ABSTRACT
Cordotomy consists in the discontinuation of the lateral spinothalamic tract (LST) in the anterolateral quadrant of the spinal cord, which aims to reduce the transference of nociceptive information in the dorsal horn of the gray matter of the spinal cord to the somatosensory cortex. The main indication is for patients with terminal cancer that have a low life expectancy. It improves the quality of life by relieving pain. The results are promising and the pain relief rate varies between 69 and 100%. Generally speaking, the complications are mostly temporary and not remarkable.
Subject(s)
Spinothalamic Tracts/surgery , Cervical Vertebrae/pathology , Cordotomy/adverse effects , Cancer Pain/surgery , Cross-Sectional Studies , Cordotomy/methods , Cancer Pain/complicationsABSTRACT
The present paper aims to demystify the use of rostral mesencephalic reticulotomy (mesencephalotomy) in the treatment of chronic pain in cancer patients. A retrospective review of the medical records from the Central Pain and Stereotaxy Department of the A. C. Camargo Cancer Center, São Paulo, state of São Paulo, Brazil, between 2005 and 2012, was performed. Surgical indication was restricted to patients with cancer pain refractory to etiological and symptomatic treatments, > 2 months of expected survival, preserved cognition, and absence of coagulation disorders, of systemic infection, and of intracranial hypertension. We have selected 34 patients, with an average follow-up of 9.4 months, an average age of 54.3 years-old, and an average follow-up time until death of 6.4 months. Lung cancer was themost frequent diagnosis. Satisfactory and immediate pain relief was achieved in 91% of the cases, and 83% of these patients had no relapses. Among the complications, ocular movement disorder was the most frequent, but often transient. Permanent disturbances occurred in 8.8% of the cases (diplopia, rubral tremor, and paresthesia). Compared to the pharmacological treatment, mesencephalotomy was economically feasible, more effective, and improved quality of life. According to the data presented, it can be concluded that mesencephalotomy is a viable procedure for cancer pain control in selected cases.
Subject(s)
Spinothalamic Tracts/surgery , Mesencephalon/surgery , Stereotaxic Techniques , Cancer Pain/therapy , Spinothalamic Tracts/physiopathology , Mesencephalon/physiopathology , Medical Records , Retrospective StudiesABSTRACT
Cordotomy consists in the discontinuation of the spinothalamic tract in the anterolateral quadrant of the spinal cord and aims to reduce the transference of nociceptive information in the dorsal horn of the grey matter of the spinal cord (CPME) for rostral units at the neural axis. Many modalities of cordotomy may be employed: anterior transdiscal between C4-C5; endoscopic infra mastoid tip between C1-C2; percutaneous guided by fluoroscopy infra mastoid tip between C1-C2; percutaneous guided by CT infra mastoid tip between C1-C2; open cordotomy by means of laminectomy. The main indication is for patients in advanced cancer disease with severe neuropathic pain bellow the neck in whom the period of survival due to cancer disease is inferior to 3-4 months. The results for immediate pain relieve ranges from 69% to 100% of the cases, while preoperative Karnofsky scores were 20 and 70, respectively versus post operative Karnofsky scores of 20 and 100 respectively; the difference was determined to be highly significant (p < 0.001).
A cordotomia consiste na discontinuação do trato espinotâmico no quadrante ântero-lateral da medula espinal e visa reduzir a transferência de informação nociceptiva no corno dorsal da substância cinzenta da medula espinal (CPME) para as unidades rostrais no neuroeixo. Muitas modalidades de cordotomia podem ser empregadas: transdiscal anterior entre C4-C5; endoscópica inframastoidea entre C1-C2; Percutânea inframastoidea entre C1-C2 guiada por fluoroscopia; percutânea inframastoidea entre C1-C2 guiada por TC; cordotomia aberta por laminectomia. A principal indicação é para pacientes com câncer avançado com dor neuropática severa abaixo do pescoço nos quais a sobrevida devido ao câncer é inferior a 3-4 meses. Os resultados para alívio imediato da dor varia de 69% a 100% dos casos, enquanto os escores de Karnofsky foram de 20 e 70 no período pré-operatório, para 20 e 100 no período pós-opertaório; a diferença foi estatisticamente significativa (p < 0.001).
Subject(s)
Spinothalamic Tracts/surgery , Cervical Vertebrae/pathology , Cordotomy/methods , Neck Pain , Electrocoagulation/methods , Pulsed Radiofrequency TreatmentABSTRACT
Oxytocin (OT) secreted by the hypothalamo-spinal projection exerts antinociceptive effects in the dorsal horn. Electrophysiological evidence indicates that OT could exert these effects by activating OT receptors (OTR) directly on dorsal horn neurons and/or primary nociceptive afferents in the dorsal root ganglia (DRG). However, little is known about the identity of the dorsal horn and DRG neurons that express the OTR. In the dorsal horn, we found that the OTR is expressed principally in neurons cell bodies. However, neither spino-thalamic dorsal horn neurons projecting to the contralateral thalamic ventral posterolateral nucleus (VPL) and posterior nuclear group (Po) nor GABaergic dorsal horn neurons express the OTR. The OTR is not expressed in skin nociceptive terminals or in dorsal horn nociceptive fibers. In the DRG, however, the OTR is expressed predominantly in non-peptidergic C-fiber cell bodies, but not in peptidergic or mechanoreceptor afferents or in skin nociceptive terminals. Our results suggest that the antinociceptive effects of OT are mediated by direct activation of dorsal horn neurons and peripheral actions on nociceptive, non-peptidergic C-afferents in the DRG.
Subject(s)
Ganglia, Spinal/metabolism , Neurons/metabolism , Nociceptors/metabolism , Posterior Horn Cells/metabolism , Receptors, Oxytocin/metabolism , Animals , Calcitonin Gene-Related Peptide/metabolism , Fluorescent Antibody Technique , Fluorescent Dyes , Ganglia, Spinal/cytology , Image Processing, Computer-Assisted , Interneurons/metabolism , Male , Nerve Fibers, Unmyelinated/metabolism , Neurons, Afferent/metabolism , Paraventricular Hypothalamic Nucleus/metabolism , Rats , Rats, Wistar , Spinothalamic Tracts/cytology , Spinothalamic Tracts/metabolism , Stilbamidines , gamma-Aminobutyric Acid/physiologyABSTRACT
Se presentan los elementos de la técnica de la tractotomía percutánea espinotalámica por vía lateral para el tratamiento del dolor intratable y los resultados obtenidos en 218 pacientes consecutivos operados por los autores en el Instituto de Neurocirugía Asenjo. Se resalta el renacer del interés en este tipo de cirugía debido a la obtención de resultados inferiores a los esperados por los procedimientos no quirúrgicos. La simplicidad del método permite la realización del procedimiento incluso en enfermos añosos y terminales