Editing Cordotomy

{{short description|Spinal cord surgery for pain management}}
{{Infobox medical intervention |
  Name        = Cordotomy |
  Image       = |
  ICD10       = |
  ICD9        = {{ICD9proc|03.2}} |
  MeshID      = D002818 |
  OtherCodes  = |
}}
'''Cordotomy''' (or '''chordotomy''') is a surgical procedure that disables selected [[pain]]-conducting tracts in the [[spinal cord]], in order to achieve loss of [[pain]] 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 [[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 [[cancer]].  Being irreversible and relatively invasive, cordotomy is used exclusively for pain where treatment to level 3 of the [[World Health Organization]] [[pain ladder]] (i.e., use of major opiates such as [[morphine]]) 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]]ly with [[fluoroscope|fluoroscopic]] 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]] (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),<ref>{{cite web|last=Mann|first=Michael|title=Somesthesia - Central Mechanisms|url=http://www.unmc.edu/physiology/Mann/mann6.html|work=The Nervous System in Action|accessdate=30 May 2011|archive-date=12 June 2011|archive-url=https://web.archive.org/web/20110612043806/http://www.unmc.edu/physiology/Mann/mann6.html|url-status=dead}}</ref> urinary retention and (for bilateral cervical cordotomy) apnea during sleep ([[acquired central hypoventilation syndrome]]) caused by inadvertent division of the [[reticulospinal tracts]].<ref>Tranmer B, Tucker W, Bilbao J.  Sleep apnea following percutaneous cervical cordotomy.  Can J Neurol Sci, 14(3):262-7, 1987</ref>

==History==

Cordotomy was first performed in 1912 by the American Neurosurgeons, William Gibson Spiller (1863&ndash;1940) and Edward Martin (1859&ndash;1938).<ref>Spiller W, Martin E.  The treatment of persistent pain of organic origin in the lower part of the body by division of the anterolateral column of the spinal cord.  JAMA, 58(1):489-90, 1912</ref>  Due to the surgical risks, it remained a rare procedure until the percutaneous technique was developed in 1965.<ref>Mullan S, Hekmatpanah J, Dobben G, Beckman F. Percutaneous, intramedullary cordotomy utilizing the unipolar anodal electrolytic lesion. J Neurosurg, 22(6):548-53, 1965</ref>  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 <ref>Viswanathan A, Burton AW, Rekito A, McCutchean IE, "Commissural myelotomy in the treatment of intractable visceral pain: technique and outcomes", Stereotactic and Functional Neurosurgery, 88(6):374-82, 2010</ref>

'''Punctate''' or '''limited midline myelotomy''' for pelvic and abdominal visceral pain,<ref>Hong D, Andren-Sandberg A, "Punctate midline myelotomy: a minimally invasive procedure for the treatment of pain in inextirpable abdominal and pelvic cancer", Journal of Pain Symptom Management, 33(1):99-109, 2007</ref><ref>Gildenberg PL, Hirshberg RM, "Limited myelotomy for the treatment of intractable cancer pain", Journal of Neurology, Neurosurgery, and Psychiatry, 47(1):94-6, 1984</ref>

Other options for medically intractable pain which do not involve open surgery include implantation of an [[intrathecal]] pump (a [[syringe driver]] delivering medication into the space around the spinal cord) administering [[local anesthetic|local anaesthetics]] and/or [[opiates]]<ref>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</ref>

== References ==
{{Reflist}}

== External links ==
*[https://journals.physiology.org/doi/full/10.1152/jn.1998.79.6.3143 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):3143-50]
*[https://web.archive.org/web/20060423072502/http://www.uams.edu/acelab/ Laboratory of Elie D. Al-Chaer for the Study of Pain]
*[https://web.archive.org/web/20100104145030/http://wcbstv.com/local/back.pain.radiofrequency.2.1396270.html A CBS HealthWatch: Breakthrough In Battling Back Pain, New Procedure Just 8 Minutes To Change Your Life]

{{Central nervous system tests and procedures}}

[[Category:Neurosurgery]]
[[Category:Surgical oncology]]