Brain Targeted Surgical Interventions

In the brain, a hypophysectomy can be performed for intractable pain in association with hormonally responsive cancers. The transsphenoidal approach is used for resection or ablation with radiofrequency or alcohol. Both metastatic breast and prostate cancer pain have been treated with very good results. Cingulotomy is usually performed for psychiatric illness, particularly obsessive compulsive disorder and depression, but is also used to treat chronic pain syndromes. Lesioning the cingulate gyrus, part of the limbic system, disrupts the perception of pain. The pain is still felt by the patient, but it does not

Pituitary gland Sphenoid sinus

Figure 13.42 Transsphenoidal hypophysectomy.

Pituitary gland Sphenoid sinus

Figure 13.42 Transsphenoidal hypophysectomy.

bother them. Aside from the operative risks, there can be cognitive side effect as well (Fig. 13.42).

Michael A. Cosgrove, MD, David K. Towns, MD, and Gilbert Fanciullo, MS, MD

You have been asked to see George, a 48-year-old man with a history of metastatic rectal cancer in remission for 5 years with recent recurrence. He had an abdominoperineal resection with adjuvant chemotherapy and radiation on his initial presentation with the malignancy. The recurrence was heralded by increasing pelvic floor and perineum pain due to local recurrent disease that is inadequately controlled with oral opioids and antiseizure medications. Further surgical resection is not an option, and he does not want chemotherapy. He has a poor prognosis and is expected to succumb in several months. His oncologist has referred him for possible interventional techniques to help with his pain.

What are your options for managing his pain?

Neuroaxial, sympathetic, or somatic nerve blocks with neurolytic agents is an option worth considering.

Pain in the lower pelvis, from the rectum and perineum, may be sympathetically mediated via the ganglion impar (ganglion of Walther). Blockade of the ganglion is effective in malignancy-related pain in this area. Normally, a block with local anesthetic would be performed initially to establish efficacy, but his dire circumstances might preclude the additional procedure and a neurolytic block might be the starting point. His post-resection anatomy actually reduces risk, as there is no bowel or anus at risk of perforation.

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