Further, one must admit that the surgeon aims at selective procedures against pain. In other words, if the root of, for example, the trigeminal nerve, or the anterolateral column contains pathways with a given anatomical orientation in the body, the surgeon wishes to sever only those sections of the pathway involved in the pain, and preserve other fibres, the section of which would be injurious, such as, for example, the motor fibres of the root of the trigeminal nerve. This would appear to be very precise work, but in fact it is not the case. Such surgery is a greater or lesser approximation, with not only an inadequacy of conceived operative approach, but also associated with recurrence of pain. In my experience, this selective approach to pain surgery does not yet have an established place.
I shall now discuss individual surgical approaches against pain, from the point of view of technique and requirements.
I. Physical-anatomical ways and means A. Operative procedures on the first neuron.
1. Interruption of the most peripheral nerve branches leading from the painful area, which can be easily delimited and determined, is in general a simple procedure. It is, however, of little effect, and so has been abandoned for a number of years. We have never carried it out as a routine procedure. It is stated that this operation can be of assistance in patients with pain in the region of the femoral cutaneous nerve, i. e. in a given region of the thigh, or of the fingers in the hand (collateral nerves of the fingers). Peripheral procedures for trigeminal neuralgia will be discussed in the appropriate chapter. Crushing of the peripheral nerve is an effective and justified procedure in cases of painful vascular disease ofthe lower extremity, and section of the nerve with severe pain from the hip joint (obturator nerve and sensory branches of the ischiac). Even if both these procedures are not often carried out, they have some value and form a good operative reserve for these painful states.
Reference should be made here to removal of nerve endings which remain after amputation, since these may develop painful neuromata. This is discussed under the heading of „Amputation Pain”.