Pain Control by Cordotomy
Dr Paul Cook
Consultant in Palliative Care & Pain Medicine
Royal Oldham Hospital
Pennine Acute Hospitals NHS Trust
Dr Kershaw’s Hospice, Oldham
Aims of talk
• What is Cordotomy ?
– Anatomy
– History
– Why in 2010?
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Demand, indications
Pros & cons – informed consent
How it is done ?
My results to date
What do patients think?
Referral Criteria, When to refer
Life
A sexually transmitted Terminal Disease
What is Cordotomy?
• Motor and Pain nerve
bundles are separate.
• Separated by a support
ligament - dentate ligament
• Motor posterior, goes to
same side of the body.
• Pain anterior, comes from
opposite side of body.
Anatomy Confusion
A little History
• First surgical anterolateral cordotomy 1912 Spiller WG, Martin E.
Cancer pain lower body
• 1920s, 1930s increasingly used,
numerous surgeons disheartened –
failure (incisions too superficial)
• 1940s lateral frontal lobotomy
(leucotomy) being used for severe pain !
Taking stock . . .
• 1950 – White JC, Sweet WH, Hawkins R, Nilges
RG -Reviewed 210 patients (1936-1948) – 241
cordotomies
Presented paper to Society of British
Neurosurgeons in Manchester
– Reasserting its use in severe pain and its “remarkably
low risk of serious complications”
– Failure rate 9%
– 4% mortality
– Bladder – 2% unilateral, 29-16% bilateral
– Bowel – 2% unilateral, 5-10% bilateral
– “Obvious” Leg weakness – 4% unilateral, 8% bilateral
(? Ant. spinal artery damage ? Too deep/dorsal)
Minimally invasive !
• 1960s – Lipton S (Liverpool)
– Percutaneous radiofrequency electrodes
– Guided by oily contrast on Dentate ligament, X-ray
control
• Mid 1980s
– Radiofrequency / stimulating / thermocouple needles
• Now
– Digital subtraction X-ray, CT control
– Non-ionic, water soluble contrast
Why do it in 2010 ?
• Problem / complex palliative patients with
severe pain
• Subgroup of these the pain is
UNILATERAL
• Analgesics (opioid, non-opioid) have not
solved the patient’s pain problems
• Aim is to maximise
the ‘quantity’ of ‘quality life’
Demand
• National Mesothelioma Framework
• 2167 new cases in 2004 in UK
• ~ 2400 by 2012
• ~ 300-600 cordotomies (=15-30%)
Pleural Mesothelioma
(Pancoast’s)
Localised unilateral Cancers
Others
• Incident pain
Indications
• UNILATERAL PAIN
– Uncontrolled, likely to become so
– Best results - Chest wall, arm (cannot lesion > C4)
• MESOTHELIOMA (90% work at Portsmouth)
– Pancoast’s tumour
– Solitary bone metastasis (incident pain)
– Other - e.g. Breast Ca, unilateral chest wall
• Limited life expectancy (< 2 yrs)
• Must be able to lie flat for 1 hour
• Awake (L.A.) - have to co-operate with
sensory/motor testing for safety
Benefits
• Success in 70-90%
• 5-20% technical failure - ‘first do no harm’
• 5-10% fails despite apparent technical success
• Pain significantly reduced in 83%
• Immediately after - halve opioids
• 38% stop opioids completely
• Patient drug side effects reduced
• One off technique - long lasting
• Up to 2 years
Risks
• Common
• Thermoanaesthesia on side of tumour pain
(contralateral to side of cordotomy)
• Troublesome dysaesthesia (contralateral)
• Headache (post dural)
• 1 in 5 - transcient overnight ipsilateral
weakness (reactive cord oedema)
• 1 in 20 - few days to weeks ipsilateral
weakness
• Failure (1 in 5-10)
Risks
• Rare
• Permanent ipsilateral weakness
(1 in 600 - series Dr D Pounder)
• Death
(1 in 600 - series Dr D Pounder)
• Central pain if > 2 yr survival (~50%)
• Theoretical
• Respiratory failure/depression – bilateral >> unilateral
cordotomy
• Bladder dysfunction – not seen in Pounder series with
unilateral cordotomy
Horner’s Syndrome
Solitariospinal -> phrenic, intercostals
Cordotomy – it’s got to hurt?
Cordotomy - how is it done ?
C1/C2 intervertebral space
Cordotomy - Step by step
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My results to date
• 47 Cordotomies since Feb 2008
• 40 Patients - 7 repeats (5M, 2F)
• 30 Male: 10 Female
Mesothelioma 55%
Lung 30%
Rest 15%
Outcomes
Cordotomies
47
Patients
40
Median Age
66.0
Mean Age
64.2
Success
%
Success
+ Tech
%
Success +
Tech +
Partial
%
Cordotomies
27
57%
31
66%
33
70%
Patients
27
68%
31
78%
33
83%
Failures - gender
Cordotomies Pts
Repeats
Failed
on
repeat
%
Male
35
30
5
1
20%
Female
12
10
2
2
100%
Complications
• 2 ipsilateral leg weakness - mild
– One overnight
– One 7 days
• 2 mirror pain
• 1 cord haematoma – no adverse
outcome
• 2 Horner’s syndrome - ipsilateral
• 1 Dysaesthesia
• 4 Pain behind ear on lesioning
Prognosis – inaccurate +++
• Medical professionals poor at prediction
– Christakis NA et al – BMJ 2000 (320)
p469-73
– 343 docs
– 20% accurate to within 33% range of
actual time of death
– OVEROPTIMISTIC (survival x 5.3)
When to refer?
• Early
• Anticipate disease course
• NOT a last ditch procedure
• When patient starts to require strong opioids
(pain will get worse with time)
Where?
Cordotomy Referral Criteria
• ONE SIDED PAIN below the neck (C4)
• Uncontrolled pain, or likely to become so
(pain not controlled by strong opioids)
• Limited life expectancy (< 2 yrs)
• Must be able to LIE FLAT for 1 hour
• Awake (Local Anaesthetic) CO-OPERATE with tests
• Stop anticoagulants
• No infection or tumour below the angle of jaw on
the opposite side to the pain
Information sources
• e-mail: paul.cook@pat.nhs.uk
Phone: 0161 656 1912 Fax: 0161 656
1929
• www.mesothelioma.uk.com
click Information & Symptom Control
->
Symptom Control ->Pain
• www.mesotheliomamatters.com
click Real Stories -> Keith’s story