Surgical interruption of a midline dorsal column visceral pain pathway

Abstract

A punctate midline myelotomy performed in a patient effectively eliminated residual, intractable pelvic pain, which remained after resolution of uterine cervical cancer. The authors describe the case history of the patient, in whom pain assessments were made, and a surgical procedure performed. Despite large doses of opiate analgesic medications, the patient experienced constant pressure pain in the right lower pelvis, with excruciating pain on bowel movement. Severe weight loss necessitated better pain control. A minimally invasive surgical procedure, a 5-mm deep puncture using a 16-gauge needle on either side of the median septum in the dorsal column of the spinal cord (T-8), resulted in no new neurological deficits. Narcotic medication was tapered, no pain was reported, and the patient resumed daily household activity. Midline myelotomy has typically been performed with the intention of eliminating the crossing fibers of the spinothalamic tract in the anterior white matter commissure. The punctate midline myelotomy described here was performed with the specific intention of interrupting a newly described visceral pain pathway that ascends to higher brain centers through the midline of the dorsal column. The effectiveness of the pain relief seen in this patient suggests that visceral pain of the pelvis in humans may be transmitted in the midline of the dorsal column, as has been recently reported in studies using rats. The effectiveness of the punctate midline myelotomy performed in this one case of pelvic visceral pain suggests that the surgery may eventually be effective in greatly reducing or replacing opiate narcotic medication for visceral pain management.

Pain outcomes after surgery in patients with intramedullary spinal cord cavernous malformations

“…Dorsal midline visceral pain pathways were recently described in rat anatomical studies. 7 Nauta et al 10 recently described the use of a midline dorsal-column myelotomy to effectively treat oncological visceral pain. The transient improvement and timeframe noted is consistent with pain improvement results obtained in the past for percutaneous cordotomy procedures.…”

Nerve injury-induced tactile allodynia is present in the absence of FOS labeling in retrogradely labeled post-synaptic dorsal column neurons

“…The dorsal column pathway consists of direct afferent projections from large-diameter Aβ fibers and projections from post-synaptic dorsal column (PSDC) neurons Hendry et al 1999;Palecek, 2004;Willis and Coggeshall, 2004). It is well established that the PSDC neurons mediate visceral pain (Al-Chaer et al 1996a,b;Hirshberg et al 1996;Houghton et al 1997;Nauta et al 1997;Houghton et al 2001). For example, the physiologic responses of PSDC neurons to colorectal distension are opioid-sensitive and behavioral responses to noxious visceral stimuli are blocked by lesions of the dorsal columns (Al-Chaer et al 1996a;Houghton et al 2001;Palecek et al 2002).…”

Mielotomia punctiforme no tratamento da dor oncológica visceral: análise de três casos

“…Seus resultados foram pouco satisfatórios e com alto índice de morbidade pós-operatória. Hitchc o c k 2 7 i n t roduziu a mielotomia limitada na linha mé-dia, que foi aperfeiçoada por Schvarcz e rebatizada com o nome de mielotomia extralemniscal 7 . Ambos os procedimentos obtiveram bons resultados, porém ainda não havia a consciência de uma via na coluna dorsal especificamente relacionada com a dor visceral.…”

“…A primeira tentativa de ablação desta via em humanos para o tratamento da dor oncológica visceral foi feita por Nauta em 1996 com excelente re s u l t a d o em uma paciente com câncer pélvico 7 . Desde então, outros autores demonstraram sua aplicabilidade no tratamento da dor abdominal no meso e epigástrio de pacientes com diversos tipos e apresentações de c â n c e r 8 -1 0 , tendo sido descrita, inclusive por via perc u-tânea, guiada por tomografia computadorizada 1 1 .…”