Cordotomy for Intractable Cancer Pain: A Historical and Technical Narrative Review with Modern Perspectives

Background: Percutaneous cervical cordotomy (PCC) is a lesioning procedure that targets the anterolateral quadrant of the spinal cord to interrupt spinothalamic pain pathways. It provides rapid and durable analgesia for patients with unilateral, medically refractory cancer pain below the C5 dermatome. Although its utilization has declined with the expansion of pharmacological and neuromodulatory therapies, PCC remains a critical palliative intervention for patients in whom opioid therapy is ineffective or intolerable. Summary: This narrative review delineates the neuroanatomical underpinnings, technical evolution, and contemporary clinical outcomes associated with PCC. The procedure is typically performed at the C1-2 level under CT guidance, allowing precise lesion placement verified through impedance monitoring and intraoperative electrophysiological testing. Recent adaptations - including the use of deep sedation combined with neurophysiological mapping - have broadened the eligible patient population to include individuals unable to undergo awake procedures. Across modern clinical series, PCC provides immediate and substantial analgesia in over 90% of patients, frequently enabling significant reductions in opioid consumption and improvements in quality of life. Adverse events are uncommon and typically transient, though hemiparesis, respiratory dysfunction, and mirror pain remain recognized risks. Median post-procedural survival is generally short, reflecting delayed referral patterns and underscoring the need for earlier multidisciplinary consideration. Key Messages: PCC achieves rapid, durable, and substantial analgesia in appropriately selected patients with unilateral, treatment-refractory cancer pain. Advances in imaging and neurophysiological guidance have enhanced procedural accuracy and safety. Earlier integration into palliative care pathways may optimize patient outcomes and quality of life.