Usefulness of Cordotomy in Patients With Cancer Who Experience Bilateral Pain

Abstract

BACKGROUND:Although mirror pain occurs after cordotomy in patients experiencing unilateral pain via a referred pain mechanism, no studies have examined whether this pain mechanism operates in patients who have bilateral pain.OBJECTIVE:To assess the usefulness of cordotomy for bilateral pain from the viewpoint of increased pain or new pain caused by a referred pain mechanism.METHODS:Twenty-six patients who underwent percutaneous cordotomy through C1-C2 for severe bilateral cancer pain in the lumbosacral nerve region were enrolled. Pain was dominant on 1 side in 23 patients, and pain was equally severe on both sides in 3 patients. Unilateral cordotomy was performed for the dominant side of pain, and bilateral cordotomy was performed for 13 patients in whom pain on the nondominant side developed or remained severe after cordotomy.RESULTS:After unilateral cordotomy, 19 patients (73.1%) exhibited increased pain, which for 14 patients was as severe as the original dominant pain. After bilateral cordotomy, 7 patients (53.4%) exhibited new pain, which was located cephalad to the region rendered analgesic by cordotomy and was better controlled than the original pain. No pathological organic causes of new pain were found in any patient, and evidence of a referred pain mechanism was found in 3 patients after bilateral cordotomy.CONCLUSION:These results show that a referred pain mechanism causes increased or new pain after cordotomy in patients with bilateral pain. Nevertheless, cordotomy can still be indicated for patients with bilateral pain because postoperative pain is better controlled than the original pain.

O-Arm-Guided Percutaneous Radiofrequency Cordotomy

“…Other authors have also noted mirror pain to be relatively common early after unilateral cordotomy, present in 17-62% of patients [9,16]. It was suggested to be a type of referred pain that results from chronic alterations in spinal cord pain circuitry coupled with disinhibition due to the lesioning of descending pathways [16,17]. …”

Temporal Summation Predicts De Novo Contralateral Pain After Cordotomy in Patients With Refractory Cancer Pain

“…The phenomenon of developing postcordotomy pain on the contralateral side is well documented and reported to occur in 17% to 73% of patients. 17,18 Still, there is longstanding uncertainty about the etiology of emergence of pain on the contralateral side. All 14 patients reported significantly reduced postcordotomy pain in the affected side, with half of them reporting total elimination and the rest only mild or moderate pain.…”

“…The phenomenon of developing postcordotomy pain on the contralateral side is well documented and reported to occur in 17% to 73% of patients. 17,18 Still, there is longstanding uncertainty about the etiology of emergence of pain on the contralateral side.…”

“…Technical details on the procedure under O-ARM guidance are available in recent publications. 6,[14][15][16][17][18] In brief, under local anesthesia, a radiofrequency electrode was introduced into the anterolateral spinal cord quadrant at the C1-2 interspace by means of a lateral percutaneous approach under imaging guidance. Once the correct anatomic position had been reached, the location of the pain-mediating STT was verified with electrophysiological testing that involves high frequency (50 Hz) stimulation trains (pw 0.1 ms) to assess the resultant patient-reported pain sensation in the contralateral hemibody.…”

Bicentre, randomized, parallel-arm, sham-controlled trial of transcranial direct-current stimulation (tDCS) in the treatment of palliative care patients with refractory cancer pain

“…Invasive treatments (e.g. cervical cordotomy [ 49 ] or implantable pumps for intrathecal drug administration [ 50 ]) specifically intended for palliative care patients can be considered in patients experiencing pain with NRS scores higher than 6–7/10 and could be proposed in the event of failure of tDCS in the context of this protocol.…”