Surgical management of pain

Abstract

Severe and intractable pain is one of the most difficult and challenging neurological conditions to deal with and to treat. The entity is not
entirely well understood, and the afflicted patients often have significant concomitant neuropsychological problems that obscure the physical
issue at hand. Physicians also do not fully understand what pain is. In a sense all pain is neural in origin. From a therapeutic perspective,
pain is divided into visceral (dull and poorly localised owing to enteric sensory receptors) and somatosensory (more discreet and localised
– often owing to nociceptors being stimulated) pain. It is detected by nociceptors, i.e. sensory reseptors with the ability to interpret and
transmit noxious stimuli. Treatment options include medication, physical therapy and psychotherapy. The availability of sophisticated new
medication, such as pregabalin, augments the medical arm of therapy. If these therapies fail, and with a thorough multidisciplinary approach
involving carefully screened cases, surgery may form part of the management. Generally, surgical pain management is divided into neuromodulative
(enhancing physiological control of the pain system) and neurodestructive (lesioning and destroying the defined pain generator
in the central nervous system) surgery. Complex pain management should not focus on cure as the only outcome. Patients often experience
pain for years before considering surgery; it would therefore be unwise to expect an immediate cure. Careful psychological support and
evaluation is of the utmost importance. This article gives an overview of the neurosurgical management of pain.