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Ashwin Viswanathan - One of the best experts on this subject based on the ideXlab platform.

  • Percutaneous Cordotomy for Pain Palliation in Advanced Cancer: A Randomized Clinical Trial Study Protocol.
    Neurosurgery, 2020
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Loretta A. Williams, Dhanalakshmi Koyyalagunta, Salahadin Abdi, Patrick M. Dougherty, Tito R. Mendoza, Roland L. Bassett, Ping Hou, Eduardo Bruera
    Abstract:

    BACKGROUND Cancer pain, one of the most common symptoms for patients with advanced cancer, is often refractory to maximal medical therapy. A controlled clinical trial is needed to provide definitive evidence to support the use of ablative procedures such as Cordotomy for patients with medically refractory cancer pain. OBJECTIVE To assess the efficacy of Cordotomy for patients with unilateral advanced cancer pain using a controlled clinical trial study design. The secondary objectives are to define the patient experience of Cordotomy for medically refractory cancer pain as well as to determine the utility of magnetic resonance imaging as a non-invasive biomarker for successful Cordotomy. METHODS We will undertake a single-institution, double-blind, sham-controlled clinical trial of Cordotomy in patients with refractory cancer pain. Patients in the Cordotomy arm will undergo a percutaneous computed tomography-guided Cordotomy at C1-C2, while patients in the control arm will undergo a similar procedure where the needle will not penetrate the thecal sac. The primary endpoint will be the reduction in pain intensity, as measured by the Edmonton Symptoms Assessment Scale. EXPECTED OUTCOMES We expect that patients randomized to Cordotomy will have a significantly greater reduction in pain intensity than those patients randomized to the control surgical intervention. DISCUSSION This randomized clinical trial comparing Cordotomy with a control intervention will provide the level of evidence necessary to determine whether Cordotomy should be the standard of care intervention for patients with advanced cancer pain.

  • Cordotomy for Intractable Cancer Pain: A Narrative Review.
    Pain physician, 2020
    Co-Authors: Saba Javed, Ashwin Viswanathan, Salahadin Abdi
    Abstract:

    BACKGROUND Cordotomy is an invasive procedure for the management of intractable pain not controlled by conventional therapies, such as analgesics or nerve block. This procedure involves mechanical disruption of nociceptive pathways in the anterolateral column, specifically the spinothalamic and spinoreticular pathways to relieve pain while preserving fine touch and proprioceptive tracts. OBJECTIVES The purpose of this review article is to refresh our knowledge of Cordotomy and support its continued use in managing intractable pain due to malignant disease. STUDY DESIGN This is a review article with the goal of reviewing and summarizing the pertinent case reports, case series, retrospective studies, prospective studies, and review articles published from 2010 onward on spinal Cordotomy. SETTING The University of Texas, MD Anderson Cancer Center. METHODS PubMed search of keywords "spinal Cordotomy," "percutaneous Cordotomy," or "open Cordotomy" was undertaken. Search results were organized by year of publication. RESULTS Cordotomy can be performed via percutaneous, open, endoscopic, or transdiscal approach. Percutaneous image-guided approach is the most well-studied and reported technique compared with others, with relatively good pain improvement both in the postoperative and short-term period. The use of open Cordotomy has diminished significantly in recent years because of the advent of other less invasive approaches. Cordotomy in children, although rare, has been described in some case reports and case series with reported pain improvement postprocedure. Although complications can vary broadly, some reported side effects include ataxia and paresis due to lesion in the spinocerebellar/corticospinal tract; respiratory failure due to lesion in the reticulospinal tract; or sympathetic dysfunction, bladder dysfunctions, or Horner syndrome due to unintentional lesions in the spinothalamic tract. LIMITATIONS Review article included literature published only in English. For the studies reviewed, the sample size was relatively small and the patient population was heterogeneous (in terms of underlying disease process, duration of symptoms, previous treatment attempted and length of follow-up). CONCLUSIONS Cordotomy results in selective loss of pain and temperature perception on the contralateral side, up to several segments below the level of the disruption. The plethora of analgesics available and advanced technologies have reduced the demand for Cordotomy in the management of intractable pain. However, some patients with pain unresponsive to medical and procedural management, particularly malignant pain, may benefit from this procedure, and it is a viable treatment option especially for patients with a limited life expectancy whose severe, unilateral pain is unresponsive to analgesic medications. KEY WORDS Cancer pain, Cordotomy complications, Cordotomy indications, intractable pain, open Cordotomy, percutaneous Cordotomy.

  • Percutaneous CT-guided Cordotomy for pain
    Neurosurgical Focus: Video, 2020
    Co-Authors: M. Benjamin Larkin, Robert Y. North, Ashwin Viswanathan
    Abstract:

    Cordotomy has evolved since the first open procedure by Spiller and the first percutaneous radiofrequency Cordotomy by Mullan in 1965. Today, the minimally invasive, CT-guided percutaneous radiofrequency Cordotomy is mostly used for the palliative management of medically intractable somatic pain related to malignancy in well-selected patients. The risk of adverse events is minimized with the use of intraoperative stimulation monitoring. This video highlights the spinal cord anatomy at the level of C1–2, the approach to patient selection, the associated risks and benefits, and, finally, the procedural setup and key steps involved in this unique neurosurgical procedure.The video can be found here: https://youtu.be/a-0ORqy0W2o

  • Magnetic Resonance-Based Radiomic Analysis of Radiofrequency Lesion Predicts Outcomes After Percutaneous Cordotomy: A Feasibility Study.
    Operative Neurosurgery, 2019
    Co-Authors: Aditya Vedantam, Ashwin Viswanathan, Islam Hassan, Aikaterini Kotrotsou, Ahmed Hassan, Pascal O. Zinn, Rivka R. Colen
    Abstract:

    Background To date, there is limited data on evaluation of the Cordotomy lesion and predicting clinical outcome. Objective To evaluate the utility of magnetic resonance (MR)-based radiomic analysis to quantify microstructural changes created by the Cordotomy lesion and predict outcome in patients undergoing percutaneous Cordotomy for medically refractory cancer pain. Methods This is a retrospective interpretation of prospectively acquired data in 10 patients (5 males, age range 43-76 yr) who underwent percutaneous computed tomography-guided high cervical Cordotomy for medically refractory cancer pain between 2015 and 2016. All patients underwent magnetic resonance imaging (MRI) of the Cordotomy lesion on postoperative day 1. After segmentation of T2-weighted images, 310 radiomic features were extracted. Pain outcomes were recorded on postoperative day 1 and day 7 using the visual analog scale. R software was used to build statistical models based on MRI radiomic features for prediction of pain outcomes. Results A total of 20 relevant radiomic features were identified using the maximum relevance minimum redundanc method. Radiomics predicted postoperative day 1 pain scores with an accuracy of 90% (P = .046), 100% sensitivity, 75% specificity, 85.7% positive predictive value, and 100% negative predictive value. The radiomics model also predicted if the postoperative day 1 pain score was sustained on postoperative day 7 with an accuracy of 100% (P = .028), 100% sensitivity, 100% specificity, and 100% positive and negative predictive value. Conclusion MR-based radiomic analysis of the Cordotomy lesion was predictive of pain outcomes at 1 wk after percutaneous Cordotomy for intractable cancer pain.

  • Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial
    The Oncologist, 2019
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Dhanalakshmi Koyyalagunta, Patrick M. Dougherty, Kenneth R. Hess, Jewel Ochoa, Akhila Reddy, Suresh K. Reddy, Eduardo Bruera
    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.

Aditya Vedantam - One of the best experts on this subject based on the ideXlab platform.

  • Percutaneous Cordotomy for Pain Palliation in Advanced Cancer: A Randomized Clinical Trial Study Protocol.
    Neurosurgery, 2020
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Loretta A. Williams, Dhanalakshmi Koyyalagunta, Salahadin Abdi, Patrick M. Dougherty, Tito R. Mendoza, Roland L. Bassett, Ping Hou, Eduardo Bruera
    Abstract:

    BACKGROUND Cancer pain, one of the most common symptoms for patients with advanced cancer, is often refractory to maximal medical therapy. A controlled clinical trial is needed to provide definitive evidence to support the use of ablative procedures such as Cordotomy for patients with medically refractory cancer pain. OBJECTIVE To assess the efficacy of Cordotomy for patients with unilateral advanced cancer pain using a controlled clinical trial study design. The secondary objectives are to define the patient experience of Cordotomy for medically refractory cancer pain as well as to determine the utility of magnetic resonance imaging as a non-invasive biomarker for successful Cordotomy. METHODS We will undertake a single-institution, double-blind, sham-controlled clinical trial of Cordotomy in patients with refractory cancer pain. Patients in the Cordotomy arm will undergo a percutaneous computed tomography-guided Cordotomy at C1-C2, while patients in the control arm will undergo a similar procedure where the needle will not penetrate the thecal sac. The primary endpoint will be the reduction in pain intensity, as measured by the Edmonton Symptoms Assessment Scale. EXPECTED OUTCOMES We expect that patients randomized to Cordotomy will have a significantly greater reduction in pain intensity than those patients randomized to the control surgical intervention. DISCUSSION This randomized clinical trial comparing Cordotomy with a control intervention will provide the level of evidence necessary to determine whether Cordotomy should be the standard of care intervention for patients with advanced cancer pain.

  • Magnetic Resonance-Based Radiomic Analysis of Radiofrequency Lesion Predicts Outcomes After Percutaneous Cordotomy: A Feasibility Study.
    Operative Neurosurgery, 2019
    Co-Authors: Aditya Vedantam, Ashwin Viswanathan, Islam Hassan, Aikaterini Kotrotsou, Ahmed Hassan, Pascal O. Zinn, Rivka R. Colen
    Abstract:

    Background To date, there is limited data on evaluation of the Cordotomy lesion and predicting clinical outcome. Objective To evaluate the utility of magnetic resonance (MR)-based radiomic analysis to quantify microstructural changes created by the Cordotomy lesion and predict outcome in patients undergoing percutaneous Cordotomy for medically refractory cancer pain. Methods This is a retrospective interpretation of prospectively acquired data in 10 patients (5 males, age range 43-76 yr) who underwent percutaneous computed tomography-guided high cervical Cordotomy for medically refractory cancer pain between 2015 and 2016. All patients underwent magnetic resonance imaging (MRI) of the Cordotomy lesion on postoperative day 1. After segmentation of T2-weighted images, 310 radiomic features were extracted. Pain outcomes were recorded on postoperative day 1 and day 7 using the visual analog scale. R software was used to build statistical models based on MRI radiomic features for prediction of pain outcomes. Results A total of 20 relevant radiomic features were identified using the maximum relevance minimum redundanc method. Radiomics predicted postoperative day 1 pain scores with an accuracy of 90% (P = .046), 100% sensitivity, 75% specificity, 85.7% positive predictive value, and 100% negative predictive value. The radiomics model also predicted if the postoperative day 1 pain score was sustained on postoperative day 7 with an accuracy of 100% (P = .028), 100% sensitivity, 100% specificity, and 100% positive and negative predictive value. Conclusion MR-based radiomic analysis of the Cordotomy lesion was predictive of pain outcomes at 1 wk after percutaneous Cordotomy for intractable cancer pain.

  • Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial
    The Oncologist, 2019
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Dhanalakshmi Koyyalagunta, Patrick M. Dougherty, Kenneth R. Hess, Jewel Ochoa, Akhila Reddy, Suresh K. Reddy, Eduardo Bruera
    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.

  • Somatotopy and Organization of Spinothalamic Tracts in the Human Cervical Spinal Cord
    Neurosurgery, 2018
    Co-Authors: Aditya Vedantam, Patrick M. Dougherty, Eduardo Bruera, Kenneth R. Hess, Ashwin Viswanathan
    Abstract:

    BACKGROUND:Understanding spinothalamic tract anatomy may improve lesioning and outcomes in patients undergoing percutaneous Cordotomy. OBJECTIVE:To investigate somatotopy and anatomical organization of spinothalamic tracts in the human cervical spinal cord. METHODS:Patients with intractable cancer pain undergoing Cordotomy underwent preoperative and postoperative quantitative sensory testing for sharp pain and heat pain on day 1 and 7 after Cordotomy. Intraoperative sensory stimulation was performed with computed tomography (CT) imaging to confirm the location of the radiofrequency electrode during Cordotomy. Postoperative magnetic resonance (MR) imaging was performed to define the location of the lesion. RESULTS:Twelve patients were studied, and intraoperative sensory stimulation combined with CT imaging revealed a somatotopy where fibers from the legs were posterolateral to fibers from the hand. Sharpness detection thresholds were significantly elevated in the area of maximum pain on postoperative day 1 (P = .01). Heat pain thresholds for all areas were not elevated significantly on postoperative day 1, or postoperative day 7. MR imaging confirmed that the Cordotomy lesion was in the anterolateral quadrant, and in this location the lesion had a sustained effect on sharp pain but a transient impact on heat pain. CONCLUSION:In the high cervical spinal cord, spinothalamic fibers mediating sharp pain for the arms are located ventromedial to fibers for the legs, and these fibers are spatially distinct from fibers that mediate heat pain.

  • Postoperative MRI Evaluation of a Radiofrequency Cordotomy Lesion for Intractable Cancer Pain.
    American Journal of Neuroradiology, 2017
    Co-Authors: Aditya Vedantam, Patrick M. Dougherty, Eduardo Bruera, P. Hou, T.l. Chi, K.r Hess, Ashwin Viswanathan
    Abstract:

    BACKGROUND AND PURPOSE: There are limited data on the use of postoperative imaging to evaluate the Cordotomy lesion. We aimed to describe the Cordotomy lesion by using postoperative MR imaging in patients after percutaneous Cordotomy for intractable cancer pain. MATERIALS AND METHODS: Postoperative MR imaging and clinical outcomes were prospectively obtained for 10 patients after percutaneous Cordotomy for intractable cancer pain. Area, signal intensity, and location of the lesion were recorded. Clinical outcomes were measured by using the Visual Analog Scale and the Brief Pain Inventory–Short Form, and correlations with MR imaging metrics were evaluated. RESULTS: Ten patients (5 men, 5 women; mean age, 58.5 ± 9.6 years) were included in this study. The Cordotomy lesion was hyperintense with central hypointense foci on T2-weighted MR imaging, and it was centered in the anterolateral quadrant at the C1–C2 level. The mean percentage of total cord area lesioned was 24.9% ± 7.9%, and most lesions were centered in the dorsolateral region of the anterolateral quadrant (66% of the anterolateral quadrant). The number of pial penetrations correlated with the percentage of total cord area that was lesioned (r = 0.78; 95% CI, 0.44–0.89; P = .008) and the length of T2-weighted hyperintensity (r = 0.85; 95% CI, 0.54–0.89; P = .002). No significant correlations were found between early clinical outcomes and quantitative MR imaging metrics. CONCLUSIONS: We describe qualitative and quantitative characteristics of a Cordotomy lesion on early postoperative MR imaging. The size and length of the lesion on MR imaging correlate with the number of pial penetrations. Larger studies are needed to further investigate the clinical correlates of MR imaging metrics after percutaneous Cordotomy.

Patrick M. Dougherty - One of the best experts on this subject based on the ideXlab platform.

  • Percutaneous Cordotomy for Pain Palliation in Advanced Cancer: A Randomized Clinical Trial Study Protocol.
    Neurosurgery, 2020
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Loretta A. Williams, Dhanalakshmi Koyyalagunta, Salahadin Abdi, Patrick M. Dougherty, Tito R. Mendoza, Roland L. Bassett, Ping Hou, Eduardo Bruera
    Abstract:

    BACKGROUND Cancer pain, one of the most common symptoms for patients with advanced cancer, is often refractory to maximal medical therapy. A controlled clinical trial is needed to provide definitive evidence to support the use of ablative procedures such as Cordotomy for patients with medically refractory cancer pain. OBJECTIVE To assess the efficacy of Cordotomy for patients with unilateral advanced cancer pain using a controlled clinical trial study design. The secondary objectives are to define the patient experience of Cordotomy for medically refractory cancer pain as well as to determine the utility of magnetic resonance imaging as a non-invasive biomarker for successful Cordotomy. METHODS We will undertake a single-institution, double-blind, sham-controlled clinical trial of Cordotomy in patients with refractory cancer pain. Patients in the Cordotomy arm will undergo a percutaneous computed tomography-guided Cordotomy at C1-C2, while patients in the control arm will undergo a similar procedure where the needle will not penetrate the thecal sac. The primary endpoint will be the reduction in pain intensity, as measured by the Edmonton Symptoms Assessment Scale. EXPECTED OUTCOMES We expect that patients randomized to Cordotomy will have a significantly greater reduction in pain intensity than those patients randomized to the control surgical intervention. DISCUSSION This randomized clinical trial comparing Cordotomy with a control intervention will provide the level of evidence necessary to determine whether Cordotomy should be the standard of care intervention for patients with advanced cancer pain.

  • Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial
    The Oncologist, 2019
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Dhanalakshmi Koyyalagunta, Patrick M. Dougherty, Kenneth R. Hess, Jewel Ochoa, Akhila Reddy, Suresh K. Reddy, Eduardo Bruera
    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.

  • Somatotopy and Organization of Spinothalamic Tracts in the Human Cervical Spinal Cord
    Neurosurgery, 2018
    Co-Authors: Aditya Vedantam, Patrick M. Dougherty, Eduardo Bruera, Kenneth R. Hess, Ashwin Viswanathan
    Abstract:

    BACKGROUND:Understanding spinothalamic tract anatomy may improve lesioning and outcomes in patients undergoing percutaneous Cordotomy. OBJECTIVE:To investigate somatotopy and anatomical organization of spinothalamic tracts in the human cervical spinal cord. METHODS:Patients with intractable cancer pain undergoing Cordotomy underwent preoperative and postoperative quantitative sensory testing for sharp pain and heat pain on day 1 and 7 after Cordotomy. Intraoperative sensory stimulation was performed with computed tomography (CT) imaging to confirm the location of the radiofrequency electrode during Cordotomy. Postoperative magnetic resonance (MR) imaging was performed to define the location of the lesion. RESULTS:Twelve patients were studied, and intraoperative sensory stimulation combined with CT imaging revealed a somatotopy where fibers from the legs were posterolateral to fibers from the hand. Sharpness detection thresholds were significantly elevated in the area of maximum pain on postoperative day 1 (P = .01). Heat pain thresholds for all areas were not elevated significantly on postoperative day 1, or postoperative day 7. MR imaging confirmed that the Cordotomy lesion was in the anterolateral quadrant, and in this location the lesion had a sustained effect on sharp pain but a transient impact on heat pain. CONCLUSION:In the high cervical spinal cord, spinothalamic fibers mediating sharp pain for the arms are located ventromedial to fibers for the legs, and these fibers are spatially distinct from fibers that mediate heat pain.

  • Postoperative MRI Evaluation of a Radiofrequency Cordotomy Lesion for Intractable Cancer Pain.
    American Journal of Neuroradiology, 2017
    Co-Authors: Aditya Vedantam, Patrick M. Dougherty, Eduardo Bruera, P. Hou, T.l. Chi, K.r Hess, Ashwin Viswanathan
    Abstract:

    BACKGROUND AND PURPOSE: There are limited data on the use of postoperative imaging to evaluate the Cordotomy lesion. We aimed to describe the Cordotomy lesion by using postoperative MR imaging in patients after percutaneous Cordotomy for intractable cancer pain. MATERIALS AND METHODS: Postoperative MR imaging and clinical outcomes were prospectively obtained for 10 patients after percutaneous Cordotomy for intractable cancer pain. Area, signal intensity, and location of the lesion were recorded. Clinical outcomes were measured by using the Visual Analog Scale and the Brief Pain Inventory–Short Form, and correlations with MR imaging metrics were evaluated. RESULTS: Ten patients (5 men, 5 women; mean age, 58.5 ± 9.6 years) were included in this study. The Cordotomy lesion was hyperintense with central hypointense foci on T2-weighted MR imaging, and it was centered in the anterolateral quadrant at the C1–C2 level. The mean percentage of total cord area lesioned was 24.9% ± 7.9%, and most lesions were centered in the dorsolateral region of the anterolateral quadrant (66% of the anterolateral quadrant). The number of pial penetrations correlated with the percentage of total cord area that was lesioned (r = 0.78; 95% CI, 0.44–0.89; P = .008) and the length of T2-weighted hyperintensity (r = 0.85; 95% CI, 0.54–0.89; P = .002). No significant correlations were found between early clinical outcomes and quantitative MR imaging metrics. CONCLUSIONS: We describe qualitative and quantitative characteristics of a Cordotomy lesion on early postoperative MR imaging. The size and length of the lesion on MR imaging correlate with the number of pial penetrations. Larger studies are needed to further investigate the clinical correlates of MR imaging metrics after percutaneous Cordotomy.

  • use of spinal cord diffusion tensor imaging to quantify neural ablation and evaluate outcome after percutaneous Cordotomy for intractable cancer pain
    Stereotactic and Functional Neurosurgery, 2017
    Co-Authors: Aditya Vedantam, Patrick M. Dougherty, Ping Hou, Kenneth R. Hess, Linda T Chi, Ashwin Viswanathan
    Abstract:

    Background: Up to 20% of patients experience only partial pain relief after percutaneous Cordotomy for cancer pain. Objective: To determine whether diffusion tensor imaging (DTI) can quantify neural ablation and help evaluate early postoperative outcomes after Cordotomy. Methods: Patients undergoing percutaneous CT-guided Cordotomy for intractable cancer pain were prospectively studied. Pre- and postoperative assessment was made using the visual analog scale (VAS) on pain and the pain severity scores of the Brief Pain Inventory Short Form. On postoperative day 1, DTI images of the high cervical spinal cord were obtained. DTI metrics were correlated with the number of ablations as well as early postoperative pain outcomes. Results: Seven patients (4 male, mean age 53.8 ± 4.6 years) were studied. Fractional anisotropy of the hemicord was significantly lower on the side of the lesion as compared to the contralateral side (0.54 ± 0.03 vs. 0.63 ± 0.03, p r = 0.88, 95% CI = 0.34-1.00, p = 0.008), as well as the change in pain severity scores at 1 week (r = 0.99, 95% CI = 0.82-1.00, p Conclusion: DTI metrics are sensitive to the number of ablations as well as early improvement in pain scores after Cordotomy. DTI of the cervical spinal cord is a potential biomarker of neural ablation after percutaneous Cordotomy for intractable cancer pain.

Y Kanpolat - One of the best experts on this subject based on the ideXlab platform.

  • CT-guided percutaneous Cordotomy for intractable pain in what is more than a disease: lung malignancies.
    Turkish Neurosurgery, 2012
    Co-Authors: Y Kanpolat, Mevci Ozdemir, Eyyub S. M. Al-beyati
    Abstract:

    AIM Lung cancer is the leading cause of cancer-related mortality worldwide. Pain is a common problem in these patients, yet inadequate or dissatisfactory management is prevalent. MATERIAL AND METHODS Between 1987 and 2012, 224 patients with intractable pain were treated with computerized tomography (CT)- guided Cordotomy. Among them, 210 had intractable pain due to malignancies. The majority of the cases were diagnosed as pulmonary malignancies (108 patients). Sixty-seven were pulmonary carcinoma, 26 mesothelioma and 15 Pancoast tumors. RESULTS After Cordotomy, 98.13% of cancer patients reported initial pain relief. Minimum and maximum preoperative scores of the Karnofsky Performance Scale were 20 and 70, versus postoperative scores of 40 and 90 (p < 0.001). The median preoperative VAS score was 8 (6-9). On the first postoperative day, the score dropped sharply to 0 (0-8) (p < 0.001). In this selected series of 108 percutaneous Cordotomy procedures, as well as in the total series of 224 patients, there was no mortality or major morbidity. CONCLUSION CT-guided percutaneous Cordotomy is an effective procedure that should be used in the treatment of cancer-related pain problems. We suggest that Cordotomy should be preferred as soon as possible in patients who fail to respond to the classic analgesic therapy.

  • Computed Tomography-guided Percutaneous Cordotomy for Intractable Pain in Malignancy
    Operative Neurosurgery, 2009
    Co-Authors: Y Kanpolat, Hasan Caglar Ugur, Murat Ayten, Atilla Halil Elhan
    Abstract:

    Abstract Objective: Pain, usually a response to tissue damage, is accepted as an unpleasant feeling generating a desire to escape from the causative stimulus. Although, in the early stages of malignant diseases, pain is seen in 5% to 10% of cases, this rate reaches nearly 90% in the terminal stage, and pain becomes a primary symptom. Cordotomy is one of the treatment choices in pain caused by malignancies localized unilaterally to the extremities as well as the thorax and the abdomen. Methods: The target of computed tomography (CT)-guided percutaneous Cordotomy is the lateral spinothalamic tract located in the anterolateral region of the spinal cord at the C1–C2 level. Between 1987 and 2007, CT-guided percutaneous cordotomies were performed in 207 patients; most (193 patients) suffered from intractable pain related to malignancy. The patients” pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively. Results: The initial success rate of CT-guided percutaneous Cordotomy was 92.5%. The success rate was higher in the malignancy group. In the cancer group, selective Cordotomy (pain sensation denervated only in the painful region of the body) was achieved in 83%. In 12 cases, bilateral selective percutaneous Cordotomy was successfully applied. Conclusion: In the treatment of intractable pain, CT-guided Cordotomy is an option in specially selected cases with malignancy. In this study, anatomic and technical details of the procedure and the experience gained from treating 207 patients over a 20-year period are discussed.

  • Computed tomography-guided percutaneous Cordotomy for intractable pain in malignancy.
    Neurosurgery, 2009
    Co-Authors: Y Kanpolat, Hasan Caglar Ugur, Murat Ayten, Atilla Halil Elhan
    Abstract:

    Pain, usually a response to tissue damage, is accepted as an unpleasant feeling generating a desire to escape from the causative stimulus. Although, in the early stages of malignant diseases, pain is seen in 5% to 10% of cases, this rate reaches nearly 90% in the terminal stage, and pain becomes a primary symptom. Cordotomy is one of the treatment choices in pain caused by malignancies localized unilaterally to the extremities as well as the thorax and the abdomen. The target of computed tomography (CT)-guided percutaneous Cordotomy is the lateral spinothalamic tract located in the anterolateral region of the spinal cord at the C1-C2 level. Between 1987 and 2007, CT-guided percutaneous cordotomies were performed in 207 patients; most (193 patients) suffered from intractable pain related to malignancy. The patients' pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively. The initial success rate of CT-guided percutaneous Cordotomy was 92.5%. The success rate was higher in the malignancy group. In the cancer group, selective Cordotomy (pain sensation denervated only in the painful region of the body) was achieved in 83%. In 12 cases, bilateral selective percutaneous Cordotomy was successfully applied. In the treatment of intractable pain, CT-guided Cordotomy is an option in specially selected cases with malignancy. In this study, anatomic and technical details of the procedure and the experience gained from treating 207 patients over a 20-year period are discussed.

  • COMPUTED TOMOGRAPHY-GUIDED PERCUTANEOUS Cordotomy FOR INTRACTABLE PAIN IN MALIGNANCY. Commentary
    Neurosurgery, 2009
    Co-Authors: Y Kanpolat, Hasan Caglar Ugur, Murat Ayten, Atilla Halil Elhan, Oren Sagher, Marc Sindou, Donlin M. Long, Nicholas M. Boulis, Richard K. Osenbach
    Abstract:

    OBJECTIVE: Pain, usually a response to tissue damage, is accepted as an unpleasant feeling generating a desire to escape from the causative stimulus. Although, in the early stages of malignant diseases, pain is seen in 5% to 10% of cases, this rate reaches nearly 90% in the terminal stage, and pain becomes a primary symptom. Cordotomy is one of the treatment choices in pain caused by malignancies localized unilaterally to the extremities as well as the thorax and the abdomen. METHODS: The target of computed tomography (CT)-guided percutaneous Cordotomy is the lateral spinothalamic tract located in the anterolateral region of the spinal cord at the C1-C2 level. Between 1987 and 2007, CT-guided percutaneous cordotomies were performed in 207 patients; most (193 patients) suffered from intractable pain related to malignancy. The patients' pain scores and Karnofsky Performance Scale scores were evaluated pre- and postoperatively. RESULTS: The initial success rate of CT-guided percutaneous Cordotomy was 92.5%. The success rate was higher in the malignancy group. In the cancer group, selective Cordotomy (pain sensation denervated only in the painful region of the body) was achieved in 83%. In 12 cases, bilateral selective percutaneous Cordotomy was successfully applied. CONCLUSION: In the treatment of intractable pain, CT-guided Cordotomy is an option in specially selected cases with malignancy. In this study, anatomic and technical details of the procedure and the experience gained from treating 207 patients over a 20-year period are discussed.

  • ct guided percutaneous selective Cordotomy for treatment of intractable pain in patients with malignant pleural mesothelioma
    Acta Neurochirurgica, 2002
    Co-Authors: Y Kanpolat, Ali Savas, Tanju Ucar, F Torun
    Abstract:

    Malignant mesotheliomas are neoplasms that arise from mesothelial cells and cause intractable pain in the chest wall, usually located unilaterally. This local pain can be well controlled by computerized tomography (CT)-guided percutaneous Cordotomy (PC). One hundred and fifty-three patients suffering from intractable pain due to malignancy were treated with CT-guided Cordotomy between 1988 and 2001. Seventy of the 153 patients had pulmonary malignancy. Among these, 40 had bronchogenic carcinoma, 11 had Pancoast tumors and the remaining 19 had mesothelioma. The latter 19 cases with malignant mesothelioma suffering from unilateral pain were treated with CT-guided PC. In 18 cases, pain was controlled totally and, in one, partial pain control was obtained. Selective pain control was obtained in 15 cases, in whom narcotic drugs were discontinued postoperatively. Post-Cordotomy dysesthesia was noted in only one case, and no complication or mortality was observed. In the treatment of intractable pain, CT-guided Cordotomy is a perfect method in selected cases with malignancy. This is the most effective and suitable treatment modality for local pain due to malignant mesothelioma.

Eduardo Bruera - One of the best experts on this subject based on the ideXlab platform.

  • Percutaneous Cordotomy for Pain Palliation in Advanced Cancer: A Randomized Clinical Trial Study Protocol.
    Neurosurgery, 2020
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Loretta A. Williams, Dhanalakshmi Koyyalagunta, Salahadin Abdi, Patrick M. Dougherty, Tito R. Mendoza, Roland L. Bassett, Ping Hou, Eduardo Bruera
    Abstract:

    BACKGROUND Cancer pain, one of the most common symptoms for patients with advanced cancer, is often refractory to maximal medical therapy. A controlled clinical trial is needed to provide definitive evidence to support the use of ablative procedures such as Cordotomy for patients with medically refractory cancer pain. OBJECTIVE To assess the efficacy of Cordotomy for patients with unilateral advanced cancer pain using a controlled clinical trial study design. The secondary objectives are to define the patient experience of Cordotomy for medically refractory cancer pain as well as to determine the utility of magnetic resonance imaging as a non-invasive biomarker for successful Cordotomy. METHODS We will undertake a single-institution, double-blind, sham-controlled clinical trial of Cordotomy in patients with refractory cancer pain. Patients in the Cordotomy arm will undergo a percutaneous computed tomography-guided Cordotomy at C1-C2, while patients in the control arm will undergo a similar procedure where the needle will not penetrate the thecal sac. The primary endpoint will be the reduction in pain intensity, as measured by the Edmonton Symptoms Assessment Scale. EXPECTED OUTCOMES We expect that patients randomized to Cordotomy will have a significantly greater reduction in pain intensity than those patients randomized to the control surgical intervention. DISCUSSION This randomized clinical trial comparing Cordotomy with a control intervention will provide the level of evidence necessary to determine whether Cordotomy should be the standard of care intervention for patients with advanced cancer pain.

  • Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial
    The Oncologist, 2019
    Co-Authors: Ashwin Viswanathan, Aditya Vedantam, Dhanalakshmi Koyyalagunta, Patrick M. Dougherty, Kenneth R. Hess, Jewel Ochoa, Akhila Reddy, Suresh K. Reddy, Eduardo Bruera
    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.

  • Somatotopy and Organization of Spinothalamic Tracts in the Human Cervical Spinal Cord
    Neurosurgery, 2018
    Co-Authors: Aditya Vedantam, Patrick M. Dougherty, Eduardo Bruera, Kenneth R. Hess, Ashwin Viswanathan
    Abstract:

    BACKGROUND:Understanding spinothalamic tract anatomy may improve lesioning and outcomes in patients undergoing percutaneous Cordotomy. OBJECTIVE:To investigate somatotopy and anatomical organization of spinothalamic tracts in the human cervical spinal cord. METHODS:Patients with intractable cancer pain undergoing Cordotomy underwent preoperative and postoperative quantitative sensory testing for sharp pain and heat pain on day 1 and 7 after Cordotomy. Intraoperative sensory stimulation was performed with computed tomography (CT) imaging to confirm the location of the radiofrequency electrode during Cordotomy. Postoperative magnetic resonance (MR) imaging was performed to define the location of the lesion. RESULTS:Twelve patients were studied, and intraoperative sensory stimulation combined with CT imaging revealed a somatotopy where fibers from the legs were posterolateral to fibers from the hand. Sharpness detection thresholds were significantly elevated in the area of maximum pain on postoperative day 1 (P = .01). Heat pain thresholds for all areas were not elevated significantly on postoperative day 1, or postoperative day 7. MR imaging confirmed that the Cordotomy lesion was in the anterolateral quadrant, and in this location the lesion had a sustained effect on sharp pain but a transient impact on heat pain. CONCLUSION:In the high cervical spinal cord, spinothalamic fibers mediating sharp pain for the arms are located ventromedial to fibers for the legs, and these fibers are spatially distinct from fibers that mediate heat pain.

  • Postoperative MRI Evaluation of a Radiofrequency Cordotomy Lesion for Intractable Cancer Pain.
    American Journal of Neuroradiology, 2017
    Co-Authors: Aditya Vedantam, Patrick M. Dougherty, Eduardo Bruera, P. Hou, T.l. Chi, K.r Hess, Ashwin Viswanathan
    Abstract:

    BACKGROUND AND PURPOSE: There are limited data on the use of postoperative imaging to evaluate the Cordotomy lesion. We aimed to describe the Cordotomy lesion by using postoperative MR imaging in patients after percutaneous Cordotomy for intractable cancer pain. MATERIALS AND METHODS: Postoperative MR imaging and clinical outcomes were prospectively obtained for 10 patients after percutaneous Cordotomy for intractable cancer pain. Area, signal intensity, and location of the lesion were recorded. Clinical outcomes were measured by using the Visual Analog Scale and the Brief Pain Inventory–Short Form, and correlations with MR imaging metrics were evaluated. RESULTS: Ten patients (5 men, 5 women; mean age, 58.5 ± 9.6 years) were included in this study. The Cordotomy lesion was hyperintense with central hypointense foci on T2-weighted MR imaging, and it was centered in the anterolateral quadrant at the C1–C2 level. The mean percentage of total cord area lesioned was 24.9% ± 7.9%, and most lesions were centered in the dorsolateral region of the anterolateral quadrant (66% of the anterolateral quadrant). The number of pial penetrations correlated with the percentage of total cord area that was lesioned (r = 0.78; 95% CI, 0.44–0.89; P = .008) and the length of T2-weighted hyperintensity (r = 0.85; 95% CI, 0.54–0.89; P = .002). No significant correlations were found between early clinical outcomes and quantitative MR imaging metrics. CONCLUSIONS: We describe qualitative and quantitative characteristics of a Cordotomy lesion on early postoperative MR imaging. The size and length of the lesion on MR imaging correlate with the number of pial penetrations. Larger studies are needed to further investigate the clinical correlates of MR imaging metrics after percutaneous Cordotomy.

  • Cordotomy for treatment of cancer-related pain: patient selection and intervention timing
    Neurosurgical Focus, 2013
    Co-Authors: Ashwin Viswanathan, Eduardo Bruera
    Abstract:

    Many neurosurgical interventions for the management of cancer-related pain have been tried, but their role in today's advanced supportive and palliative care is not well described. The authors discuss the current knowledge gaps that prevent successful integration of neurosurgical interventions and patients with cancer-related pain. Two patients underwent percutaneous CT-guided Cordotomy for refractory cancer-related pain: one patient had melanoma and the other had ovarian carcinoma. Both patients seemed to have unilateral, somatic, nociceptive cancer-related pain. Cordotomy was effective for only 1 patient. Percutaneous CT-guided Cordotomy is a low-risk intervention that can benefit carefully selected patients with cancer-related pain. There is a clear need for prospective controlled studies to evaluate the effectiveness of Cordotomy for patients receiving optimal medical treatment. A multidisciplinary study design could help to identify factors correlated with a positive outcome.