Cordotomy for Intractable Cancer Pain: A Narrative Review

Abstract

Background: Cordotomy is an invasive procedure for the management of intractable pain not controlled by conventional therapies, such as analgesics or nerve block. This procedure involves mechanical disruption of nociceptive pathways in the anterolateral column, specifically the spinothalamic and spinoreticular pathways to relieve pain while preserving fine touch and proprioceptive tracts. Objectives: The purpose of this review article is to refresh our knowledge of cordotomy and support its continued use in managing intractable pain due to malignant disease. Study Design: This is a review article with the goal of reviewing and summarizing the pertinent case reports, case series, retrospective studies, prospective studies, and review articles published from 2010 onward on spinal cordotomy. Setting: The University of Texas, MD Anderson Cancer Center. Methods: PubMed search of keywords “spinal cordotomy,” “percutaneous cordotomy,” or “open cordotomy” was undertaken. Search results were organized by year of publication. Results: Cordotomy can be performed via percutaneous, open, endoscopic, or transdiscal approach. Percutaneous image-guided approach is the most well-studied and reported technique compared with others, with relatively good pain improvement both in the postoperative and shortterm period. The use of open cordotomy has diminished significantly in recent years because of the advent of other less invasive approaches. Cordotomy in children, although rare, has been described in some case reports and case series with reported pain improvement postprocedure. Although complications can vary broadly, some reported side effects include ataxia and paresis due to lesion in the spinocerebellar/corticospinal tract; respiratory failure due to lesion in the reticulospinal tract; or sympathetic dysfunction, bladder dysfunctions, or Horner syndrome due to unintentional lesions in the spinothalamic tract. Limitations: Review article included literature published only in English. For the studies reviewed, the sample size was relatively small and the patient population was heterogeneous (in terms of underlying disease process, duration of symptoms, previous treatment attempted and length of follow-up). Conclusions: Cordotomy results in selective loss of pain and temperature perception on the contralateral side, up to several segments below the level of the disruption. The plethora of analgesics available and advanced technologies have reduced the demand for cordotomy in the management of intractable pain. However, some patients with pain unresponsive to medical and procedural management, particularly malignant pain, may benefit from this procedure, and it is a viable treatment option especially for patients with a limited life expectancy whose severe, unilateral pain is unresponsive to analgesic medications. Key words: Cancer pain, cordotomy complications, cordotomy indications, intractable pain, open cordotomy, percutaneous cordotomy