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Neurosurg Clin N Am 15 (2004) ixx

Preface
Pain Treatment

Gary Heit, MD, PhD


Guest Editor

Chronic pain is a debilitating disorder with an Clinics of North America provides an intellectual
estimated cost to society ranging in the billions of framework for approaching many of the common
dollars. The treatment of chronic pain represents problems encountered in the neurosurgical treat-
one of the most challenging problems in modern ment of pain. (However, given the scope of the
neurosurgery given its poorly understood patho- issue, there is a lack of discussion about some of
physiology, intractability to surgical intervention, the nonsurgical soft aspects of treatment eluded
pervasive nature, and impact on the psychosocial to earlier and I urge readers not to ignore the
aspects of the patient. Many patients who suer importance of these issues.) Additionally, I have
from chronic pain syndromes have had sucient taken the liberty of outlining a heuristic approach
derangement of their lives for so long that the syn- to treatment planning and some commonly
drome itself no longer becomes the primary dis- encountered problems in the perioperative period.
turbance to them having a meaningful quality of All patients should be judged as medically
life. This leads to the common phenomenon of a intractable before a surgical intervention. This
successful surgical outcome but an overall unsatis- typically should involve a patients participation
factory clinical result. To combat this, a multimo- in an interdisciplinary medical-based pain service.
dal approach to the treatment of the pain oers Establishing a relationship with such a group can
the best possibility of an overall acceptable clinical eliminate much of the overhead associated with an
outcome for the patient. The goal of a surgical appropriate workup of the patient who has
intervention should never be complete resolution chronic pain. A workup should consist of exhaus-
of pain, but return of the patient to a meaningful tive medical trials of narcotics, antineuropathic
quality of life. This latter notion of quality of life agents, and physical and occupational therapies.
versus pain-free should be the overriding principle Equally important is an extensive psychologic
in any surgical approach to a patient. Multiple assessment of the patients coping skills, the possi-
factors are aected by this statement. Patient ble use of cognitive behavioral therapies, and the
expectations postsurgery, choice of surgical target, psychologic impact of the patients pain. This
perioperative risk assessment, and long-term pain comprehensive workup has diagnostic implica-
control are some factors that readily come to tions for the choice of surgical interventions.
mind that can be prejudiced by the surgeons pre- Many of the therapeutic interventions that a mul-
determined goal. This issue of the Neurosurgery tidisciplinary pain service will use have diagnostic
1042-3680/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.nec.2004.03.003
x G. Heit / Neurosurg Clin N Am 15 (2004) ixx

and prognostic value for the surgeon. Patients A wide variety of surgical options are open to
who have narcotic responsive pain that are poorly the clinician. The selection of a procedure should
maintained on oral opiates can benet from always be grounded in the a priori goal of the
intrathecal opiates by improved local drug intervention: pain relief to a meaningful quality
concentrations to appropriate receptors in the of life. As a general rule, neuroablative procedures
spinal cord or periventricular spaces with concomi- are best used in situations where the goal is pain
tant decrease receptor exposure to central nervous relief in the range of months to a few years at best.
system sites that limit the size of the therapeutic A meta-analysis of the ablative literature suggests
window. If the patients pain has a partial response that these procedures should be used sparingly in
to membrane stabilization, it implies that they will chronic pain syndromes and then only after the
not respond as well to intrathecal narcotics therapeutic failure of appropriate neuromodula-
but may do better with neuromodulation or non- tion applications. There are exceptions to the rule
narcotic intrathecal medications. In addition, (eg, trigeminal neuralgia, in which percutaneous
many of these presurgical interventions, though approaches by way of the foramen of ovale or
unsuccessful before a surgical intervention, may stereotactic radiosurgery oer a sucient risk/
subsequently prove benecial following the pro- benet ratio) that are warranted in appropriate
cedure. I always encourage the patient to consider candidates. Even now, microvascular decompres-
pain relief to be accomplished by a tool box of sion is still the preferred therapeutic option to tri-
which the surgical procedure is but one element, geminal pain in healthy individuals.
and that can often enable other tools to become I hope that readers nd the following
ecacious again. articles informative as well as provocative in their
The initial surgical evaluation of a patient who consideration of the surgical management of
has chronic pain should always identify the nature, chronic pain. I believe that within the domain of
location, and factors that inuence pain. These functional neurosurgery, chronic pain still repre-
determinates should include the character and sents one of the more challenging diagnostic
quality of the pain (ie, burning versus achy), its and therapeutic disease states for clinicians to
location and distribution, responses to medical address.
treatments, and factors that can worsen or improve
it. A careful temporally coherent history of the
Gary Heit, MD, PhD
pain, inclusive of the aforementioned factors, is
Department of Neurosurgery
essential in formulating a hypothesis regarding
Stanford University Medical Center
the location, type, and number of the generators
R207 Edwards Building
of the patients pain syndrome. This hypothetical
300 Pasteur Drive
construct then allows the surgeon develop a
Stanford, CA 94305-5327, USA
rational for the type and location of a surgical pro-
cedure other than an empirical application. E-mail address: gary.heit@kp.org

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