Ball Tyler, Aljuboori Zaid, Nauta Haring
Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky.
Oper Neurosurg. 2020 Aug 1;19(2):E183. doi: 10.1093/ons/opaa034.
Punctate midline myelotomy (PMM) is a surgical procedure that damages the ascending fibers of the postsynaptic dorsal column (PSDC) pathway to interrupt visceral pain transmission.1-3 It can offer relief to patients with chronic visceral pain conditions that are refractory to other treatments. Here, we present a surgical video of midthoracic PMM in a patient with chronic, intractable, nonmalignant visceral abdominal pain that failed over a decade of medical treatment. We choose T7-8 as the level for laminectomy in patients with pelvic or lower abdominal pain, because the postsynaptic pain fibers transmitting visceral pain sensation from the lower abdominal organs will invariably be caudal to this level. The patient developed immediate and complete relief of her visceral pain after the procedure, which was sustained through the 11-wk follow-up period to date and was able to be weaned off narcotics. Postoperatively, she remained full strength and had no impairment of light touch or proprioception of her lower extremities. Detailed physical examination showed a reduced vibratory sensation on the glabrous skin of her great toes. Regarding patient-reported sensory changes (not detected on physical examination), she reported some numbness on the insides of her feet that had resolved by 11-wk follow-up. She also reported some numbness of the vulva, but not of the vagina. However, by 11-wk follow-up, she reported this had resolved and she had normal sexual function. The only persistent sensation at 11-wk follow-up was slight tingling in her toes that was not bothersome to her.4 The patient presented in the following video consented to both the surgical procedure and the publication of her clinical history and operative video.
点状中线脊髓切开术（PMM）是一种外科手术，它会损伤突触后背柱（PSDC）通路的上行纤维，以中断内脏痛觉传递。1-3 它可以为患有其他治疗方法难以治愈的慢性内脏痛的患者提供缓解。在此，我们展示了一段针对一名患有慢性、顽固性、非恶性腹部内脏痛且经过十多年药物治疗无效的患者进行胸段中部PMM的手术视频。对于患有盆腔或下腹部疼痛的患者，我们选择T7-8作为椎板切除术的水平，因为从下腹部器官传递内脏痛觉的突触后痛觉纤维总是在这个水平以下。手术后，患者的内脏痛立即完全缓解，至今在11周的随访期内一直保持，并且能够停用麻醉药。术后，她保持了全部体力，下肢的轻触觉或本体感觉没有受损。详细的体格检查显示她大脚趾无毛皮肤的振动觉减退。关于患者报告的感觉变化（体格检查未发现），她报告双脚内侧有一些麻木，在11周的随访时已缓解。她还报告了外阴有些麻木，但阴道没有。然而，到11周随访时，她报告这种情况已缓解，并且性功能正常。在11周随访时唯一持续存在的感觉是她脚趾有轻微刺痛，但这对她并不造成困扰。4 以下视频中的患者同意了手术以及公布她的临床病史和手术视频。
