1. Neurosurgical management of intractable pain
Mohammad.reza akrami M.D.

2. Pain
Acute
Chronic
Nociceptive
Neuropathic

3. Surgical treatment of intractable pain is not usually the first treatment option
Medication
Adjuvant therapy
Simple nerve block
Augmentative
ablative

4. Patient selection for surgical pain therapies

5. Surgical procedures for trigeminal pain
Surgical procedures for nontrigeminal pain

7. Neurosurgical pain therapies

9. Augmentative Stimulation Neuroaxial drug infusion
Advantages……. safe,adjustable,reversibilty
Disadvantages…….expensive ,need to maintenance,life expectancy >3 m

10. stimulation
SCS
Main indication is neuropathic pain in limbs
FBSS
CRPS

12. Stimulation PNS Cranial PHN Occipital neuralgia
When pain is limited to specific nerve
Cranial PHN
Occipital neuralgia

15. stimulation
DBS
Target
Thalamus
PAG
INDICATION
TGN
FBSS
Cancer pains

17. stimulation
MCS
INDICATIONS
TGN
FBSS
CANCER PAIN (3M+)
MCS vs. DBS

22. neuroaxial drug infusion
Intrathecal/epidural
Intraventricular
For below the neck pains
For above the neck intraven.
Effective in both nociceptive and neuropathic pain
Expensive and need for maintenance

25. ablative The last choice 3 site for intervention Peripheral
Cheap, less technique demanding ,no need for f/u, feasible in cancers
Invasive ,irreversible
3 site for intervention
Peripheral
Spinal cord
intracranial

26. Sympathectomy visceral pain in cancers limb pain in vasospastic dis
Sympathectomy visceral pain in cancers limb pain in vasospastic dis. No good for nonmalignant pain

27. Neurectomy usually in non functionl limb or amputated limb

28. Neurectomy

29. Dorsal rhizotomy and ganglionectomy back, neck ,abdoman no good for functional limb

30. DREZ lesioning for trunk and limbs in cord inj pains trumatic avulsion of root

31. cordotomy Target :spinothalamic tract Excellent response 80%
Open vs percutaneous
No need for f/u
Good for cancer

34. thalamotomy
In all types of pain
Steriotaxic RF
SRS

36. Singolotomy The last choice When others ineffective
Good for cancer pains

37. hypophysectomy Good relief of hormone responsive cancers pain
Specific mechanism of pain relief is unknown
Techinques
SRS
SURGERY