Cingulotomy for medically refractory cancer pain

Viswanathan, Ashwin; Harsh, Viraat; Pereira, Erlick A. C.; Aziz, Tipu Z.

doi:10.3171/2013.6.focus13236

Cited by 59 publications

(42 citation statements)

References 23 publications

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“…However, many patients suffer from diffuse pain due to widespread metastases or head-and-neck malignancies not amenable to cordotomy. In this carefully selected subset of patients, small but increasing evidence indicates that stereotactic anterior cingulotomy could be an effective treatment option [8,9]. The dorsal anterior cingulate cortex is considered part of the limbic circuit and is thought to have a major role in cognitive and emotional processing, as well as the perception of pain [10].…”

Section: Introductionmentioning

confidence: 99%

Double Anterior Stereotactic Cingulotomy for Intractable Oncological Pain

Strauss¹,

Berger²,

S³

et al. 2017

Stereotact Funct Neurosurg

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Background: Stereotactic anterior cingulotomy has been used in the treatment of patients suffering from refractory oncological pain due to its effects on pain perception. However, the optimal targets as well as suitable candidates and outcome measures have not been well defined. We report our initial experience in the ablation of 2 cingulotomy targets on each side and the use of the Brief Pain Inventory (BPI) as a perioperative assessment tool. Methods: A retrospective review of all patients who underwent stereotactic anterior cingulotomy in our Department between November 2015 and February 2017 was performed. All patients had advanced metastatic cancer with limited prognosis and suffered from intractable oncological pain. Results: Thirteen patients (10 women and 3 men) underwent 14 cingulotomy procedures. Their mean age was 54 ± 14 years. All patients reported substantial pain relief immediately after the operation. Out of the 6 preoperatively bedridden patients, 3 started ambulating shortly after. At the 1-month follow-up, the mean preoperative Visual Analogue Scale score decreased from 9 ± 0.9 to 4 ± 2.7 (p = 0.003). Mean BPI pain severity and interference scores decreased from levels of 29 ± 4 and 55 ± 12 to 16 ± 12 (p = 0.028) and 37 ± 15 (p = 0.043), respectively. During the 1- and 3-month follow-up visits, 9/11 patients (82%) and 5/7 patients (71%) available for follow-up reported substantial pain relief. No patient reported worsening of pain during the study period. Neuropsychological analyses of 6 patients showed stable cognitive functions with a mild nonsignificant decline in focused attention and executive functions. Adverse events included transient confusion or mild apathy in 5 patients (38%) lasting 1-4 weeks. Conclusions: Our initial experience indicates that double stereotactic cingulotomy is safe and effective in alleviating refractory oncological pain.

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Section: Introductionmentioning

confidence: 99%

Double Anterior Stereotactic Cingulotomy for Intractable Oncological Pain

Strauss¹,

Berger²,

S³

et al. 2017

Stereotact Funct Neurosurg

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“…We have successfully implanted DBS into the anterior cingulate cortex in such patients with the rationale of reducing the emotional saliency of pain perception while not seeking to alter its nociceptive component [82,197]. Such work draws upon a wealth of literature, and our own positive clinical experience of anterior cingulotomy for cancer pain [38,198]. We expect that anterior cingulate DBS will not only become established as a viable novel target in DBS for chronic pain, but also that its use and related translational investigations will yield many neuropsychological insights into emotion, attention, and executive function.…”

Section: Discussionmentioning

confidence: 99%

“…Observations from inadvertent localization errors and investigations into current spread from the PAG led others to target more medial thalamic nuclei, including the centromedian-parafascicular complex (Cm-Pf) [31][32][33][34]. The rostral anterior cingulate cortex (Cg24) was recently targeted for DBS on the basis of functional neuroimaging demonstrating its activation and half a century of its lesioning by cingulotomy in cancer pain [35][36][37][38].…”

Section: Introductionmentioning

confidence: 99%

Neuropathic Pain and Deep Brain Stimulation

Pereira

Aziz

2014

Neurotherapeutics

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Deep brain stimulation (DBS) is a neurosurgical intervention the efficacy, safety, and utility of which are established in the treatment of Parkinson's disease. For the treatment of chronic, neuropathic pain refractory to medical therapies, many prospective case series have been reported, but few have published findings from patients treated with current standards of neuroimaging and stimulator technology over the last decade . We summarize the history, science, selection, assessment, surgery, programming, and personal clinical experience of DBS of the ventral posterior thalamus, periventricular/periaqueductal gray matter, and latterly rostral anterior cingulate cortex (Cg24) in 113 patients treated at 2 centers (John Radcliffe, Oxford, UK, and Hospital de São João, Porto, Portugal) over 13 years. Several experienced centers continue DBS for chronic pain, with success in selected patients, in particular those with pain after amputation, brachial plexus injury, stroke, and cephalalgias including anesthesia dolorosa. Other successes include pain after multiple sclerosis and spine injury. Somatotopic coverage during awake surgery is important in our technique, with cingulate DBS under general anesthesia considered for whole or hemibody pain, or after unsuccessful DBS of other targets. Findings discussed from neuroimaging modalities, invasive neurophysiological insights from local field potential recording, and autonomic assessments may translate into improved patient selection and enhanced efficacy, encouraging larger clinical trials.

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Section: Discussionmentioning

confidence: 99%

“…Viswanathan et al [25] outline some of the earliest surgical experiences in cancer pain and note the strong cognitive and emotional pain profiles suffered by many of the patients involved in these early studies. This early work helped to validate the cingulate gyrus as a potential target for the neuromodulation of pain, particularly by modulating both cognitive and emotional components [21,22,23,24,25]. Hutchison et al [26] identified single cortical neurons within the anterior cingulate cortex of 11 patients undergoing cingulotomy that were nociception-specific; these cells responded during nociceptive input to the patient, as well as to the examiner, and in anticipation of a noxious stimulus.…”

Section: Discussionmentioning

confidence: 99%

Further Evidence for a Pain Pathway Involving the Cingulate Gyrus: A Case of Chronic Cluster Headache Cured by Glioblastoma

Robin¹,

Pabaney²,

Mitsias

et al. 2015

Stereotact Funct Neurosurg

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The authors report a case of a 49-year-old man with long-standing, chronic cluster headache (CH) refractory to medical therapy and occipital nerve stimulation that resolved a few weeks prior to the diagnosis of glioblastoma involving primarily the right cingulate gyrus. An attempt to explore the underlying role of the cingulate cortex in pain modulation by appraising the current literature is presented. This report suggests that the cingulate gyri could be a potential target for neuromodulation in patients with medically refractory chronic CH.

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Cingulotomy for medically refractory cancer pain

Cited by 59 publications

References 23 publications

Double Anterior Stereotactic Cingulotomy for Intractable Oncological Pain

Double Anterior Stereotactic Cingulotomy for Intractable Oncological Pain

Neuropathic Pain and Deep Brain Stimulation

Further Evidence for a Pain Pathway Involving the Cingulate Gyrus: A Case of Chronic Cluster Headache Cured by Glioblastoma

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