Chronic Pain: Lesions

  • Patrick J. Karas
  • Ashwin ViswanathanEmail author


Though neuromodulation, either through neurostimulation or intrathecal drug delivery, has become the mainstay of chronic pain treatment, the use of lesional techniques remains an invaluable approach for the treatment of medically intractable pain. Lesional approaches targeting both the brain and spinal cord are used for intractable pain, largely in the setting of cancer. However, in selected cases, ablation for non-cancer chronic pain is appropriate. Cordotomy and myelotomy are two techniques for lesioning the two main spinal cord pain pathways, the spinothalamic tract and the dorsal columns visceral pain pathway, respectively. Cingulotomy is an approach for lesioning the anterior cingulate cortex, of use in patients with widespread intractable pain which has a significant affective component to the pain.


Pain Cancer pain Chronic pain Ablation Cingulotomy Cordotomy Myelotomy 


  1. 1.
    Raslan AM. Percutaneous computed tomography-guided radiofrequency ablation of upper spinal cord pain pathways for cancer-related pain. Neurosurgery. 2008;62(3 Suppl 1):226–33; discussion 233-4.PubMedGoogle Scholar
  2. 2.
    Kanpolat Y, Ugur HC, Ayten M, Elhan AH. Computed tomography-guided percutaneous cordotomy for intractable pain in malignancy. Oper Neurosurg. 2009;64(3 Suppl):ons187–94.CrossRefGoogle Scholar
  3. 3.
    Viswanathan A, Vedantam A, Hess KR, Ochoa J, Dougherty PM, Reddy AS, et al. Minimally invasive cordotomy for refractory cancer pain: a randomized controlled trial. Oncologist. 2019;24(7):):e590–6. Scholar
  4. 4.
    Krieger AJ, Rosomoff HL. Sleep-induced apnea. 1. A respiratory and autonomic dysfunction syndrome following bilateral percutaneous cervical cordotomy. J Neurosurg. 1974;40(2):168–80.CrossRefGoogle Scholar
  5. 5.
    Nannapaneni R, Behari S, Todd NV, Mendelow AD. Retracing “Ondine’s curse”. Neurosurgery. 2005;57(2):354–63.CrossRefGoogle Scholar
  6. 6.
    Viswanathan A. Spinal ablation for cancer pain (cordotomy and myelotomy). In: Burchiel KJ, Raslan AM, editors. Functional neurosurgery and neuromodulation. St. Louis: Elsevier; 2019. p. 63–8.CrossRefGoogle Scholar
  7. 7.
    Fonoff ET, de Oliveira YSA, Lopez WOC, Alho EJL, Lara NA, Teixeira MJ. Endoscopic-guided percutaneous radiofrequency cordotomy. J Neurosurg. 2010;113(3):524–7.CrossRefGoogle Scholar
  8. 8.
    Šourek K. Commissural myelotomy. J Neurosurg. 1969;31(5):524–7.CrossRefGoogle Scholar
  9. 9.
    Gildenberg PL, Hirshberg RM. Limited myelotomy for the treatment of intractable cancer pain. J Neurol Neurosurg Psychiatry. 1984;47(1):94–6.CrossRefGoogle Scholar
  10. 10.
    Hitchcock E. Stereotactic cervical myelotomy. J Neurol Neurosurg Psychiatry. 1970;33(2):224–30.CrossRefGoogle Scholar
  11. 11.
    Schvarcz JR. Stereotactic extralemniscal myelotomy. J Neurol Neurosurg Psychiatry. 1976;39(1):53–7.CrossRefGoogle Scholar
  12. 12.
    Kanpolat Y, Savas A, Caglar S, Akyar S. Computerized tomography-guided percutaneous extralemniscal myelotomy. Neurosurg Focus. 1997;2(1):e5.CrossRefGoogle Scholar
  13. 13.
    Nauta HJ, Soukup VM, Fabian RH, Lin JT, Grady JJ, Williams CG, et al. Punctate midline myelotomy for the relief of visceral cancer pain. J Neurosurg. 2000;92(2 Suppl):125–30.PubMedGoogle Scholar
  14. 14.
    Armour D. Lettsomian lecture on the surgery of the spinal cord and its membranes. Lancet. 1927;209(5405):691–8.CrossRefGoogle Scholar
  15. 15.
    Brogan SE, Sindt J, Viswanathan A. Interventional pain therapies. In: Ballantyne JC, Fishman Scott M, Rathmell JP, editors. Bonica’s management of pain. 5th ed. Philadelphia: Wolters Kluwer Health; 2019.Google Scholar
  16. 16.
    Al-Chaer ED, Lawand NB, Westlund KN, Willis WD. Pelvic visceral input into the nucleus gracilis is largely mediated by the postsynaptic dorsal column pathway. J Neurophysiol. 1996;76(4):2675–90.CrossRefGoogle Scholar
  17. 17.
    Wang Y, Wu J, Lin Q, Nauta H, Yue Y, Fang L. Effects of general anesthetics on visceral pain transmission in the spinal cord. Mol Pain. 2008;4:50.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Willis WD, Al-Chaer ED, Quast MJ, Westlund KN. A visceral pain pathway in the dorsal column of the spinal cord. Proc Natl Acad Sci. 1999;96(14):7675–9.CrossRefGoogle Scholar
  19. 19.
    Vedantam A, Koyyalagunta D, Bruel BM, Dougherty PM, Viswanathan A. Limited midline myelotomy for intractable visceral pain: surgical techniques and outcomes. Neurosurgery. 2018;83(4):783–9.CrossRefGoogle Scholar
  20. 20.
    Nauta HJW, Hewitt E, Westlund KN, Willis WD. Surgical interruption of a midline dorsal column visceral pain pathway. J Neurosurg. 1997;86(3):538–42.CrossRefGoogle Scholar
  21. 21.
    Hong D, Andrén-Sandberg A. Punctate midline myelotomy: a minimally invasive procedure for the treatment of pain in inextirpable abdominal and pelvic cancer. J Pain Symptom Manag. 2007;33(1):99–109.CrossRefGoogle Scholar
  22. 22.
    Hwang S-L, Lin C-L, Lieu A-S, Kuo T-H, Yu K-L, Ou-Yang F, et al. Punctate midline myelotomy for intractable visceral pain caused by hepatobiliary or pancreatic cancer. J Pain Symptom Manag. 2004;27(1):79–84.CrossRefGoogle Scholar
  23. 23.
    Kim YS, Kwon SJ. High thoracic midline dorsal column myelotomy for severe visceral pain due to advanced stomach cancer. Neurosurgery. 2000;46(1):85–90; discussion 90-2.CrossRefGoogle Scholar
  24. 24.
    Vilela Filho O, Araujo MR, Florencio RS, Silva MA, Silveira MT. CT-guided percutaneous punctate midline myelotomy for the treatment of intractable visceral pain: a technical note. Stereotact Funct Neurosurg. 2001;77(1–4):177–82.CrossRefGoogle Scholar
  25. 25.
    Ballantine HT, Cassidy WL, Flanagan NB, Marino R. Stereotaxic anterior cingulotomy for neuropsychiatric illness and intractable pain. J Neurosurg. 1967;26(5):488–95.CrossRefGoogle Scholar
  26. 26.
    Foltz EL, White LE. The role of rostral cingulumotomy in “pain” relief. Int J Neurol. 1968;6(3–4):353–73.PubMedGoogle Scholar
  27. 27.
    Viswanathan A, Harsh V, Pereira EAC, Aziz TZ. Cingulotomy for medically refractory cancer pain. Neurosurg Focus. 2013;35(3):E1.CrossRefGoogle Scholar
  28. 28.
    Hunt PJ, Karas PJ, Viswanathan A, Sheth SA. Cingulotomy for intractable pain. In: Sagher O, Levin E, Pilitsis J, editors. Pain neurosurgery (neurosurgery by example). New York: Oxford University Press; 2019.Google Scholar
  29. 29.
    Wang G-C, Harnod T, Chiu T-L, Chen K-P. Effect of an anterior Cingulotomy on pain, cognition, and sensory pathways. World Neurosurg. 2017;102:593–7.CrossRefGoogle Scholar
  30. 30.
    Sharim J, Pouratian N. Anterior cingulotomy for the treatment of chronic intractable pain: a systematic review. Pain Physician. 2016;19(8):537–50.PubMedGoogle Scholar
  31. 31.
    Steele JD, Christmas D, Eljamel MS, Matthews K. Anterior cingulotomy for major depression: clinical outcome and relationship to lesion characteristics. Biol Psychiatry. 2008;63(7):670–7.CrossRefGoogle Scholar
  32. 32.
    Patel NV, Agarwal N, Mammis A, Danish SF. Frameless stereotactic magnetic resonance imaging-guided laser interstitial thermal therapy to perform bilateral anterior cingulotomy for intractable pain: feasibility, technical aspects, and initial experience in 3 patients. Oper Neurosurg (Hagerstown, Md). 2015;11(Suppl 2):17–25; discussion 25.CrossRefGoogle Scholar
  33. 33.
    Agarwal N, Choi PA, Shin SS, Hansberry DR, Mammis A. Anterior cingulotomy for intractable pain. Interdiscip Neurosurg. 2016;6:80–3.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of NeurosurgeryBaylor College of MedicineHoustonUSA

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