Neurosurgical Procedures for the Relief of Pain in Advanced Cancer

Abstract

Rarely should a defeatist attitude toward intractable pain be entertained without an investigation of the possibilities of relief by means of surgery. This applies especially to patients with incurable cancer because to them the actual and potential penalties involved are insignificant when compared with the relief of pain which they may expect from surgical treatment. In this country alone, cancer takes 160,000 lives each year. Of this number of patients passing through the terminal stages of the disease, comparatively few require neurosurgery. Local treatment of the growth, together with other measures such as x-ray therapy and the administration of analgesic drugs, tides the majority of patients over until there are complications causing rapid failure or until cerebral metastases occur which may not only raise the threshold of pain but also make the patient indifferent to his condition. It is in those patients with intractable pain, whether this comes early or late in the course of a malignant neoplasm, that neurosurgery has a wide field of usefulness. When pain becomes unbearable, relief by surgical means should be considered before allowing the patient to become addicted to opiates. At present, the number of patients being treated in this manner is small, but when the possibilities and advantages of surgery are more widely appreciated, a greater number will be benefited. Opiates may control pain for a brief period, but this interval is shortened as tolerance to the drug is increased. Furthermore, gastro-intestinal disturbances are common and may be as disquieting as the pain itself. The general well-being of patients relieved of pain by surgical means is far better. Often they are able to pursue a gainful occupation for months or years. Moreover, treatment of the formerly painful areas can be pushed to the limit. Chordotomy and Tractotomy Any operation for relief of pain due to cancer should not only produce anesthesia, preferably analgesia, well beyond the limits of the tumor area, but also render insensitive, so far as possible, that part of the body to which pain is apt to spread. For the most part, section of the pain-conducting tracts in the spinal cord (chordotomy) answers these requirements. For many years, following its introduction by Spiller and Martin (1) in 1912 and subsequent refinement by Frazier, chordotomy was applied only for relief of pain below the diaphragm—mainly in the pelvis and lower extremities. There remained unsolved the problem of pain in the chest, upper extremities, neck, and head, except for such procedures as posterior root section, which left much to be desired. Stookey (2), in 1931, introduced high cervical chordotomy to raise the level of analgesia to include the upper chest and arm, mainly for the purpose of relieving pain resulting from carcinoma of the breast. In more recent years, other significant contributions have been made.