Predictors of outcome in surgically managed patients with typical and atypical trigeminal neuralgia: comparison of results following microvascular decompression.

OBJECT: Microvascular decompression (MVD) has become one of the primary treatments for typical trigeminal neuralgia (TN). Not all patients with facial pain, however, suffer from the typical form of this disease; many patients who present for surgical intervention actually have atypical TN. The authors compare the results of MVD performed for typical and atypical TN at their institution. METHODS: The results of 2675 MVDs in 2264 patients were reviewed using information obtained from the department database. The authors examined immediate postoperative relief in 2003 patients with typical and 672 with atypical TN, and long-term follow-up results in patients for whom more than 5 years of follow-up data were available (969 with typical and 219 with atypical TN). Outcomes were divided into three categories: excellent, pain relief without medication; good, mild or intermittent pain controlled with low-dose medication; and poor, no or poor pain relief with large amounts of medication. The results for typical and atypical TN were compared and patient history and pain characteristics were evaluated for possible predictive factors. CONCLUSIONS: In this study, MVD for typical TN resulted in complete postoperative pain relief in 80% of patients, compared with 47% with complete relief in those with atypical TN. Significant pain relief was achieved after 97% of MVDs in patients with typical TN and after 87% of these procedures for atypical TN. When patients were followed for more than 5 years, the long-term pain relief after MVD for those with typical TN was excellent in 73% and good in an additional 7%, for an overall significant pain relief in 80% of patients. In contrast, following MVD for atypical TN, the long-term results were excellent in only 35% of cases and good in an additional 16%, for overall significant pain relief in only 51%. Memorable onset and trigger points were predictive of better postoperative pain relief in both atypical and typical TN. Preoperative sensory loss was a negative predictor for good long-term results following MVD for atypical TN.

pain relief by surgery in chronic pancreatitis? Relationship between pain relief, pancreatic dysfunction, and alcohol withdrawal.

Since 1963, 57 consecutive patients with chronic pancreatitis, 44 of them alcoholics who had been operated upon for recurrent severe pain, have been controlled regularly for an average of 6 years. Thirty-two of them had a cyst drainage procedure (group A), and 25 had a ductal drainage procedure and/or distal pancreatectomy (group B). Ten patients died within 2 years (group A, n = 5). Lasting pain relief by surgery occurred in 19 patients only. Of 28 patients with pain relapses after surgery (group A, n = 15), however, 22 (78.6%) obtained late pain relief 1-8 years after surgery in association with marked increase of pancreatic dysfunction (group A, n = 12). pain relief was associated with pancreatic calcifications in 71-86% of the alcoholics. Cyst drainage procedures were successful in preventing pain relapses mainly in patients with either advanced pancreatic dysfunction or in non-alcoholic pancreatitis. The data suggest that in chronic pancreatitis lasting pain relief is more often due to marked pancreatic dysfunction than to surgery. Alcohol abstinence after surgery was probably an additional factor for lasting pain relief in some patients.

pain relief mediated by implantable drug delivery devices.

Various totally implantable drug delivery systems from single access ports to micropumps are now available for administration of repeated boluses, and continuous or programmable infusions. In this respect, emphasis is given to a relatively cheap, totally implantable system for self-administering intraspinal opiates in the treatment of cancer pain. The SECOR pump system, developed by Cordis, consists of a dual pump with refill port and safety valve. The volume of the pliable reservoir is 12 ml and refill is accomplished with a 25-G needle. The bolus delivered with each transcutaneous activation of the pumps is 0.1 ml. Clinical results demonstrated that this patient-controlled drug delivery system is safe and provides excellent pain relief associated with terminal cancer. A possible advantage of this drug delivery system over continuous infusion pumps is that patients can elect to have the morphine delivered only when they feel pain. Thus pain relief would be maximized and tolerance build-up would be minimized.

Near-total pancreatectomy for chronic pancreatitis.

Eighty-seven patients underwent distal subtotal or near-total (80% to 95%) pancreatectomy (NTP) during a 25-year period for management of intractable pain resulting from chronic pancreatitis. Alcoholism affected the majority of patients and 20% of cases were idiopathic in origin. Ten patients (12%) exhibited insulin-requiring diabetes before operation. The perioperative mortality rate was 3.4%. Significant improvement or complete pain relief was achieved in 75% of patients while 14% remained narcotic dependent. Forty-four patients (51%) required insulin postoperatively, with an average insulin requirement of 35 U per day. Thirty late deaths occurred 2 to 15 years after operation, 12 (40%) of which were related to complications of pancreatic insufficiency or persistent alcoholism. Five patients (8.5%) required completion pancreatectomy 6 months to 4 years after NTP for complications relating to persistent pancreatitis. NTP provides effective pain relief in the majority of patients with chronic pancreatitis. While this procedure can be performed with a low operative mortality rate, the high incidence of endocrine and exocrine insufficiency after operation may contribute to late deaths. Consequently, this procedure should be performed only when the underlying disease has functionally destroyed the pancreas or when lesser procedures have failed to provide adequate pain relief.