Results up to death in the treatment of persistent cervico-thoracic (Pancoast) and thoracic malignant pain by unilateral percutaneous cervical cordotomy.

The authors analyse the results up to death in 103 followed-up patients undergoing unilateral percutaneous cervical cordotomy for persistent cervico-thoracic malignant pain (45 cases of Pancoast syndrome and 58 cases of thoracic pain associated with lung cancer or metastases). On the basis of epidemiological data, relationships emerge between onset of pain, stage of cancer, patient survival and lasting efficacy of pain relief. Twenty (44%) of 45 patients with Pancoast syndrome were pain-free up to death as a result of cordotomy alone, while only 13/58 patients (22%) with thoracic pain were pain-free as a result of cordotomy alone owing to the very high incidence of mirror pain in this group of patients (42/58 patients, 72%) compared to those with Pancoast syndrome (14/45 patients, 31%). The type and intensity of mirror pain, however, were of such a nature in both groups as to be amenable to control with analgesic drugs. In both groups of patients, there was a low incidence of the causes of post-cordotomy pain recurrence contralateral to the lesion, i.e., deafferentation pain, fading of analgesia, and pain above the levels up to which deep pin-prick analgesia had been obtained. Cordotomy alone or, as necessary, in conjunction with analgesic drugs afforded complete pain control in 34/45 patients (75%) with Pancoast syndrome and in 50/58 patients (86%) with thoracic pain. These data provide evidence of the unique usefulness of the procedure in controlling otherwise intractable persistent cervicothoracic malignant pain, when the technique is correctly performed.

Subarachnoid neurolytic block (L5-S1) and unilateral percutaneous cervical cordotomy in the treatment of pain secondary to pelvic malignant disease.

The present study deals with the immediate and long-term results of subarachnoid neurolytic block (L5-S1) with 7.5%, 10% and 15% concentrations of phenol in glycerine and/or unilateral percutaneous cervical cordotomy in 73 patients (follow-up in 56 patients) suffering from perineal, perineopelvisacral or pelvisacral pain secondary to malignant diseases of the pelvic cavity. Subarachnoid neurolytic block (L5-S1) produced satisfactory, long-lasting relief of perineal pain when the higher concentrations of phenol (10 and 15%) were used. The only sequela reported was urinary retention. Percutaneous cervical cordotomy used for the treatment of pelvisacral or predominantly unilateral perineal pain gave complete pain relief until death in 76.7% of patients, either alone (36.7%) or in conjunction with pharmacological therapy (40%). Analysis of the data enabled us to establish the respective indications for the two procedures and to identify those cases in which their use may be complementary.

A new approach to the neurolytic block of the coeliac plexus: the transaortic technique.

The present study critically examines the coeliac plexus block techniques hitherto adopted, pointing out the complications involved and stressing the seriousness of the neurological complications due to spread of the neurolytic agent to the sympathetic chain and the lumbar plexus. Contrast enhanced CT scans demonstrate the difficulties involved in confining the neurolytic agent to the anterior, peri-aortic and precrural regions. The authors report their recent experience with coeliac plexus block by means of a single transaortic needle in 28 patients. In 12 of the patients, the CT scan revealed a spread was anterior to the medial crura of the diaphragm, sometimes extending laterally towards the costovertebral gutter along the ventral surface of the diaphragm.