Evolution of Microendoscopic-guided Percutaneous Cordotomy for Intractable Pain: Case series of 24 patients.

Presented at SMISS Annual Forum 2014
By William Lopez
With Erich Fonoff , Manoel Teixeira ,

Disclosures: William Lopez None Erich Fonoff None, Manoel Teixeira None,

Introduction:
Percutaneous anterolateral cordotomy is currently performed under indirect X-ray visualization (fluoroscopy or CT). In 2010, the authors proposed a new technique involving the use of an intradural endoscope for direct visualization of the spinal cord through a percutaneous approach. Herein, the authors describe a series of 24 patients who received a cordotomy using such technique.

Aims/Objectives:
The aim of this study was to show that endoscopic guidance can be safely applied during percutaneous cordotomy with significant advantages and clear visualization of anatomical landmarks, spinal cord and surrounding structures by double channel technique achieving real time endoscopic visualization of the entire procedure.

Methods:
Twenty-four adult patients with intractable cancer pain were treated by means of endoscopic-guided percutaneous radiofrequency cordotomy, using double-channel endoscopic technique. The procedure was performed under local anesthesia. Initially a percutaneous lateral puncture was performed under fluoroscopy guidance to localize the target (spinal canal in C1-C2 interspace). As soon as subarachnoid space was reached by the guide cannula (17-gauge needle), the endoscope was inserted for visualization of the spinal cord and surrounding structures. The target for spinal cord puncture was established as the midpoint of the distance from the dentate ligament and the ventral root entry zone. After right visualization of the target a second needle was inserted to guide the radiofrequency electrode. Cordotomy was performed by a standard radiofrequency method.

Results:
The endoscopic double-channel approach achieved a clearly neuroanatomical visualization of the target in 91% of the cases. This was transmuted into satisfactory postoperative outcome, reaching analgesia in the region in more than 90% of the cases. Two patients presented transient ataxia lasting few weeks until total recovery.

Conclusions:
This study demonstrates that the use of percutaneous endoscopic cordotomy with the double-channel technique is useful for particular manipulation of the spinal cord, adding a degree of safety to the procedure achieving important effectiveness.
Endoscopic guided high-level selective PCC is an effective and safer neurosurgical procedure for the treatment of unilateral or bilateral intractable cancer pain.