The authors present a review of 146 patients who underwent 181 percutaneous cervical cordotomies for intractable pain. In addition, an anatomical-clinical correlation was carried out for 29 of these patients. It was found that the fibers subserving pain sensation in the C-2 segment lie in the anterolateral funiculus between the level of the denticulate ligament and a line drawn perpendicularly from the medial angle of the ventral gray-matter horn to the surface of the cord. The best analgesic results have been obtained by creating lesions that extend 5.0 mm deep to the surface of the cord and destroy about 20% of the hemicord. There is a somatotopic organization with sacral fibers running ventromedially and cervical fibers running dorsolaterally. The authors believe that the ascending fibers subserving the distinct sensations of pain induced by tissue damage and pinprick, although mixed (overlapping) in the anterolateral funiculus of the spinal cord, are physiologically distinct from one another. Whereas some cordotomies, both in the current series and as reported in the literature, may affect these functions differentially, optimum pain relief seems to be obtained only when pinprick sensation is also abolished in the affected segments. Evoked pain sensation is not abolished by cordotomy, but its threshold is greatly raised. When pathological pain is completely abolished, so is pinprick sensation. However, in a number of cases where pathological pain was only partially alleviated, pinprick sensation remained intact. The significance of these and other cases reported in the literature is discussed. The importance of clinically distinguishing between pain caused by tissue damage and pinprick sensation is emphasized, as well as that between return of pre-existing or new tissue-damage pain and painful dysesthesia.
After high cervical percutaneous cordotomy for pain in malignant disease, 12 patients died during sleep at postoperative intervals between 1 and 8 days. Nine died after a first cordotomy and three after a second (contralateral) procedure. All except one had known pulmonary disease before operation. The operated segment of the spinal cord (C2) was studied histologically after death. Superposition of lesion outlines made it possible to determine those parts of the lesioned areas common to all unilateral and bilateral cases respectively. All cases dying of presumed respiratory dysfunction syndrome had lesions involving the region of the anterolateral funiculus in the C2 segment containing "pain" fibres activated from the second to fifth thoracic dermatomes.
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