Punctate midline myelotomy - A new approach in the management of visceral pain

Nauta et al. reported on a successful punctate midline myelotomy (PMM) for the treatment of intractable pelvic pain. The authors describe an other case history of a patient with multiple anaplastic carcinomas of the small intestine, peritoneal carcinosis and retroperitoneal lymphomas, suffering from severe visceral pain in the hypo-, meso-, and epigastrium. Nauta's PMM was successfully performed at the Th4 level. Narcotic medication was tapered from 30 mg iv, morphine per hour pre-operatively to 5 mg per hour within 5 days postoperatively. Intensity of pain decreased from 10 to 2-3 on the visual analog scale. Only minor transient side effects appeared and the patient was discharged 5 days postoperatively. The pain reduction was maintained until the patient died from the extended disease five weeks later. We conclude that punctate midline myelotomy sufficiently controls not only pelvic visceral pain, but also visceral pain generated in the meso- and epigastrium. The findings support the concept of a midline dorsal column visceral pain pathway.