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

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

-conducting tracts in the

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...

, in order to achieve loss of

and

temperature Temperature is a physical quantity that quantitatively expresses the attribute of hotness or coldness. Temperature is measurement, measured with a thermometer. It reflects the average kinetic energy of the vibrating and colliding atoms making ...

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 syste ...

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

cancer Cancer is a group of diseases involving Cell growth#Disorders, abnormal cell growth with the potential to Invasion (cancer), invade or Metastasis, spread to other parts of the body. These contrast with benign tumors, which do not spread. Po ...

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

. 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 list of specialized agencies of the United Nations, specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Gen ...

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 Morphine, formerly also called morphia, is an opiate that is found naturally in opium, a dark brown resin produced by drying the latex of opium poppies (''Papaver somniferum''). It is mainly used as an analgesic (pain medication). There are ...

) has proved inadequate. Cordotomy is especially indicated for pain due to

asbestos Asbestos ( ) is a group of naturally occurring, Toxicity, toxic, carcinogenic and fibrous silicate minerals. There are six types, all of which are composed of long and thin fibrous Crystal habit, crystals, each fibre (particulate with length su ...

-related cancers such as

pleural The pleural cavity, or pleural space (or sometimes intrapleural space), is the potential space between the pulmonary pleurae, pleurae of the pleural sac that surrounds each lung. A small amount of serous fluid, serous pleural fluid is maintained ...

and

peritoneal mesothelioma Peritoneal mesothelioma is the name given to the cancer that attacks the lining of the abdomen. This type of cancer affects the lining that protects the contents of the abdomen and provides a lubricating fluid to enable the organs to move and work ...

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 Fluoroscopy (), informally referred to as "fluoro", 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 surgeon to see t ...

or CT guidance while the patient is awake under

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

. The

spinothalamic tract The spinothalamic tract is a nerve tract in the anterolateral system in the spinal cord. This tract is an ascending sensory pathway to the thalamus. From the ventral posterolateral nucleus in the thalamus, sensory information is relayed upwar ...

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 of the vertebral arch, lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postla ...

(removal of part of one or more vertebrae), takes place under

general anaesthetic General anaesthetics (or anesthetics) 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 coma that causes lack of awaren ...

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 (: thoraces or thoraxes) or chest is a part of the anatomy of 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 ...

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 but may also present as an inappropriate, ...

(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 ( ...

) caused by inadvertent division of the

reticulospinal tracts The reticular formation is a set of interconnected nuclei in the brainstem that spans from the lower end of the medulla oblongata to the upper end of the midbrain. The neurons of the reticular formation make up a complex set of neural networks i ...

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 (sin. ''intrathecal space'') so that it reaches the cerebrospinal fluid (CSF). It is useful in several applic ...

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

opiates An opiate is an alkaloid substance derived from opium (or poppy straw). It differs from the similar term ''opioid'' in that the latter is used to designate all substances, both natural and synthetic, that bind to opioid receptors in the brain ( ...

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