Cordotomy procedures for cancer pain: A discussion of surgical procedures and a review of the literature

Abstract

Treating pain in patients with terminal cancer is challenging but essential part of their care. Most patients can be managed with pharmacological options but for some these pain control methods are inadequate. Ablative spinal procedures offer an alternative method of pain control for cancer patients with a terminal diagnosis that are failing to have their pain controlled sufficiently by other methods. This paper provides a review of ablative spinal procedures for control of cancer pain. Patient selection, surgical methods, outcomes and complications are discussed in detail for cordotomy, dorsal root entry zone (DREZ) lesioning and midline myelotomy. Cordotomy is primarily done by a percutaneous method and it is best suited for patients with unilateral somatic limb and trunk pain such as due to sarcoma. Possible complications include unilateral weakness possibly respiratory abnormalities. Approximately 90% of patients have significant immediate pain relief following percutaneous cordotomy but increasing portions of patients have pain recurrence as the follow-up period increases beyond one year. The DREZ lesion procedure is best suited to patients with plexus invasion due to malignancy and pain confined to one limb. Possible complications of DREZ procedures include hemiparesis and decreased proprioception. Midline myelotomy is best suited for bilateral abdominal, pelvic or lower extremity pain. Division of the commissure is necessary to address bilateral lower extremity pain. This procedure is relatively rare but published case series demonstrate satisfactory pain control for over half of the patients undergoing the procedure. Possible complications include bilateral lower extremity weakness and diminished proprioception below the lesion level. Unlike cordotomy and DREZ this procedure offers visceral pain control as opposed to only somatic pain control. Ablative spinal procedures offer pain control for terminal cancer patients that are not able to managed medically. This paper provides an in depth review of these procedures with the hope of improving education regarding these underutilized procedures.

Keywords: Cordotomy, Cancer pain, Dorsal root entry zone, Percutaneous cordotomy, Midline myelotomy

Core tip: Pain is a significant symptom that degrades the quality of life for terminally ill cancer patients. For many terminally ill oncology patients medical management is sufficient. However, some patient’s will fail medical management or have unwanted side effects from their medical regimen. Patient’s failing medical management may warrant consideration for interventional procedures such as cordotomy, dorsal root entry zone or midline myelotomy. Of these three procedures only midline myelotomy can address visceral pain, the others are best suited to somatic pain. This review discusses surgical anatomy, patient selection and surgical nuances of these techniques.