Computed tomography-guided percutaneous cordotomy for intractable pain in malignancy

Effectiveness of CT-guided percutaneous cordotomy in intractable cancer pain: Experience in 14 patients

BACKGROUND

Severe and treatment-resistant pain is a major issue for patients with cancer. Cordotomy is an effective approach for addressing severe cancer-related pain. It is based on blocking the transmission of pain by damaging the lateral spinothalamic tract.

METHODS

Computed tomography guided cordotomy was performed on 14 patients who did not respond to medical and interventional pain management methods.

RESULTS

Fourteen patients with cancer pain underwent CT-guided percutaneous cordotomy. Pain relief was reported in 86% of the patients. The visual analog scale values before and after cordotomy were compared and a significant difference was found (p = 0.0001). The improvement in the Karnofsky Performance Scale score of the patients was found to be statistically significant (p = 0.0001).

CONCLUSION

We believe that CT-guided cordotomy, performed by experienced hands in a team of experienced individuals and applied to the right patients, is an effective treatment. However, it is crucial to exercise extreme caution regarding potential side effects and serious complications during the cordotomy procedure.

Neurosurgical Treatments for Cancer Pain

Cancer-related pain is a uniquely challenging entity for treating practitioners for a variety of reasons, including its often severe and medically refractory nature, the emotional and social circumstances surrounding the disease process, and the frequently associated limited life expectancy.

Percutaneous trigeminal tractotomy for trigeminal neuralgia: Postoperative MRI findings

BACKGROUND AND PURPOSE

Percutaneous trigeminal tractotomy is an ablative procedure that can be used to treat trigeminal neuralgia in patients who have failed prior pharmacologic and surgical treatments. Using perioperative computed tomography (CT) guidance, ablation of the descending spinal trigeminal nucleus and trigeminal tract can be performed precisely to mitigate damage to surrounding structures. These patients are subsequently followed with postoperative imaging and clinical visits to assess long-term pain relief.

METHODS

In this report, we present a series of four patients with trigeminal neuralgia who were had refractory disease after prior medical and surgical interventions. These patients underwent CT-guided percutaneous trigeminal tractotomy for pain relief. The patients underwent postoperative MRI and were followed for up to 6 months for long-term clinical outcomes.

RESULTS

For intraoperative CT, we find that preprocedure lumbar contrast injection enables better visualization of the cord during placement of the ablation probe. On postoperative imaging, we find that all four patients have hyperintense lesions on T2-weighted MRI that correspond with the location of the trigeminal nucleus and tract. Three patients had short-term pain relief, one of which continued to have long-term relief.

CONCLUSION

Intraoperative CT and postoperative MRI serve as useful modalities for confirming localization, evaluating complications, and can be used as a metric for quality control.

The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain

Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.

Cervical Cordotomy for Intractable Pain: Do Postoperative Imaging Features Correlate with Pain Outcomes and Mirror Pain?

BACKGROUND AND PURPOSE

Percutaneous cervical cordotomy offers relief of unilateral intractable oncologic pain. We aimed to find anatomic and postoperative imaging features that may correlate with clinical outcomes, including pain relief and postoperative contralateral pain.

MATERIALS AND METHODS

We prospectively followed 15 patients with cancer who underwent cervical cordotomy for intractable pain during 2018 and 2019 and underwent preoperative and up to 1-month postoperative cervical MR imaging. Lesion volume and diameter were measured on T2-weighted imaging and diffusion tensor imaging (DTI). Lesion mean diffusivity and fractional anisotropy values were extracted. Pain improvement up to 1 month after surgery was assessed by the Numeric Rating Scale and Brief Pain Inventory.

RESULTS

All patients reported pain relief from 8 (7-10) to 0 (0-4) immediately after surgery (P = .001), and 5 patients (33%) developed contralateral pain. The minimal percentages of the cord lesion volume required for pain relief were 10.0% on T2-weighted imaging and 6.2% on DTI. Smaller lesions on DWI correlated with pain improvement on the Brief Pain Inventory scale (r = 0.705, P = .023). Mean diffusivity and fractional anisotropy were significantly lower in the ablated tissue than contralateral nonlesioned tissue (P = .003 and P = .001, respectively), compatible with acute-phase tissue changes after injury. Minimal postoperative mean diffusivity values correlated with an improvement of Brief Pain Inventory severity scores (r = -0.821, P = .004). The average lesion mean diffusivity was lower among patients with postoperative contralateral pain (P = .037).

CONCLUSIONS

Although a minimal ablation size is required during cordotomy, larger lesions do not indicate better outcomes. DWI metrics changes represent tissue damage after ablation and may correlate with pain outcomes.

Percutaneous Cordotomy for Pain Palliation in Advanced Cancer: A Randomized Clinical Trial Study Protocol

BACKGROUND

Cancer pain, one of the most common symptoms for patients with advanced cancer, is often refractory to maximal medical therapy. A controlled clinical trial is needed to provide definitive evidence to support the use of ablative procedures such as cordotomy for patients with medically refractory cancer pain.

OBJECTIVE

To assess the efficacy of cordotomy for patients with unilateral advanced cancer pain using a controlled clinical trial study design. The secondary objectives are to define the patient experience of cordotomy for medically refractory cancer pain as well as to determine the utility of magnetic resonance imaging as a non-invasive biomarker for successful cordotomy.

METHODS

We will undertake a single-institution, double-blind, sham-controlled clinical trial of cordotomy in patients with refractory cancer pain. Patients in the cordotomy arm will undergo a percutaneous computed tomography-guided cordotomy at C1-C2, while patients in the control arm will undergo a similar procedure where the needle will not penetrate the thecal sac. The primary endpoint will be the reduction in pain intensity, as measured by the Edmonton Symptoms Assessment Scale.

EXPECTED OUTCOMES

We expect that patients randomized to cordotomy will have a significantly greater reduction in pain intensity than those patients randomized to the control surgical intervention.

DISCUSSION

This randomized clinical trial comparing cordotomy with a control intervention will provide the level of evidence necessary to determine whether cordotomy should be the standard of care intervention for patients with advanced cancer pain.

Somatotopy and Organization of Spinothalamic Tracts in the Human Cervical Spinal Cord

BACKGROUND

Understanding spinothalamic tract anatomy may improve lesioning and outcomes in patients undergoing percutaneous cordotomy.

OBJECTIVE

To investigate somatotopy and anatomical organization of spinothalamic tracts in the human cervical spinal cord.

METHODS

Patients with intractable cancer pain undergoing cordotomy underwent preoperative and postoperative quantitative sensory testing for sharp pain and heat pain on day 1 and 7 after cordotomy. Intraoperative sensory stimulation was performed with computed tomography (CT) imaging to confirm the location of the radiofrequency electrode during cordotomy. Postoperative magnetic resonance (MR) imaging was performed to define the location of the lesion.

RESULTS

Twelve patients were studied, and intraoperative sensory stimulation combined with CT imaging revealed a somatotopy where fibers from the legs were posterolateral to fibers from the hand. Sharpness detection thresholds were significantly elevated in the area of maximum pain on postoperative day 1 (P = .01). Heat pain thresholds for all areas were not elevated significantly on postoperative day 1, or postoperative day 7. MR imaging confirmed that the cordotomy lesion was in the anterolateral quadrant, and in this location the lesion had a sustained effect on sharp pain but a transient impact on heat pain.

CONCLUSION

In the high cervical spinal cord, spinothalamic fibers mediating sharp pain for the arms are located ventromedial to fibers for the legs, and these fibers are spatially distinct from fibers that mediate heat pain.

Percutaneous cervical cordotomy for cancer-related pain: national data

Objectives

Percutaneous cervical cordotomy (PCC) is an interventional ablative procedure in the armamentarium for cancer pain treatment, but there is limited evidence to support its use. This study aimed to assess the effectiveness and safety of PCC.

Methods

Analysis was undertaken of the first national (UK) prospective data repository of adult patients with cancer undergoing PCC for pain treatment. The relationship between pain and other outcomes before and after PCC was examined using appropriate statistical methods.

Results

Data on 159 patients’ PCCs (performed from 1 January 2012 to 6 June 2017 in three centres) were assessed: median (IQR) age was 66 (58–71) years, 47 (30%) were female. Mesothelioma was the most common primary malignancy (57%). The median (IQR) time from cancer diagnosis to PCC assessment was 13.3 (6.2–23.2) months; PCC to follow-up was 9 (8–25) days; and survival after PCC was 1.3 (0.6–2.8) months. The mean (SD) for ‘average pain’ using a numerical rating scale was 6 (2) before PCC and 2 (2) at follow-up, and for ‘worst pain’ 9 (1) and 3 (3), respectively. The median (IQR) reduction in strong opioid dose at follow-up was 50% (34–50). With the exception of ‘activity’, all health-related quality of life scores (5-level version of EuroQol-5 Dimension) either improved or were stable after PCC. Six patients (4%) had PCC-related adverse events.

Conclusions

PCC is an effective treatment for cancer pain; however, findings in this study suggest PCC referrals tended to be late in patients’ disease trajectories. Further study into earlier treatment and seeking international consensus on PCC outcomes will further enhance opportunities to improve patient care.

Somatotopic organization of the human spinothalamic tract: in vivo computed tomography-guided mapping in awake patients undergoing cordotomy

OBJECTIVE

The location of the human spinothalamic tract (STT) in the anterolateral spinal cord has been known for more than a century. The exact nature of the neuronal fiber lamination within the STT, however, remains controversial. After correlating in vivo macrostimulation-induced pain/temperature sensation during percutaneous cervical cordotomy with simultaneous CT imaging of the electrode tip location, the authors present a modern description of the somatotopy of the human cervical STT.

METHODS

Twenty patients underwent CT-guided percutaneous cervical cordotomy to alleviate contralateral medication-refractory cancer pain. Patient responses to electrical stimulation (0.01-0.1 V, 50 Hz, 1 msec) were recorded and the electrode location for each response was documented with a contemporaneous CT scan. In a post hoc analysis of the data, the location for each patient's response(s) was measured and drawn on a diagram of their cord. Positive responses were represented only when the lowest possible voltage (≤ 0.02 V) elicited a response. Negative responses were recorded if there was no clinical response at 0.1 V.

RESULTS

Clinically, patients did well with an average reduction in opiates of 75% at 1 week, and 67% were able to leave the palliative care unit. The size of the cervical cord varied between patients, with an average lateral extent (width) of 11 mm and a height of 9 mm. Responses from the lower limb were represented superficially (lateral) and posteriorly within the anterolateral cord. The area with responses from the upper limb was larger and surrounded those with responses from the lower limb primarily anteriorly and medially, but also posteriorly.

CONCLUSIONS

In this study, the somatotopic organization of the human STT was elucidated for the first time using in vivo macrostimulation and contemporaneous CT imaging during cordotomy. In this cohort of patients, the STT from the lower-limb region was located superficially and posteriorly in the anterolateral quadrant of the cervical cord, with the STT from the upper-limb region surrounding it primarily anteriorly and medially (deep) but also posteriorly. The authors discuss how the previous methods of cordotomy may have biased the earlier versions of STT lamination. They suggest that an ideal spinal cord entry site for cordotomy of either the upper- or lower-limb pain fibers is halfway between the equator and anterior pole of the cord.

Interventional Techniques to Management of Cancer-Related Pain: Clinical and Critical Aspects

Interventional techniques to manage cancer-related pain may be efficient treatment modalities in patients unresponsive or unable to tolerate systemic opioids. However, indication and selection of the right technique demand knowledge, which is still incipient among clinicians. The present article summarizes the current evidence regarding the five most essential groups of interventional techniques to treat cancer-related pain: Neuraxial analgesia, minimally invasive procedures for vertebral pain, sympathetic blocks for abdominal cancer pain, peripheral nerve blocks, and percutaneous cordotomy. Furthermore, indication, mechanism, drug agents, contraindications, and complications of the main techniques of each group are discussed.

Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial

BACKGROUND

Up to 30% of patients with cancer continue to suffer from pain despite aggressive supportive care. The present study aimed to determine whether cordotomy can improve cancer pain refractory to interdisciplinary palliative care.

MATERIALS AND METHODS

In this randomized controlled trial, we recruited patients with refractory unilateral somatic pain, defined as a pain intensity (PI) ≥4, after more than three palliative care evaluations. Patients were randomized to percutaneous computed tomography-guided cordotomy or continued interdisciplinary palliative care. The primary outcome was 33% improvement in PI at 1 week after cordotomy or study enrollment as measured by the Edmonton Symptom Assessment Scale.

RESULTS

Sixteen patients were enrolled (nine female, median age 58 years). Six of seven patients (85.7%) randomized to cordotomy experienced >33% reduction in PI (median preprocedure PI = 7, range 6-10; 1 week after cordotomy median PI = 1, range 0-6; p = .022). Zero of nine patients randomized to palliative care achieved a 33% reduction in PI. Seven patients (77.8%) randomized to palliative care elected to undergo cordotomy after 1 week. All of these patients experienced >33% reduction in PI (median preprocedure PI = 8, range 4-10; 1 week after cordotomy median PI = 0, range 0-1; p = .022). No patients were withdrawn from the study because of adverse effects of the intervention.

CONCLUSION

These data support the use of cordotomy for pain refractory to optimal palliative care. The findings of this study justify a large-scale randomized controlled trial of percutaneous cordotomy.

IMPLICATIONS FOR PRACTICE

This prospective clinical trial was designed to determine the improvement in pain intensity in patients randomized to either undergo cordotomy or comprehensive palliative care for medically refractory cancer pain. This study shows that cordotomy is effective in reducing pain for medically refractory cancer pain, and these results can be used to design a large-scale comparative randomized controlled trial that could provide the evidence needed to include cordotomy as a treatment modality in the guidelines for cancer pain management.

Decompression nerve surgery for diabetic neuropathy: a structured review of published clinical trials

AIM

To assess lower extremity decompression nerve surgery (DNS) to treat the consequences of diabetic distal symmetric peripheral neuropathy (DPN).

RESEARCH DESIGN AND METHODS

MEDLINE, PubMed, and related registries were searched through December 2017 to identify randomized, quasi-randomized or observational trials that evaluated the efficacy of lower extremity DNS on pain relief (primary outcome) or other secondary outcomes. Observational studies were included, given investigators' reluctance to use sham surgery controls. Outcome effect size was estimated, and a weighted average was calculated.

RESULTS

Eight of 23 studies evaluated pain relief, including a double-blind randomized controlled trial (with a sham surgery leg), an unblinded trial with a nonsurgical control leg, and 6 observational studies. All reported substantial pain relief post-DNS with average effect sizes between two and five. Unexpectedly, the double-blind trial showed improvement in the sham leg comparable to the DNS leg and exceeding the improvement observed in the nonsurgical leg in the unblinded study. Sensory testing showed generally favorable results supporting DNS, and nerve conduction velocities increased post-DNS relative to deterioration in controls. Ultrasound revealed fusiform nerve swelling near compression sites. Morphological results of DNS were generally favorable but inconsistent, whereas hemodynamic measures showed a positive effect on arterial parameters, as did transcutaneous oximetry (improved microcirculation). The incidence of initial and recurrent neuropathic diabetic foot ulcers appeared reduced post-DNS relative to the contralateral foot (borderline significant).

CONCLUSION

The data remain insufficient to recommend DNS for painful DPN, given conflicting and unexpectedly positive results involving sham surgery relative to unblinded controls. The generally supportive sensory and nerve conduction results are compromised by methodological issues, whereas more favorable results support DNS to prevent new or recurrent neuropathic foot ulcers. Future studies need to clarify subject selection vis-à-vis DPN vs superimposed compressed nerves, utilize appropriate validated instruments, and readdress use of sham surgical controls in light of recent results.

Postoperative MRI Evaluation of a Radiofrequency Cordotomy Lesion for Intractable Cancer Pain

BACKGROUND AND PURPOSE

There are limited data on the use of postoperative imaging to evaluate the cordotomy lesion. We aimed to describe the cordotomy lesion by using postoperative MR imaging in patients after percutaneous cordotomy for intractable cancer pain.

MATERIALS AND METHODS

Postoperative MR imaging and clinical outcomes were prospectively obtained for 10 patients after percutaneous cordotomy for intractable cancer pain. Area, signal intensity, and location of the lesion were recorded. Clinical outcomes were measured by using the Visual Analog Scale and the Brief Pain Inventory-Short Form, and correlations with MR imaging metrics were evaluated.

RESULTS

Ten patients (5 men, 5 women; mean age, 58.5 ± 9.6 years) were included in this study. The cordotomy lesion was hyperintense with central hypointense foci on T2-weighted MR imaging, and it was centered in the anterolateral quadrant at the C1-C2 level. The mean percentage of total cord area lesioned was 24.9% ± 7.9%, and most lesions were centered in the dorsolateral region of the anterolateral quadrant (66% of the anterolateral quadrant). The number of pial penetrations correlated with the percentage of total cord area that was lesioned (r = 0.78; 95% CI, 0.44-0.89; P = .008) and the length of T2-weighted hyperintensity (r = 0.85; 95% CI, 0.54-0.89; P = .002). No significant correlations were found between early clinical outcomes and quantitative MR imaging metrics.

CONCLUSIONS

We describe qualitative and quantitative characteristics of a cordotomy lesion on early postoperative MR imaging. The size and length of the lesion on MR imaging correlate with the number of pial penetrations. Larger studies are needed to further investigate the clinical correlates of MR imaging metrics after percutaneous cordotomy.

Use of Spinal Cord Diffusion Tensor Imaging to Quantify Neural Ablation and Evaluate Outcome after Percutaneous Cordotomy for Intractable Cancer Pain

BACKGROUND

Up to 20% of patients experience only partial pain relief after percutaneous cordotomy for cancer pain.

OBJECTIVE

To determine whether diffusion tensor imaging (DTI) can quantify neural ablation and help evaluate early postoperative outcomes after cordotomy.

METHODS

Patients undergoing percutaneous CT-guided cordotomy for intractable cancer pain were prospectively studied. Pre- and postoperative assessment was made using the visual analog scale (VAS) on pain and the pain severity scores of the Brief Pain Inventory Short Form. On postoperative day 1, DTI images of the high cervical spinal cord were obtained. DTI metrics were correlated with the number of ablations as well as early postoperative pain outcomes.

RESULTS

Seven patients (4 male, mean age 53.8 ± 4.6 years) were studied. Fractional anisotropy of the hemicord was significantly lower on the side of the lesion as compared to the contralateral side (0.54 ± 0.03 vs. 0.63 ± 0.03, p < 0.001). Mean diffusivity correlated with the improvement in the VAS score at 1 week (r = 0.88, 95% CI = 0.34-1.00, p = 0.008), as well as the change in pain severity scores at 1 week (r = 0.99, 95% CI = 0.82-1.00, p < 0.001).

CONCLUSION

DTI metrics are sensitive to the number of ablations as well as early improvement in pain scores after cordotomy. DTI of the cervical spinal cord is a potential biomarker of neural ablation after percutaneous cordotomy for intractable cancer pain.

Palliative CT-Guided Cordotomy for Medically Intractable Pain in Patients with Cancer

Palliative cervical cordotomy can be performed via percutaneous radiofrequency ablation of the lateral C1-2 spinothalamic tract. This rare procedure can be safe, effective, and advantageous in mitigating medically intractable unilateral extremity pain for selected patients with end-stage cancer. This report reviews the indications, techniques, risks, and potential benefits of cordotomy. We describe our recent experience treating 3 patients with CT-guided C1-2 cordotomy and provide the first characterization of spinal cord diffusion MR imaging changes associated with successful cordotomy.

Usefulness of cordotomy in patients with cancer who experience bilateral pain: implications of increased pain and new pain

BACKGROUND:

Although mirror pain occurs after cordotomy in patients experiencing unilateral pain via a referred pain mechanism, no studies have examined whether this pain mechanism operates in patients who have bilateral pain.

OBJECTIVE:

To assess the usefulness of cordotomy for bilateral pain from the viewpoint of increased pain or new pain caused by a referred pain mechanism.

METHODS:

Twenty-six patients who underwent percutaneous cordotomy through C1-C2 for severe bilateral cancer pain in the lumbosacral nerve region were enrolled. Pain was dominant on 1 side in 23 patients, and pain was equally severe on both sides in 3 patients. Unilateral cordotomy was performed for the dominant side of pain, and bilateral cordotomy was performed for 13 patients in whom pain on the nondominant side developed or remained severe after cordotomy.

RESULTS:

After unilateral cordotomy, 19 patients (73.1%) exhibited increased pain, which for 14 patients was as severe as the original dominant pain. After bilateral cordotomy, 7 patients (53.4%) exhibited new pain, which was located cephalad to the region rendered analgesic by cordotomy and was better controlled than the original pain. No pathological organic causes of new pain were found in any patient, and evidence of a referred pain mechanism was found in 3 patients after bilateral cordotomy.

CONCLUSION:

These results show that a referred pain mechanism causes increased or new pain after cordotomy in patients with bilateral pain. Nevertheless, cordotomy can still be indicated for patients with bilateral pain because postoperative pain is better controlled than the original pain.

Microendoscopy-guided percutaneous cordotomy for intractable pain: case series of 24 patients

OBJECTIVE

The aim of this study was to show that microendoscopic guidance using a double-channel technique could be safely applied during percutaneous cordotomy and provides clear real-time visualization of the spinal cord and surrounding structures during the entire procedure.

METHODS

Twenty-four adult patients with intractable cancer pain were treated by microendoscopic-guided percutaneous radiofrequency (RF) cordotomy using the double-channel technique under local anesthesia. A percutaneous lateral puncture was performed initially under fluoroscopy guidance to localize the target. When the subarachnoid space was reached by the guiding cannula, the endoscope was inserted for visualization of the spinal cord and surrounding structures. After target visualization, a second needle was inserted to guide the RF electrode. Cordotomy was performed by a standard RF method.

RESULTS

The microendoscopic double-channel approach provided real-time visualization of the target in 91% of the cases. The other 9% of procedures were performed by the single-channel technique. Significant analgesia was achieved in over 90% of the cases. Two patients had transient ataxia that lasted for a few weeks until total recovery.

CONCLUSIONS

The use of percutaneous microendoscopic cordotomy with the double-channel technique is useful for specific manipulations of the spinal cord. It provides real-time visualization of the RF probe, thereby adding a degree of safety to the procedure.

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

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.

Surgical/radiological interventions for cancer pain

Pain is a major morbidity associated with cancer and up to 20% patients require invasive procedures for pain relief. Ablative techniques can be directed towards the spinal cord and brain to palliate pain or modify its perception. Anterolateral cordotomy, myelotomy, DREZotomy and cingulotomy are useful interventions for the management of refractory cancer pain. Advanced imaging modalities, including intraoperative computed tomography (CT) guidance, have increased safety and efficacy of these interventions. In this paper, authors review the recent literature regarding surgical interventions for the management of cancer pain.

Cordotomy for treatment of cancer-related pain: patient selection and intervention timing

Many neurosurgical interventions for the management of cancer-related pain have been tried, but their role in today's advanced supportive and palliative care is not well described. The authors discuss the current knowledge gaps that prevent successful integration of neurosurgical interventions and patients with cancer-related pain.

Two patients underwent percutaneous CT-guided cordotomy for refractory cancer-related pain: one patient had melanoma and the other had ovarian carcinoma. Both patients seemed to have unilateral, somatic, nociceptive cancer-related pain.

Cordotomy was effective for only 1 patient.

Percutaneous CT-guided cordotomy is a low-risk intervention that can benefit carefully selected patients with cancer-related pain. There is a clear need for prospective controlled studies to evaluate the effectiveness of cordotomy for patients receiving optimal medical treatment. A multidisciplinary study design could help to identify factors correlated with a positive outcome.

Percutaneous cervical cordotomy for the management of pain from cancer: a prospective review of 45 cases

BACKGROUND

Percutaneous cervical cordotomy (PCC) is a well recognized but infrequently performed procedure for the relief of unilateral intractable pain from malignancy. There is a paucity of data regarding efficacy and safety of PCC.

OBJECTIVES

The study's objectives were to demonstrate the efficacy and safety of PCC in cancer pain.

DESIGN

The study was a prospective review of 45 cases undergoing PCC at a tertiary referral center over a three-year period.

SETTINGS/SUBJECTS

All patients were suffering from severe, refractory unilateral pain secondary to malignancy with poor pain relief or intolerable side effects of conventional analgesics including opioids and adjuvants.

MEASUREMENTS

Variables recorded preprocedure, at 2 days, and at 28 days postprocedure were numerical rating scale for maximum and average pain, oral morphine equivalent dose, and global impression of change. Adverse events and survival postprocedure were recorded.

RESULTS

Prospective data was obtained in 45 patients. Survival postprocedure ranged from 7 days to 33 months. There was a significant reduction from baseline in pain scores at 2 days and at 28 days postprocedure. Thirty-two patients experienced significant pain relief--average numerical rating scale (NRS) of zero--on day 2. Improvement in pain scores was sustained at 28 days. There were no serious adverse events observed such as respiratory failure.

CONCLUSIONS

PCC is a safe and highly effective procedure to treat intractable unilateral cancer pain. It offers significant advantages over other pain control methods. Patient selection and attention to detail is paramount for a successful outcome.

Percutaneous CT-guided cordotomy for the treatment of pediatric cancer pain

Percutaneous cordotomy using CT guidance has been shown to be a safe and effective means of reducing pain in adults with cancer in 2 large case series. Its effectiveness in pediatric patients, however, has not been reported. Here, the authors present a case of CT-guided percutaneous cordotomy being used effectively for the treatment of unilateral limb pain in a 9-year-old boy suffering from metastatic medulloblastoma. The efficacy and minimally invasive nature of this procedure support its use in selected pediatric cases.

Neurosurgical advances in cancer pain management

Neurosurgical procedures to treat pain are mainly destructive and involve the spinal cord and occasionally the brain. Targets include the spinothalamic tract, the trigeminal tract nucleus, the midline ascending visceral pain pathway, the brainstem spinal lemniscus, the thalamus, and the cingulate gyrus. Since the introduction of intrathecal opioids, the need for neurosurgical destructive procedures has been in decline. In recent years, cordotomy, trigeminal tractotomy, and dorsal root entry zone (DREZ) operations are the neurosurgical procedures most often utilized to treat cancer pain. The addition of CT guidance to spinal cord pain pathway ablation was a major addition and refinement to the procedure. Here the authors review the latest techniques and recently published results for CT-guided cordotomy, CT-guided trigeminal tractotomy, and DREZ operations utilized to treat cancer pain.