Spinal epidural stimulation for central pain caused by spinal cord lesion

Epidural spinal cord stimulation was carried out in 4 patients with denervation caused by spinal cord lesion, and we reviewed previously reported cases. Initial result showed at 1 week in 100% of our cases, but about 1/3 of the cases, even those with the same denervation caused by spinal cord lesion, had no pain relief at this stage in previously reported cases. In our cases, excellent pain relief was gained temporarily, even though the painful area and the spinal cord lesion were separated somatotopically in 2 cases (case 3, 4). Temporary success bore no relationship to quality and duration of pain. In all cases except case 1, a rapidly decreasing effectiveness was noted, and finally no pain relief was gained at all after 4, 3 and 5 months, respectively. In case 1 there was persistent pain relief estimated at 70-80% after 19 months, only when the spinal cord was stimulated. Epidural stimulation also produced sensations in the painful area. Spinal cord stimulation would suppress at least the dorsal horn neurons which were destroyed by various kinds of diseases. A decline in effectiveness with time would occur due to essential causes of the deafferentation pain, such as anatomical and regeneration factors.

Repeat radiosurgery for refractory trigeminal neuralgia.

OBJECTIVE: Stereotactic radiosurgery has become an important and minimally invasive alternative for patients with refractory trigeminal neuralgia. When a second procedure is necessary, the outcomes are unknown. The degree of pain relief and morbidity after repeat radiosurgery were studied. METHODS: Thirty-one patients underwent a second gamma knife radiosurgery procedure because of unsatisfactory or unsustained relief of pain after the first procedure. Twenty-seven patients were assessable at median follow-up periods of 42.7 and 20.4 months after the first and second procedures, respectively. Most patients had undergone multiple previous operations of other types (microvascular decompression, radiofrequency rhizotomy, glycerol rhizotomy, balloon compression). The median target doses of the first and second radiosurgeries were 75 and 64 Gy, respectively. All patients were evaluated by a physician who did not participate in patient treatment. RESULTS: After the first radiosurgical procedure, 13 patients had an excellent response initially (complete relief without any medication), 3 had a good response (complete relief with some medication), 7 had a fair response (>50% relief), and 4 had a poor response (<50% pain relief or treatment failure). Repeat radiosurgery was performed in patients with recurrent or residual pain. After the second radiosurgical procedure, 5 patients had an excellent response, 8 had a good response, 10 had a fair response, and 4 had a poor response. Thirteen patients (48%) achieved complete pain relief (with or without medication). Two patients (7.4%) experienced new sensory symptoms after the first radiosurgical procedure, and three (12.7%, actuarial) experienced new sensory symptoms after the second procedure. CONCLUSION: Repeat radiosurgery provided a similar rate of pain relief as the first procedure, despite a modest dose reduction. The risk of new sensory symptoms was increased, but no other morbidity was identified. For patients who experience recurrent pain and choose to undergo a second procedure, our current procedure is to deliver a maximum dose of 50 to 60 Gy to a trigeminal target anterior to the root entry zone near the entrance of the nerve beneath the petrous dura.

Piroxicam, acetylsalicylic acid and placebo for postoperative pain.

A double-blind comparison of the pain-relieving effect of piroxicam 5 and 10 mg, acetylsalicylic acid 648 mg and placebo was performed in 120 patients with moderate to severe pain on the morning after orthopedic surgery. The changes in pain intensity and pain relief during the 8 h following medication were recorded by a trained nurse observer. 67% of the placebo-treated patients needed rescue drugs compared to 41% of the acetylsalicylic acid, 43% of the piroxicam 5 mg, and 45% of the piroxicam 10 mg treated patients. One to three hours after ingestion of the test drug, the piroxicam and the acetylsalicylic acid groups had significantly improved verbal rating pain intensity scores compared to placebo. In the overall assessment of pain relief at the end of the observation period, the patients' own assessment was significantly superior for acetylsalicylic acid and piroxicam 10 mg compared with placebo. In the observer's assessment of overall pain relief, placebo was significantly inferior to the three other groups. Thus piroxicam 5 mg and 10 mg give relief of pain after orthopedic surgery similar to that given by acetylsalicylic acid 648 mg. The pain-relieving effect of these drugs can be distinguished from placebo, but not from each other. They are not potent enough when pain is moderate to severe after orthopedic surgery.

Radiotherapy of vertebral hemangiomas

The paper presents the analysis of results of treatment with radiotherapy of 14 cases of vertebral hemangiomas. All patients were irradiated in accordance with conventional schedule fractionated doses, using 2 Gy per fraction. The total radiation dose amounted to 20 Gy (1 case), 24 Gy (4 cases) and 30 Gy (9 cases). The degree of pain relief and lesion reossification was assessed 1 months and 6 months after completion of radiotherapy. Complete pain relief 1 month post radiotherapy was noted in 5 cases (on average patients claimed that radiotherapy resulted in a 70% decrease of pain syndromes). Six months post radiotherapy complete pain relief was noted in 8 cases (on average patients reported a 90% decrease in pain). Signs of reossification were observed in cases 6 months after treatment. No correlation was noted neither between the degree of pain relief and reossification, nor between the total delivered dose and the degree of pain relief. The obtained results allow to conclude that conventionally fractionated radiotherapy (using 20-24 Gy as total dose) is a good method of analgetic treatment of vertebral hemangiomas probably based on the anti-inflammatory effect of radiation.

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.

Trigeminal sensory evoked potential in retrogasserian glycerol injection for trigeminal neuralgia

Since Dr. Hakanson reported retrogasserian glycerol injection method for treatment of idiopathic trigeminal neuralgia, its effectiveness for pain relief has been documented in a few reports. However, effects of glycerol in nervous tissue and mechanism of pain relief of the trigeminal neuralgia have not been elucidated yet. So we attempted to make clear what changes happen in trigeminal sensory evoked potential (TEP) of the patients with trigeminal neuralgia after retrogasserian glycerol injection. For this purpose we had to obtain normal TEP from 12 normal subjects in the beginning. The TEP by upper lip stimulation and recorded at contralateral C5 or C6 (TEP.V2) was consisted of 4 positive and 2 negative potentials in the analysis time of 40 msec which were named P3, N10, P14, P20, N30 and P40. The TEP.V3 that was obtained by lower lip stimulation was consisted of 3 positive and 3 negative potentials that were named N3, P10, N14, P20, N30 and P40. Most remarkable change of the TEP.V2 after glycerol injection in the pain relief group of patients with trigeminal neuralgia involving second division was amplitude attenuation of N10. There was no significant prolongation of peak latencies of P3, N10 and P20. It was remarkable that this amplitude decrease (about 38% of the pre-injection value) was recognized only in the pain relief group. On the contrary the mean amplitude of no relief group decreased only to 86% of the pre-injection value.(ABSTRACT TRUNCATED AT 250 WORDS)

Half-body irradiation in the treatment of metastatic prostatic carcinoma.

High dose radiation therapy given as a single fraction to the upper and lower halves of the body gives effective palliation for metastatic solid tumours. This treatment modality appears to be particularly effective in tumours which may have a slow doubling time such as carcinoma of the prostate. Fifty-two patients with metastatic carcinoma of the prostate involving the skeletal system have received half-body irradiation. All had prior treatment with additive hormones or orchiectomy and the majority had received localised irradiation and/or chemotherapy. Significant immediate pain relief was achieved in 42 out of 52 patients (80%). This pain relief was maintained until death in 29 out of 43 patients (67%). pain relief in responders appears to occur within 24 to 48 h of treatment.

Assessing pain and pain relief in geriatric patients with non-pathological fractures with different rating scales.

Although pain is a frequent problem among elderly patients, they are often omitted in clinical trials and few studies have focused on assessing pain relief in this population. The aim of this study was to compare geriatric patients' verbally reported effect of analgesics with changes in pain experience rated with four different rating scales: the Visual Analogue Scale (VAS), the Graphic Rating Scale (GRS), the Numeric Rating Scale (NRS), and the pain relief Scale (PRS). Altogether 53 geriatric patients (mean=82 yrs) with non-pathological fractures in 4 geriatric units at a large university hospital were selected. In connection with the administration of analgesics, the patients were asked to "Mark the point that corresponds to your experience of pain just now at rest" on the VAS, GRS and NRS. This was repeated after 1.5-2 hours, and a direct question was asked about whether the analgesic medication given in connection with the initial assessment had had any pain-alleviation effect. Two comparisons were conducted with each patient. The results show that the probability of accomplishing a rating on the VAS, GRS, NRS, and PRS was lower with advancing age in these elderly fracture patients. The correlations between the ratings of the VAS, GRS and NRS were strong and significant (r=0.80-0.95; p<0.001) both at the initial assessments and at the re-assessments. However, the verbally reported effects of the analgesics were often directly opposite to the changes in rated pain. Therefore, application of the VAS, NRS, GRS and PRS for the purpose of assessing pain relief must be combined with supplementary questions that allow the patient to verbally describe possible experience of pain relief.

Does pain relief during delivery decrease the risk of postnatal depression?

BACKGROUND: To test the hypothesis that sufficient pain relief during delivery decreases the risk of postnatal depression. METHODS: As part of a prospective follow-up study of the risk factors for postnatal depression and its impact on the mother-infant interaction and child development, 185 parturients filled in the Edinburgh Postnatal Depression Scale (EPDS), first during the first postpartum week and again (n = 162) 4 months later. The incidence and the risk of high EPDS scores was calculated according to the mode of delivery and the mode of pain relief during vaginal delivery, also after adjusting for the length of labor. RESULTS: Mothers who received epidural/paracervical blockade during their delivery spent less time in the delivery room than mothers in the nitrous oxide/acupuncture group (p = 0.033) or mothers with no pain relief (p = 0.026) and had shorter length of labor than mothers without pain relief (p = 0.04). The adjusted risk of depressive scores at the first postnatal week was decreased in the epidural/paracervical group when compared with no analgesia group (OR: 0.25, 95% CI: 0.09-0.72). This difference was not shown at 4 months postpartum. Elective or emergency cesarean section did not increase the risk of high EPDS scores at the first week or at 4 months postpartum. CONCLUSION: The mode of pain relief during vaginal delivery seems to be associated with the incidence of postpartum depression, especially immediately after delivery.

Centro-median thalamotomy for central pain following stroke --its effectiveness and limits

Centro-median thalamotomy was performed on 18 patients with central pain caused by cerebrovascular disease. Fourteen were males and four were females. Clinical diagnoses were thalamic pain in 17 cases including cheiro-orale syndrome in one case and phantom limb pain in one case. CT scans were performed on six recent cases. Four cases had a small low density sera in the thalamus. The other two cases had no remarkable findings. The target was 7.5-11.0 nm posterior to the middle point of the intercommissural line, 1.0 mm below-2.0 mm above that line and 5.5-10.0 mm from the midline. Unilateral lesion was made on 15 cases. Postoperatively, five cases had almost completely relief of pain and four cases had partial improvement. The duration of pain relief was, however, less than two months in four cases, and between three and seven months in four cases. One case had a pain free period for seven months. But, then, severe dysesthesia appeared. Six cases had no pain relief by unilateral lesion. Two cases had no pain relief by bilateral lesions. In the remaining case, unilateral lesion was effective for six months. Then lesion of opposite side was made, but the result was unsatisfactory. The durations from the onset of apoplectic attack to the occurrence of pain were between four months and three years in ten effective cases, and within three months in six among eight failed cases. Many surgical and medical treatments have been attempted for central pain. However, ideal method is still not appeared. Centro-median thalamotomy was effective for 56% of the patients with central pain. But in most of the cases, the duration of pain relief is about a half year at the longest. And may be, this is the limit of effectiveness of centro-median thalamotomy for central pain.