Cordotomy in mesothelioma-related pain: a systematic review

BMJ Support Palliat Care. 2014 March.  [Link]

France B. D., Lewis R. A., Poolman M, Sharma M. L.

North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK; The Walton Centre for Neurology and Neurosurgery, Liverpool, UK

Abstract

Background:
Cordotomy can be effective in relieving pain for patients with mesothelioma, but the evidence to support continued provision is limited. This review forms part of the Invasive Neurodestructive Procedures in Cancer Pain pilot study: The role of cordotomy in mesothelioma-related pain in the UK.

Methods:

This systematic review was conducted and reported according to NHS Centre for Reviews and Dissemination (CRD) Report 47 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.6 ,7 A preliminary scoping search showed a limited evidence base; the search strategy was therefore designed for sensitivity rather than specificity. A search strategy developed for Medline was adapted for 13 other databases; all were searched from inception until March 2012 (table 1). Reference lists from previous reviews and included studies were hand searched.

Inclusion criteria were as follows:

• Participants: patients with mesothelioma where the intention was to perform cordotomy (open or percutaneous) as a treatment for the control of intractable pain.

• Intervention: cordotomy: the creation of a permanent (often heat created by radiofrequency technique) lesion in the lateral spinothalamic tract in the anterolateral spinal cord.

• Control: treatment for pain using other modalities (pharmacotherapy or other neuroinvasive or neuroablative procedures).

• Outcomes: effectiveness in relieving pain and side effects.

• Study design: any, except reviews and single case reports.

There were no limits on language, year of publication or publication status. Two reviewers independently screened the titles and abstracts for relevancy. Disagreements were resolved by discussion or, if necessary, a third reviewer.

In studies that reported data on multiple diseases (including mesothelioma), only information relevant to mesothelioma was extracted. In studies where this was not possible (n=11), we wrote to the corresponding author and asked if they could supply us with separate data for mesothelioma patients.8–18 One author forwarded individual patient data.

Quality assessment was performed using criteria based on the CRD quality assessment guideline for case series.19 Data were extracted into predesigned forms.

Results:
Nine studies met the inclusion criteria, all of which were case series of percutaneous cervical cordotomy (PCC) involving 160 patients. All studies demonstrated good pain relief in the majority of patients. Initial post-procedure measurements showed the greatest reduction in pain. Some side effects (headache, mirror pain, motor weakness) occurred relatively frequently but were mostly transient. Respiratory dysfunction post-PCC was rare. No deaths were directly ascribed to cordotomy.

Conclusions:
The available evidence is significantly limited in quantity and quality. Although it seems to suggest that cordotomy might be safe and effective in this setting, more reliable evidence is needed to aid decision making on continued provision. A national registry for cordotomy would be a valuable first step in this process.