- A relatively quick method for open cervical cordotomy.
- Can theoretically be done under local for patients who cannot tolerate general anesthesia.
- Technique
- Position: prone;
- Face carefully placed on padded horseshoe headrest, neck slightly flexed to open the interlaminar spaces and to lower the head to prevent accumulation of intracranial air
- Skin incision:
- Midline from occiput to C3.
- Working only on the side contralateral to the pain, muscles are stripped off the posterior lip of the foramen magnum, and from the lamina of C1 and C2.
- A Schwartz or Gelpi retractor is engaged between the occiput and C2.
- To increase exposure, the inferior half of C1 and superior half of C2 lamina are removed with a punch.
- Dural incision:
- The ligamentum flavum is thin between C1–2, and can usually be opened with the dura in a linear incision from the lamina of C1 to C2 placed in the lateral third of the exposure, taking care to avoid bleeding from epidural veins.
- An angle is cut in the incision at either end to allow increased dural retraction.
- Tack-up dura,
- Open arachnoid
- Dentate ligament identified and gripped with a hemostat and freed from the dura.
- Cordotomy:
- The dentate ligament is used to slightly rotate the spinal cord.
- A cordotomy knife (or 11 blade) with bone wax placed at 5mm, is inserted into the cord in an avascular area just anterior to the dentate ligament, sharp side down.
- The anterolateral quadrant of the cord is cut with the following caveats:
- Do not go posterior to the dentate ligament (to avoid corticospinal tract)
- Do not cross the midline of the spinal cord
- Do not injure the anterior spinal artery
- For patients with lower extremity pain, be sure to start exactly at the dentate ligament (to avoid missing lumbar and sacral fibers).
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