Percutaneous Radiofrequency Cordotomy Research Articles

Percutaneous CT-guided cordotomy for pain.

Cordotomy has evolved since the first open procedure by Spiller and the first percutaneous radiofrequency cordotomy by Mullan in 1965. Today, the minimally invasive, CT-guided percutaneous radiofrequency cordotomy is mostly used for the palliative management of medically intractable somatic pain related to malignancy in well-selected patients. The risk of adverse events is minimized with the use of intraoperative stimulation monitoring. This video highlights the spinal cord anatomy at the level of C1–2, the approach to patient selection, the associated risks and benefits, and, finally, the procedural setup and key steps involved in this unique neurosurgical procedure.The video can be found here: https://youtu.be/a-0ORqy0W2o

Flat Panel Fluoroscopy (O-Arm) Guided Percutaneous Radiofrequency Anterolateral Cordotomy

Abstract INTRODUCTION Chronic pain is a major cause of the current opioid epidemic in the United States. Cancer related intractable pain represents a challenging condition to manage medically. Most patients with this condition need increasingly higher doses of opioid analgesics due to receptor downregulation. This put patients at risk of opioid addiction, and it results in financial burden on both the patients and healthcare system. Anterolateral cordotomy is an ablative pain procedure that works through interrupting the ascending pain pathways contralateral to the pain site, namely the spinothalamic tract. Here, we present a case with unilateral cancer related somatic pain that was treated with a contralateral C1-C2 cordotomy. METHODS A 55-yr-old female with a stage 4 breast cancer that invaded her chest wall and axilla on the right side was studied. The tumor eroded through the skin of the breast. She has been having worsening chronic somatic pain that required hospital admission. She was using 60 mg of oral Methadone and 300 mg of Dilaudid delivered through patient control analgesia (PCA), with residual pain scored at 5 (1-10). She underwent a left sided C1-C2 O-arm guided percutaneous Radiofrequency cordotomy. RESULTS The patient had an immediate complete relief of her pain in the operating room that lasted throughout her hospital stay. On postop day 1 the Dilaudid was cut down by 50%. On postop day 2 it was stopped, and the patient was continued on oral protocol. She was discharged home on postop day 3. Neurologically the patient had no pain/temperature sensation on the right arm and chest, but she maintained motor strength, proprioception, vibration, and balance equally on both sides. CONCLUSION O-arm guided percutaneous Radiofrequency cordotomy is an effective minimally invasive method to treat chronic somatic pain. It results in immediate pain relief in 90% of patients with resultant reduction in opioids consumption and decrease hospital length of stay.

O-Arm-Guided Percutaneous Radiofrequency Cordotomy

Background: Pain is often one of the most debilitating symptoms in patients with advanced oncological disease. Patients with localized pain due to malignancy refractory to medical treatment can benefit from selective percutaneous cordotomy that disconnects the ascending pain fibers in the spinothalamic tract. Objectives: Over the past year, we have been performing percutaneous radiofrequency cordotomy with the use of the O-Arm intraoperative imaging system that allows both 2D fluoroscopy and 3D reconstructed computerized tomography imaging. We present our experience using this technique, focusing on technical nuances and complications. Methods: A retrospective analysis was conducted of all patients who underwent percutaneous cordotomy between March 2016 and March 2017. Results: Nineteen patients underwent percutaneous cordotomy procedures. Two patients developed intraoperative delirium and were unable to tolerate the procedure. In 16 out of 17 completed procedures, we achieved excellent immediate pain relief (94%). At 1 month after operation, 15 of the 17 (88%) patients were pain free, and at 3 months 5 out of 5 patients available for follow-up were still free of their original pain. Mirror pain developed in 6 of the 17 patients (35%), but was mild in 4 of these cases and controlled with medications. We experienced 1 serious complication (6%) of ipsilateral hemiparesis. Conclusion: Percutaneous cordotomy using the O-Arm is safe and effective in the treatment of intractable oncological pain.

Microstructural mechanisms of analgesia in percutaneous cervical cordotomy revealed by diffusion tensor imaging

The purpose of this study is to demonstrate the potential of diffusion tensor imaging (DTI) to reveal structural mechanisms underlying spinal ablative procedures, including percutaneous radiofrequency cordotomy (PRFC). PRFC is a surgical procedure that produces analgesia through focal ablation of the lateral spinothalamic tract (STT), thereby interrupting the flow of pain information from the periphery to the brain. To date, studies regarding mechanisms of analgesia after PRFC have been limited to postmortem cadaveric dissection and histology. However, with recent advances in DTI, the opportunity has arisen to study the STT non-invasively in vivo. In this technical note, an individual with successful pain relief following unilateral STT PRFC was examined using DTI, with the contralateral STT serving as an internal control. PRFC substantially reduced rostrocaudal directional DTI signal in the STT from the lesion in the cervical spinal cord through the pons and mesencephalon. Our findings confirm that focal ablation and anterograde degeneration accompany the analgesic effects of PRFC. In vivo imaging of the STT with DTI may contribute to surgical targeting for PRFC procedures, better understanding of the therapeutic and untoward effects of PRFC, and a deeper understanding of spinothalamic contributions to nociception.

Flat-Panel Fluoroscopy O-arm–Guided Percutaneous Radiofrequency Cordotomy

Percutaneous radiofrequency cordotomy (PRFC) involves controlled ablation of the anterolateral quadrant of the spinal cord, thereby relieving pain. Evolving from a morbid open surgery, the procedure has been modernized through the application of physiological target confirmation, well-regulated thermal ablation, and improved intraoperative imaging. To evaluate the utility in PRFC of a new high-resolution, portable flat-panel fluoroscopic imaging technology, the O-arm Imaging System. The O-arm allows traditional 2-dimensional fluoroscopy in addition to axial and 3-dimensional reconstructed computed tomography imaging. PRFC was performed using the O-arm Imaging System in 6 patients with unilateral cancer pain. Patients experienced 90% to 100% initial pain relief, with 50% to 100% sustained pain relief at the time of death at 2 to 12 months. There were no complications. Portable flat-panel fluoroscopy allows high-resolution, readily updated computed tomography and fluoroscopic image guidance during PRFC. Use of this new technology may assist neurosurgeons in providing an important analgesic intervention at centers possessing the imaging technology.

Endoscopic-guided percutaneous radiofrequency cordotomy

The authors present the first clinical implementation of an endoscopic-assisted percutaneous anterolateral radiofrequency cordotomy. The aim of this article is to demonstrate the intradural endoscopic visualization of the cervical spinal cord via a percutaneous approach to refine the spinal target for anterolateral cordotomy, avoiding undesired trauma to the spinal tissue or injury to blood vessels. Initially, a lateral puncture of the spinal canal in the C1-2 interspace is performed, guided by fluoroscopy. As soon as CSF is reached by the guide cannula (17-gauge needle), the endoscope can be inserted for visualization of the spinal cord and its surrounding structures. The endoscopic visualization provided clear identification of the pial surface of the spinal cord, arachnoid membrane, dentate ligament, dorsal and ventral root entry zone, and blood vessels. The target for electrode insertion into the spinal cord was determined to be the midpoint from the dentate ligament and the ventral root entry zone. The endoscopic guidance shortened the fluoroscopy usage time and no intrathecal contrast administration was needed. Cordotomy was performed by a standard radiofrequency method after refining of the neurophysiological target. Satisfactory analgesia was provided by the procedure with no additional complications or CSF leak. The initial use of this technique suggests that a percutaneous endoscopic procedure may be useful for particular manipulation of the spinal cord, possibly adding a degree of safety to the procedure and improving its effectiveness.

CT-assisted percutaneous anterior cordotomy: technical note

Percutaneous radiofrequency cordotomy remains a useful modality for managing selected patients with unremitting pain due malignancy. Although the lateral C1–C2 method is widely used certain clinical situations may call for a low anterior cervical approach via the disc space. The anterior method can be technically exacting due to the need for precision in the angle of approach at the point of disc space entry. Here we describe how CT imaging can be used to simplify target localization during percutaneous anterior cervical cordotomy.

Relief of Intractable Pain in Cervical Carcinoma with Percutaneous Radiofrequency Cordotomy

Relief of Intractable Pain in Cervical Carcinoma with Percutaneous Radiofrequency Cordotomy

Posterior approach for high cervical percutaneous radiofrequency cordotomy.

Posterior approach for high cervical percutaneous radiofrequency cordotomy.