bilateral percutaneous cervical-claude-bernard-horner syndrome 36pts. (100%) of varying degree and...

Journal of Neurology, Neurosurgery, and Psychiatry 1984;47: 141-147

Bilateral percutaneous cervical cordotomy:immediate and long-term results in 36 patients withneoplastic diseaseSTEFANO ISCHIA, ALDO LUZZANI, ALBERTO ISCHIA, GIANFRANCO MAFFEZZOLI

From the Anaesthesiology and Intensive Care Institute, Pain Relief Centre, University of Verona School ofMedicine, Verona, Italy

SUMMARY Thirty-six patients with neoplastic disease suffering from chronic bilateral pain were

subjected to bilateral percutaneous cervical cordotomy. The technique and precautions to betaken in bilateral percutaneous cervical cordotomy performed either in one or two stages are

described using a traditional or Levin's thermocouple-monitored electrode. The sequelae, com-

plications and immediate and long-term results are reported.

Bilateral percutaneous cervical cordotomy is rarelyused, owing to its possible sequelae and complica-tions. The main potential adverse consequences ofthe procedure are: a fairly high rate of operativemortality;8 9 13 20 sleep-induced apnoea;' 6 8 9 13 15 20muscular weakness;9 20 urinary retention;9 13 20 asubstantial reduction in sympathetic tone withresulting hypotension, especially orthostatic;' 9 13 20a high degree of prostration and a deterioration inthe patient's general sense of well-being.'3 Twoseparate operations are usually performed at vary-ing time intervals.

Bilateral percutaneous cervical cordotomy is indi-cated in patients with bilateral pain from neoplasticdisease which cannot be controlled in any other way.Of a total of 540 cordotomies in our clinic the pro-cedure was bilateral in 36 patients; the cordotomieswere performed by one of the authors (SI). In 29 ofthe subjects the operation was performed in twoseparate stages at time intervals ranging from 1 to 2weeks, using radiofrequency diathermocoagulationwith a traditional electrode and fixed 3 mm expos-ure. In six patients the lesion was made bilaterally ina single operating session, using Levin'sthermocouple-monitored cordotomy electrode." Inone patient percutaneous cervical cordotomy wasperformed, using diathermocoagulation, followed

Address for reprint requests: Prof S Ischia, Centro OspedalieroClinicizzato di Borgo Roma, 37100 Verona, Italy.

Received 30 June 1983 and in revised form 20 August 1983.Accepted 14 September 1983

22 months later by percutaneous cervical cordotomyon the other side using Levin's thermocouple-monitored electrode. The indications, the immedi-ate and long-term results, technique, sequelae andcomplications of bilateral percutaneous cervicalcordotomy in this series are reported.

Method

The various steps involved in percutaneous cervical cor-dotomy are the following:5 5-17

1 The patient is positioned so that the cervical spine isstraight and the sagittal plane of the head perpendicular tothe frontal plane.2 The pilot needle is placed in the subarachnoid spaceimmediately above the dentate ligament (subarachnoidtarget). With the aid of lateral fluoroscopy a short-bevel18-gauge pilot needle is introduced immediately below thetip of the mastoid process in a direction perpendicular tothe sagittal plane so as to reach the subarachnoid target.The latter is located a few millimetres immediately abovethe dentate ligament and as a rule can be imagined as lyingat a distance of 1 cm from the posterior edge of the body ofC2. We perform myelography, using 1 ml of iophendylate(Myodie Glaxo) contrast medium emulsified in 4 ml ofCSF. This contrast medium provides an extremely accuratemyelographic image with precise visualisation of the twodentate ligaments and the anterior edge of the spinal cord.This quality of image is essential for judging the degree ofany possible rotation of the cord and thus affords a guaran-tee that the electrode is positioned perfectly at right anglesto the spinal target. This is particularly important whenperforming bilateral percutaneous cervical cordotomy.3 The pilot needle is next aligned with the sector of thespinothalamic tract where the lesion is to be made (spinaltarget). The spinal target is generally immediately along-side the dentate ligament in the lumbosacral segments,

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1-2 mm anteriorly in the thoracolumbar segments, and3 mm in the upper thoracic and cervical segments. Duringbilateral percutaneous cervical cordotomy it is imperativeto malke sure that the ventral portion of the antero-lateralquadrant is not involved in the lesion, to avoid the destruc-tion of the reticulo-spinal respiratory fibres capping theanterior horn.' 6 8 For this purpose it is essential to alignthe pilot needle immediately alongside the dentate liga-ment or at most 1 mm anterior to it, taking the maximumpossible care to achieve this alignment without any separa-tion of the images of the two dentate ligaments.

4 The normal or the thermocouple electrode is intro-duced with the hand free and unsupported so as to be ableto feel the resistance afforded by contact with, and subse-quent penetration of, the pia mater.'5 Measurement of theimpedance values and subsequent lateral fluoroscopyenable us to ascertain whether image shifting has occurred,especially rotation, following the introduction of the elec-trode.5 The simple mechanical stimulation resulting from theintroduction of the electrode into the spinothalamic tract isfrequently enough to cause the disappearance or reductionof spontaneous pain and to evoke thermal sensations ofvarying degrees of intensity in all or part of the contralat-eral half of the body.(a) Motor stimulation is used to make sure that the elec-trode is properly positioned in the spinal quadrant con-cerned. The strength of stimulus which is used (2-5 Hz;0-5-1 V) is such that the motoneurons of the anterior hornare only stimulated when the electrode is properlypositioned. If the electrode is excessively ventral or in avery deep position, the motoneurons of the contralateralanterior horn will also be stimulated. Rhythmic contractionaffecting the more cranial or more caudal portions of thetrapezius and sternocleidomastoid muscles is evidence of amore ventral or more dorsal positioning of the electrode.When performing bilateral percutaneous cervical cor-dotomy it is necessary to avoid positioning the electrode insuch a way as to cause contraction of the medium or highportions of these muscles, as this means it has beeninserted in an excessively ventral position.7(b) Sensory stimulation is carried out with frequencies of75-100 Hz and 0-05-0-1 V. The stimulation sequencesthus imparted provide a number of basic pointers: tetaniccontractions of the ipsilateral muscles (hand and foot) indi-cate involvement of pyramidal fibres (electrode situated inan excessively dorsal position and thus necessitating repos-itioning); intense thermal sensations affecting a given con-tralateral area of the body are evidence of perfect position-ing of the electrode in the spinothalamic fibres.6 The lesion is made in successive steps with progressiveincrements in current intensity for predetermined timeperiods (5-10 s), when using the traditional electrode, andin temperature when using the thermocouple electrode. Itis essential to keep a constant check, before and duringeach lesion, on conservation of strength in the ipsilateralhalf or the body (upper and lower limbs) and stop immedi-ately at the first hint of muscle weakness. The lesion ismade only after making quite sure that all the variablesexamined match up to the above-mentioned requirementsand is then continued until deep analgesia is achieved.

Ischia, Luzzani, Ischia, Maffezzoli

Bilateral percutaneous cervical cordotomy in one stage only,using Levin's thermocouple-monitored electrodeThis procedure is performed using an 18-gauge pilot nee-dle instead of a 20-gauge needle; this needle offers bettercorrection of alignment with the spinal target.On completion of unilateral percutaneous cervical cor-

dotomy, we slowly advance the same electrode with con-tinuous application of the stimulation parameters used formotor stimulation (2 Hz; 0-5-1 V). We thus observe dis-appearance of stimulation of the motoneurons of theipsilateral anterior horn and appearance of contralateralmotoneuron stimulation. When the rhythmic contractionof the caudal portions of the trapezius and sternocleido-mastoid muscles is only contralateral and in all respectssimilar to that obtained ipsilaterally for identical stimula-tion parameters, we perform sensory stimulation. Onobtaining the latter, we then proceed to make the lesion.

It proved possible to perform a histological examinationin three patients who died in hospital. In all three patients,bilateral percutaneous cervical cordotomy had been per-formed in two stages, and the result was similar to thatshown in the figure, though not at the same levels.

Results

We treated 36 patients suffering from neoplasticdisease, in whom the pain often involved numeroussegments and was felt often in parts of the body farremoved one from another. In one group of patientsthe pain was originally bilateral and the stage of thedisease so far advanced as to indicate an immediatebilateral operation. Among these were the six casesof bilateral percutaneous cervical cordotomy per-formed in a single stage using Levin'sthermocouple-monitored electrode technique. Inother patients unilateral percutaneous cervical cor-dotomy was followed shortly afterwards by the onsetof contralateral pain. In mediastinal, pulmonary,abdominal and bladder neoplasm and in neoplasticvertrebal pathology, pain localised in one half of thebody may be minimised or completely masked bythe predominance of pain present in the other halfof the body. Once these symptoms have been elimi-nated, free rein is given to the contralateral pain. Insuch patients a second percutaneous cervical cor-dotomy was indicated shortly after the first opera-tion. Finally, in a further group of patients who hadalready undergone percutaneous cervical cor-dotomy, the evolution of the neoplasm led in duecourse to the onset and aggravation of contralateralpain of such a nature as to require a second per-cutaneous cervical cordotomy. In our series the timeelapsing between the first and second operationranged from 2 days to 2 weeks. Only in one patientwas the second percutaneous cervical cordotomyperformed much later (22 months) than the first.

In the 36 patients subjected to bilateral per-cutaneous cervical cordotomy deep pin-prick



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Bilateral percutaneous cervical cordotomy: immediate and long-term results

Fig Cross section ofthe spinal cord at C-C2 level. Patient subjected to bilateral percutaneouscervical cordotomy by radiofrequency diathermocoagulation in two separate stages. The areasofthe lesions are clearly visible anterior to the dentate ligaments. The lesions spare the areassurrounding the anterior spinal horns. Deep pin-prick analgesia from T4 to S5. Arrows indicatethe two lesions (L and L1). L = 30 mA 5 s; 40 mA S s; SOmA 15 s. LI = 30mA 5 s; 40mA5 s; SO mA IO s. DL = dentate ligament.

analgesia was obtained from T10, T4 or Ti to S5 in35 patients (97.2%), while hypoalgesia resulted inone case (2.8%). The Claude Bernard-Horner syn-drome occurred in all patients (table 1).The mortality during the 7 days after operation

was four patients (11-1%) (table 2).As in the case of unilateral percutaneous cervical

cordotomy, the sequelae were partly the result ofthe operations and partly related to nerve structuresdirectly or indirectly involved in the lesion. The gre-ater incidence of sequelae in bilateral percutaneouscervical cordotomy is attributable to the loss of thefunctions performed by the contralateral spinalfibres spared in the previous percutaneous cervicalcordotomy. The immediate reversible sequelaeresulting from the operations were usually of onlyminor significance and were identical in degree andfrequency to those observed -during unilateral per-cutaneous cervical cordotomy (headache, neck pain,high temperature).7Much more important were the immediate

sequelae resulting from the spinal lesion (table 3):(a) In 13 patients in our series (36.1%), weakness

Table 1 Results (36 patients)

Immediate effect achieved bilaterally(single-stage cordotomy) or contralaterallyto the second cordotomy:

- deep pin-prick analgesia (from TIO,T4 or Ti to S5) 35 pts. ( 97-2%)

- hypoalgesia T4 -S5 1 pt. ( 2-8%)Immnediate effect on same side as lesion:- Claude-Bernard-Horner syndrome 36 pts. (100%)

of varying degree and duration occurred in theipsilateral lower limb; it generally improved withtime. Paresis occurred in one patient (2.8%); therewas no case of hemiplegia. Evaluation of thepatient's ability to walk provided a further indica-tion as to the extent of the motor involvement aswell as to the patient's general condition followingbilateral percutaneous cervical cordotomy. Thedegree of damage to the pyramidal tract could beassessed from the patient's ability to walk. In the 29percutaneous cervical cordotomies performed intwo stages, 21 patients (72.4%) could not be evalu-ated as they were bedridden; six of the other eightpatients (20.7%) were still able to walk, while theremaining two patients (6-9%) could no longer doso. In the six patients undergoing bilateral per-cutaneous cervical cordotomy in a single operation,walking could not be evaluated in one case; theother five retained their ability to walk. The abilityto walk could not be assessed in the patient whounderwent a contralateral percutaneous cervicalcordotomy 22 months after the first operation.Within the context of motor problems secondary

to percutaneous cervical cordotomy we should also

Table 2 Mortality (first 7 days)

1 death after 6 days: brain metastases, coma1 death after 6 days: cachexia, coma1 death after 2 days: sepsis1 death after 5 days: cardiocirculatory collapse in a patient

with coronary heart disease

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Table 3 Immediate sequelae as a result ofthe spinal lesion

Motor - weakness 13 pts. (36-1%)- paresis 1 pt. (2.8%)- total

paralysis 0

on-assessable 21 pts. (72-4%)

- abilit -intact 6 pts. (20-7%)to walk(2 stages, lost 2 pts. (6.9%)29 pts.)

Bladder - non-assessable 12 pts. (33-3%)- assessable 24 pts. (15 males and 9 females)

A malespermanent urinary retention<

3 females

1 maleurinary incontinence

1 female

Blood pressure - arterial hypotension: 13 pts. (36-1%)

Sleep-induced apnoea (Ondine's syndrome) - 0 pts.

include paralysis or paresis of the ipsilateralrespiratory muscles. This becomes more importantwhen ventilation is already compromised by pathol-ogy involving the lungs or rib cage. In our series,however, impaired ventilatory efficiency did notprove to be of any great clinical significance.(b) The motor fibres of the striate sphincters of thebladder and anus have partly crossed and partlyuncrossed spinal innervation. For this reason urinaryretention, generally of a transient nature, was

observed in a modest percentage (6%) of patientsundergoing unilateral percutaneous cervical cor-dotomy,' but in a higher percentage in patients withexisting subclinical sphincter problems. At the timebilateral percutaneous cervical cordotomy was per-

formed, 10 patients (28%) had a permanent in-dwelling catheter and two (5-6%) had ureteros-tomies. Of the remaining 24 patients (15 males andnine females) nine males and three females alreadyhad permanent urinary retention, and one male andone female had urinary incontinence. Overall, 14out of 24 patients with no serious sphincter prob-lems at the time of the bilateral operation subse-quently acquired permanent sphincter disorders. Inour series the incidence may be summarised as fol-lows: 12 patients (33.3%) could not be evaluatedbecause they already possessed no micturition abil-ity, 14 patients (38.9%) exhibited postoperativesphincter disorders, and 10 patients (27.7%) had nosuch disorders. Incontinence of the anal sphincterwas observed in one patient, while another exhibitedchronic constipation.(c) Thirteen patients (36.1%) had varying degreesof arterial hypotension, accentuated in the orthosta-

Ischia, Luzzani, Ischia, Maffezzolitic posture. The pathogenesis of this condition maybe ascribed to the interruption of reticulo-spinalfibres partly distributed among and mingling withthe tracts of the antero-lateral funiculus and partlygrouped together in the lateral and ventral reticulo-spinal tracts.(d) Destruction or disturbance of the antero-lateralreticulo-spinal fibres capping the anterior horn ofthe spinal cord may give rise to loss of automaticcontrol of respiration (Ondine's syndrome). Thephenomenon manifests itself during sleep when thevoluntary respiration mediated by the pyramidaltract ceases. None of our patients exhibited thisphenomenon. In view of the danger of this complica-tion, we started performing bilateral percutaneouscervical cordotomy only when we had completelymastered the technique, that is to the extent that wewere at all times in a position to know the site of thelesion within the spinal quadrant with a sufficientdegree of precision. From the technical point ofview, we should stress the particular attention paidto reaching the spinal target: it is essential, both inpatients undergoing bilateral percutaneous cervicalcordotomy in two separate operations and, evenmore so, in those undergoing a single-stage bilateraloperation, for the two dentate ligaments to appearin line with one another on the lateral myelographicimage. This enables us to achieve penetration of theelectrode in very close proximity to the dentate lig-ament and perpendicular to the spinal cord. In thisway there is no risk of the lesion involving the ven-tral portion of the antero-lateral quadrant of thespinal cord, which means that the reticulo-spinalfibres will remain intact. In our experience a lesionin this site will always succeed in producing equallydeep analgesia in the segments below T10, some-times extending even up to T4-T1, and very rarelyas far as CS, suggesting that the spinothalamic fibreswere grouped together in a small, clearly delimitedtract. In those cases in which the analgesia obtainedis confined to T10 and S5, that is a level inadequateto deal with pain at higher levels, one only needs tokeep the electrode inserted in the spinal cord in aposition just above the dentate ligament and per-form the lesion by slightly depressing the outer endof the pilot needle. This will yield an extension ofdeep analgesia as far as T4-T1.

Long-term pain relief (Table 4).The pain relief was assessed during the rest of thepatient's life and with the aid of informationreceived from relatives after the patient's death. Inthe four patients who died during the first week,there was complete relief in three cases; in thefourth it could not be assessed as this patient fell intocoma.



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Table 4 Long-term pain relief (32 patients) *

complete 15 pts. (47%)partial 4 pts. (12.5%)persistent pain in the site treated by

the 2nd cordotomy 8 pts. (25%)recurrence of pain in the site treated by

the 1st cordotomy 1 pt. (3-1%)occufrence of pain m another site 1 Pt. (3-1%)diffuse pain 3 pts. (9-4%)

*Mortality (1st week): 4 pts. (12.5%)

In 15 cases (47%) pain relief was complete: thesepatients died pain-free. Three of them died duringthe second week after operation, two within one

month, four within a month and a half, three within2 months, one within 4 months, one within 5 monthsand one within 9 months. In four patients (12.5%),pain relief was partial, the residual pain being con-trolled with minor analgesics and mild narcotics.Two died in the second week, one within 20 days,and one within 1 month. In eight patients (25%)undergoing bilateral percutaneous cervical cor-

dotomy in two separate operations, pain persisted inthe site treated by the second cordotomy despitedeep pin-prick analgesia. One patient (3.1%) whohad contralateral percutaneous cervical cordotomy22 months after the previous operation experiencedpain in the site treated by the first percutaneous cer-vical cordotomy 24 hours after the second opera-

tion, which, however, had been performed in a tech-nically correct manner. The pain was well controlledby means of narcotics.

In one case (3-1%) the pain was experienced inother segments not affected by the analgesia (aboveT4). Diffuse pain was experienced by three patients(9.4%).

Discussion

Bilateral cervical cordotomy has a fairly high mortal-ity rate. This mortality is mainly associated withsleep-induced apnoea and cardiovascular col-lapse.' 8-10 13 20 Mortality rates have been reportedby various authors according to criteria which arenot always sufficiently precise or homogene-ous. 3 4 9 10 13 20 23 24 In the case of surgical cor-

dotomy, French34 reported a 41-6% mortality ratein 12 patients subjected to a bilateral high cervicalcordotomy performed in a single stage; Rosomoff20reported a mortality rate ranging from 20 to 36%for the same operation; White and Sweet23 reportedthat out of 84 patients undergoing the bilateraloperation, 65 of whom were operated on in one

stage and 19 in two stages, the operative deathsamounted to six cases (7-1%), five of them among

patients operated on in one stage. These latterauthors did not state at which level the bilateral inci-

sions were performed, but merely stated that theincidence of mortality in the unilateral operationwas greater when it was performed at high cervicallevel than when performed at high thoracic level.White and Sweet,24 comparing the results of per-cutaneous cervical cordotomy with those of opencordotomy, concluded that mortality was higher forthe open operation; the latter is still recommendedat the second stage at high thoracic level in case ofbilateral pain of the abdomen, pelvis or lower limbs.The mortality rate in bilateral percutaneous cervicalcordotomy ranged from 12%, as reported byRosomoff,20 with 2% due to sleep-induced apnoea,to 10%, as reported by Kuhner,9 10 due to respirat-ory and blood pressure complications, and 4%, asreported by Lipton,'3 due entirely to sleep-inducedapnoea. The mortality figure in the 36 patients wesubjected to bilateral percutaneous cervical cor-dotomy was four patients (11.1%) (table 2).The incidence of sleep-induced apnoea in bilat-

eral percutaneous cervical cordotomy was 4% asreported by Rosomoff,20 8% as reported by Lip-ton,'3 and 18.1% as reported by Kuhner.9 To pre-vent sleep-induced apnoea from occurring, alterna-tive routes have been proposed such as the anteriorroute between C5 and C6,'2 or high thoracic opensurgery as the second stage of a unilateral per-cutaneous cervical cordotomy.24 None of the 36patients treated by us exhibited sleep-inducedapnoea (table 3). This result confirms that the ven-tral portion of the antero-lateral quadrant of thespinal cord may be spared by the lesion, if care istaken to perform the operation according to thetechniques described above. The site and extent ofthe lesion just above the dentate ligament are com-patible with the achievement of deep pin-prickanalgesia in the regions from T10, T4 or Ti to S5.Impairment of sympathetic tone is the rule follow-

ing bilateral cordotomy. Belmustol asserted thathypotension may be used as a measure of the ade-quacy of a surgical cordotomy in a bilateral proce-dure when performed in the lower cervical region.In his experience a permanent analgesic level wasnot produced unless hypotension was observed aftercutting the second side.The incidence of hypotension in the course of

bilateral percutaneous cervical cordotomy rangedfrom 40% as reported by Kuhner,'0 to 4% asreported by Rosomoff.20 In particularly debilitatedpatients or those with hypovolaemic coronary heartdisease, such alterations may be the cause of opera-tive mortality. Arterial hypotension, especiallyorthostatic, occurred in 13 (36-1%) of our 36patients (table 3), and in one case this event was thecause of death (table 2).As regards motor disorders, White and Sweet23

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observed a motor weakness in 8% of patients sub-jected to cervical or high thoracic surgical bilateralcordotomy performed in a single operating session,and in 10% when the patients are treated in twostages. Rosomoff0 reported an incidence of paresisranging from 2% to 12% after surgical cervical cor-dotomy and a 10% incidence (3% permanent) afterbilateral percutaneous cervical cordotomy. Accord-ing to Kuhner,9 bilateral cordotomy is characterisedby the same incidence of motor deficit as unilateralcordotomy (hemiplegia in 5% of patients treated viathe percutaneous route and in 8% of those treatedsurgically). The motor sequelae occurring in our 36patients are given in Table 3. Permanent paresisoccurred in only one case (2.8%), while on no occa-sion did we observe recurrence of paresis on thesame side as the first cordotomy after performing asecond cordotomy.9 '9

After bilateral surgical cervical cordotomy,Rosomoff0 reported an incidence of permanentbladder sphincter disorders ranging from 11% to92%; White23 reported a 29% incidence after cor-dotomies performed in a single stage and a 16%incidence after a two-stage procedure; Brihaye2reported a 33% incidence. Bilateral percutaneouscervical cordotomy presented a varying percentageof permanent bladder function impairment: 2%according to Rosomoff,'9 12% according toKuhner,'0 21% according to Tasker21 and 60%according to Lipton'3 (40% manifested prior to thesecond operation). In 33-3% of our 36 patientsbladder function impairment could not be assessedbecause the patients were already catheterised orhad ureterostomies, while 38-9% were obliged touse indwelling catheters after the second cordotomy.

In our series of 36 patients suffering from chronicpain of neoplastic origin and undergoing bilateralpercutaneous cervical cordotomy, 15 patients(47%) had complete pain relief for the entire periodof remaining life and died pain-free. Four patients(12.5%) obtained sufficient benefit to be able toeliminate their pain with the aid of non-narcoticanalgesic drugs or mild narcotics. Eight patients(25%) complained of persistence of the originalpain in the site treated by the second cordotomydespite deep pin-prick analgesia. This phenomenonmay be related to a preoperative unsuspected orundiagnosed deafferentation pain,'4 22 or may beinterpreted as a phenomenon originating at spinallevel.'8 The reason for such a high incidence of per-sistence of pain in the site treated by the secondpercutaneous cervical cordotomy remains, however,difficult to explain. In the case of unilateral or bilat-eral pain, it is essential to obtain as complete a pic-ture as possible of the case history and objectivedata ("numb, tingling, pins and needles, the freezing

Ischia, Luzzani, Ischia, Maffezzoli

coming out and pricking" 22) to assist in the diag-nosis of deafferentation pain. In the presence ofthese evident or highly suspect symptoms a per-cutaneous cervical cordotomy is useless. The reasonfor the reappearance of pain in the site treated bythe first cordotomy on performance of a second cor-dotomy 22 months later might be explained as areference of sensation from the analgesic side to theanalogous place on the opposite side'8 on whichhypoalgesia subsequently set in.

Bilateral percutaneous cervical cordotomy carriesa fairly high mortality (approximately 10%) even inthe absence of respiratory complications. The opera-tion should be performed only by those who canguarantee that the ventral portion of antero-lateralquadrant of the spinal cord will be spared.The effects on sympathetic tone, sphincter control

and, albeit to a lesser extent, muscular strengthaffect the quality of life of patients who are alreadysorely tried as a result of the progressive, inexorabledecline in their general condition associated with theneoplasm. It is thus difficult to assess whether a cer-tain measure of the deterioration observed in thegeneral sense of well-being of our patients is relatedto the procedure itself or is due to other causes.Enhanced quality of life following bilateral per-cutaneous cervical cordotomy was observed by us inpatients in good general condition with no cardiocir-culatory problems. In such patients with bilateralneoplastic pain without unmistakeable or highlysuspect signs of deafferentation pain, we now usu-ally perform bilateral percutaneous cervical cor-dotomy. It is our opinion that there is now nojustification for proposing and performing open cor-dotomy, even when carried out at high thoracic levelas the second stage of a bilateral procedure.

The authors thank Mr Anthony Steele for hisinvaluable assistance in translating and revising thetext of this paper. Their thanks also go to Mr SergioFaggion for his photographic assistance.

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