Percutaneous and open anterolateral cordotomy for intractable cancer pain: a technical note

•Anterolateral cordotomy is effective for intractable cancer pain alleviation.•Advancing technology allows accurate and safe targeting of the spinothalamic tract.•There is a need to continue to promote and teach anterolateral cordotomy. Anterolateral cordotomy (AL-C) is a long-established treatment for alleviating intractable cancer pain. However, AL-C has progressively fallen into desuetude, leading to the risk of a definitive loss of expertise within neurosurgical teams. Our objective was therefore to provide an update on percutaneous and open AL-C, with special emphasis on contemporary operative technique. Patient selection, indications, outcomes and up-to-date operative technique are reviewed through illustrative cases, including intraoperative photographs and video. Main indications are represented by unilateral, nociceptive pain refractory to best pharmacological treatment in patients with limited life expectancy. Percutaneous AL-C is performed under cooperative sedation at C1-C2 level. CT myelography guidance and intraoperative electrophysiology allow accurate targeting of the spinothalamic tract (STT). Thermocoagulation is performed at 80 °C for 60 s during a Mingazzini maneuver, in order to promptly detect the potential onset of a motor weakness. Open AL-C is performed under general anesthesia at T2-T3 level. The dentate ligament is suspended to gently rotate the spinal cord and expose the anterolateral column. Section of the STT is made with a micro scalpel blade at a depth of 4−5 mm, from the dentate ligament to the emergence of ventral rootlets. Success rate after AL-C is high and allows a marked reduction in antalgic drugs intake. Main limitations include failure in achieving long-standing pain relief and the new occurrence of spontaneous, mirror pain. AL-C is a safe and effective option for the management of opioid-resistant cancer pain, which should be part of the neurosurgeon’s armamentarium.