An estimated 25% of all patients wi...

An estimated 25% of all patients with cancer die while experiencing pain. (1) Pain management is single in kind of the fundamental services that enhances patients' ability to cope with cancer and its therapy. Systemic pharmacological medications are the first choice for therapy to relieve cancer pain based onward their effectiveness and practicality. (2) Other pain-relieving [i]modus operandi[/i]s should be considered, however, when systemic pharmacological therapy does not provide adequate pain relief for patients or is associated with intolerable side events The most beneficial nonpharmacological pain-relieving proceedings are percutaneous chordotomy, epidural portals, celiac and hypogastric plexus ablation, spinal neurolysis, and epidural injection of steroids. (3)

Since its introduction in the early twentieth hundred anterolateral chordotomy has been single in kind of the most popular and effective steps for the relief of unilateral pain caused by means of malignant disease. The procedure involves destroying spinal cord fibers, thereby eliminating pain. Although anterolateral chordotomy regularly was performed as an render free of access procedure, a team of surgeon expanded the percutaneous technique. This approach increases the patient selection criteria to patients who otherwise are unable to withstand an expand procedure. (4)

Fluoroscopy typically is the classic visualization rule used for the percutaneous technique. Unlike fluoroscopy, however, comput tomography (CT) imaging can be used to provide direct visualization of the upper cervical spinal cord region, allowing for more selective cervical chordotomy conducts with fewer complications. (5) At Ege University Medical exercise Izmir, Turkey, percutaneous cervical chordotomy using radiofrequency has been performed routinely with CT guidance since 1991 (6) The objective of the conduct is not to treat cancer itself yet to relieve cancer pain on destroying the spinal cord fibers at the cervical level

THEORETICAL FRAMEWORK

Pain is a mingled and multidimensional experience. Accurate management of pain requires a comprehensive understanding of the phenomenon. Although scientific knowledge of pain is evolving continually, common theory provides a powerful theoretical basis for pain management. (7) The "gate control" theory recommends that there is a relationship between the physical (ie, sensory, discriminative), psychological (ie, affective, motivational), and cognitive (ie, interpretive) ingredients of the pain experience. This theory also acknowledges the interplay of the peripheral coolnesss dorsal horn of the medulla spinalis, brain branch and corresponding cerebral cortex in reducing pain. According to the theory, pain can be reduc or modulated at four points:

* at the peripheral site of pain,

* in the brain stem

* in the cerebral cortex, and

* in the spinal cord.

Based forward this, application of heat and hyemal and use of nonnarcotic analgesics (eg nonsteroidal anti-inflammatory medications, topical anesthetics, injectable anesthetics) can alter the release of nociceptive substances at the peripheral site. Similarly, analgesic administration by the agency of epidural ports, along with celiac and hypogastric plexus ablation, can interrupt force conduction and decrease pain perception at the periphery. Interventions that can effectively shorten or eliminate the transmission of pain impulses in the brain trunk include electrical stimulation, acupuncture, and narcotic analgesics. Cognitive techniques (eg hypnosis, imagery, music therapy, relaxation, distraction, behavioral training) and narcotic analgesics are interventions that work primarily in consequence of action in the cerebral cortex. In the spinal cord, direct electrical stimulation, massage, and heat and biting applications can stimulate large hardihood fibers and, thus, interfere with transmission of pain impulses. Anterolateral chordotomy, whether performed as an unclose or a percutaneous procedure, interrupts the contralateral pain fibers in the spinal cord and stops the conduction of pain stimuli.

ANATOMICAL BACKGROUND

Pain perception begins at the receptor site that corresponds to damaging stimuli. The stimuli generated in the pain receptor are mannersed by the peripheral nerve fibers entering the spinal round pillar through the posterior gray row (ie, dorsal horn). After synaptic interaction in the posterior gray round pillar the fibers decussate to form the spinothalamic tract just anterolateral to the anterior gray array of less front than depth (Figure 1). The anterolateral spinothalamic tract ascends within the brain stem to the thalamic nucleus ventralis posterior lateralis. It then lasts in the corresponding cerebral cortex (ie, postcentral sensory area). (8) The spinothalamic tract is a major path that be of use tos thermal, touching, and somatic pain senses

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PATIENT SELECTION

To be eligible for percutaneous radiofrequency (RF) chordotomy at Ege University Medical teach patients must meet the following criteria:

* have unilateral, somatic, and cancer-related pain;

* achieve inadequate pain reign over by conventional medication (eg, 30 to 180 mg by day of oral morphine with or without nonsteroidal anti-inflammatory medications); and