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Punctate Midline Myelotomy: A Historical Overview and Case Series with Detailed Efficacy and Side Effect Profiles
Tyler Ball1, Zaid Aljuboori2, Haring Nauta1
1Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA.
Objective:
To review our experience with punctate midline myelotomy (PMM) for malignant and benign visceral pain with an emphasis on detailed side-effect profiles and efficacy.
Methods:
Thirteen adults (5 men) underwent microsurgical transverse-crush PMM.
Results:
Median follow-up for the benign pain group (n = 6) was 17.5 months (10-72) and for the malignant group (n = 7) was 8 months (0.5-31). Five of seven patients in the malignant pain group obtained excellent, lasting relief. Two had initial relief followed by worsening pain with disease progression. In the benign pain group, two patients with endodermal-origin pain (gastrointestinal tract, bladder) had complete, long-lasting relief. Three patients with mesodermal-origin pain (ureter) had excellent relief for 2-3 months, followed by recurrence in two and partial (40%) recurrence in the third. One man with pre-existing cervical myelopathy underwent PMM for benign testicular-region pain from which he had long-term relief but only transient relief of coexisting low-back and leg pain. There were no motor deficits in either group, and all patients remained ambulatory and continent. The most common side effect was transient numbness of the medial leg and foot. Two patients (both with pre-existing spinal pathology) reported persistent moderate reduction of bowel, bladder, and sexual sensation.
Conclusions:
PMM offers substantial pain relief for carefully selected patients with intractable visceral pain. Relief from primarily endoderm-derived structures was most complete and long-lasting. Relief from mesoderm-derived structures was typically transient or incomplete. There was essentially no relief from pain of ectoderm-derived structures. Detailed preoperative counseling is important, especially for those with pre-existing neurologic deficits.
Insights
Punctate midline myelotomy (PMM) offers significant pain relief for select intractable visceral pain patients. Relief is most effective for endoderm-derived pain, with variable results for mesoderm-derived pain.
Area of Science:
- Neurosurgery
- Pain Management
- Oncology
Background:
- Visceral pain, both malignant and benign, presents significant management challenges.
- Punctate midline myelotomy (PMM) is a neurosurgical technique for intractable pain.
- Understanding PMM's efficacy and side effect profile is crucial for patient selection.
Purpose of the Study:
- To evaluate the efficacy and side effect profile of PMM for malignant and benign visceral pain.
- To analyze pain relief based on the origin of visceral structures (endoderm, mesoderm, ectoderm).
Main Methods:
- Microsurgical transverse-crush PMM was performed on thirteen adult patients.
- Patients were divided into malignant (n=7) and benign (n=6) pain groups.
- Follow-up duration varied, with median follow-ups of 8 months (malignant) and 17.5 months (benign).
Main Results:
- Excellent, lasting relief was achieved in 5/7 patients with malignant visceral pain.
- Complete, long-lasting relief was observed in 2/6 patients with endodermal-origin benign pain (GI tract, bladder).
- Mesodermal-origin pain (ureter) showed transient or incomplete relief in 3/6 patients. Transient medial leg/foot numbness was common; persistent sensory reduction occurred in 2 patients with pre-existing spinal pathology.
Conclusions:
- PMM provides substantial pain relief for carefully selected patients with intractable visceral pain.
- Pain relief is most complete and durable for endoderm-derived structures.
- Preoperative counseling is essential, particularly for patients with pre-existing neurological deficits.
