Chronic Pain: Lesions

Though neuromodulation, either through neurostimulation or intrathecal drug delivery, has become the mainstay of chronic pain treatment, the use of lesional techniques remains an invaluable approach for the treatment of medically intractable pain. Lesional approaches targeting both the brain and spinal cord are used for intractable pain, largely in the setting of cancer. However, in selected cases, ablation for non-cancer chronic pain is appropriate. Cordotomy and myelotomy are two techniques for lesioning the two main spinal cord pain pathways, the spinothalamic tract and the dorsal columns visceral pain pathway, respectively. Cingulotomy is an approach for lesioning the anterior cingulate cortex, of use in patients with widespread intractable pain which has a significant affective component to the pain.