MRI-guided focused ultrasound thalamotomy for neuropathic pain in an adolescent with cranial metastases: illustrative case

BACKGROUND Neuropathic cancer pain (NCP) is a debilitating condition that is often refractory to conventional medical management. MRI-guided focused ultrasound (MRgFUS) central lateral thalamotomy (CLT) is an incisionless neurosurgical option for neuropathic pain palliation, but its use in pediatric patients and those with cranial metastases, a relative contraindication to MRgFUS, remains largely unexamined. OBSERVATIONS A 16-year-old male with metastatic rhabdomyosarcoma (RMS) with numerous cranial metastases experienced severe, diffuse, refractory NCP. The patient underwent bilateral CLT with MRgFUS. After the procedure, the patient experienced complete and durable resolution of his neuropathic pain. He only reported occasional somatic pain at sites of visible tumor growth. His pain remained well controlled until his death 1.5 months later due to disease progression. LESSONS MRgFUS CLT appears to be a feasible and efficacious option for adolescent cancer patients with atypical cranial anatomy due to metastatic disease. This case highlights the potential for durable pain control in refractory NCP and suggests MRgFUS as a valuable palliative tool, warranting further investigation in pediatric patients and unique anatomical scenarios. https://thejns.org/doi/10.3171/CASE25221