Pain Control by Cordotomy

Dr Paul CookConsultant in Palliative Care & Pain MedicineRoyal Oldham HospitalPennine Acute Hospitals NHS TrustDr Kershaw’s Hospice, Oldham

Aims of talk

• What is Cordotomy ?– Anatomy– History– Why in 2010?

• 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 cordotomiesPresented 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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© PRCook

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© PRCook

© PRCook

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.ukPhone: 0161 656 1912 Fax: 0161 656 1929

• www.mesothelioma.uk.comclick Information & Symptom Control -> Symptom Control ->Pain

• www.mesotheliomamatters.comclick Real Stories -> Keith’s story