Tomycz Luke, Forbes Jonathan, Ladner Travis, Kahn Elyne, Maris Alexander, Neimat Joseph, Konrad Pete
Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States.
J Neurol Surg A Cent Eur Neurosurg. 2014 Mar;75(2):126-32. doi: 10.1055/s-0033-1349340. Epub 2013 Aug 8.
The treatment of patients with debilitating lower extremity or medically refractory quadrant pain presents a challenge for management. Contemporary neuromodulatory therapies may not be affordable or practical, especially in patients with limited life expectancy or from countries with limited resources. We present a small retrospective series to evaluate the role of open thoracic cordotomy as a practice option in the treatment of patients with severe, unilateral, medically refractory pain of the lower abdominal quadrant, hip, or leg. Technical aspects of the procedure, anatomic pathways within the spinal cord, and intraoperative maneuvers are described.
The medical records of 9 patients (7 men, 2 women; median age, 57 years) treated between 1998 and 2010 were reviewed. Each patient underwent open thoracic cordotomy after 1998 for severe lower quadrant or lower extremity pain refractory to multiple other treatment modalities. The indications for surgery included cancer-related pain (4 of 9), postherpetic neuralgia (2 of 9), post-spinal cord injury pain (2 of 9), and multiple sclerosis (1 of 9).
Six of nine patients reported improvement in their postoperative level of pain after a median follow-up of 31 weeks. Complications included ipsilateral lower extremity weakness, urinary incontinence, and the development of new postcordotomy pain. A higher incidence of complications, including ipsilateral motor weakness, was observed in this series than with previous reports of percutaneous cervical cordotomy (PCC).
Although open thoracic cordotomy may be cautiously recommended as a treatment option in certain settings, this procedure should be viewed only as a second-line treatment option in settings where the technology and expertise to perform PCC are available.
治疗下肢功能严重受损或药物治疗无效的象限性疼痛患者对管理工作构成挑战。当代神经调节疗法可能费用高昂或不切实际，尤其是对于预期寿命有限的患者或来自资源有限国家的患者。我们展示一个小型回顾性系列研究，以评估开放性胸段脊髓切开术作为治疗下腹部象限、髋部或腿部严重单侧药物治疗无效疼痛患者的一种实践选择的作用。描述了该手术的技术方面、脊髓内的解剖路径以及术中操作。
回顾了1998年至2010年间接受治疗的9例患者（7例男性，2例女性；中位年龄57岁）的病历。1998年后，每例患者因严重的下象限或下肢疼痛经多种其他治疗方式无效而接受开放性胸段脊髓切开术。手术适应症包括癌症相关疼痛（9例中的4例）、带状疱疹后神经痛（9例中的2例）、脊髓损伤后疼痛（9例中的2例）和多发性硬化症（9例中的1例）。
9例患者中有6例在中位随访31周后报告术后疼痛程度有所改善。并发症包括同侧下肢无力、尿失禁以及新出现的脊髓切开术后疼痛。与先前经皮颈段脊髓切开术（PCC）的报告相比，本系列中观察到包括同侧运动无力在内的并发症发生率更高。
尽管在某些情况下可谨慎推荐开放性胸段脊髓切开术作为一种治疗选择，但在具备实施PCC的技术和专业知识的情况下，该手术应仅被视为二线治疗选择。
