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Cordotomy is the name of a surgical procedure aimed at destroying the pain-conducting tracts of the spinal cord. The cordotomy to be effective at decreasing the transmission of temperature and pain sensations. It was originally widely used for chronic pain, but now it is only used in cancer patients. The open procedure is rarely performed due to its associated high risk. This activity describes the indications, contraindications, and complications of cordotomy and highlights the interprofessional team's role in the management of patients with malignancy-related pain. Objectives: Describe the technique involved in performing a cordotomy. List the indications for cordotomy. Summarize the complications of cordotomy. Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients undergoing a cordotomy. Access free multiple choice questions on this topic.

Cordotomy is the name of a surgical procedure aimed at destroying the pain-conducting tracts of the spinal cord. First performed in 1912 by neurosurgeons William Spiller and Edward Martin, cordotomy effectively reduced pain and temperature sensation in patients with painful conditions. It was originally widely used for chronic pain, but now it has been adapted for use in patients with cancer only. The open procedure is rarely performed due to the high risk and complication rates observed previously. The open method was further adapted into a percutaneous cervical cordotomy in 1963 (see Image. Percutaneous Cordotomy). In the 1990s, with improvements in pain management, the cordotomy again fell out of favor. However, it is still a palliative option for therapy-resistant pain. Given the population which receives this procedure, there is severely limited availability of studies testing its long-term effects. There is a case study of a patient with seminoma who underwent a right-sided percutaneous cervical cordotomy and chemotherapy. Five years later, the physicians found that the patient had continued sensory impairment with minimal effects on motor and autonomic function.[1]

Only a few experience serious post-procedure side effects.[7] They include dysesthesia, urinary retention, ataxia, paresis, sympathetic dysfunction (hypotension, Horner syndrome, and bladder dysfunction), sexual sensitivity impaired or lost sexual sensitivity, and a form of sleep apnea (acquired central hypoventilation syndrome). The bulk of these complications result from the accidental division of the unintended reticulospinal tracts. Another serious complication is spontaneous new pain. New pain may be old (previously extant) pain that was previously unrecognized and now unmasked by removing prior distractions. Likewise, the new pain can be viewed as an unpreventable complication from the interruption of nociceptive pathways. Overall, the risk of severe complications with unilateral cordotomy is low. Procedure-related mortality is reported in the range of 1%-6%, which is mainly due to respiratory dysfunction.[8] With more accurate ablation techniques, no respiratory dysfunction is rare.[9]

The cordotomy is a palliative procedure. It is often performed in patients with a life expectancy of less than 6 months and entails significant risks and potential benefits. Obtaining a thorough history is essential, and the clinician should demonstrate empathy for the patient and their condition, whether the condition is a malignancy or another pathology. This decision is not to be made alone or lightly by the patient, family, or clinician. Patients must not feel rushed when having their options for intractable pain laid out before them. Furthermore, this is a surgical procedure, so interprofessional communication must occur. Proper communication should occur between the nurse, palliative physician, surgeon, oncologist, and the primary physician. Each specialty should help the patient make an informed decision that best aligns with their goals of care. As always, especially for palliative care patients with often numerous comorbidities, the patient's medical history and background should be clearly documented for members of the healthcare team. Any deviation from thoroughness can pose significant challenges and risks to patients, their families, and their clinicians. Medical errors are to be actively avoided. If any nurse or clinician believes that significant palliative procedures, such as cordotomy, are not the best choice for the patient, they should tactfully raise their concern with the clinicians involved in that patient's care. This interprofessional approach ensures that they have a comprehensive and clear understanding of the procedure, its risks, and its benefits before presenting their professional opinion to the patient.[12]

Before cordotomy can be performed, the nurse must ensure that the patient understands the procedure and has signed a consent form. While most cordotomies are done percutaneously, sometimes general anesthesia is required. Irrespective of how the procedure is done, patient monitoring is vital. Resuscitative equipment must be in the room before the procedure is started. Breathing and oxygen need to be continuously monitored. A nurse dedicated to patient monitoring is vital.

Once cordotomy is completed, the patient's vital signs and neurological status need to be monitored. The patient may develop urinary retention that may require catheterization, apnea, and fecal incontinence. Oxygen saturation must be continuously monitored until the patient is stable.