Pain

Question 1

Following an uneventful bilateral high cervical cordotomy, a 35-year-old patient with metastatic carcinoma dies unexpectedly during the night. Which of the following is the most likely cause of death?

A. Central hypoventilation syndrome
B. Pulmonary embolism
C. Myocardial infarction
D. Cerebrovascular accident
E. Rapid progression of metastatic disease

Answer 1

Central hypoventilation syndrome

Central hypoventilation syndrome (aka Ondine’s curse) is a breathing disorder whereby patients become apneic. It is an uncommon but fatal complication of cordotomy, and thus bilateral cordotomy is not often performed. The hypoventilation usually happens during sleep. There are several possible mechanisms that may explain this syndrome: 1) the anterior spinothalamic tract that conducts pain fibers in intermingled with fibers that mediate respiratory and autonomic function, and cordotomy involves interruption of these fibers, 2) ascending and descending reticulospinal axons from the medulla, which mediate respiratory motor control and arousal are in proximity and may be injured, 3) the corticospinal tract is in close to proximity to the spinothalamic tract and may be injured.