Cordotomy

A cordotomy is a surgical procedure that severs certain nerve pathways in the spinal cord to relieve intractable pain. It is primarily used for chronic pain that is unresponsive to other treatments. The procedure targets the spinothalamic tract, which carries pain and temperature sensations to the brain.

There are two main types of cordotomy: open and percutaneous.

• Open Cordotomy: This involves a laminectomy (surgical removal of a portion of a vertebra) to directly access the spinal cord and cut the targeted nerve fibers. It is a more invasive procedure.

• Percutaneous Cordotomy: This is a minimally invasive technique performed with a needle electrode inserted through the skin and guided to the spinal cord using fluoroscopy (X-ray imaging). Radiofrequency energy is then used to selectively destroy the nerve fibers.

Indications:

Cordotomy is typically considered for:

• Unilateral (one-sided) pain, often associated with cancer.
• Intractable pain that has not responded to other pain management strategies such as medications, nerve blocks, or other surgical interventions.
• Patients with a limited life expectancy due to a terminal illness, where the primary goal is pain relief and improved quality of life.

Risks and Complications:

Like any surgical procedure, cordotomy carries potential risks, including:

• Weakness or paralysis (usually temporary, but can be permanent)
• Loss of bladder and bowel control (incontinence)
• Sexual dysfunction
• Respiratory insufficiency, particularly with bilateral (both sides) procedures or high cervical cordotomies.
• Sensory changes, such as numbness or tingling
• Post-cordotomy dysesthesia (a type of pain that can develop after the procedure)
• Headache
• Spinal fluid leak
• Infection

Contraindications:

Cordotomy may not be suitable for all patients. Contraindications include:

• Bilateral pain (depending on the circumstances and type of cordotomy)
• Pre-existing respiratory compromise (especially for high cervical procedures)
• Coagulation disorders
• Certain spinal cord pathologies

Note: Cordotomy is a complex procedure, and patient selection is critical. The decision to proceed with a cordotomy should be made in consultation with a multidisciplinary team, including a pain specialist, neurosurgeon, and other relevant healthcare professionals. The benefits and risks must be carefully weighed for each individual patient.