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The history of neurosurgical procedures for the relief of pain
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The History of Neurosurgical Procedures for the Relief of Pain Charles Rawlings, III, M.D., Eugene Rossitch, Jr., M.D., and Blaine S. Nashold, Jr., M.D. Forsyth Neurosurgical Associates, Winston-Salem, and Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
Rawlings C III, Rossitch E Jr, Nashold BS Jr. The history of neurosurgical procedures for the relief of pain. Surg Neurol 1992;38:454-63.
Pain has been a major medical problem from the beginning of recorded history. Since the earliest medical writings, there have been innumerable procedures designed to relieve pain and its suffering. In this study, we have reviewed both the early medical writings of various civilizations and the first modern publications, to compile a history of neurosurgical procedures for the relief of pain. KEY WORDS: Ablation; History; Pain; Stimulation
The history of pain is as old and as convoluted as that of the human species, for the treatment of pain has occupied humankind and its medicine for countless aeons. People have exerted an untold amount of energy in their search for methods to understand and control pain. Because of the ubiquitousness and the profound suffering associated with pain, a multitude of procedures and remedies have been tried in attempts to alleviate it [9,14,41,65,67,90]. Early attempts at the neurosurgical relief of pain were crude and often unsuccessful, but as knowledge of anatomy, physiology, and biochemistry increased, along with the development of technology, neurosurgical procedures became more sophisticated and successful. This technological growth has continued, and today, a great number of neurosurgical procedures exist for the relief of pain and most can be effective if used judiciously. This, unfortunately, has not always been the case. Primitive peoples were perpetually exposed to pain and its aftermath, as evidenced by archeological records [9,14,41,65,90]. Their methods for pain relief seem unsophisticated by current standards, but many were the precursors to our modern procedures and pharmacopeia. These early treatments were employed by many cultures and recorded in several ancient medical texts Address reprint requests to: Charles Rawlings, III, M.D., Forsyth Neurosurgical Associates, 3080 Trenwest Drive, Winston-Salem, NC 27103. Received May 26, 1992; accepted June 24, 1992.
© 1992 by Elsevier Science PublishingCo., Inc.
such as the Edwin Smith Papyrus, the Ebers Papyrus, the Rig-Veda, the Huang Ti Nei Ching Su Wen, and Babylonian clay tablets from Nippur [9,14,41,65,90]. All these texts discuss elaborate methods of pain control. These manuscripts helped to usher medicine from the primitive to the modern tradition. To combat pain, primitive peoples generally sought some type of shaman or medicine-woman or -man skilled in mysticism, sorcery, conjuring, or other powerful methods of exorcising disease and pain. Along with their spells and incantations, these early tribal physicians used heat, cold, pressure, massage, trephination, and herbs to treat pain. The earliest herbs included poppy, mandragora, hemp, henbane, and nephenthe. From these early practices, came the neurosurgical procedures of stimulation, ablation, as well as the use of opioids and analgesics [9,14,41,65,90]. Stimulation Procedures Once the therapeutic limits of heat, cold, pressure, and massage were reached, the primitive patient was often then treated with the application of electrical shocks in order to relieve his or her pain. Natural sources of electricity were employed because the invention of batteries was thousands of years away. The use of natural electricity for pain relief was quite common in ancient times. These natural sources of electricity, which are documented in early medical texts, include the electric catfish, torpedo ray, and eel. The electric Nile catfish is prominently portrayed in 5th dynastic Egyptian tomb reliefs (Figure 1). The Greeks and Romans were also acquainted with these animals. In fact, the English translations of the Greek "narke" meaning numbness-producing fish and of the Roman "topere" (sluggish) form the basis of the words narcotics, torpid, and their various derivatives [9,42,83,98,100]. Aristotle, Pliny, and Plutarch all made references to the numbness and shocks caused by these fish, but Scribonius Largus was among the first to document their use for electrotherapy [4,9,42,61,62,79,83,98,100]. H e spoke of the relief of pain associated with gout and headache following the application of these fish: 0090-3019/92/$5.00
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Figure 1. The nile catfish is depicted in this 5 th dynasty Egyptian tomb at Sakkara of the great architect Ti. Source: Kellaway [42]. Used by permission.
H e a d a c h e . . . is taken a w a y . . , by alive black torpedo placed on the spot which is in pain, until the pain ceases. As soon as the numbness has been felt the remedy should be removed lest the ability to feel be taken from the part [42,79]. Galen noted that a torpedo ray could be an effective headache remedy, and others including Marcellus Empiricus, Paulus Aeginata, and Aetius o f Amida also recognized its medical usefulness [40,42,83]. In the 17th century, Perrault, Redi and especially Lorenzini commented on the paresthesia and numbness caused by the Torpedo [40,42,46,64,83,98]. Interestingly, these fish produce an electrical current similar in both voltage and frequency to m o d e r n stimulatory instruments including transcutaneous electrical nerve stimulator units and peripheral nerve stimulators. Even today, primitive peoples still use electrical fish therapeutically [9,40,42]. Stimulation for pain relief, however, was clearly limited by the source o f its electricity (i.e., fish). The creation by Von Guericke o f an electrostatic machine in 1650 and its improvement into the Leyden jar in 1745 brought forth a new era in electrotherapy [9,10,40,83]. Beginning late in the 1700s, interest grew in electrotherapy, which was used to treat conditions as diverse as mental illness, pain, and paralysis and even to prevent death [10,40]. In fact, the Academie at Lyon offered prizes for its applications and further advancement [10]. Walsh and Cavendish were the first to describe the numbing paresthesia experienced when electrostatic machines were applied to peripheral nerves [12,40,100].
John Wesley, the founder o f the Methodist Church, was a great advocate of electrotherapy and in T h e Desideratum described a multitude of cases in which painful conditions were relieved [40,83,101]. While the search for wider applications o f electrotherapy in medicine began to b o r d e r on the absurd, more knowledge o f muscle and nerve physiology was being accrued. Volta showed that electrical currents existed in living organisms and powered such structures as nerves and muscles. Furthermore, he discovered that an electric current flowed between two dissimilar metals and thus created the voltaic pile, the direct forerunner o f the battery. This gave to medicine a constant source o f stronger, more controllable, and more flexible electric current and, as a consequence, caused a flurry o f new applications of electrotherapy [9,10,83]. Both Golding Bird and D u c h e n n e de Boulogne were strong advocates of the improved electrotherapy, but only Duchenne appears to have used it in the treatment of pain (i.e., "neuralgic, sciatiques et rhumatisme") [8,13,40,83]. In the mid 1800s, electrotherapy began to be used for the relief of dental pain. Francis, in 1858, was first to produce analgesia during a dental procedure, passing current through the extracted tooth. H e went on to report 164 extractions using electrotherapy, the majority of which were pain free [23,40]. T h e use of electroanesthesia in dentistry quickly spread throughout the United States and into Europe. Concurrent to this usage o f stimulation, other forms o f electroanesthesia were being investigated. Hermel, in 1844, reported his experience with elec-
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Figure 2. Olive,s electroanesthetic apparatus as illustrated in a 1859 U.S. Patent Office Report. Source: Kane & Taub [40]. Used by permission.
troanalgesia in eight patients with neuralgia. H e directly stimulated the nerves by puncturing them with electrodes [83]. Garratt, a Boston dentist, experimented with different current strengths and advocated the direct application o f a strong current in the treatment of peripheral neuralgias, tic douloureux, hyperalgesia, and toothache [24,40]. In 1858, another American, W.G. Oliver, began to experiment with stimulation for surgical anesthesia. Using a copper wire and a wet bandage wrapped around an ulcerated leg and a similar cooper-wound bandage at the ankle, he was able to painlessly debride the ulcer. In addition, he used cauterization to control bleeding. N o t only did Oliver use electrical current effectively in a clinical situation but he also demonstrated that there was an o n - o f f p h e n o m e n o n in paresthesias associated with the current and that temperature sensation was not abolished by the current. In addition, he advocated the use of electroanalgesia in amputation and delivery (Figure 2) [40,57]. In England, electroanesthesia was similarly being used in dentistry, as well as in other fields. One of the first Englishmen to use electrical stimulation for medical purposes was the physician Julius Althaus. H e applied electricity transcutaneously to peripheral nerves to achieve analgesia, and his descriptions of the effects of peripheral nerve stimulation foreshadowed those descriptions in the next century: I . . . applied a rapidly interrupted current to Dr. R's ulnar nerve, placing one moistened conductor between the olecranon and the internal condyle, such as was not powerful enough to produce contraction of the muscles animated by the ulnar nerve. After the current has acted for a few minutes, I increased the intensity, so that a strong flexion of the fourth and little finger was produced.
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The action of this current was at first painful to bear • . . but after a certain time the pain excited by very severe shocks was comparatively little. At last the normal sensibility of the ulnar nerve was so much diminished, that a current of such high tension was borne without inconvenience by Dr. R . . . he did not feel the board upon which his fingers rested . . . . It is therefore obvious that a direct reduction of sensibility of the ulnar nerve was accomplished by electricity. . . . [30,40]. By using this technique in pathological conditions, Althaus also determined that the effects o f stimulation were more easily attained, and o f longer duration, in abnormal nerves. In his Treatise on MedicalElectricity [3], he discussed a multitude o f pathological conditions for which he found electrical stimulation useful. These included neuritis o f the trifacial nerve, headaches, tinnitis aurium, cervico-occipital neuralgia, intercostal neuralgia, and sciatica. For all o f these conditions, Althaus gave a m o d e r n description o f the disease in his case presentations and asserted that, with judicial use o f electrical current, all could be alleviated [3,40]. Other, less prominent physicians used electrotherapy for the relief o f other painful conditions. Tripier advocated it for both rectal and urethral pain, whereas Revillout, by passing a current through the hypogastrium and the uterus, relieved posthysterectomy pain [40,68,94]. Unfortunately, in the subsequent years, 1870 to 1900, electrotherapy and electroanesthesia fell into disuse due to its sometimes variable results. However, there were some physicians who continued to use electrotherapy intermittently, especially Araya in Chile, but they were few and far between [40,60]. In the later portion o f the 19th and early 20th centuries, several physicians including Beard, Rockwell, Hutchinson, Peterson, LeDuc, and Robinovitch used electrotherapy and electroanesthesia for various conditions including neuralgias, lancing o f boils, and amputations [6,28,39,40, 44,59]. In 1928, electrical stimulation o f peripheral nerves for pain relief was "rediscovered" by T h o m p s o n et al at Berkeley [93]. They showed, once again, that "the cutaneous area supplied by a nerve may be rendered insensible to light touch by subjecting the nerve trunk to the influence o f an alternating current." T h e y mapped all cutaneous peripheral forearm nerves in a patient and showed that analgesia was induced with increased current [93]. As an extension o f this technique, Paraf, in 1948, reported pain relief in 127 patients with a variety of pain syndromes, including sciatica, postherpetic neuralgia, and tic douloureux [58]. Between 1948 and 1965, there was a gradual resumption o f interest in electrotherapy, and as anatomical and physiological pathways were better elucidated, stimulation o f the pathways was undertaken for relief o f pain. T h e r e were various reports
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during this time of stimulation of the spinothalamic tract, the brain stem, and the thalamus for pain relief [9,40,50,83]. Finally, in 1965, Melzack and Wall developed the "gate theory" of pain, which consolidated a multitude of past experimental and therapeutic observations into a coherent physiological theorem [9,99]. This opened the door for more neurosurgical stimulatory procedures. The most important premises, with respect to neurosurgical stimulation, of the gate-control theory were that stimulation of large-diameter afferent fibers decreases pain and that there exist descending inhibitory pathways derived from upper-level neural substrates, that modulate pain transmission. Based on these premises, Wall and Sweet, in 1967, once again showed that stimulation of peripheral nerves decreased pain. Eight patients with severe nerve pain with diverse etiologies ranging from diabetic neuropathy to metastatic cancer were treated with neural stimulation. All experienced good pain relief [99]. In a follow-up study, Sweet and Wepsic performed the first implantation of peripheral nerve stimulators in two patients with severe pain due to median and ulnar nerve dysfunction. Both patients had had previous neurosurgical procedures, nerve blocks and intensive medical therapy. Both obtained good pain relief, but in one, the relief decreased over time [89]. Also, at this same time, Shelden et al reported the results in three patients in whom they had implanted stimulating electrodes on the mandibular nerve for third division tic douloureux. They reported good pain relief with follow-up periods between 3 and 4 years [82]. Finally, with technical improvements in stimulating electrodes and electronic systems, more implantable nerve stimulators were used. Nashold et al, in 1982, summarized their experience with 35 patients. The results varied depending on the nerve stimulated and the cause of the pain [54]. Shealy et al focused on the spinal cord and demonstrated that "an electrophysiologic system activated by noxious stimuli is suppressed by stimulation of the dorsal columns or of the anterolateral spinal cord." They showed that a prolonged after-discharge evoked from a maximally stimulated peripheral nerve or a noxious stimulus can be inhibited by spinal cord stimulation [80,81]. These studies led to the clinical use of spinal cord stimulation for pain relief. Sweet and Wepsic, in their paper detailing peripheral nerve stimulation, discussed their attempts at stimulating the spinal cord. They noted varying results, especially when only one set of parameters (i.e., duration and frequency) was used [89]. In 1967, in a follow~up paper, Shealy et al showed spinal cord stimulation to be of clinical value [80], and since then, a multitude of studies have reported the results of spinal cord stimulation [47,84,95]. Spinal cord stimula-
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tion for pain relief still plays a role in modern neurosurgical practice and is directly based on these early electrophysiological and clinical studies. Along with peripheral nerve and spinal cord stimulation, deep brain stimulation has also been used for pain relief. Except for generalized shock treatments given to patients suffering from a plethora of conditions, deep brain stimulation is, not surprisingly, a recent phenomenon [10,40,83]. Olds and Milner, in 1954, were among the first to try deep brain stimulation in animals (the septal region in rats) [56], and Heath and Mickle [31] and Gol [25], in the early 1960s, attempted pain relief with temporary electrodes implanted in the septal region of patients. At this time, two main uses of deep brain stimulation based on two diverse electrophysiological conditions have emerged--periaqueductal gray (PAG)/ periventricular gray (PVG) stimulation based on endorphin chemistry, and thalamic/internal capsule stimulation based on the "gate-control" theory. In 1968, in his landmark paper, Reynolds showed that rats could undergo laparotomy without anesthesia, as long as their midbrain central gray region was stimulated [69]. Following this, a host of studies began to detail the endogenous opioids and the neural substrates responsible for this stimulation-produced analgesia. In 1977, Richardson and Akil demonstrated this type of analgesia in humans with both PVG and PAG stimulation [70-72]. Since then, Hosobuchi and coworkers have refined PAG and PVG stimulation for the treatment of pain in humans [2,35-37]. At this point, it appears that PAG/PVG stimulation is most useful in patients with nociceptive pain, especially cancer pain, although much investigation continues in this area. Like the gate-control theory of pain, the 1911 theory of Head and Holmes stated that pain results from an imbalance between the protopathic and epicritic systems [30]. Thus, neurosurgeons began to stimulate the ventroposteromedial nucleus (VPM), ventroposterolateral nucleus (VPI), and internal capsule to provide pain relief. It appears that Mazars et al were one of the first groups to stimulate the VPM and VPL for pain relief and, in 1973, they reported on 17 patients who had undergone thalamic stimulation [49]. Their work was based primarily on the theories of Head and Holmes, and their patients suffered from a variety of pain syndromes, ranging from anesthesia dolorosa to brachial plexus avulsion. They noted that good results were obtained in patients with postamputation, atypical facial, and peripheral nerve pain, whereas patients with cancer pain and tic douloureux fared poorly [48,50]. At the same time that Mazars et al reported their findings (1973), both Hosobuchi et al and Adams et al reported their results of VPM, VPL, and internal capsule stimulation [2,37]. Since that time, both Mazars and Hosobuchi
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have been extremely active and influential in bringing thalamic stimulation into the neurosurgical armamentarium. Although still not completely characterized or totally effective, thalamic stimulation has been shown to be an effective addition to the fight against pain. Ablative Procedures Trephination was probably the earliest ablative procedure for pain relief and was practiced by many cultures in a multitude of regions. Even today, certain tribes still perform trephinations, primarily to cure headache and to "release spirits" [9,14,65,103 ]. Until the Renaissance, there was little documentation, aside from trephinations, about the use of ablative procedures for pain relief. The great surgeon, Ambroise Par~, a specialist in warfarerelated traumatic injuries, evidently was exposed to a great number of peripheral nerve injuries that resulted in pain. In the late 1500s, he was able to relieve this type of pain by transecting the peripheral nerve involved. Unfortunately, little else is known about his pain operations. In the late 1600s, Marechal, the court physician to Louis XIV, performed neurotomies for tic douloureux [9]. Later, Letievant proposed sectioning nerves to both the face and extremities as a method of controlling pain [3]. Ablative neurosurgical procedures developed and became more refined as modern surgical doctrine emerged. Early stimulation procedures were less dependent on surgical technique. This becomes apparent when one compares the profusion of the stimulatory procedures to the paucity of informaiton about early ablative procedures. Stimulation was used frequently and by many physicians, whereas ablative procedures were used infrequently. It is also no surprise that peripheral neurotomies were the only procedure to be used prior to the modern era of surgery, for they were the least invasive, gave immediate results, left little dysfunction, and had a low mortality rate. It was not until the late 1800s, with the advent of anesthesia, antisepsis, and more advanced knowledge of physiology and anatomy, that the proliferation of ablative neurosurgical procedures for pain relief began. Neurologists contributed to many of these early ablative procedures by studying the relevant anatomical pathways and by helping to devise the procedure itself [1,11,51,103]. For example, Dana, the first chairman of neurology at Cornell, in 1888, suggested posterior rhizotomies for certain pain syndromes. Subsequently, Bennett, in England, and Abb6, in the United States, performed this procedure [ 1,7,9,14,103]. Bennett's case was a 45-year-old man with severe leg pain due to tibial osteomyelitis. Following an amputation, the pain continued and he subsequently underwent lumbar and sacral
Figure 3. Anterolateral tract section. From a 192 7 review article on surgery of the spinal cord. Source: Armour [5]. Used by permission.
rhizotomies. H e experienced good pain relief, but suffered an intracranial hemorrhage postoperatively [7]. Abb6's patient, referred to him by Dana, was a 43year-old male with brachial plexus neuralgia secondary to a shrapnel and stretch injury. H e had been treated with nerve stretching, amputation of the arm, and neuroma excision, all without success. Abb6 performed C6C8 posterior spinal rhizotomies in two separate procedures, with good results. Just as significantly, during these procedures, Abb~ stimulated the nerve roots to determine their functions; this was the first instance of intraoperative localization and stimulation [1]. Following these successes, other surgeons including Horsley, Kfitmer, Giordano, Kaune, and Hunter gradually began to use posterior rhizotomy for pain relief [1,9,14,29,38]. More significantly, using the technique of posterior rhizotomy, Forster et al were able to map the human dermatomes [20,22]. Following the introduction of rhizotomy, attention was directed at the spinal cord for relief of pain syndromes. Anterolateral cordotomy was the first procedure to be devised and implemented (Figure 3). Gowers, M/iller, and others had earlier shown that the anterolateral portion of the spinal cord carried pain fibers [5,11,26,76,88]. Caldwalader and Sweet, in 1912, at the suggestion of Spiller, investigated the anterolateral tract in dogs and showed that pain sensation was dependent on the intactness of that portion of the spinal cord [ 11].
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Figure 4. Pathological specimen of the spinal cord following percutaneous intramedullary cordotomy. (Left) Tract of needle. (Center) Arrow points to site of needlepenetration anterior to the dentate ligament. (Right) Destruction of quadrant. Source: Mullah et al [53]. Used by permission.
As it became apparent that rhizotomies sometimes failed to relieve pain, or more importantly, the pain recurred, a better procedure was sought for pain relief. In 1910, Schiiller proposed, based on previous experimental evidence, that sectioning of the anterolateral spinal cord pathways would effect pain relief [76]. It was not until 1912, however, that Spiller and Martin, after the investigations of Caldwalader and Sweet, performed the first anterolateral cordotomy [88]. The patient was a 47-year-old man with bilateral lower extremity pain secondary to a malignant conus tumor. Following bilateral sectioning of the anterolateral tracts through T6-T8 laminectomies, the patient was pain free at 1 year [88]. Forster and Gagel then performed the first cervical cordotomy in 1931 [21]. Since the first open cordotomy was performed, the procedure has gained worldwide acceptance for the relief of malignant pain. It was recognized early, however, that many patients who could benefit from the procedure were too ill to undergo a major operation. Thus, in the 1960s, Mullan et al and then Rosomoff et al modified the procedure so that it could be done percutaneously under local anesthesia [52,53,73]. Mullan et al, using air myelography and a strontium-90 needle introduced with fluoroscopic guidance, lesioned the anterolateral cord with excellent results [52]. Mullan et al and then Rosomoff et al, in subsequent years, replaced the strontium needle with a radiofrequency lesioning electrode and further improved the technique (Figure 4) [53,73]. With this procedure, the contemporary neurosurgeon has an operation that is easily and quickly performed under local anesthesia, has a low morbidity, and gives an excellent result in malignant pain relief. Along with anterolateral cordotomy, several other procedures based on spinal cord anatomy and physiology were formulated in the early 1900s. One of these pain procedures was commissural myelotomy. In his classic paper of 1927 dealing with various procedures on the spinal cord, Armour discussed, in detail, both rhizotomies and cordotomies and their respective physiological anatomy. Moreover, he introduced a new procedure, commissural myelotomy, for the relief of pain. He detailed his operation on a patient with gastric crises and pointed out that the operation was simple and effective. His patient, unfortunately, died of pneumonia several
days following the procedure [5]. Following this, Putnam, in 1934, published his results of three patients on whom he performed commissural myelotomies [66]. All three had metastatic disease with bilateral upper extremity pain. Two had good to excellent pain relief while the third died, due to her malignancy. He did extensive myelotomies, through multiple laminectomies, using a special blunt myelotome [66]. Over the ensuing decades, commissural myelotomy was shown to have a fairly low success rate. However, it is still occasionally used today in patients with malignant disease and bilateral extremity pain [9]. As the anatomy and physiology of the pain pathways were further elucidated, neurosurgeons more frequently attempted different, more extensive ablative procedures for the relief of pain. A logical extension of cordotomy and myelotomy proposed by Schwartz and O'Leary in 1941 was the sectioning of the spinothalamic tract at the medullary level [77]. Similarly, Sj6quist had introduced medullary trigeminal tractotomy earlier, in 1938, but due to its invasiveness and high morbidity, it never gained wide acceptance [85]. It appears that Schwartz and O'Leary [77] and White [102] simultaneously were responsible for the first medullary spinothalamic tractotomy. Based on previous anatomical studies that elucidated the pathway of the spinothalamic tract and the clinical syndrome of thrombosis of the posterior inferior cerebellar artery, these authors postulated that sectioning of the spinothalamic tract in the medulla would relieve otherwise untreatable pain in the shoulder and neck. Schwartz and O'Leary's patient was a 30-year-old woman with intractable neck, chest, and abdominal pain due to metastatic disease; she underwent a suboccipital craniectomy and sectioning of the spinothalamic tract through a 3-mm-deep incision at the rostral portion of the inferior olivary eminence. She had complete contralateral analgesia with pain relief postoperatively; unfortunately, she died several days later of pneumonia [77]. White's patient was a 29-year-old woman with neurogenic pain secondary to Raynaud's phenomena who had undergone multiple procedures, including sympathectomies and rhizotomies but who continued to have severe neuralgia in the neck, occiput, arm, and chest. She underwent sectioning of the medullary tract with a 4-mm-deep incision at the level of the olivary eminence under local
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anesthesia. Following the incision, she felt immediate pain relief with contralateral analgesia [102]. Although this procedure was an interesting extension of the knowledge of the day, it never gained popularity due to its morbidity, its limited usefulness in debilitated patients, and more importantly, its replacement by more easily accomplished procedures. Stereotactic lesioning of the medullary spinothalamic tract has similarly not gained wide acceptance [33,34]. Since certain pain syndromes were not amenable to the then known pain procedures, it was only natural that the spinothalamic tract should be interrupted at an even higher level. This was important, especially in the subgroup of patients with shoulder, arm, and face pain who were too debilitated for open sectioning or in patients with thalamic pain or anesthesia dolorosa. Dogliotti, in 1938, first suggested this upper level sectioning of the spinothalamic tract, making his incision in the pons [ 16]. Walker was the first to attempt an open mesencephalic tractotomy. In two publications, he reported five patients with unilateral pain syndromes of various etiologies. In each, he performed an open sectioning of the spinothalamic/quintothalamic tract through an occipital craniotomy. With elevation of the occipital lobe, retraction of the cerebellum, and through a transtentorial approach, he made a 5-mm-deep incision at the level of the posterior margin of the superior colliculus across the brachium at the inferior colliculus to the base of the superior colliculus. All his patients experienced good pain relief but also had various accompanying deficits (Figure 5) [96,97]. Spiegel and Wycis and their colleagues then improved the procedure. Since they had recently constructed a human stereotactic frame, they believed that stereotactic mesencephalotomy would be a major advance over the open procedure [87]. In 1953, they reported six patients who had undergone stereotactic mesencephalotomy. Three of these patients had anesthesia dolorosa, two had thalamic pain, and one had postherpetic neuralgia. All patients had previously undergone multiple procedures. Following the stereotactic operation, all experienced pain relief, which lasted for several years [86,104]. Stereotactic mesencephalotomy has continued to be successfully performed for pain syndromes such as thalamic pain, anesthesia dolorosa, and unilateral head and neck pain secondary to malignancy. Moreover, the ability to lesion exquisitely small, specific anatomical sites with acceptable morbidity was first demonstrated by this procedure [9,92,105]. Stereotactic thalamotomy for the relief of pain also had its origins during this time. In fact, it appears that Wycis et al, in the above reported group of patients, performed the first thalamotomy [ 104]. Their procedure was coupled with mesencephalotomy. About the same
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time, Hecaen et al [32] and Talairach et al [91] performed thalamotomies, unaccompanied by any other procedure, for the relief of pain. Their patients, five in all, had a number of diverse pain syndromes that were labeled "thalamic pain." Their lesions were primarily in the ventrobasal complex, centromedian nucleus, and various combinations of these nuclei. The results were only ~air, but over the ensuing years, Spiegel, White, and Sweet helped to improve outcome with careful patient selection. Today, although not widely used, thalamotomy can help in relieving the pain of diffuse cancer [9,67,86]. Finally, several procedures less widely used illustrate how neurosurgeons have innovatively sought new forms of pain therapy. For example, dorsal root entry zone (DREZ) lesions appear to be effective in the treatment of certain deafferentation pains. In 1976, Nashold and colleagues reported on a procedure that produced focal destruction of the substantia gelatinosa [55]. This area of the spinal cord was recognized by Rolando in the 18th century, but it was not until the early 20th century that Ranson, a neuroanatomist, suggested that the substantia gelantinosa was involved in the neurophysiology of pain. In animal experiments in which deafferentation of the dorsal horn is experimentally produced, the secondary interneurons in the superficial and deep Rexed layers exhibit abnormal electrical activity within a few hours of the insult. This electrical abnormality can continue for many months. The theoretical basis for the DREZ operation is that pain relief following DREZ lesions occurs as a result of destroying these abnormal secondary interneurons and their connections. Since 1975, the operation has been used successfully in treating pain resulting from brachial or sacral plexus avulsions, paraplegia, herpes, cancer, and phantom limb. Sano, in 1962, lesioned the posterior hypothalamus for aggressive behavior and observed a decrease in sympathicotonia and an increase in parasympathicotonia [74]. Noting that pain syndromes produced an increase in sympathetic output, as well as causing suffering, Sano et al performed hypothalamotomy for pain resulting from malignancy, causalgia, or neuralgia on 18 patients. Twelve patients experienced relief and Sano et al noted that it was the emotional and motivational aspects of the pain that were alleviated [75]. Similarly, Fairman reported on 12 hypothalamotomy patients with malignant pain; 80% had good pain relief [17]. Although, currently not in vogue, hypothalamotomy may represent an interesting alternative for treatment of malignant pain. Leriche, as early as 1937, suggested that corticectomy might aid in pain control; he subsequently performed a postcentral gyrectomy for the relief of phantom-limb pain [ 15,45]. Pool and Bridges went a step further and
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Figure 5. Sketchesshowing Walker's operative approach for mesencephalic tractotomy. Source: Walker [97]. Used by permission.
performed a subcortical parietal lobotomy for phantomlimb pain [63]. Subsequent experience has shown, however, that cortical removal is very seldom effective in pain control, except in one instance--cingulotomy. Cingulotomy, a descendant of the psychosurgical procedure of frontal leukotomy, is at present the only effective form of corticectomy in pain control. LeBeau [43] Foltz and White [18,19] were among the first to advocate and to perform selective bilateral cingulotomies for the relief of pain. Today, this procedure is a well-recognized, albeit last, alternative in the management of certain intractable pain syndromes [9,18,19,27,43,78]. In conclusion, humankind's battle with pain and its effects has been a universal and almost timeless endeavor. The history of pain neurosurgery has its beginnings with the shamans and tribal healers who, through massage, heat, cold, and the ancient procedure of trephination, were the first to begin the ministrations of pain. Even though humankind has made great strides in the relief of pain, many procedures are not as effective as had been hoped. The search for effective pain remedies continues, and neurosurgeons lead the way. At some point, the anatomy of pain and the secret to its defeat will be discovered.
References 1. Abh~ R. A contribution to the surgery of the spine. Med Rec (NY) 1889;35:149-52.
2. Adams JE, Hosobuchi Y, Fields HL. Stimulation of internal capsule for relief of chronic pain. J Neurosurg 1974;41:740-7. 3. AlthausJ. A treatise on medical electricity theoretical and practical and its use in the treatment of paralysis, neuralgia and other diseases. London: Trubner, 1859. 4. Aristotle. Historia animalium. 5. Armour D. Surgery of the spinal cord and its membranes. Lancet 1927;1:691-7. 6. Beard GM, Rockwell AD. Practical treatise on the medical and surgical uses of electricity. New York: William Wood, 1881. 7. Bennett WH. A case in which acute spasmodic pain in the left lower extremity was completely relieved by subdural division of the posterior roots of certain spinal nerves. Med Chir Trans (London) 1889;72:329-48. 8. Bird G. Lectures on electricity and galvanism. London: Green & Longmans, 1849. 9. BonicaJJ. History of pain concepts and pain therapies. In: Bonica JJ, ed. The management of pain, 2nd ed. Philadelphia: Lea & Febiger, 1990:2-17,1850-76,2040-103. 10. Brazier MAB. A history of neurophysiology in the 17th and 18th centuries: from concept to experiment. New York: Raven Press, 1984:187-216. 11. Caldwalader WB, Sweet JE. Experimental work on the function of the anterolateral column of the spinal cord. JAMA 1912;58:1490-3. 12. Cavendish H. An account of some attempts to imitate the effects of the torpedo fish by electricity. Philos Trans B 1776;66: 196-225. 13. Colwell HA. An essay on the history of electrotherapy and diagnosis. London: Heinemann, 1922. 14. Crawford JV, Walker AE. Surgery for pain. In: Walker AE, ed. A history of neurological surgery. Baltimore: Williams & Wilkins, 1951:308-30,583. 15. DeGutierrez-Mahoney CG. The treatment of painful phantom
462
16.
17.
18. 19. 20. 21.
22.
23. 24. 25. 26.
27.
28. 29. 30. 31.
32.
33. 34.
35.
36.
37.
38.
Surg N e u r o l 1992;38:454-63
limb by removal of post central cortex. J Neurosurg 1944;1:156-62. Dogliotti AM. First surgical sections in man of the lemniscus lateralis (pain-temperature path) at the brain stem, for the treatment of diffuse rebellious pain. Anesth Analg 1938;17:143-5. Fairman D. Hypothalamotomy as a new perspective for alleviation of intractable pain and regression of metastatic tumors. In: Fusek I, Kunc Z, eds. Present limits of neurosurgery. Prague: Avicenum, 1972:525-8. Foltz E, White L. Experimental cingulumotomy and modification of morphine withdrawal. J Neurosurg 1957; 14:655-73. Foltz E, White L. The role of rostral cingulumotomy in "pain" relief. I n t J Neurol 1968;6:353-73. F6rster O. The dermatomes in man. Brain 1933;56:1-39. F6rster O, Gagel O. Die Vorderseiten strangdurchschneidung beim Menschen. Eine Klinisch-pathophysiologisch-anatomische Studie. Z Gesamte Neurol Psychiatr 1931;138:1-93. F6rster O, Kiittner H. lJber operative Behandlung gastrischer Krisen durch Resektion der 7-10 hinteren Dorselwurzel. Beitr Kiln Chir 1909;63:245-56. Francis JB. Extracting teeth by galvanism. Dent Rep 1858;1:65-9. Garratt AC. Galvanism for counteracting pain in the extraction of teeth. Boston Med Surg 1859;59:32-4. Gol A. Relief of pain by electrical stimulation of the septal area. J Neurol Sci 1967;5:115-20. GoldsteinK. l~lberdieaufsteigendedegenerationnachQuerschnittsunterbrechung des Riickenmarks (Tractus spinocerebellaris posterior, Tractus spino-olivaris, Tractus spino-thalamicus). Neurol Zentralbl 1910;29:898-911. Grantham EG. Prefrontal lobotomy for relief of pain--with a report of a new operative technique. J Neurosurg 1951;8: 405-10. Gwathmey JT. Anesthesiology. New York: Appleton, 1914:628-43. Gybels JM, Sweet WH. Neurosurgical treatment of persistent pain. Basel: Karger, 1989. Head H, Holmes G. Sensory disturbances from cerebral lesions. Brain 1911;34:102-254. Heath RG, Mickle WA. Evaluation of seven years experience with depth electrode studies in human patients. In: Ramey ER, O'Doherty DS, eds. Electrical studies on the unanesthetized brain. New York: Hoeber, 1960:214. H~caen H, TalairachJ, David M, Dell MB. Coagulations limit6es du thalamus dans les algies du syndrome thalamique. R6sultats th6rapeutiques et physiologiques. Rev Neurol (Paris) 1949;81: 917-31. Hitchcock E. Stereotactic cervical myelotomy. J Neurol Neurosurg Psychiatry 1970;33:224-30. Hitchcock E, Sotelo MG, Kim MCH. Analgesic levels and technical method in stereotaxic pontine spinothalamic tractotomy. Acta Neurochir 1985;77:29-36. Hosobuchi Y. Subcortical electrical stimulation for control of intractable pain in humans. Report of 122 cases (1970-1984). J Neurosurg 1986;64:543-53. Hosobuchi Y, Adams JE, Linchitz R. Pain relief by electrical stimulation of the central grey matter in humans and its reversal by naloxone. Science 1977;197:183-5. Hosobuchi Y, Adams JE, Rutkin B. Chronic thalamic stimulation for the control of facial anesthesia dolorosa. Arch Neurol 1973;29:158-61. Hunter CR, Mayfield FH. Role of the upper cervical roots in the production of pain in the head. Am J Surg 1949;78:743-51.
Rawlings et al
39. Hutchinson WF. Electrical anesthesia by means of the singing rheotome. N Engl Med Mon 1892;12:41-6. 40. Kane K, Taub A. History of local electrical analgesia. Pain 1975;1:125-38. 41. Keele KD. Anatomies of pain. Springfield, Ill.: Charles C Thomas, 1957. 42. Kellaway P. The part played by electric fish in the early history of bioelectricity and electrotherapy. Bull Hist Med 1946;20: 112-22. 43. LeBeau J. Anerior cingulectomy in man. J Neurosurg 1954;11:268-76. 44. LeDuc S. Production of sleep and general and local anesthesia by intermittent current of low voltage. Arch Elect M6d 1902;10:617-21. 45. Leriche R. La chirurgie de la douleur. Paris: Masson, 1937. 46. Lorenzini S. The curious and accurate observations of Mr. Stephen Lorenzini of Florence on the dissections of the cramp-fish. London: Jeffrey Wale, 1705. 47. Maiman DJ, Larson SJ, Sances A. Spinal cord stimulation for pain. In: Myklebust JB, Cusick JF, Sances A, Larson SJ, eds. Neural stimulation, vol I. Boca Raton, Fla.: CRC Press, 1985,147-54. 48. Mazars G, M6rienne L, Ciolocca C. Comparative study of electrical stimulation of posterior thalamic nuclei, periaqueductal grey and other midline mesencephalic structures in man. Adv Pain Res Ther 1979;3:541-6. 49. Mazars G, M6rienne L, Ciolocca C. Stimulations thalamiques intermittentes antalgiques. Notes pr~liminaire. Rev Neurol (Paris) 1973;128:273-9. 50. Mazars G, Roge R, Mazars Y. R6sultats de la stimulation du faisceau spino-thalamique et leur incidence sur la physiolopathologle de la douleur. Rev Neurol (Paris) 1960;103:136-40. 51. Mingazzini G. Proposta di un atto operatiro per la cura radicaie della tabe inferiore. Pol Sez Prat 1899;5:750-1. 52. Mullan S, Harper PV, Hekmatpanah J, Torres H, Dobbin G. Percutaneous interruption of spinal pain tracts by means of a strontium-90 needle. J Neurosurg 1963;20:931-9. 53. Mullan S, HekmatpanahJ, Dobben G, Beckman F. Percutaneous intramedullary cordotomy utilizing the unipolar anodal electrolytic lesion. J Neurosurg 1965;22:548-53. 54. Nashold BS, Goldner JL, Mullen JB, Bright DS. Long-term pain control by direct peripheral nerve stimulation. J Bone Joint Surg [Am] 1982;64A: 1-10. 55. Nashold BS, Urban B, Zorub DS. Phantom pain relief by focal destruction of the substantia gelatinosa of Rolando. In: Bonita JJ, Albe-Fessard D, eds. Advances in pain research and therapy, vol 1. New York: Raven Press, 1976:959-63. 56. OldsJ, Milner B. Positive reinforcement produced by electrical stimulation of the septal area and other regions of the rat brian. J Comp Physiol Psychol 1954;47:419-27. 57. Oliver WG. Electrical anaesthesia, comprisng a brief history of its discovery, a synopsis of experiments, also full directions for its application in surgical and dental operations. Buffalo: Murray Rockwell, 1858. 58. Paraf P. Traitement des algiers par les courants diadynamiques. Bull Soc Med (Paris) 1948;64:114-5. 59. Peterson F. Notes on some newer methods of treatments of nervous and mental disease. Am Med Surg Bull 1896;9: 765-808. 60. Pierron EJM, L'inhibition 61ectrique: recherches historiques et exp6rimentales sur l'~lectroanesth6sie d'araya. Paris: Libraire Le Francois, 1926. 61. Pliny. Natural history. 62. Plutarch. Morales.
History of Neurosurgical Procedures
63. Pool JL, Bridges TJ. Subcortical parietal lobotomy for relief of phantom limb syndrome in the upper extremity. A case report. N Y Acad Med Bull 1954;30:302-9. 64. Pringle J. A discourse on the Torpedo. London: Royal Society of London, 1775. 65. Procacci P, Maresca M. Pain concept in Western civilization: a historical review. In: Benedetti C, ed. Advances in pain research and therapy, vol 7. New York: Raven Press, 1984: 1-11. 66. Pumam TJ. Myelotomy of the commissure. Arch Neurol Psychiatry 1934;32:1189-93. 67. Rasmussen PP. Facial pain. Copenhagen: Ejnar Munksgaards Forlag, 1965:210-96. 68. Revillout V. Acad6mie de m6decine, de l'61ectricit6 comme anesth6sique. Arch G6n M6d 1868;2:356. 69. Reynolds DV. Surgery in the rat during electrical analgesia induced by focal brain stimulation. Science 1968;164:444-5. 70. Richardson DE, Akil H. Long term results of periventricular gray self-stimulation. Neurosurgery 1977;1:199-202. 71. Richardson DE, Akil H. Pain reduction by electrical brain stimulation in man. 1. Chronic self-administration in the periventricular gray matter. J Neurosurg 1977;47:178-83. 72. Richardson DE, Akil H. Pain reduction by electrical brain stimulation in man. II. Chronic self-administration in the periventricular gray matter. J Neurosurg 1977;47:184-94. 73. Rosomoff HL, Carroll F, Brown J, Sheptak P. Percutaneous radiofrequency cervical cordotomy: technique. J Neurosurg 1965;23:639-44. 74. Sano K. Sedative neurosurgery with special reference to posteromedial hypothalamotomy. Neurol Med Chir (Tokyo) 1962;4: 112-42. 75. Sano K, Sekino H, Hashimoto I, Amano K, Sugiyama H. Posteromedial hypothalamotomy in the treatment of intractable pain. Confinia Neurol 1975;37:285-90. 76. Schfiller A. Uber operative Durchtrennung der Reckenmarksstrange (Chordotomie). Wien Med Wochenschr 1910;60: 2292-6, 77. Schwartz HG, O'Leary JL. Section of the spinothalamic tract in the medulla with observation on the pathway for pain. Surgery 1941;9:183-93. 78. ScovilleWB. Selective cortical undercutting as ameansofmodilying and studying frontal lobe function in man. J Neurosurg 1949;6:65-73. 79. Scribonius L. Compositiones medicae. Padua: Frambo Hus, 1655. 80. Shealy CN, MortimerJT, ReswickJ. Electrical inhibition of pain by stimulation of the dorsal column: preliminary clinical reports. Anesth Analg 1967;46:489-91. 81. Shealy CN, Taslitz N, Mortimer JT, Becker DP. Electrical inhibition of pain: experimental evaluation. Anesth Analg 1967;46:299-305. 82. Shelden CH, Pudenz RH, Doyle J. Electrical control of facial pain. Am J Surg 1967;114:209-12. 83. Siegfried J. Introduction-historique. In: Sedan R, Lazorthes Y,
Surg N e u r o l 1992;38:454-63
84.
85.
86. 87. 88.
89.
90. 91.
92.
93.
94. 95.
96. 97. 98. 99. 100. 101. 102.
103. 104.
105.
463
eds. La neurostimulation electrique th6rapeutique. Paris: Masson, 1978:5-10. Siegfried J. Long term results of electrical stimulation in the treatment of pain by means of implanted electrodes (epidural, spinal cord and deep brain stimulation). In: Rizzi R, Visentin M, eds. Pain therapy. Amsterdam: Elsevier, 1983:463-75. Sj6quist O. Studies on pain conduction in the trigeminal nerve. A contribution to the surgical treatment of facial pain. Acta Psychiatr Scand Suppl 1938; 17:1-139. Spiegel EA, Wycis HT. Mesencephalotomy in treatment of intractable facial pain. Arch Neurol Psychiatr 1953;69:1-13. Spiegel EA, Wycis HT, Marks M, Lee AJ. Stereotaxic apparatus for operation on the human brain. Science 1947;106:349-50. Spiller WG, Martin E. The treatment ofpersistent pain or organic origin in the lower part of the body by division of the anterolateral column of the spinal cord. JAMA 1912;58:1489-90. Sweet WH, Wepsic JG. Treatment of chronic pain by stimulaton of fibers of primary afferent neuron. Trans Am Neurol Assoc 1968;93:103-5. Tainter ML. Pain. Ann N Y Acad Sci 1948;51:3-11. Talairach J, H6caen H, David M, Monnier M, Ajuriaguerra J. Recherches sur la coagulation th6rapeutique des structures souscorticales chez l'homme. Rev Neurol (Paris) 1949;81:4-23. Tasker RR. Stereotaxic surgery. In: Wall PD, Melzack R, eds. Textbook of pain, 2nd ed. Edinburgh: Churchill Livingstone, 1989:840-55. Thompson IM, Inman VT, Brownfield B. Cutaneous nerve areas of the forearm and hand. Los Angeles: University of California, 1934:195-236. Tripier A. Faradic anaesthesia. Arch Electrol Neurol 1874;1:90-115. UrbanBJ, Nashold BS. Percutaneousepiduralstimulationofthe spinal cord for relief of pain. Long-term results. J Neurosurg 1978;48:323-28. Walker AE. Relief of pain by mesencephalic tractotomy. Arch Neurol Psychiatry 1942;48:865-83. Walker AE. The spinothalamic tract in man. Arch Neurol Psychiatry 1940;43:284-98. Walker WC. Animal electricity before Galvini. Am Sci 1937;2:84-112. Wall DP, Sweet WH. Temporary abolition of pain in man. Science 1967;155:108-9. Walsh J. Of the electric property of the Torpedo. Philos Trans B 1773;63:461-80. Wesley J. The desideratum. London: Flexney, 1760. White JC. Spinothalamic tractotomy in the medulla oblongata. An operation for the relief of intractable neuralgias of the occiput, neck and shoulder. Arch Surg 1941;43:113-27. Wilkins RH. A brief history of neurosurgery. New Physician 1965; 14:211-5. Wycis HT, Soloff L, Spiegel EA. Facial pain, persisting after retrogasserian rhizotomy, relieved by mesencephalothalamotomy. Surgery 1950;27:115-2 I. Wycis HT, Spiegel EA. Long-range results in the treatment of intractable pain by stereotaxic midbrain surgery. J Neurosurg 1962;19:101-7.
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The History of Neurosurgical Procedures for the Relief of Pain Charles Rawlings, III, M.D., Eugene Rossitch, Jr., M.D., and Blaine S. Nashold, Jr., M.D. Forsyth Neurosurgical Associates, Winston-Salem, and Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
Rawlings C III, Rossitch E Jr, Nashold BS Jr. The history of neurosurgical procedures for the relief of pain. Surg Neurol 1992;38:454-63.
Pain has been a major medical problem from the beginning of recorded history. Since the earliest medical writings, there have been innumerable procedures designed to relieve pain and its suffering. In this study, we have reviewed both the early medical writings of various civilizations and the first modern publications, to compile a history of neurosurgical procedures for the relief of pain. KEY WORDS: Ablation; History; Pain; Stimulation
The history of pain is as old and as convoluted as that of the human species, for the treatment of pain has occupied humankind and its medicine for countless aeons. People have exerted an untold amount of energy in their search for methods to understand and control pain. Because of the ubiquitousness and the profound suffering associated with pain, a multitude of procedures and remedies have been tried in attempts to alleviate it [9,14,41,65,67,90]. Early attempts at the neurosurgical relief of pain were crude and often unsuccessful, but as knowledge of anatomy, physiology, and biochemistry increased, along with the development of technology, neurosurgical procedures became more sophisticated and successful. This technological growth has continued, and today, a great number of neurosurgical procedures exist for the relief of pain and most can be effective if used judiciously. This, unfortunately, has not always been the case. Primitive peoples were perpetually exposed to pain and its aftermath, as evidenced by archeological records [9,14,41,65,90]. Their methods for pain relief seem unsophisticated by current standards, but many were the precursors to our modern procedures and pharmacopeia. These early treatments were employed by many cultures and recorded in several ancient medical texts Address reprint requests to: Charles Rawlings, III, M.D., Forsyth Neurosurgical Associates, 3080 Trenwest Drive, Winston-Salem, NC 27103. Received May 26, 1992; accepted June 24, 1992.
© 1992 by Elsevier Science PublishingCo., Inc.
such as the Edwin Smith Papyrus, the Ebers Papyrus, the Rig-Veda, the Huang Ti Nei Ching Su Wen, and Babylonian clay tablets from Nippur [9,14,41,65,90]. All these texts discuss elaborate methods of pain control. These manuscripts helped to usher medicine from the primitive to the modern tradition. To combat pain, primitive peoples generally sought some type of shaman or medicine-woman or -man skilled in mysticism, sorcery, conjuring, or other powerful methods of exorcising disease and pain. Along with their spells and incantations, these early tribal physicians used heat, cold, pressure, massage, trephination, and herbs to treat pain. The earliest herbs included poppy, mandragora, hemp, henbane, and nephenthe. From these early practices, came the neurosurgical procedures of stimulation, ablation, as well as the use of opioids and analgesics [9,14,41,65,90]. Stimulation Procedures Once the therapeutic limits of heat, cold, pressure, and massage were reached, the primitive patient was often then treated with the application of electrical shocks in order to relieve his or her pain. Natural sources of electricity were employed because the invention of batteries was thousands of years away. The use of natural electricity for pain relief was quite common in ancient times. These natural sources of electricity, which are documented in early medical texts, include the electric catfish, torpedo ray, and eel. The electric Nile catfish is prominently portrayed in 5th dynastic Egyptian tomb reliefs (Figure 1). The Greeks and Romans were also acquainted with these animals. In fact, the English translations of the Greek "narke" meaning numbness-producing fish and of the Roman "topere" (sluggish) form the basis of the words narcotics, torpid, and their various derivatives [9,42,83,98,100]. Aristotle, Pliny, and Plutarch all made references to the numbness and shocks caused by these fish, but Scribonius Largus was among the first to document their use for electrotherapy [4,9,42,61,62,79,83,98,100]. H e spoke of the relief of pain associated with gout and headache following the application of these fish: 0090-3019/92/$5.00
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Figure 1. The nile catfish is depicted in this 5 th dynasty Egyptian tomb at Sakkara of the great architect Ti. Source: Kellaway [42]. Used by permission.
H e a d a c h e . . . is taken a w a y . . , by alive black torpedo placed on the spot which is in pain, until the pain ceases. As soon as the numbness has been felt the remedy should be removed lest the ability to feel be taken from the part [42,79]. Galen noted that a torpedo ray could be an effective headache remedy, and others including Marcellus Empiricus, Paulus Aeginata, and Aetius o f Amida also recognized its medical usefulness [40,42,83]. In the 17th century, Perrault, Redi and especially Lorenzini commented on the paresthesia and numbness caused by the Torpedo [40,42,46,64,83,98]. Interestingly, these fish produce an electrical current similar in both voltage and frequency to m o d e r n stimulatory instruments including transcutaneous electrical nerve stimulator units and peripheral nerve stimulators. Even today, primitive peoples still use electrical fish therapeutically [9,40,42]. Stimulation for pain relief, however, was clearly limited by the source o f its electricity (i.e., fish). The creation by Von Guericke o f an electrostatic machine in 1650 and its improvement into the Leyden jar in 1745 brought forth a new era in electrotherapy [9,10,40,83]. Beginning late in the 1700s, interest grew in electrotherapy, which was used to treat conditions as diverse as mental illness, pain, and paralysis and even to prevent death [10,40]. In fact, the Academie at Lyon offered prizes for its applications and further advancement [10]. Walsh and Cavendish were the first to describe the numbing paresthesia experienced when electrostatic machines were applied to peripheral nerves [12,40,100].
John Wesley, the founder o f the Methodist Church, was a great advocate of electrotherapy and in T h e Desideratum described a multitude of cases in which painful conditions were relieved [40,83,101]. While the search for wider applications o f electrotherapy in medicine began to b o r d e r on the absurd, more knowledge o f muscle and nerve physiology was being accrued. Volta showed that electrical currents existed in living organisms and powered such structures as nerves and muscles. Furthermore, he discovered that an electric current flowed between two dissimilar metals and thus created the voltaic pile, the direct forerunner o f the battery. This gave to medicine a constant source o f stronger, more controllable, and more flexible electric current and, as a consequence, caused a flurry o f new applications of electrotherapy [9,10,83]. Both Golding Bird and D u c h e n n e de Boulogne were strong advocates of the improved electrotherapy, but only Duchenne appears to have used it in the treatment of pain (i.e., "neuralgic, sciatiques et rhumatisme") [8,13,40,83]. In the mid 1800s, electrotherapy began to be used for the relief of dental pain. Francis, in 1858, was first to produce analgesia during a dental procedure, passing current through the extracted tooth. H e went on to report 164 extractions using electrotherapy, the majority of which were pain free [23,40]. T h e use of electroanesthesia in dentistry quickly spread throughout the United States and into Europe. Concurrent to this usage o f stimulation, other forms o f electroanesthesia were being investigated. Hermel, in 1844, reported his experience with elec-
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I
Figure 2. Olive,s electroanesthetic apparatus as illustrated in a 1859 U.S. Patent Office Report. Source: Kane & Taub [40]. Used by permission.
troanalgesia in eight patients with neuralgia. H e directly stimulated the nerves by puncturing them with electrodes [83]. Garratt, a Boston dentist, experimented with different current strengths and advocated the direct application o f a strong current in the treatment of peripheral neuralgias, tic douloureux, hyperalgesia, and toothache [24,40]. In 1858, another American, W.G. Oliver, began to experiment with stimulation for surgical anesthesia. Using a copper wire and a wet bandage wrapped around an ulcerated leg and a similar cooper-wound bandage at the ankle, he was able to painlessly debride the ulcer. In addition, he used cauterization to control bleeding. N o t only did Oliver use electrical current effectively in a clinical situation but he also demonstrated that there was an o n - o f f p h e n o m e n o n in paresthesias associated with the current and that temperature sensation was not abolished by the current. In addition, he advocated the use of electroanalgesia in amputation and delivery (Figure 2) [40,57]. In England, electroanesthesia was similarly being used in dentistry, as well as in other fields. One of the first Englishmen to use electrical stimulation for medical purposes was the physician Julius Althaus. H e applied electricity transcutaneously to peripheral nerves to achieve analgesia, and his descriptions of the effects of peripheral nerve stimulation foreshadowed those descriptions in the next century: I . . . applied a rapidly interrupted current to Dr. R's ulnar nerve, placing one moistened conductor between the olecranon and the internal condyle, such as was not powerful enough to produce contraction of the muscles animated by the ulnar nerve. After the current has acted for a few minutes, I increased the intensity, so that a strong flexion of the fourth and little finger was produced.
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The action of this current was at first painful to bear • . . but after a certain time the pain excited by very severe shocks was comparatively little. At last the normal sensibility of the ulnar nerve was so much diminished, that a current of such high tension was borne without inconvenience by Dr. R . . . he did not feel the board upon which his fingers rested . . . . It is therefore obvious that a direct reduction of sensibility of the ulnar nerve was accomplished by electricity. . . . [30,40]. By using this technique in pathological conditions, Althaus also determined that the effects o f stimulation were more easily attained, and o f longer duration, in abnormal nerves. In his Treatise on MedicalElectricity [3], he discussed a multitude o f pathological conditions for which he found electrical stimulation useful. These included neuritis o f the trifacial nerve, headaches, tinnitis aurium, cervico-occipital neuralgia, intercostal neuralgia, and sciatica. For all o f these conditions, Althaus gave a m o d e r n description o f the disease in his case presentations and asserted that, with judicial use o f electrical current, all could be alleviated [3,40]. Other, less prominent physicians used electrotherapy for the relief o f other painful conditions. Tripier advocated it for both rectal and urethral pain, whereas Revillout, by passing a current through the hypogastrium and the uterus, relieved posthysterectomy pain [40,68,94]. Unfortunately, in the subsequent years, 1870 to 1900, electrotherapy and electroanesthesia fell into disuse due to its sometimes variable results. However, there were some physicians who continued to use electrotherapy intermittently, especially Araya in Chile, but they were few and far between [40,60]. In the later portion o f the 19th and early 20th centuries, several physicians including Beard, Rockwell, Hutchinson, Peterson, LeDuc, and Robinovitch used electrotherapy and electroanesthesia for various conditions including neuralgias, lancing o f boils, and amputations [6,28,39,40, 44,59]. In 1928, electrical stimulation o f peripheral nerves for pain relief was "rediscovered" by T h o m p s o n et al at Berkeley [93]. They showed, once again, that "the cutaneous area supplied by a nerve may be rendered insensible to light touch by subjecting the nerve trunk to the influence o f an alternating current." T h e y mapped all cutaneous peripheral forearm nerves in a patient and showed that analgesia was induced with increased current [93]. As an extension o f this technique, Paraf, in 1948, reported pain relief in 127 patients with a variety of pain syndromes, including sciatica, postherpetic neuralgia, and tic douloureux [58]. Between 1948 and 1965, there was a gradual resumption o f interest in electrotherapy, and as anatomical and physiological pathways were better elucidated, stimulation o f the pathways was undertaken for relief o f pain. T h e r e were various reports
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during this time of stimulation of the spinothalamic tract, the brain stem, and the thalamus for pain relief [9,40,50,83]. Finally, in 1965, Melzack and Wall developed the "gate theory" of pain, which consolidated a multitude of past experimental and therapeutic observations into a coherent physiological theorem [9,99]. This opened the door for more neurosurgical stimulatory procedures. The most important premises, with respect to neurosurgical stimulation, of the gate-control theory were that stimulation of large-diameter afferent fibers decreases pain and that there exist descending inhibitory pathways derived from upper-level neural substrates, that modulate pain transmission. Based on these premises, Wall and Sweet, in 1967, once again showed that stimulation of peripheral nerves decreased pain. Eight patients with severe nerve pain with diverse etiologies ranging from diabetic neuropathy to metastatic cancer were treated with neural stimulation. All experienced good pain relief [99]. In a follow-up study, Sweet and Wepsic performed the first implantation of peripheral nerve stimulators in two patients with severe pain due to median and ulnar nerve dysfunction. Both patients had had previous neurosurgical procedures, nerve blocks and intensive medical therapy. Both obtained good pain relief, but in one, the relief decreased over time [89]. Also, at this same time, Shelden et al reported the results in three patients in whom they had implanted stimulating electrodes on the mandibular nerve for third division tic douloureux. They reported good pain relief with follow-up periods between 3 and 4 years [82]. Finally, with technical improvements in stimulating electrodes and electronic systems, more implantable nerve stimulators were used. Nashold et al, in 1982, summarized their experience with 35 patients. The results varied depending on the nerve stimulated and the cause of the pain [54]. Shealy et al focused on the spinal cord and demonstrated that "an electrophysiologic system activated by noxious stimuli is suppressed by stimulation of the dorsal columns or of the anterolateral spinal cord." They showed that a prolonged after-discharge evoked from a maximally stimulated peripheral nerve or a noxious stimulus can be inhibited by spinal cord stimulation [80,81]. These studies led to the clinical use of spinal cord stimulation for pain relief. Sweet and Wepsic, in their paper detailing peripheral nerve stimulation, discussed their attempts at stimulating the spinal cord. They noted varying results, especially when only one set of parameters (i.e., duration and frequency) was used [89]. In 1967, in a follow~up paper, Shealy et al showed spinal cord stimulation to be of clinical value [80], and since then, a multitude of studies have reported the results of spinal cord stimulation [47,84,95]. Spinal cord stimula-
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tion for pain relief still plays a role in modern neurosurgical practice and is directly based on these early electrophysiological and clinical studies. Along with peripheral nerve and spinal cord stimulation, deep brain stimulation has also been used for pain relief. Except for generalized shock treatments given to patients suffering from a plethora of conditions, deep brain stimulation is, not surprisingly, a recent phenomenon [10,40,83]. Olds and Milner, in 1954, were among the first to try deep brain stimulation in animals (the septal region in rats) [56], and Heath and Mickle [31] and Gol [25], in the early 1960s, attempted pain relief with temporary electrodes implanted in the septal region of patients. At this time, two main uses of deep brain stimulation based on two diverse electrophysiological conditions have emerged--periaqueductal gray (PAG)/ periventricular gray (PVG) stimulation based on endorphin chemistry, and thalamic/internal capsule stimulation based on the "gate-control" theory. In 1968, in his landmark paper, Reynolds showed that rats could undergo laparotomy without anesthesia, as long as their midbrain central gray region was stimulated [69]. Following this, a host of studies began to detail the endogenous opioids and the neural substrates responsible for this stimulation-produced analgesia. In 1977, Richardson and Akil demonstrated this type of analgesia in humans with both PVG and PAG stimulation [70-72]. Since then, Hosobuchi and coworkers have refined PAG and PVG stimulation for the treatment of pain in humans [2,35-37]. At this point, it appears that PAG/PVG stimulation is most useful in patients with nociceptive pain, especially cancer pain, although much investigation continues in this area. Like the gate-control theory of pain, the 1911 theory of Head and Holmes stated that pain results from an imbalance between the protopathic and epicritic systems [30]. Thus, neurosurgeons began to stimulate the ventroposteromedial nucleus (VPM), ventroposterolateral nucleus (VPI), and internal capsule to provide pain relief. It appears that Mazars et al were one of the first groups to stimulate the VPM and VPL for pain relief and, in 1973, they reported on 17 patients who had undergone thalamic stimulation [49]. Their work was based primarily on the theories of Head and Holmes, and their patients suffered from a variety of pain syndromes, ranging from anesthesia dolorosa to brachial plexus avulsion. They noted that good results were obtained in patients with postamputation, atypical facial, and peripheral nerve pain, whereas patients with cancer pain and tic douloureux fared poorly [48,50]. At the same time that Mazars et al reported their findings (1973), both Hosobuchi et al and Adams et al reported their results of VPM, VPL, and internal capsule stimulation [2,37]. Since that time, both Mazars and Hosobuchi
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have been extremely active and influential in bringing thalamic stimulation into the neurosurgical armamentarium. Although still not completely characterized or totally effective, thalamic stimulation has been shown to be an effective addition to the fight against pain. Ablative Procedures Trephination was probably the earliest ablative procedure for pain relief and was practiced by many cultures in a multitude of regions. Even today, certain tribes still perform trephinations, primarily to cure headache and to "release spirits" [9,14,65,103 ]. Until the Renaissance, there was little documentation, aside from trephinations, about the use of ablative procedures for pain relief. The great surgeon, Ambroise Par~, a specialist in warfarerelated traumatic injuries, evidently was exposed to a great number of peripheral nerve injuries that resulted in pain. In the late 1500s, he was able to relieve this type of pain by transecting the peripheral nerve involved. Unfortunately, little else is known about his pain operations. In the late 1600s, Marechal, the court physician to Louis XIV, performed neurotomies for tic douloureux [9]. Later, Letievant proposed sectioning nerves to both the face and extremities as a method of controlling pain [3]. Ablative neurosurgical procedures developed and became more refined as modern surgical doctrine emerged. Early stimulation procedures were less dependent on surgical technique. This becomes apparent when one compares the profusion of the stimulatory procedures to the paucity of informaiton about early ablative procedures. Stimulation was used frequently and by many physicians, whereas ablative procedures were used infrequently. It is also no surprise that peripheral neurotomies were the only procedure to be used prior to the modern era of surgery, for they were the least invasive, gave immediate results, left little dysfunction, and had a low mortality rate. It was not until the late 1800s, with the advent of anesthesia, antisepsis, and more advanced knowledge of physiology and anatomy, that the proliferation of ablative neurosurgical procedures for pain relief began. Neurologists contributed to many of these early ablative procedures by studying the relevant anatomical pathways and by helping to devise the procedure itself [1,11,51,103]. For example, Dana, the first chairman of neurology at Cornell, in 1888, suggested posterior rhizotomies for certain pain syndromes. Subsequently, Bennett, in England, and Abb6, in the United States, performed this procedure [ 1,7,9,14,103]. Bennett's case was a 45-year-old man with severe leg pain due to tibial osteomyelitis. Following an amputation, the pain continued and he subsequently underwent lumbar and sacral
Figure 3. Anterolateral tract section. From a 192 7 review article on surgery of the spinal cord. Source: Armour [5]. Used by permission.
rhizotomies. H e experienced good pain relief, but suffered an intracranial hemorrhage postoperatively [7]. Abb6's patient, referred to him by Dana, was a 43year-old male with brachial plexus neuralgia secondary to a shrapnel and stretch injury. H e had been treated with nerve stretching, amputation of the arm, and neuroma excision, all without success. Abb6 performed C6C8 posterior spinal rhizotomies in two separate procedures, with good results. Just as significantly, during these procedures, Abb~ stimulated the nerve roots to determine their functions; this was the first instance of intraoperative localization and stimulation [1]. Following these successes, other surgeons including Horsley, Kfitmer, Giordano, Kaune, and Hunter gradually began to use posterior rhizotomy for pain relief [1,9,14,29,38]. More significantly, using the technique of posterior rhizotomy, Forster et al were able to map the human dermatomes [20,22]. Following the introduction of rhizotomy, attention was directed at the spinal cord for relief of pain syndromes. Anterolateral cordotomy was the first procedure to be devised and implemented (Figure 3). Gowers, M/iller, and others had earlier shown that the anterolateral portion of the spinal cord carried pain fibers [5,11,26,76,88]. Caldwalader and Sweet, in 1912, at the suggestion of Spiller, investigated the anterolateral tract in dogs and showed that pain sensation was dependent on the intactness of that portion of the spinal cord [ 11].
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Figure 4. Pathological specimen of the spinal cord following percutaneous intramedullary cordotomy. (Left) Tract of needle. (Center) Arrow points to site of needlepenetration anterior to the dentate ligament. (Right) Destruction of quadrant. Source: Mullah et al [53]. Used by permission.
As it became apparent that rhizotomies sometimes failed to relieve pain, or more importantly, the pain recurred, a better procedure was sought for pain relief. In 1910, Schiiller proposed, based on previous experimental evidence, that sectioning of the anterolateral spinal cord pathways would effect pain relief [76]. It was not until 1912, however, that Spiller and Martin, after the investigations of Caldwalader and Sweet, performed the first anterolateral cordotomy [88]. The patient was a 47-year-old man with bilateral lower extremity pain secondary to a malignant conus tumor. Following bilateral sectioning of the anterolateral tracts through T6-T8 laminectomies, the patient was pain free at 1 year [88]. Forster and Gagel then performed the first cervical cordotomy in 1931 [21]. Since the first open cordotomy was performed, the procedure has gained worldwide acceptance for the relief of malignant pain. It was recognized early, however, that many patients who could benefit from the procedure were too ill to undergo a major operation. Thus, in the 1960s, Mullan et al and then Rosomoff et al modified the procedure so that it could be done percutaneously under local anesthesia [52,53,73]. Mullan et al, using air myelography and a strontium-90 needle introduced with fluoroscopic guidance, lesioned the anterolateral cord with excellent results [52]. Mullan et al and then Rosomoff et al, in subsequent years, replaced the strontium needle with a radiofrequency lesioning electrode and further improved the technique (Figure 4) [53,73]. With this procedure, the contemporary neurosurgeon has an operation that is easily and quickly performed under local anesthesia, has a low morbidity, and gives an excellent result in malignant pain relief. Along with anterolateral cordotomy, several other procedures based on spinal cord anatomy and physiology were formulated in the early 1900s. One of these pain procedures was commissural myelotomy. In his classic paper of 1927 dealing with various procedures on the spinal cord, Armour discussed, in detail, both rhizotomies and cordotomies and their respective physiological anatomy. Moreover, he introduced a new procedure, commissural myelotomy, for the relief of pain. He detailed his operation on a patient with gastric crises and pointed out that the operation was simple and effective. His patient, unfortunately, died of pneumonia several
days following the procedure [5]. Following this, Putnam, in 1934, published his results of three patients on whom he performed commissural myelotomies [66]. All three had metastatic disease with bilateral upper extremity pain. Two had good to excellent pain relief while the third died, due to her malignancy. He did extensive myelotomies, through multiple laminectomies, using a special blunt myelotome [66]. Over the ensuing decades, commissural myelotomy was shown to have a fairly low success rate. However, it is still occasionally used today in patients with malignant disease and bilateral extremity pain [9]. As the anatomy and physiology of the pain pathways were further elucidated, neurosurgeons more frequently attempted different, more extensive ablative procedures for the relief of pain. A logical extension of cordotomy and myelotomy proposed by Schwartz and O'Leary in 1941 was the sectioning of the spinothalamic tract at the medullary level [77]. Similarly, Sj6quist had introduced medullary trigeminal tractotomy earlier, in 1938, but due to its invasiveness and high morbidity, it never gained wide acceptance [85]. It appears that Schwartz and O'Leary [77] and White [102] simultaneously were responsible for the first medullary spinothalamic tractotomy. Based on previous anatomical studies that elucidated the pathway of the spinothalamic tract and the clinical syndrome of thrombosis of the posterior inferior cerebellar artery, these authors postulated that sectioning of the spinothalamic tract in the medulla would relieve otherwise untreatable pain in the shoulder and neck. Schwartz and O'Leary's patient was a 30-year-old woman with intractable neck, chest, and abdominal pain due to metastatic disease; she underwent a suboccipital craniectomy and sectioning of the spinothalamic tract through a 3-mm-deep incision at the rostral portion of the inferior olivary eminence. She had complete contralateral analgesia with pain relief postoperatively; unfortunately, she died several days later of pneumonia [77]. White's patient was a 29-year-old woman with neurogenic pain secondary to Raynaud's phenomena who had undergone multiple procedures, including sympathectomies and rhizotomies but who continued to have severe neuralgia in the neck, occiput, arm, and chest. She underwent sectioning of the medullary tract with a 4-mm-deep incision at the level of the olivary eminence under local
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anesthesia. Following the incision, she felt immediate pain relief with contralateral analgesia [102]. Although this procedure was an interesting extension of the knowledge of the day, it never gained popularity due to its morbidity, its limited usefulness in debilitated patients, and more importantly, its replacement by more easily accomplished procedures. Stereotactic lesioning of the medullary spinothalamic tract has similarly not gained wide acceptance [33,34]. Since certain pain syndromes were not amenable to the then known pain procedures, it was only natural that the spinothalamic tract should be interrupted at an even higher level. This was important, especially in the subgroup of patients with shoulder, arm, and face pain who were too debilitated for open sectioning or in patients with thalamic pain or anesthesia dolorosa. Dogliotti, in 1938, first suggested this upper level sectioning of the spinothalamic tract, making his incision in the pons [ 16]. Walker was the first to attempt an open mesencephalic tractotomy. In two publications, he reported five patients with unilateral pain syndromes of various etiologies. In each, he performed an open sectioning of the spinothalamic/quintothalamic tract through an occipital craniotomy. With elevation of the occipital lobe, retraction of the cerebellum, and through a transtentorial approach, he made a 5-mm-deep incision at the level of the posterior margin of the superior colliculus across the brachium at the inferior colliculus to the base of the superior colliculus. All his patients experienced good pain relief but also had various accompanying deficits (Figure 5) [96,97]. Spiegel and Wycis and their colleagues then improved the procedure. Since they had recently constructed a human stereotactic frame, they believed that stereotactic mesencephalotomy would be a major advance over the open procedure [87]. In 1953, they reported six patients who had undergone stereotactic mesencephalotomy. Three of these patients had anesthesia dolorosa, two had thalamic pain, and one had postherpetic neuralgia. All patients had previously undergone multiple procedures. Following the stereotactic operation, all experienced pain relief, which lasted for several years [86,104]. Stereotactic mesencephalotomy has continued to be successfully performed for pain syndromes such as thalamic pain, anesthesia dolorosa, and unilateral head and neck pain secondary to malignancy. Moreover, the ability to lesion exquisitely small, specific anatomical sites with acceptable morbidity was first demonstrated by this procedure [9,92,105]. Stereotactic thalamotomy for the relief of pain also had its origins during this time. In fact, it appears that Wycis et al, in the above reported group of patients, performed the first thalamotomy [ 104]. Their procedure was coupled with mesencephalotomy. About the same
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time, Hecaen et al [32] and Talairach et al [91] performed thalamotomies, unaccompanied by any other procedure, for the relief of pain. Their patients, five in all, had a number of diverse pain syndromes that were labeled "thalamic pain." Their lesions were primarily in the ventrobasal complex, centromedian nucleus, and various combinations of these nuclei. The results were only ~air, but over the ensuing years, Spiegel, White, and Sweet helped to improve outcome with careful patient selection. Today, although not widely used, thalamotomy can help in relieving the pain of diffuse cancer [9,67,86]. Finally, several procedures less widely used illustrate how neurosurgeons have innovatively sought new forms of pain therapy. For example, dorsal root entry zone (DREZ) lesions appear to be effective in the treatment of certain deafferentation pains. In 1976, Nashold and colleagues reported on a procedure that produced focal destruction of the substantia gelatinosa [55]. This area of the spinal cord was recognized by Rolando in the 18th century, but it was not until the early 20th century that Ranson, a neuroanatomist, suggested that the substantia gelantinosa was involved in the neurophysiology of pain. In animal experiments in which deafferentation of the dorsal horn is experimentally produced, the secondary interneurons in the superficial and deep Rexed layers exhibit abnormal electrical activity within a few hours of the insult. This electrical abnormality can continue for many months. The theoretical basis for the DREZ operation is that pain relief following DREZ lesions occurs as a result of destroying these abnormal secondary interneurons and their connections. Since 1975, the operation has been used successfully in treating pain resulting from brachial or sacral plexus avulsions, paraplegia, herpes, cancer, and phantom limb. Sano, in 1962, lesioned the posterior hypothalamus for aggressive behavior and observed a decrease in sympathicotonia and an increase in parasympathicotonia [74]. Noting that pain syndromes produced an increase in sympathetic output, as well as causing suffering, Sano et al performed hypothalamotomy for pain resulting from malignancy, causalgia, or neuralgia on 18 patients. Twelve patients experienced relief and Sano et al noted that it was the emotional and motivational aspects of the pain that were alleviated [75]. Similarly, Fairman reported on 12 hypothalamotomy patients with malignant pain; 80% had good pain relief [17]. Although, currently not in vogue, hypothalamotomy may represent an interesting alternative for treatment of malignant pain. Leriche, as early as 1937, suggested that corticectomy might aid in pain control; he subsequently performed a postcentral gyrectomy for the relief of phantom-limb pain [ 15,45]. Pool and Bridges went a step further and
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Figure 5. Sketchesshowing Walker's operative approach for mesencephalic tractotomy. Source: Walker [97]. Used by permission.
performed a subcortical parietal lobotomy for phantomlimb pain [63]. Subsequent experience has shown, however, that cortical removal is very seldom effective in pain control, except in one instance--cingulotomy. Cingulotomy, a descendant of the psychosurgical procedure of frontal leukotomy, is at present the only effective form of corticectomy in pain control. LeBeau [43] Foltz and White [18,19] were among the first to advocate and to perform selective bilateral cingulotomies for the relief of pain. Today, this procedure is a well-recognized, albeit last, alternative in the management of certain intractable pain syndromes [9,18,19,27,43,78]. In conclusion, humankind's battle with pain and its effects has been a universal and almost timeless endeavor. The history of pain neurosurgery has its beginnings with the shamans and tribal healers who, through massage, heat, cold, and the ancient procedure of trephination, were the first to begin the ministrations of pain. Even though humankind has made great strides in the relief of pain, many procedures are not as effective as had been hoped. The search for effective pain remedies continues, and neurosurgeons lead the way. At some point, the anatomy of pain and the secret to its defeat will be discovered.
References 1. Abh~ R. A contribution to the surgery of the spine. Med Rec (NY) 1889;35:149-52.
2. Adams JE, Hosobuchi Y, Fields HL. Stimulation of internal capsule for relief of chronic pain. J Neurosurg 1974;41:740-7. 3. AlthausJ. A treatise on medical electricity theoretical and practical and its use in the treatment of paralysis, neuralgia and other diseases. London: Trubner, 1859. 4. Aristotle. Historia animalium. 5. Armour D. Surgery of the spinal cord and its membranes. Lancet 1927;1:691-7. 6. Beard GM, Rockwell AD. Practical treatise on the medical and surgical uses of electricity. New York: William Wood, 1881. 7. Bennett WH. A case in which acute spasmodic pain in the left lower extremity was completely relieved by subdural division of the posterior roots of certain spinal nerves. Med Chir Trans (London) 1889;72:329-48. 8. Bird G. Lectures on electricity and galvanism. London: Green & Longmans, 1849. 9. BonicaJJ. History of pain concepts and pain therapies. In: Bonica JJ, ed. The management of pain, 2nd ed. Philadelphia: Lea & Febiger, 1990:2-17,1850-76,2040-103. 10. Brazier MAB. A history of neurophysiology in the 17th and 18th centuries: from concept to experiment. New York: Raven Press, 1984:187-216. 11. Caldwalader WB, Sweet JE. Experimental work on the function of the anterolateral column of the spinal cord. JAMA 1912;58:1490-3. 12. Cavendish H. An account of some attempts to imitate the effects of the torpedo fish by electricity. Philos Trans B 1776;66: 196-225. 13. Colwell HA. An essay on the history of electrotherapy and diagnosis. London: Heinemann, 1922. 14. Crawford JV, Walker AE. Surgery for pain. In: Walker AE, ed. A history of neurological surgery. Baltimore: Williams & Wilkins, 1951:308-30,583. 15. DeGutierrez-Mahoney CG. The treatment of painful phantom
462
16.
17.
18. 19. 20. 21.
22.
23. 24. 25. 26.
27.
28. 29. 30. 31.
32.
33. 34.
35.
36.
37.
38.
Surg N e u r o l 1992;38:454-63
limb by removal of post central cortex. J Neurosurg 1944;1:156-62. Dogliotti AM. First surgical sections in man of the lemniscus lateralis (pain-temperature path) at the brain stem, for the treatment of diffuse rebellious pain. Anesth Analg 1938;17:143-5. Fairman D. Hypothalamotomy as a new perspective for alleviation of intractable pain and regression of metastatic tumors. In: Fusek I, Kunc Z, eds. Present limits of neurosurgery. Prague: Avicenum, 1972:525-8. Foltz E, White L. Experimental cingulumotomy and modification of morphine withdrawal. J Neurosurg 1957; 14:655-73. Foltz E, White L. The role of rostral cingulumotomy in "pain" relief. I n t J Neurol 1968;6:353-73. F6rster O. The dermatomes in man. Brain 1933;56:1-39. F6rster O, Gagel O. Die Vorderseiten strangdurchschneidung beim Menschen. Eine Klinisch-pathophysiologisch-anatomische Studie. Z Gesamte Neurol Psychiatr 1931;138:1-93. F6rster O, Kiittner H. lJber operative Behandlung gastrischer Krisen durch Resektion der 7-10 hinteren Dorselwurzel. Beitr Kiln Chir 1909;63:245-56. Francis JB. Extracting teeth by galvanism. Dent Rep 1858;1:65-9. Garratt AC. Galvanism for counteracting pain in the extraction of teeth. Boston Med Surg 1859;59:32-4. Gol A. Relief of pain by electrical stimulation of the septal area. J Neurol Sci 1967;5:115-20. GoldsteinK. l~lberdieaufsteigendedegenerationnachQuerschnittsunterbrechung des Riickenmarks (Tractus spinocerebellaris posterior, Tractus spino-olivaris, Tractus spino-thalamicus). Neurol Zentralbl 1910;29:898-911. Grantham EG. Prefrontal lobotomy for relief of pain--with a report of a new operative technique. J Neurosurg 1951;8: 405-10. Gwathmey JT. Anesthesiology. New York: Appleton, 1914:628-43. Gybels JM, Sweet WH. Neurosurgical treatment of persistent pain. Basel: Karger, 1989. Head H, Holmes G. Sensory disturbances from cerebral lesions. Brain 1911;34:102-254. Heath RG, Mickle WA. Evaluation of seven years experience with depth electrode studies in human patients. In: Ramey ER, O'Doherty DS, eds. Electrical studies on the unanesthetized brain. New York: Hoeber, 1960:214. H~caen H, TalairachJ, David M, Dell MB. Coagulations limit6es du thalamus dans les algies du syndrome thalamique. R6sultats th6rapeutiques et physiologiques. Rev Neurol (Paris) 1949;81: 917-31. Hitchcock E. Stereotactic cervical myelotomy. J Neurol Neurosurg Psychiatry 1970;33:224-30. Hitchcock E, Sotelo MG, Kim MCH. Analgesic levels and technical method in stereotaxic pontine spinothalamic tractotomy. Acta Neurochir 1985;77:29-36. Hosobuchi Y. Subcortical electrical stimulation for control of intractable pain in humans. Report of 122 cases (1970-1984). J Neurosurg 1986;64:543-53. Hosobuchi Y, Adams JE, Linchitz R. Pain relief by electrical stimulation of the central grey matter in humans and its reversal by naloxone. Science 1977;197:183-5. Hosobuchi Y, Adams JE, Rutkin B. Chronic thalamic stimulation for the control of facial anesthesia dolorosa. Arch Neurol 1973;29:158-61. Hunter CR, Mayfield FH. Role of the upper cervical roots in the production of pain in the head. Am J Surg 1949;78:743-51.
Rawlings et al
39. Hutchinson WF. Electrical anesthesia by means of the singing rheotome. N Engl Med Mon 1892;12:41-6. 40. Kane K, Taub A. History of local electrical analgesia. Pain 1975;1:125-38. 41. Keele KD. Anatomies of pain. Springfield, Ill.: Charles C Thomas, 1957. 42. Kellaway P. The part played by electric fish in the early history of bioelectricity and electrotherapy. Bull Hist Med 1946;20: 112-22. 43. LeBeau J. Anerior cingulectomy in man. J Neurosurg 1954;11:268-76. 44. LeDuc S. Production of sleep and general and local anesthesia by intermittent current of low voltage. Arch Elect M6d 1902;10:617-21. 45. Leriche R. La chirurgie de la douleur. Paris: Masson, 1937. 46. Lorenzini S. The curious and accurate observations of Mr. Stephen Lorenzini of Florence on the dissections of the cramp-fish. London: Jeffrey Wale, 1705. 47. Maiman DJ, Larson SJ, Sances A. Spinal cord stimulation for pain. In: Myklebust JB, Cusick JF, Sances A, Larson SJ, eds. Neural stimulation, vol I. Boca Raton, Fla.: CRC Press, 1985,147-54. 48. Mazars G, M6rienne L, Ciolocca C. Comparative study of electrical stimulation of posterior thalamic nuclei, periaqueductal grey and other midline mesencephalic structures in man. Adv Pain Res Ther 1979;3:541-6. 49. Mazars G, M6rienne L, Ciolocca C. Stimulations thalamiques intermittentes antalgiques. Notes pr~liminaire. Rev Neurol (Paris) 1973;128:273-9. 50. Mazars G, Roge R, Mazars Y. R6sultats de la stimulation du faisceau spino-thalamique et leur incidence sur la physiolopathologle de la douleur. Rev Neurol (Paris) 1960;103:136-40. 51. Mingazzini G. Proposta di un atto operatiro per la cura radicaie della tabe inferiore. Pol Sez Prat 1899;5:750-1. 52. Mullan S, Harper PV, Hekmatpanah J, Torres H, Dobbin G. Percutaneous interruption of spinal pain tracts by means of a strontium-90 needle. J Neurosurg 1963;20:931-9. 53. Mullan S, HekmatpanahJ, Dobben G, Beckman F. Percutaneous intramedullary cordotomy utilizing the unipolar anodal electrolytic lesion. J Neurosurg 1965;22:548-53. 54. Nashold BS, Goldner JL, Mullen JB, Bright DS. Long-term pain control by direct peripheral nerve stimulation. J Bone Joint Surg [Am] 1982;64A: 1-10. 55. Nashold BS, Urban B, Zorub DS. Phantom pain relief by focal destruction of the substantia gelatinosa of Rolando. In: Bonita JJ, Albe-Fessard D, eds. Advances in pain research and therapy, vol 1. New York: Raven Press, 1976:959-63. 56. OldsJ, Milner B. Positive reinforcement produced by electrical stimulation of the septal area and other regions of the rat brian. J Comp Physiol Psychol 1954;47:419-27. 57. Oliver WG. Electrical anaesthesia, comprisng a brief history of its discovery, a synopsis of experiments, also full directions for its application in surgical and dental operations. Buffalo: Murray Rockwell, 1858. 58. Paraf P. Traitement des algiers par les courants diadynamiques. Bull Soc Med (Paris) 1948;64:114-5. 59. Peterson F. Notes on some newer methods of treatments of nervous and mental disease. Am Med Surg Bull 1896;9: 765-808. 60. Pierron EJM, L'inhibition 61ectrique: recherches historiques et exp6rimentales sur l'~lectroanesth6sie d'araya. Paris: Libraire Le Francois, 1926. 61. Pliny. Natural history. 62. Plutarch. Morales.
History of Neurosurgical Procedures
63. Pool JL, Bridges TJ. Subcortical parietal lobotomy for relief of phantom limb syndrome in the upper extremity. A case report. N Y Acad Med Bull 1954;30:302-9. 64. Pringle J. A discourse on the Torpedo. London: Royal Society of London, 1775. 65. Procacci P, Maresca M. Pain concept in Western civilization: a historical review. In: Benedetti C, ed. Advances in pain research and therapy, vol 7. New York: Raven Press, 1984: 1-11. 66. Pumam TJ. Myelotomy of the commissure. Arch Neurol Psychiatry 1934;32:1189-93. 67. Rasmussen PP. Facial pain. Copenhagen: Ejnar Munksgaards Forlag, 1965:210-96. 68. Revillout V. Acad6mie de m6decine, de l'61ectricit6 comme anesth6sique. Arch G6n M6d 1868;2:356. 69. Reynolds DV. Surgery in the rat during electrical analgesia induced by focal brain stimulation. Science 1968;164:444-5. 70. Richardson DE, Akil H. Long term results of periventricular gray self-stimulation. Neurosurgery 1977;1:199-202. 71. Richardson DE, Akil H. Pain reduction by electrical brain stimulation in man. 1. Chronic self-administration in the periventricular gray matter. J Neurosurg 1977;47:178-83. 72. Richardson DE, Akil H. Pain reduction by electrical brain stimulation in man. II. Chronic self-administration in the periventricular gray matter. J Neurosurg 1977;47:184-94. 73. Rosomoff HL, Carroll F, Brown J, Sheptak P. Percutaneous radiofrequency cervical cordotomy: technique. J Neurosurg 1965;23:639-44. 74. Sano K. Sedative neurosurgery with special reference to posteromedial hypothalamotomy. Neurol Med Chir (Tokyo) 1962;4: 112-42. 75. Sano K, Sekino H, Hashimoto I, Amano K, Sugiyama H. Posteromedial hypothalamotomy in the treatment of intractable pain. Confinia Neurol 1975;37:285-90. 76. Schfiller A. Uber operative Durchtrennung der Reckenmarksstrange (Chordotomie). Wien Med Wochenschr 1910;60: 2292-6, 77. Schwartz HG, O'Leary JL. Section of the spinothalamic tract in the medulla with observation on the pathway for pain. Surgery 1941;9:183-93. 78. ScovilleWB. Selective cortical undercutting as ameansofmodilying and studying frontal lobe function in man. J Neurosurg 1949;6:65-73. 79. Scribonius L. Compositiones medicae. Padua: Frambo Hus, 1655. 80. Shealy CN, MortimerJT, ReswickJ. Electrical inhibition of pain by stimulation of the dorsal column: preliminary clinical reports. Anesth Analg 1967;46:489-91. 81. Shealy CN, Taslitz N, Mortimer JT, Becker DP. Electrical inhibition of pain: experimental evaluation. Anesth Analg 1967;46:299-305. 82. Shelden CH, Pudenz RH, Doyle J. Electrical control of facial pain. Am J Surg 1967;114:209-12. 83. Siegfried J. Introduction-historique. In: Sedan R, Lazorthes Y,
Surg N e u r o l 1992;38:454-63
84.
85.
86. 87. 88.
89.
90. 91.
92.
93.
94. 95.
96. 97. 98. 99. 100. 101. 102.
103. 104.
105.
463
eds. La neurostimulation electrique th6rapeutique. Paris: Masson, 1978:5-10. Siegfried J. Long term results of electrical stimulation in the treatment of pain by means of implanted electrodes (epidural, spinal cord and deep brain stimulation). In: Rizzi R, Visentin M, eds. Pain therapy. Amsterdam: Elsevier, 1983:463-75. Sj6quist O. Studies on pain conduction in the trigeminal nerve. A contribution to the surgical treatment of facial pain. Acta Psychiatr Scand Suppl 1938; 17:1-139. Spiegel EA, Wycis HT. Mesencephalotomy in treatment of intractable facial pain. Arch Neurol Psychiatr 1953;69:1-13. Spiegel EA, Wycis HT, Marks M, Lee AJ. Stereotaxic apparatus for operation on the human brain. Science 1947;106:349-50. Spiller WG, Martin E. The treatment ofpersistent pain or organic origin in the lower part of the body by division of the anterolateral column of the spinal cord. JAMA 1912;58:1489-90. Sweet WH, Wepsic JG. Treatment of chronic pain by stimulaton of fibers of primary afferent neuron. Trans Am Neurol Assoc 1968;93:103-5. Tainter ML. Pain. Ann N Y Acad Sci 1948;51:3-11. Talairach J, H6caen H, David M, Monnier M, Ajuriaguerra J. Recherches sur la coagulation th6rapeutique des structures souscorticales chez l'homme. Rev Neurol (Paris) 1949;81:4-23. Tasker RR. Stereotaxic surgery. In: Wall PD, Melzack R, eds. Textbook of pain, 2nd ed. Edinburgh: Churchill Livingstone, 1989:840-55. Thompson IM, Inman VT, Brownfield B. Cutaneous nerve areas of the forearm and hand. Los Angeles: University of California, 1934:195-236. Tripier A. Faradic anaesthesia. Arch Electrol Neurol 1874;1:90-115. UrbanBJ, Nashold BS. Percutaneousepiduralstimulationofthe spinal cord for relief of pain. Long-term results. J Neurosurg 1978;48:323-28. Walker AE. Relief of pain by mesencephalic tractotomy. Arch Neurol Psychiatry 1942;48:865-83. Walker AE. The spinothalamic tract in man. Arch Neurol Psychiatry 1940;43:284-98. Walker WC. Animal electricity before Galvini. Am Sci 1937;2:84-112. Wall DP, Sweet WH. Temporary abolition of pain in man. Science 1967;155:108-9. Walsh J. Of the electric property of the Torpedo. Philos Trans B 1773;63:461-80. Wesley J. The desideratum. London: Flexney, 1760. White JC. Spinothalamic tractotomy in the medulla oblongata. An operation for the relief of intractable neuralgias of the occiput, neck and shoulder. Arch Surg 1941;43:113-27. Wilkins RH. A brief history of neurosurgery. New Physician 1965; 14:211-5. Wycis HT, Soloff L, Spiegel EA. Facial pain, persisting after retrogasserian rhizotomy, relieved by mesencephalothalamotomy. Surgery 1950;27:115-2 I. Wycis HT, Spiegel EA. Long-range results in the treatment of intractable pain by stereotaxic midbrain surgery. J Neurosurg 1962;19:101-7.