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Seminars in Neurosurgery 2004; 15(2/03): 203-219
DOI: 10.1055/s-2004-835709
Copyright © 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Percutaneous Cordotomy, Tractotomy, and Midline Myelotomy: Minimally Invasive Stereotactic Pain Procedures

Yucel Kanpolat1
  • 1Department of Neurosurgery, Ankara University School of Medicine, Ankara, Turkey
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Publication History

Publication Date:
25 October 2004 (online)

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In medical practice, each time span has a dogma of that period. Now, in the science and technology age, one particular dogma is very extensively accepted and used in pain practice. There is a general belief in neurosurgical practice that lesioning of the pain conducting system is accepted as ablative and dangerous. This idea is a dogma and it is wrong. In modern times, modern stereotactic pain surgery is performed in three important steps. First, morphology and localization of the pain conducting pathways are demonstrated with special imaging techniques; the surgeon approaches the target percutaneously by a specially designed needle electrode system. Second, the function of the target and surrounding structures can be defined by stimulation just after the target is totally, partially, or selectively destroyed by radiofrequency lesion. Third, lesioning of the system is controlled at every step of the procedure. These procedures are applied with morphological real-time demonstration, physiological evaluation of the target, and, finally, controlled lesioning. In this way, this surgery is performed safely and effectively. In this paper, I describe the techniques of this method based on a 17-year experience with three different stereotactic destructive procedures: CT-guided percutaneous cordotomy, trigeminal tractotomy, and extralemniscal myelotomy.

KEYWORDS

Intractable pain - minimally invasive - selective - destructive - pain procedures - CT-guidance

REFERENCES

  • 1 Spiller W G, Martin E. The treatment of persistent pain of organic origin in the lower part of the body by division of the antero-lateral column of the spinal cord.  JAMA. 1912;  58 1489
    PubMedGoogle Scholar
  • 2 Schüller A. Über operative Durchtrennung der Rückenmarksstränge (Chordotomie).  Wien Med Wochenschr. 1910;  60 2291
    PubMedGoogle Scholar
  • 3 Foerster O. Die Leitungsbahnen des Schmerzgefühls und die Chirurgische Behandlung des Schmerzzustände. Berlin; Urban und Schwarzenberg 1927
    Google Scholar
  • 4 Sjöqvist O. Studies on pain conduction in the trigeminal nerve: a contribution to the surgical treatment of facial pain.  Acta Psychiatr Neurol Scand. 1938;  (suppl XVII) 93
    PubMedGoogle Scholar
  • 5 Nauta H JW, Hewitt E, Weslund K N et al.. Surgical interruption of a midline dorsal column visceral pain pathway: case report and review of the literature.  J Neurosurg. 1997;  86 538-542
    PubMedGoogle Scholar
  • 6 Mullan S, Harper P V, Hekmatpanach J et al.. Percutaneous interruption of spinal pain tracts by means of a strontium 90 needle.  J Neurosurg. 1963;  20 931-939
    CrossrefPubMedGoogle Scholar
  • 7 Rosomoff H L, Carroll F, Brown J et al.. Percutaneous radiofrequency cervical cordotomy technique.  J Neurosurg. 1965;  23 639
    CrossrefPubMedGoogle Scholar
  • 8 Gildenberg P L, Zanes C, Flitter M et al.. Impedance measuring device for detection of penetration of the spinal cord in anterior percutaneous cervical cordotomy. Technical note.  J Neurosurg. 1969;  30 87-92
    PubMedGoogle Scholar
  • 9 Taren J A, Davis R, Crosby E C. Target physiologic corroboration in stereotactic cervical cordotomy.  J Neurosurg. 1969;  30 569-584
    CrossrefPubMedGoogle Scholar
  • 10 Kanpolat Y, Atalag M, Deda H et al.. CT-guided extralemniscal myelotomy.  Acta Neurochir (Wien). 1988;  91 151-1520
    CrossrefPubMedGoogle Scholar
  • 11 Kanpolat Y, Deda H, Akyar S et al.. CT-guided percutaneous cordotomy.  Acta Neurochir Suppl (Wien). 1989;  46 67-68
    PubMedGoogle Scholar
  • 12 Kanpolat Y, Deda H, Akyar S et al.. CT-guided trigeminal tractotomy.  Acta Neurochir (Wien). 1989;  100 112-114
    CrossrefPubMedGoogle Scholar
  • 13 McGirt M J, Villavicencio A T, Bulsara K R, Gorecki J. MRI-guided frameless stereotactic percutaneous cordotomy.  Stereotact Funct Neurosurg. 2002;  78 53-63
    PubMedGoogle Scholar
  • 14 Collis Jr J S. Anterolateral cordotomy by an anterior approach: report of a case.  J Neurosurg. 1963;  20 445-446
    PubMedGoogle Scholar
  • 15 Cloward R B. Cervical cordotomy by the anterior approach: technique and advantages.  J Neurosurg. 1964;  21 19-25
    PubMedGoogle Scholar
  • 16 Mullan S. Percutaneous cordotomy.  J Neurosurg. 1971;  35 360-366
    PubMedGoogle Scholar
  • 17 Mullan S, Hekmatpanah J, Dobben G, Beckman F. Percutaneous intramedullary cordotomy utilizing the unipolar anodal electrolytic lesion.  J Neurosurg. 1965;  22 548-553
    CrossrefPubMedGoogle Scholar
  • 18 Gildenberg P L, Lin P M, Polakoff P P, Flitter M A. Anterior percutaneous cervical cordotomy. Determination of target point and calculation of angle of insertion: technical note.  J Neurosurg. 1968;  28 173-177
    PubMedGoogle Scholar
  • 19 Lin P M, Gildenberg P L, Polakoff P P. An anterior approach to percutaneous lower cervical cordotomy.  J Neurosurg. 1966;  25 553-560
    CrossrefPubMedGoogle Scholar
  • 20 Kanpolat Y, Akyar S, Caglar S et al.. CT-guided percutaneous selective cordotomy.  Acta Neurochir (Wien). 1993;  123 92-96
    CrossrefPubMedGoogle Scholar
  • 21 Kanpolat Y, Cosman E. Special RF electrode system for CT-guided pain procedures.  Neurosurgery. 1996;  38 600-602
    CrossrefPubMedGoogle Scholar
  • 22 Kanpolat Y, Savas A, Caglar S et al.. Computerized tomography-guided percutaneous bilateral selective cordotomy. Neurosurg Focus 1997 2 article 4
    Google Scholar
  • 23 Martin J H, Jessel T M. Anatomy of the somatic sensory system. In: Kandel ER, Schwartz JH, Jessel TM Principles of Neural Science. New York; Elsevier 1991: 353
    Google Scholar
  • 24 Everett N B. The spinal cord. In: Functional Neuroanatomy Philadelphia; Lea & Febiger 1967: 34
    Google Scholar
  • 25 Hyndman O R, Van Epps C. Possibility of differential section of the spinothalamic tract: a clinical and histologic study.  Arch Surg. 1939;  38 1036
    CrossrefPubMedGoogle Scholar
  • 26 Peet M M. The control of intractable pain in lumbar region, pelvis and lower extremities.  Arch Surg. 1926;  13 153
    PubMedGoogle Scholar
  • 27 Walker E A. The spinothalamic tract in man.  Arch Neurol Psychiatry. 1940;  43 284
    CrossrefPubMedGoogle Scholar
  • 28 Brihaye J, Thiry S, Le Clerco R et al.. Le traitement chirurgical de la douleur.  Acta Chir Belg. 1962;  ( suppl 2) 255-475
    PubMedGoogle Scholar
  • 29 White J C, Sweet W H. Spinothalamic tractotomy. In: Pain and the Neurosurgeon Springfield, IL; Charles C Thomas 1969: 678
    Google Scholar
  • 30 Belmusto L, Brown E, Owens G. Clinical observations on respiratory and vasomotor disturbance as related to cervical cordotomies.  J Neurosurg. 1963;  20 225-232
    PubMedGoogle Scholar
  • 31 Rosomoff H L, Krieger A J, Kuperman A S. Effects of percutaneous cervical cordotomy on pulmonary function.  J Neurosurg. 1969;  31 620-627
    PubMedGoogle Scholar
  • 32 Rosomoff H L. Bilateral percutaneous cervical radiofrequency cordotomy.  J Neurosurg. 1969;  31 41-46
    PubMedGoogle Scholar
  • 33 Lorenz R. Methods of percutaneous spinothalamic tract section. In: Krayenbühl H Advances and Technical Standards in Neurosurgery. Vol 3. Vienna; Springer Verlag 1976: 123
    Google Scholar
  • 34 Onofrio B M. Cervical spinal cord and dentate delineation in percutaneous radiofrequency cordotomy at the level of the first to second cervical vertebrae.  Surg Gynecol Obstet. 1971;  133 30-34
    PubMedGoogle Scholar
  • 35 Kanpolat Y, Akyar S, Caglar S. Diametral measurements of the upper spinal cord for stereotactic pain procedures: experimental and clinical study.  Surg Neurol. 1995;  43 478-482
    CrossrefPubMedGoogle Scholar
  • 36 Lahuerta J, Bowsher D, Lipton S et al.. Percutaneous cervical cordotomy: a review of 181 operations on 146 patients with a study on the location of “pain fibers” in the C-2 spinal cord segment of 29 cases.  J Neurosurg. 1994;  80 975-985
    CrossrefPubMedGoogle Scholar
  • 37 Tasker R R. Cordotomy for pain. In: Youmans JR Neurological Surgery. Philadelphia; WB Saunders 1996: 3463
    Google Scholar
  • 38 Tasker R R, North R. Cordotomy and myelotomy. In: Tasker RR, North R Neurological Management of Pain. New York; Springer Verlag 1997: 191
    Google Scholar
  • 39 Kanpolat Y, Caglar S, Akyar S et al.. CT-guided pain procedures for intractable pain in malignancy.  Acta Neurochir (Wien) (suppl). 1995;  64 88-91
    PubMedGoogle Scholar
  • 40 Kanpolat Y, Savas A, Ucar T, Torun F. CT-guided percutaneous selective cordotomy for treatment of intractable pain in patients with malignant pleural mesothelioma.  Acta Neurochir (Wien). 2002;  144 595-599
    CrossrefPubMedGoogle Scholar
  • 41 Gybels J M. Indications for the use of neurosurgical techniques in pain control. In: Bond MR, Charlton JE, Wolf J Proceedings of the Sixth World Congress on Pain Amsterdam; Elsevier 1995: 475
    Google Scholar
  • 42 Fenstermaker R, Sternau L, Takaoka Y. CT-assisted percutaneous anterior cordotomy: technical note.  Surg Neurol. 1995;  43 147-149
    PubMedGoogle Scholar
  • 43 Sindou M, Jeanmonod D, Mertens P. Ablative neurosurgical procedures for the treatment of chronic pain.  Neurophysiol Clin. 1990;  20 399-423
    CrossrefPubMedGoogle Scholar
  • 44 American Cancer Society Cancer Statistics CA .1997: 47-8
  • 45 Schvarcz J R. Postherpetic craniofacial dysesthesiae: their management by stereotactic trigeminal nucleotomy.  Acta Neurochir (Wien). 1977;  38 65-72
    CrossrefPubMedGoogle Scholar
  • 46 Nashold B S, El-Naggar A, Abdulhak M M et al.. Trigeminal nucleus caudalis dorsal root entry zone: a new surgical approach.  Stereotact Funct Neurosurg. 1992;  59 45-51
    PubMedGoogle Scholar
  • 47 Nashold B S, Rossitch E. Anesthesia dolorosa and the trigeminal caudalis nucleus DREZ operation. In: Rovit RL, Murali R, Janetta PJ Trigeminal Neuralgia Baltimore; Williams & Wilkins 1990: 223
    Google Scholar
  • 48 Taren J A, Kahn E A. Anatomic pathways related to pain in face and neck.  J Neurosurg. 1962;  19 116-121
    PubMedGoogle Scholar
  • 49 Taren J A, Kahn E A, Humphrey T. The surgery of pain. In: Kahn EA, Crosby EC, Schneider RC Correlative Neurosurgery. Springfield, IL; Charles C Thomas 1969: 464
    Google Scholar
  • 50 Broadal A. Central course of afferent fibers for pain in facial, glossopharyngeal and vagus nerves.  Arch Neurol Psychiatry. 1947;  57 292
    PubMedGoogle Scholar
  • 51 Kunc Z. Treatment of essential neuralgia of the 9th nerve by selective tractotomy.  J Neurosurg. 1965;  23 494-500
    PubMedGoogle Scholar
  • 52 Crue B L, Carregal J A, Felsoory A. Percutaneous stereotactic radiofrequency: trigeminal tractotomy with neurophysiological recordings.  Clin Neurol. 1972;  34 389-397
    PubMedGoogle Scholar
  • 53 Hitchcock E R. Stereotactic trigeminal tractotomy.  Ann Clin Res. 1970;  19 131-135
    PubMedGoogle Scholar
  • 54 Schvarcz J R. Stereotactic trigeminal tractotomy.  Confin Neurol. 1975;  37 73-77
    PubMedGoogle Scholar
  • 55 Hitchcock E R, Schvarcz J R. Stereotactic trigeminal tractotomy for post-herpetic facial pain.  J Neurosurg. 1972;  37 412-417
    PubMedGoogle Scholar
  • 56 Hosobuchi Y, Rutkin B. Descending trigeminal tractotomy. Neurophysiological approach.  Arch Neurol. 1971;  25 115-125
    PubMedGoogle Scholar
  • 57 Kanpolat Y, Savas A, Caglar S et al.. Computed tomography-guided percutaneous trigeminal tractotomy-nucleotomy.  Tech Neurosurg. 1999;  3 244-251
    PubMedGoogle Scholar
  • 58 Kerr L WF. The fine structure of the subnucleus caudalis of the trigeminal nerve.  Brain Res. 1970;  23 29-145
    PubMedGoogle Scholar
  • 59 Poletti C E. Open cordotomy and medullary tractotomy. In: Schmidek HH, Sweet WH Operative Neurosurgical Techniques Philadelphia; WB Saunders 1995: 1469
    Google Scholar
  • 60 Schvarcz J R. Functional exploration of the spinomedullary junction.  Acta Neurochir (Wien). 1977;  (suppl 24) 179-185
    CrossrefPubMedGoogle Scholar
  • 61 Schvarcz J R. Descending trigeminal nucleotomy for dysesthetic facial pain. In: Al-Mefty O, Origitano TC, Haarkey HL Controversies in Neurosurgery Stuttgart; Georg Thieme Verlag 1996: 351
    Google Scholar
  • 62 Kanpolat Y, Savas A, Batay F, Sinav A. Computed tomography-guided trigeminal tractotomy-nucleotomy in the management of vagoglossopharyngeal and geniculate neuralgias.  Neurosurgery. 1998;  43 484-489
    PubMedGoogle Scholar
  • 63 Teixeira M J. Various functional procedures for pain; Part II: facial pain. In: Gildenberg PL, Tasker RR Text Book of Stereotactic and Functional Neurosurgery 140. New York; McGraw-Hill 1998: 1389
    Google Scholar
  • 64 Morita M, Hosobuchi Y. Descending trigeminal tractotomy for trigeminal neuralgia after surgical failure.  Stereotact Funct Neurosurg. 1992;  59 52-55
    PubMedGoogle Scholar
  • 65 Burchiel K. Treatment of facial pain. In: Gildenberg PL, Tasker RR Text Book of Stereotactic and Functional Neurosurgery 176. New York; McGraw-Hill 1998: 1723
    Google Scholar
  • 66 Resnick D K, Janetta P J, Bissonnette D G et al.. Microvascular decompression for glossopharyngeal neuralgia.  Neurosurgery. 1995;  36 64-68
    CrossrefPubMedGoogle Scholar
  • 67 Taha J M, Tew J M. Long-term results of surgical treatment of idiopathic neuralgias of the glossopharyngeal and vagal nerves.  Neurosurgery. 1995;  36 926-930
    PubMedGoogle Scholar
  • 68 Hitchcock E. Stereotactic cervical myelotomy.  J Neurol Neurosurg Psychiatry. 1970;  33 224-230
    CrossrefPubMedGoogle Scholar
  • 69 Schvarcz J R. Stereotactic extralemniscal myelotomy.  J Neurol Neurosurg Psychiatry. 1976;  39 53-57
    PubMedGoogle Scholar
  • 70 Sweet W H, Poletti C E. Operations in the brain stem and spinal canal, with an appendix on open cordotomy. In: Wall PD, Melzack R Textbook of Pain. 2d ed. Edinburgh; Churchill Livingstone 1989: 819
    Google Scholar
  • 71 Hitchcock E. Stereotactic myelotomy.  Proc R Soc Med. 1974;  67 771-772
    PubMedGoogle Scholar
  • 72 Papo I, Luongo A. High cervical commissural myelotomy in the treatment of pain.  J Neurol Neurosurg Psychiatry. 1976;  39 705-710
    PubMedGoogle Scholar
  • 73 Gildenberg P L, Hirshberg R M. Treatment of cancer pain with limited myelotomy.  Med J St Jos Hosp (Houston). 1981;  16 199-204
    PubMedGoogle Scholar
  • 74 Hirshberg R M, Al-Chaer E D, Lawand N B et al.. Is there a pathway in the posterior funiculus that signals visceral pain?.  Pain. 1996;  67 291-305
    CrossrefPubMedGoogle Scholar
  • 75 Nauta H J, Hewitt E, Westlund K N et al.. Surgical interruption of a midline dorsal column visceral pain pathway: case report and review of the literature.  J Neurosurg. 1997;  86 538-542
    PubMedGoogle Scholar
  • 76 Becker R, Sure U, Bertalanffy H. Punctuate midline myelotomy: a new approach in the management of visceral pain.  Acta Neurochir (Wien). 1999;  141 881-883
    CrossrefPubMedGoogle Scholar
  • 77 Eiras J, Garcia J, Gomez J et al.. First results with extralemniscal myelotomy.  Acta Neurochir Suppl (Wien). 1980;  30 377-381
    PubMedGoogle Scholar
  • 78 Kanpolat Y, Savas A, Caglar S et al.. Computerized tomography-guided percutaneous extralemniscal myelotomy.  Neurosurg Focus. 1997;  2 article 5
    PubMedGoogle Scholar
  • 79 Shealy C N, Tyner C F, Taslitz N. Physiological evidence of bilateral spinal projections of pain fibers in cats and monkeys.  J Neurosurg. 1966;  24 708-713
    PubMedGoogle Scholar
  • 80 Al-Chaer E D, Lawand N B, Weslund K N, Willis W D. Visceral nociceptive input into the ventral posterolateral nucleus of the thalamus: a new function for the dorsal column pathway.  J Neurophysiol. 1996;  76 2661-2674
    PubMedGoogle Scholar
  • 81 Al-Chaer E D, Lawand N B, Weslund K N, Willis W D. Pelvic visceral input into the nucleus gracilis is largely mediated by the postsynaptic dorsal column pathway.  J Neurophysiol. 1996;  76 2675-2690
    PubMedGoogle Scholar
  • 82 Kanpolat Y. Percutaneous stereotactic pain procedures: percutaneous cordotomy, extralemniscal myelotomy, trigeminal tractotomy-nucleotomy. In: Burchiel KJ Surgical Management of Pain. New York; Thieme 2002: 745-762
    Google Scholar

Yucel KanpolatM.D. 

Inkilap Sokak 24/2

Kizilay 06640, Ankara, Turkey

Email: kanpolat@ada.net.tr

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