Surgical Treatments for Severe Chronic Pain

Indian doctor talking with patient
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Surgery often is considered the last resort for pain: When all else fails, cut the nerve endings. Surgery can bring about instant, almost magical release from pain caused by cancer or other incurable diseases, even in cases where strong medications such as morphine have failed to control the pain.

But there are significant downsides to surgery for pain.

Surgery may destroy other sensations along with the pain, or inadvertently become the source of new pain. It has the potential for other side effects, some of which may be serious. And the relief from pain offered by surgical treatment isn't always permanent — after six months or a year, the pain may return.

Therefore, the decision to proceed with surgery must involve careful discussions with your physician about your condition and your prognosis. It also should include evaluations of the potential alternatives to surgery, which may include implanted devices to deliver medication directly to the source of your pain, or devices that use electrical impulses to interrupt the pain signals in your nerves.

Cordotomy to Stop Pain

There are a variety of operations surgeons perform to relieve pain.

The most common is cordotomy, in which your surgeon will cut the nerve fibers on one or both sides of your spinal cord that serve as an express conduit to the brain.

Cordotomy can stop pain but also will eliminate your sense of temperature since the nerves that help you sense temperature are bundled with the nerves that allow you to feel pain.

Other possible side effects of cordotomy include weakness on one side of your body, an inability to completely empty the bladder, and so-called "mirror image pain," where you feel the same pain on the opposite side of your body.

Other Pain-Relieving Procedures

Besides cordotomy, surgery within the brain or spinal cord to relieve pain includes severing connections at major junctions in pain pathways, such as at the places where pain fibers cross from one side of the cord to the other, or destroying parts of important pain relay stations in the brain, such as the thalamus, an egg-shaped cluster of nerve cells near the center of the brain.

For example, gamma knife surgery focuses multiple beams of radiation on the thalamus to destroy it in a non-invasive procedure. It's also possible to use ultrasound to accomplish the same goal. Both of these procedures are used to treat Parkinson's disease but are considered experimental in treating pain.

Surgeons sometimes can relieve pain by destroying nerve fibers or related cells outside the brain or spinal cord. For example, they can destroy certain nerves to relieve the severe pain that sometimes follows a penetrating wound from a sharp instrument or bullet.

Some surgeons have reported success with a brain operation called cingulotomy, which destroys part of the brain called the anterior cingulate cortex, to relieve severe chronic pain, usually from cancer, stroke or spinal cord injury.

The surgery, which can be performed in a minimally invasive way with thermal energy or lasers, also is used to treat severe treatment-resistant obsessive compulsive disorder and severe depression.

Effectiveness and Temporary Pain Blocks

When pain affects the upper extremities or is widespread, the surgeon has fewer options and surgery may not be as effective. Still, skilled neurosurgeons have achieved good results with upper spinal cord or brain surgery to treat severe pain.

Prior to operating, physicians can often test the effectiveness of surgery by using anesthetic drugs to block nerves temporarily.

In some chronic pain conditions — like the pain from a penetrating wound — these temporary blocks can in themselves be beneficial, promoting repair of nerve damage.