Bilateral Medial Thalamotomy and Anterior Cingulotomy With Gamma Knife Radiosurgery for Refractory Pain: A Case Report.

Medial thalamotomy as well as cingulotomy has been a classical neurosurgical practice for pain, and the latter has also been used for treatment-resistant psychiatric conditions, particularly affective disorders. Here, we present the case of a patient with a seven-year history of progressive refractory neuropathic pain secondary to an intramedullary tumor treated solely with radiotherapy. She had regular emergency room visits for breakthrough pain unresponsive to high-dose opioids and was eventually referred to palliative care. Due to the severe impact of chronic pain on her quality of life, she developed a comorbid anxiety-depressive disorder and was treated in the national psychiatric center for several years without improvement. With no further treatment options available, she was referred for Gamma Knife radiosurgery. She was treated with bilateral irradiation of the cingulum and medial thalamus. Prior to treatment, her Visual Analogue Scale (VAS) pain score was 9/10. One year post-treatment, the patient reported a substantial reduction in pain intensity (VAS 2/10), along with a marked improvement in quality of life, enabling her to return to work. Follow-up neuroimaging at eight and twelve months revealed a unilateral hyper-response to the treatment exclusively on the left hemisphere. This case emphasizes a possible treatment option for patients with chronic neuropathic, intractable pain for achieving effective, prolonged pain control, improved functionality, with no adverse physical effects. To the best of our knowledge, to date, a radiosurgical treatment combining cingulotomy and thalamotomy has not been previously reported.