Overview of Cordotomy
Cordotomy is a type of surgery aimed at trying to eliminate paths in the spinal cord that carry pain signals. This surgery was first done in 1912 by two neurosurgeons, William Spiller and Edward Martin. They discovered that severe pain and body temperature sensations were reduced in patients who underwent this treatment. Initially, it was used frequently for chronic pain, but now it’s mainly reserved for treating patients with cancer. The traditional way of carrying out this surgery is rarely used due to high risk and potential complications linked with this method.
The original cordotomy was modified in 1963 to become a “percutaneous cervical cordotomy” (where the procedure is done through the skin rather than with a full-on surgical opening). However, with advancements in pain management in the 1990s, this surgery became less popular. Despite this, it’s still considered as a treatment option for severe pain that doesn’t respond to other treatments. Since the people who typically have this procedure are quite unwell, there is a lack of research examining the long-term effects of this procedure.
There is one case of a patient with a specific kind of cancer called seminoma who had a right-sided percutaneous cervical cordotomy along with chemotherapy. Doctors observed that, even after five years, the patient still experienced continued changes in sensation but with minimal impact on movement and automatic bodily functions.
Anatomy and Physiology of Cordotomy
Nowadays, doctors use a procedure called percutaneous cervical cordotomy. This procedure is used to destroy certain pathways in the spinal cord that are responsible for pain sensations. These pathways are located along the side of the spinal cord in an area referred to as the anterolateral column. More specifically, the procedure is carried out in the uppermost region of the spinal cord, between the first and second cervical vertebrae (known as C1-C2).
Why do People Need Cordotomy
In the past, doctors mainly focused on pain relief for patients with certain conditions such as cancerous growths only on one side (unilateral), problems in their lower limbs, a condition called failed back syndrome, and chronic pains. In some cases, doctors also tried bilateral cordotomies for pain affecting both sides or internal organs (visceral).
Recently, a new approach has become more common. This method involves a simple surgery that affects a specific part of the spinal cord in the neck area of a patient (at C1-C2 level). This treatment disrupts pain sensations on the opposite side of the body, from about the mid-neck level (C4) and downwards.
This new method is often used for patients with cancer who don’t have long to live, and who are experiencing severe pain that can’t be relieved by usual painkillers. Whether a doctor uses the old or the new method, they’ll generally only consider this sort of treatment if a patient is in severe pain that hasn’t improved with regular treatments.
It’s not necessary for a patient to have cancer to be a candidate for this treatment. It might be beneficial for anyone in severe, unmanageable pain due to a condition that won’t get better. However, it’s important to note that this is a major procedure, and usually only considered when a patient’s pain has reached level 3 on the World Health Organization (WHO) pain scale.
This process, called a cordotomy, has been documented to be especially helpful in relieving pain caused by diseases such as mesothelioma, Pancoast syndrome, and lung cancer.
When a Person Should Avoid Cordotomy
The medical treatment called percutaneous cordotomy may not be suitable for some individuals. Those with a blood clotting disorder, severe breathing issues, or those who may struggle to follow instructions during the procedure may not be good candidates.
In the last century, doctors have come up with different treatment options. Commissural myelotomy is one such procedure, specifically designed for patients who have pain in both the abdominal and pelvic regions due to cancerous growths. Similarly, punctate or limited midline myelotomy aims to alleviate pain in the abdomen and pelvis. As such, if patients only have pain in these specific areas, it might be more beneficial to opt for these newer procedures instead of a cordotomy.
Finally, with the development of more modern methods like intrathecal pumps and spinal cord stimulators, it’s often a good idea to consider these options before resorting to cordotomy. These newer procedures are typically less invasive and come with fewer risks.
How is Cordotomy performed
In a common surgical treatment called cordotomy, the surgeon will often work at the top of your spine, around the areas labelled as C1-C2. To help guide them, they might use a special imaging technology similar to an x-ray called fluoroscopy, or they might use a CT scan, which is like a three-dimensional x-ray. During this procedure, you’ll likely be awake but will be given local anesthesia, so you don’t feel any pain.
If a more open and direct approach is needed to perform the cordotomy, the surgeon may need to do a procedure called a laminectomy. This involves removing some bone to get to the spinal cord. Although this approach has its benefits, it usually calls for a longer recovery period and may present more risks of side effects. However, in some cases, like with children, or when the common cordotomy technique cannot be done, this open procedure is considered a better option.
Possible Complications of Cordotomy
After a certain medical procedure, only a small number of people encounter serious side effects. These may include abnormal sensations or numbness (dysesthesia), difficulty in emptying the bladder (urinary retention), lack of coordination (ataxia), weakness of body movement (paresis), and issues with automatic bodily functions (sympathetic dysfunction) such as low blood pressure, drooping eyelid or inability to sweat on one side of the face (Horner’s syndrome), and bladder issues. Other side effects can include decreased or lost sexual sensitivity, and a specific type of sleep apnea called ‘acquired central hypoventilation syndrome’.
Many of these issues occur because, during the procedure, some parts of the reticulospinal tracts within the spinal cord may accidentally be cut. This is the part of the body’s nervous system that controls voluntary movement. Another serious problem can be new pain that arises post-procedure. This could be a previously unnoticed old pain that becomes apparent once other pain distractions are removed. Alternatively, it could be seen as an unavoidable complication from interrupting pain pathways in the body.
On a brighter note, very few people experience severe issues after this particular procedure. The risk of major complications is low. Reports suggest that between 1% to 6% of people may pass away due to the procedure, largely because of issues with breathing. However, with more precise techniques being used, instances of breathing problems after the procedure are now quite rare.
What Else Should I Know About Cordotomy?
Percutaneous cervical cordotomy is a surgery that is recommended for patients who are expected to live for less than six months and who suffer from severe pain. This procedure helps to reduce pain and make patients more comfortable, but it is important to understand that it is not a cure.
About three-quarters of patients who undergo this surgery get instantaneous relief from their pain. However, it should be noted that the effectiveness of this procedure tends to decrease over time. After two years, fewer than half of the patients continue to experience pain relief.
Moreover, it’s possible that new pain issues can arise after the procedure. This is a risk that all patients must understand and be prepared to accept.
One study noted some side-effects including reduced feeling of touch on the left side of the body. This indicates that there might be some damage to the anterior spinothalamic tract, which helps the body recognize and respond to physical sensations. But, it’s reassuring to note that other pathways in the spinal cord (the ones involved with balance, automatic body functions, and voluntary movements) were unaffected as there were no signs of imbalance, issues with automatic body functions, or problems with voluntary movement.