The punctate midline myelotomy concept for visceral cancer pain control--case report and review of the literature.

Abstract

Nauta et al. first reported on a successful punctate midline myelotomy (PMM) at the spinal cord Th 10 level for the treatment of intractable pelvic cancer pain. The authors published another case history of a patient with multiple anaplastic carcinomas of the small intestine, peritoneal carcinosis and retroperitoneal lymphomas, suffering from severe visceral pain in the hypo-, meso-, and epigastrium. Nauta's PMM was successfully performed at the level Th 4. Narcotic medication was tapered from 30 mg i.v. morphine per hour preoperatively to 5 mg per hour within 5 days postoperatively. Pain intensity decreased from 10 to 2-3 on the visual analog scale. Only minor transient side effects appeared postoperatively. Pain reduction remained until the patient died from the extended disease five weeks later. Meanwhile Nauta et al. reported on 5 additional patients, in whom PMM led to a sufficient pain reduction. Another paper reported on sufficient control of visceral pain due to advanced stomach cancer after a modified Th 1-2 PMM. PMM sufficiently controls not only pelvic visceral pain, but also visceral pain generated in the meso- and epigastrium. The findings support the concept of a midline dorsal column visceral pain pathway.