Open Thoracic Cordotomy as a Treatment Option for Severe, Debilitating Pain

Abstract

Objective The treatment of patients with debilitating lower extremity or medically refractory quadrant pain presents a challenge for management. Contemporary neuromodulatory therapies may not be affordable or practical, especially in patients with limited life expectancy or from countries with limited resources. We present a small retrospective series to evaluate the role of open thoracic cordotomy as a practice option in the treatment of patients with severe, unilateral, medically refractory pain of the lower abdominal quadrant, hip, or leg. Technical aspects of the procedure, anatomic pathways within the spinal cord, and intraoperative maneuvers are described.

Methods The medical records of 9 patients (7 men, 2 women; median age, 57 years) treated between 1998 and 2010 were reviewed. Each patient underwent open thoracic cordotomy after 1998 for severe lower quadrant or lower extremity pain refractory to multiple other treatment modalities. The indications for surgery included cancer-related pain (4 of 9), postherpetic neuralgia (2 of 9), post-spinal cord injury pain (2 of 9), and multiple sclerosis (1 of 9).

Results Six of nine patients reported improvement in their postoperative level of pain after a median follow-up of 31 weeks. Complications included ipsilateral lower extremity weakness, urinary incontinence, and the development of new postcordotomy pain. A higher incidence of complications, including ipsilateral motor weakness, was observed in this series than with previous reports of percutaneous cervical cordotomy (PCC).

Conclusions Although open thoracic cordotomy may be cautiously recommended as a treatment option in certain settings, this procedure should be viewed only as a second-line treatment option in settings where the technology and expertise to perform PCC are available.

Keywords

cordotomy - lateral spinothalamic tract - pain

• References

• 1 Cetas JS, Saedi T, Burchiel KJ. Destructive procedures for the treatment of nonmalignant pain: a structured literature review. J Neurosurg 2008; 109 (3) 389-404
• 2 Whitworth LA, Feler CA. Application of spinal ablative techniques for the treatment of benign chronic painful conditions: history, methods, and outcomes. Spine 2002; 27 (22) 2607-2612 , discussion 2613
• 3 Tasker R. Percutaneous cordotomy for persistent pain. In: Gildenberg P, Tasker R, , eds. Textbook of Stereotactic and Functional Neurosurgery. New York: McGraw-Hill; 1998: 1491-1505
• 4 Meeuse JJ, Vervest ACM, van der Hoeven JH, Reyners AK. Five-year follow-up of a cordotomy. Pain Res Manag 2008; 13 (6) 506-510
• 5 Griffin MJ, Chambers FA, MacSullivan R. Post herpetic neuralgia: a review. Ir J Med Sci 1998; 167 (2) 74-78
• 6 Kanpolat Y, Deda H, Akyar S, Bilgiç S. CT-guided percutaneous cordotomy. Acta Neurochir Suppl (Wien) 1989; 46: 67-68
• 7 Lahuerta J, Bowsher D, Lipton S, Buxton PH. Percutaneous cervical cordotomy: a review of 181 operations on 146 patients with a study on the location of “pain fibers” in the C-2 spinal cord segment of 29 cases. J Neurosurg 1994; 80 (6) 975-985
• 8 Tasker RR, DeCarvalho GT, Dolan EJ. Intractable pain of spinal cord origin: clinical features and implications for surgery. J Neurosurg 1992; 77 (3) 373-378
• 9 Spiller WG, Martin E. The treatment of persistent pain of organic origin in the lower part of the body by division of the anterolateral column of the spinal cord. JAMA 1912; LVIII (20) 1489-1490
• 10 Rosomoff HL, Brown CJ, Sheptak P. Percutaneous radiofrequency cervical cordotomy: technique. J Neurosurg 1965; 23 (6) 639-644
• 11 Mullan S, Harper PV, Hekmatpanah J, Torres H, Dobbin G. Percutaneous interruption of spinal-pain tracts by means of a strontium90 needle. J Neurosurg 1963; 20: 931-939
• 12 Meyerson BA. Neurosurgical approaches to pain treatment. Acta Anaesthesiol Scand 2001; 45 (9) 1108-1113
• 13 Kanpolat Y, Atalağ M, Deda H, Siva A. CT guided extralemniscal myelotomy. Acta Neurochir (Wien) 1988; 91 (3-4) 151-152
• 14 Kanpolat Y, Deda H, Akyar S, Caglar S. C.T.-guided pain procedures. Neurochirurgie 1990; 36 (6) 394-398
• 15 Jones B, Finlay I, Ray A, Simpson B. Is there still a role for open cordotomy in cancer pain management?. J Pain Symptom Manage 2003; 25 (2) 179-184
• 16 Romanelli P, Esposito V, Adler J. Ablative procedures for chronic pain. Neurosurg Clin N Am 2004; 15 (3) 335-342
• 17 Sundaresan N, DiGiacinto GV, Hughes JE. Neurosurgery in the treatment of cancer pain. Cancer 1989; 63 (11, Suppl): 2365-2377
• 18 Kanpolat Y. The surgical treatment of chronic pain: destructive therapies in the spinal cord. Neurosurg Clin N Am 2004; 15 (3) 307-317
• 19 Foley K. Management of cancer pain. In: Devita Jr., V, Hellman S, Rosenberg S, , eds. Cancer: Principles & Practice of Oncology. Philadelphia: Lippincott Williams & Wilkins; 2000: 2615-2649
• 20 O'Shea P, Sutcliffe J. An asleep-awake-asleep anaesthetic technique for open spinothalamic tract cordotomy in patients with intractable cancer pain. J Neurosurg Anesthesiol 1999; 11 (4) 332
• 21 Nagaro T, Adachi N, Tabo E, Kimura S, Arai T, Dote K. New pain following cordotomy: clinical features, mechanisms, and clinical importance. J Neurosurg 2001; 95 (3) 425-431
• 22 Jack TM, Lloyd JW. Long-term efficacy of surgical cordotomy in intractable non-malignant pain. Ann R Coll Surg Engl 1983; 65 (2) 97-102
• 23 Severinghaus J. Ondine's curse; failure of respiratory center automaticity while awake. Clin Res 1962; 10: 122
• 24 Polatty RC, Cooper KR. Respiratory failure after percutaneous cordotomy. South Med J 1986; 79 (7) 897-899
• 25 Kanpolat Y, Ugur HC, Ayten M, Elhan AH. Computed tomography-guided percutaneous cordotomy for intractable pain in malignancy. Neurosurgery 2009; 64 (3, Suppl): ons187-ons193 , discussion ons193–ons194
• 26 Raslan AM. Percutaneous computed tomography-guided radiofrequency ablation of upper spinal cord pain pathways for cancer-related pain. Neurosurgery 2008; 62 (3) (Suppl. 01) 226-233 , discussion 233–234
• 27 Jackson MB, Pounder D, Price C, Matthews AW, Neville E. Percutaneous cervical cordotomy for the control of pain in patients with pleural mesothelioma. Thorax 1999; 54 (3) 238-241
• 28 Sanders M, Zuurmond W. Safety of unilateral and bilateral percutaneous cervical cordotomy in 80 terminally ill cancer patients. J Clin Oncol 1995; 13 (6) 1509-1512