BACKGROUND 
The treatment of chronic pain is challenging. When standard therapies fail, there remains little to offer the debilitated patient. “Painful surgery” is a technique whereby awake, sedated patients guide the surgeon to the painful site in real time during the procedure. Minimal amounts of local anesthesia are used in the skin and subcutaneous tissues to keep the procedure tolerable, but not enough is used to anesthetize the painful site. “Painful surgery” is reserved for pain that is of an unusual origin, is located at an unusual site, has been missed on prior exploration, and/or fails to respond to standard treatment. The technique is akin to awake craniotomy in which oral feedback from the patient allows maximal tumor excision while protecting critical brain functions.
PURPOSE

Our goal is to describe a surgical technique that has been used successfully to treat localized, reproducible chronic pain that is unusual in nature or that has been refractory to other treatment modalities and to analyze our results.

METHOD

Eight patients with chronic localized pain underwent “painful surgery” for the excision of painful loci. Sites of painful loci included the ankle, groin, transradial amputation stump, lower abdomen, and paramedian lower back. Seven sites were post-surgical and one site was post-laser vein ablation. Once the locus was identified intraoperatively with the patient's guidance, additional local anesthesia was injected at the site in order to allow definitive resection. After resection, further digital palpation demonstrated no residual painful areas.
The long-term outcome of surgery was determined by telephone questionnaire. The patient’s preoperative pain score was compared to the postoperative score. Pain scores were determined using a numerical rating scale from 0 (no pain) to 10 (the worst pain imaginable). A positive outcome was defined as a reduction in the preoperative pain score.
RESULTS

The mean duration of pain before “painful surgery” was 17.07 months (range, 7 to 36 months). The mean follow-up was 18 months. All patients demonstrated a positive outcome. The mean preoperative pain score was 8.0 and the mean postoperative pain score was 0.63. 
CONCLUSION

“Painful surgery” is a reliable intervention for the removal of painful loci when standard treatment modalities have failed. Oral feedback from the awake patient is vital to the success of this treatment modality.