Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial

Abstract

Background: Up to 30% of patients with cancer continue to suffer from pain despite aggressive supportive care. The present study aimed to determine whether cordotomy can improve cancer pain refractory to interdisciplinary palliative care.

Materials and methods: In this randomized controlled trial, we recruited patients with refractory unilateral somatic pain, defined as a pain intensity (PI) ≥4, after more than three palliative care evaluations. Patients were randomized to percutaneous computed tomography-guided cordotomy or continued interdisciplinary palliative care. The primary outcome was 33% improvement in PI at 1 week after cordotomy or study enrollment as measured by the Edmonton Symptom Assessment Scale.

Results: Sixteen patients were enrolled (nine female, median age 58 years). Six of seven patients (85.7%) randomized to cordotomy experienced >33% reduction in PI (median preprocedure PI = 7, range 6-10; 1 week after cordotomy median PI = 1, range 0-6; p = .022). Zero of nine patients randomized to palliative care achieved a 33% reduction in PI. Seven patients (77.8%) randomized to palliative care elected to undergo cordotomy after 1 week. All of these patients experienced >33% reduction in PI (median preprocedure PI = 8, range 4-10; 1 week after cordotomy median PI = 0, range 0-1; p = .022). No patients were withdrawn from the study because of adverse effects of the intervention.

Conclusion: These data support the use of cordotomy for pain refractory to optimal palliative care. The findings of this study justify a large-scale randomized controlled trial of percutaneous cordotomy.

Implications for practice: This prospective clinical trial was designed to determine the improvement in pain intensity in patients randomized to either undergo cordotomy or comprehensive palliative care for medically refractory cancer pain. This study shows that cordotomy is effective in reducing pain for medically refractory cancer pain, and these results can be used to design a large-scale comparative randomized controlled trial that could provide the evidence needed to include cordotomy as a treatment modality in the guidelines for cancer pain management.

Keywords: Cancer pain; Cordotomy; Intractable pain; Palliative care; Randomized controlled trial.

Figure 1.

CONSORT flow diagram.

Figure 2.

Pain outcomes as reported by the patient with the Brief Pain Inventory. A significant reduction in “worst pain” was seen in patients randomized to cordotomy (n = 7) (A), whereas patients randomized to continued palliative care (n = 9) experienced only minimal further improvement in pain (B).

Figure 3.

Long‐term outcomes for all patients who underwent cordotomy (n = 14) as determined by the worst pain score of the BPI (A) and the pain interference score of the BPI (B). Abbreviation: BPI, Brief Pain Inventory.

Figure 4.

Case illustration. (A): Ideal candidate for cordotomy to palliate pain. Unilateral nociceptive pain that is below the shoulder level. (B): Intraprocedural computed tomography scan demonstrating radiofrequency electrode within the anterolateral spinal cord, the location of the spinothalamic tract. (C): Postoperative magnetic resonance imaging performed on postprocedure day 1 revealing a lesion in the anterolateral quadrant of the spinal cord.