Cordotomy is usually done percutaneously with fluoroscopic guidance while the patient is under local anesthesia. Open cordotomy, which requires a laminectomy, is often risky for patients with poor medical conditions, but may be required if percutaneous cordotomy is not feasible or an attempt has failed.
Cordotomy is now used exclusively for pain due to cancer where treatment to level 3 of the World Health Organisation analgesic ladder has proved ineffective. Cordotomy is especially indicated for pain due to mesothelioma (asbestos-related lung cancer).
A number of alternative surgical procedures have evolved in the 20th century; these include:
"Commissural myelotomy", with limited rostro-caudal range; it produces bilateral analgesia (Armour 1927; Hitchcock 1970; 74).
"Limited midline myelotomy" for the treatment of pelvic visceral cancer pain (Gildenberg and Hirshberg, 1984).
Recently, Dr. Elie D. Al-Chaer and his colleagues discovered a new pathway in the spinal cord relatively specific for visceral pain - the pain that originates from visceral organs such as the colon, the bladder and the pancreas. The new pathway is located in the posterior columns, traditionally believed to mediate light touch and kinesthesia. This discovery led to a paradigm shift in our understanding of pain pathways and in the approach to treat intractable visceral pain. As a result, "punctate midline myelotomy" was introduced around the world as a new surgical procedure for the treatment of visceral pain residual to cancer and refractory to conventional treatment.