients in the U.S. do not have access to these types of procedures. Lack of exposure has confined these procedures to a small number of highly-specialized centers scattered throughout the country.
To ensure that these and other specialized pain procedures continue to be effectively used and further refined, the next generation of surgeons must understand their indications and learn the nuances of surgical technique. This is particularly challenging, given the limited number of neurosurgeons who currently possess this expertise. In order to teach this effectively, neurosurgeons must become aware of the breadth of these surgical options and seek out specialty training opportunities in courses, national meetings and visits to specialty centers.
The lack of education on the armamentarium of pain procedures has led to the virtual elimination of many of these techniques and limited our capacity to treat patients. In the midst of our national opioid crisis, the field of neurosurgery must reclaim these effective treatments as an alternative method to medications to control chronic, refractory pain. We must reintegrate these procedures into our neurosurgical lexicon and make a concerted effort to include them in the curriculum of our trainees in order to have the capacity to provide our patients with the safest and most effective treatment options.
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