The dying art of percutaneous cordotomy in Canada.

Cordotomy involves the surgical ablation of the spinothalamic tract within the spinal cord to treat pain. In 1912, Spiller and Martin described an ‘open’ cordotomy where the spinal cord was directly visualized through a thoracic laminectomy. In 1963, Mullan introduced a less invasive percutaneous technique using a needle inserted between the first and second vertebra under fluoroscopic guidance. Additional advances in intraoperative imaging and electrophysiological confirmation of the target improved the outcomes and reduced complications. In the 1970s, cordotomy was a common neurosurgical procedure for chronic pain. It became clear, however, that the effects could wear off over time and could occasionally cause a new deafferentation neuropathic pain. Cordotomy was therefore usually reserved for patients with nociceptive pain of malignant origin, because the patients’ reduced lifespan would reduce the likelihood of wearing off or neuropathic pain. Since the 1990s, the widespread use of oral opioids and the more recent introduction of intrathecal opioids dramatically reduced the use of cordotomy to manage pain. In the last 20 years, many neurosurgeons have been trained without ever seeing this operation. In 2012, an informal survey of all the functional neurosurgeons within Canada revealed that only 10 of these operations had been performed in the last five years. Cordotomy is a dying art. Our rare but continued experience with this operation has reinforced our belief that there are patients with medically refractory, unilateral, nociceptive pain due to malignancy who are ideally treated with percutaneous cervical cordotomy. In this paper we present a small, contemporary series of patients with medically intractable pain in a tertiary care hospital palliative care setting who underwent unilateral percutaneous cervical cordotomy. This cohort is used to highlight the ideal candidate for cordotomy and their expected outcome following surgery. An argument is made for the preferential use of cordotomy in the treatment of patients with medically refractory, unilateral nociceptive pain with life expectancy less than one year. We hope that the operation will continue to be utilized and will be taught to the next generation of neurosurgeons. Methods