CHAPTER 153 Pain
General Historical Considerations
Pain, originating from the Greek poine, which means penalty or punishment, has been described since the dawn of time. In Greek civilization, pain secondary to disease was believed to be caused by supernatural forces. And according to a Latin inscription attributed to Hippocrates of Kos (460-370 BC), alleviating pain was the work of the divine—sedare dolorem opus divinum est. In Greek mythology, drugs (including opium, hashish, and mandrake), magic, and even surgery were used by the gods to produce hypnosis and amnesia and heal pain. However, as the myth of the wounded immortal centaur Chiron shows, even gods would trade their divinity to avoid a life of unrelieved pain.1
The advent of the modern era in the neurosurgical management of pain can be traced to the start of the 19th century. In 1809, Walker proposed that the anterior and posterior spinal roots serve distinct motor and sensory functions.2 Bell subsequently expanded this idea,3 and Magendie in 1822 provided evidence of the role of the posterior spinal roots in the transmission of pain.4 However, it was close to another 100 years until Spiller5 and Schüller6 described the pain conduction pathways in the anterolateral columns of the spinal cord. Although debate concerning the anatomic and physiologic substrate serving pain continued, evidence for the specificity theory of pain gained momentum, and neurosurgeons exploited the existing knowledge of pain pathways to perform pain surgery, often with great success. Neurosurgeons were also quick to adapt new technology, most notably stereotaxy, radiofrequency generators, and the operating microscope, for pain procedures. A chronology of modern neurosurgical management of pain is presented in Table 153-1, which covers techniques from 1873 to 1991.
TABLE 153-1 Chronology of Modern Neurosurgical Management of Pain
| YEAR* | INVESTIGATOR | TECHNIQUE |
|---|---|---|
| 18731 | Létiévant | Neurotomies for facial and extremity neuralgias |
| 18892,3 | Abbe and Bennet | Spinal dorsal rhizotomy |
| 18914 | Horsley et al. | Gasserian ganglionectomy for trigeminal neuralgia |
| 18995 | Francois-Franck | Conception of the potential of sympathectomy |
| 19016 | Spiller and Frazier | Open trigeminal rhizotomy (middle fossa) |
| 19057 | Spiller | Spinothalamic tract in the anterolateral cord |
| 19128 | Spiller and Martin | First cordotomy |
| 19139 | Leriche | Sympathectomy for painful extremities |
| 191610 | Jonnesco | Sympathectomy for angina pectoris |
| 192211 | Läwen | Diagnostic nerve blocks |
| 192512 | Dandy | Trigeminal rhizotomy (posterior fossa) |
| 192713 | Armour | Midline commissural myelotomy |
| 193314 | Foerster | Mapping of the spinal dermatomes in humans |
| 193815 | Sjöqvist | Trigeminal tractotomy |
| 194116,17 | Schwartz and O’Leary and White | Open medullary spinothalamic tractotomy |
| 194218 | Walker | Open mesencephalic tractotomy |
| 195319 | Spiegel and Wycis | Stereotactic thalamotomy and mesencephalotomy |
| 196020 | Heath and Mickle | Deep brain (septal) stimulation for pain |
| 196021 | Mazars et al. | Thalamic (VPL) stimulation for pain |
| 196222 | Foltz and White | Bilateral cingulotomy for pain |
| 196323 | Mullan et al. | First percutaneous cordotomy |
| 196524 | Melzack and Wall | Gate theory of pain |
| 196625 | Sano et al. | Posteromedial hypothalamotomy for pain |
| 196626 | Kudo et al. | Pulvinotomy |
| 196727,28 | Jannetta | Trigeminal microvascular decompression |
| 196729 | Shealy et al. | Spinal cord stimulation |
| 196930 | Kapur and Dalton | Hypophysectomy for cancer pain |
| 197031 | Hitchcock | Extralemniscal myelotomy |
| 197232,33 | Nashold and Ostdahl and Sindou | DREZ lesions |
| 197334 | Hitchcock | Stereotactic pontine spinothalamic tractotomy |
| 197435 | Sweet and Wepsic | Radiofrequency trigeminal rhizolysis |
| 197636 | Sweet | Peripheral nerve stimulation |
| 197937 | Wang et al. | Intrathecal morphine |
| 197938 | Behar et al. | Epidural morphine |
| 198139 | Hakanson | Glycerol trigeminal chemoneurolysis |
| 198340 | Mullan and Lichtor | Trigeminal balloon microcompression |
| 199141 | Tsubokawa et al. | Motor cortex stimulation |
DREZ, dorsal root entry zone; VPL, nucleus ventroposterolateralis.
* 
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Probably the first reported procedure for the relief of pain was in 1873, when Létiévant published his description of peripheral and cranial nerve rhizotomies.7 Sectioning of the posterior spinal roots for the relief of pain in humans was first proposed by Charles Dana in 18878 and performed by Bennet9 in 1889 and also by Abbe10,11 in four patients. Otrid Foerster of Breslau, Poland, a neurologist by training, gained enough experience with the operation of posterior rhizotomy to perform it himself. Foerster later presented his landmark paper mapping the dermatomes in humans.12
Trigeminal Neuralgia
Early pain surgeons were also interested in cranial nerve pathologies, especially tic douloureux, a condition that had vexed patients and physicians alike for more than 2 centuries.13 Bell had established the trigeminal nerve as the sensory nerve for the face in 1844.14 Although Victor Horsley is credited with the first gasserian ganglionectomy and retrogasserian neurotomy in 1891,15 in truth, the contributory efforts of several other neurosurgical pioneers helped transform the management of trigeminal neuralgia. Horsley used the extradural temporal approach described by Hartley16 and Krause,17 but because his patient died, retrogasserian neurotomy was abandoned until Tiffany18 in 1896 and Spiller and Frazier19 in 1901 revived it. Dandy described the posterior fossa approach for retrogasserian neurotomy in 1925,20 although this was probably not his own original idea.21 His experience led him to conclude that subtotal section spared significant sensation without a major increase in pain recurrence.22 Although Dandy frequently observed vascular loops compressing the trigeminal nerve and, like Gardner and Miklos some 30 years later,23 suspected this to be the cause of neuralgia, Dandy did not conceive of decompression as a solution. With the introduction of better medical therapy and percutaneous procedures using the Härtel approach to the foramen ovale,24 open surgical procedures for trigeminal neuralgia fell into decline until Jannetta in 1967 reported his experience with microvascular decompression,25 a procedure that has stood the test of time.26–34
Cordotomy
Bell, with the sole aid of the naked eye and the scalpel, had also traced the posterior spinal roots up the spinal cord into the brainstem and cerebrum.14 Accurately filling in the details would take the rest of the 19th century. Both Schiff and Brown-Séquard had performed numerous experiments trying to locate the sensory tracts in the spinal cord35 when, in 1871, Müller cited a case of a stab wound involving half of the spinal cord and the opposite dorsal column that produced bilateral anesthesia for touch but caused analgesia only on the side opposite the lesion.36 Gowers later reported a case that he had seen in 1876 of a student who had shot himself through the mouth.37 The patient had intact tactile sensibility in his left limbs, but pain sensation was abolished. Postmortem examination revealed that the injury to the spinal cord was a spicule of bone that had effectively caused unilateral sectioning of the cervical cord and destroyed the continuity of the anterior and lateral columns on the right side. Gowers concluded that this part of the cord carries the fibers for the transmission of contralateral pain impulses. Edinger in 1889 demonstrated the existence of the spinothalamic tract in newborn cats and amphibians.38 It remained for Spiller, however, to prove conclusively that the spinothalamic tract carries pain and temperature impulses.5 In 1905 he described a patient with pain and temperature loss in the lower part of the body who at autopsy was confirmed to have bilateral tuberculomas involving the lower thoracic anterolateral tracts. Schüller in 1910 sectioned the anterolateral tract in monkeys.6 Martin performed the first “cordotomy” in another patient with a tuberculoma of the cord at the instigation of Spiller in 1912.39 Their short- and long-term results were encouraging and established the technique for treating intractable pain. Stookey was probably the first to perform a high cervical cordotomy in 1931 for pain in the chest and upper extremity.40 Mullan and colleagues introduced a technique for percutaneous cordotomy at the C1-2 level that involved use of a radioactive needle tip and reported it in 1963.41 The lesioning utility of radiofrequency thermocoagulation was applied to the technique by Rosomoff and coworkers,42 and cord penetration as determined by electrical impedance was described by Gildenberg and associates.43 Kanpolat and colleagues described a computed tomography–guided percutaneous procedure.44 Despite the obvious efficacy of this procedure, particularly for malignant disease and with low morbidity when performed with the most recent advances, cordotomy is unfortunately being used less and less, in part because of advances in pain management, lack of referral, and patient unwillingness to undergo ablative and potentially irreversible procedures.
Stereotaxy
Pain affecting the face, head, and shoulder could not be managed effectively by cordotomy, so open brainstem spinothalamic tractotomies were attempted.45–47 Unfortunately, the analgesic effects were short-lived, and morbidity and mortality rates were high. Spiegel and Wycis, the great pioneers of human stereotaxy, applied their technique to perform mesencephalotomy and thalamotomy with greater accuracy and success.48 Subsequently, Hitchcock introduced a stereotactic technique for pontine spinothalamic and trigeminal tractotomy.49,
