Percutaneous Cordotomy Research Articles

Technique of High Cervical Percutaneous Cordotomy

Percutaneous cordotomy offers relief of pain to many patients who would not otherwise be candidates for cordotomy. The procedure described does not require general anesthesia, and recuperation from a major surgical procedure is not necessary. Another advantage is that the lesion can be monitored carefully.

Outlining the cervical spinal cord with tantalum powder: application to percutaneous cordotomy. Technical note.

✓ Powdered tantalum introduced into the subarachnoid space at C-2 clearly outlines the anterior aspect of the cord and dentate ligaments. Accurate electrode placement for percutaneous intramedullary cordotomy is made easier by the presence of a radiopaque target.

The Spinal Cord: Basic Aspects and Surgical Considerations

Under one cover this book includes much of what is known and what interests those dealing with the spinal cord. The new sections on neurochemistry and the measurement of blood flow are especially helpful, for they relate to the spinal cord these rapidly expanding areas in brain research. The section on neurochemistry provides much useful background information on neurotransmitters while discussing cogently current relevant research. The chapters on anterior spinal fusion by Cloward and percutaneous cordotomy by Rosomoff should enable neurosurgeons to include these two procedures in their surgical armamentarium if they have not already done so. The neuroanatomy of the cord is presented in a traditional manner and little new information is mentioned. The section devoted to the surgical care of patients with spinal injuries, tumors, and disk herniations discusses most problems ordinarily encountered. The fact that the author of this section (the editor) uses case reports to illustrate

Orthostatic hypotension following bilateral percutaneous cordotomy. A case report of treatment with anti-G suit.

We have described a case of orthostatic hypotension following bilateral percutaneous cordotomy for relief of severe, chrome back and leg pain. The blood pressure of 40/0 mm Hg with the patient standing was corrected to normal levels by the use of an anti-G flight suit with minor modifications.

Percutaneous Cordotomy

The essentials for performing a safe and satisfactory percutaneous cordotomy are: (1) a suitable type of pain in a patient without respiratory hazard, (2) a very fine electrode, (3) contrast visualization of the dentate ligament, (4) electrical stimulation before lesion making, (5) slow increase in strength of the lesion-making current, (6) careful motor as well as sensory testing between lesions, (7) a willingness to desist in the face of difficulties, and (8) an awareness of the possibility of respiratory problems in the postoperative period.

Easing the Pain

To the Editor. —Your news item Easing the Pain in the February issue ( Arch Intern Med 127 :200, 1971) is inaccurate in two important details. Neither open surgical cordotomy nor percutaneous cordotomy deprives a patient of his sense of touch. What is lost is the perception of pain, heat, and cold. Further, I doubt that injecting any amount of normal in the patient's lumbar subarachnoid space will relieve pain. The original work that was done on this procedure involved injecting the supernatant of iced saline. In actual fact of the matter, the supernatant ends up being hypertonic saline because of the crystallization out of water and the concentration of the hypertonic saline is somewhere between 3% and 5%. The problem of midline, lower back, and bilateral lower extremity pain in patients who have had extensive cobalt therapy and surgery for malignancies in the pelvis is a most difficult one.

Easing the pain

<h3>To the Editor.</h3> —Your news item "Easing the Pain" in the February issue (<i>Arch Intern Med</i><b>127</b>:200, 1971) is inaccurate in two important details. Neither open surgical cordotomy nor percutaneous cordotomy deprives a patient of his sense of touch. What is lost is the perception of pain, heat, and cold. Further, I doubt that injecting any amount of "normal saline" in the patient's lumbar subarachnoid space will relieve pain. The original work that was done on this procedure involved injecting the supernatant of iced saline. In actual fact of the matter, the supernatant ends up being hypertonic saline because of the crystallization out of water and the concentration of the hypertonic saline is somewhere between 3% and 5%. The problem of midline, lower back, and bilateral lower extremity pain in patients who have had extensive cobalt therapy and surgery for malignancies in the pelvis is a most difficult one.

Angle-meter to indicate the proper angle of insertion in anterior percutaneous cervical cordotomy. Technical note.

An angle meter has been devised to facilitate the anterior approach to lower cervical percutaneous cordotomy and to afford the operator increased accuracy in placing the needle electrode. A method is described which allows the operator to set the trajectory of the needle electrode accurately at the stage when only the tip of the needle is inserted into the disc. The procedure requires no mathematical calculations and has proved accurate in 40 cases.

Stereotactic simultaneous approach of sub- and supra-tentorial structures in the human nervous system. Introduction of an original apparatus.

Presentation of a new apparatus which allows the rapid performance – with great precision and a minimum of calculations – of several simultaneous penetrations of double sagittal and frontal obliquity, in a manner that is comfortable for both patient and surgeon. Furthermore, it should permit the approach of extra-encephalic structures: posterior percutaneous cordotomy (Hitchcock), intra-hypophyseal implantation or cryodestruction, for example.

Experimental relationship of radiofrequency electrical current and lesion size for application to percutaneous cordotomy

✓ Using the brains of anesthetized dogs, a study was carried out to evaluate the role played by differences in electrode size and inaccuracies in electrode placement during percutaneous cordotomy. It was determined that if the bare, active-electrode actually is entirely inside neural tissue, an effective lesion can be created with a minimum of current. For example, by using an electrode 3 mm in length and 0.4 mm in diameter, a radiofrequency current level of 50 mA (1.3 W) for 60 sec will create a lesion 5.5 mm long and 5 mm wide. If this electrode is properly positioned within neural tissue, it is impossible to achieve current levels of 75 mA or more, for the power density becomes so high that the local tissue is boiled and fried, which creates a gaseous and/or organic insulation around the electrode causing the current to drop to zero. The same phenomenon occurs at lower current levels if a smaller electrode is used due to the higher power density caused by putting the current through a smaller electrode-tissue interface. If all or any part of the bare, active electrode is outside neural tissue and in contact with cerebrospinal fluid, up to 100 to 300 mA of current may be needed to effect an adequate lesion since most of the current supplied is then shunted proportionately away from the high impedance neural tissue and into the lower impedance CSF. The heat spreading to the leptomeninges probably accounts for the severe neck pain experienced.

Localization of the respiratory motor pathway in the upper cervical spinal cord following percutaneous cordotomy.

Localization of the respiratory motor pathway in the upper cervical spinal cord following percutaneous cordotomy.

Percutaneous cervical cordotomy for relief of intractable pain.

Percutaneous cervical cordotomy for relief of intractable pain.

Bilateral percutaneous cervical radiofrequency cordotomy.

HE development of percutaneous techniques has made it necessary to revise some of the former criteria for cordotomyY -',1~ The ease, simplicity, and safety of percutaneous cordotomy have increased in number the patients for whom the procedure can be used. These factors, together with the associated relief from pain, have resulted in our use of the percutaneous method in an initial series of 400 patients subjected to more than 600 cordotomies in a 2-year period. Previously on this service only 20 to 30 open cordotomies would have been done in a comparable period. Among the 400 patients was a group of 100 who required bilateral lesions. This report will review data from the 225 cervical percutaneous cordotomies performed on these 100 patients. Methods and Material The technique for percutaneous radiofrequency cervical cordotomy is that described previously 17 with the following modification. An omnidirectional cineradiographic unit is now used exclusively for radiographic visualization. During placement of the cordotomy needle, a specific attempt is made to introduce 0.2 to 0.5 ml of 1.5% lidocaine into the epidural space; when the needle enters the subarachnoid space an additional 0.1 ml is injected intrathecally. The radiofrequency lesion is made progessively with 2.5 sec increments, rather than 5 sec. Once the desired level of analgesia is attained, the last time-exposure is repeated three times, or a total of four, to assure more complete necrosis. This last modification was instituted with the sixteenth patient in this series and probably represents the reason for the better long-term results in those patients who followed.

Percutaneous cordotomy for pain.

Percutaneous cordotomy is a technically safe and simple method of performing spinothalamic tractotomy. It is ideally suited to the patient with normal lung function who has unilateral pain due to cancer. With some modifications and reservations, it may be recommended for patients with bilateral pain or with pain due to nonmalignant disease and for those with some pulmonary impairment.

Stereotaxic surgery using a television guidance system. II. Percutaneous cordotomy.

We have described a method of carrying out percutaneous cordotomy by the anterior transdiscal approach. The technique consists of using a unique TV camera developed by us to survey the guideneedle in the polar plane. A parallel grid line image is televised simultaneously and is used to transmit the angle of guide-needle correction to the real guide-needle and align it with the spinothalamic target.

Electrical resistance in percutaneous cordotomy. Technical note.

We have described the use of a simple ohm-meter in measurement of a prominent increase in direct current resistance upon insertion of an electrode from spinal fluid into spinal cord. This is another parameter of measurement indicating passage of the electrode into the spinal cord during percutaneous cordotomy for relief of intractable pain.

Posterior percutaneous tractotomy and cordotomy.

Posterior percutaneous tractotomy and cordotomy.

Percutaneous thoracic and high cervical cordotomy by the anterior approach.

Percutaneous thoracic and high cervical cordotomy by the anterior approach.

Percutaneous stereotaxic cordotomy. I. Problems encountered.

A technique of low cervical percutaneous stereotaxic anterolateral cordotomy for relief of intractable pain is described. This is a modification of the method ofGildenberg, Lin, andPolakoff and consists of the use of a surveying telescope developed by us to guide the needle-electrode in the proper angle towards the target. Localization of the spinothalamic tract is approximated by stereotaxis under radiographic control and finally achieved by stimulation.

Percutaneous Cordotomy for Relief of Intractable Pain

Most nurses have experienced a feeling of helplessness when caring for a patient with unrelenting pain, pain which dominates his life, which renders him physically disabled, emotionally unstable, and even drug addicted, pain for which he will try anything to secure relief. Such patients welcome attempts by neurosurgeons to find ways of relieving their intractable pain. One such effort is described in this article.