Cordotomy


Article Author:
Dac Teoli


Article Editor:
Jason An


Editors In Chief:
Stephen Leslie
Karim Hamawy


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Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
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Heba Mahdy
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Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/28/2019 11:25:42 AM

Introduction

Cordotomy is the name of a surgical procedure aimed at destroying the pain-conducting tracts of the spinal cord. First performed in 1912 by neurosurgeons William Spiller and Edward Martin, they found the cordotomy to be effective at decreasing temperature and pain sensations in patients which suffer from painful conditions. It was originally widely used for chronic pain, but now it has been adapted for use in cancer patients only.   The open procedure is rarely performed due to the high risk and complication rates observed previously.

The open method underwent further adaptation to a percutaneous cervical cordotomy in 1963. In the 1990s, with improvements in pain management, the cordotomy again fell out of favor. However, it is still a palliative option for therapy-resistant pain. Given the population which receives this procedure, there is severely limited availability of studies testing its long-term effects. There is a case study of a patient with seminoma who underwent a right-sided percutaneous cervical cordotomy and chemotherapy. The physicians found the patient, five years later, to have continued sensory impact with minimal impact on motor and autonomic function.[1]

Anatomy

Today with the percutaneous cervical cordotomy, the nociceptive pathways in the lateral spinothalamic tract anterolateral column are destroyed in the cervical spinal cord at the level of C1-C2.[2]

Indications

The original approach focused on pain relief for patients with unilateral malignancies, lower extremity pathologies, failed back syndrome, chronic nociceptive painful conditions, and cancer patients.  On the other hand, bilateral cordotomies for visceral or bilateral pain is also an option. In the more recent percutaneous approach, destruction of the lateral spinothalamic at the level of C1-C2 results in a contralateral disruption of painful sensations beyond C4. Today, this latter approach is most commonly used in patients with limited life expectancy and suffering from opioid-resistant cancer pain. Irrespective of the procedure or technique, one uniform indication for this intervention is having severely intractable pain which has not responded to conventional therapies. Cancer-related pain is an indication, but not a requirement as it can be done in populations suffering other irreversible painful conditions. Pain severity level is essential when considering appropriate indications.  The patient's pain must have advanced to level 3 of the World Health Organization pain ladder before considering this invasive procedure. 

The cordotomy has been documented as particularly impactful for pain secondary to mesothelioma, Pancoast syndrome, and lung cancer.[3]

Contraindications

Percutaneous cordotomy is contraindicated in patients with a coagulation disorder, severely reduced ventilator function, and if a patient is unable to cooperate.[4] Several alternative procedures were developed in the 20th century. The commissural myelotomy was developed for bilateral pain arising from pelvic or abdominal neoplastic disease. Likewise, the punctate or limited midline myelotomy also aimed at pelvic and abdominal visceral pain. Therefore, if patients have pain solely localized to these regions, the cordotomy can be avoided and these newer procedures adopted.  With the introduction of intrathecal pumps and spinal cord stimulators, it is prudent to steer many patients away from cordotomies.[5]

Technique

Most cordotomies utilize the percutaneous approach at the level of C1-C2. The surgeon often uses fluoroscopic or CT guidance. Patients are usually awake for the procedure which is performed under local anesthesia. A laminectomy is required to execute an open cordotomy. It comes with a lengthier recovery and a higher risk of side effects. However, when percutaneous cordotomy is unfeasible, especially in children, the open procedure is preferred.[6]

Complications

Only experience serious post-procedure side effects.[7]  They include dysesthesia, urinary retention, ataxia, paresis, sympathetic dysfunction (hypotension, Horner’s syndrome and bladder dysfunction), sexual sensitivity impaired or lost, and a form of sleep apnea (acquired central hypoventilation syndrome). The bulk of these complications result from the accidental division of the unintended reticulospinal tracts. Another serious complication is spontaneous new pain. New pain may be old (previously extant) pain which was previously unrecognized and now unmasked by removing prior distractions. Likewise, new pain can be viewed as an unpreventable complication from the interruption of nociceptive pathways.

Overall, the risk of severe complications with unilateral cordotomy is low. Procedure-related mortality is reported in the range of 1%-6% which is mainly due to respiratory dysfunction.[8]  With more accurate ablation techniques, no respiratory dysfunction is rare.[9]

Clinical Significance

Percutaneous cervical cordotomy is recommended for patients with a life expectancy of fewer than six months and who also meet the pain severity indications. It is a palliative procedure. Successful, immediate pain relief results in approximately three-quarters of patients.[7]   However, the rate of pain relief declines to less than 50% after two years.  As was noted earlier, new pain syndromes can also arise, unfortunately, and patients must be aware and be willing to accept that risk. As a depiction of efficacy and clinical significance and side effects, there is a study which showed diminished touch perception on the left side of the body which points to likely an anterior spinothalamic tract lesion. The nearby anterior spinocerebellar (mediating proprioception), reticulospinal (mediating autonomic outflow) and cerebrospinal (mediating voluntary movement) tracts were deemed unaffected given no signs of ataxia, autonomic issues, or motor dysfunction.[10][11]

Enhancing Healthcare Team Outcomes

The cordotomy is a palliative procedure. It is often performed on patients with a life expectancy under six months and comes with significant risks and with possible significant benefits. Obtaining a thorough history is essential, and questioning by the clinician should show empathy to the patient and their condition, whether it be a malignancy or other pathology.  This decision is not to be made alone or lightly by the patient, family, or a clinician. Patients must not feel rushed when having their options for intractable pain laid out before them. Furthermore, this is a surgical procedure, so interdisciplinary approaches to conversations must take place. Dialogue should take place between the nurse, palliative physician, the surgeon, the oncologist, and the primary physician. Each specialty should be involved with helping the patient make an informed decision which the patient feels is best for their own goals of care. As always, especially in palliative care patients with often many co-morbidities, the patient's medical history and background should be clearly defined to members of the patient's healthcare team. Any deviation from thoroughness can create significant challenges and risks for the patients, their family, and their clinicians. Medical errors are to be actively avoided. If any particular nurse or clinician feels that significant palliative procedures, such as the cordotomy, are not the best choice for the patient, they should tactfully bring up their concern to the clinicians involved in that patient's care. This approach ensures that they have a full and clear understanding of the procedure, risks, and benefits prior to approaching the patient with their professional opinion.[12]


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Cordotomy - Questions

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What is the most common indication for cordotomy?



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What is the most frequent complication of cordotomy?



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Which of the following is the most common result from cordotomy?



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At what level is the percutaneous cervical cordotomy most often performed?



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Which part of the spine is targeted in the cordotomy?



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A 46-year-old man presents to the clinic after being referred by his palliative medicine specialist. The patient has a history of metastatic lung cancer with debilitating pain severely impacting his quality of life. Despite aggressive medical management and pain specialist intervention, his pain persists, and he reports that he is starting to experience thoughts of suicidal ideation because of his discomfort. The patient requests to be provided with information about the well-known invasive surgical procedure, which is often performed in cancer patients with refractory somatic pain. Which of the following is the earliest exam finding of the most common complication leading to mortality in patients that undergo this procedure?



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A 50-year-old woman presents to the clinic for follow-up after having undergone a unilateral cordotomy. The patient currently works as a chef and has a history of metastatic breast cancer. Her vital signs are all within normal reference ranges. The patient states that while her somatic pain has improved, she has noticed other side effects of the procedure. Which of the following is the most appropriate precaution the patient must take given the interventional target of this procedure?



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A 38-year-old man with metastatic colon cancer has undergone a bilateral cordotomy for refractory opioid-resistant pain. The patient has no other significant prior medical conditions, and a percutaneous cervical approach for the procedure was chosen. In the clinic, his vital signs are within normal reference ranges. He reports improvement to his somatic pain. However, he describes a new "annoyance" with eating and drinking. Regarding the risk to surrounding structures, given the anatomic location most commonly targeted with this procedure, what deficit is most expected as leading to his new complaint regarding oral intake?



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A 66-year-old woman presents to the clinic for evaluation of her pharmacology-resistant cancer pain. Her discomfort is localized to the bilateral pelvic region and is debilitating. The patient has a history of metastatic breast cancer with a prognosis of five months. Her vital signs are all within normal reference ranges. After discussing the options, the surgeon decides to perform the closely related, alternative surgical procedure to the cordotomy for the patient's complaint. Given the referenced procedure, its anatomic targets, and the potential side effects, which of the following is most likely to be seen after the intervention?



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Cordotomy - References

References

Shepherd TM,Hoch MJ,Cohen BA,Bruno MT,Fieremans E,Rosen G,Pacione D,Mogilner AY, Palliative CT-Guided Cordotomy for Medically Intractable Pain in Patients with Cancer. AJNR. American journal of neuroradiology. 2017 Feb     [PubMed]
Tinkler M,Royston R,Kendall C, Palliative care for patients with mesothelioma. British journal of hospital medicine (London, England : 2005). 2017 Apr 2     [PubMed]
Sharma ML,Marley K,McGlone FP,Gupta M,Marshall AG, Dissociation of Spinothalamic Modalities Following Anterolateral Cordotomy. The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques. 2018 May     [PubMed]
Fontaine D,Blond S,Mertens P,Lanteri-Minet M, [Neurosurgical treatment of chronic pain]. Neuro-Chirurgie. 2015 Feb     [PubMed]
Berger A,Tellem R,Arad M,Hochberg U,Gonen T,Strauss I, [NEUROSURGICAL INTERVENTIONS FOR INTRACTABLE ONCOLOGICAL PAIN]. Harefuah. 2018 Feb     [PubMed]
Vedantam A,Bruera E,Hess KR,Dougherty PM,Viswanathan A, Somatotopy and Organization of Spinothalamic Tracts in the Human Cervical Spinal Cord. Neurosurgery. 2018 Jul 13     [PubMed]
Stuart G,Cramond T, Role of percutaneous cervical cordotomy for pain of malignant origin. The Medical journal of Australia. 1993 May 17     [PubMed]
Higaki N,Yorozuya T,Nagaro T,Tsubota S,Fujii T,Fukunaga T,Moriyama M,Yoshikawa T, Usefulness of cordotomy in patients with cancer who experience bilateral pain: implications of increased pain and new pain. Neurosurgery. 2015 Mar     [PubMed]
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 Mar     [PubMed]
Sanders M,Zuurmond W, Safety of unilateral and bilateral percutaneous cervical cordotomy in 80 terminally ill cancer patients. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 1995 Jun     [PubMed]
Blaauw G,Zuijderduijn J,Hilvering C, [Percutaneous chordotomy, a method for the treatment of unbearable pain]. Nederlands tijdschrift voor geneeskunde. 1975 Jan 11     [PubMed]
Price C,Pounder D,Jackson M,Rogers P,Neville E, Respiratory function after unilateral percutaneous cervical cordotomy. Journal of pain and symptom management. 2003 May     [PubMed]

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