RSD Puzzle #093

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

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INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

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RSD Puzzle #93
Will A Rhizotomy Help My RSD?

There are three kinds of pain. First, the acute pain, which may require narcotics or surgery to correct the source of the problem. Second, cancer pain, which is destructive and shortens the life expectancy, should be treated with any form of medication or operations that provide temporary relief for the patient to make the short life less painful and less miserable. Third is complex chronic pain, which is completely different from the other two. The complex chronic pain should not be treated as an acute pain, or as a cancer pain. The cancer pain is combination of acute, subacute and chronic pain. The true chronic pain has had a pathology that has been partially healed, but is causing continuous pain. There is nothing in common among the above three types of pain in regard to treatment.

This mixing of the cancer pain and chronic pain entities was the beginning of the anesthesiologists reinventing the wheel. They started doing surgical procedures that were tried by neurosurgeons in the 1950's and 60's and were found to be of no use for chronic pain. These consisted of rhizotomies (cutting the nerve roots), neurotomies and chordotomies (dissecting the pain tracts in the spinal cord), tractotomies (cutting the tract of the pain fibers in the medulla and spinal cord), thalamotomies, singulotomies, frontal lobotomy, and insertion of deep brain stimulators, followed later on by insertion of spinal canal stimulators.

The above surgical procedures are quite reasonable and kosher for cancer patients because they are palliative in nature. They do not cure anybody, but they get rid of the intractable, pain of the poor cancer patient who has only a few months to live. If the patient lives longer than a few months, it is still ok to go ahead and cut more tracts and more nerves. Such treatments in cancer patients are humane and justifiable.

However, an RSD patient has a life expectancy of anywhere from three to five decades. It would be cruel to do such operations, the benefits of which last only a few months up to a maximum of a year-year and a half, and to expect the patient to shut-up and not complain after the benefit is over. RSD is usually caused by a minor injury, but it's pain is more severe than even cancer pain. Invasive operations, as outlined above, only add new sources of pain in the RSD patient.

The reason rhizotomy does not work for RSD is because the patient lives longer than nine months and has to put up with a new source of pain from in the form of this surgical resection of the sensory nerve root. An anatomical reason the rhizotomy does not work is because a sensation does not limit itself to one sensory nerve root as it enters the spinal cord. It usually spreads up to three or four sensory nerve roots, than an area larger than 1 1/2" in the spinal cord becomes defective and causes a phenomenon called deafferentation, which becomes a new source of pain because of the fact that the deprivation of the nerves in the spinal cord from the input of sensation from periphery causes gradual death of the nerve cells in the spinal cord, opening the gate and causing severe pain, even in the normal areas of the body where the sensory nerve roots have been dissected.

H. Hooshmand, M.D.

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