Neurosurgical advances in cancer pain management

Neurosurgical procedures to treat pain are mainly destructive and involve the spinal cord and occasionally the brain. Targets include the spinothalamic tract, the trigeminal tract nucleus, the midline ascending visceral pain pathway, the brainstem spinal lemniscus, the thalamus, and the cingulate gyrus. Since the introduction of intrathecal opioids, the need for neurosurgical destructive procedures has been in decline. In recent years, cordotomy, trigeminal tractotomy, and dorsal root entry zone (DREZ) operations are the neurosurgical procedures most often utilized to treat cancer pain. The addition of CT guidance to spinal cord pain pathway ablation was a major addition and refinement to the procedure. Here the authors review the latest techniques and recently published results for CT-guided cordotomy, CT-guided trigeminal tractotomy, and DREZ operations utilized to treat cancer pain.