Cordotomy

Anatomy and Physiology

Today, with the percutaneous cervical cordotomy, the nociceptive pathways in the lateral spinothalamic tract (in the anterolateral column) are destroyed in the cervical spinal cord at the level of C1-C2.[2]

Indications

The original approach focused on pain relief for patients with unilateral malignancies, lower extremity pathologies, failed back syndrome, chronic nociceptive painful conditions, and cancer patients. On the other hand, bilateral cordotomies for visceral or bilateral pain are also an option. In the more recent percutaneous approach, the destruction of the lateral spinothalamic tract at the level of C1-C2 results in a contralateral disruption of painful sensations beyond C4. Today, this latter approach is most commonly used in patients with limited life expectancy and suffering from opioid-resistant cancer pain. Irrespective of the procedure or technique, a uniform indication for this intervention is having severe intractable pain that has not responded to conventional therapies. Cancer-related pain is an indication but not a requirement, as it can be done in populations suffering from other irreversible painful conditions. The severity of pain is essential when assessing appropriate indications. The patient's pain must have advanced to level 3 of the World Health Organization (WHO) pain ladder before considering this invasive procedure. 

The cordotomy has been documented as particularly impactful for pain secondary to mesothelioma, Pancoast syndrome, and lung cancer.[3]

Contraindications

Percutaneous cordotomy is contraindicated in patients with a coagulation disorder, severely reduced ventilator function, or if a patient is unable to cooperate.[4] Several alternative procedures were developed in the 20th century. The commissural myelotomy was developed for bilateral pain arising from pelvic or abdominal neoplastic disease. Likewise, the punctate or limited midline myelotomy also aimed at pelvic and abdominal visceral pain. Therefore, if patients have pain localized solely to these regions, cordotomy can be avoided and newer procedures adopted. With the introduction of intrathecal pumps and spinal cord stimulators, it is prudent to steer many patients away from cordotomies.[5]

Technique or Treatment

Most cordotomies utilize the percutaneous approach at the level of C1-C2. The surgeon often uses fluoroscopic or computed tomography guidance. Patients are usually awake for the procedure, which is performed under local anesthesia. A laminectomy is required to execute an open cordotomy. It entails a longer recovery and a higher risk of side effects. However, when percutaneous cordotomy is unfeasible, especially in children, the open procedure is preferred.[6]

Complications

Only a few experience serious post-procedure side effects.[7] They include dysesthesia, urinary retention, ataxia, paresis, sympathetic dysfunction (hypotension, Horner syndrome, and bladder dysfunction), sexual sensitivity impaired or lost sexual sensitivity, and a form of sleep apnea (acquired central hypoventilation syndrome). The bulk of these complications result from the accidental division of the unintended reticulospinal tracts. Another serious complication is spontaneous new pain. New pain may be old (previously extant) pain that was previously unrecognized and now unmasked by removing prior distractions. Likewise, the new pain can be viewed as an unpreventable complication from the interruption of nociceptive pathways.

Overall, the risk of severe complications with unilateral cordotomy is low. Procedure-related mortality is reported in the range of 1%-6%, which is mainly due to respiratory dysfunction.[8] With more accurate ablation techniques, respiratory dysfunction is rare.[9]

Clinical Significance

Percutaneous cervical cordotomy is recommended for patients with a life expectancy of fewer than 6 months who also meet the pain severity indications. It is a palliative procedure. Successful, immediate pain relief results in approximately three-quarters of patients. However, the rate of pain relief declines to less than 50% after 2 years. As noted earlier, new pain syndromes can also arise, and patients must be aware of and willing to accept that risk. As measures of efficacy, clinical significance, and side effects, a study reported diminished touch perception on the left side of the body, consistent with an anterior spinothalamic tract lesion. The nearby anterior spinocerebellar tract, reticulospinal tract, and corticospinal tract were presumed to be spared, as the patient exhibited no evidence of ataxia, autonomic dysfunction, or motor weakness.[10][11]

Enhancing Healthcare Team Outcomes

The cordotomy is a palliative procedure. It is often performed in patients with a life expectancy of less than 6 months and entails significant risks and potential benefits. Obtaining a thorough history is essential, and the clinician should demonstrate empathy for the patient and their condition, whether the condition is a malignancy or another pathology. This decision is not to be made alone or lightly by the patient, family, or clinician. Patients must not feel rushed when having their options for intractable pain laid out before them. Furthermore, this is a surgical procedure, so interprofessional communication must occur. Proper communication should occur between the nurse, palliative physician, surgeon, oncologist, and the primary physician. Each specialty should help the patient make an informed decision that best aligns with their goals of care. As always, especially for palliative care patients with often numerous comorbidities, the patient's medical history and background should be clearly documented for members of the healthcare team. Any deviation from thoroughness can pose significant challenges and risks to patients, their families, and their clinicians. Medical errors are to be actively avoided. If any nurse or clinician believes that significant palliative procedures, such as cordotomy, are not the best choice for the patient, they should tactfully raise their concern with the clinicians involved in that patient's care. This interprofessional approach ensures that they have a comprehensive and clear understanding of the procedure, its risks, and its benefits before presenting their professional opinion to the patient.[12]

Nursing, Allied Health, and Interprofessional Team Interventions

Before cordotomy can be performed, the nurse must ensure that the patient understands the procedure and has signed a consent form. While most cordotomies are done percutaneously, sometimes general anesthesia is required. Irrespective of how the procedure is done, patient monitoring is vital. Resuscitative equipment must be in the room before the procedure is started. Breathing and oxygen need to be continuously monitored. A nurse dedicated to patient monitoring is vital.

Nursing, Allied Health, and Interprofessional Team Monitoring

Once cordotomy is completed, the patient's vital signs and neurological status need to be monitored. The patient may develop urinary retention that may require catheterization, apnea, or fecal incontinence. Oxygen saturation must be continuously monitored until the patient is stable.