Punctate Midline Myelotomy for Chronic, Intractable, Non-malignant Visceral Pain: A Case Report

Punctate midline myelotomy (PMM) has a strong anatomic and functional basis for its role in the treatment of visceral pain. The procedure derived from advances in the understanding of the postsynaptic dorsal column (PSDC) pathway and the converging laboratory and clinical evidence that this spinal cord pathway plays a dominant role in conveying visceral pain to higher levels of the nervous system. The result of PMM is a concise, effective interruption of the PSDC pathway with minimal to no side effects. While considerable evidence now documents that PMM has good efficacy and safety in treating malignant visceral pain, there is little experience describing its application to chronic severe refractory visceral pain of benign origin.  We present the case of a patient with a 13-year history of severe non-malignant chronic abdominal visceral pain who obtained complete pain relief from a PMM at the T7 level. Intraoperative somatosensory evoked potential (SSEP) monitoring did not show changes after making the PMM lesion. As of six-months postoperative follow-up, the benefit shows no sign of fading, all pain medications have been discontinued, and there has been no impairment of motor function, bowel or bladder function, sexual function, gait or station. Upon detailed questioning, the patient endorsed only mild subjective reduced sensation of the inner aspects of her feet that was not bothersome to her. On detailed testing, position sense was preserved throughout; the Romberg test was negative, and the only finding was reduced vibratory sensation over the great toe pads. We cautiously suggest that the PMM operation may allow relief from severe, intractable, benign visceral pain syndromes for which effective treatments are otherwise elusive. The procedure warrants further study for such conditions.