Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Surg Proced. Mar 28, 2015; 5(1): 111-118
Published online Mar 28, 2015. doi: 10.5412/wjsp.v5.i1.111
Cordotomy procedures for cancer pain: A discussion of surgical procedures and a review of the literature
Wendell B Lake, Peter E Konrad
Wendell B Lake, Peter E Konrad, Department of Neurosurgery, Vanderbilt University School of Medicine, Nashville, TN 37232, United States
Author contributions: Lake WB and Konrad PE contributed to this paper.
Conflict-of-interest: Wendell B Lake, no conflicts of interest; Peter E Konrad, honoraria from Medtronic Inc.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Peter E Konrad, MD, PhD, Department of Neurosurgery, Vanderbilt University School of Medicine, 1500 21st Ave South, Suite 4333, Nashville, TN 37232, United States.
Telephone: +1-615-3439822 Fax: +1-615-3436948
Received: September 28, 2014
Peer-review started: September 29, 2014
First decision: December 17, 2014
Revised: January 10, 2015
Accepted: January 30, 2015
Article in press: February 2, 2015
Published online: March 28, 2015

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.