Gamma Knife radiosurgery for treatment of trigeminal neuralgia: idiopathic and tumor related.

Sixty patients with trigeminal neuralgia who did not have a response to pharmacologic treatment (including 22 who had no response to conventional surgical treatment) underwent stereotactic radiosurgical treatment with the Leksell Gamma Knife. A radiosurgical maximum dose of 70 Gy was delivered to the trigeminal nerve root adjacent to the pons via a 4-mm collimator helmet in 51 patients who presented with trigeminal neuralgia unrelated to tumors. In these patients, the root was localized by stereotactic MRI. Follow-up assessment of pain relief was accomplished by a third party not involved in the patients' clinical care. Within a latency period of 1 day to 4 months following the treatment, 38 of 51 patients (74.5%) were completely free of pain and eventually all medications were tapered off. An additional seven patients (13.7%) experienced reductions in pain from 50 to 90% and utilized little or no medications. Patients who had no prior surgical intervention fared much better than those who had previous surgery to relieve their facial pains. At last follow-up, a mean of 16.3 months (range 6-36 months) after treatment, 41 patients (80.4%) remained pain-free or had marked pain reduction. There were four patients with recurrent pain. All 26 patients with classical symptoms of trigeminal neuralgia with no atypical features who had no prior surgery, had complete or nearly complete pain relief, and none of these patients had recurrent pain. Nine patients with trigeminal neuralgia due to tumors received standard radiosurgical treatment directed at their tumors, and eight of nine (88.8%) had pain relief. Of the total of 60 patients treated for trigeminal neuralgia, 49 (81.7%) experienced complete or nearly complete relief of pain at last follow-up. Only one patient with pre-existing facial sensory loss due to a tumor had a mild increase in facial numbness. No other patient experienced either loss of facial sensation or any other complication. Gamma Knife radiosurgery appears to be a minimally invasive, safe, and effective therapy of trigeminal neuralgia.

Percutaneous alcoholization of the celiac plexus under echographic guidance: an alternative to splanchnicectomy? Study of 21 cases

Celiac plexus block is usually performed under fluoroscopic or tomodensitometric guidance. We report on a new procedure using sonographic guidance. The patient lies in supine position. We use a real-time sonograph (Kontron Sigma 1 AC) with a 3.5 MHz probe. On a transverse plane, the celiac axis is localized emerging from aorta. After local anesthesia, the tip of the spinal needle (177 mm, 22 G) is placed close to aorta (about 5 mm) on both sides. 10 to 15 ml of 1 per cent lidocaine then 10 to 15 ml of absolute alcohol are injected on each side. 21 patients (10 males, 11 females, mean age: 61) underwent the procedure. They presented with cancer of the pancreas in 14 cases, metastatic nodes in 3 cases, cholangiocarcinoma in 2 cases and chronic calcifying pancreatitis (CCP) in 2 cases. No pain relief occurred in 3 patients (14 per cent). On of those presented with CCP but the endoscopic cystic diversion of a small cyst was successful to eradicate pain. Partial pain relief occurred in 5 cases (24 per cent). Total pain relief was obtained in 13 cases (62 per cent). No complication related to the treatment was observed. Sonography is a simple and safe method of guidance to perform alcohol block of the celiac plexus. The anterior approach may prevent neurologic complications related to other methods of guidance.

Intraventricular morphine administration for control of chronic cancer pain.

Twenty cancer patients with severe chronic pain have been treated with intraventricular morphine sulfate. Adequate pain relief until death was achieved in 10 patients; 1 patient has been treated for 9 months and is still being treated. In 2 patients, the effects of the morphine sulfate on their unilateral pelvic pain wore off after 4 and 6 months because of tumor progression. At that time, they underwent chordotomy procedures elsewhere. The treatment was discontinued in 4 patients for reasons other than inadequate pain relief, such as medical complications or resolution of pain. In 3 patients, the procedure was abandoned when emotional and psychological factors interfered with pain control. Dose requirements of intraventricular morphine sulfate varied greatly, depending on the total daily dose of systemic narcotic intake at the onset of the study. Intraventricular morphine sulfate is a feasible and reliable method to achieve pain relief in selected cancer patients with severe chronic pain when the maximum tolerated dose of systemic narcotic analgesics has become insufficient to control their pain.

Ibuprofen ( Motrin ) 400 mg is effective in women, and women are well represented in trials.

BACKGROUND: A recent article in the New Scientist argued that women were under-represented in clinical trials which, until now, had masked the finding that Ibuprofen ( Motrin ) 400 mg was ineffective in women. METHODS: Meta-analysis of randomised, double-blind placebo-controlled trials of Ibuprofen ( Motrin ) 400 mg in acute pain, and use of individual patient information were planned to test the hypothesis that Ibuprofen ( Motrin ) is ineffective in women. For each trial the proportion of women participating, the number of patients with at least 50% pain relief and the overall event rate for Ibuprofen ( Motrin ) 400 mg and placebo was calculated. For each patient percentage pain relief was calculated, and the numbers of women and men achieving at least 50% pain relief used to calculate number-needed-to-treat (NNT) for Ibuprofen ( Motrin ) 400 mg compared to placebo. RESULTS: Thirty-seven included trials had 3,577 patients, 67% of whom were women. The proportion with at least 50% pain relief was unaffected by how many women were included. In an analysis of 678 individual patients the proportion of women and men with at least 50% pain relief was the same, NNT 3.4 (2.6 to 4.6) and 2.5 (2.0 to 3.3) respectively. CONCLUSION: There is no clinically meaningful difference in the efficacy of Ibuprofen ( Motrin ) 400 mg between men and women experiencing moderate to severe postoperative pain and women were well represented.