Neurosurgery clinics of North America
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Metastatic spine tumors affect a large number of patients each year, resulting in significant pain,destruction of the spinal column causing mechanical instability, and neurologic deficits. Standard therapeutic options include surgery and fractionated external beam radiotherapy. The first option can be associated with significant morbidity and limited local tumor control. ⋯ The major potential benefit of radiosurgical ablation of spinal lesions is a relatively short treatment time in an outpatient setting combined with potentially better local control of the tumor with minimal risk of side effects. CyberKnife spinal radiosurgery offers a new and important alternative therapeutic modality for the treatment of spinal metastases in medically inoperable patients, previously irradiated sites, and for lesions not amenable to open surgical techniques or as an adjunct to surgery. Spinal radiosurgery is likely to become an essential part of any neurosurgical spine center that treats a large number of patients with spinal metastases.
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Neurosurg. Clin. N. Am. · Jul 2004
ReviewDeep brain stimulation for the treatment of chronic, intractable pain.
Deep brain stimulation (DBS) was first used for the treatment of pain in 1954. Since that time, remarkable advances have been made in the field of DBS, largely because of the resurgence of DBS for the treatment of movement disorders. ⋯ Furthermore, nuclei not yet fully explored are known to play a role in the transmission and modulation of pain. This article outlines the history of DBS for pain, pain classification, patient selection criteria, DBS target selection, surgical techniques, indications for DBS (versus ablative techniques), putative new DBS targets, complications, and the outcomes associated with DBS for pain.
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The generation of neuropathic pain is a complex phenomenon involving a process of peripheral and central sensitization producing enhanced transmission of nociceptive inputs to the brain associated with the loss of discriminatory processing of noxious and innocuous stimuli. This increased flow of abnormally processed nociceptive inputs to the brain may overcome the ability of descending modulatory pathways to produce analgesia, causing further worsening of the pain. Several crucial locations involved in the physiologic generation of pain inputs (eg, peripheral nociceptors, dorsal horns, thalamus, cortex) show evidence of functional reorganization and altered nociceptive processing in association with chronic pain. These locations present the best targets for therapeutic intervention, including systemic administration of drugs able to counteract the chemical storm induced by neural injuries in the nociceptive afferents and dorsal horns, or for more focused intervention, such as neuroablative procedures; intrathecal drug delivery; and spinal cord, deep brain, or motor cortex stimulation.
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As a general rule, even though it is always difficult to predict the efficacy of a method ina single patient, we consider SCS in every non-malignant chronic pain patient when other conservative treatments have failed. After three decades of clinical experience with SCS, we have learned a lot about its efficacy indifferent pain conditions and have made great technical progress with the materials and surgical procedures. Acceptance of the technique was slow at the beginning; however, we must be aware of the problems related to the application of a therapy that cannot be shamed, and thus the necessity of performing studies that include large numbers of patients. ⋯ As mentioned in the introduction of this article and discussed in the section on the effects of SCS, particularly in clinical applications like peripheral vascular disease and angina, the results of the interaction with the function of the nervous system can be observed in other systems in the body affecting pathologic conditions that are of interest to different specialists. Only the strict cooperation of different medical disciplines can provide substantial help in acquiring knowledge about the mechanisms put into play by SCS and the possible extension of its clinical applications. The complexity of the procedures of neuromodulation and the theoretic background needed for safe and proficient clinical use and for progress raise the issue for medical schools of offering courses in this new discipline.
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Although the definitive treatment for neuropathic pain remains elusive, scientific investigation continues to provide the field with better and better therapies. As our understanding of the neurophysiologic mechanisms of pain improves, pharmaceutic therapies have become more effective even as side effects are minimized. ⋯ Advances in neurophysiology have given rise to new advances in the field of neuro-modulation. As this therapy continues to emerge, ablative procedures recede as therapies offering minimal invasiveness, reversible mechanisms, and long-standing relief emerge to the forefront of treatment for neuropathic pain.