Prospective study of transcutaneous oxygen tension (TcPO2) measurement in the testing period of spinal cord stimulation in diabetic patients with critical lower limb ischaemia.

BACKGROUND: Spinal cord stimulation improves microcirculatory blood flow, relieves diabetic neuropathic and ischaemic pain and reduces the amputation rate in patients with severe peripheral arterial occlusive disease. Aim: To evaluate whether transcutaneous oxygen tension (TcPO2) measurements can be used as a specific prognostic parameter in the assessment of suitability for permanent device implantation in a prospective controlled study on diabetic patients with peripheral arterial occlusive disease. METHODS: Sixty patients (39 men, 21 women; mean age: 60 years; range: 46-75) were submitted to implantation of a spinal cord electrical generator for severe peripheral vascular disease, after failed conservative or surgical treatment. The clinical status was classified as Fontaine's stage III and IV and the main pathology was diabetic vascular disease. Pedal TcPO2 was assessed on the dorsum of the foot and ankle and toe pressure Doppler measurements were performed before, two weeks and four weeks after implantation. RESULTS: pain relief of over 75% and limb salvage were achieved in 35 diabetic patients, while in 12 a partial success with pain relief over 50% and limb salvage for at least 6 months was obtained. In 13 patients the method failed and the affected limbs were amputated. Clinical improvement and spinal cord stimulation success were associated with increases of TcPO2, within the first two weeks after implantation (temporary period). Limb salvage was achieved with significant increase of TcPO2 within the first two weeks of the testing period (from 21.4 to 31.5 mmHg in rest pain patients, p=0.030, from 15.1 to 22.0 mmHg, p=0.030 in patients with trophic lesions under 3 cm2 in size and in those with trophic lesions over 3 cm2, from 12.1 to 17.9 mmHg, p=0.025) unrelated to the stage of the disease and the initial TcPO2 value. TcPO2 changes were related to the presence of adequate paraesthesias and warmth in the painful area during the trial period. The systolic ankle/brachial blood pressure index and toe pressure did not change under stimulation. CONCLUSIONS: A two-week testing period should be performed in all diabetic patients treated with spinal cord stimulation for peripheral arterial occlusive disease to identify the candidates for permanent implantation. Only diabetic patients with significant increases of TcPO2 and clinical improvement, during the test period, should be considered for permanent implantation and not merely all patients with pain relief. TcPO2 changes could be used as a predictive index of the therapy success and should be considered in terms of cost effectiveness before the final decision to permanent implantation.

Percutaneous vertebroplasty--a new method for alleviation of back pain

Percutaneous vertebroplasty (PV) is an interventional radiological procedure for the treatment of pain in patients with vertebral compressions caused by osteoporosis, metastases or hemangioma. The method was introduced by Professors P Galibert and H Deramond at the University Hospital of Amiens, France in 1984. It consists of percutaneous injection of bone cement (polymethylmethacrylate) into the vertebral body under fluoroscopy guidance. PV has proved to be effective and safe. Permanent complete or partial pain relief is obtained within hours or days in more than 90% of cases. The complication rate is low, less than 3% for patients with osteoporosis and up to 10% in patients with metastases. We report on the first 17 patients (11 with osteoporosis, 3 with metastases and 3 with hemangiomas) treated in Sweden at the Department of Interventional Neuroradiology, Sahlgrenska Hospital, Goteborg University. We obtained complete pain relief in 71% and partial pain relief in 17% of cases. The majority of the patients improved in mobility and quality of life. We had no clinical complications.

A retrospective analysis of neurolytic celiac plexus block for nonpancreatic intra-abdominal cancer pain.

Neurolytic celiac plexus block (NCPB) has been reported to be an effective method for pain relief for a variety of intra-abdominal malignancies, especially pancreatic. In spite of this, few data exist concerning efficacy of the block for pain related to other intraabdominal tumors. The author analyzed the quality of pain relief obtained and complications during the use of NCPB in 66 patients with nonpancreatic intraabdominal malignancies. Seventy-three percent of the patients with nonpancreatic cancer pain had good pain relief, which in 59% of cases lasted through the remaining life of the patients. The incidence of neurologic injury (footdrop) was less than 0.5%. This therapy deserves more widespread use in patients with abdominal pain secondary to a variety of other malignancies, in addition to that of the pancreas.

pain relief through transcutaneous electrical nerve stimulation (TENS). Results on painful neurological disorders in 180 cases (author's transl)

A series of 180 patients with painful neurological disorders were treated with TENS. The findings most frequently encountered when the treatment was successful are analyzed. Depending upon the etiology of the primary disorder, good results (i.e. pain relief of 20% or higher) were obtained as follows : -- Peripheral Nerve Involvement : Amputation - 35 cases; Traumatism - 13 cases ; Miscellaneous - 7 cases. (87 %). -- Radicular Syndromes : Epidural scar and/or Arachnoiditis - 19 cases; Miscellaneous - 9 cases. (60 %). -- Post Herpetic Pain : 34 cases. (67 %). -- Brachial Plexus Lesions (Avulsions) : 12 cases. (25 %). -- Spinal Cord Disorders : 17 cases. (11 %). --Thalamic Pain : 5 cases. (0 %). -- Post-Radiation Pain or Carcinomatous Pain : 16 cases. (30 %). Satisfactory long-term results (over 3 years) were maintained in 80 % of cases of peripheral nerve involvement. In all other cases the percentage of pain relief decreased with follow-up. In this series the likelyhood of good results was associated with the following objective data : 1) Pain is generally secondary to deafferentation. 2) Pain is localized. 3) TENS application in close contact with the nervous structure innervating the painful area is more productive. 4) A relative preservation of lemniscal fibers to superior centers must be present so that stimulation can be transmitted.