Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.
Analgesics ; therapeutic use ; Humans ; Neoplasms ; physiopathology ; Pain Measurement ; Pain, Intractable ; drug therapy ; surgery

The technique of anterolateral cordotomy for relief of pain was first performed by Spiller and Martin (1912). It was accepted as the best available method for long-term relief despite its disadvantages. It has been well documented that the procedure often caused weakness of an extremity or the loss of sphincter control and respietory impairment associated with high surgical cervical cordotomy. In 1963, Mullan et al. devised an approach to the cervical spinal cord by inserting a needle through the neck under roentgenologic control. They introduced a radioactive needle (Strontium90) to produce a lesion interrupting the lateral spinothalamic tract. Mullan and Rosomoff et al. (1965) later simplified the produce by using an electrical current to produce the lesion. The percutaneous method has considerable advantages. The mortality and morbidity are very small and the technique can be used on any patient including even the terminal state. If the required level is not attained on the first attempt, or if the level subsequently drops, the procedure is easily repeated. Most patients can be discharged early after this type of cordotomy. Authors have reviewed 46 cordotomies on 35 patients with intractable pain carried out by the percutaneous radiofrequency procedure at the Neurosurgery Department of Yonsei University from 1972 to 1975:36 cases were treated by a modification of the Rosomoffs technique, 10 cases by Lin's technique. Intractable pain has been a continuing problem in neurosurgery and many methods have been employed in its treatment. The function of lateral spinothalamic tract was described by Spiller and Martin in 1912. and they described the posterior approach to the spinal cord which has been widely used for cordotomy in the 50 years since. However, in elderly or debilitated patients, this method has proved to have many complications and is poorly tolerated and has a morbidity and mortality rate. In 1963, Sean Mullan, using a Strontium90 electrode accomplished a lateral spinothalamic cordotomy by stereotaxic surgery under local anesthesia (Mullan, et al., 1963; 1965; 1965). Later, in 1965, Rosomoff (Rosomoff,et al., 1965; Rosomoff, et al., 1966) developed an improved technique using UHF radio waves, which achieved wide popularity. Using radiological equipment and measuring the impedance of various portions of the spinal cord with electrodes, the exact area of the lateral spinothalamic tract to be destroyed could be located. Utilizing localizing electrodes and the above method, complications from destruction of the tracts near the lateral spinothalamic tract which formerly resulted in hemiparesis, respiratory difficulty, urinary difficulties and other surgical difficulties could be minimized much more effectively than with open surgical approaches (Mullan and Hosobuchi, 1968). In bilateral, high cervical cordotomy the complication of sleep induced apnea may be a cause of death. Belmusto (Belmusto, et al., 1963; Belmusto; et al., 1965) indicated that the respiratory fibers are very near the lateral spinothalamic tract in the C-1 to C-3 spinal region. The respiratory fibers are located in the anterior one fourth of the spinal cord, extending from the median fissure 3~3.5 mm lateral wards towards the region of the median part of the lateral spinothalamic tract. (Mullan and Mosobuchi, 1968; Nathan, 1963; Hitchcock and Lee ce, 1967; Crosby, et al., 1962). In 1966, Lin (Lin, et al., 1966), developed a low cervical anterior approach, in order to avoid damage to the respiratory tract, and found that respiratory tract damage was actually decreased, and also found that regional analgesia was easily accomplished. Over the last three years, the authors, applying a percutaneous cervical cordotomy technique, have studied 46 patients, recording the present illness, method of surgery, postoperative analgesic area and its change with time, and complications. This material was analyzed and conclusions drawn.
Adult ; Aged ; Cordotomy/methods* ; Female ; Human ; Male ; Middle Age ; Pain, Intractable/surgery* ; Radio Waves*

Spinal cord stimulation (SCS) has been used since 1967 for refractory chronic pain. SCS has recently undergone a variety of technical modifications and advances, and it has been applied in a variety of pain conditions. SCS has been most commonly applied for those patients with chronic back and leg pain and failed back surgery syndrome (FBSS). The clinical hallmark of FBSS is chronic postoperative pain. The pain pattern varies and the pain may show an axial or radicular distribution. Chronic intractable pain after FBSS is difficult to treat. This report describes our experience with treating chronic pain in two patients who suffered from FBSS with a spinal cord stimulator. A permanent spinal cord stimulator was implanted after a successful trial of stimulation with temporarily implanted electrodes. After 5 months of follow-up, the two patients had satisfactory improvement of their pain.
Chronic Pain ; Electrodes, Implanted ; Failed Back Surgery Syndrome* ; Follow-Up Studies ; Humans ; Leg ; Low Back Pain ; Pain, Intractable ; Pain, Postoperative ; Spinal Cord Stimulation ; Spinal Cord*

Spinal cord stimulation (SCS) has been used since 1967 for refractory chronic pain. SCS has recently undergone a variety of technical modifications and advances, and it has been applied in a variety of pain conditions. SCS has been most commonly applied for those patients with chronic back and leg pain and failed back surgery syndrome (FBSS). The clinical hallmark of FBSS is chronic postoperative pain. The pain pattern varies and the pain may show an axial or radicular distribution. Chronic intractable pain after FBSS is difficult to treat. This report describes our experience with treating chronic pain in two patients who suffered from FBSS with a spinal cord stimulator. A permanent spinal cord stimulator was implanted after a successful trial of stimulation with temporarily implanted electrodes. After 5 months of follow-up, the two patients had satisfactory improvement of their pain.
Chronic Pain ; Electrodes, Implanted ; Failed Back Surgery Syndrome* ; Follow-Up Studies ; Humans ; Leg ; Low Back Pain ; Pain, Intractable ; Pain, Postoperative ; Spinal Cord Stimulation ; Spinal Cord*

Spinal cord stimulation (SCS) was first attempted by Shearly et al for the relief of intractable pain. A spinal cord stimulator has traditionally been used for failed back surgery syndrome (FBSS) angina pectoris, complex regional pain syndrome (CRPS) and ischemic pain in the extremity. However, the complications associated with the use of a spinal cord stimulator, such as wound infection, hematoma, lead migration and device malfunction; make its long term application difficult. Here, our experience of an interesting case, in which intractable right leg pain was controlled using a spinal cord stimulator placed in the left epidural space, is reported, with a review of the literature.
Angina Pectoris ; Epidural Space* ; Extremities ; Failed Back Surgery Syndrome ; Hematoma ; Leg* ; Pain, Intractable ; Spinal Cord Stimulation ; Spinal Cord* ; Wound Infection

OBJECTIVETo study the clinical effect of combination of mesencephalotomy with bilateral anterior cingulotomy, and destroy spinal cord dorsal root entry zone (DREZ) treatment for phantom limb pain (PLP).

METHODSFifteen patients suffering from PLP secondary to amputation were treated with neurosurgical procedures, including 7 cases of left upper limb pain, 4 cases of right upper limb pain, 1 case of left lower limb pain and 3 cases of right lower limb pain. Group A, the mesencephalotomy and bilateral anterior cingulotomy, were co-performed in 4 patients. Group B, the other 11 patients were treated with DREZ lesion on the same side in the C5-T1 or L2-S1 spinal cord segments. The visual analog scale (VAS) and the McGill pain questionnaire (MPQ) were used for preoperative and postoperative evaluation of the pain status of each patient. Statistical analyses were conducted using paired-samples t test.

RESULTSAll cases had pain relief immediately after operation and did not take medicine. In group A, the short-term (3 months) follow-up results indicated a significant reduction in patients' pain scales (P < 0.01), but pain recurred in 4-18 months after operation. In group B, one patient died of serious lung infection at 2 months after operation. The other 10 patients had pain relief satisfactorily in long-term follow-up period (12-24 months postoperative, P < 0.05). There were no serious complication and surgery-related mortality.

CONCLUSIONThe cooperation of mesencephalotomy and bilateral anterior cingulotomy, DREZ lesion are effective methods for relieving PLP. DREZ lesion has a good long-term effect.

Adult ; Female ; Follow-Up Studies ; Gyrus Cinguli ; surgery ; Humans ; Male ; Mesencephalon ; surgery ; Middle Aged ; Neurosurgical Procedures ; methods ; Pain, Intractable ; surgery ; Phantom Limb ; Spinal Nerve Roots ; surgery ; Treatment Outcome

Intrathecal drug administration system (ITDAS) can reduce the side effects while increasing the effectiveness of opioids compared to systemic opioid administration. Therefore, the use of ITDAS has increased in the management of cancer pain and chronic intractable pain. Catheter obstruction is a serious complication of ITDAS. Here, we present a case of catheter obstruction by a mass formed at the side hole and in the lumen. A 37-year-old man suffering from failed back surgery syndrome received an ITDAS implantation, and the ITDAS was refilled with morphine every 3 months. When the patient visited the hospital 18 months after ITDAS implantation for a refill, the amount of delivered morphine sulfate was much less than expected. Movement of the pump rotor was examined with fluoroscopy; however, it was normal. CSF aspiration through the catheter access port was impossible. When the intrathecal catheter was removed, we observed that the side hole and lumen of the catheter was plugged.
Adult ; Analgesics, Opioid ; Catheter Obstruction ; Catheters ; Catheters, Indwelling ; Failed Back Surgery Syndrome ; Humans ; Infusion Pumps, Implantable ; Injections, Spinal ; Morphine ; Pain, Intractable ; Stress, Psychological

Post-herpetic neuralgia is the most frequent and feared complication of herpes zoster and is a common cause of chronic intractable pain in the elderly population. An 80 year old man who had suffered from intractable post-herpetic neuralgia received a percutaneous permanant spinal cord stimulator (ITREL3 Neurostimulator-Model 7425, Medtronic, USA) implantation. After implantation, he could sleep without interference of frequent acute sharp attacks of pain and showed improved daily life. We may suggest that this procedure could be applied for several kinds of intractable pain of neuropathic origin, including post-herpetic neuralgia, failed back surgery syndrome, complex regional pain syndrome, peripheral vascular disease and chronic intractable angina, after careful selection of the patient.
Aged ; Aged, 80 and over ; Failed Back Surgery Syndrome ; Herpes Zoster ; Humans ; Neuralgia* ; Pain, Intractable ; Peripheral Vascular Diseases ; Spinal Cord Stimulation* ; Spinal Cord*

OBJECTIVETo investigate the clinical outcomes of semicircular decompression in treating old thoracolumbar fractures and intractable neuropathic pain.

METHODSFrom September 2009 to September 2013, 21 patients with old thoracolumbar fracture and intractable neuropathic pain were treated with semicircular decompression. Among initial surgery, posterior pedicle screw fixation was used in these patients, with or without laminectomy. All patients were male, range in age from 20 to 28 years old with an average of (25.00±2.38) years. Vertebral body residual bone block resulted in intra-spinal placeholder more than 50%. All patients were complete spinal cord injury (ASIA grade) or cauda equina injury. VAS scores was from 6 to 10 points with the mean of 7.14±0.91. In these patients, MRI, CT, X-rays were performed; denomination and dosage of analgesics were recorded; nerve function and pain status were respectively evaluated by ASIA grade and VAS score before and after operation.

RESULTSAll patients were followed up from 8 to 32 months with an average of (17.29±6.02) months. All bone fragments of spinal canal were removed and spinal cord decompressions were achieved. At final follow-up, VAS scores were from 0 to 8 points with an average of (2.43±2.46) points, and were obviously reduced than peroperative data (P<0.05). Eleven cases of them stopped analgesic intake and 7 cases reduced using. Three patients' symptoms and VAS scores were not improved.

CONCLUSIONOld thoracolumbar fractures and intractable neuropathic pain need receive imaging examination as soon as possible and consider semicircular decompression therapy if bone fragments were in vertebral canal and spinal canal stenosis existed. This therapy can effectively relieve pain and profit nerve functional recovery.

Adult ; Decompression, Surgical ; methods ; Humans ; Lumbar Vertebrae ; injuries ; surgery ; Male ; Neuralgia ; etiology ; surgery ; Pain, Intractable ; etiology ; surgery ; Spinal Fractures ; physiopathology ; surgery ; Thoracic Vertebrae ; injuries ; surgery ; Visual Analog Scale ; Young Adult

BACKGROUND: The results of 51 cases of trial spinal cord stimulation which had been carried out for relief of intractable pain were analyzed. METHODS: Most patients were referred due to failure of conventional pain treatment modalities. They consisted of 35 men and 16 women, ranging in age from 21 to 74 years. In 17 cases pain was associated with postherpetic neuralgia, 14 with failed back surgery syndrome, 3 with cauda equina syndrome, 3 with reflex sympathetic dystrophy, 3 with spinal cord injury, 2 with brachial plexus injury, 2 with torticollis, 2 with vertebral injury, 1 with phantom limb pain, 1 with myelitis, 1 with paraplegia, 1 with low back pain, and 1 with cancer metastasis to the vertebra. An electrode tip was positioned at varying sites from C1-2 to T11 dictated by the location of pain. T3, T6, and T8 were the most frequent sites. RESULTS: Pain due to postherpetic neuralgia, failed back surgery syndrome, cauda equina syndrome, reflex sympathetic dystrophy, and brachial plexus injury was well controlled. Noticeable complications included wound infection and electrode displacement. Following a trial period of stimulation, 10 patients had permanent stimulators implanted, while one patient died as a result of unrelated causes. CONCLUSIONS: We may suggest that spinal cord stimulation represents a useful technique in a well- selected group of patients with no other treatment options.
Brachial Plexus ; Electrodes ; Failed Back Surgery Syndrome ; Female ; Humans ; Low Back Pain ; Male ; Myelitis ; Neoplasm Metastasis ; Neuralgia, Postherpetic ; Pain, Intractable ; Paraplegia ; Phantom Limb ; Polyradiculopathy ; Reflex Sympathetic Dystrophy ; Spinal Cord Injuries ; Spinal Cord Stimulation ; Spinal Cord* ; Spine ; Torticollis ; Wound Infection