Neurosurgical treatments of intractable pain

Intractable pain may require neurosurgical intervention. This review provides a critical update of neurosurgical techniques available to treat this condition. Neurosurgery can affect pain's pathways from the receptor up to the “centers” of its reception and perception, either by destroying or by stimulating them. Early in neurosurgery's development, and still today, ablative procedures are able to suppress or alleviate pain. However, in most cases, such ablations have only remained effective for a few months or, at best, a few years. This is why, from the 1960s on, a better understanding of the mechanism of pain inspired development of electrical and chemical neuromodulation procedures at every level of the nociceptive system (peripheral nerve, cord, thalamic, periventricular/aqueductal gray, and cortical centers). The encouraging outcomes that resulted are attracting increasing attention and interest among clinicians. The indications for undertaking an ablative vs a neurostimulative procedure, as well as selection of the anatomical target, depend largely on whether pain is nociceptive or neuropathic, given that most of these indications overlap to some extent. In addition, because the published outcomes are not based on universal criteria, it is difficult for the attending physician to select the type of procedure most suitable to the pain problem. This brief review surveys the various neurosurgical procedures together with their corresponding indications in the hope that the information provided will help practitioners choose (1) the type of neurosurgical therapy most appropriate to their patients' needs and (2) the neurosurgical group best equipped to implement that choice.