Neurosurgery in the treatment of cancer pain

Patients with pain syndromes resulting from recurrent or metastatic cancer should be evaluated carefully to determine the cause of their pain and the need for appropriate antitumor treatment. Currently, opioid analgesics are the mainstay of pain control, but side effects limit their use in some patients. When pharmacologic pain control is inadequate or associated with intolerable side effects, neurosurgery should be considered. Currently the implantation of a pump for the intraspinal infusion of opioid analgesics is the most popular procedure, but its usefulness may be limited by the development of opioid tolerance. The most effective ablative pain control procedure at the current time is cordotomy, which is indicated in patients with unilateral pain. Although the place of neurostimulatory procedures in controlling cancer pain is not well established, they are attractive because of their nondestructive nature and potential usefulness in the treatment of bilateral pain syndromes. Specific antitumor surgical procedures should be considered in patients with certain spinal and plexopathy syndromes, because such intervention offers the prospect of both pain relief and tumor control. In this article, the neurosurgical procedures used in the management of cancer pain are reviewed.