Introduction

Neurosurgical procedures for pain management in cancer patients are at a crossroad. Although the intracranial operations traditionally have been used as later options, there is a movement toward applications of these techniques in earlier stages of disease. It is estimated that 10% or more of cancer patients do not receive adequate relief with pharmacological treatment options because they are often troubled by dose-limiting side effects such as nausea or cognitive dysfunction (1). Earlier use is now suggested by improvements in accuracy as well as the cost-containment benefits and ease of discomfort that these techniques provide. One-time procedures, performed with the patient under local anesthesia, allow for short hospital stays and low morbidity rates and are now useful, if not desirable, because of their cost-containment considerations. Although many of these procedures are old, recent improvements and technological innovations have renewed interest in their use (Fig. 15.1). Some of these improvements, such as focused radiotherapy, allow almost non-invasive interventional pain techniques at the intracranial level. Despite newer developments, the role of spinal ablative procedures, with their low risks, remains stable in overall pain management.

The relative roles of ablative and augmentative procedures are still controversial in neurosurgical pain management. Many of these ablative procedures have been available for 40 to 50 years, yet, in many situations, they have been replaced by newer augmentative procedures over the past 10 years. Pain relief from ablative procedures may be of shorter duration than that resulting from stimulation and may be accompanied by deafferentation pain (2). More recently, however, older techniques for intracranial ablative procedures have been updated.