Procedures designed to surgically denervate the painful area have been developed for every level of the nervous system, from peripheral nerve to cortex.¹¹ Although these techniques are now rarely performed, the most useful has been cordotomy (spinothalamic tractotomy), which is performed percutaneously in the awake patient with unilateral pain below the mid thoracic level. It has been reported to provide more than 80% of patients with initial pain relief. Efficacy gradually declines over time, and the technique was usually reserved for patients with far advanced disease, generally with unilateral nonaxial pain. Potential adverse effects include ipsilateral leg and arm paresis, ataxia, and bladder dysfunction. Postcordotomy dysesthesia, a neuropathic pain that is often refractory to treatment, can appear many months after cordotomy and is an infrequent but potentially serious complication.

Cordotomy and other denervating procedures (such as neurectomy or rhizotomy) were previously considered for pain syndromes refractory to routine drug therapies. They have been supplanted by more sophisticated techniques of pharmacotherapy and interventional approaches that are not neurodestructive, the most important of which is neuraxial infusion.

Specific surgical approaches also have been developed to address pain related to metastases. These included conventional surgical resection and stereotactic radiosurgery.^12,13 These approaches should be considered for patients with refractory pain and those whose lesions are at high risk for fracture.