Open thoracic cordotomy as a treatment option for severe, debilitating pain

The treatment of patients with debilitating lower extremity or medically refractory quadrant pain presents a challenge for management. Contemporary neuromodulatory therapies may not be affordable or practical, especially in patients with limited life expectancy or from countries with limited resources. We present a small retrospective series to evaluate the role of open thoracic cordotomy as a practice option in the treatment of patients with severe, unilateral, medically refractory pain of the lower abdominal quadrant, hip, or leg. Technical aspects of the procedure, anatomic pathways within the spinal cord, and intraoperative maneuvers are described.

The medical records of 9 patients (7 men, 2 women; median age, 57 years) treated between 1998 and 2010 were reviewed. Each patient underwent open thoracic cordotomy after 1998 for severe lower quadrant or lower extremity pain refractory to multiple other treatment modalities. The indications for surgery included cancer-related pain (4 of 9), postherpetic neuralgia (2 of 9), post-spinal cord injury pain (2 of 9), and multiple sclerosis (1 of 9).

Six of nine patients reported improvement in their postoperative level of pain after a median follow-up of 31 weeks. Complications included ipsilateral lower extremity weakness, urinary incontinence, and the development of new postcordotomy pain. A higher incidence of complications, including ipsilateral motor weakness, was observed in this series than with previous reports of percutaneous cervical cordotomy (PCC).

Although open thoracic cordotomy may be cautiously recommended as a treatment option in certain settings, this procedure should be viewed only as a second-line treatment option in settings where the technology and expertise to perform PCC are available.