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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
© PRCook
© PRCook
© PRCook
© PRCook
© 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: [email protected]: 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