Neurosurgical techniques in the management of chronic pain

Neurosurgical treatment for pain can be classified into three parts: treatment of the cause; neuromodulation using electrical stimulation or drug delivery systems; and neuro-ablative techniques. Treatment of the cause is exemplified by microvascular decompression for trigeminal neuralgia, arguably the treatment of choice for this condition. Lumbar microdiscectomy for sciatica can also be viewed in this light. Neuromodulation is a growing field. The most common technique is spinal cord stimulation and a growing body of evidence supports its use (e.g. for treatment of persistent pain following spinal surgery and complex regional pain syndrome). Rarer and more specialist techniques of stimulation are motor cortex and deep-brain stimulation. Intrathecal drug delivery systems are increasingly used, and may have increasing application in pain associated with malignancy. Neuro-ablative techniques are used less frequently, but find a place in restricted situations such as cordotomy for focal pain of malignancy and the DREZ lesion following spinal cord avulsion injury. All of these treatments are now delivered in a multidisciplinary context, with availability of other adjunctive treatments (be they comprehensive medical management) and the use of cognitive techniques – pain management programmes.