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Percutaneous cordotomy in the treatment of intractable pain caused by malignant lesions
Percutaneous Cordotomy in the Treatment of Intractable Pain Caused by Malignant Lesions
John S. Tytus, MD, Seattle. Washington
Since its introduction by Spiller and Martin f1 J in 1912, cordotomy, the surgical interruption of t.he spinothalamic tracts in the upper spinal cord, has been a valuable adjunct in the control of intractable pain due to malignant lesions. However, the procedure entails a major operation, laminectomy, and many patients with severe pain but debilitat. ed by disease are unable to withstand such a procedure. ln 1963 Mullan et al (2J introduced a method whereby the spinal cord could be approached percutaneously. Initially, they utilized II strontium needle which was introduced into the spinal cord through a spinal needle inserted at the level of the first or second cer....ical vertebra_ The technic was later modified by employing an electrolytic lesion to achieve the same effect {J], The procedure waq popularized by Rosomoff et al [4], who utilized a radiofrequency current, Respiratory complications from spinal cord lesions at tbis high le\-e1 led Lin, Gildenberg, and Polakoff [5j to develop an anterior approach at lower cervical levels whereby the spinal pain pathways were entered obliquely and the autonomic respiratory pathwayil could be avoided, Although this method did away with respiratory problems, the technic was so difficult that the higher, lateral From the Section of Neurowrgery, The Mason Clinic, Sell!tle, Wasil. 1!\gIOn,
l'IeprlnllequllslSshouldbllllddlllssedtoOr Tylus,1118NlnthAvlIlIue,Seattle Washlllgtoll98101. Presented at lhe Forty-Fourth Annual Mealing of tho Pael/It: Coast 5lJfgleaIAssoclation, Yosemite,CalUornla, FebruafY 19-22, 1973.
116
approach of Mullan and Rosomoff has gained wider acceptance. Satisfactory relief of pain has been reported in 65 to 80 per cent of patients so treated U-·:5'l. QccasionaHy, pain may be relieved in patients in whom the interruption of pain fibers is incomplete. In a few patients no decrease in pain sensation can be obtained. despite the apparently satisfactory position of the electrode. The procedure is not without complications. Significant respiratory failure occurs in 25 per cent oi patients undergoing the unilateral procedure. especially if they already have significant pulmonary disease 161. Such problems are almost inevitable in patients undergoing bilateral cordotomy and are the most common cause of death from this procedure. The ineidence of some degree of motor weakness may be as high as ;15 per cent l7]. [n aile quarter of these patients, the weakness may he permanent. Urinary retention is a problem in 25 per cent. The incidence of bladder problems is probably 50 ptr cent in those patients undergoing the bilateral procedure. Technic The technic thllt we employ utilizes the head holder and Radionics radiofrequency lesion generator, as described by Rosomoff et al [4], together with the smaller (10 mil), Teflonfl·coated steel electrodes suggested by Mullan [8]. The procedure is carried out using local anesthesia supplemented by intravenous Demerol tl . Our approach to the spinal pain pathways follows as closely as possible thatof Mullan [8}.
TheAmerleanJOllrnalolSurlierr
l'ercutaneous Cordotomy Clinical Material We hAve performed twenty-seven cordotomies in t.....enty-three patients. Two had the bilateral procedure. A sati~f8ctory senso!')' result was initially ob· tained in sixteen (70 per cent). In four patientD thl! loss of pain sensation was incomplete, and in three others no change in pain sensation was evident, In two of these- patients the procedure was repel!ted, and an ade· quate sensory level was eventually obtained in one. Seventeen patients (74 per cent) experienced satisfac· tory relief of pain. There were two death! in this series, both from respiratory complications. One other patient died at home three weeks after cordotomy. He WS$ 8n elderly man who had undergone 8 bilateral pf'OCedure, and this death may also have been caused by respinuOo ry failure. Seven patients had hemiparesis alter cordot· omy, an incidence of 30 per cent. Significant improvement occurred in five. Respiratory insufficiency oc· curred in five patients. Two patients had undergone bilateral cordotomy nnd in tW(\ others there was a sig. nificant :fecreRse in pulmonary function from lung cancer. Urinary retention occurred in six patients. [n one patient who underwent bilateral cordotomy the prob. lem was permanent. Comments A review of this small series of patients points up a discrepancy between satisfacLory relief of pain and good results. The value of cordotomy in our patients depended. on other factors as well, such as pain in the opposite side (four patients), addiction (two patients), pain and discomfort in the neck from the procedure (one patient), and other problems related to the disease, including depression, severe debility, nau~ea, vomiting, and diarrhea. Considering these factors together with the complications, cordotomy was worthwhile in about 50 per cent of our patients. The procedure, however, remains a valuable adjunct to the management of intractable pain due to malignant lesions. Its value is enhanced by ad. herence to certain criteria. [t should only be performed in patients in whom pain is the primary reason for incapacity. Cordotomy will be of little benefit to patients in whom pain is merely one of several factors contributing to debility. Addiction is a contraindication to the procedure. Because of the hazards attending bilateral high cervical cordotomy, the procedure should be restricted to those patients with unilateral pain. Patients with involvement of the brachial or lumbosacral plexus may be suitable candidates. Patients with unHat. eral chest pain may also be good candidates for this procedure if the pulmonary function is ade·
Vo1um.12&,Au(lult1973
quale. As a rule. we do not undertake the proce· dure in patients with blood PaO.:! below 70 mm
Hg. Patients with abdominal or pelvic cancer are usually not suitable candidates, since the pain is seldom confined to one side. Occasionally, such a patient with a reasonable life expectancy who presents with primarily unilateral pain benefits from high cervical cordotomy on one side and later, should the need arise, from open cordotomy at a lower level on the opposite side. Summary L Percutaneous high cervical cordotomy is effective in controlling unilnteral pilin due to malignant lesions. 2. Our experience with this procedure in twenty-three patients is reviewed. ;l. Unilateral weakness and urinary retention are significant complications of this procedure, but are often transient. 4. Respiratory insufficiency after bilateral cordotomy obviates its use except in unusual circumstances. 5. The procedure is most effective for pain second~ny to brachial plexus and lumbosacr:J.! neoplastic invasion. It is also useful in patients with pulmonary neoplasm. providing the Pa02 is above 70 mm Hg. It is not particul:J.r1y beneficial to pa· tients with pain secondary to involvement of the bladder, liver, !itomach, bowel, OT sacrum since such pain invariably involves both sides of the body.
References MarUn E: The treatment of persistent pain '" organk: origin in the lower part 01 the body by division 01 the anlerolatl!l'"sl cOlumn 01 the spinal cord. JAMA
1. Spiller WG.
58: 1-489. 1912.
2.
Mullan S, Harpe, PV. Hekmalpanat! J. Torres H. Dobbin G: Percutaneous Interruption of spinal pain tracts by means ot a strontium needle. J Neurosurg 20: 931.
3.
Mullan 5, Hekmalpanah J, Dobbin G. Beckman F: Percu· taneous Intramedullary cordotomy. utilizing the unipolar anodal electrolytic lesion. J Neurosurg 22: 548, 1965. Rosomolf HL, carroll F, Brown J. Shaptak P: Percuta· neous radlolrequency cervical cordotomy: technique. J
1963.
4.
Neufosurg23:639,1965. 5.
Un· PM. Gildenberg PL. Polakoll P: An anterIor approach 10 perculaneoos lower cervical cordolomr. J Neurosurl}
6.
Mullan 5, Hosobuchl V: P.espiralOfy hazards 01 high cerviclll percutaneous cordotomy. J NeurO$urg 28: 291.
7.
Un PM: Personal communication. Mullan 5: Percutaneous cor-dotomy. J
25: 533.1966.
1968.
8.
1971.
Neurosurg 35: 360.
Tylus
Discussion dohn Hallr (Portland, Ore): I hove rcad Dr 'I)otus' pllper on percutaneous cordC'tomy with mixed tll!lOtions: admiration for his success with this procedure, chagrin that to date we have not been able to duplicate this success, and ske9tici~m that this procedure should be part of the armamentarium of all neurologic surgeons. I ha~ not performeo the procedure myself and I doubt that I am aoout to begin. Twelve patients havc undergone percutaneous cordotomy at our hospital; ten of these were operated on by a former resident who was as handy with 8 needle as anyone J know. He has kindly given me permission to review the patients treated by percutaneous cordotomy at Ollr hospital. Twenty percutaneous cordotomy procedures were carried out in twelve patienls; in four of the procedures the technic was that ol Mullan and in sixleen that of Lin. Multiple procedures were carried out. in some patients, either because the initial cordotomy failed and had to 6e repeated on the same side or because the poin was bilateral and lhe procedure was performcd first on one side and then on the other. J have Llied to evaluate the results, from bolh the standpoint of lhe success of the twenty procedures in relieving pain and the standpoint of the result insofftt as the patient was concerned. For example, if the patient WIiS relieved of pain but died a week or so after the procedure, it seems to me, in relrospect, that it might have been prefer3ble to use narcotics rather than subject the patient to cordotomy. Six of the twelve patients did die within sixteen days after percutaneous cordotomy had been performed. Calculating the success rate in these twelve patients by factors other than relief of pain, 75 per cent would have to be classified as failures. Seven of the twenty cordotomy procedures (35 per ~nt) could probably be called successful in relieving ps:;; and thirteen (65 per cent) were failures. Complicatiort:i, too, are not infrpquent; in four patients motor weakn~s developed after percutaneous cordotomy, but in the reries at our hospital I did not classify 8 result as unsa'dsfactory because of the development of a complication. Percutaneous cordotomy is a very exact technical procedure. The placement of the needle must be accurate within a millimeter or two, otherwise disaster may result. There is no doubt that experience should produce better results, but where can a large num ber of patients needing this procedure be brought together? The experience with percutaneous cordotomy in our hospital covers a five year period; twelve patients in five years is scarcely more than two a year. If a surgeon is to become highly skilled, experience with a much greater number would be required. It seems to me that Dr Tytus should be the only one in the city of Seattle performing percutaneous cordotomy. In Portland the procedure is being attempted in at least four hospitals. The question, as in other procedures requiring great technical skill, is how to obtain specialization within a specialt.y. tn the highly competitive atmosphere of
medical practice in this country, there is a great temptation for everyone to try everything new. ConcenLlatjng delicate technical procf'dures such as this in a few hands is quite a problem. Until this millennium comes, I am inclined to treat the pAtient who hilS terminal cancer with p.ithO!r drugs or, if it appears that he has some months to survive, open cordotomy. I have one question, Dr Tytus. You state that the procedure should be restricted to patients with unilateral pain. In my experience with open cordotomy, a pl:!tient may emphatically insist the pain is unilateral but within 11 few days or weeks after rclief has been obtained on one side by unilateral cordotomy, a high per· centage of patients begin to complain ('of pain on the other side. Has this not been your experience with percutaneous cordotomy? W. Eugene Stern (Los Angeles, Calif): This proce· durc, although it is a good one and the one I would select if cordotomy is indicated, presents difficulty in the placement of the needle. It can displat:C the spinal cord as it impales the pia. Electrical stimulation contributes to' precision in the procedure. The patient is awake. and if movement is produced by the stimulating electrode, the needle is replaced so that stimulation produces sensation rather than movement. The wakeful patient can also be tested for relief of pain. Although at times the procedure is tediov.'l, it is applicable in patients in whom thtte open procp.dure is not. Doctor Tytus has alluded to the possibility of applying it more than once. It does not tnx the patient particu/tlrly nor require general anesthesia. The morbidity is 10y.'Cr than it is with th~ open procedure. The primary advantage of the open procedure is that the cord can be seen and the landmarks for pic.cement of the knife can be identified. We no longer use c(),dotomy for benign lesions; the results do not hold up in time. I compliment Dr Tytus on pursuinG" percutaneous cordotomy as a useful tool in skilled hands for the contro!ofpain. Robert W. Jamplis (Palo Alto, CaIiO: Two weeks ago a thirty-three year old mother of four children was referred to me because of a bronchogenic carcinoma in the right superior sulcus; the diagnosis had been made by biopsy of a mass at the base of the neck. She w.'ls undergoing supervoltage radiation therapy but the pain became unbearable. I first saw iter at this point. We have had some success in patients with tumors of the superior sulcus, following the lead of Dr Paulson, hut I believed that this particular tumor was inoperable, so we turned to our neurosurgical colleagues. They advised that posterior rhizotomy would have left hl!r with a flail arm and that she really needed cotdotomy. However, they had never performed cordot· omy percutaneously. We therefore referred lhe plltient to Dr Philip Lippe in San Jose, who was the only one in the area perform-
Percutnneous Cordolomy
ing the percutaneous procedure. Within a few houn her need for drugs d«reased from near addiction to morphine to 10 gr of aspirin daily for tension headaches. She is again undergoing supervoltage radiation therapy without p:l.in. John S. Tytus (closing): Doctor Roar, I think you are absolutely right. As Dr Stern suggested, the proce· dure was introduced with a grellt deal of enthusiasm. It setffifd to be the panacea for all kinds of pain. We reo alize now that it is not. I would re·emphasi7.e that we obtained good results in about 50 per cent of our patients. One of the prob. lems is, inaeed, pain that has spread to the other side and I do not know how tc anticipate this. For this reason we try to limit use of the procedure to patien:.s with pain in lhe lumbosacral or brachial plexus, such as in Dr Jamplis' caSE, or, when indicated, pain in the chest.
VetlumolU,Augulllg73
One answer to this problem in patients who haye a fairly good prognosis for a year or so of· life is to perfonn percutaneous cordotomy on one side and then if the pain spreads to the other side, open cordotomy can be performed contralaterally at lower cervical levels to avoid interfering with respiration. Doctor Mullan ndvocates this and certainly he knows marc about the procedure than onyone else in the world, Doctor Stern. we do not use electrical stimulation; we start with a very low voltage current, and if IIny ad· verse signs develop. we stop immediately and reploet lheneedle_ As you point out, the procedure can be Quite length)'. In our early cases it look as long as three hours. which is certainly a long time for the patient. I would also like 10 emphasize that .....e do nol perform cordotomy (or. benign conditions; it is used ani)' for malignant lesions.
John S. Tytus, MD, Seattle. Washington
Since its introduction by Spiller and Martin f1 J in 1912, cordotomy, the surgical interruption of t.he spinothalamic tracts in the upper spinal cord, has been a valuable adjunct in the control of intractable pain due to malignant lesions. However, the procedure entails a major operation, laminectomy, and many patients with severe pain but debilitat. ed by disease are unable to withstand such a procedure. ln 1963 Mullan et al (2J introduced a method whereby the spinal cord could be approached percutaneously. Initially, they utilized II strontium needle which was introduced into the spinal cord through a spinal needle inserted at the level of the first or second cer....ical vertebra_ The technic was later modified by employing an electrolytic lesion to achieve the same effect {J], The procedure waq popularized by Rosomoff et al [4], who utilized a radiofrequency current, Respiratory complications from spinal cord lesions at tbis high le\-e1 led Lin, Gildenberg, and Polakoff [5j to develop an anterior approach at lower cervical levels whereby the spinal pain pathways were entered obliquely and the autonomic respiratory pathwayil could be avoided, Although this method did away with respiratory problems, the technic was so difficult that the higher, lateral From the Section of Neurowrgery, The Mason Clinic, Sell!tle, Wasil. 1!\gIOn,
l'IeprlnllequllslSshouldbllllddlllssedtoOr Tylus,1118NlnthAvlIlIue,Seattle Washlllgtoll98101. Presented at lhe Forty-Fourth Annual Mealing of tho Pael/It: Coast 5lJfgleaIAssoclation, Yosemite,CalUornla, FebruafY 19-22, 1973.
116
approach of Mullan and Rosomoff has gained wider acceptance. Satisfactory relief of pain has been reported in 65 to 80 per cent of patients so treated U-·:5'l. QccasionaHy, pain may be relieved in patients in whom the interruption of pain fibers is incomplete. In a few patients no decrease in pain sensation can be obtained. despite the apparently satisfactory position of the electrode. The procedure is not without complications. Significant respiratory failure occurs in 25 per cent oi patients undergoing the unilateral procedure. especially if they already have significant pulmonary disease 161. Such problems are almost inevitable in patients undergoing bilateral cordotomy and are the most common cause of death from this procedure. The ineidence of some degree of motor weakness may be as high as ;15 per cent l7]. [n aile quarter of these patients, the weakness may he permanent. Urinary retention is a problem in 25 per cent. The incidence of bladder problems is probably 50 ptr cent in those patients undergoing the bilateral procedure. Technic The technic thllt we employ utilizes the head holder and Radionics radiofrequency lesion generator, as described by Rosomoff et al [4], together with the smaller (10 mil), Teflonfl·coated steel electrodes suggested by Mullan [8]. The procedure is carried out using local anesthesia supplemented by intravenous Demerol tl . Our approach to the spinal pain pathways follows as closely as possible thatof Mullan [8}.
TheAmerleanJOllrnalolSurlierr
l'ercutaneous Cordotomy Clinical Material We hAve performed twenty-seven cordotomies in t.....enty-three patients. Two had the bilateral procedure. A sati~f8ctory senso!')' result was initially ob· tained in sixteen (70 per cent). In four patientD thl! loss of pain sensation was incomplete, and in three others no change in pain sensation was evident, In two of these- patients the procedure was repel!ted, and an ade· quate sensory level was eventually obtained in one. Seventeen patients (74 per cent) experienced satisfac· tory relief of pain. There were two death! in this series, both from respiratory complications. One other patient died at home three weeks after cordotomy. He WS$ 8n elderly man who had undergone 8 bilateral pf'OCedure, and this death may also have been caused by respinuOo ry failure. Seven patients had hemiparesis alter cordot· omy, an incidence of 30 per cent. Significant improvement occurred in five. Respiratory insufficiency oc· curred in five patients. Two patients had undergone bilateral cordotomy nnd in tW(\ others there was a sig. nificant :fecreRse in pulmonary function from lung cancer. Urinary retention occurred in six patients. [n one patient who underwent bilateral cordotomy the prob. lem was permanent. Comments A review of this small series of patients points up a discrepancy between satisfacLory relief of pain and good results. The value of cordotomy in our patients depended. on other factors as well, such as pain in the opposite side (four patients), addiction (two patients), pain and discomfort in the neck from the procedure (one patient), and other problems related to the disease, including depression, severe debility, nau~ea, vomiting, and diarrhea. Considering these factors together with the complications, cordotomy was worthwhile in about 50 per cent of our patients. The procedure, however, remains a valuable adjunct to the management of intractable pain due to malignant lesions. Its value is enhanced by ad. herence to certain criteria. [t should only be performed in patients in whom pain is the primary reason for incapacity. Cordotomy will be of little benefit to patients in whom pain is merely one of several factors contributing to debility. Addiction is a contraindication to the procedure. Because of the hazards attending bilateral high cervical cordotomy, the procedure should be restricted to those patients with unilateral pain. Patients with involvement of the brachial or lumbosacral plexus may be suitable candidates. Patients with unHat. eral chest pain may also be good candidates for this procedure if the pulmonary function is ade·
Vo1um.12&,Au(lult1973
quale. As a rule. we do not undertake the proce· dure in patients with blood PaO.:! below 70 mm
Hg. Patients with abdominal or pelvic cancer are usually not suitable candidates, since the pain is seldom confined to one side. Occasionally, such a patient with a reasonable life expectancy who presents with primarily unilateral pain benefits from high cervical cordotomy on one side and later, should the need arise, from open cordotomy at a lower level on the opposite side. Summary L Percutaneous high cervical cordotomy is effective in controlling unilnteral pilin due to malignant lesions. 2. Our experience with this procedure in twenty-three patients is reviewed. ;l. Unilateral weakness and urinary retention are significant complications of this procedure, but are often transient. 4. Respiratory insufficiency after bilateral cordotomy obviates its use except in unusual circumstances. 5. The procedure is most effective for pain second~ny to brachial plexus and lumbosacr:J.! neoplastic invasion. It is also useful in patients with pulmonary neoplasm. providing the Pa02 is above 70 mm Hg. It is not particul:J.r1y beneficial to pa· tients with pain secondary to involvement of the bladder, liver, !itomach, bowel, OT sacrum since such pain invariably involves both sides of the body.
References MarUn E: The treatment of persistent pain '" organk: origin in the lower part 01 the body by division 01 the anlerolatl!l'"sl cOlumn 01 the spinal cord. JAMA
1. Spiller WG.
58: 1-489. 1912.
2.
Mullan S, Harpe, PV. Hekmalpanat! J. Torres H. Dobbin G: Percutaneous Interruption of spinal pain tracts by means ot a strontium needle. J Neurosurg 20: 931.
3.
Mullan 5, Hekmalpanah J, Dobbin G. Beckman F: Percu· taneous Intramedullary cordotomy. utilizing the unipolar anodal electrolytic lesion. J Neurosurg 22: 548, 1965. Rosomolf HL, carroll F, Brown J. Shaptak P: Percuta· neous radlolrequency cervical cordotomy: technique. J
1963.
4.
Neufosurg23:639,1965. 5.
Un· PM. Gildenberg PL. Polakoll P: An anterIor approach 10 perculaneoos lower cervical cordolomr. J Neurosurl}
6.
Mullan 5, Hosobuchl V: P.espiralOfy hazards 01 high cerviclll percutaneous cordotomy. J NeurO$urg 28: 291.
7.
Un PM: Personal communication. Mullan 5: Percutaneous cor-dotomy. J
25: 533.1966.
1968.
8.
1971.
Neurosurg 35: 360.
Tylus
Discussion dohn Hallr (Portland, Ore): I hove rcad Dr 'I)otus' pllper on percutaneous cordC'tomy with mixed tll!lOtions: admiration for his success with this procedure, chagrin that to date we have not been able to duplicate this success, and ske9tici~m that this procedure should be part of the armamentarium of all neurologic surgeons. I ha~ not performeo the procedure myself and I doubt that I am aoout to begin. Twelve patients havc undergone percutaneous cordotomy at our hospital; ten of these were operated on by a former resident who was as handy with 8 needle as anyone J know. He has kindly given me permission to review the patients treated by percutaneous cordotomy at Ollr hospital. Twenty percutaneous cordotomy procedures were carried out in twelve patienls; in four of the procedures the technic was that ol Mullan and in sixleen that of Lin. Multiple procedures were carried out. in some patients, either because the initial cordotomy failed and had to 6e repeated on the same side or because the poin was bilateral and lhe procedure was performcd first on one side and then on the other. J have Llied to evaluate the results, from bolh the standpoint of lhe success of the twenty procedures in relieving pain and the standpoint of the result insofftt as the patient was concerned. For example, if the patient WIiS relieved of pain but died a week or so after the procedure, it seems to me, in relrospect, that it might have been prefer3ble to use narcotics rather than subject the patient to cordotomy. Six of the twelve patients did die within sixteen days after percutaneous cordotomy had been performed. Calculating the success rate in these twelve patients by factors other than relief of pain, 75 per cent would have to be classified as failures. Seven of the twenty cordotomy procedures (35 per ~nt) could probably be called successful in relieving ps:;; and thirteen (65 per cent) were failures. Complicatiort:i, too, are not infrpquent; in four patients motor weakn~s developed after percutaneous cordotomy, but in the reries at our hospital I did not classify 8 result as unsa'dsfactory because of the development of a complication. Percutaneous cordotomy is a very exact technical procedure. The placement of the needle must be accurate within a millimeter or two, otherwise disaster may result. There is no doubt that experience should produce better results, but where can a large num ber of patients needing this procedure be brought together? The experience with percutaneous cordotomy in our hospital covers a five year period; twelve patients in five years is scarcely more than two a year. If a surgeon is to become highly skilled, experience with a much greater number would be required. It seems to me that Dr Tytus should be the only one in the city of Seattle performing percutaneous cordotomy. In Portland the procedure is being attempted in at least four hospitals. The question, as in other procedures requiring great technical skill, is how to obtain specialization within a specialt.y. tn the highly competitive atmosphere of
medical practice in this country, there is a great temptation for everyone to try everything new. ConcenLlatjng delicate technical procf'dures such as this in a few hands is quite a problem. Until this millennium comes, I am inclined to treat the pAtient who hilS terminal cancer with p.ithO!r drugs or, if it appears that he has some months to survive, open cordotomy. I have one question, Dr Tytus. You state that the procedure should be restricted to patients with unilateral pain. In my experience with open cordotomy, a pl:!tient may emphatically insist the pain is unilateral but within 11 few days or weeks after rclief has been obtained on one side by unilateral cordotomy, a high per· centage of patients begin to complain ('of pain on the other side. Has this not been your experience with percutaneous cordotomy? W. Eugene Stern (Los Angeles, Calif): This proce· durc, although it is a good one and the one I would select if cordotomy is indicated, presents difficulty in the placement of the needle. It can displat:C the spinal cord as it impales the pia. Electrical stimulation contributes to' precision in the procedure. The patient is awake. and if movement is produced by the stimulating electrode, the needle is replaced so that stimulation produces sensation rather than movement. The wakeful patient can also be tested for relief of pain. Although at times the procedure is tediov.'l, it is applicable in patients in whom thtte open procp.dure is not. Doctor Tytus has alluded to the possibility of applying it more than once. It does not tnx the patient particu/tlrly nor require general anesthesia. The morbidity is 10y.'Cr than it is with th~ open procedure. The primary advantage of the open procedure is that the cord can be seen and the landmarks for pic.cement of the knife can be identified. We no longer use c(),dotomy for benign lesions; the results do not hold up in time. I compliment Dr Tytus on pursuinG" percutaneous cordotomy as a useful tool in skilled hands for the contro!ofpain. Robert W. Jamplis (Palo Alto, CaIiO: Two weeks ago a thirty-three year old mother of four children was referred to me because of a bronchogenic carcinoma in the right superior sulcus; the diagnosis had been made by biopsy of a mass at the base of the neck. She w.'ls undergoing supervoltage radiation therapy but the pain became unbearable. I first saw iter at this point. We have had some success in patients with tumors of the superior sulcus, following the lead of Dr Paulson, hut I believed that this particular tumor was inoperable, so we turned to our neurosurgical colleagues. They advised that posterior rhizotomy would have left hl!r with a flail arm and that she really needed cotdotomy. However, they had never performed cordot· omy percutaneously. We therefore referred lhe plltient to Dr Philip Lippe in San Jose, who was the only one in the area perform-
Percutnneous Cordolomy
ing the percutaneous procedure. Within a few houn her need for drugs d«reased from near addiction to morphine to 10 gr of aspirin daily for tension headaches. She is again undergoing supervoltage radiation therapy without p:l.in. John S. Tytus (closing): Doctor Roar, I think you are absolutely right. As Dr Stern suggested, the proce· dure was introduced with a grellt deal of enthusiasm. It setffifd to be the panacea for all kinds of pain. We reo alize now that it is not. I would re·emphasi7.e that we obtained good results in about 50 per cent of our patients. One of the prob. lems is, inaeed, pain that has spread to the other side and I do not know how tc anticipate this. For this reason we try to limit use of the procedure to patien:.s with pain in lhe lumbosacral or brachial plexus, such as in Dr Jamplis' caSE, or, when indicated, pain in the chest.
VetlumolU,Augulllg73
One answer to this problem in patients who haye a fairly good prognosis for a year or so of· life is to perfonn percutaneous cordotomy on one side and then if the pain spreads to the other side, open cordotomy can be performed contralaterally at lower cervical levels to avoid interfering with respiration. Doctor Mullan ndvocates this and certainly he knows marc about the procedure than onyone else in the world, Doctor Stern. we do not use electrical stimulation; we start with a very low voltage current, and if IIny ad· verse signs develop. we stop immediately and reploet lheneedle_ As you point out, the procedure can be Quite length)'. In our early cases it look as long as three hours. which is certainly a long time for the patient. I would also like 10 emphasize that .....e do nol perform cordotomy (or. benign conditions; it is used ani)' for malignant lesions.