Editorial: Neurosurgical treatment of cancer pain

Abstract

Since I had the pleasure of writing an editorial on these authors’ earlier paper on neurosurgical procedures to control nonmalignant pain,2 I have been looking forward to this follow-up article.3 The authors have delivered the quality work expected of them. In this article, they review in a very scholarly fashion the recent literature concerning neurosurgical procedures for control of malignant pain. The article is excellent and, in my opinion, very timely. Essentially, I see it as a call for neurosurgeons not to abandon their pioneering historical role in the treatment of pain, specifically in this article, cancer pain. I consider the article very timely because it is clear that neurosurgeons are ceding this field to other specialties such as anesthesiology, neurology, and physical medicine and rehabilitation. Even of more concern is the proliferation of “pain clinics” where in some cases practitioners with very little specific training and understanding of the intricate pathophysiology of pain, develop lucrative schemes to treat pain with ineffective injections of “trigger points,” unnecessary “blocks,” and a variety of unconventional and unphysiological maneuvers. I will begin my comments by repeating my concerns about the original article from these authors on nonmalignant pain.1 These comments are not meant as a criticism of the authors’ scholarly work, but rather are indicative of the limitations of the methodology they use which focused their search mostly in peer-reviewed articles published between 1966 and 2009. Granted, the authors searched for references within those articles of pertinent previous work. However, they left out a very important body of literature published in classic textbooks such as White and Sweet’s.5 Although I share the authors’ pessimism about the future of destructive neurosurgical procedures in the treatment of pain, I take issue with their statement that “To stimulate appropriate interest in these procedures, evidence needs to meet the current evidence-based standards through clinical trials.” First of all, I believe that from the practical point of view, it is inconceivable that appropriate large randomized studies that meet today’s standards can be developed in the present environment to test the value of some of these classic neurosurgical procedures. More importantly, I strongly believe that although the existing evidence may not meet today’s scientific criteria for Level I evidence, extensive and carefully documented clinical experience has clearly indicated the effectiveness of some of these procedures, as discussed by the authors particularly in the case of cordotomy. Such experience, again in my opinion, amply justifies the performance of many of these procedures in carefully selected patients. I believe that the lack of interest and consequent lack of experience of the current neurosurgical generation, rather than the lack of randomized trials, is the main reason for the near-abandonment of this field by the neurosurgical community. This lack of interest has various explanations, an obvious one is the fact that patients suffering pain, particularly those with chronic nonmalignant pain, are difficult and frequently many patients have to be carefully screened to select the few that are appropriate candidates for surgery. Another reason is our understandable reluctance to put some of these patients, particularly those with terminal cancer, through the stress of open, invasive procedures. However, again through the pioneering efforts of some neurosurgeons coupled with technical advances, less invasive percutaneous procedures continue to be developed and refined. As I stated in my previous editorial, we are fortunate that a few dedicated neurosurgeons, such as Dr. Burchiel, have kept this field alive and hopefully could reinvigorate it in the future. To conclude, I sincerely applaud the very scholarly and useful review that these authors have provided. I agree 100% with their conclusion that a renewal of neurosurgical interest in the treatment of pain is appropriate and represents a unique challenge to our profession and, more importantly, would offer these unfortunate patients with intractable cancer pain an opportunity to live the rest of their days in relative freedom from pain and without the undesirable side effects of narcotic medications. I could not agree more and was particularly impressed with the authors’ very elegant statement that, “uncertainty of efficacy does not necessarily equate with a certainty of inefficacy in the surgical treatment of cancer pain.” Clearly, it is essential for neurosurgery to continue to explore and develop less invasive and elegant ways to control pain such as with neural modulation; however, as the authors eloquently point out, abandonment of such timeproven procedures as sympathectomy and cordotomy (and, from personal experience, I would add others such as Sourek’s commissural myelotomy,4 dorsal root entry zone procedures, rhizotomy, and cingulotomy) is highly inappropriate and a great disservice to the many patients who, when carefully selected, could benefit from them. I thank the authors for challenging us to reconsider the role of neurosurgery in the treatment of pain!