Surgical techniques for patients with cancer-related neuropathic pain.

Key Points

As patients live longer with and beyond a cancer diagnosis, methods to treat cancer pain beyond pain medications like opioids must be explored.

Intrathecal therapy and spinal cord stimulation are underused in cancer spaces and may have particular utility for certain pain states seen in neuro-oncology patients.

These treatment options provide individualized care plans for patients specific to their pain and circumstances.

Cancer pain, either as a consequence of the cancer or of treatment, is reported by 59% of oncology patients. 1 Even after curative treatment, 33% of patients report pain. 1 , 2 Patients with primary or metastatic tumors of the central nervous system (CNS) typically experience advanced disease, for which the prevalence of pain is 64%. 1 Neuro-oncology patients have a unique symptom burden that must be addressed.

The World Health Organization (WHO) 3-step analgesic ladder was introduced in 1986 as guidelines for chronic pain management: patients begin with nonopioid medications such as NSAIDs, then progress to weak opioids, and finally strong opioids such as oxycodone. 3 , 4 If properly used, the WHO analgesic ladder provides sufficient analgesia for 80%–90% of cancer patients and 75% of patients with a terminal diagnosis. 1 The NCCN Clinical Practice Guidelines in Oncology for Adult Cancer Pain further address the complexities of cancer pain, including specific pain syndromes such as bone pain and neuropathic pain. Recommendations differ depending on the opioid tolerance of the patient. Mild pain is treated with non-opioids and adjuvant drugs. Severe pain is treated with opioids. If patients are refractory to oral drug therapy, the NCCN Guidelines recommend interventional strategies, such as regional infusions (epidural or intrathecal) or neurostimulation. 2

The WHO analgesic ladder and the NCCN guidelines rely on opioid therapy for moderate to severe pain, with neuromodulatory techniques considered a last resort. Considering the opioid epidemic, these methods warrant challenging. 5 Additionally, opioids have adverse effects such as respiratory depression, substance use disorders, constipation, cognitive impairment, and endocrinopathies. 2 , 6 For patients with chronic pain, these side effects can become debilitating. As pain progresses and opioid tolerance develops, larger doses of opioids may be needed. 7

Improved oncological treatments have increased cancer survivorship. Since people live longer with and beyond a cancer diagnosis, the pain patients endure as a result of their disease or their treatment must be addressed. Proper pain management has been linked to improved quality of life and prolonged survivorship, thus necessitating an escalation of therapy for pain relief. Below, we discuss neurosurgical approaches and neuromodulation, such as spinal cord stimulation (SCS) and intrathecal therapy (IT), for pain management in neuro-oncology patients.

Spinal Cord Stimulation

In 1967, SCS techniques involved the direct implantation of electrodes on the dorsal surface of the spinal cord. Direct electrical stimulation of the dorsal columns was proposed as a way to disrupt the transmission of ascending pain signals and decrease chronic pain. 8 , 9 The mechanism by which this alleviates pain is not completely known. Animal studies have shown that SCS can attenuate the development of mechanical and cold hypersensitivity related to chemotherapy-induced peripheral neuropathy (CIPN) in rats. This may occur due to changes in gene expression related to astrocytes, microglia, GABA reuptake, calcium ion regulation, neuron projection development, and mechanosensory function. 10 The dorsal root ganglia show increased spontaneous excitability in paclitaxel-treated animals, and it has been theorized that SCS regulates this excitability. 11 However, a case report has also shown that spinal cord nerve conduction velocity between C6 and L1 is slowed in radiation myelopathy, which could indicate that SCS may be helpful in increasing nerve conduction abilities. 12

Human trials of SCS demonstrated initial success in decreasing pain. However, SCS was temporarily abandoned and relatively contraindicated for cancer pain because the therapy failed to provide prolonged relief. 9 A retrospective study conducted between 1970 and 1991 included 445 patients with SCS leads inserted percutaneously into the posterior epidural space depending on the segmental distribution of pain. 71% of the patients reported decreased pain, with no major complications recorded over the time period of indwelling of the lead (3-67 days). 11.5% of patients reported complete pain relief, 12.3% reported a partial decrease between 70% and 100%, 47.4% reported a partial decrease between 30% and 70%, 27.5% reported a decrease of less than 30%, and 1.3% reported aggravated pain. In total, 11.7% of the patients stopped pain medication and 59% reduced pain medication intake. This study included patients with a variety of chronic pain types. However, patients suffering from carcinoma, sarcoma, and causalgia were significantly more likely to report pain relief greater than 50% ( P < .0001). 9

Due to its effectiveness in cancer patients and the rising incidence of pain in oncology patients, the administration of this technique has changed to accommodate the compromised immune systems of cancer patients. Changes include administering doses of antibiotics, aseptic implantations, and permanent lead placements. Patients undergo a trial period where temporary percutaneous leads are placed under fluoroscopy epidurally to cover the painful region and connected to an external pulse generator, which the patient can control. The temporary lead procedure is an outpatient procedure performed under local anesthetic. If pain levels are reduced by more than 50% during the trial and daily life activities are improved, the patient undergoes outpatient surgery for the permanent implantation of the epidural leads which are tunneled and connected to a subcutaneous generator. Multiple parameters are personalized through clinic visits. 8 , 13

In 1993, the first case series to study cancer pain relief exclusively 1993 reported a decrease in pain symptoms by at least 50% in 53 oncology patients of heterogeneous cancer diagnoses with intractable pain. 14 SCS has since been used to treat cancer- and treatment-related pain including CIPN, neuropathic pain after surgery, Raynaud’s syndrome induced by chemotherapy, phantom limb pain after amputation, neuropathic pain after radiation treatment, and transverse myelitis after radiation. 14

A number of case studies have measured pain reduction, average pain medication intake, and long-term effectiveness of SCS. One review of case studies from 2002 to 2021 across 56 cancer patients reported that 48 patients reported reduced pain by at least 50%, 53 patients reported increased quality of life, 20 patients reduced drug intake, and 26 patients stopped taking pain medication entirely. The rate of complications for the implantation surgery remained low with 2 cases reporting lead migration, one case reporting infection, and 1 case reporting an allergic reaction. 14

A 2024 literature review reported the use of SCS and dorsal root ganglion stimulation across a variety of cancers including breast, colorectal, multiple myeloma, ewing sarcoma, lymphoma, melanoma, renal, and lung. Patients reported pain from an array of chemotherapy agents single and multiple drug regimens including fluorouracil, leucovorin, and oxaliplatin (FLOX), or interleukin-2, vincristine, and oxaliplatin alone. All patients demonstrated improvement in pain control, sensory deficits, and opioid consumption. 15

The long-term effectiveness of SCS shows positive trends in cancer patients, with 90-100% pain reduction and complete pain medication cessation in 2 case studies reported 12 months after implantation. 13 A report of 8 pediatric oncology patients aged 13–19 given permanent implants also showed a reduction in Visual Analog Scale of Pain Intensity (VASPI) scores from 9.2 to 2.9 maintained through a 12-month follow-up. The number of pain medications also went down from an average of 4.6 to 2.1, 2 patients completely stopped pain medications, and 2 patients reduced or stopped completely opioid usage. Benefits after 12 months are currently unclear. 11 , 13–15 Despite its many benefits, SCS remains underutilized in this space, potentially secondary to a lack of awareness.

Intrathecal Therapy

In 1979, intrathecal administration of morphine successfully provided pain relief in a human subject. 3 Since then, IT has become regarded as an effective and safe treatment for cancer and non-cancer-related pain. 16 The Polyanalgesic Consensus Conference (PACC) outlines recommendations for IT, indicating that IT should not be used as a last resort therapy due to strong evidence of its efficacy for cancer pain. IT drug administration can be titrated, allowing for increased coverage. 16

Direct administration of analgesics to the cerebrospinal fluid (CSF) bypasses the BBB and allows for more rapid analgesia. 3 The dorsal horn of the spinal cord is rich in mu opioid receptors, and IT administration of opioids allows for targeted pain relief at the spinal cord level. 4 , 17 About a tenth of the typical epidural dose is needed for subarachnoid dosing. 4 This reduced dose requirement diminishes systemic side effects associated with the analgesics being administered, such as the sedation or respiratory depression seen with opioids. This could drastically improve the quality of life.

Continued advancements in IT have led to the development of permanent implants that are programmable and customizable. 18 , 19 Before implantation, patients undergo a trial period in which pain medication is administered intrathecally, typically through a 1-time injection. If the patient is a responder, a permanent system is implanted which consists of a pump in the subcutaneous plane of the abdomen attached to a catheter inserted into the intrathecal space. Current recommendations dictate that the catheter tip be placed in the spinal dermatome most strongly associated with the pain. 16 IT pumps are filled with the medication of choice by the implanter, and dosing is adjusted over time. IT systems are useful for patients with complicated analgesic regimens or progressive diseases that may require dose escalation over time. 3 , 7 The pumps can be programmed so that a bolus dose for breakthrough pain can be administered as needed. 11

IDDS implantation is an outpatient procedure. Meaningful dosing can occur within days. In cases where light general anesthesia cannot be tolerated, or if the patient has a life expectancy of 3 months or less, epidural catheters connected to external pumps may be available for home use. 20 In cases of headache related to leptomeningeal disease, Ommaya reservoirs have been implanted to deliver more consistent drug levels to the targeted region. 18

IT is vastly underutilized, especially in patients with cancer. An analysis of the Nationwide Inpatient Sample database found that of 7 million individuals with cancer, only 22 895 received an IDDS from 2016 to 2019. In this sample size, 802 545 patients had a malignant neoplasm of the brain, spinal cord, or other CNS structures. However, only 490 patients (2.14) received an IDDS for pain control. 21 Additionally, only 760 (3.3%) of patients who received an IDDS were undergoing palliative care. There are many potential reasons for the limited use of IT, beginning with a lack of patient referral.

Second, IT is initially more expensive than conventional management. However, some studies have suggested that while initial costs may be higher, IT is cumulatively more cost-effective compared to conventional management. 21 , 22 Savings may occur as early as 2 months into treatment. 23 Restrictive reimbursement rates for IDDS implantation and refill may also decrease the number of IT recipients. 3

Procedural risks include post-dural puncture headaches, hematomas, spinal cord injury, CSF leaks, and discomfort at the site of implantation. 24 Safety concerns for IT include inflammation or granuloma formation, dosing errors or overdose due to pump malfunction, respiratory depression, and drug interactions. 3 , 17 In 2011, the FDA issued a recall for certain implantable infusion pumps after 8 deaths and 270 adverse events occurred due to pocket fills, instances where the drug was administered to the subcutaneous space. 3 A 2009 review of IDDS mortality demonstrated that IT had higher mortality at the 1-year mark than other procedures for pain like SCS or a lumbar discectomy. 3 Many of these complications, including pocket fills, can be avoided via proper protocols, adequate patient follow-up, and supervision by an interdisciplinary team. Adequate risk mitigation must be in place to reduce mortality. An IDDS implant requires refills and maintenance by nursing services, which may not be available for all patient populations.

Agents for IT Pain Relief

Intrathecal administration of different agents has demonstrated efficacy in the treatment of cancer pain ( Table 1 ). The PACC guidelines provide algorithms for selecting analgesics. 16 ( Figure 1 ) For neuropathic pain, ziconotide, opioids with a local anesthetic, local anesthetic alone, clonidine with opioids, and clonidine alone seem to produce the best results. 16 Patients with nociceptive pain respond to opioids, ziconotide, opioids with a local anesthetic, or local anesthetic alone. 16 Typically, opioids are used for palliative care while ziconotide is used for peripheral neuropathy, including that induced by chemotherapy. Briefly, we touch on the mechanism of action below.

IT morphine has consistently demonstrated efficacy for cancer patients. Opioids act at mu receptors in the dorsal horn, reducing neurotransmitter release and hyperpolarizing dorsal horn neurons, preventing the transmission of pain signals. 3 A large-scale randomized controlled trial showed reductions in opioid toxicity ( P = .004) compared to conventional medical management. 22 Specifically, respiratory depression and sedation are less common. Twenty-three complications such as infection requiring device removal, replacement, or revision occurred in 3.2% of patients, with 2 deaths thought to be linked to IT. 29 A prospective, long-term multicenter registry analysis of 1403 patients with cancer pain demonstrated that the 283 patients with baseline scores available had VASPI scores improved at 6 months ( P = .0007) and at 12 months ( P = .0026). 29 IT hydromorphone may prevent breakthrough pain more successfully than morphine. 25 Fentanyl and sufentanil use is more speculative. Similarly, though epidural clonidine has demonstrated analgesia for cancer patients, IT with clonidine for cancer pain patients specifically has not been studied. 3

IT with Ziconotide is FDA-approved for pain relief. 3 Ziconotide antagonizes N-type voltage-sensitive calcium channels on presynaptic nerve terminals at the dorsal horn. 16 Unlike opioids, ziconotide may be discontinued without major withdrawal symptoms. 27 The most common side effects are urinary retention and hallucinations. 28 However, the incidence of these side effects can be reduced by slowing the infusion rate. 28 A double-blind, placebo-controlled RCT of 111 cancer or AIDS patients with neuropathic pain demonstrated improved mean VASPI scores in the IT ziconotide group compared to placebo ( P < .001). 28

Bupivacaine is a commonly used off-label drug for IT and has demonstrated synergistic effects in combination with IT analgesic therapies, particularly morphine. 3 , 16 One prospective observational study of 60 patients with cancer pain refractory to opioids administered IT with morphine, ziconotide, and levobupivacaine. There was a significant mean VASPI reduction at day 2 ( P < .001) that persisted to day 56 ( P < .001). 26 Bupivacaine is generally well tolerated though sensorimotor loss is possible with high doses. 16 Baclofen, a GABA-A receptor agonist, can be effective in combination therapy for neuropathic pain with spasticity. 16 Intrathecal baclofen has not yet been studied in depth for cancer patients. Baclofen can hyperpolarize the motor horn cells, decreasing motor tone. 16 Baclofen withdrawal as a result of device malfunction can be life-threatening. 16

Choosing Between Therapies

A number of pain syndromes with unique etiologies can arise in patients with cancer. These syndromes can be acute or chronic, or related to the cancer itself or to the treatment received. Therapy must be chosen based on these factors and the location of the cancer ( Table 2 ). When patients with cancer have whole-body pain and/or continue to have disease progression, IT is usually most helpful. An IT pump is usually preferred when offering palliative care. In cases where the disease is controlled and/or in the aftermath of surgery, radiation or chemotherapy is being treated SCS may be considered. Near the end of life, patients may not be able to interact with the handheld remote and interface involved with a SCS.

Cancer patients are uniquely immunocompromised and susceptible to infection. However, a study conducted at MD Anderson consisting of 83 patients with an intrathecal drug delivery system (IDDS) and 59 patients with SCS systems showed no significant difference in rates of infection between cancer and non-cancer patients (2.7 % and 3.3%, respectively). 42 Longer surgeries were correlated with infection. 42 Infection most commonly occurred at the internal pulse generator site for SCS patients or at the pump pocket site for IT patients. 42

Headache and Leptomeningeal Disease

There remain limited neuromodulatory options, however, for patients with headaches, which are very common in patients with brain tumors or metastases. 30 Treating the underlying brain tumor via chemotherapy, radiation, or surgical resection is first-line therapy. There are reports of intrathecal ziconotide for migraine pain. 38 , 39 IT with a high cervical catheter to deliver opioids has demonstrated success in treating head and neck cancer patients with headaches. 32 Further, administration of morphine via the intracerebroventricular route with the Ommaya reservoir device can also provide pain relief. 32 , 31 A similar strategy can be used for patients with leptomeningeal disease. As the prognosis for patients with leptomeningeal metastases is poor, patients with a limited life expectancy may receive an external pump rather than an implantable device. 20

For patients with cranial neuralgias due to cancer metastases or treatment, ziconotide is a therapeutic option for facial and cranial-associated pain that has demonstrated efficacy in a number of case reports. 38 , 39 Case studies of IT with a high cervical catheter to deliver bupivacaine and diamorphine, or clonidine and/or baclofen in patients experiencing cranial neuralgias have demonstrated efficacy in treating facial pain. 40 Additionally, pain syndromes of the face may benefit from intraventricular morphine administration. 43 Efficacy of these techniques for neuro-oncology patients requires further study.

Pain Associated With Vertebral and Sacral Metastases

Bone metastases are the most common cause of chronic cancer pain, and the spine is the most common site of bone metastases. 37 Pain may be due to pathologic fracture or to damage of structures surrounding the metastases. Vertebral lesions cause referred pain syndromes below the site of metastasis. For example, tumor injury of the sacrum and presacral tissues can cause pain that radiates to the buttocks, posterior thighs, or perineum. 37 Activities that place pressure on these areas or involve hip rotation exacerbate pain, severely limiting patients’ mobility.

Generally, vertebral metastases are managed by radiation, surgery, or chemotherapy. In cases where the disease is diffuse, IT with morphine, bupivacaine, and clonidine may be used. 34

Of note, epidural metastases may cause spinal stenosis, impeding IT efficacy by preventing the diffusion of drugs to the nerve roots and increasing the likelihood of complications with the catheter. 20 While not considered a contraindication for IT, the location of the catheter must be carefully evaluated. 20 For patients who are stable or in remission, SCS may provide relief from radiculopathy. In a case study of a 69-year-old female with a metastatic lesion to the sacrum and a primary complaint of resultant radicular pain down the right lower extremity, SCS effectively resolved the patient’s symptoms. 34 In cases of plexopathy, cancer control with surgery, radiation, and chemotherapy are first line. SCS and IT with baclofen for severe cases have been suggested but not robustly studied. 41

Nervous System Dysfunction Following Chemotherapy and Radiation

Although not specific to neuro-oncology patients, many patients experience some nervous system injury as a consequence of the treatment received. CIPN arises in the hands and feet in a “stocking-glove” distribution and is seen with the use of therapies like vinca alkaloids and cisplatin. 11 CIPN rarely remits, thereby having long-term effects on quality of life. First-line therapy is antidepressants, anticonvulsants, or a topical agent. 2 As discussed previously, SCS has been shown to provide relief in many cancer patients experiencing CIPN.

Radiation-induced neuropathy is a condition that usually resolves with cessation of treatment. SCS may be indicated for radiation-induced neuropathy that persists.

Other Neurosurgical Techniques

Pain signals can be intercepted from their point of origin all the way along the pain pathway to the cerebral cortex. Patients refractory to oral drug therapy or ineligible for the previously mentioned therapies may benefit from the following neurosurgical procedures.

Cordotomy

Cordotomies can be used to treat pain below the C4 dermatome. 33 Anterolateral cordotomy is accomplished via laminectomy and creates a lesion of the spinothalamic tract contralateral to the affected area. It can provide somatic and visceral pain relief in oncology patients, diminishing pain and temperature signals while preserving touch, pressure, and vibration. 35 Anterolateral cordotomies have provided relief for pain in the chest, abdomen area, and lower extremities, as well as for painful bone tumors and tumors that invade nerve plexuses. 35

Percutaneous cervical cordotomy (PCC) involves lesioning the spinothalamic tract. It can be done with local anesthesia and has fewer complications compared to an open cordotomy. A bilateral PCC (BPCC) is indicated for patients with pain from spinal metastases. 35 The placement of the contralateral lesion is typically performed weeks after the first to prevent respiratory complications. 4 , 7 , 35

In a study of cancer patients with pain refractory to pharmacological therapy, 62 patients received PCC and 18 patients received BPCC. 87% of the patients who received PCC exhibited satisfactory pain relief and 10% experienced partial relief. Of the patients who received BPCC, 50% experienced satisfactory pain relief and 33% partial pain relief. Side effects included urinary retention issues, hemiparesis, and mirror-image pain. 44 High-level cervical cordotomy may put patients at risk for respiratory insufficiency. 7 One case report discussed a patient with a metastatic lesion in L5 and S1 causing low back pain even after radiation therapy and analgesic drug trials. 35 A right percutaneous cordotomy at C1-2 provides analgesia on the left below C3 while preserving motor function. 35

Myelotomy

A midline commissural myelotomy disrupts second-order spinothalamic neurons carrying pain signals as they cross the spinal cord. This allows for bilateral analgesia over a targeted area, particularly for midline structures, without disrupting motor function. One study demonstrated satisfactory pain relief at the 1-year mark in 59% of patients. 7 A myelotomy should be considered for bilateral pain syndromes below the shoulders that have not responded to other therapies. 7 For example, a lumbar myelotomy can relieve pain in the sacrum, pubic area, and perineum. A laminectomy may be needed for this procedure, and complications such as proprioceptive disturbances or dysesthesias may arise. 7 , 35 The development of minimally invasive myelotomy allows the procedure to occur under local anesthesia. 33 Stereotactic central myelotomy is a variation of myelotomy that interrupts both the spinothalamic tract fibers and the spinoreticular tracts involved in the sensory pathway. In a study of 120 patients with cancer pain who received stereotactic central myelotomy, 85% of patients were pain-free within a month of the surgery and 81% of patients were pain-free within 4–14 months. 45

Side effects include bowel and bladder dysfunction, loss of proprioception, and occasional weakness. 33

Cingulotomy

The anterior cingulate gyrus is integral for the processing of pain. Under anesthesia, unilateral or bilateral lesions of the anterior cingulate bundle can disrupt the patient’s emotional response to pain. 35 Cingulotomies may benefit patients with diffuse pain or pain where emotional distress is a significant component. This includes vertebral metastases, headache, and pain associated with cranial neuralgias. 33 In a study of patients with refractory cancer pain who received cingulotomy, 51% of the patients had moderate to complete pain relief 3 months post-procedure. 46 Analgesia tends to be temporary, especially in patients with neoplasms. 35 One case study of a 57-year-old man with bony metastases to the lumbar spine received a bilateral cingulotomy and was able to decrease daily opioid usage by 50%. Another 38-year-old man with melanoma and widespread spinal and epidural disease experienced dramatic pain reduction after a bilateral cingulotomy. 36 Side effects include transient headache and fever, and rarely bladder or bowel dysfunction and confusion. 33

Motor Cortex Stimulation

Motor cortex stimulation can lead to pain relief, likely due to its connections to the thalamus and somatosensory cortex. The motor cortex can be stimulated via epidural or subdural placements of electrodes onto the motor cortex. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive method of motor cortex stimulation via a magnetic coil that delivers pulses. There is limited research on motor cortex rTMS for cancer pain, but several case studies indicate it may relieve pain in cancer patients. 47 Transcranial direct-current stimulation is another method for noninvasive stimulation of the motor cortex. A case study of a patient with sacral pain due to sacral metastasis experienced pain relief. 48 Cancer patients with refractory pain in palliative care may benefit from these noninvasive procedures if the patient cannot otherwise withstand IT or neurosurgical procedures.

Future Directions

Spinal Cord Stimulation

After an SCS trial, the majority of patients choose to pursue permanent implants. About 17%–20% experience no beneficial response and choose to remove the temporary leads to pursue other treatments such as IT devices. 8 However, improvements in SCS technology and better identification of patients who might be responders have resulted in higher trial success rates. Whether sub-paresthesia waveforms are more effective in the treatment of cancer pain remains to be elucidated. The fact that new waveforms are effective for the treatment of diabetic peripheral neuropathy is promising for CIPN treatment and establishes the use of SCS for the treatment of peripheral neuropathy. 49 The creation of MRI conditional SCS implants has removed the barrier that many cancer patients face in pursuing permanent leads while undergoing regular scans to track tumor progression. 8 , 13

Intrathecal Therapy

Efforts must be made to address the factors that prevent widespread IT use. Physician education and a more robust referral system are needed. Further study is required to determine if earlier IT intervention improves cancer patient outcomes or survival. 21 As CSF in the intrathecal space may affect drug flow, continued research is also needed study is needed to determine the pharmacokinetics and pharmacodynamics of IT. 3

Currently, monotherapy is the mainstay of IT pain relief. However, as demonstrated by the triple IT study, polyanalgesic regimens of analgesic drugs allow for pain modulation via multiple nociceptive mechanisms. 26 More studies into the efficacy, safety, and interactions between combination therapy for cancer pain are needed. Additionally, engineered nanoparticles have the potential to further improve IT for cancer pain. Already, nanoparticle formulations encapsulating analgesics and opioids have demonstrated decreased toxicity and longer half-lives. 18

Delivering hybrid neuromodulatory therapy may also be a future direction for the treatment of pain. There is some indication that hybrid therapy of IT with SCS could convert SCS trial non-responders into trial responders through synergistic modulation of neuron activity. 3

Additionally, IT with focused ultrasound may increase drug potency through the manipulation of CSF. 50 These combination therapies could offer an additional next step for patients with persistent chronic pain.

Conclusion

SCS and IT can provide immense pain relief for neuro-oncological patients. These devices can be used in combination with chemotherapy and radiation and provide a multimodal approach to cancer pain relief. The increased use of SCS and IT as an approach to pain management and cancer pain treatment is an exciting opportunity for patients who do not respond to current treatment options. While there has been early success shown with these models, there are still limitations in the amount of data accessible for each method, particularly for neuro-oncology patients. Despite these limitations, current work suggests that these approaches can contribute to an improved quality of life for neuro-oncology patients.

Contributor Information

Erica Gillespie, Department of Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA.

Elise Bouchal, Department of Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA.

Gordon Li, Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.

Julie G Pilitsis, Department of Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA.

Supplement Sponsorship

This article appears as part of the supplement “Neurosurgical Oncology at the Crossroad of Neurosurgery Subspecialties: Intersections of Sections,” sponsored by the Halpern Family Funds.

Authorship Statement

Conceptualization: J.G.P., E.G., and E.B.. Writing of the original draft: E.G. and E.B. are co-first authors. Review and editing: E.G., E.B., J.G.P., and G.L.

Conflicts of Interest Statement

Dr. Pilitsis receives grant support from Medtronic, Boston Scientific, Abbott, and Focused Ultrasound Foundation, NIH-NeuroBlueprint MedTech 5U54EB033650, and NIH R18EB036591. She is the medical advisor for Aim Medical Robotics and has stock equity.

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