62 F I S I O T E R A P I E SEPTEMBER 1979 research th a t p h y sio th erap ists m ay well be interested in. C O M M U N IC A T IO N I N T H E R E S E A R C H E N V IR O N M E N T A n im p o rta n t p a r t o f any research u n d ertak in g is the o p p o rtu n ity to discuss its value w ith o n e ’s peers. T h e M R C has a n u m b e r o f schem es to encourage c o m m u nication am ongst m em bers o f sp eciality groups an d in this way fo ster co -o p cration an d en sure th a t th e re is n o t a d u p licatio n o f effort. F o r exam ple, the M R C w ill s u p p o rt atte n d an ce a t local conferences and assist scientists in this way to co m m un icate w ith one an other. T h e M R C also p rovid es the o p p o rtu n ity fo r scien­ tists to ap p ly fo r funds to spend a p e rio d o f tim e at an o th er research establish m ent w ith in the co un try w here a p a rtic u la r expertise is available. F o r exam ple, one m igh t wish to spend 3 m onths at a p a rtic u la r u n i­ versity w o rk in g on a research p ro jec t w ith p h y sio ­ th erapists o f standin g and this sort o f v isit could well be sponsored by th e M edical R esearch C ouncil. T h e M R C also m akes bursaries av ailab le f o r over­ seas stu d y in a p a rtic u la r techniqu e o r area w here S outh A frica does n o t have the necessary facilities. T h e qu e stio n o f th e av ailab ility o f sim ilar facilities T H E NEUROSURGEON J. C. D E V IL L IE R S * M .D ., T h e n e u ro su rg eo n is concerned p red o m in an tly with th e m anagem ent o f ch ro n ic pain. H is dealings with acute p a in a r e sim ilar to those o f m ost o th e r surgeons in th a t h e atte m p ts to rem ove the cause o f the trouble, as in ac u te disc p ro lap se w ith back and leg pain. A cute p a in seems to serve a purpose. I t causes av oidan ce o f the in ju rin g ag ent and induces rest. Some recu rren t attacks o f ac u te p a in , how ever, m ay lead to a ch ro n ic d isab ility e.g. b a ckache w ith o r w ith o u t sciatica. Som e recu rren t acute attacks o f p a in , such as in trigem inal n e u ra lg ia, serve no p u rp o se and can driv e th e sufferer to suicide. \ P atie n ts w ith persisten t pain can b e divided into two categories: (a) T h o se w ith lo ng-standing p a in o f co ntinuo u s o r recu rrin g n a tu re due to a lesion w hich is n o t life-th reate n in g b u t in w hich the p a in m ay th rea ten th e p a tie n t’s social integrity, (b) T h o se w ith severe p a in o f prolonged d u ra tio n d ue to life-th reaten in g lesions. W h atev er o ne believes ab o u t ac u te p a in does not ho ld fo r ch ro n ic pain. C h ro n ic u n relieved p a in is a disease in itself. T h e p a tie n t does n o t ad ap t to it; on th e c o n tra ry th e sufferer seems to becom e sensitized. L ack o f sleep, in a b ility to co ncen trate an d irrita b ility a re com m on associated features. T h e p a in becom es the focal p o in t o f th e p a tie n t’s existence and he loses in te r­ est in everything else. H e has seen m any doctors, is disillu sioned , dish earten ed an d suspicious. D epression is a fre q u e n t fe a tu re o f this state, th e treatm en t o f w hich can n ev er b e stra ig h tfo rw a rd , sim ple o r rap id . * H elen and M o rris M au e rb erg er P ro fesso r o f N e u ro ­ surgery, U n iv ersity o f C ape T ow n an d G ro o te S chuur H o spital. t P a p e r read at P a in Sym posium , precedin g 13th N a tio n al C ouncil M eeting 2 3 - 2 7 A p ril 1979. in South A frica is an im p o rta n t one, as th e M R C m ust en courag e the full u tiliz a tio n o f its ow n scientific facilities b e fo re scientists go a b ro a d to o th e r establish­ ments. So in effect we only s u p p o rt overseas visits if it involves som ething w hich can n o t b e don e in South A frica and w hich has v alu e fo r the South A frican situ atio n . Scientists who o b ta in these overseas travel b u rsaries o r overseas study b u rsaries, have to enter into an un d ertak in g w ith the M edical R esearch Council to re tu rn to S outh A frica fo r a p e rio d o f tim e so that w h at they have learn ed can be tran sferre d to their colleagues in South A frica. T h e M R C also suppo rts th e u n d ertak in g o f inter­ n a tio n a l o r natio n al conferences. It does not, how ever, assist societies w ith th e ir m eetings; there are so m any in the co u n try th a t this w ould b e a v irtu a lly im pos­ sible task. H ow ever, if an a re a o f m edicine w arrants a scientific m eeting and the research can clearly profit by the visit o f overseas scientists to such a conference the M R C w ill su p p o rt the u n d ertak in g financially and offer the facilities o f its C onference D iv isio n foi th e o rg an isa tio n of such a n M R C conference. j f I hop e fro m w h at I have said th a t you will n t | b elieve that “research en d eav o u rs” w ill cu re all the prob lem s facing th e p hy sio therapist. B ut certainly ] believe th a t it will offer an en riched career and im ­ proved treatm en t fo r th e p a tie n t — an aim that everyone involved in health care shares! AND CHRONIC PAIN t F.R .C .S. (Eng. & E din.) T H E P A T IE N T , T H E P A IN A N D T H E P H Y S IC IA N I t has been a tra d itio n a l concept that surgeons should be concerned w ith the excision o f lesions w hich are held to be useless o r deleterious in th e ir effects. S im ilarly it ap p eared logical th a t nerves, tracts and “ centres” concerned w ith th e tran sm issio n o r in te r­ p reta tio n o f im pulses concerned w ith th e ap p re ciatio n o f p a in should be divided o r ab ated if such pain served no purpose. T h e h isto ry o f surgery fo r pain shows that this a ttitu d e has been follow ed by disaster. U sually, w hen all surgery has failed, som eo s''- m iracu lously discovers th a t the p a tie n t is an individuft ' w ith problem s, w o rth y o f co n sid eratio n by a psychiatrist." All o th e r “a b stra c t” aids are then invoked to absolve the surgeon fro m an y gu ilt feeling w hich he m ay have engend ered as a result o f having becom e p a rt o f the n a tu ra l h isto ry o f the p a tie n t’s disease. A ny surgeon who em barks on surgery fo r ch ronic pain, w ith o u t having spent tim e w ith his p a tien t is set on a disaster course. O th er p eo p le who will talk to the p atien t, no m a tter who they a re — psychiatrists, psychologists, social w orkers, a nu rsin g sister o r p a ra ­ m edical staff — can lea rn a b o u t the p a tie n t and his reaction s and should sh are th e ir views w ith the sur­ geon; th e re is th e re fo re everything to b e said fo r a team ap p ro ach . T h e surgeon m ust get to know his p a tie n t and get to know him well an d this know ledge can b e gained only by repeated con versation in depth. A n attem pt sh o u ld be m ad e to establish the follow ing points: W h a t sensation does the p a tie n t call “p a in ” ? H o w does he describe it in his ow n w ords w ith o u t any p ro v o ­ ca tio n on th e p a rt o f th e exam iner? W h at does this sensation, call it p a in if you m ust, do to him , w hat does it do f o r him and w hat does he do w ith it? One R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) SEPTEMBER 1979 P H Y S I O T H E R A P Y 63 should explore those reaches o f co n versation w here one can fo rm an inklin g o f w hat he expects o r has expected fro m life. If his p a in has been o f long d u ra tio n an d d ue to a non -m alig n an t co n d itio n , has he accepted th e b a sic d isab ility w hich has caused this d iscom fort? T h a t p a in is n o t m erely d e pend en t on th e intensity o f stim u latio n o f afferent nerve fibres, b u t is also p r o ­ found ly influenced by psychological facto rs, has been show n by m any w orkers. M any fo re b ra in stru ctu res can influence th e ac tiv ity o f ascending fibres in spinal cord an d b ra in stem reticu lar fo rm atio n . T h e re is th e re fo re co nsid erable n e u ro p h y sio lo g ical evidence f o r a central co ntro l o f afferent inpu t. In the “gate c o n tro l” concept o f the dorsal ho rn , it is believed th a t the ra p id ly co n ­ ducting lem niscal system triggers this central in h ib itin g m echanism . T h e re is am ple evidence th a t these central m echanism s — phy sical an d phsychological — play an im p o rta n t p a rt, if n o t an all-im p o rta n t p a rt, in p ain experience. T h is m ay explain the co n d itio n in g tre a t­ m ent o f p a in fu l states o r th e ap p a re n tly excessive p a in Experienced b y an xious and excitable persons, a p h e n o ­ m e n o n witH w hich we a re all too fam iliar. P a in is n o t a n ab stra c tio n b u t requires a perso n to en dure it and describ e it; it can n o t exist outsid e a person. T h is co m p lain t is an in te ra ctio n betw een cause, reception and reaction. T h e re is no such th ing as real p a in and im a g in ary pain. C h ro n ic p a in is a to tal ex­ perience o f a p a rtic u la r personality. W e do n o t experience pain a t any one site in the nervous system b u t th ro u g h o u t its e n tire stru c tu re fro m the sim plest sensory recepto r to its “high est centres” in a com plex in te ra ctio n o f intensity o f stim ulus and psychological reaction. C onsequently it should n o t su r­ prise us to find th a t persistent p ain is o ften associated w ith a long h isto ry o f pain, an x iety and depression, p o o r general h ealth, resentm ent and lack o f confidence in the doctor. P a in is n o t a n ab so lu te quality. I t fluctuates and can be influenced by th e situ atio n s in w hich th e p a tien t finds him self. I f he is intensely interested in som ething or is preoccup ied w ith o th e r problem s, the p a in tends to wane. T h is history, if elicited, is alrea d y o f great assistance in th e f u tu re m anagem ent o f th e patient. It w ould be to ta lly w rong to leave the im pression th a t all ch ro n ic pain is d ue to psychological factors. I t w ould b e eq ually foolish to reg ard ch ro n ic p a in as having no psychological accom panim ent. k E very neuro su rg eo n w ith experience in this field has ) a d m it th a t there are, w h at o ne could call “painfu l peo p le” . T h ey have fro m an early life ad o p ted the role o f the sufferer fo r one reason o r the o th e r. P erhaps life was too p a in fu l fo r them! T h ey b rin g th e ir p ain to the d o c to r an d d isplay it to him as any o th e r person w ould show his collection o f sem i-precious stones, old books o r stam ps. T h is is do n e w ith a c e rta in pride, w hich m ust o bv iously b e subdued, an d they have every reason to b e proud . H a v e n o t m an y physicians and surgeons failed m iserably, d espite th e ir em inence, in the presence o f this e x tra o rd in a ry p a in ? T h e y th em ­ selves a re passive, gently sm iling spectators o f th e ir ow n suffering an d p lay little p a rt in a n a tte m p t to alleviate it. N o fo rm o f surgery will do these p atients any good. B efore one considers an y surgical o r o th e r d estructiv e p ro cedure fo r th e relief o f p a in , it is m a n d ato ry to have a clear an atom ical, p ath o lo g ical an d perso n ality diagnosis available. A ny good n euro su rg eon m ust have at least a m o d erate av ersion to destructiv e surgery. A ny p a tie n t w ith ch ro n ic pain m ay develop new lesions w hich m ay b e m asked by his old com plaint. An em otionally overactive o r “n e u ro tic ” p erso n has only the language o f o v e rre actio n to tell o f h e r sym ptom s even if these sym ptom s indicate o rg an ic disease. A p a tie n t m ay h a v e had 3 o p e ra tio n s on h is b ack and th e basic lesion m ay yet have been m issed. One should have a h e alth y d istru st o f prev io u s diagnoses o f “fu n c­ tional s ta te ” an d “hysterical p a in ” , w h atever th a t m ay mean. PRO C ED URE S AV AILA BLE TO TH E SU R G E O N C on sidering th e procedures th a t can b e used in treatin g pain, one can start w ith p e rip h e ra l nerve- section and end w ith variou s psy ch o su rg ical procedures w ith an endless v a ria tio n in betw een. T hese procedures will b e briefly m entio ned w ith th e ir in d icatio n s and draw backs. PRO C ED URE S D IR E C T E D TO THE PER IPH ERA L NE R V ES Peripheral N erve Blocking In te rru p tio n o f co nduction in p e rip h e ra l nerves by m eans o f local a n aesth etic o r n e u ro ly tic agents plays an im p o rta n t p a rt in p a in relief, no m a tte r w h ether one practices in a sophisticated h o sp ita l o r in th e bush. Local A naesthetic Injection Local an aesth etic injectio n provides analgesia in th e a re a o f d is trib u tio n o f th e n e rv e w hich has been blocked. A n interestin g o b serv a tio n is th a t the p ain relief m ay o ften o u tlast th e d u ra tio n o f the p h a rm a ­ cological action o f th e blocking agent, p ro b a b ly because th e n e rv e block in te rru p ts the reflex reaction s evoked by the nox ious stim ulus w hich m a in tain s a vicious cycle. A p a rt fro m its th e ra p e u tic effects a nerve block m ay be used fo r three reasons:— # It can h elp to establish th e an ato m ical ro u te by w hich th e ab n o rm al im pulses are conducted, i.e. th e n e rv e w hich is involved. # It can, to som e extent, help to d ifferentiate between different types o f p ain alth ough this is less accurate; fo r instance, injecting a site w h ere referred p a in is felt w ill also reliev e pain alth ou gh one is not block ing th e site o f p rim a ry o rig in o f the ab norm al impulses. # I t can serve a p rogn ostic fu n ctio n in th a t it m ay in d ic ate w h eth er a section o f a n e rv e will give relief. T h is is less useful th a n o ne w ould like it to be, because relie f can be o b ta in ed fro m injecting a site o f referred pain . I t is p e rh aps m ost useful as a p ro g n o stic m easu re in th a t it allows one to observe th e p a tie n t’s reac tio n to th e a re a o f num bness w hich is p rodu ced by blocking. T h e re are a sm all n u m b er o f p a tien ts who react so adversely to th e area of num bness th a t p e rm a n en t n e rv e blocking can n o t be tolerated. A n aesthetic blocks w o rk n o t only by in te rru p tin g pain pathw ays b u t also by reducing the to ta l in p u t o f im pulses w hich im pinge on th e T cells o f th e cord. T h e techniq u e o f n e rv e blocks will n o t be described b u t it m ust be stressed th a t th e p a tie n t’s co -op eration and un d erstan d in g a re vital be fo re one can expect any success w ith this kin d o f procedure. C hem ical N eurolysis T h e use o f chem ical n eu ro ly tic agents usually p ro ­ duces a m uch long er p a in relief w hich m ay range fro m weeks to m onths, alth ough it is ra re fo r it to last fo r long er th a n a few m onths. C hem ical neuro lysis is m uch m ore difficult than local an aesth etic injections because th e placem ent of th e need le m ust b e f a r m o re accurate, as m uch sm aller doses h ave to b e used in o rd e r to av o id undesired side effects. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 64 F I S I O T E R A P I E SEPTEMBER 1979 Peripheral N erve Section S urgery fo r p e rip h eral nerves is lim ited by the fact th at ax on fibres will inevitably regenerate and w ith this the o rig inal p a in will return. In a d d itio n to this, m ost p e rip h e ra l nerves are o f a m ixed v a rie ty w hich m eans that m o to r p aralysis as well as sensory loss w ould follow section o f such a nerve. T his transgresses the basic p rin c ip le o f all d estructiv e surgery, nam ely, th a t the la tte r should pro d u ce as little added deficit as possible. T h e presence o f an an aesth etic patch m ay have a disadvantage, depending on w here it is. T h ere are also p a tien ts w ho becom e m o rb id ly preoccup ied w ith an area o f num bness. N erv e section is still done in occasional cases of single division trig em inal n e u ra lg ia b u t then only if th ere a re c o n tra -in d ica tio n s to a form al attack on the ganglion o r root. T h e re is also the n o t insignificant risk o f so-called n eu ro m a fo rm atio n , w hich in its own right m ay be fa r m ore difficult to tre a t th an the p rim ary co ndition. T h is p a in fu l sequence o f nerve section — n e u ro m a fo rm atio n — repeated nerve section — m ore n e u ro m a fo rm a tio n — hig h er nerve section ad infinitum is a dism al story w hich was often seen in the m is­ m anagem ent o f a m p u tatio n stum p pain in fo rm er times. Interruption o f A utonom ic Nerves A fter the great vogue fo r sym pathectom y in the nineteen th irtie s and forties, th e sym pathetic system seems to have fallen into disfav o u r an d its fu n ctio n as an afferent p a th w ay has been disregarded o r forgotten. It supplies a very w ide field in the bod y and th e re are certain p ro ced u res directed at this system w hich have lim ited but h ig h ly effective results in p ain relief. T he au to n o m ic afferents fro m the v iscera a re p red o m in an tly concerned w ith v a so m o to r tone an d m uscu lar co n tra c­ tility. V isceral p ain is p o o rly localised, som ew hat vaguely referred to the region o f the org an involved bu t o fte n m o re distan tly felt. Because sym pathetic nerves a re p o o rly m yelinated, sy m pathetic nerve block requires a low co n cen tratio n o f an aesth etic ag ent and a successful block does n o t bring a b o u t an y hyper- aesthesia o r h yp oaesthesia. If the latte r do ap p ear, it is due to co incidental involvem ent o f som atic nerves in the vicinity. Successful sym pathetic block is accom ­ panied by local elev ation in tem perature, both su b ­ jective an d objective, w hich m ay tak e , som e m inutes before it can be registered; plethysm ograp hically in ­ creased p u lsatio n m ay be dem onstrated. T h e p a rt b e­ comes dry because sw eating is ab olish ed and locally th e veins a re d ilated. T h e m ost com m only used sym ­ p a th etic blocks are those o f th e lu m b ar plexus, coeliac plexus an d stellate ganglion. L u m b a r p lexu s blocks are done m ostly fo r periph eral v ascu lar disease involving th o legs. Coeliac plexu s block can be a very effective m ethod fo r th e co ntro l o f u p p e r ab d o m in a l p a in resulting fro m carcinom a o f th e pancreas o r u p p er abdom inal viscera. T h e coeliac ganglion an d splanchnic nerves co ntain pain-m ediating fibres fro m , as well as sym pathetic fibres to, the u p p e r abdo m inal viscera. If the disease is confined to th e viscera an d does n o t involve the ab dom in al w all, intercostal nerves o r lum b ar plexus, the p ain m ay be relieved by coeliac block. S ym pathectom y can follow effective sym pathetic block if the p a tien ts’ general co n d itio n will allow surgery, w h ich is usually fairly m a jo r an d n o t w ith o u t risk. Rhizotom y T h e o n e g rea t ad van tage o f p o sterio r ro o t section o v er p e rip h e ra l nerve section is that it is n o t follow ed by axonal regeneration. On the strength o f this, Abbe (1889) in trod u ced this o p e ra tio n . It has the added ad­ vantage th a t th e re is no associated m o to r paralysis U n fo rtu n ately , com plete block o f im pulses a t this level also in te rru p ts p ro p rio c ep tio n an d jo in t sensation; if extensive areas are involved, th e re m ay be skin dam age d ue to loss o f sensation. It is co ntra-indicated fo r the spinal roots o f the b rac h ial an d lu m b ar plexus unless the lim b is alrea d y useless ow ing to the prim ary disease. It has som e ap p licatio n in the m anagem ent of in trac tab le p ain due to m alig n an t in filtratio n o f tissues in th e neck w hich cann ot be treated in any o th e r way. It has a lim ited success rate, p ro b a b ly m uch less than 60% , an d th e cause o f fa ilu re is a ttrib u te d to the great ov e rla p betw een ad jacen t nerve territo ries. M u l t i p l e ro o t sections only p a rtia lly overcom e this pro b le m and involve a fa irly extensive o p e ra tio n to w hich one cannot sub m it very ill patients. D o rsal rh izo to m y is su itab le fo r p a tien ts w hose pain involves stru ctures innerv ated by only o ne o r two dorsal roots. T h e p atien t m ust be in good general co n d itio n to w ith stand the o p e ra tio n an d have a reasoijj ab le life expectancy. ® T h e one o u tstan d in g in d icatio n fo r ro o t section is trigem inal neuralg ia, in w hich it is successful in m ore than 90% of cases. It requires an open o peration w hich is done th roug h the m iddle fossa eith er intra- d u rally o r ex tradu rally, o r fro m th e p o sterio r fossa. A com bined ro o t section o f the 5th - 10th and upper 3 o r 4 cervical nerves can b e an ideal o p e ra tio n for th e relief o f p a in in the low er jaw and neck region d ue to infiltrative carcino m a o f the floor o f the m outh if the p a tie n t is fit enough to tolerate such surgery. C o ntro lled rad io -freq u en cy therm al destructio n of th e trig em in al ro o t and ganglion, v ia an appro ach thro ug h the foram en ovale w ith a special electrode, m ay give excellent results in trigem inal neuralgia (Sweet and W epsic 1974). Its advantage is th a t it does n o t re q u ire an open o p e ra tio n , and general superficial sensation to the face is spared. T h e only problem is th a t the recu rren ce rate o f pain m ay be hig h er than w ith o th e r procedures, b u t the p rocedure can be repeated. Chemical R h izotom y By this m ethod n e u ro ly tic solution s are introduced into th e su b arac h n o id space an d m an ip u la ted in such a w ay th a t only the nerve roots concerned are bathed in the destructiv e solution . In o rd e r to fa cilita te thitf use is m ade o f g ravity co ntro l by utilising 5% phenpf in glycerin w hich is heav ier than spinal fluid and wfh perco late dow n into the desired ro o t sleeves (M aher 1955). T h is techniq u e has been used p artic u larly for the relief o f cancer pain and in the treatm en t of spasticity and p a in fu l flexor spasm s. It requires a m eticulous techn iqu e; if this is strictly ad hered to, th e re are very few co m plications. It is only w hen one uses high er co ncen trations o f n e u ro ly tic agent and p e rfo rm s repeated o r bilateral injections th a t problems occur. U n fo rtu n ately , the fe a r o f co m plications has tu rn ed m an y doctors aw ay from this very useful m ethod of giving relief to patients for w hom no other fo rm o f th e ra p y is available. PR O C ED U R E S O N THE SPIN A L CORD Antero-lateral Cordotomy S ection o f the sp in o th alam ic tract was first per­ form ed by M artin in 1912 follow ing a suggestion by S piller in 1905. T h e o p e ra tio n is usu ally done in the u p p e r th o rac ic level, a t a b o u t th e level T.2, 3 for relie f to be o b ta in ed u n ila terally to the level of the R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) SEPTEMBER 1979 P H Y S I O T H E R A P Y 65 um bilicus. U p p er co rdo tom y will give 70% -7 5 % p a in relief. C o m plicatio ns o ccu r in a b o u t 15% o f in d i­ viduals an d w h en b ila teral op e ra tio n s a re done, the co m plication rate is even higher. A ssociated m uscle weakness in th e leg, loss o f bla d d er an d rectal contro l and im potence a re som e o f the grav e r sequelae. R elief of p a in can be h ig h ly effective b u t in terferen ce w ith the au to n o m ic system m ay lead to an u n stab le blood pressure w hich h as p a rtic u la r significance in the elderly o r fra il p atien t. T h e m a jo r draw back o f this o p e ra tio n is the significant n u m b e r o f people w ho fail to benefit fro m it, o r w ho a fte r an initial successful result later relap se into p a in again. W hy this should happen is n o t clearly u n d ersto o d b u t there is no d ou bt th a t it occurs an d one m ust assum e th a t alte rn a te pathw ays are opened up to conduct these im pulses. T h e re is also th e p ro b le m o f u np leasant dysaesthesia developing in the a re a o f an alg esia and this is p ro p o rtio n a l to the length o f survival o f th e patient. In sum m ary it can be stated th a t it is a good o p e ra ­ tion fo r relief o f strictly u n ila teral p a in associated ^vith m a lig n an t disease in p atien ts w ith a lim ited life expectancy. I t is n o t a very good o p e ra tio n fo r patients with ch ro n ic p a in o f non -m alig n an t aetiology. I f the level o f analgesia is to include the u p p er ab do m en and th o ra x a hig h cerv ical co rdo tom y has to b e perfo rm ed . T h is o p e ra tio n is, how ever, n o t to be un d ertak en lightly as th e re is a m uch grea ter risk due to resp ira­ to ry depression as well as the added loss o f m o to r elements o f th e p h ren ic nerve. Effective an algesia of the fingers m ay lead to in ju ry and ch ron ic u lceratio n after m inim al trau m a . A n o th e r u n to w ard fe a tu re is incapacitating dysaesthesia below the level o f the should er and incom plete p a in relief in th e leg. O pen co rdotom y, w h eth er dorsal o r cervical, d e­ m ands a general an aesth etic and a period o f p o st­ o p e ra tiv e recovery and m ay n o t be to le ra ted by d e­ bilitated peo p le in w h om it is indicated. It is an o p e ra tio n n o t w ith o u t risk and the risk is p ro p o rtio n a l to th e inexperien ce o f the o p e ra to r, because it is don e on an atom ical ra th e r th a n fu n ctio n al grounds. Percutaneous Cordotomy H ig h frequency co ag ulation o f th e v en tro -lateral q u a d ran t o f th e sp in al cord utilising a u n ip o la r needle electrode w h ich is introdu ced thro ug h the second cervi­ cal in te rv e rteb ral fo ram e n is a p ro ce d u re w hich has Jpecome w ell-established since its in tro d u ctio n by [ \lu lla n e t al. in 1965. I t does n o t re q u ire a general (anaesthetic o r a p o st-o p e ra tiv e p e rio d o f recovery as is the case fo r o p e n co rdo tom y and th e re fo re becom es m o re ap p licab le to th e fra il d e b ilitated p a tie n t suffering fro m term in al cancer. T h e risks of the p ro ced u re are greatly reduced because th e localisation o f th e lesion is dep end ent on fu n ctio n al testing by m eans o f ele ctri­ cal stim u latio n so th a t m uscu lar paralysis and o th e r und esirable side effects can v irtu a lly be elim inated . It has th e added ad v an tag e th a t it can be repeated if the in itia l result is n o t satisfactory . As w ith open co r­ dotom y, risks o f serious co m plications a re grea ter if the o p e ra tio n is done b ilaterally. I t has a highly ch aracteristic risk w hich is n o t p resen t in the open th oracic p ro ce d u re in th a t it creates a resp irato ry hazard in p a tien ts w ith lim ited re sp ira o try reserve. E ven in p atients w ith n orm al re sp irato ry fu n ctio n , the bilateral o p e ra tio n has the ch aracte ristic p ro b le m of O n dine’s curse i.e. th e fa ilu re o f re sp ira to ry drive w hen th e p a tie n t falls asleep. I t w ould seem th a t this o p e ra tio n had b e tte r n o t be don e b ila te ra lly unless it is absolu tely indicated ; if a second pro ced u re is done, it should be done at a m uch low er level to elim inate th e risk o f re sp ira to ry failu re. T h is o p e ra tio n also should be lim ited to p a tien ts w ith p ain d ue to m a lig n an t disease an d a life expectancy of n o t m ore th a n 6 m on ths because o f the hig h risk o f u np leasant dysaesthesia. T h e p a tie n t w ith ch ro n ic pain not th re a te n in g life is n o t a ca n d id a te fo r th is op eratio n . Commissural M yelotom y T h is o p e ra tio n , w hich involves a m e d ian lo ngitudinal section o f th e cord, has been p e rfo rm ed in a sporadic way since 1926. In th e last few years it has gained in p o p u la rity ag ain and can p ro b a b ly be done m ore accu rate ly w ith th e aid o f th e op e ra tin g m icroscope. It has several ad vantages in th e treatm en t o f severe p a in : (1) I t h as v irtu ally no m o rtality . (2) I t is effective in reliev ing b ila teral pain in m a lig n an t disease. (3) T h e re is no p e rm a n en t d istu rb an ce o f m ictu ritio n , bowel fu n ctio n o r m o to r pow er. It has som e draw backs, how ever: (1) I t is an open o p e ra tio n . (2) Im m ed iately p o st-o p e ra tiv ely tran sien t b u t v ery severe dysaesthesiae an d h yp eralgesia m ay develop. (3) P ro p rio c e p tio n is d isturbed b u t this tends to im prove. (4) T h e re is a p o st-o p e ra tiv e change in ap p re c ia tio n o f p in -p rick and te m p e ra tu re sensation in a band a ro u n d the low er tru n k an d dow n the thighs. (5) P a in in th e pelvis is n o t alw ays relieved. (6) I t is n o t indicated in n o n -m alig n a n t conditions. O PERATIO NS O N THE B R A IN STEM M edullary Spinothalam ic Tractomy T h eo retically , this o p e ra tio n w ould be expected to yield a h ig h er an aesth etic level than a high p e rc u ­ tan eous cervical cordotom y. T h e re a re two reasons th a t m a k e it an u n acceptable o p e ra tio n . I t is a m uch m o re dangerous p ro ce d u re an d less accurate because general an aesthesia prevents sim p le physiological test­ ing an d verification o f th e p o sitio n o f th e tra c t by these m eans. E voked p o ten tials could be used b u t this adds even m o re tim e to an o p e ra tio n p rim a rly indi­ cated fo r the seriously ill. Trigeminal Tractotomy S jo q vist’s o p e ra tio n , w hich divides the descending tract o f th e trigem inal fo r in trac tab le facial pain, has been a v ailab le since 1938 b u t has n ever gained great favour. T h e tra c t is n o t easily identifiable on the surface o f th e b rain. I f th e incision is placed too far m edially, it divides p ro p rice p tiv e fibres fro m th e arm and if too fa r laterally, it involves th e spinoth alm ic fibres fro m th e co n tra lateral side. I t can be localised a t o p e ra tio n u n d e r local an aesth esia but this precludes its use in th e seriously ill. H e re , the use of evoked p o ten tials is fa r b e tter than fo r any o th e r system of m ixed nerves. U sing evoked p o te n tials an d com bining th e o p e ra tio n w ith u p p e r cervical p o sterio r ro o t sec­ tio n can give good p a in relief in cancer of th e face and th ro at. M id-brain Tractotomy T h is o p e ra tio n , w hich was intended to in te rru p t the s p in o th alam ic tra c t a t its h igh est level in the d o rso ­ lateral tegm entu m , has been v irtu ally ab an d o n ed be­ cause o f the h ig h incidence o f p o st-o p e ra tiv e dys­ aesthesia and also the risk o f deafness if th e op e ra tio n is d on e b ilaterally. Stereotactic M esenoephalotomy T h is has som e ad vantages in th a t a very small lesion can be m ad e very accurately and its aim is to R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 66 F I S I O T E R A P I E SEPTEMBER 1979 include th e m o re m edially placed p a laeo -sp in o th alam ic fibres. Its co m p licatio n is a very high risk o f d ip lo ­ p ia an d it can n o t be done b ila terally because o f the risk of he arin g loss. It is a p ro ce d u re w ith lim ited a p p lic a tio n an d is done only at a few centres w here p a rtic u larly interested surgeon s p e rfo rm it (N ashold et al. 1969). O P E R A T IO N S O N T H E T H A L A M U S D esp ite m o re th an 20 years o f ac tiv ity in th is field, th e re is little in d ic atio n th a t a single o p e ra tio n , or even a m u ltic en tric o p e ra tio n in this region, w ill give p ain relie f devo id o f co m plications. T h e re is a fairly hig h risk w ith a reasonably low level o f success. It is as yet no m ore th a n ex p erim en tal surgery, best suited to a lim ite d n u m b er o f centres an d n o t u n i­ versally applicab le. It is o f v ery little use in the treatm en t o f th a la m ic p a in and f o r o th e r conditions in w hich it has been tried. B etter m ethods of tr e a t­ m ent a r e available. O P E R A T IO N S O N T H E F R O N T A L L O B E T h ere was a tim e w hen it was th o u g h t th a t a b la tio n o f p a rts o f th e f ro n ta l lobes w o uld solve th e problem o f suffering associated w ith pain. P re fro n ta l leucotom y in te rru p ts the fro n to th a la m ic p ro je c tio n system , and e m otional responses a r e affected m o re th a n intensity o f p a in ex p erience because th e re is no d ivision of fibre tracts d irectly resp onsible fo r th e carryin g of im pulses co ncerned w ith no cicep tion. T o b e effective, these o p e ra tio n s h ave to be ra th e r extensive a n d then ca rry a n u n a cce p tab le risk o f p e rso n a lity disturban ce. W hen they a re o f sm aller fo rm at, they fail in their pu rp o se o f p a in relief. T h e advent o f vario u s psych o­ tro p ic drugs h as m a d e th e u se o f these op e ra tio n s v ery lim ite d indeed. In som e ve ry selected in div iduals w ith p a in , th is type o f o p e ra tio n , p a rtic u la rly th e very lim ite d o p e ra tio n o f cingulotom y, m ay p lay a p art, A p a tie n t w ith an obsessive com pulsive p erso ­ n a lity w ho now has th e b u rden o f being m o rb id ly p re ­ occupied w ith his p lig h t could p e rh a p s be helped. E L E C T R IC A L S T IM U L A T IO N E lectrical stim u latio n can b e effective in co ntro llin g p a in , even if severe an d persistent, alth o u g h ap p re ciab le difficulties an d lim ita tio n s still exist. .Effective pain co n tro l m ethods are transcutaneo us, percutaneous, p e ri­ ph e ra l nerve, dorsal colum n, ventral colum n, thalam ic an d in te rn a l capsu lar stim u latio n . T hese m ethods vary in reg a rd to risk, effectiveness in given p a in problem s d u ra tio n o f benefits and technical difficulties. T he en thu siasm f o r b ra in stim u latio n m ethods has som e­ w h at decreased alm ost as ra p id ly as they have evolved. T h e tech n ical p roblem s o f electrode failu re, electrode m ov em ent an d th e v a ria b ility o f h u m a n an ato m y are m e asu re ab le defects. T h e difficulties w ith p a tie n t selec­ tio n still seem to reign suprem e an d th e success and fa ilu re rates ru n p a ra llel to all oth e r m ethods o f pain treatm en t. T im e is necessary to assess th e long-term results o f treatm en t an d effects on the b rain. I t has a lim ite d a p p lic a tio n in carefu lly selected p atients and this should be don e a t special centres. T h e an sw er to p a in is n o t surgery. It is doubtful w h eth er th e answ er will be electrical stim u latio n be­ cause it is based on the sam e sh aky an atom ico/physio- logical assum ption s as surgery. T h e answ er w ill most likely b e b iochem ical and at th e as yet nebulo us plane of in te ra ctio n betw een chem ical a c tio n an d psych ologi­ cal experience. R eferences A bbe, R . (1889): A c o n trib u tio n to surgery of th e spine. M ed . Rec. N .Y . 35, 149 - 152. M aher, R . M . (1955): R elief o f pain in incurab le cancer. L an cet 1, 18 - 20. M ullan, S., H e k m atp an a h , J., D o bben , G . a n d Beckman, F . (1965): P ercutaneous in tram ed u llary cordotom y u tiliz in g th e u n ip o la r electrolytic lesion. J. N eurosurg. 22, 548 - 553. N ash o ld, B. S., W ilson, W. P. an d Slaughter, D. G. (1969): S tereo tactic m id -b ra in lesions fo r central dys- aesthesia an d p h a n to m pain. J. N eurosurg., 30, 116 - 126. Sjoqvist von O. (1937): E in e neue O p eratio nsm ethode bei T rigem inusneuralgie durch Schneidung des T ractus Spinalis Trigem ini. Z b l. N eurochir. 2, 2 7 4 -2 8 1 . Spiller, W. G. an d M artin, E. (1912): T h e treatm ent of p ersistent pain o f organic origin in th e low er p a rt of the body by division o f th e an tero lateral colum n of th e spinal cord. J. A m . M ed. Ass. 58, 1489- 1490. Sweet, W. H . an d W epsic, J. G. (1974): C ontrolled therm ocoagulation o f th e T rig em inal ganglion and rootlets fo r differential destruction o f pain fibres. P a rt I: Trigem inal neuralgia. J. N eurosurg. 40, 143 - 156. T H E ATTITUDE O F T H E MEDICAL PROFESSION TO CHIROPRACTIC t J. N. D E K L E R K * M .B. Ch.B. (U.C.T.), F .R .C .S . (Edin.) H IS T O R IC A L B A C K G R O U N D T h e p h ilo so p h y u nd erlying c h iro p ra c tic was first p ro p o u n d e d by D a niel D a vid Palm er in the city of * H e ad , D e p t o f U rolo gy, U n iv ersity o f Stellenbosch an d C h airm an , F e d e ra l C ouncil, M edical A sso ciation o f S ou th A frica, t A ddress given to ph y sio th erap ists and stu den ts as p a rt o f C ongress an d 13th N atio n al C ouncil in C ape T ow n, 27th A p ril 1979. D av en p o rt, U.S.A., in 1895. P alm er claim ed th a t the secret o f a ll disease had been revealed to him and it w as caused by displaced v e rte b rae w h ich pressed ag ainst nerves. “By displacem ent an d pressure, they elo ng ate the p athw ay o f th e nerve in a m a n n er sim ilar to th a t by w hich an im pin gem ent u p o n a w ire o f a m usical in stru m en t induces it to becom e ta u t by displacing it. fro m a direct line. T his pressu re upon a nerve creates g rea ter ten sion , increased v ib ra tio n and consequently an increased am o u n t o f heat. H e a t alters tissue; a lte re d tissue m odifies transm issio n o f im pulses; m odified im pulses cause fu n c tio n to b e p e rform ed R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )