Destructive procedures for control of cancer pain: the case for cordotomy

A review

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Object

Historically, destructive procedures for cancer pain were the main line of treatment therapy. However, the use of high-dose opioids has essentially replaced such procedures. Recognition of the limits of medical therapy to treat cancer pain effectively is growing, while conversely, in regions with limited access to pain medications, the importance of destructive surgical techniques is increasing. A critical evaluation of the evidence for destructive techniques is warranted, and the authors review current evidence underlying these procedures.

Methods

A US National Library of Medicine PubMed search for “ablation,” “DREZ,” “dorsal root entry zone,” “cingulotomy,” “cordotomy,” “ganglionectomy,” “mesencephalotomy,” “myelotomy,” “neurotomy,” “neurectomy,” “rhizotomy,” “sympathectomy,” “thalamotomy,” “tractotomy,” and “pain” was undertaken. The search was then limited to human studies, English-language literature, cancer pain, and reports with more than 1 patient.

Results

One hundred twenty papers were identified and reviewed based on the selection criteria described. According to the Canadian and US task forces, classification of clinical research literature only “sympathectomy” was supported by Class I or II studies, with 2 Class I papers and 1 Class II paper identified for cancer pain. All other procedures were supported by Class III studies of variable quality. Cordotomy in particular was the most extensively studied and reviewed procedure. Given the large number of patients studied, consistent results, multiplicity of reports and, even though evidence quality for individual studies was relatively low, cumulative evidence suggests that cordotomy may play an important role in the treatment of cancer pain.

Conclusions

Destructive procedures for cancer pain may play more than a historic role in the management of cancer pain. Cumulative evidence from even the poorest quality studies suggests that some procedures, such as cordotomy, should be included in the armamentarium available to the neurosurgeon today. To renew appropriate interest in these procedures, evidence and studies that meets today's evidence-based research criteria are warranted.

Abbreviations used in this paper: ADL = activities of daily living; DREZ = dorsal root entry zone; GRADE = Grades of Recommendation Assessment, Development and Evaluation; KPS = Karnofsky Performance Scale; NHS = National Health Service; RCT = randomized controlled trial; USPSTF = US Preventive Services Task Force; VAS = visual analog scale.

Article Information

Address correspondence to: Kim Burchiel, M.D., Department of Neurological Surgery, CH8N, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, Oregon 97239. email: burchiek@ohsu.edu.

Please include this information when citing this paper: published online August 6, 2010; DOI: 10.3171/2010.6.JNS10119.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Graph showing the number of papers in each decade since 1965.

  • View in gallery

    Graph showing the number of papers by number of patients.

  • View in gallery

    Graph showing the number of papers per number of patients by procedure. The asterisk denotes an unknown number but more than 1, and the double asterisks denote a meta-analysis.

  • View in gallery

    Graph showing the number of patients reported per procedure.

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