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J Neurosurg Case Lessons
J Neurosurg Case Lessons
J Neurosurg Case Lessons
Journal of Neurosurgery: Case Lessons
2694-1902
American Association of Neurological Surgeons

39222543
10.3171/CASE2427
CASE2427
Functional-NeurosurgeryFunctional NeurosurgeryOncologyOncologyPainPainPediatricPediatricTechniqueTechniqueCase Lesson
Cordotomy under general anesthesia for a pediatric palliative patient: illustrative case
Schmidt Franziska A MD 12
Pietramala Danielle A BA 1
Honey Christopher R MD, DPhil 1
Heran Manraj K. S MD 3
1 Division of Neurosurgery, Department of Surgery, University of British Columbia, British Columbia, Vancouver, Canada
2 Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
3 Division of Neuroradiology, Department of Radiology, University of British Columbia, British Columbia, Vancouver, Canada
Correspondence Christopher R. Honey: University of British Columbia, Vancouver, BC, Canada. chris.honey@telus.net.
INCLUDE WHEN CITING Published September 2, 2024; DOI: 10.3171/CASE2427.

Disclosures Dr. Honey reported grants from Medtronic and Boston Scientific outside the submitted work.

02 9 2024
02 9 2024
8 10 CASE242707 1 2024
06 5 2024
© 2024 the authors
2024
the authors
https://creativecommons.org/licenses/by-nc-nd/4.0/ CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

BACKGROUND

Computed tomography (CT)–guided cordotomy has been shown to be a safe and effective method for treating cancer pain in adults in a palliative care setting. Its effectiveness has been rarely reported in children. During cordotomy, patient feedback is considered essential. Unfortunately, in this report, the featured patient’s age and demeanor precluded an awake cordotomy. The authors report the first case, to their knowledge, of percutaneous cordotomy with the patient under general anesthesia.

OBSERVATIONS

An 11-year-old boy with osteosarcoma of the right pelvis presented with medically refractory unilateral nociceptive pain. The pain prevented ambulation, interfered with sleep, was the focus of his concern, and could not be relieved without sedation. A left percutaneous CT-guided cervical cordotomy while he was under general anesthesia was performed without complication and provided sufficient pain relief to allow ambulation and restorative sleep. Pain was no longer an issue for the patient and his family.

LESSONS

CT-guided percutaneous cervical cordotomy can be accomplished in a pediatric patient under general anesthesia. The risks of cordotomy under general anesthesia without patient feedback must be weighed against the opportunity to improve palliative care.

https://thejns.org/doi/abs/10.3171/CASE2427

cordotomy
CT guided
palliative care
pediatric
general anesthesia
cancer pain
ABBREVIATIONS

CT = computed tomography
IV = intravenously
PO = by mouth
TID = three times a day.
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pmcPercutaneous cordotomy is an effective option for medically refractory unilateral cancer pain. It has been rarely reported in the pediatric population because patient cooperation to guide lesion placement has been considered essential. There are only 2 pediatric case reports.1, 2

In this report, we describe an 11-year-old boy with a history of progressive osteosarcoma and medically refractory right pelvic nociceptive pain. Due to concerns about his ability to tolerate an awake procedure, the patient and his family opted for percutaneous cordotomy, considered less invasive than an open procedure. The final outcome was successful, with significant pain relief and no unwanted side effects. The aim of this case report is to share our experience with percutaneous cordotomy in a pediatric patient under general anesthesia and potentially add this technique to the palliative care repertoire.

Illustrative Case

An 11-year-old boy had osteosarcoma in the right pelvis and metastatic lesions in both femurs. He was admitted to the hospital for pain management. His medications included gabapentin (300 mg by mouth [PO] three times a day [TID]), methadone (10 mg PO TID), fentanyl (600 μg/day intravenously [IV]), acetaminophen (500 mg PO, every 6 hours), and fentanyl for breakthrough pain (50 μg IV, every 30 minutes, averaging 7 times/day). He was also prescribed sertraline (50 mg PO) and clonazepam (1.5 mg PO two times a day) for low mood and anxiety. He continued to have intractable, constant pain in his right hip, which limited his mobility, ambulation, and hygiene.

The option of an awake percutaneous computed tomography (CT)–guided cordotomy was discussed with the family, but the patient refused to be awake for any procedure. Therefore, the option of performing the cordotomy while he was under general anesthesia was discussed. The standard risks of cordotomy were explained, as was the increased chance of a misplaced lesion resulting in inadequate pain relief or damage to the corticospinal tract (left hemiplegia). We then discussed open versus percutaneous cordotomy, and the family selected the percutaneous approach.

Procedure

General anesthesia was induced with fentanyl, propofol, and dexmedetomidine infusions, using a laryngeal mask. The patient was then positioned supine on the CT gantry. The right side of the neck was prepped, draped, and infiltrated with a local anesthetic. A 22-gauge spinal needle was then directed at the target area of the spinal cord, with subsequent advancement of the cordotomy probe coaxially through it, into the desired location within the spinothalamic tract. The positioning was done under CT guidance in the subarachnoid space posterior to the cord at the C1–2 level. A CT myelogram was obtained using Omnipaque (iohexol) to visualize the cord. The left side of the patient's neck was then prepped, draped, and infiltrated with a local anesthetic, and a 20-gauge cordotomy guide needle (LCED disposable cordotomy kit, Boston Scientific) was advanced under CT guidance through the dura toward a location 1 mm anterior to the equator of the spinal cord. The cordotomy electrode was then advanced through the needle, under impedance monitoring, approximately 3 mm into the cord (Fig. 1). FIG. 1. A: CT scan illustrating the tip of the cordotomy probe within the anterolateral spinal cord at the C1–2 level. B: Magnified view of the image in A showing bisection of the cord, with the cordotomy probe advanced 3 mm deep and 1 mm anterior to the equator. C: Diagram of the spinothalamic tract at the same level with fibers from the lower limb (red) and upper limb (yellow).

Stimulation (radiofrequency lesion generator RFG-1A, Cosman Medical) at 2 Hz and 1 msec induced no ipsilateral motor response in the hand until 0.2 V. A lesion was made at 70°C for 60 seconds. The needles were removed without bleeding, swelling, or cerebrospinal fluid leakage, and small band-aids were placed on the punctures.

Postoperative Course

The patient tolerated the procedure well. On postoperative day 1, he reported significant pain relief. No unexpected neurological deficits were detected. Three weeks after the intervention, the oral doses of gabapentin, methadone, and acetaminophen were unchanged, but intravenous fentanyl was discontinued, and breakthrough opiates were no longer required. He was able to ambulate to the bathroom, stand in the shower, and sleep without pain. The family reported he no longer talked about pain. The patient’s right hemibody caudal to C4 had absent pinprick and temperature sensation. There was no weakness in his left hemibody. The patient was transferred to a hospice, where he died peacefully without pain, 2 months after the intervention.

Informed Consent

The necessary informed consent was obtained in this study.

Discussion

Cordotomy is a palliative care procedure for the management of intractable nociceptive pain. First described in 1912,3 it is now used when all medical therapies have failed. Cordotomy is designed to interrupt the spinothalamic pathway and can be performed using an open, percutaneous, or endoscope-guided percutaneous technique. The spinothalamic tract conveys somatic pain and temperature sensation and has a somatotopic distribution. A post hoc analysis of in vivo CT-guided mapping in awake patients has shown that responses from the lower limb are represented superficially (laterally) and posteriorly within the anterolateral cord, whereas responses from the upper limb are represented anteriorly and medially.4

The afferent pain fibers enter the cord and synapse in the dorsal horn. The spinothalamic neuron then crosses over to the contralateral side of the cord to ascend in the spinothalamic tract. Therefore, a left-sided cordotomy was performed to address the patient’s right-sided pain. Cordotomy at the C1–2 level affects only the fibers that have already crossed, reliably eliminating pain caudal to the C4 dermatome. For pain relief more rostral than C4, a mesencephalotomy may be required.5

During awake cordotomy, patients lose pain and temperature sensation in the dermatomes corresponding to the portion of the spinothalamic tract that has been lesioned. This can be a good indicator that a sufficient lesion has been made (i.e., loss of pinprick or temperature sensation in the painful area).6–9 Cordotomy under general anesthesia, however, does not allow for this important feedback and therefore relies on the past experience of the surgeon to predict what lesion will be sufficient.

Complications are less common in CT-guided cordotomies than in open approaches or radiography-guided cordotomies.10 Complications can be transient, related to the expected temporary swelling around the lesion, or permanent related to a misplaced lesion. Permanent ataxia or paresis has been reported in up to 20% of procedures.8, 11 Additional potential complications include respiratory failure and bladder dysfunction.8, 12

Observations

Cordotomy in children has only been described in 2 case reports.1, 2 Reddy et al. reported on a 9-year-old boy with metastatic medulloblastoma who benefited from a percutaneous CT-guided cordotomy under local anesthesia. The patient tolerated the awake procedure well, and his pain and mobility significantly improved for the remaining 10 days of his life. Steel et al. reported their experience with open anterolateral cordotomy under general anesthesia in 2 pediatric cases. The authors concluded that both children experienced effective analgesia and suggested considering this surgery earlier before the patient reaches a terminal condition.

In summary, we present the case of an 11-year-old patient with medically intractable cancer pain in his right hip and femur who could not tolerate an awake cordotomy. We discussed an open cordotomy under general anesthesia but believed a percutaneous cordotomy under general anesthesia would have less perioperative morbidity. Our detailed understanding of the spinothalamic tract anatomy in the cervical cord facilitated targeting and provided the desired pain control.4 This procedure may be a suitable option for pediatric palliative patients with unilateral, intractable pain who are not suitable for an awake procedure, for example, those with primary bone diseases or metastases.

Lessons

This is the first case report of a pediatric percutaneous cordotomy performed under general anesthesia. Our 11-year-old patient with medically refractory unilateral pain from a pelvic osteosarcoma was treated with CT-guided cordotomy under general anesthesia. The desired pain control was achieved, and no new neurological symptoms were detected. This proof of concept demonstrates that percutaneous cordotomy under general anesthesia is another option for patients with medically refractory unilateral cancer pain.

Acknowledgments

The illustration of Fig. 1C was provided by Ms. Vicky Earle.

Disclosures

Dr. Honey reported grants from Medtronic and Boston Scientific outside the submitted work.

Author Contributions

Conception and design: Honey, Schmidt, Heran. Acquisition of data: Schmidt, Pietramala, Heran. Analysis and interpretation of data: Schmidt, Heran. Drafting the article: Schmidt. Critically revising the article: Honey, Heran. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Honey. Administrative/technical/material support: Schmidt, Pietramala. Study supervision: Heran.

Correspondence

Christopher R. Honey: University of British Columbia, Vancouver, BC, Canada. chris.honey@telus.net.
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