Cordotomy (or chordotomy) is a surgical procedure that disables selected pain-conducting tracts in the

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the sp ...

, in order to achieve loss of pain and

temperature Temperature is a physical quantity that expresses quantitatively the perceptions of hotness and coldness. Temperature is measurement, measured with a thermometer. Thermometers are calibrated in various Conversion of units of temperature, temp ...

perception Perception () is the organization, identification, and interpretation of sensory information in order to represent and understand the presented information or environment. All perception involves signals that go through the nervous system ...

. This procedure is commonly performed on patients experiencing severe pain due to

cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...

or other incurable diseases. Anterolateral cordotomy is effective for relieving unilateral, somatic pain 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

. Being irreversible and relatively invasive, cordotomy is used exclusively for pain where treatment to level 3 of the

World Health Organization The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...

pain ladder (i.e., use of major opiates such as

morphine Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies (''Papaver somniferum''). It is mainly used as a pain medication, and is also commonly used recreationally, or to make other illicit opioids. T ...

) has proved inadequate. Cordotomy is especially indicated for pain due to asbestos-related cancers such as pleural and peritoneal mesothelioma.

Procedure

Most cordotomies are now performed

percutaneous {{More citations needed, date=January 2021 In surgery, a percutaneous procedurei.e. Granger et al., 2012 is any medical procedure or method where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using ...

ly with fluoroscopic or CT guidance while the patient is awake under

local anesthesia Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...

. The

spinothalamic tract The spinothalamic tract is a part of the anterolateral system or the ventrolateral system, a sensory pathway to the thalamus. From the ventral posterolateral nucleus in the thalamus, sensory information is relayed upward to the somatosensory co ...

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 General anaesthetics (or anesthetics, see spelling differences) are often defined as compounds that induce a loss of consciousness in humans or loss of righting reflex in animals. Clinical definitions are also extended to include an induced com ...

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 The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the crea ...

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 Dysesthesia is an unpleasant, abnormal sense of touch. Its etymology comes from the Greek word "dys," meaning "bad," and "aesthesis," which means "sensation" (abnormal sensation). It often presents as pain Joseph J. Marbach, Joseph Marbach hypo ...

(abnormal sensation), urinary retention and (for bilateral cervical cordotomy) apnea during sleep ( acquired central hypoventilation syndrome) 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 Intrathecal administration is a route of administration for drugs via an injection into the spinal canal, or into the subarachnoid space so that it reaches the cerebrospinal fluid (CSF) and is useful in spinal anesthesia, chemotherapy, or pain ma ...

pump (a syringe driver delivering medication into the space around the spinal cord) administering

local anaesthetics A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general an ...

and/or

opiates An opiate, in classical pharmacology, is a substance derived from opium. In more modern usage, the term ''opioid'' is used to designate all substances, both natural and synthetic, that bind to opioid receptors in the brain (including antagonist ...

Do 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