Surgical interruption of a midline dorsal column visceral pain pathway. Case report and review of the literature.
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abstract
A punctate midline myelotomy performed in a patient effectively eliminated residual, intractable pelvic pain, which remained after resolution of uterine cervical cancer. The authors describe the case history of the patient, in whom pain assessments were made, and a surgical procedure performed. Despite large doses of opiate analgesic medications, the patient experienced constant pressure pain in the right lower pelvis, with excruciating pain on bowel movement. Severe weight loss necessitated better pain control. A minimally invasive surgical procedure, a 5-mm deep puncture using a 16-gauge needle on either side of the median septum in the dorsal column of the spinal cord (T-8), resulted in no new neurological deficits. Narcotic medication was tapered, no pain was reported, and the patient resumed daily household activity. Midline myelotomy has typically been performed with the intention of eliminating the crossing fibers of the spinothalamic tract in the anterior white matter commissure. The punctate midline myelotomy described here was performed with the specific intention of interrupting a newly described visceral pain pathway that ascends to higher brain centers through the midline of the dorsal column. The effectiveness of the pain relief seen in this patient suggests that visceral pain of the pelvis in humans may be transmitted in the midline of the dorsal column, as has been recently reported in studies using rats. The effectiveness of the punctate midline myelotomy performed in this one case of pelvic visceral pain suggests that the surgery may eventually be effective in greatly reducing or replacing opiate narcotic medication for visceral pain management.
