Palliative Radiofrequency Ablation Therapy for Intractable Cancer-Related Pain Due to Malignant Psoas Syndrome: Case Report

Uncontrollable cancer pain is a highly feared and debilitating symptom. The effectiveness of radiofrequency ablation (RFA) for osseous metastases with intractable cancer-related pain refractory to pharmacological therapy has been reported previously. This case report is the first to demonstrate the use of RFA to achieve pain relief in a patient suffering severe pain caused by para-aortic lymph node metastasis. A 55-year-old male complained of intractable pain in the left groin and perineum due to malignant psoas syndrome caused by metastatic para-aortic lymph nodes. The pain was refractory to medications including opioids and nerve blocks. Considering the dermatome indicating referred pain and the imaging findings, RFA of the area of invasion was performed at the L3 level. The severe pain was relieved within 24 hours without any complications. Opioids were tapered at each postoperative outpatient visit. We discuss the use of RFA for control of intractable cancer-related pain refractory to medication, including opioids.

Effectiveness of CT-guided percutaneous cordotomy in intractable cancer pain: Experience in 14 patients

BACKGROUND

Severe and treatment-resistant pain is a major issue for patients with cancer. Cordotomy is an effective approach for addressing severe cancer-related pain. It is based on blocking the transmission of pain by damaging the lateral spinothalamic tract.

METHODS

Computed tomography guided cordotomy was performed on 14 patients who did not respond to medical and interventional pain management methods.

RESULTS

Fourteen patients with cancer pain underwent CT-guided percutaneous cordotomy. Pain relief was reported in 86% of the patients. The visual analog scale values before and after cordotomy were compared and a significant difference was found (p = 0.0001). The improvement in the Karnofsky Performance Scale score of the patients was found to be statistically significant (p = 0.0001).

CONCLUSION

We believe that CT-guided cordotomy, performed by experienced hands in a team of experienced individuals and applied to the right patients, is an effective treatment. However, it is crucial to exercise extreme caution regarding potential side effects and serious complications during the cordotomy procedure.

Open Thoracic Cordotomy for Cancer Pain with Intraoperative Neuromonitoring: A Case Series and Critical Review of the Literature

OBJECTIVE

Cordotomy is a viable option for patients with intractable cancer pain and limited survival. Open thoracic cordotomy is offered when patients are not candidates for percutaneous cordotomy. After the open procedure, traditionally performed purely based on anatomic landmarks, up to 22% of patients experience postoperative limb weakness. The objective of this study is to report our experience with neurophysiology-guided open cordotomy along with a critical review of the literature.

METHODS

Between 2019 and 2022, 5 open thoracic cordotomies were performed in our center. Intraoperative neurophysiologic monitoring was used in all cases to guide the lesion and standard single-level laminectomy or hemilaminectomy was performed for exposure. Outcome measures were retrospectively reviewed focusing on pain control and neurologic status. Existing literature on cordotomy was critically reviewed.

RESULTS

There was satisfactory pain relief with preservation of motor function in all 5 cases. Temperature sensation was preserved in all but 1 patient, who lost it after the previous ipsilateral percutaneous cordotomy (PCC). No procedural complications were experienced. We found that the neurophysiology monitoring lesion was guided anterior compared with what would have been lesioned on an anatomic basis.

CONCLUSIONS

Open thoracic cordotomy is a safe and effective procedure for intractable cancer-related pain. Technical advancements significantly reduced mortality and major morbidity of PCC. Our series suggests that neurophysiology monitoring alters the location of the lesion and may help better targeting of pain fibers within the spinothalamic tract and preserve other long tracts. The safety profile of open cordotomy with neurophysiology compares favorably with the PCC.

Open thoracic cordotomy for intractable cancer pain: a how I do it

BACKGROUND

Some cancers of the lower extremity involve nerves and plexuses and can produce extreme drug-resistant noceptive pain. In these cases, open thoracic cordotomy can be proposed.

METHOD

This procedure involves disruption of the spinothalamic tract, which sustains nociceptive pathways. After placement in the prone position, selection of the side to be operated on (contralateral to the pain), and dura exposure, microsurgery is used to section the anterolateral spinal cord quadrant previously exposed by gently pulling on the dentate ligament.

CONCLUSION

Open thoracic cordotomy is a moderate invasive, safe, and effective option for the management of drug-resistant unilateral lower extremity cancer pain in well-selected patients.

INTRACTABLE PAIN AND DIPLOPIA AFTER SCLERAL BUCKLE SURGERY

PURPOSE

To report a case of early postoperative scleral buckle slippage because of the dehiscence of scleral belt loop tunnels.

METHOD

Case report.

RESULTS

A 54-year-old woman presented with painful diplopia after a combination pars plana vitrectomy and scleral buckling procedure. Ocular movements were limited. Forced duction testing was restricted in all directions. Anterior slippage of the silicone band was suggested on computed tomography (CT) scans and was confirmed with surgical exploration. During surgery, it was found that thin-roofed scleral belt loop tunnels were dehisced in three quadrants leading to anterior slippage of the buckle. The displaced buckle was removed. Diplopia and pain resolved, and ocular motility improved immediately afterward. The retina remained attached at six months follow-up. A supplemental video summarizes the surgical findings and postoperative results.

CONCLUSION

Spontaneous dehiscence of scleral belt loops may occur in thinly dissected scleral tunnels. Painful eye movement, diplopia, and a positive forced duction test should raise suspicion about a displaced scleral buckle. A CT scan may help with the diagnosis. Early diagnosis and immediate surgical intervention are needed to minimize patient discomfort and to improve long-term ocular motility.

Cervical Cordotomy for Intractable Pain: Do Postoperative Imaging Features Correlate with Pain Outcomes and Mirror Pain?

BACKGROUND AND PURPOSE

Percutaneous cervical cordotomy offers relief of unilateral intractable oncologic pain. We aimed to find anatomic and postoperative imaging features that may correlate with clinical outcomes, including pain relief and postoperative contralateral pain.

MATERIALS AND METHODS

We prospectively followed 15 patients with cancer who underwent cervical cordotomy for intractable pain during 2018 and 2019 and underwent preoperative and up to 1-month postoperative cervical MR imaging. Lesion volume and diameter were measured on T2-weighted imaging and diffusion tensor imaging (DTI). Lesion mean diffusivity and fractional anisotropy values were extracted. Pain improvement up to 1 month after surgery was assessed by the Numeric Rating Scale and Brief Pain Inventory.

RESULTS

All patients reported pain relief from 8 (7-10) to 0 (0-4) immediately after surgery (P = .001), and 5 patients (33%) developed contralateral pain. The minimal percentages of the cord lesion volume required for pain relief were 10.0% on T2-weighted imaging and 6.2% on DTI. Smaller lesions on DWI correlated with pain improvement on the Brief Pain Inventory scale (r = 0.705, P = .023). Mean diffusivity and fractional anisotropy were significantly lower in the ablated tissue than contralateral nonlesioned tissue (P = .003 and P = .001, respectively), compatible with acute-phase tissue changes after injury. Minimal postoperative mean diffusivity values correlated with an improvement of Brief Pain Inventory severity scores (r = -0.821, P = .004). The average lesion mean diffusivity was lower among patients with postoperative contralateral pain (P = .037).

CONCLUSIONS

Although a minimal ablation size is required during cordotomy, larger lesions do not indicate better outcomes. DWI metrics changes represent tissue damage after ablation and may correlate with pain outcomes.

A Clinical Review of Slipping Rib Syndrome

ABSTRACT

Slipping rib syndrome is pain created at the lower, anterior border of the rib cage when performing upper-extremity activities, coughing, laughing, or leaning over. Defects in the costal cartilage of ribs 8 to 10 result in increased movement of the ribs, impinging soft tissue and intercostal nerves. Advancements have been made in the diagnosis of slipping rib syndrome by dynamic ultrasound. Ultrasound can identify abnormalities in the rib and cartilage anatomy, as well as soft tissue swelling. Although the mainstays of treatment continue to be reassurance, nonsteroidal anti-inflammatory drugs, physical therapy, intercostal nerve injections, osteopathic manipulative treatment, surgery for refractory pain, and botulinum toxin injections have been attempted, and there may be a role for prolotherapy in treatment. Surgical techniques are being examined secondary to recurrence of pain following resection. The hooking maneuver and surgery remain important for identification and treatment, respectively.

Neuroablative surgical treatments for pain due to cancer

Cancer pain is common and challenging to manage - it is estimated that approximately 30% of cancer patients have pain that is not adequately controlled by analgesia. This paper discusses safe and effective neuroablative treatment options for refractory cancer pain. Current management of cancer pain predominantly focuses on the use of medications, resulting in a relative loss of knowledge of these surgical techniques and the erosion of the skills required to perform them. Here, we review surgical methods of modulating various points of the neural axis with the aim to expand the knowledge base of those managing cancer pain. Integration of neuroablative approaches may lead to higher rates of pain relief, and the opportunity to dose reduce analgesic agents with potential deleterious side effects. With an ever-increasing population of cancer patients, it is essential that neurosurgeons maintain or train in these techniques in tandem with the oncological multi-disciplinary team.

Interventional Cryoneurolysis: An Illustrative Approach

The application of advanced imaging guidance and the interventional radiology skill set has expanded the breadth of nerve and nerve plexus targets in the body for potential cryoneurolysis. Advancement of the basic science supporting cryoneurolysis has further solidified proceduralists' confidence and ability to select and manage patients clinically. As these procedures continue to evolve, a structured approach to the wide variety of indications is necessary.

The evaluation of the treatment for old osteoporotic vertebral compression fracture pain by percutaneous vertebroplasty

The aim of the present study was to evaluate the clinical effect of percutaneous vertebroplasty (PVP) in the treatment of old osteoporotic vertebral compression fracture (OVCF) pain.A retrospective study was conducted on the clinical and imaging data of 31 patients with old OVCF treated by PVP from June 2010 to September 2011. Clinical efficacy was evaluated by the visual analog scale (VAS) scores, the oswestry disability index (ODI), the Cobb angle, and vertebral kyphotic angle at pre-operation and post-operation 3 days, 3 months, and 12 months.The VAS scores and ODI scores of 3 day, 3 month, and 12 month after PVP were significantly improved compared with those before operation (P < .05), but the Cobb angle and vertebral kyphosis angle were not significantly improved compared with those before operation (P > .05).PVP can effectively relieve the pain caused by old OVCF, and the motor ability of the patients is improved obviously. However, the recovery of Cobb angle and vertebral kyphosis angle was not obvious.

Breast cancer spinal metastases: Prognostic factors affecting survival after surgery. A retrospective study

Breast cancer spinal metastases (BCSM) are common and require proper treatment that leads to an improvement of the quality of life and contributes to the quod vitam prognosis. Surgical treatment is often required for intractable pain, spinal cord compression or spinal instability. The aim of this retrospective study is to identify which prognostic factors could affect postoperative overall survival in patients affected by BCSM. We report a retrospective cohort study of patients with BCSM, surgically treated from September 2009 to May 2018. Demographic and clinical data were collected. Kaplan-Meier method was used to estimate overall survival, and the log-rank test was used to compare survival curves. A total of 77 patients were studied. The median age at the time of surgery was 54 years. The median follow-up was 49 months. The 3-year and 5-year overall survival rates were 61% (95%CI: 47.5-72.1) and 43.3% (95%CI: 28.8-57.1). Metastatic bone disease (p = 0.0196), preoperative neurological impairment (p = 0.0029), Karnofsky status <70 (p = 0.0241) reduce survival. With multivariate analysis, the effect of Karnofsky score loses statistical significance. The presence of concurrent bone metastases and a preoperative neurological deficit are independent prognostic factors. Therapeutic choices are based on a multidisciplinary assessment that takes into consideration several factors, including an accurate study of prognostic factors.

Cordotomy for Intractable Cancer Pain: A Narrative Review

BACKGROUND

Cordotomy is an invasive procedure for the management of intractable pain not controlled by conventional therapies, such as analgesics or nerve block. This procedure involves mechanical disruption of nociceptive pathways in the anterolateral column, specifically the spinothalamic and spinoreticular pathways to relieve pain while preserving fine touch and proprioceptive tracts.

OBJECTIVES

The purpose of this review article is to refresh our knowledge of cordotomy and support its continued use in managing intractable pain due to malignant disease.

STUDY DESIGN

This is a review article with the goal of reviewing and summarizing the pertinent case reports, case series, retrospective studies, prospective studies, and review articles published from 2010 onward on spinal cordotomy.

SETTING

The University of Texas, MD Anderson Cancer Center.

METHODS

PubMed search of keywords "spinal cordotomy," "percutaneous cordotomy," or "open cordotomy" was undertaken. Search results were organized by year of publication.

RESULTS

Cordotomy can be performed via percutaneous, open, endoscopic, or transdiscal approach. Percutaneous image-guided approach is the most well-studied and reported technique compared with others, with relatively good pain improvement both in the postoperative and short-term period. The use of open cordotomy has diminished significantly in recent years because of the advent of other less invasive approaches. Cordotomy in children, although rare, has been described in some case reports and case series with reported pain improvement postprocedure. Although complications can vary broadly, some reported side effects include ataxia and paresis due to lesion in the spinocerebellar/corticospinal tract; respiratory failure due to lesion in the reticulospinal tract; or sympathetic dysfunction, bladder dysfunctions, or Horner syndrome due to unintentional lesions in the spinothalamic tract.

LIMITATIONS

Review article included literature published only in English. For the studies reviewed, the sample size was relatively small and the patient population was heterogeneous (in terms of underlying disease process, duration of symptoms, previous treatment attempted and length of follow-up).

CONCLUSIONS

Cordotomy results in selective loss of pain and temperature perception on the contralateral side, up to several segments below the level of the disruption. The plethora of analgesics available and advanced technologies have reduced the demand for cordotomy in the management of intractable pain. However, some patients with pain unresponsive to medical and procedural management, particularly malignant pain, may benefit from this procedure, and it is a viable treatment option especially for patients with a limited life expectancy whose severe, unilateral pain is unresponsive to analgesic medications.

KEY WORDS

Cancer pain, cordotomy complications, cordotomy indications, intractable pain, open cordotomy, percutaneous cordotomy.

A Novel Technique of Saddle Rhizotomy Using Thermal Radiofrequency for Intractable Perineal Pain in Pelvic Malignancy: A Pilot Study

BACKGROUND

The prevalence of pain in advanced pelvic cancer may reach up to 95%. Control of such pain is often difficult owing to a variety of neuroanatomical and functional peculiarities. Different modalities have been utilized to treat this pain including saddle chemical rhizolysis with the potential for jeopardizing the neural control of the sphincters.

OBJECTIVE

The aim of this pilot study is to determine the feasibility of using selective thermal radiofrequency as an alternative to saddle chemical rhizolysis in patients with refractory perineal pain associated with pelvic malignancies.

STUDY DESIGN

Pilot study.

SETTING

Pain Relief Department of the National Cancer Institute, Cairo University.

METHODS

Forty patients, 18 years of age or older, who had pelvic malignancy and were complaining of moderate or severe perineal pain not controlled with maximum tolerable doses of morphine sulfate for at least 4 weeks were randomly allocated to receive selective saddle rhizotomy using thermal radiofrequency ablation of S3 on one side and bilateral ablation of S4 and S5 (RF group, n = 20) or conventional chemical rhizotomy using hyperbaric 6% phenol in glycerin (Phenol group, n = 20). Patients were assessed for the intensity of pain, daily consumption of analgesics, functional improvement, overall patient satisfaction, degree of disability and occurrence of procedure-related side effects at 1,4, and 12 weeks.

RESULT

The results were comparable in both groups regarding the control of pain and functional improvement. The incidence of specific procedure-related adverse outcomes was also equivalent for both interventions, although per-patient incidence of major complications was significantly higher in the phenol group.

LIMITATION

Small sample size to demonstrate statistical significance of the relatively small frequency of events, and the patients could not be blinded to the intervention they received owing to the technical uniqueness of either intervention.

CONCLUSION

Selective thermal radiofrequency ablation of the S3 root on one side, S4 root on both sides, and S5 roots could serve as a feasible alternative to conventional saddle rhizotomy using hyperbaric phenol.

KEY WORDS

Perineal cancer pain, chemical rhizotomy, thermal radiofrequency.

[NEUROSURGICAL INTERVENTIONS FOR INTRACTABLE ONCOLOGICAL PAIN]

Pain is one of the most common symptoms among cancer patients, and particularly in those who suffer from metastatic or terminal disease. There is great importance in delivering good pain management to these patients in order to alleviate their suffering, improve their functional status and their overall quality of life. In most cases, pain management is based on pharmacotherapy with opioids and other medications. However, there are selected patients for whom pharmacotherapy does not achieve acceptable pain relief or is associated with marked side effects. These patients, who suffer from refractory cancer pain, may benefit from neurosurgical procedures selectively intervening in different locations along the pain signaling pathways. This article summarizes several of these neurosurgical procedures: percutaneous cordotomy for unilateral pain, punctuate midline myelotomy for visceral pain and stereotactic cingulotomy for diffuse pain syndromes. This article demonstrates the use of careful patient selection by an interdisciplinary team which is critical for the success of these procedures. The team consists of palliative care specialists, pain specialists and a neurosurgeon. These neurosurgical interventions are presented through representative clinical cases, followed by a discussion of the clinical considerations that guided the choice of the therapeutic approach for each case.

Pulsed Radiofrequency Ablation of Pudendal Nerve for Treatment of a Case of Refractory Pelvic Pain

Pudendal neuralgia (PN) is a result of pudendal nerve entrapment or injury, also called "Alcock syndrome." Pain that develops is often chronic, and at times debilitating. If conservative measures fail, invasive treatment modalities can be considered. The goal of this case report is to add to a small body of literature that a pulsed radiofrequency (PRF) ablation can be effectively used to treat PN and to show that high resolution MR neurography imaging can be used to detect pudendal neuropathy.

CASE PRESENTATION

We present a case of a 51-year-old woman with 5 years of worsening right groin and vulva pain. Various medication trials only lead to limited improvement in pain. The first diagnostic right pudendal nerve block was done using 3 mL of 0.25% bupivacaine with 6mg of betamethasone using a transgluteal technique and a target of the right ischial spine; this procedure resulted in ~8 hours of > 50% pain relief. The patient was then referred for MR neurography of the lumbosacral plexus. This study revealed increased signal of the right pudendal nerve at the ischial spine and in the pudendal canal, findings consistent with the clinical picture of PN. Six weeks after the initial block, the patient underwent a second right transgluteal pudendal nerve block, utilizing 3 mL of 0.25% bupivacaine with 40 mg of triamcinolone acetonide; this procedure resulted in ~8 hours of 100% pain relief. Satisfied with these results the patient decided to undergo pudendal nerve PRF ablation for possible long-term relief. For this therapeutic procedure, a right transgluteal approach was again utilized. PRF ablation was performed for 240 seconds at 42° Celsius. Following this ablation the patient reported at least 6 weeks of significant (> 50%) pain relief.

DISCUSSION AND CONCLUSION

In this paper we presented a case of successful treatment of PN with PRF ablation and detection of pudendal neuropathy on MR neurography. We believe that transgluteal PRF ablation for PN might be an effective, minimally invasive option for those patients that have failed conservative management. MR neurography employed in this case is not only helpful in confirming the diagnosis of PN but could also be useful in ruling out other causes of pelvic pain, such as genitofemoral neuropathy, endometriosis, adenomyosis, or pelvic mass lesion. To conclude, transgluteal PRF ablation can serve as a viable treatment option for mitigating symptoms of pudendal neuropathy and MR neurography is useful in confirming a clinically suspected diagnosis of PN.Key words: Pelvic pain, pudendal neuralgia, MR neurography, pulsed radiofrequency ablation, transgluteal technique, Alcock canal syndrome.

Video-Assisted Thoracoscopic Neurectomy of Intercostal Nerves in a Patient With Intractable Cancer Pain

Cancer-related pain is complicated and unbearable. Pain management techniques must be constantly modified and improved, with the goal of decreasing pain and enabling patients to withstand it. A 56-year-old man with colon cancer and multiple metastases was suffering from intense pain that was not relieved by extremely high doses of intravenous morphine. Temporary pain relief was achieved twice by blockade of the intercostal nerves with local anesthetics. Radiofrequency ablation was then performed under fluoroscopic monitoring; however, the procedure resulted in little pain relief. Finally, a neurectomy to cauterize the intercostal nerves was completed with video-assisted thoracoscopy under general anesthesia.

Bilateral Thoracoscopic Splanchnotomy to Alleviate Pain in Chronic Pancreatic Disease

Chronic intractable pain is a common problem in severe pancreatic disease. Bilateral thoracoscopic splanchnotomy, a thoracoscopic neurotomy of the splanchnic nerves, is rarely performed but may provide significant pain relief in these patients. We present a safe strategy that uses prone positioning and two thoracoscopic ports for either hemithorax, permitting easy exposure and simple dissection of the greater and lesser splanchnic nerves. In our experience, this technique provides excellent pain relief with a minimal postoperative stay and few postoperative adverse events. This intervention has the potential to reduce dependency on opioid agents and improve quality of life in carefully selected patients.

Spine Cryoablation: Pain Palliation and Local Tumor Control for Vertebral Metastases

BACKGROUND AND PURPOSE

Percutaneous cryoablation has emerged as a minimally invasive technique for the management of osseous metastases. The purpose of this study was to assess the safety and effectiveness of percutaneous imaging-guided spine cryoablation for pain palliation and local tumor control for vertebral metastases.

MATERIALS AND METHODS

Imaging-guided spine cryoablation was performed in 14 patients (31 tumors) with vertebral metastases refractory to conventional chemoradiation therapy or analgesics, to achieve pain palliation and local tumor control in this retrospective study. Spinal nerve and soft-tissue thermal protection techniques were implemented in all ablations. Patient response was evaluated by a pain numeric rating scale administered before the procedure and 1 week, 1 month, and 3 months after the procedure. Pre- and postprocedural analgesic requirements (expressed as morphine-equivalent dosages) were also analyzed at the same time points. Pre- and postprocedural cross-sectional imaging was evaluated in all patients to assess local control (no radiographic evidence of disease at the treated sites). Complications were monitored. Analysis of the primary end points was undertaken via paired-comparison procedures by using the Wilcoxon signed rank test.

RESULTS

Thirty-one tumors were ablated in 14 patients (9 women and 5 men; 20-73 years of age; mean age, 53 years). The most common tumor location was in the lumbar spine (n = 14, 45%), followed by the thoracic spine (n = 8, 26%), sacrum (n = 6, 19%), coccyx (n = 2, 6%), and cervical spine (n = 1, 3%). There were statistically significant decreases in the median numeric rating scale score and analgesic usage at 1-week, 1-month, and 3-month time points (P < .001 for all). Local tumor control was achieved in 96.7% (30/31) of tumors (median follow-up, 10 months). Two patients had transient postprocedural unilateral lower extremity radiculopathy and weakness.

CONCLUSIONS

Percutaneous imaging-guided spine cryoablation is a safe and effective treatment for pain palliation and local tumor control for vertebral metastases.

Early MRI Characteristics after MRI-Guided Laser-Assisted Cingulotomy for Intractable Pain Control

BACKGROUND AND PURPOSE

Cingulotomy is a well-accepted stereotactic procedure in the treatment of debilitating pain syndromes. At our institution, we used a 980-nm diode laser to perform MR imaging-guided laser-assisted cingulotomy. We report the early MR imaging changes associated with this technique.

MATERIALS AND METHODS

In this retrospective analysis, MR imaging-guided laser-assisted cingulotomy was performed in 4 patients with intractable pain secondary to metastatic disease. Patients were imaged at various time points postprocedure, with visual analysis of MR imaging changes in the cingulate gyri during that timeframe.

RESULTS

Twenty-four hours postablation, 4 distinct zones of concentric rings reminiscent of an "owl eye" shape were noted in the cingulate gyri. Extrapolating from the imaging characteristics of the rings, we defined each zone as follows: The central zone (zone 1) represents a laser probe void with fluid, zones 2 and 3 have signal characteristics that represent hemorrhage and leaked protein, and zone 4 has a peripheral ring of acute infarction, enhancement, and surrounding edema. One patient with 1-year follow-up showed persistent concentric rings with resolution of enhancement and edema.

CONCLUSIONS

Post-MR imaging-guided laser-assisted cingulotomy rings appear to represent a continuum of injury created by the laser probe and thermal injury. The imaging changes are similar to those described for laser ablation of tumor-infiltrated brain with a 1064-nm laser. This is the first study to characterize early MR imaging changes after MR imaging-guided laser-assisted cingulotomy by using a 980-nm laser. It is important for neuroradiologists and neurosurgeons to understand expected imaging findings as laser ablation cingulotomy re-emerges to treat intractable pain.

[Neurosurgical treatment of chronic pain]

Neurosurgical treatment of pain used two kind of techniques: 1) Lesional techniques interrupt the transmission of nociceptive neural input by lesionning the nociceptive pathways (drezotomy, cordotomy, tractotomy…). They are indicated to treat morphine-resistant cancer pain and few cases of selected neuropathic pain. 2) Neuromodulation techniques try to decrease pain by reinforcing inhibitory and/or to limit activatory mechanisms. Chronic electrical stimulation of the nervous system (peripheral nerve stimulation, spinal cord stimulation, motor cortex stimulation…) is used to treat chronic neuropathic pain. Intrathecal infusion of analgesics (morphine, ziconotide…), using implantable pumps, allows to increase their efficacy and to reduce their side effects. These techniques can improve, sometimes dramatically, selected patients with severe and chronic pain, refractory to all other treatments. The quality of the analgesic outcome depends on the relevance of the indications.

[Semicircular decompression for the treatment of old thoracolumbar fractures and intractable neuropathic pain]

OBJECTIVE

To investigate the clinical outcomes of semicircular decompression in treating old thoracolumbar fractures and intractable neuropathic pain.

METHODS

From September 2009 to September 2013, 21 patients with old thoracolumbar fracture and intractable neuropathic pain were treated with semicircular decompression. Among initial surgery, posterior pedicle screw fixation was used in these patients, with or without laminectomy. All patients were male, range in age from 20 to 28 years old with an average of (25.00±2.38) years. Vertebral body residual bone block resulted in intra-spinal placeholder more than 50%. All patients were complete spinal cord injury (ASIA grade) or cauda equina injury. VAS scores was from 6 to 10 points with the mean of 7.14±0.91. In these patients, MRI, CT, X-rays were performed; denomination and dosage of analgesics were recorded; nerve function and pain status were respectively evaluated by ASIA grade and VAS score before and after operation.

RESULTS

All patients were followed up from 8 to 32 months with an average of (17.29±6.02) months. All bone fragments of spinal canal were removed and spinal cord decompressions were achieved. At final follow-up, VAS scores were from 0 to 8 points with an average of (2.43±2.46) points, and were obviously reduced than peroperative data (P<0.05). Eleven cases of them stopped analgesic intake and 7 cases reduced using. Three patients' symptoms and VAS scores were not improved.

CONCLUSION

Old thoracolumbar fractures and intractable neuropathic pain need receive imaging examination as soon as possible and consider semicircular decompression therapy if bone fragments were in vertebral canal and spinal canal stenosis existed. This therapy can effectively relieve pain and profit nerve functional recovery.

Psychosurgery: past, present, and future, including prefrontal lobotomy and Connecticut's contribution

Psychosurgery, a subspecialty of functional neurosurgery, has been used in the treatment of psychiatric illness, intractable pain, and, controversially, as ameans to control and modify violent human behavior. Prefrontal lobotomy, a procedure developed in the 20th century, arose as a result of pioneering research, includingwork done atYaleUniversity in New Haven. Prominent clinicians throughout Connecticut contributed to the development of modern psychosurgery. Neuroethics or ethics of neuroscience is essential to the study and practice ofpsychosurgery. New technology has provided improved accuracy with less morbidity. The progressive replacement of ablative procedures with deep-brain stimulation and restorative neurosurgery offers new perspectives in the treatment of some psychiatric conditions.

Clinical benefits of femoroplasty: a nonsurgical alternative for the management of femoral metastases

BACKGROUND

Bone metastases occur frequently in advanced cancer. The spine, pelvis, ribs, skull and femur are the most affected sites. It is reported that up to 83% of the patients develop pain at some point of the disease. The patient can also develop fractures and disability, particularly in the femur..

OBJECTIVES

To evaluate the effectiveness of percutaneous femoroplasty in patients with metastatic osseous disease located in the proximal femur (trochanter, neck, and femoral head).

STUDY DESIGN

A retrospective clinical review, comparing pain status "before vs after" intervention.

SETTING

National Cancer Institute in Mexico.

METHODS

We included patients over 18 years old, with mild to severe pain due to metastasis in the proximal femur (trochanter, neck, or head), or with a high risk of fracture according to Mirels scale (> 8 points) or severe osteoporosis according to the World Health Organization (a Karnofsky score more than 50%). Exclusion criteria were femoral fracture. We recorded the following variables age, sex, type of neoplasm, concomitant therapy, We used the Karnofsky functionality scale, the VAS pain intensity assessment, the "Mayo Clinic" scale to measure improved functionality, and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative (EORTC QLQ-C15-PAL) (Spanish version) questionnaires. Follow-up was performed at 7 days, one month after femoroplasty, and during the individual outpatient that lasted one year on average.

RESULTS

Eighty subjects were enrolled. Seventy-three percent were women. The most frequent tumors were breast (46.3%), followed by multiple myeloma (18.7%). All patients had a decrease in the intensity of pain, analgesic consumption, and improved quality of life, at 7 and 30 days after the intervention. There were no complications with serious consequences. Two participants experienced polymethylmetacrylate (PMMA) leakage, without clinical or functional impact. In 4 patients, the needle was occluded during the filling process and we had to place another biopsy needle through the same entry site to finish the injection process.

LIMITATIONS

The sample was a single group of patients evaluated before and after the femoroplasty. We did not include a control group.

CONCLUSION

The results of the current report suggest that femoroplasty, a percutaneous cement placement analogous to a vertebroplasty, might be a therapeutic option for patients with metastatic bone disease of the proximal femur, providing the patient an analgesic reduction and a better quality of life.

Thoracoscopic left splanchnicectomy - role in pain control in unresectable pancreatic cancer. Initial experience

BACKGROUND

The management of opiate-dependent intractable abdominal pain caused by unresectable pancreatic cancer remains challenging. The aim of this study was to evaluate the safety and efficacy of thoracoscopic unilateral left splanchnicectomy for pain control in a first series of 15 patients with unresectable pancreatic cancer.

PATIENTS AND METHODS

Fifteen patients suffering from intractable pain due to unresectable pancreatic cancer (stage III and IV)underwent thoracoscopic unilateral left splanchnicectomy. To assess pain severity and the impact of this palliative procedure for pain relief, all patients completed Wong-Baker Faces Pain Rating Scale with a preoperative pain degree between 7 and 9.

RESULTS

Surgical intervention duration varied from 30 minutes to 1 hour. Pleural drainage tube was removed 24 hours postoperatively.There were no complications nor deaths.Immediate pain relief (pain degree 0-2) was achieved in all patients after thoracoscopic unilateral splanchnicectomy, same level being registered at first check-up after one month.

CONCLUSIONS

Thoracoscopic unilateral left splanchnicectomy decreases the pain substantially and significantly improves the quality of life in patients with unresectable pancreatic cancer.

Synergy-S stereotactic radiosurgery for spinal tumors

BACKGROUND

Radiation treatment of spinal and paraspinal tumors has been limited by the tolerance of the spinal cord. As such, therapeutic options are restricted to surgically accessible lesions or the use of suboptimal dosing of external beam irradiation.

OBJECTIVES

To evaluate the safety and applicability of the Elekta Synergy-S radiation unit for the treatment of spinal tumors.

METHODS

We retrospectively reviewed all patients treated with stereotactic radiosurgery for spinal tumors between November 2007 and June 2011.

RESULTS

Thirty-four patients were treated for 41 lesions. Treatment indications were local tumor control and pain palliation. The mean follow-up was 10.8 +/- 11.6 months (range 0.5-38 months). No acute radiation toxicity or new neurological deficits occurred during the follow-up period. Local tumor control was achieved in 21 of the 24 lesions (87.5%) available for radiological follow-up at a median of 9.8 months (range 3-32 months). Good analgesia was achieved in 24/30 lesions (80%) that presented with intractable pain.

CONCLUSIONS

The safety and feasibility of delivering single and multiple-fraction stereotactic spinal irradiation was demonstrated and became a standard treatment option in our institution.

[Clinical observation of CT guided two needles puncturing crossed through disc for superior hypogastric block to manage intractable pelvic cancer pain]

OBJECTIVE

To observe the feasibility and clinical efficacy of CT guided two needles puncturing crossed through disc for superior hypogastric block with alcohol to manage intractable pelvic cancer pain.

METHODS

Thirty-one cases of advanced pelvic cancer suffering from untreatable pain in lower abdomen in our hospital from December 2009 to May 2012 were analyzed, the patients were treated with both sides of superior hypogastric block with absolute alcohol by CT guided two needles puncturing crossed through L5-S1 interlaminar space. Complications during and after the surgery were recorded. To observe and follow-up visual analog scale pain scores (VAS) and the daily oral morphine consumption on just before operation, at 1 week, 1 and 3 months after operation.

RESULTS

No case suffered serious complication. A week later of surgery the curative effect of 20 patients: clinical cure in 17 cases, excellent in 14 cases, the effective rate was 100%. Compared with preoperation, The score of VAS on 1 week, 1 and 3 months after the surgery (2.0±0.7, 2.3±0.6, 3.0±0.4) were strikingly lower than before operation (7.7±0.7, P < 0.01); The daily oral dose of morphine of post-operation were significantly decreased in the three time points ((35±17) mg, (42±22) mg and (53±19) mg respectively) than the dose of pre-operation ((201±119)mg, P < 0.01).

CONCLUSION

Superior hypogastric block with alcohol with double needles crossed transdiscal approach may be a safe, simple and effective method for relieving the severe pain of advanced pelvic cancer patients.

Abdominal implantation of testicles in the management of intractable testicular pain in Fournier gangrene

Fournier gangrene (FG) is a necrotizing soft tissue infection involving the superficial and fascial planes of the perineum. In many cases of FG, debridement of the scrotum is necessary, leaving definitive management of the exposed testicles a significant surgical challenge. Frequent incidental trauma to the testicles can cause severe pain, especially in laborers. Practical surgical solutions are few and not well detailed. Various options exist, including creating a neoscrotum with adjacent thigh tissue, split-thickness skin grafts (STSGs), or even creating a subcutaneous thigh pocket. We describe a case of abdominal implantation of bilateral testicles for persistent testicular pain in a case where STSGs did not provide adequate protection, adjacent thigh skin was not available for creation of a neoscrotum, and significant cord contracture occurred. We detail the advantages and disadvantages of the commonly described techniques, including this approach, and how in select individuals this may be a suitable alternative.

[Reliving refractory pain of spinal metastasis patients with radiofrequency ablation through transforaminal endoscopy]

OBJECTIVE

To explore the short-term outcomes of radiofrequency ablation treatment of bone metastasis.

METHODS

Between November 2011 and November 2012, a total of 18 cases were retrospectively reviewed. They underwent resection of bone metastasis with radiofrequency ablation through transforaminal endoscopic spine system. According to the Tomita classification system, the classifications were type 5 (n = 8), type 6 (n = 4) and type 7 (n = 6). There were 8 males and 10 females with a median age of 52.1 (32-76) years. The primary lesions were breast cancer (n = 5), carcinoma of prostate (n = 3), digestive cancer (n = 4), thyroid carcinoma (n = 2)and lung cancer (n = 4). And two cases had pathologic fracture.

RESULTS

The operative duration was 118 (90-180) min and blood loss volume 30.6 (10-60) ml. All incisions achieved excellent healing.One case of pneumonia recovered with antibiotic. The postoperative visual analogue scale (VAS) scores were 2.4 ± 0.4, 2.6 ± 0.6, 3.0 ± 0.3 and 2.8 ± 0.7.

CONCLUSION

Radiofrequency ablation through transforaminal endoscopy may be a safe and efficacious option for refractory pain with bone metastasis, especially for those with uncontrolled pain. This procedure is mini-invasive and causes less bleeding.

Cutaneous nerve transection for the management of intractable upper extremity pain caused by invasive squamous cell carcinoma

A recurrent clinical dilemma in the management of patients with painful metastatic lesions is achieving a balance between effective analgesic therapies versus intolerable side effects, in particular altered mental status. We present the case of an immunosuppressed patient post-lung transplant who was suffering from intractable pain caused by widely metastatic squamous cell carcinoma. The patient's progressive, excruciating neuropathic pain was localized to the area of the left wrist and forearm. Additionally, the patient complained of moderate pain at sites of tumor involvement on her right arm and scalp. Attempts to adequately manage her left upper extremity pain included a combination of pharmacologic treatments intended to treat neuropathic pain (gabapentin, SNRI, ketamine, opioids) and focused regional analgesia (infraclavicular infusion of local anesthetic). However, the patient developed intolerable side effects including altered mental status and delirium associated with the systemic agents and suboptimal control with the infraclavicular infusion. Given that the most severe pain was well localized, we undertook a diagnostic block of the cutaneous nerves of the left forearm. As this intervention significantly reduced her pain, we subsequently performed neurectomies to the left superficial radial nerve, lateral cutaneous nerve of the forearm and the posterior cutaneous nerve of the forearm. This resulted in immediate and continued relief of her left upper extremity pain without an altered mental status. Residual focal pain from lesions over her right arm and scalp was successfully managed with daily topical applications of lidocaine and capsaicin cream. Successful pain control continued until the patient's death five months later.

Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience

BACKGROUND

Surgical treatment of chronic pancreatitis is indicated for intractable pain. Frey's procedure is an accepted treatment for this disease. The aim of the present study was to describe a single-centre experience in the treatment of chronic pancreatitis using Frey's procedure.

METHODS

A retrospective analysis of 73 patients who underwent a Frey's procedure between 1991 to 2007 and had at least 1 year of follow-up. Demographics, indication for surgery, peri-operative complications and late outcomes were analysed.

RESULTS

The median age was 39.9 years. Seventy out of the 73 (95.8%) patients were male. The median pre-operative body mass index (BMI) was 19.1 kg/m(2). All patients had abdominal pain, 34 (46.6%) of them daily and 13 (17.8%) weekly, with moderate or severe intensity in 98.6% (n= 72). The aetiology was secondary to alcohol in 70 patients (95.9%), with a median consumption of 278 g per day. The surgical morbidity rate was 28.7%; there were no deaths. Median post-operative follow-up was 77.0 months; 64 patients (91.4%) had complete pain relief and post-operative BMI was 22.4 kg/m(2) (P<0.001). All patients with pre-operative endocrine and exocrine insufficiencies showed no reversal of the situation. New onset insufficiencies appeared late.

CONCLUSIONS

Frey's procedure was a safe and effective therapeutic option for the surgical treatment of patients with intractable pain caused by chronic pancreatitis.

Neurosurgical treatments of intractable pain

Intractable pain may require neurosurgical intervention. This review provides a critical update of neurosurgical techniques available to treat this condition. Neurosurgery can affect pain's pathways from the receptor up to the "centers" of its reception and perception, either by destroying or by stimulating them. Early in neurosurgery's development, and still today, ablative procedures are able to suppress or alleviate pain. However, in most cases, such ablations have only remained effective for a few months or, at best, a few years. This is why, from the 1960s on, a better understanding of the mechanism of pain inspired development of electrical and chemical neuromodulation procedures at every level of the nociceptive system (peripheral nerve, cord, thalamic, periventricular/aqueductal gray, and cortical centers). The encouraging outcomes that resulted are attracting increasing attention and interest among clinicians. The indications for undertaking an ablative vs a neurostimulative procedure, as well as selection of the anatomical target, depend largely on whether pain is nociceptive or neuropathic, given that most of these indications overlap to some extent. In addition, because the published outcomes are not based on universal criteria, it is difficult for the attending physician to select the type of procedure most suitable to the pain problem. This brief review surveys the various neurosurgical procedures together with their corresponding indications in the hope that the information provided will help practitioners choose (1) the type of neurosurgical therapy most appropriate to their patients' needs and (2) the neurosurgical group best equipped to implement that choice.

Bilateral open thoracic cordotomy for refractory cancer pain: a neglected technique?

At least 10% of patients with cancer have pain that is refractory to systemic analgesics. For most of these patients, interventional techniques may be of benefit but are often not considered or are difficult to access. Of these techniques, spinal analgesia is most commonly used in Australia and the United Kingdom, and neurosurgical procedures, such as open cordotomy with sectioning of the spinothalamic tract, are rarely used. We describe a case illustrating the successful use of bilateral open thoracic cordotomy in a patient with refractory mixed nociceptive and neuropathic pain secondary to a lumbosacral tumor. We discuss the various interventional options and review the recent literature regarding the use of both percutaneous and open cordotomy for cancer pain.

[Thoracoscopic sympathsplanchnectomy in treatment of patients with unresectable cancer of the pancreas]

The authors have analyzed experience with treatment of pain syndrome in 45 patients, in 31 of them thoracoscopic sympathsplanchnectomy was fulfilled. The operation was shown to give a pronounced analgetic effect and improved quality of life of patients.

The role of interventional therapies in cancer pain management

Cancer pain is complex and multifactorial. Most cancer pain can be effectively controlled using analgesics in accordance to the WHO analgesic ladder. However, in a small but significant percentage of cancer patients, systemic analgesics fail to provide adequate control of cancer pain. These cancer patients can also suffer from intolerable adverse effects of drug therapy or intractable cancer pain in advance disease. Though the prognosis of these cancer patients is often very limited, the pain relief, reduced medical costs and improvement in function and quality of life from a wide variety of available interventional procedures is extremely invaluable. These interventions can be used as sole agents or as useful adjuncts to supplement analgesics. This review will discuss interventional procedures such as epidural and intrathecal drug infusions, intrathecal neurolysis, sympathetic nervous system blockade, nerve blocks, vertebroplasty and the more invasive neurosurgical procedures. Intrathecal medications including opioids, local anaesthetics, clonidine, and ziconotide will also be discussed.

Screw placement and osteoplasty under computed tomographic-fluoroscopic guidance in a case of advanced metastatic destruction of the iliosacral joint

We present a case of combined surgical screw placement and osteoplasty guided by computed tomography-fluoroscopy (CTF) in a 68-year-old man with unilateral osteolytic destruction and a pathological fracture of the iliosacral joint due to a metastasis from renal cell carcinoma. The patient experienced intractable lower back pain that was refractory to analgesia. After transarterial particle and coil embolization of the tumor-feeding vessels in the angiography unit, the procedure was performed under general anesthesia by an interdisciplinary team of interventional radiologists and trauma surgeons. Under intermittent single-shot CTF, two K wires were inserted into the left iliosacral joint from a lateral transiliac approach at the S1 level followed by two self-tapping surgical screws. Continuous CTF was used for monitoring of the subsequent polymethylmethacrylate injection through two vertebroplasty cannulas for further stabilization of the screw threads within the osteolytic sacral ala. Both the screw placement and cement injection were successful, with no complications occurring during or after the procedure. With additional nonsteroidal anti-inflammatory and opioid medication, the patient reported a marked decrease in his lower back pain and was able to move independently again at the 3-month follow-up assessment. In our patient with intolerable back pain due to tumor destruction and consequent pathological fracture of the iliosacral joint, CTF-guided iliosacral screw placement combined with osteoplasty was successful with respect to joint stabilization and a reduction in the need for analgesic therapy.

Microvascular decompression for glossopharyngeal neuralgia: a long-term retrospectic review of the Milan-Bologna experience in 31 consecutive cases

OBJECTIVE

To examine surgical findings and results of microvascular decompression (MVD) for glossopharyngeal neuralgia (GN).

METHODS

Between 1990 and 2007, 31 consecutive patients affected by drug-resistant GN underwent MVD through a retromastoid keyhole in the supine position with the head rotated to the opposite side. A retrospective analysis was performed that paid particular attention to the relationship among surgical technique, pain control and side effects.

RESULTS

A vascular compression of the glossopharyngeal nerve was found in all cases. Twenty-eight out of 31 patients (90.3%) were found to be pain free without medication at long-term follow-up (1-17 years, mean 7.5 years). Three patients (9.7%) were found to require medication to control pain paroxysms that were less frequent and less severe than those observed preoperatively. Two patients required repeated surgery for a drug-resistant recurrence of pain for a total of 33 MVDs. We observed no mortality and did not find any long-term surgical morbidity. Cranial nerve impairment, when observed, always resolved in the following months.

CONCLUSIONS

MVD is a safe and effective treatment for GN in patients of all ages.

Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency

Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy.

The painless brain: lobotomy, psychiatry, and the treatment of chronic pain and terminal illness

This article examines the use of lobotomy as a treatment for chronic intractable pain and reconstructs then-common perceptions of pain and of the patients who suffered from it. It delineates the social expectations and judgments implicit in physicians' descriptions of the patients, analyzing what was expected from such patients and how the medical establishment responded to non-normative expressions of suffering. I argue that the medicalized response to an expectation for normativity demonstrates the convergence between psychiatric and palliative interventions. Based on a historically informed perspective of psychiatric interventions in the field of pain medicine, I examine the use of psychiatric medications for pain syndromes today and evaluate the interface between depression, chronic pain, and terminal illness. While not detracting from the medical imperative to alleviate pain, I question the usage of social criteria and normative judgments in the clinical decision of how to treat pain. What normalizing social function does the use of psychiatric interventions in pain treatment fulfill? This approach leads to a reexamination of perceptions of dualism in pain medicine.

Clinical characteristics and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan

PURPOSE

This study aimed to evaluate the clinical features and visual outcomes of non-traumatic suprachoroidal haemorrhage (SH) in Taiwan.

METHODS

We report a retrospective, non-comparative, interventional case series study carried out in an institutional setting. Thirty-nine eyes with non-traumatic SH were studied using a new system for grading the severity of SH. The aetiologies of SH were analysed. The correlations between grades and prognoses of SH were studied. Multiple logistic regression was used to assess factors associated with final visual outcome.

RESULTS

Conditions causing SH in the eyes considered in this study included cataract surgery (43.59%), age-related macular degeneration (AMD) (17.95%), filtering operation and vitrectomy (both 10.26%), scleral buckling (5.13%) and others. Twelve eyes (12/39, 30.77%) had a final visual outcome of no light perception. Only 12 eyes (12/39, 30.77%) had final visual acuity (VA) > 4/200. Grade of SH correlated significantly with need for surgical drainage and with final visual outcome (Spearman rank correlations 0.313 and - 0.408, p = 0.010 and p = 0.00317, respectively). 'Good' and 'poor' final VA was significantly associated with VA at the time of SH (multiple logistic regression coefficients 2.132 and - 2.809, p = 0.015 and p = 0.008, respectively), as well as initial retinal detachment (multiple logistic regression coefficients - 2.267 and 2.223, p = 0.036 and p = 0.006, respectively). Higher grades of SH and increased age were associated with poor final visual outcome (multiple logistic regression coefficients - 1.332 and - 0.122, p = 0.013 and p = 0.022, respectively).

CONCLUSIONS

Suprachoroidal haemorrhage is a devastating ocular problem. Complications of intraoperative surgery and AMD are common causes. The new SH grading system provides a simple method for evaluating the need for drainage and for predicting visual prognosis. Visual acuity and retinal detachment at the time of SH are major factors associated with good and poor final VA, respectively.

[A study on neurosurgical treatment for phantom limb pain]

OBJECTIVE

To study the clinical effect of combination of mesencephalotomy with bilateral anterior cingulotomy, and destroy spinal cord dorsal root entry zone (DREZ) treatment for phantom limb pain (PLP).

METHODS

Fifteen patients suffering from PLP secondary to amputation were treated with neurosurgical procedures, including 7 cases of left upper limb pain, 4 cases of right upper limb pain, 1 case of left lower limb pain and 3 cases of right lower limb pain. Group A, the mesencephalotomy and bilateral anterior cingulotomy, were co-performed in 4 patients. Group B, the other 11 patients were treated with DREZ lesion on the same side in the C5-T1 or L2-S1 spinal cord segments. The visual analog scale (VAS) and the McGill pain questionnaire (MPQ) were used for preoperative and postoperative evaluation of the pain status of each patient. Statistical analyses were conducted using paired-samples t test.

RESULTS

All cases had pain relief immediately after operation and did not take medicine. In group A, the short-term (3 months) follow-up results indicated a significant reduction in patients' pain scales (P < 0.01), but pain recurred in 4-18 months after operation. In group B, one patient died of serious lung infection at 2 months after operation. The other 10 patients had pain relief satisfactorily in long-term follow-up period (12-24 months postoperative, P < 0.05). There were no serious complication and surgery-related mortality.

CONCLUSION

The cooperation of mesencephalotomy and bilateral anterior cingulotomy, DREZ lesion are effective methods for relieving PLP. DREZ lesion has a good long-term effect.

Outcome after pituitary radiosurgery for thalamic pain syndrome

PURPOSE

To evaluate outcomes after pituitary radiosurgery in patients with post-stroke thalamic pain syndrome.

METHODS AND MATERIALS

From 2002 to 2006, 24 patients with thalamic pain syndrome underwent pituitary radiosurgery at Tokyo Women's Medical University and were followed at least 12 months thereafter. The radiosurgical target was defined as the pituitary gland and its connection with the pituitary stalk. The maximum dose varied from 140 to 180 Gy. Mean follow-up after treatment was 35 months (range, 12-48 months).

RESULTS

Initial pain reduction, usually within 48 h after radiosurgery, was marked in 17 patients (71%). However, in the majority of cases the pain recurred within 6 months after treatment, and at the time of the last follow-up examination durable pain control was marked in only 5 patients (21%). Ten patients (42%) had treatment-associated side effects. Anterior pituitary abnormalities were marked in 8 cases and required hormonal replacement therapy in 3; transient diabetes insipidus was observed in 2 cases, transient hyponatremia in 1, and clinical deterioration due to increase of the numbness severity despite significant reduction of pain was seen once.

CONCLUSIONS

Pituitary radiosurgery for thalamic pain results in a high rate of initial efficacy and is accompanied by acceptable morbidity. It can be used as a primary minimally invasive management option for patients with post-stroke thalamic pain resistant to medical therapy. However, in the majority of cases pain recurrence occurs within 1 year after treatment.

[Effect of neurolysis on intractable greater occipital nerve neuralgia]

OBJECTIVE

To investigate the effect of neurolysis on intractable greater occipital nerve neuralgia.

METHODS

From March 1998 to August 2005, twenty-six patients suffering from intractable greater occipital nerve neuralgia were treated. There were 12 males and 14 females with an average age of 52 years (ranged 38-63 years). The disease course was 3-7 years. Sixteen cases had a long duration of work with bowing head, 5 cases symptoms appeared after trauma, and others had no identified causes. The visual analogue scales (VAS) scoring was 6.0 to 9.5, averaged 8. 6. Seven cases were treated by apocope of obliquus capitis inferior under general anaesthesia and 19 cases were treated by neurolysis of greater occipital nerve under local anaesthesia. The compression mass were examined.

RESULTS

Symptoms ameliorated or disappeared in 26 cases immediately after operation. The wounds healed by first intention. The pathological results of the removal mass included lymph node (3 cases), neurilemmoma (2 cases) and scar (5 cases). The VAS scoring of 26 cases was 0 to 5 (average, 2) 3 days after operation. Twenty-three cases were followed up for 1 to 3 years. The VAS scoring of 23 cases was 0 to 4.5 ( average, 1.9) 1 months after operation. Only two cases recurred and the symptoms were ameliorated. Pain aggavated after tiredness and reliveed after oral anti-inflammatory analgesics in 6 cases. No relapse occurred in the others.

CONCLUSION

The complete neurolysis of greater occipital nerve (including apocope of obliquus capitis inferior, release between the cucullaris and semispinalis) which make the greater occipital nerve goes without any compression is the key point to treat intractable greater occipital nerve neuralgia.

Demineralized bone matrix composite grafting for posterolateral spinal fusion

In a prospective series, the 24-month fusion status was evaluated radiographically among patients undergoing instrumented posterolateral lumbosacral spinal fusion. Seventy-three patients had a diagnosis of degenerative disk disease or degenerative spondylolisthesis and had supplemental bone grafting with demineralized bone matrix (DBM) putty (Grafton DBM; Osteotech, Eatontown, NJ) enriched with aspirated bone marrow (DBM bone marrow), DBM putty combined with iliac crest autograft (DBM autograft), or autograft. Overall, approximately 63% (12 of 19) of DBM bone marrow, 70% (19 of 27) of DBM autograft, and 67% (18 of 27) of autograft patients were fused at 24 months (P = .875). These findings suggest that both DBM composites offer similar performance to autograft in posterolateral spinal fusion.