Cordotomy
Encyclopedia
Cordotomy is a surgical procedure that disables selected pain
-conducting tracts in the spinal cord
, in order to achieve loss of pain
and temperature
perception
. This procedure is commonly performed on patients experiencing severe pain due to cancer
or other diseases for which there is currently no cure. Anterolateral cordotomy is effective for relieving unilateral, somatic pain
while bilateral cordotomies may be required for visceral or bilateral pain.
Cordotomy is usually done percutaneous
ly with fluoroscopic guidance while the patient is under local anesthesia
. Open cordotomy, which requires a laminectomy
, is often risky for patients with poor medical conditions, but may be required if percutaneous cordotomy is not feasible or an attempt has failed.
Cordotomy is now used exclusively for pain due to cancer where treatment to level 3 of the World Health Organisation pain ladder
has proved ineffective. Cordotomy is especially indicated for pain due to asbestos
-related cancers such as pleural and peritoneal mesothelioma
.
Although cordotomy is effective in the relief of pain, the effect is usually temporary. Dysesthesia
develops after most cordotomies.
A number of alternative surgical procedures have evolved in the 20th century; these include:
Commissural myelotomy, with limited rostro-caudal range; it produces bilateral analgesia (Armour 1927; Hitchcock 1970; 74).
Limited midline myelotomy for the treatment of pelvic visceral cancer pain
(Gildenberg and Hirshberg, 1984).
Recently, doctors at the University of Arkansas for Medical Sciences
discovered a new pathway in the spinal cord relatively specific for visceral pain - the pain that originates from visceral organs such as the colon, bladder and pancreas. The new pathway is located in the posterior columns, traditionally believed to mediate light touch and kinesthesia. This discovery led to a paradigm shift in the understanding of pain pathways and in the approach to treat intractable visceral pain. As a result, punctate midline myelotomy was introduced around the world as a new surgical procedure for the treatment of visceral pain residual to cancer and refractory to conventional treatment.
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
-conducting tracts in the spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...
, in order to achieve loss of pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
and temperature
Temperature
Temperature is a physical property of matter that quantitatively expresses the common notions of hot and cold. Objects of low temperature are cold, while various degrees of higher temperatures are referred to as warm or hot...
perception
Perception
Perception is the process of attaining awareness or understanding of the environment by organizing and interpreting sensory information. All perception involves signals in the nervous system, which in turn result from physical stimulation of the sense organs...
. This procedure is commonly performed on patients experiencing severe pain due to cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
or other diseases for which there is currently no cure. Anterolateral cordotomy is effective for relieving unilateral, somatic pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
while bilateral cordotomies may be required for visceral or bilateral pain.
Cordotomy is usually done percutaneous
Percutaneous
In surgery, percutaneous pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an "open" approach where inner organs or tissue are exposed .The percutaneous approach is commonly used in vascular procedures...
ly with fluoroscopic guidance while the patient is under local anesthesia
Local anesthesia
Local anesthesia is any technique to induce the absence of sensation in part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It allows patients to undergo surgical and dental procedures with...
. Open cordotomy, which requires a laminectomy
Laminectomy
Laminectomy is a spine operation to remove the portion of the vertebral bone called the lamina. There are many variations of laminectomy. In the most minimal form small skin incisions are made, back muscles are pushed aside rather than cut, and the parts of the vertebra adjacent to the lamina are...
, is often risky for patients with poor medical conditions, but may be required if percutaneous cordotomy is not feasible or an attempt has failed.
Cordotomy is now used exclusively for pain due to cancer where treatment to level 3 of the World Health Organisation pain ladder
Pain ladder
The pain ladder is a term originally coined by the World Health Organization to describe a method of controlling pain. It was originally described for the management of cancer pain, but is now widely used by medical professionals for the management of all types of pain.The general principle in...
has proved ineffective. Cordotomy is especially indicated for pain due to asbestos
Asbestos
Asbestos is a set of six naturally occurring silicate minerals used commercially for their desirable physical properties. They all have in common their eponymous, asbestiform habit: long, thin fibrous crystals...
-related cancers such as pleural and peritoneal mesothelioma
Peritoneal mesothelioma
Peritoneal mesothelioma is the name given to the cancer that attacks the lining of the abdomen. This type of cancer affects the lining that protects the contents of the abdomen and which also provides a lubricating fluid to enable the organs to move and work properly.The peritoneum is made of two...
.
Although cordotomy is effective in the relief of pain, the effect is usually temporary. Dysesthesia
Dysesthesia
Dysesthesia comes from the Greek word "dys", meaning "not-normal" and "aesthesis", which means "sensation" . It is defined as an unpleasant, abnormal sense of touch, and it may be, or not be, considered as a kind of pain...
develops after most cordotomies.
A number of alternative surgical procedures have evolved in the 20th century; these include:
Commissural myelotomy, with limited rostro-caudal range; it produces bilateral analgesia (Armour 1927; Hitchcock 1970; 74).
Limited midline myelotomy for the treatment of pelvic visceral cancer pain
Cancer pain
Pain is a symptom frequently associated with cancer. Cancer can cause pain by irritating or damaging nerves, by stimulating nociceptors , or by releasing chemicals that make nociceptors respond to normally non-painful stimuli. Cancer pain may be caused by the tumor itself or by medical...
(Gildenberg and Hirshberg, 1984).
Recently, doctors at the University of Arkansas for Medical Sciences
University of Arkansas for Medical Sciences
The University of Arkansas for Medical Sciences is part of the University of Arkansas System, a state-run university in the U.S. state of Arkansas...
discovered a new pathway in the spinal cord relatively specific for visceral pain - the pain that originates from visceral organs such as the colon, bladder and pancreas. The new pathway is located in the posterior columns, traditionally believed to mediate light touch and kinesthesia. This discovery led to a paradigm shift in the understanding of pain pathways and in the approach to treat intractable visceral pain. As a result, punctate midline myelotomy was introduced around the world as a new surgical procedure for the treatment of visceral pain residual to cancer and refractory to conventional treatment.
External links
- Al-Chaer ED et al. A role for the dorsal column in nociceptive visceral input into the thalamus of primates. J Neurophysiol. 1998 Jun;79(6):3143-50
- Laboratory of Elie D. Al-Chaer for the Study of Pain
- Science News Online (2/13/99): Pain, Pain, Go Away
- A CBS HealthWatch: Breakthrough In Battling Back Pain, New Procedure Just 8 Minutes To Change Your Life