Cervical Cordotomy in Terminal Cancer: Pain Relieving in Oncological Treatment

Cordotomy consists in the discontinuation of the lateral spinothalamic tract (LST) in the anterolateral quadrant of the spinal cord, which aims to reduce the transference of nociceptive information in the dorsal horn of the gray matter of the spinal cord to the somatosensory cortex. The main indication is for patients with terminal cancer that have a low life expectancy. It improves the quality of life by relieving pain. The results are promising and the pain relief rate varies between 69 and 100%. Generally speaking, the complications are mostly temporary and not remarkable.

Cervical cordotomy for the treatment of oncological pain / Cordotomia cervical para tratamento da dor oncológica: revisâo de literatura

Cordotomy consists in the discontinuation of the spinothalamic tract in the anterolateral quadrant of the spinal cord and aims to reduce the transference of nociceptive information in the dorsal horn of the grey matter of the spinal cord (CPME) for rostral units at the neural axis. Many modalities of cordotomy may be employed: anterior transdiscal between C4-C5; endoscopic infra mastoid tip between C1-C2; percutaneous guided by fluoroscopy infra mastoid tip between C1-C2; percutaneous guided by CT infra mastoid tip between C1-C2; open cordotomy by means of laminectomy. The main indication is for patients in advanced cancer disease with severe neuropathic pain bellow the neck in whom the period of survival due to cancer disease is inferior to 3-4 months. The results for immediate pain relieve ranges from 69% to 100% of the cases, while preoperative Karnofsky scores were 20 and 70, respectively versus post operative Karnofsky scores of 20 and 100 respectively; the difference was determined to be highly significant (p < 0.001).

A cordotomia consiste na discontinuação do trato espinotâmico no quadrante ântero-lateral da medula espinal e visa reduzir a transferência de informação nociceptiva no corno dorsal da substância cinzenta da medula espinal (CPME) para as unidades rostrais no neuroeixo. Muitas modalidades de cordotomia podem ser empregadas: transdiscal anterior entre C4-C5; endoscópica inframastoidea entre C1-C2; Percutânea inframastoidea entre C1-C2 guiada por fluoroscopia; percutânea inframastoidea entre C1-C2 guiada por TC; cordotomia aberta por laminectomia. A principal indicação é para pacientes com câncer avançado com dor neuropática severa abaixo do pescoço nos quais a sobrevida devido ao câncer é inferior a 3-4 meses. Os resultados para alívio imediato da dor varia de 69% a 100% dos casos, enquanto os escores de Karnofsky foram de 20 e 70 no período pré-operatório, para 20 e 100 no período pós-opertaório; a diferença foi estatisticamente significativa (p < 0.001).

Percutaneous Cervical Radiofrequency Cordotomy for Intractable Pain

The technique of anterolateral cordotomy for relief of pain was first performed by Spiller and Martin (1912). It was accepted as the best available method for long-term relief despite its disadvantages. It has been well documented that the procedure often caused weakness of an extremity or the loss of sphincter control and respietory impairment associated with high surgical cervical cordotomy. In 1963, Mullan et al. devised an approach to the cervical spinal cord by inserting a needle through the neck under roentgenologic control. They introduced a radioactive needle (Strontium90) to produce a lesion interrupting the lateral spinothalamic tract. Mullan and Rosomoff et al. (1965) later simplified the produce by using an electrical current to produce the lesion. The percutaneous method has considerable advantages. The mortality and morbidity are very small and the technique can be used on any patient including even the terminal state. If the required level is not attained on the first attempt, or if the level subsequently drops, the procedure is easily repeated. Most patients can be discharged early after this type of cordotomy. Authors have reviewed 46 cordotomies on 35 patients with intractable pain carried out by the percutaneous radiofrequency procedure at the Neurosurgery Department of Yonsei University from 1972 to 1975:36 cases were treated by a modification of the Rosomoffs technique, 10 cases by Lin's technique. Intractable pain has been a continuing problem in neurosurgery and many methods have been employed in its treatment. The function of lateral spinothalamic tract was described by Spiller and Martin in 1912. and they described the posterior approach to the spinal cord which has been widely used for cordotomy in the 50 years since. However, in elderly or debilitated patients, this method has proved to have many complications and is poorly tolerated and has a morbidity and mortality rate. In 1963, Sean Mullan, using a Strontium90 electrode accomplished a lateral spinothalamic cordotomy by stereotaxic surgery under local anesthesia (Mullan, et al., 1963; 1965; 1965). Later, in 1965, Rosomoff (Rosomoff,et al., 1965; Rosomoff, et al., 1966) developed an improved technique using UHF radio waves, which achieved wide popularity. Using radiological equipment and measuring the impedance of various portions of the spinal cord with electrodes, the exact area of the lateral spinothalamic tract to be destroyed could be located. Utilizing localizing electrodes and the above method, complications from destruction of the tracts near the lateral spinothalamic tract which formerly resulted in hemiparesis, respiratory difficulty, urinary difficulties and other surgical difficulties could be minimized much more effectively than with open surgical approaches (Mullan and Hosobuchi, 1968). In bilateral, high cervical cordotomy the complication of sleep induced apnea may be a cause of death. Belmusto (Belmusto, et al., 1963; Belmusto; et al., 1965) indicated that the respiratory fibers are very near the lateral spinothalamic tract in the C-1 to C-3 spinal region. The respiratory fibers are located in the anterior one fourth of the spinal cord, extending from the median fissure 3~3.5 mm lateral wards towards the region of the median part of the lateral spinothalamic tract. (Mullan and Mosobuchi, 1968; Nathan, 1963; Hitchcock and Lee ce, 1967; Crosby, et al., 1962). In 1966, Lin (Lin, et al., 1966), developed a low cervical anterior approach, in order to avoid damage to the respiratory tract, and found that respiratory tract damage was actually decreased, and also found that regional analgesia was easily accomplished. Over the last three years, the authors, applying a percutaneous cervical cordotomy technique, have studied 46 patients, recording the present illness, method of surgery, postoperative analgesic area and its change with time, and complications. This material was analyzed and conclusions drawn.