Cordotomy (or chordotomy) is a surgical procedure that disables selected

pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...

-conducting tracts in the spinal cord, in order to achieve loss of

and temperature perception. This procedure is commonly performed on patients experiencing severe pain due to cancer or other incurable diseases. Anterolateral cordotomy is effective for relieving unilateral, somatic

while bilateral cordotomies may be required for visceral or bilateral pain.

Indications

Cordotomy is performed as for patients with severe intractable pain, usually but not always due to cancer. Being irreversible and relatively invasive, cordotomy is used exclusively for pain where treatment to level 3 of the World Health Organization

pain ladder "Pain ladder", or analgesic ladder, was created by the World Health Organization (WHO) as a guideline for the use of drugs in the management of pain. Originally published in 1986 for the management of cancer pain, it is now widely used by medical p ...

(i.e., use of major opiates such as morphine) has proved inadequate. Cordotomy is especially indicated for pain due to

asbestos Asbestos () is a naturally occurring fibrous silicate mineral. There are six types, all of which are composed of long and thin fibrous crystals, each fibre being composed of many microscopic "fibrils" that can be released into the atmosphere b ...

-related cancers such as

pleural The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...

and peritoneal mesothelioma.

Procedure

Most cordotomies are now performed percutaneously with

fluoroscopic Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal anatomy, structure and ...

or CT guidance while the patient is awake under local anesthesia. The spinothalamic tract is normally divided at the level C1-C2. Open cordotomy, which requires a

laminectomy A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending ...

(removal of part of one or more vertebrae), takes place under general anaesthetic and has a longer recovery time and a higher risk of side-effects including permanent weakness. However, it is still sometimes used where percutaneous cordotomy is unfeasible, especially in children or other patients who are unable to co-operate. In open cordotomy, a thoracic approach is normally used so that the spinal cord tracts controlling the breathing muscles are not put at risk.

Adverse effects

Cordotomy can be highly effective in relieving pain, but there are significant side effects. These include dysesthesia (abnormal sensation), urinary retention and (for bilateral cervical cordotomy) apnea during sleep (

acquired central hypoventilation syndrome Central hypoventilation syndrome (CHS) is a sleep-related breathing disorder that causes ineffective breathing, apnea, or respiratory arrest during sleep (and during wakefulness in severe cases). CHS can either be congenital (CCHS) or acquired (A ...

) caused by inadvertent division of the

reticulospinal tracts The reticular formation is a set of interconnected nuclei that are located throughout the brainstem. It is not anatomically well defined, because it includes neurons located in different parts of the brain. The neurons of the reticular formatio ...

History

Cordotomy was first performed in 1912 by the American Neurosurgeons, William Gibson Spiller (1863–1940) and Edward Martin (1859–1938). Due to the surgical risks, it remained a rare procedure until the percutaneous technique was developed in 1965. During the 1990s the procedure became less widely used, partly because medical pain-control options had improved, and partly due to concern about side-effects. Nevertheless, it is still considered an effective treatment for severe pain.

Alternative surgical procedures for pain

A number of alternative surgical procedures have evolved in the 20th century. These include: Commissural myelotomy, for bilateral pain arising from pelvic or abdominal malignancies Punctate or limited midline myelotomy for pelvic and abdominal visceral pain, Other options for medically intractable pain which do not involve open surgery include implantation of an intrathecal pump (a

syringe driver A syringe driver, also known as a syringe pump, is a small infusion pump, used to gradually administer small amounts of fluid (with or without medication) to a patient or for use in chemical and biomedical research. Some syringe drivers can both ...

delivering medication into the space around the spinal cord) administering local anaesthetics and/or opiatesDo Ouro S, Esteban S, Sibercerva U, Whittenberg B, Portenov R, Cruciani RA, "Safety and tolerability of high doses of intrathecal fentanyl for the treatment of chronic pain", Journal of Opioid Management, 2(6):365-8, 2006

References

External links

Al-Chaer ED et al. A role for the dorsal column in nociceptive visceral input into the thalamus of primates. J Neurophysiol. 1998 Jun;79(6):3143-50Laboratory of Elie D. Al-Chaer for the Study of Pain
{{Central nervous system tests and procedures Neurosurgery Surgical oncology