Spinal cord myelotomy and its subtypes for management of the intractable visceral pain like cancer head of Pancreas and colon

1. Punctate Midline Myelotomy
for
treatment of intractable visceral pain
Mohamed Elsayed Elsebaey, MSc1
Prof. Tariq El Emam El Shafaey, MD2
Ismailia General Hospital 1, Suez Canal University Hospital 2, Ismailia,
Egypt
Seba3y700025@gmail.com
Mohamed E Elsebaey

2. General Idea
• Patient has visceral abdominal cancer
• Complaining from severe intolerable pain
• underwent PMM technique
• Pain relieved or dose of narcotics needed for
him, decreased in marked way

3. Visceral pain
• Pain that results from the activation of
nociceptors of the thoracic, pelvic, or
abdominal viscera (Organs).
• Visceral structures are highly sensitive to
distension (stretch), ischemia, inflammation,
but relatively insensitive to other stimuli that
normally evoke pain like, cutting or burning.

4. • Visceral (Deep sitted)
• Somatic
• Neuropathic

5. Neuromodulation
Neurostimulation
Peripheral N. stimulation
Spinal cord stimulation
Motor cortex stimulation
Deep brain stimulation (DBS)
Neuroablation
Neurotomy
Neuroctomy
Ganglionectomy
Rhizotomy
Spinal cord dorsal horn lesioning
DREZ lesioning
Cordotomy
Myelotomy
Tractotomy
Thalamotomy
Cingulotomy

6. Neuromodulation
Neurostimulation
• Merits
Safety
reversible
wide range of amplitude and effect
• Demerits
High cost
device related complications
Neuroablation
Low cost
May be ttt of choice
Often the last resort in ttt

7. Neuromodulation
Neurostimulation
Peripheral N. stimulation
Spinal cord stimulation
Motor cortex stimulation
Deep brain stimulation
Neuroablation
Neurotomy
Neuroctomy
Ganglionectomy
Rhizotomy
Spinal cord dorsal horn lesioning
DREZ lesioning
Cordotomy
Myelotomy
Tractotomy
Thalamotomy
Cingulotomy
Commissural
Punctate
Anterolateral
Unilateral
Bilateral

8. A. the divisions of the gray matter, B. the divisions of the white matter, C. Fasciculi proprii

9. Synaptic layers of the gray matter in thoracic region
• The gray matter can be divided into layers of axon termination
based on cytological criteria
• First done by Swedish neuroanatomist Bror Rexed.
• This laminar architecture is well defined in the dorsal horn where
sensory axons make synapses in specific layers that be important in
pain pathway

10. Ascending tracts in the spinal cord (overview)

11. Ascending tracts in the Gracilis and cuneate fasciculis
Cervical axons are laterally to the thoracic axons laterally to lumbar axons laterally
to sacral axons

13. PMM
• First described by Nauta et al. In 1997
• The rationale of this PMM is the destruction of
midline dorsal column visceral pathway
evidenced in 1996 by Al-Chaer et al.
• Evidence is provided that axons in the medial part
of the posterior column convey ascending
nociceptive signals from pelvic visceral organs.
• Those visceral nociceptive afferents project to the
thalamus via the nucleus gracilis
• Limited lesioning in this area eliminate the pelvic
pain without producing neurological deficits.

14. • Visceral pain is thought to be mediated by spinothalamic
tract and possibly the spinoreticular tract, but recent
expermental researches suggested that:
Dorsal column is more important than the STT as visceral
pain pathway.
• Generally the dorsal column pathway is generally
considered to be pathway for proprioception, fine
discriminatory touch information and vibratory sensation.
• (research and clinical) reports showed that visceral
nociceptive pathway ascending in the midline of the dorsal
column.

15. • It is believed that this dorsal column pathway
may not contribute to pain sensation under
normal conditions but, it could become
sensitized by visceral inflammation and
distention.

16. Surgical Steps
• General Anesthesia
• Prone position
• Intended level was marked preoperative and
confirmed intraoperative
• Laminectomy of T4 Vertebra

17. • Longitudinal opening of the Dura
• Opening septum posticum
• Incision of arachnoid using arachnoid knife

18. • Measuring midway between the two root entry zones
• Identification of the dorsal midline vein
• Using microscope
• Using 16 G spinal needle
• Punctate myelotomy is done 0.5 mm on each side of the
midline and 5 mm in depth

20. Tip of the Needle is being lateral

22. Other Studies
• In 1970, Hitchcock, performed stereotactic
limited midline myelotomy at C1 .
• In 1996, Al-Chaer et al. published study
showed that the dorsal column lesioning is
more effective in controlling the visceral pain
than the ventral column lesioning.
• In 1997, Nauta et al, done the PMM for the
first time.
• In 2000, kim et al, performed high thoracic
midline dorsal column myelotomy.

23. • In 2000, Nauta et al, crushed the midline
tissue, extending 1 mm on each side and 5
mm in depth by using fine forceps to minimize
the risk of causing bleeding within the spinal
cord.
• In 2000, kim et al, used micro dissector to cut
the medial aspect of the fasciculus gracilis
from the posterior surface of the spinal cord
to the central gray area to make sure of the
appropriate depth of the lesion.

24. Our case
History & Examination
• 57 year old male patient
• Abdominal pain, vomiting and generalized faigue
• Ultrasonography and CT abdomen revealed cancer head of pancreas
• Underwent surgical intervention and whipple procedure was done for him
• The tumour was found invading the celiac plexus
• Visceral pain continues (VAS 10)
Pain Management
• Narcotics were tried , Tramadol oral and Injection
• Naluphine injection was needed 3 amp per day
• Ultrasonic guided celiac block was done and resulted in pain relief for 24 hours
only
• Flouroscopic mesentric and splanchnic block were tried but no benefit gained
Surgery
• Prepared for PMM at level of T4
• Steps of surgical intervention.
• Post operative marked improvement of pain and no need for naluphine injection
any more.
• Three (3) months later, the patient died from extended sequel of the cancer and
chemotherapy

25. Inclusion criteria of the Protocol of the
ongoing study
1. Patients have abdominal visceral cancer
2. intolerable visceral pain with WHO analgesic
protocol for patients suffering from cancer
3. Major side effects of those analgesics that
interfere analgesic administration
4. Expected life is more than 3 months

26. Take home message
• (PMM) is for attacking the dorsal column pain
pathway.
• PMM is successful method in controlling
severe abdominal and pelvic visceral pain
caused by advanced cancer.
• PMM minimizes the risk of neurological
deficits.

27. References
• Hwang SL, Lin Cl, Lieu AS, Kuo TH, Yu KL, Yang FO et al: Punctate Midline
Myelotomy for Intractable Visceral Pain Caused by Hepatobiliary or Pancreatic
Cancer. Journal of Pain and Symptoms Management. (1) 27, 2004
• Becker R, Gatscher S, Sure U, Bertalanffy H: The Punctate Midline Myelotomy
Concept for Visceral Cancer Pain control- Case Report and Review of the Literature.
Acta Neurochir 79: 77-78, 2001
• Becker R, Sure U, Bertalanffy: Punctate Midline Myelotomy A New Approach in the
Management of Visceral Pain. Acta Neurochir 141: 881-883, 1999
• Francisco AN, Lobao CAF, Sassaki VS, Garbossa MCP, Aguiar LR: Mielotmia
Punctiforme No Tratamento Da Dor Oncologica Visceral. Arq Neuropsiquiatr 64:
446-450, 2006
• Hong D, Sandberg AA: Punctate Midline Myelotomy: A Minimally Invasive
Procedure for the Treatment of Pain. Journal of Pain and Symptoms Management.
33, 2007