Deltoid muscle flap for massive rotator cuff tears: 41 cases with a mean 7-year (minimum 5 year) follow-up

PURPOSE OF THE STUDY: The aim of this study was to assess outcome after deltoid muscle flap repair of massive rotator cuff tears. We examined functional and radiological results at least five years after surgery. MATERIAL AND METHODS: We reviewed 41 shoulders operated by three senior surgeons (MC, DK, HT). None of the patients were lost to follow-up. The global Constant score was used for pre- and postoperative functional assessment. Three groups were distinguished by preoperative active flexion (group I<90 degrees, group II 90 degrees -120 degrees, group III > 120 degrees ). AP, double oblique (3 rotation views to measure the subacromial space), and Lamy lateral radiographs were obtained in all patients. Shoulder anatomy was evaluated at last follow-up in eight patients: magnetic resonance imaging (MRI) because of persistent pain in one patient and ultrasonography performed by one radiologist (NC) in seven patients. RESULTS: The study population included 26 men and 15 women, mean age at surgery 59 years (42-78, 8). Mean follow-up was 7 years (5-8.5, 0.9). In the coronal plane, there were no distal tears, the stump was in an intermediate position in 7 cases (17%) and retracted to the glenoid in 34 (83%). In the sagittal plane, the supraspinatus exhibited a full thickness tear in all cases. The tear extended anteriorly or posteriorly in all cases. Thirty-eight patients (92%) were satisfied at last follow-up; their global Constant score had improved from 37 to 62 points. Mean anterior flexion improved from 113 degrees to 148 degrees and flexion force from 1.3 kg to 2.9 kg. When preoperative flexion was less than 90 degrees (11 cases), mean gain was + 89 degrees. Inversely, 7 of the 18 patients with flexion > 120 degrees lost a mean 40 degrees at last follow-up. Twenty-seven patient were reviewed at 12 and 89 months: pain relief and force were maintained. The subacromial space, measured in 88% of the cases, was 7.3 mm preoperatively and 5.5 mm at last follow-up. The subacromial space narrowed in 20 patients (56%); none of the patients exhibited an improvement. The flap was explored by ultrasonography in seven patients and by MRI in one: the flap was continuous in 50% and measured more than 4 mm in thickness. Reviews at 12 then 89 months demonstrated good maintenance of pain relief and progression of active flexion and force. DISCUSSION AND CONCLUSION: This long-term study confirms the usefulness of the deltoid flap for the treatment of full thickness massive tears of the rotator cuff. The flap provides persistent pain relief and good function and force. This technique should be discussed for young patients in good physical condition when preoperative imaging demonstrates and irreparable alteration of the tendinomuscular structures (supraspinatus retraction, fatty degeneration, severe amyotrophy). The technique is particularly useful when preoperative flexion is less than 90 degrees. Although the population size is too small for statistical analysis, indications for deltoid flap repair should probably be limited to tears involving at most two tendons and sparing the subscapularis.

Endoscopic pancreatic stent drainage improves pain in chronic pancreatitis.

Pain in chronic pancreatitis is due to intraglandular neural affection and to pancreatic duct drainage obstruction with an increased intraductal pressure. To achieve pain relief, medical, surgical and endoscopic procedures have been developed. AIM: To evaluate the efficacy of pancreatic duct stenting in patients with narcotic-dependent pain due to chronic pancreatitis. PATIENTS AND METHOD: From May-1994 to May-1996, ten patients (medium age: 47.5 yr) with alcoholic chronic pancreatitis were selected for this procedure. Pancreatography showed single or multiple Wirsung strictures in all cases. Papillotomy and pancreatic duct sphincterotomy were performed before stenting. Strictures were negotiated with a 7F dilating catheter over a guide wire, and intraductal calculi were removed as well. We used 7F plastic stents with variable lengths (5-10 cm), that were exchanged when the patient presented pain recurrence. Stent survival time was defined as the patient's pain-free time. RESULTS: In 6 of the 10 patients stent placement was carried out successfully. A single distal Wirsung stricture was diagnosed in 3 patients while in the remaining 3 there were several strictures associated to ductal lithiasis in two of them. Mean time to achieve pain relief was 3 days and mean stent survival time was 166.5 days. There were no complications due to the procedure. CONCLUSIONS: When placed through the stricture, endoscopic pancreatic stent drainage is effective in achieving pain relief. It is a safe procedure with no complications in our short series.

MRI-guided frameless stereotactic percutaneous cordotomy.

BACKGROUND: Use of intraoperative myelography as a radiologic guidance for percutaneous cervical cordotomy (PCC) has been superseded by more modern imaging. The only significant advancement in cordotomy techniques over the last 30 years has been CT-guided PCC. The goal of this study was to demonstrate the feasibility of an MRI-guided frameless technique in high cervical cordotomy. METHODS: We describe 6 patients with intractable pain treated using a frameless, MRI-guided, stereotactic, PCC technique in combination with standard physiological localization procedures. Results were compared with those from 32 patients who underwent PCC in the last 5 years using physiological localizing techniques only. RESULTS: Six patients (100%) who underwent the frameless technique had excellent pain relief postoperatively. Patients in the non-stereotactic group, on average, required a higher number of lesions (2.5 vs. 1.2, p < 0.005), and 7 (22%) of these patients had unsatisfactory pain relief following PCC (p = 0.21). Five patients in the non-stereotactic group had weakness postoperatively and 1 had changes in bladder function. Postoperative weakness occurred in 1 patient undergoing the frameless technique. At an average of 6 months of follow-up (range 5-11), excellent pain relief was achieved in 83% (5/6) of MRI frameless PCC patients and 55% (16/29) of standard PCC patients (p = 0.20). CONCLUSIONS: Intraoperative frameless stereotaxy provides surgeons with accurate information that helps to guide the operative approach and precisely tailor the trajectory and depth of the electrode, potentially increasing the safety and efficacy of the operation. Copyright 2003 S. Karger AG, Basel

Dorsal root entry zone lesions for the treatment of post-herpetic neuralgia.

Post-herpetic pain was treated in 12 patients using dorsal root entry zone ( DREZ ) lesions. All patients had failed to receive adequate pain relief from conservative therapy consisting of transcutaneous nerve stimulation, carbamazepine, and/or amitriptyline. Dorsal root entry zone lesions were made to include the involved dermatomes plus one-half of the dermatomes above and below the painful areas. Eight patients reported good pain relief with follow-up periods ranging from 6 to 21 months. A ninth patient obtained satisfactory pain relief, but the superior 1 cm of the original painful area was not included in the distribution of the DREZ lesions. Patients whose lesions were performed using a thermally controlled lesion probe suffered no significant postoperative neurological deficit. Dorsal root entry zone lesions appeared to be a satisfactory treatment for post-herpetic neuralgia in patients who have failed to respond to more conservative modes of therapy.

Relief of cancer pain in man: alcohol-induced neuroadenolysis vs. electrical stimulation of the pituitary gland.

To explore new methods for the control of intractable pain caused by advanced cancer, the analgesic effect of electrical stimulation of the pituitary gland was investigated in 25 patients. The results were compared with a control study and with the effects of alcohol-induced pituitary neuroadenolysis (NALP) in the same patients. The pain score (0: no pain at all, 4: extreme pain) in the control study was 3.88 +/- 0.33. After electrical stimulation of the pituitary gland it was 1.24 +/- 1.61; and after NALP it was 1.0 +/- 1.60. The pain scores after electrical stimulation and NALP were significantly lower (P less than 0.01) than those in the control study; but there was no significant difference when the two were compared with each other. The duration of pain relief following NALP (59.65 +/- 68.72 days) was significantly longer compared with that recorded following electrical stimulation (2.97 +/- 2.58 days). Autopsy examinations of 3 patients who expired from their malignancies revealed that the pain relief was unrelated to the degree of necrosis induced in the pituitary by alcohol. Naloxone administration did not inhibit the analgesic effect of either NALP or electrical stimulation. The advantages and disadvantages of electrical stimulation, the pain relief mechanism activated by this method, and potential clinical applications are also discussed.

pain relief following tennis elbow release.

We studied the outcome of tennis elbow release in 27 patients at an average of 29.6 months after surgery. We found that 44% of patients had obtained complete pain relief, 37% of patients experienced occasional pain and 19% of patients still experienced moderate pain. pain relief was significantly better in those patients with the shorter duration of preoperative symptoms. We therefore conclude that surgery for tennis elbow should be employed at an earlier stage than is currently practised.

Use of the World Health Organization guidelines on cancer pain relief before referral to a specialized pain service

In 1986 the World Health Organization (WHO) released guidelines for cancer pain relief. Since then, several controlled studies on effectiveness and practicability of these guidelines have been published. Various authors described inadequate use of these guidelines.We analysed, whether the pain medication of 160 cancer patients referred to the anesthesiological pain clinic at the university hospital of Vienna corresponded to the WHO guidelines or not. Adequacy of pain treatment was assessed using the pain management index (PMI). Multiple criteria were chosen to assess the conformity of the treatment with the guidelines. Furthermore we studied the effect of a strict use of the WHO guidelines in these patients.The average pain intensity of the referred patients was 75 mm (VAS). Negative PMI scores, indicating inadequate pain therapy, were fount in 39 % of cases. A violation of the rules was found in 38% of the therapy schedules. Pain medication was then modified by switching to fixed time intervals, escalation of the steps of the WHO ladder, increasing the dosage or treating neuropathic pain with adjuvant drugs. Two weeks later the average pain score of the patients was reduced to 27 mm (VAS). At that time 72% of the patients quoted an adequate reduction of pain.Inadequate knowledge or disregard of the WHO guidelines for cancer pain relief are common and result in unnecessary and prolonged suffering in these patients.

Comparison of bromfenac and Naproxen ( Naprosyn ) sodium in the management of primary dysmenorrhea.

Objective: To compare a new analgesic with an established standard and placebo in the treatment of primary dysmenorrhea.Methods: Bromfenac (B) 25 or 50 mg prn, up to 4 doses daily, was compared with Naproxen ( Naprosyn ) sodium (N) (550/275 mg) and placebo (P) in a double-blind crossover randomized trial where 54 women were treated over 4 menstrual periods. Each treatment lasted up to 3 days. The first-dose analysis was based on a 6-hour observation period. Total pain relief (TOPAR) and summed pain intensity difference (SPID) scores were calculated from hourly collected data as areas under the respective time curves.Results: All 3 active treatments were superior to placebo in all summary variables (SPID and TOPAR for 3 and 6 hours) and corresponding peak pain relief and peak PID, duration of pain half-gone, and global assessment. Both B doses were superior to P in providing significant pain relief between hours 1 and 6, whereas N was superior to P at hours 1, 3, and 4. Good to excellent global rating was achieved by 74% of patients on B 50 mg, 59% on B 25 mg, 57% on N and 33% on P (P <.001) after the first dose. Patients rated the trial medication superior to their usual treatment as follows: B 50 mg: 65%, B 25 mg: 55%, N: 51%, P: 29% (P <.001). Adverse events were infrequent and not significantly different among the 4 treatments.Conclusion: Both doses of bromfenac were significantly superior to placebo and at least as efficacious as Naproxen ( Naprosyn ) sodium in management of primary dysmenorrhea.

Bilateral thoracoscopic splanchnicectomy in patients with chronic pancreatitis.

BACKGROUND: Intractable pain, the most prominent feature of chronic pancreatitis, causes the patient great disability, and its treatment poses a difficult problem for gastroenterologist and surgeon alike. The main goal of treatment is to provide sufficient and lasting pain relief without the use of opiates. Conservative management, including stopping alcohol consumption, dietary measures, pancreatic enzyme suppletion and analgesics, is discussed. When these measures fail, surgery is often unavoidable. Indications, effect on pain relief, morbidity and mortality of drainage and resection procedures are described. Bilateral thoracoscopic splanchnicectomy, a newly developed operation to alleviate pain irrespective of the type of anatomic abnormality, is outlined in more detail. Early encouraging results of pain relief in patients with chronic pancreatitis after thoracoscopic splanchnicectomy are presented.

Caudal epidural blocks for elderly patients with lumbar canal stenosis.

OBJECTIVE: To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS). DESIGN: This study was a descriptive, prospective study with a 10-month follow-up. PARTICIPANTS AND SETTING: Thirty patients, 76 +/- 6.7 years of age, with leg discomfort with or without back pain and with LCS documented by magnetic resonance imaging (MRI) within 1 year of the study, were recruited from the outpatient clinic of the Cleveland Clinic Florida. None of the subjects had received CEB or surgery for their leg discomfort and none had relief of pain by analgesics alone. MEASUREMENTS AND INTERVENTIONS: Subjects received a total of three doses of 0.5% Xylocaine with 80 mg Depo-Medrol into the caudal epidural space through the sacral hiatus at weekly intervals. The Roland 5-point pain rating scale was utilized before and at 2-month intervals up to 10 months after the CEB was administered. MRI was used to identify the degree of LCS. RESULTS: The degree of LCS on admission was moderate in 66.7% (n = 20) of the patients, mild in 23.3% (n = 7), and severe in the remaining 10% (n = 3). Patients had LCS involving 2.4 +/- 0.49 lumbar vertebrae. The degree of LCS is directly correlated with the pain level before CEB. After CEB, the pain level changed from 3.43 +/- 0.82 to 1.5 +/- 0.86 (P < 0.0000), with a significant relief of pain up to 10 months (the end of observation). The duration of pain relief ranged from 4 to 10 months (P < 0.0001). CONCLUSION: CEB offers significant pain relief and appears to be a reasonable therapeutic option among elderly patients with LCS. This alternative seems particularly important among patients with poor response to drug therapy and who are either poor surgical risks or who have refused surgery.