The role of surgical neuroablation for pain control

The management of cancer pain represents a difficult diagnostic and therapeutic problem for the clinician. Pain is present in up to 90 per cent of patients in the terminal stages of malignancy. In a multi–disciplinary approach to the management of cancer pain, neurosurgical methods are an essential part of the therapy.

Despite the many advances in analgesic drug therapy, it is estimated that 10—20 per cent of cancer patients fail to obtain adequate analgesia with pharmacological treatments. These patients must be considered for alternative strategies, among which are surgical approaches. These treatments historically have been destructive or ablative techniques involving intracranial and spinal targets. In the last 20 years, however, with advances in knowledge of cancer pain mechanisms and technological developments, such as microsurgical and stereotactic techniques, implant technology, and computed tomography (CT) and magnetic resonance imaging, older methods have been replaced by more precise, safer, and presumably more effective techniques. These include percutaneous and minimally invasive ablative methods and non–destructive or augmentative techniques such as electrical stimulation or the implantation of sophisticated devices for intrathecal drug delivery.

For most of the pain syndromes occurring in patients who may be candidates for neuroablation, there are potentially several ablative techniques which could be employed. The use of a given technique should depend on a thorough assessment of its likelihood to yield adequate analgesia, the duration of its effect, potential adverse consequences, and the likely life expectancy of the patient.