Percutaneous cervical cordotomy for managing refractory pain in a patient with a Pancoast tumor: A case report

Abstract

Background: According to the World Health Organization analgesic ladder, cancer-related pain generally begins with pharmacotherapy in a stepwise approach. Nevertheless, some patients continue to experience poorly controlled pain despite medications, particularly when considering adverse effects and self-care quality. Percutaneous cervical cordotomy is an alternative interventional procedure for unremitting unilateral intractable cancer-related pain.

Case summary: The patient was diagnosed with lung cancer with destruction of the brachial plexus and ribs. For 2 mo, the patient experienced progressive severe weakness and pain in the right upper extremity. Notably, the pain intensity reached an extreme level, particularly when lying supine, even under heavy sedation. This heightened pain response posed a significant challenge; as a result, the patient was unable to undergo further evaluation through magnetic resonance imaging. Ultimately, he underwent percutaneous cervical cordotomy for symptom relief, resulting in complete resolution of right arm pain. After a 3-mo follow-up, the pain did not recur, and only a flurbiprofen local patch was required for mild scapular tightness.

Conclusion: Cordotomy, under careful patient selection, appears to enhance the quality of life of patients with unilateral cancer-related pain.

Keywords: Cancer pain; Case report; Cordotomy; Fluoroscopy; Intractable pain; Radiofrequency therapy.

Figure 1

Preoperative imaging shows a huge space-occupying lesion at the right apical lung with adjunct bony destruction. A: Chest radiograph. The asterisks indicate the second and third ribs at the left side, which was blurred at the right side; B: Chest computed tomography. A soft tissue mass (> 10 cm in diameter) occupied the entire right apical lung. The arrows indicate the first rib. The first rib in the right side was surrounded by the mass. The asterisk indicates the second rib. The second rib in the right side was damaged. The feature of the image highly suggested a locally advanced bronchogenic carcinoma.

Figure 2

Pathological examination of the patient’s lung, which was obtained from the computed tomography-guided biopsy. A: Lung parenchyma with infiltrating adenocarcinoma cells; B: Infiltrating adenocarcinoma cells with an acinar growth pattern.

Figure 3

Fluoroscopy image of the anterior-posterior view when advancing the spinal needle during percutaneous cervical cordotomy. A: When the needle tip enters the intrathecal space, the cerebrospinal fluid is drained. The needle tip did not cross through the midline, which is indicated by an asterisk, the dens of axis (C2); B: Radiofrequency (RF) generator was inserted into the spinal needle. The patient’s discomfort area was triggered by the sensory test. After confirmation of the target lesion, RF thermocoagulation was applied to destroy the neuropathway of the pain; C: Schematic illustration of percutaneous cervical cordotomy and the relative anatomical position of the lateral spinothalamic tract. C: Cervical; L: Lumbar; T: Thoracic.

Figure 4

Trajectory of pain alteration. The orange arrow and black dot represent the percutaneous cervical cordotomy. A: Numeric rating scale score of pain during hospitalization. After the procedure, a pain-free period was noted. He complained of intermittent pain, which can be relieved by nonopioid medications, during the cancer treatment; B: Oral morphine equivalent dosage during hospitalization. After the procedure, the opioid dosage was tapered gradually.

Figure 5

Spinal needle crossing the midline. The spinal needle appears to have crossed the midline (asterisk) and near the contralateral lamina. However, the patient did not complain of any discomfort. We presumed that the needle may have pushed the spinal cord, instead of being stabbed, when we were advancing the needle. Therefore, the path of the spinal needle should be adjusted after going backward.