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Role of unilateral percutaneous cervical cordotomy in the treatment of neoplastic vertebral pain
123
Pain, 19 (1984) 123-131 Elsevier
PAI 00638
Research
Reports
Role of Unilateral Percutaneous Cervical Cordotomy in the Treatment of Neoplastic Vertebral Pain Stefano Ischia’, Aldo Luzzani, Albert0 Ischia and Lorenzo Pacini Annesthesiology
and Intensive Care Institute, Pain Relief Centre, University of Verona School of Medicine, Centro Ospedaliero Clinicizrato Borg0 Roma, 37134 Verona (Italy) (Received
25 August
1983, accepted
29 November
1983)
Summary
The present study is a long-term report on 69 patients undergoing unilateral percutaneous cervical cordotomy for vertebral pain due to neoplastic bone metastases. The pain was unilateral or bilateral and was characterised by a chronic and/or an incident component. Seventy-one per cent (49/69) of the patients benefitted from the operation, obtaining complete, lasting pain relief or a reduced degree of pain, amenable to control by medication with narcotic or non-narcotic drugs. There was a survival Q(50%) of 5 months (S.E. = 1.6) with no pain and a satisfactory quality of life.
Introduction Pain of vertebral localisation due to neoplastic bone metastases is a frequent phenomenon, especially in the evolution of certain neoplasms (cancer of the breast, prostate and lungs). Usually such pain will have both a chronic and an incident component: the chronic component manifests itself in the form of continuous, dull, deep-seated, generally midline pain, involving one or more vertebrae and often extending to the paravertebral regions on both sides; the incident component manifests itself in the form of excruciating pain which appears and disappears suddenly and is caused by body weight or movements. Vertebral pain is frequently accompanied by unilateral, or, more rarely, bilateral radicular pain (often of the incident type) experienced by the patient in the dermatomes corresponding to nerve ’ To whom requests 0304-3959/84/$03.00
for reprints
should be addressed.
Q 1984 Elsevier Science Publishers
B.V.
124
roots which are compressed and/or infiltrated by the neoplasm. In addition to the oppressive chronic pain and the incident pain, there may also be deafferentation pain, particularly of the dysaesthetic type (‘numb, tingling, pins and needles, the freezing coming out, or pricking’) [11,12,18]. The present study is a long-term report on 69 patients belonging to a group of 81 patients suffering from pain of vertebral localisation due to neoplastic bone metastases and therefore subjected to unilateral percutaneous cervical cordotomy (PCC) [7]. The cordotomies were performed by one of the authors (!%I.).
Patients and Method All the patients had pain originating from one or more neoplastic bone localisations in the vertebral region (Table I). All lesions were ascertained by means of radiographic examinations, total body bone scans and/or CT scans. A number of patients presented neoplastic bone involvement of other areas (e.g., scapula, femur, ribs) with no pain in these sites. The primary pathology of the 69,031 patients (45 males and 24 females) in whom follow-up proved possible mainly comprised
TABLE
1
PRIMARY PATHOLOGY AND VERTEBRAL MALES, 24 FEMALES) IN WHOM LONG-TERM
SEGMENTS INVOLVED IN 69 PATIENTS FOLLOW-UP WAS POSSIBLE
Primary pathology Cancer of Cancer of Cancer of Cancer of Cancer of Chordoma Cancer of Cancer of Cancer of Cancer of Cancer of Cancer of Unknown
the prostate the breast the lungs the colon-rectum the uterus the the the the the the
bladder kidneys oesophagus larynx penis sublingual sulcus
16 13 11 6 5 3 3 1 1 1 1 1 7
Vertebrae involved Lumbar Dorsal Multiple Sacral Lumbar Lumbar Lumbar Cervical
and and and and
sacral dorsal cervical dorsal
19 14 10 9 8 I 1 1
(45
125
neoplasms of the prostate (16/69 patients, 23.2%) breast (13/69 patients, 18.8%) and lungs (11/69 patients, 15.9%) (Table I). All the patients with tumours of the prostate and breast had previously been treated with polychemotherapy and/or hormone therapy. In addition, a number of patients with vertebral metastases secondary to other tumours (e.g., uterus, rectum) had already been subjected to courses of hormone therapy. Thirty out of 69 patients (43.5%) had been given courses of radiotherapy, and 41/69 (59.4%) were on treatment with narcotics via the oral, parenteral or intrarachidian route over a period ranging from a minimum of 10 days to a maximum of 3 months. The patients were referred to us with spontaneous chronic and/or incident pain affecting only one side or with bilateral pain with a distinct predominance of pain on one side (Table II). In 47/69 patients (68.1%) the pain occurred in only one half of the body and was of terribly excruciating intensity (above the 6 mark on the Scott-Huskisson visual analogue scale [15]). The existence of pain confined to one half of the body only could be explained by the presence, on CT scanning, of paravertebral neoplastic deposits spreading from infiltration of the body of the vertebra (6 cases of carcinoma of the lungsj, or in other cases by the wedge-type collapsing of one or more vertebral bodies (13 cases); in other cases we were unable to find an explanation for the unilateral restriction of the pain. In 22/69 patients (31.9%), in addition to continuous and/or incident pain of intensity above the 6 mark, there was also spontaneous or provoked, continuous or intermittent contralateral pain of moderate intensity (below 5). The possible existence of spontaneous or induced contralateral pain was searched for in all cases; particular attention was paid to the history, taken from the patient himself and from close relatives, and to the clinical examination. The patient was deemed to be suffering from bilateral pain when, in addition to excruciating pain in one half of the body, he also had continuous or intermittent contralateral pain, possibly brought out by certain positions, and when contralateral pain was induced by percussion or pressure on the spinal column or paravertebral regions, or by active or passive movements. The intensity of such pain proved to be substantially slighter and tended to be understated by the patient, whose attention was invariably focussed on the tremendous pain suffered in the other half of the body. When the patients were referred to us for observation, the drug therapy they were TABLE II TYPE OF PAIN (69 PATIENTS)
Unilateral Bilateral Total
Chronic
Incident
Chronic plus incident
Total
31(45%) 19 (27.5%) 50 (72.5%)
5 (7.2%) _ 5 (7.2%)
11 (16%) 3 (4.3%) 14 (20.3%)
47 (68.1%) 22 (31.9%)
126
on proved efficacious only in resolving was controlled only when the analgesic
the less intense pain. In some cases the pain was administered in narcotic doses.
Results A properly performed cordotomy should produce: (i) deep pin-prick analgesia on the entire side contralateral to the cordotomy lesion from C, to S,; (ii) a Claude Bernard-Horner’s syndrome and (iii) a sympathetic block ipsilateral to the lesion [7,8]. The immediate results achieved in our series were deep pin-prick analgesia in 62/69 patients (89.9%) and hypoalgesia in 7/69 (10.1%). These latter 7 patients belong to the group comprising the first 150 cordotomies out of a total of 540 patients from among whom we obtained the patients in the present study. The Claude Bernard-Homer’s syndrome occurred in 65/69 patients, and sympathetic block in all patients. The mortality over the 7 day postoperative period was 2/69 patients (2.9%). One of these 2 patients, who was suffering from carcinoma of the penis, died as a result of femoral haemorrhage on postoperative day 4; the other patient exhibited neoplastic cachexia and died on the fifth day after a coma lasting 3 days. The patients were followed up for the rest of their lives. The survival of the entire group of 81 patients (Q(50%) = the 50% quantile) is 5.55 months (SE. = 1.04; range: 4 days-3 years). No reliable follow-up could be obtained in 12 of these patients and they have been left out of the case study analysis. There were 46/69 patients suffering from unilateral pain (Table III). Their survival Q(50%) was 4.44 months (S.E. = 2.16; range: 15 days-40 months). In 37/46 patients there was abolition of the pain on the side contralateral to the cordotomy lesion. In 24/46 patients no pain was observed on the side ipsilateral to the cordotomy lesion; the survival Q(50%) was 4.6 months (SE. = 4.2; range 15 days-40 months). In 17 of these 24 patients pain relief was complete and lasting; their survival Q(50%) was 3.8 months (S.E. = 0.24; range: 15 days-2 years); 2/17 are still alive and pain-free after 2 years. In 6/17 patients in this group the pain was only incident (2/17 patients) or had an incident component (4/17 patients); while in the other 11/17 patients the pain was of the chronic continuous type. Of the remaining 7/24 patients in the group without occurrence of pain on the side ipsilateral to the lesion, 2 presented widespread pain in areas not affected by deep pin-prick analgesia, while the other 5 presented pain on the side contralateral to the cordotomy lesion. One had an immediate deafferentation pain and 1 presented it after 20 days, 1 persistence of moderate pain (hypoalgesia after PCC), and 2 persistence of pain (deafferentation pain). In 22/46 patients, on the other hand, pain ipsilateral to the lesion was experienced with an appearance Q(50%) of 75 days (S.E. = 0; range: O-4 months); the survival Q(5OW) in this group was 4.3 months (S.E. = 1.9; range: 15 days-20 months). In 9/22 patients the pain was controlled by medication with non-narcotic analgesic drugs or mild narcotics and in 5/22 by medication with narcotics, while in the remaining 8/22 patients the pain was poorly controlled by narcotics. In these
III
died during
no abolition of pain
6
a One patient
partial abolition of pain
disappearante of p&l
3
37
’
of pain
IN PATIENTS
SUFFERING
FROM
ipsifateralf0
the f&on:
analgesia
PAIN (46 a): RESULTS
AND MANAGEMENT
inadequate
1
6
inadequate
inadequate
1
1
inadequate medication with narcotics adequate medication with narcotics adequate medication with non-narcotics mild narcotics adequate medication with non-narcotics
medication
medication
medication
with narcotics
with narcotics
with narcotics
with narcotics
3 5 8
medication
inadequate
with narcotics
with narcotics
1
medication
medication
inadequate
adequate
1
2
or
Management of residual pain contralateral to the lesion and/or pain ipsilateral to the lesion
UNILATERAL
22 patients
of severe pain on the side contrathe lesion and appearance of pain to the lesion despite deep pin-prick of severe pain on the side contrathe lesion
of moderate pain on the side contrathe lesion and appearance of pain to the lesion of moderate pain on the side contrathe lesion of moderate pain on the side contrathe lesion despite deep pin-prick
Appearance ofpain
persistence lateral to ipsilateral persistence lateral to persistence lateral to analgesia 4 persistence lateral to ipsilateral 2 persistence lateral to
17 complete pain relief 2 widespread pain in areas not affected by deep pin-prick analgesia reappearance of pain 20 days later on the side contralateral to the lesion despite deep pinprick analgesia reappearance of pain 15 days later on the side contralateral to the lesion despite deep pinprick analgesia and appearance of puin ipsilateral to the lesion 16 appearance of pain ipsilateral to the lesion
Course
CORDOTOMY
the first week (total 47 patients).
CERVICAL
Results on the side contratateral to the lesion
PERCUTANEOUS UP TO DEATH
TABLE
5
128
8/22 cases it is hard to assess whether the inadequate response to narcotics is attributable to tolerance or to the presence of deafferentation pain. The patients suffering from bilateral pain (Table IV) were 21/69; their survival Q(50%) was 5.5 months (SE. = 1.5; range: 15 days-30 months). In 18/21 patients the pain disappeared on the side contralateral to the cordotomy lesion. In 14 of these 18 patients the pain ipsilateral to the lesion was controlled up to the time of death by means of narcotics (7/18 patients) or with non-narcotic analgesics or mild narcotics (7/18 patients), while in 2/18 the pain failed to respond adequately to medication with narcotics, and a further 2/18 patients presented the characteristic signs of a mild dysaesthesia. In the remaining 3/21 patients in the bilateral pain group, i.e., those with partial or no pain relief on the side contralateral to the cordotomy lesion, the residual and/or ipsilateral pain was treated with narcotics, achieving adequate medication in 1 case and inadequate medication in 2. Nineteen out of 69 patients (Table II) presented intense incident pain either as the sole pain manifestation (5/19 patients) or in association with chronic pain (14/19 patients); the incident pain was generally unilateral (16/19) and more rarely bilateral (3/19). The survival Q(50%) of this group was 4.2 months (S.E. = 1.37: range: 15 days-26 months). The PCC abolished the pain in the half of the body contralateral to the lesion in 13/19 patients. whereas the pain persisted despite the presence of deep pin-prick analgesia in 6/19 patients. These patients failed to benefit from subsequent medication with narcotics. As regards the side effects observed in the entire group of 69 patients treated by unilateral PCC, these were essentially of two types: loss of ability to walk and urinary retention. The ability to walk could not be evaluated in 19 patients (27.5%) as they were already bedridden. A further 7 patients (10.1%) were bedridden after the operation, though it should be emphasised that these patients had already shown signs of severe radicular damage in one limb and walked with difficulty before the operation. Urinary retention could not be assessed in 11 patients (15.9%) as they
TABLE
IV
PERCUTANEOUS CERVICAL CORDOTOMY PAIN (21”): RESULTS AND MANAGEMENT Results on the side contralateral the lesion
18 disappearance
to
of pain
1 partial abolition of pain 2 no abolition of pain a One patient
died during
IN PATIENTS SUFFERING UP TO DEATH
Management lesion and/or f 2 7 7 I 2 1 2
FROM
of pain on the side ipsilateral to the residual pain contralateral to the lesion
inadequate medication with narcotics adequate medication with narcotics adequate medication with non-narcotics mild dysaesthesia adequate medication with narcotics inadequate medication with narcotics
the first week (total 22 patients).
BILATERAL
129
were already catheterised. A further 5 patients (7.2%) required catheterisa~on after PCC. The cumulative survival functions were obtained using the actuarial-type life table (Olivetti MZOST computering).
Discussion
Vertebral pain of neoplastic origin appears in patients with a fairly long life expectancy and is of such a type and intensity as to reach the m~mum values of the Scott-Huskisson visual analogue scale, especially as regards the incident component. Oncological therapy (radio-, chemo-, hormonotherapy) [1,2,3,6,9,10,14,16,17] or medication with narcotic or non-narcotic analgesics proves inefficacious in a certain number of patients, or is only temporarily efficacious in controlling the pain. The period of survival of the patient, the intensity and type of pain, its possible bilaterality, and the inadequate response to oncological or pharmacological treatment all combine to make the management of such pain a difficult matter. In the 46 patients in our series suffering from unilateral neoplastic pain, PCC proved capable, either alone (17/46) or in conjunction with narcotic and non-narcotic drug therapy (17/46), of subduing the pain up to the time of the patient’s death; of the remaining 12/46 patients, 4 patients, belonging to the group of 24 who never at any time suffered from pain on the side ipsilateral to the lesion, presented deafferentation pain on the side contralateral to the operation, while the other 8 patients, belonging to the group of 22 who presented pain on the side ipsilateral to the cordotomy, failed to respond adequately to medication with narcotics. We are not in a position to establish whether the inadequate medication with narcotics was due to tolerance or to deafferentation pain. In the 21 patients suffering from bilateral pain with predominance of pain on one side of such a type as to render medication with narcotics inadequate, PCC made adequate medication possible in 15/21 patients (8/21 with narcotic drugs and 7/21 with non-narcotic analgesics); in 4/21 patients the pain eventually failed to respond adequately to medication with narcotics in the course of the survival period (Q(50%) = 5.5 months); in 2/21 patients a mild dysaesthesia was observed. Percutaneous cervical cordotomy is indicated in terrible, excruciating-killing neoplastic pain or wherever there is an incident component, as soon as oncological treatments have proved inefficacious or when the possibility of performing surgical fusion of the spinal column [4,5,13] has been excluded. Forty-nine out of the 69 patients we treated benefitted from the operation. The survival rate of these patients, some of whom following the operation were medicated, as and when necessary, with narcotic or non-narcotic analgesics, was 5 months (SE. = 1.6; range: 15 days-2 years}. These patients were free from pain and had a satisfactory quality of life. The concept of a planned unilateral cordotomy for bilateral or midline pain has been rejected by most neurosurgeons because it failed. Our results are distinctly at
130
variance with this traditional experience and perhaps a reappraisal of the procedure is worthwhile. The reason for these differing results is, in our opinion. related to the fact that the sine qua non for a homogeneous evaluation of the results of a cordotomy is an in-depth knowledge of the follow-up of patients in whom deep pin-prick analgesia contralateral to the lesion and Claude Bernard-Horner’s syndrome and sympathetic block ipsilateral to the lesion are achieved. We are convinced that our results would have been better, if we had obtained deep pin-prick analgesia also in the 7 patients (10.1%) where this was not possible.
The authors wish to thank Mr. Anthony Steele for his invaluable translating and revising the text of this paper.
assistance
in
References
10 11
12 13 14
Bonadonna, G. and Molinari, R., Role and limits of anticancer drugs in the treatment of advanced cancer pain. In: J.J. Bonica and V. Ventafridda (Eds.), Advances in Pain Research and Therapy, Vol. 2. Raven Press, New York, 1979, pp. 131-138. Carter, SK., Barkowski, M.T. and Hellmann, K., Chemotherapy of Cancer, Wiley, New York, 1977. Clarysse, A., Kenis, Y. and Mathe, G., Cancer Chemotherapy: its Role in the Treatment Strategy of Hematologic Malignancies and Solid Tumors. Recent Results in Cancer Research, Vol. 53, Springer, Berlin, 1976. Freebody, D., Bedall, R. and Taylor, R.D., Anterior transperitoneal lumbar fusion, J. Bone Jt Surg., S3B (1971) 617. Heipertz, W., Fohler, N. und Schmitt, E., Stabilisierung der Wirbelsaule durch Spondylodese bei Tumoren, 2. Orthop., 112 (1974) 851-853. Huggins, C., Endocrine-induced regression of cancers, Cancer Res.. 27 (1967) 1925-1930. Ischia, S., Luzzani, A., Maffezzoli, G.F., Pacini, L. and Nicoiini, F., Percutaneous cervical cordotomy: technical considerations and results in 400 treated cases. In; R. Rizzi and M. Visentini (Eds.). Pain Therapy, Elsevier Biomedical Press, Amsterdam, 1983, pp. 367-379. Ischia, S., Luzzani, A., Ischia, A. and Maffezzob, G.F., Bilateral percutaneous cervical cordotomy: immediate and long-term results in 36 patients with neoplastic disease, J. Neurol. Neurosurg. Psychiat., 47 (1984) 141-147. Klaassen, D.J., Rapp, E.J. and Hirte, W.E., Response to medroxyprogesterone acetate (NSC-26386) as secondary hormone therapy for metastatic breast cancer in postmenopausal women, Cancer Treatm. Rep., 60 (1976) 251-253. Lewison, E.J., Trimble, F.H., Grow, G.L. and Masukawa, T., Results of combined hormone therapy in advanced breast cancer, Cancer, 16 (1963) 1243-1245. Loeser, J.D., Definition, etiology, and neurological assessment of pain o~~nating in the nervous system folIowing deafferentation. In: J.J. Bonica, U. Lindblom and A. Iggo (Eds.), Advances in Pain Research and Therapy, Vol. 5, Raven Press, New York, 1983, pp. 701-711. Noordenbos, W., Pathologic aspects of central pain states. In: J.J. Bonica (Ed.), Advances in Neurology, Vol. 4, Raven Press, New York, 1974, pp. 333-337. Polster, J. und Brinckmann, P., Ein Wirbelkorperimplantat zur Verwendung bei Palliativ-Operationen an der Wirbelsaule, Z. Orthop., 115 (1977) 118-122. Raffa, S. and Johnson, R., The treatment of advanced prostate carcinoma with medroxyprogesterone, Curr. Ther. Res., 16 (1974) 261-267.
131 15 Scott, J. and Husk&son, E.G., Graphic representation of pain, Pain, 2 (1976) 175-184. 16 Susan, L.P., Roth, B.R. and Adkins, W.C., Regression of prostatic cancer metastases by high doses of diethylstilbestroi diphosphate, Urology (Baltimore), 7 (1976) 589-601. 17 Tagnon, H.J., Coune, A., Henson, J.C. and Van Rymenant, N., Problems in the treatment of disseminated cancer of the breast: selection of patients for hormone treatment. In: L. Manuila, S. Moles and P. Rentchnick (Bds.), New Trends in the Treatment of Cancer, Springer, Berlin, 1967, pp. 126-133. 18 Tasker, R.R., Tsuda, T. and Hawrylshyn, A., Clinical neurophysiological investigation of deafferentation pain. In: J.J. Bonica, U. Lindblom and A. Iggo (Eds.), Advances in Pain Research and Therapy, Vol. 5, Raven Press, New York, 1983, pp. 713-738.
Pain, 19 (1984) 123-131 Elsevier
PAI 00638
Research
Reports
Role of Unilateral Percutaneous Cervical Cordotomy in the Treatment of Neoplastic Vertebral Pain Stefano Ischia’, Aldo Luzzani, Albert0 Ischia and Lorenzo Pacini Annesthesiology
and Intensive Care Institute, Pain Relief Centre, University of Verona School of Medicine, Centro Ospedaliero Clinicizrato Borg0 Roma, 37134 Verona (Italy) (Received
25 August
1983, accepted
29 November
1983)
Summary
The present study is a long-term report on 69 patients undergoing unilateral percutaneous cervical cordotomy for vertebral pain due to neoplastic bone metastases. The pain was unilateral or bilateral and was characterised by a chronic and/or an incident component. Seventy-one per cent (49/69) of the patients benefitted from the operation, obtaining complete, lasting pain relief or a reduced degree of pain, amenable to control by medication with narcotic or non-narcotic drugs. There was a survival Q(50%) of 5 months (S.E. = 1.6) with no pain and a satisfactory quality of life.
Introduction Pain of vertebral localisation due to neoplastic bone metastases is a frequent phenomenon, especially in the evolution of certain neoplasms (cancer of the breast, prostate and lungs). Usually such pain will have both a chronic and an incident component: the chronic component manifests itself in the form of continuous, dull, deep-seated, generally midline pain, involving one or more vertebrae and often extending to the paravertebral regions on both sides; the incident component manifests itself in the form of excruciating pain which appears and disappears suddenly and is caused by body weight or movements. Vertebral pain is frequently accompanied by unilateral, or, more rarely, bilateral radicular pain (often of the incident type) experienced by the patient in the dermatomes corresponding to nerve ’ To whom requests 0304-3959/84/$03.00
for reprints
should be addressed.
Q 1984 Elsevier Science Publishers
B.V.
124
roots which are compressed and/or infiltrated by the neoplasm. In addition to the oppressive chronic pain and the incident pain, there may also be deafferentation pain, particularly of the dysaesthetic type (‘numb, tingling, pins and needles, the freezing coming out, or pricking’) [11,12,18]. The present study is a long-term report on 69 patients belonging to a group of 81 patients suffering from pain of vertebral localisation due to neoplastic bone metastases and therefore subjected to unilateral percutaneous cervical cordotomy (PCC) [7]. The cordotomies were performed by one of the authors (!%I.).
Patients and Method All the patients had pain originating from one or more neoplastic bone localisations in the vertebral region (Table I). All lesions were ascertained by means of radiographic examinations, total body bone scans and/or CT scans. A number of patients presented neoplastic bone involvement of other areas (e.g., scapula, femur, ribs) with no pain in these sites. The primary pathology of the 69,031 patients (45 males and 24 females) in whom follow-up proved possible mainly comprised
TABLE
1
PRIMARY PATHOLOGY AND VERTEBRAL MALES, 24 FEMALES) IN WHOM LONG-TERM
SEGMENTS INVOLVED IN 69 PATIENTS FOLLOW-UP WAS POSSIBLE
Primary pathology Cancer of Cancer of Cancer of Cancer of Cancer of Chordoma Cancer of Cancer of Cancer of Cancer of Cancer of Cancer of Unknown
the prostate the breast the lungs the colon-rectum the uterus the the the the the the
bladder kidneys oesophagus larynx penis sublingual sulcus
16 13 11 6 5 3 3 1 1 1 1 1 7
Vertebrae involved Lumbar Dorsal Multiple Sacral Lumbar Lumbar Lumbar Cervical
and and and and
sacral dorsal cervical dorsal
19 14 10 9 8 I 1 1
(45
125
neoplasms of the prostate (16/69 patients, 23.2%) breast (13/69 patients, 18.8%) and lungs (11/69 patients, 15.9%) (Table I). All the patients with tumours of the prostate and breast had previously been treated with polychemotherapy and/or hormone therapy. In addition, a number of patients with vertebral metastases secondary to other tumours (e.g., uterus, rectum) had already been subjected to courses of hormone therapy. Thirty out of 69 patients (43.5%) had been given courses of radiotherapy, and 41/69 (59.4%) were on treatment with narcotics via the oral, parenteral or intrarachidian route over a period ranging from a minimum of 10 days to a maximum of 3 months. The patients were referred to us with spontaneous chronic and/or incident pain affecting only one side or with bilateral pain with a distinct predominance of pain on one side (Table II). In 47/69 patients (68.1%) the pain occurred in only one half of the body and was of terribly excruciating intensity (above the 6 mark on the Scott-Huskisson visual analogue scale [15]). The existence of pain confined to one half of the body only could be explained by the presence, on CT scanning, of paravertebral neoplastic deposits spreading from infiltration of the body of the vertebra (6 cases of carcinoma of the lungsj, or in other cases by the wedge-type collapsing of one or more vertebral bodies (13 cases); in other cases we were unable to find an explanation for the unilateral restriction of the pain. In 22/69 patients (31.9%), in addition to continuous and/or incident pain of intensity above the 6 mark, there was also spontaneous or provoked, continuous or intermittent contralateral pain of moderate intensity (below 5). The possible existence of spontaneous or induced contralateral pain was searched for in all cases; particular attention was paid to the history, taken from the patient himself and from close relatives, and to the clinical examination. The patient was deemed to be suffering from bilateral pain when, in addition to excruciating pain in one half of the body, he also had continuous or intermittent contralateral pain, possibly brought out by certain positions, and when contralateral pain was induced by percussion or pressure on the spinal column or paravertebral regions, or by active or passive movements. The intensity of such pain proved to be substantially slighter and tended to be understated by the patient, whose attention was invariably focussed on the tremendous pain suffered in the other half of the body. When the patients were referred to us for observation, the drug therapy they were TABLE II TYPE OF PAIN (69 PATIENTS)
Unilateral Bilateral Total
Chronic
Incident
Chronic plus incident
Total
31(45%) 19 (27.5%) 50 (72.5%)
5 (7.2%) _ 5 (7.2%)
11 (16%) 3 (4.3%) 14 (20.3%)
47 (68.1%) 22 (31.9%)
126
on proved efficacious only in resolving was controlled only when the analgesic
the less intense pain. In some cases the pain was administered in narcotic doses.
Results A properly performed cordotomy should produce: (i) deep pin-prick analgesia on the entire side contralateral to the cordotomy lesion from C, to S,; (ii) a Claude Bernard-Horner’s syndrome and (iii) a sympathetic block ipsilateral to the lesion [7,8]. The immediate results achieved in our series were deep pin-prick analgesia in 62/69 patients (89.9%) and hypoalgesia in 7/69 (10.1%). These latter 7 patients belong to the group comprising the first 150 cordotomies out of a total of 540 patients from among whom we obtained the patients in the present study. The Claude Bernard-Homer’s syndrome occurred in 65/69 patients, and sympathetic block in all patients. The mortality over the 7 day postoperative period was 2/69 patients (2.9%). One of these 2 patients, who was suffering from carcinoma of the penis, died as a result of femoral haemorrhage on postoperative day 4; the other patient exhibited neoplastic cachexia and died on the fifth day after a coma lasting 3 days. The patients were followed up for the rest of their lives. The survival of the entire group of 81 patients (Q(50%) = the 50% quantile) is 5.55 months (SE. = 1.04; range: 4 days-3 years). No reliable follow-up could be obtained in 12 of these patients and they have been left out of the case study analysis. There were 46/69 patients suffering from unilateral pain (Table III). Their survival Q(50%) was 4.44 months (S.E. = 2.16; range: 15 days-40 months). In 37/46 patients there was abolition of the pain on the side contralateral to the cordotomy lesion. In 24/46 patients no pain was observed on the side ipsilateral to the cordotomy lesion; the survival Q(50%) was 4.6 months (SE. = 4.2; range 15 days-40 months). In 17 of these 24 patients pain relief was complete and lasting; their survival Q(50%) was 3.8 months (S.E. = 0.24; range: 15 days-2 years); 2/17 are still alive and pain-free after 2 years. In 6/17 patients in this group the pain was only incident (2/17 patients) or had an incident component (4/17 patients); while in the other 11/17 patients the pain was of the chronic continuous type. Of the remaining 7/24 patients in the group without occurrence of pain on the side ipsilateral to the lesion, 2 presented widespread pain in areas not affected by deep pin-prick analgesia, while the other 5 presented pain on the side contralateral to the cordotomy lesion. One had an immediate deafferentation pain and 1 presented it after 20 days, 1 persistence of moderate pain (hypoalgesia after PCC), and 2 persistence of pain (deafferentation pain). In 22/46 patients, on the other hand, pain ipsilateral to the lesion was experienced with an appearance Q(50%) of 75 days (S.E. = 0; range: O-4 months); the survival Q(5OW) in this group was 4.3 months (S.E. = 1.9; range: 15 days-20 months). In 9/22 patients the pain was controlled by medication with non-narcotic analgesic drugs or mild narcotics and in 5/22 by medication with narcotics, while in the remaining 8/22 patients the pain was poorly controlled by narcotics. In these
III
died during
no abolition of pain
6
a One patient
partial abolition of pain
disappearante of p&l
3
37
’
of pain
IN PATIENTS
SUFFERING
FROM
ipsifateralf0
the f&on:
analgesia
PAIN (46 a): RESULTS
AND MANAGEMENT
inadequate
1
6
inadequate
inadequate
1
1
inadequate medication with narcotics adequate medication with narcotics adequate medication with non-narcotics mild narcotics adequate medication with non-narcotics
medication
medication
medication
with narcotics
with narcotics
with narcotics
with narcotics
3 5 8
medication
inadequate
with narcotics
with narcotics
1
medication
medication
inadequate
adequate
1
2
or
Management of residual pain contralateral to the lesion and/or pain ipsilateral to the lesion
UNILATERAL
22 patients
of severe pain on the side contrathe lesion and appearance of pain to the lesion despite deep pin-prick of severe pain on the side contrathe lesion
of moderate pain on the side contrathe lesion and appearance of pain to the lesion of moderate pain on the side contrathe lesion of moderate pain on the side contrathe lesion despite deep pin-prick
Appearance ofpain
persistence lateral to ipsilateral persistence lateral to persistence lateral to analgesia 4 persistence lateral to ipsilateral 2 persistence lateral to
17 complete pain relief 2 widespread pain in areas not affected by deep pin-prick analgesia reappearance of pain 20 days later on the side contralateral to the lesion despite deep pinprick analgesia reappearance of pain 15 days later on the side contralateral to the lesion despite deep pinprick analgesia and appearance of puin ipsilateral to the lesion 16 appearance of pain ipsilateral to the lesion
Course
CORDOTOMY
the first week (total 47 patients).
CERVICAL
Results on the side contratateral to the lesion
PERCUTANEOUS UP TO DEATH
TABLE
5
128
8/22 cases it is hard to assess whether the inadequate response to narcotics is attributable to tolerance or to the presence of deafferentation pain. The patients suffering from bilateral pain (Table IV) were 21/69; their survival Q(50%) was 5.5 months (SE. = 1.5; range: 15 days-30 months). In 18/21 patients the pain disappeared on the side contralateral to the cordotomy lesion. In 14 of these 18 patients the pain ipsilateral to the lesion was controlled up to the time of death by means of narcotics (7/18 patients) or with non-narcotic analgesics or mild narcotics (7/18 patients), while in 2/18 the pain failed to respond adequately to medication with narcotics, and a further 2/18 patients presented the characteristic signs of a mild dysaesthesia. In the remaining 3/21 patients in the bilateral pain group, i.e., those with partial or no pain relief on the side contralateral to the cordotomy lesion, the residual and/or ipsilateral pain was treated with narcotics, achieving adequate medication in 1 case and inadequate medication in 2. Nineteen out of 69 patients (Table II) presented intense incident pain either as the sole pain manifestation (5/19 patients) or in association with chronic pain (14/19 patients); the incident pain was generally unilateral (16/19) and more rarely bilateral (3/19). The survival Q(50%) of this group was 4.2 months (S.E. = 1.37: range: 15 days-26 months). The PCC abolished the pain in the half of the body contralateral to the lesion in 13/19 patients. whereas the pain persisted despite the presence of deep pin-prick analgesia in 6/19 patients. These patients failed to benefit from subsequent medication with narcotics. As regards the side effects observed in the entire group of 69 patients treated by unilateral PCC, these were essentially of two types: loss of ability to walk and urinary retention. The ability to walk could not be evaluated in 19 patients (27.5%) as they were already bedridden. A further 7 patients (10.1%) were bedridden after the operation, though it should be emphasised that these patients had already shown signs of severe radicular damage in one limb and walked with difficulty before the operation. Urinary retention could not be assessed in 11 patients (15.9%) as they
TABLE
IV
PERCUTANEOUS CERVICAL CORDOTOMY PAIN (21”): RESULTS AND MANAGEMENT Results on the side contralateral the lesion
18 disappearance
to
of pain
1 partial abolition of pain 2 no abolition of pain a One patient
died during
IN PATIENTS SUFFERING UP TO DEATH
Management lesion and/or f 2 7 7 I 2 1 2
FROM
of pain on the side ipsilateral to the residual pain contralateral to the lesion
inadequate medication with narcotics adequate medication with narcotics adequate medication with non-narcotics mild dysaesthesia adequate medication with narcotics inadequate medication with narcotics
the first week (total 22 patients).
BILATERAL
129
were already catheterised. A further 5 patients (7.2%) required catheterisa~on after PCC. The cumulative survival functions were obtained using the actuarial-type life table (Olivetti MZOST computering).
Discussion
Vertebral pain of neoplastic origin appears in patients with a fairly long life expectancy and is of such a type and intensity as to reach the m~mum values of the Scott-Huskisson visual analogue scale, especially as regards the incident component. Oncological therapy (radio-, chemo-, hormonotherapy) [1,2,3,6,9,10,14,16,17] or medication with narcotic or non-narcotic analgesics proves inefficacious in a certain number of patients, or is only temporarily efficacious in controlling the pain. The period of survival of the patient, the intensity and type of pain, its possible bilaterality, and the inadequate response to oncological or pharmacological treatment all combine to make the management of such pain a difficult matter. In the 46 patients in our series suffering from unilateral neoplastic pain, PCC proved capable, either alone (17/46) or in conjunction with narcotic and non-narcotic drug therapy (17/46), of subduing the pain up to the time of the patient’s death; of the remaining 12/46 patients, 4 patients, belonging to the group of 24 who never at any time suffered from pain on the side ipsilateral to the lesion, presented deafferentation pain on the side contralateral to the operation, while the other 8 patients, belonging to the group of 22 who presented pain on the side ipsilateral to the cordotomy, failed to respond adequately to medication with narcotics. We are not in a position to establish whether the inadequate medication with narcotics was due to tolerance or to deafferentation pain. In the 21 patients suffering from bilateral pain with predominance of pain on one side of such a type as to render medication with narcotics inadequate, PCC made adequate medication possible in 15/21 patients (8/21 with narcotic drugs and 7/21 with non-narcotic analgesics); in 4/21 patients the pain eventually failed to respond adequately to medication with narcotics in the course of the survival period (Q(50%) = 5.5 months); in 2/21 patients a mild dysaesthesia was observed. Percutaneous cervical cordotomy is indicated in terrible, excruciating-killing neoplastic pain or wherever there is an incident component, as soon as oncological treatments have proved inefficacious or when the possibility of performing surgical fusion of the spinal column [4,5,13] has been excluded. Forty-nine out of the 69 patients we treated benefitted from the operation. The survival rate of these patients, some of whom following the operation were medicated, as and when necessary, with narcotic or non-narcotic analgesics, was 5 months (SE. = 1.6; range: 15 days-2 years}. These patients were free from pain and had a satisfactory quality of life. The concept of a planned unilateral cordotomy for bilateral or midline pain has been rejected by most neurosurgeons because it failed. Our results are distinctly at
130
variance with this traditional experience and perhaps a reappraisal of the procedure is worthwhile. The reason for these differing results is, in our opinion. related to the fact that the sine qua non for a homogeneous evaluation of the results of a cordotomy is an in-depth knowledge of the follow-up of patients in whom deep pin-prick analgesia contralateral to the lesion and Claude Bernard-Horner’s syndrome and sympathetic block ipsilateral to the lesion are achieved. We are convinced that our results would have been better, if we had obtained deep pin-prick analgesia also in the 7 patients (10.1%) where this was not possible.
The authors wish to thank Mr. Anthony Steele for his invaluable translating and revising the text of this paper.
assistance
in
References
10 11
12 13 14
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