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Se describen la talamotomia estereotaxica medial y basal, la ablacion hipofisaria, la girectomia precentral y poscentral y las lesiones en el sistema limbico para el tratamiento del dolor. Estos procedimientos lesivos del cerebro supratentorial, en la actualidad se realizan de forma infrecuente, y han sido reemplazados por la estimulacion cerebral y por la administracion intraventricular de farmacos. La potencia de la evidencia de la eficacia de estos diversos procedimientos lesivos quirurgicos para el alivio del dolor cronico es debil, debido a que no son posibles los procedimientos doble ciego controlados por placebo. Sin embargo, las publicaciones de autoridades respetables en la materia muestran que se han obtenido resultados muy notables en sindromes dolorosos «intratables», y esto es mas evidente en el dolor nociceptivo que en el dolor de caracter neuropatico. Ademas, estas intervenciones han ofrecido la oportunidad de realizar observaciones electrofisiologicas de las estructuras cerebrales supratentoriales durante los procedimientos estereotaxicos en pacientes completamente despiertos, revelando la actividad neuronal asociada con condiciones clinicas particulares.

Deep brain stimulation (DBS) has virtually replaced thalamotomy for the treatment of essential tremor. It is thought that the site for DBS is the same as the optimal lesion site; however, this match has not been investigated previously. We sought to determine whether the location of thalamic DBS matched the site at which thalamotomy would be performed. Eleven patients who had detailed microelectrode recording and stimulation for placement of DBS electrodes and subsequent successful tremor control were analysed. An experienced surgeon, blinded to outcome and final electrode position, selected the ideal thalamotomy site based on the reconstructed maps obtained intraoperatively. When the site of long-term clinically used DBS and theoretical thalamotomy location was calculated in three-dimensional space and compared for each of the x, y, and z axes in stereotactic space, there was no significant difference in the mediolateral location of DBS and theoretical lesion site. There was also no difference between the theoretical lesion site and the placement of the tip of the electrode; however, the active electrodes used for chronic stimulation were significantly more anterior (P = 0.005) and dorsal (P = 0.034) to the ideal thalamotomy target. This mismatch may reflect the compromise required between adverse and beneficial effects with chronic stimulation, but it also suggests different mechanisms of effect of DBS and thalamotomy.