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AANS Neurosurgeon | Volume 26, Number 1, 2017

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Neuroablation: An Under-utilized Tool

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).

As a result, the American Society for Clinical Oncology (ASCO) uses quantification of pain severity as a “high priority measure” for certification of cancer centers in the Quality Oncology Practice Initiative (QOPI) (7).

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;
  • 68 percent are academics;
  • 27 percent are in private practice; and
  • 9 percent are in hybrid practice.

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). 

References
1. Jacox, A., Carr, D. B., & Payne, R. (1994). New clinical-practice guidelines for the management of pain in patients with cancer. New England Journal of Medicine, 330(9), 651-655. 

2. Kroenke, K., Theobald, D., Wu, J., Loza, J.K., Carpenter, J.S., & Tu, W. (2010). The association of depression and pain with health-related quality of life, disability, and health care use in cancer patients. Journal of Pain and Symptom Management. 40(3):327-341.

3. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington D.C.: National Academies Press. 

4. Teno, J.M., Shu, J.E., Casarett, D., Spence, C., Rhodes, R., & Connor, S. (2007). Timing of referral to hospice and quality of care: length of stay and bereaved family members’ perceptions of the timing of hospice referral. Journal of Pain and Symptom Management. 34(2):120-125. 

5. Smith, T. J., Staats, P. S., Deer, T., Stearns, L. J., Rauck, R. L., Boortz-Marx, R. L., . . . Pool, G. E. (2002). Randomized Clinical Trial of an Implantable Drug Delivery System Compared With Comprehensive Medical Management for Refractory Cancer Pain: Impact on Pain, Drug-Related Toxicity, and Survival. Journal of Clinical Oncology, 20(19), 4040-4049.

6. Lillemoe, K.D., Cameron, J.L., Kaufman, H.S., Yeo, C.J., Pitt, H.A., & Sauter, P.K. (1993) Chemical splanchnicectomy in patients with unresectable pancreatic cancer. A prospective randomized trial. Annals of Surgery. 217(5):447-457.

7. 2017 QCDR Measures. (2017). ASCO Institute For Quality. 

8. Raslan, A.M., Cetas, J.S., McCartney, S., & Burchiel, K.J. (2011). Destructive procedures for control of cancer pain: the case for cordotomy. Journal of Neurosurgery. 114(1):155-170. \

9. Raphael, J., Hester, J., Ahmedzai, S., Barrie, J., Farqhuar-Smith, P., Williams, J., . . . Sparkes, E. (2010). Cancer Pain: Part 2: Physical, Interventional and Complimentary Therapies; Management in the Community; Acute, Treatment-Related and Complex Cancer Pain: A Perspective from the British Pain Society Endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners: Table 1. Pain Medicine, 11(6), 872-896. 

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.

DREZ Lesion ablative procedure for Pain

N=8

Very comfortable

5

63%

Somewhat Comfortable

3

38%

Procedures done for pain in last 12 months

 

 

1-5

7

88%

6-10

1

13%

Techniques used

 

 

Mechanical

0

0%

Laser

0

0%

Radiofrequency

6

75%

Mechanical & Radiofrequecy

1

13%

Laser & Radiofrequency

1

13%

Cordotomy

N=7

 

Very comfortable

3

43%

Somewhat Comfortable

4

57%

Procedures done for pain in last 12 months

 

 

1-5

6

86%

6-10

1

14%

Techniques used

 

 

Open

1

14%

Endoscopic

0

0%

Percutaneous

5

71%

Open & percutaneous

1

14%

Intraoperative guidance used

 

 

MRI

1

14%

CT

5

71%

Fluoroscopy alone

0

0%

Myelographic contrast

 

 

Yes

5

71%

No

0

0%

Midline Myelotomy

N=5

 

Very comfortable

3

60%

Somewhat Comfortable

2

40%

Procedures done for pain in last 12 months

 

 

1-5

5

100%

Techniques used

 

 

Open

4

80%

Endoscopic

0

0%

Percutaneous

0

0%

Open & Percutaneous

1

20%

Intraoperative guidance used

 

 

MRI

0

0%

CT

1

20%

Fluoroscopy

0

0%

Myelographic contrast

 

 

Yes

1

20%

No

0

0%

Cingulotomy

N=4

 

Very comfortable

2

50%

Somewhat Comfortable

2

50%

Procedures done for pain in last 12 months

 

 

1-5

4

100%

Techniques used

 

 

Radiofrequency

2

50%

Laser interstitial thermal therapy

2

50%

Radiosurgery

0

0%

Radiofrequency & Radiosurgery

0

0%

Radiofrequency & Laser interstitial thermal therapy

0

0%

Capsulotomy

N=1

 

Very comfortable

0

0%

Somewhat Comfortable

1

100%

Procedures done for pain in last 12 months

 

 

1-5

1

100%

Techniques used

 

 

Radiofrequency

1

100%

Laser interstitial thermal therapy

0

0%

Radiosurgery

0

0%

Dorsal Rhizotomy

N=6

 

Very comfortable

3

50%

Somewhat Comfortable

3

50%

Procedures done for pain in last 12 months

 

 

1-5

6

100%

Techniques used

 

 

Open

6

100%

Percutaneous

0

0%

Procedure

 

 

Intradurally

4

67%

Extradurally

2

33%

Dorsal Root Ganglionectomy

N=6

 

Very comfortable

3

50%

Somewhat Comfortable

3

50%

Procedures done for pain in last 12 months

 

 

1-5

4

67%

6-10

2

33%

Region

 

 

Upper cervical region

4

67%

Thoracic

2

33%

Other

0

0%

Sympathectomy

N=1

 

Very comfortable

1

100%

Procedures done for pain in last 12 months

 

 

1-5

1

100%

Techniques used

 

 

Endoscopic transection/ligation/extirpation

1

100%

Percutaneous radiofrequency

0

0%

Open technique

0

0%

Neurectomy

N=9

 

Very comfortable

8

89%

Somewhat Comfortable

1

11%

Procedures done for pain in last 12 months

 

 

1-5

7

78%

6-10

2

22%

Indications for technique used

 

 

Stump neuroma

2

22%

Meralgia paresthetica

0

0%

Occipital neuralgia

2

22%

Hypothalamotomy

N=1

 

Very comfortable

1

100%

Somewhat Comfortable

0

0%

Procedures done for pain in last 12 months

 

 

1-5

0

0%

6-10

1

100%

Techniques used

 

 

Radiofrequency

1

100%

Laser interstitial thermal therapy

0

0%

Radiosurgery

0

0%

Hypophysectomy

N=3

 

Very comfortable

2

67%

Somewhat Comfortable

1

33%

Procedures done for pain in last 12 months

 

 

1-5

2

67%

6-10

0

0%

11-20

0

0%

20+

1

33%

Techniques used

 

 

Open microsurgical

0

0%

Endoscopic

1

33%

Intrasellar alcohol installation

0

0%

Radiosurgery

1

33%

Cryotherapy

0

0%

Brachytherapy

0

0%

Open microsurgical & Endoscopic

1

33%

Thalamotomy

N=1

 

Very comfortable

0

0%

Somewhat Comfortable

1

100%

Procedures done for pain in last 12 months

 

 

1-5

1

100%

Techniques used

 

 

Radiofrequency

1

100%

Laser interstitial thermal therapy

0

0%

Radiosurgery

0

0%

Mesencephalic Tractotomy

N=1

 

Very comfortable

1

100%

Somewhat Comfortable

0

0%

Procedures done for pain in last 12 months

 

 

1-5

1

100%

Techniques used

 

 

Radiofrequency

1

100%

Laser interstitial thermal therapy

0

0%

Radiosurgery

0

0%

 

 

Calendar/Courses

15th Annual WCIRDC California
Nov. 30-Dec. 2, 2017; Universal City, Calif.

Miami Brain Symposium
Dec. 1, 2017; Coral Gables, FL

Interactive Calendar

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