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31 NEUROPATHIC PAIN MANAGEMENT: EFFICACY, SAFETY, COMPLICATIONS OF INTERVENTIONAL TECHNIQUES: SPINAL CORD STIMULATION
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Oral presentations / European Journal of Pain Supplements 4 (2010) 1–46
There have been a variety of economic studies on intrathecal pumps ranging from cost modelling to cost utility analyses. Intrathecal analgesia is found to be more cost-effective than systemic medication beyond 3 to 6 months for cancer pain and beyond 11 to 22 months for non-cancer pain. Cost analysis by Bedder et al suggests that an external pump system should be used if patient’s survival is expected to be less than 3 months. Kumar et al looked at the cost of implanting a programmable drug delivery pump vs. conservative treatment of chronic pain. Successful outcomes were measured using the pain scales, ODI (Oswestry Disability Index) and QOL (Quality of Life). Further clinical studies are needed to evaluate the efficacy and safety of new intrathecal drugs (e.g. ziconotide, gabapentin), the combination of intrathecal drugs, the potential complications of therapy or those related to these devices and the proper selection of patients to receive these treatments. 31 NEUROPATHIC PAIN MANAGEMENT: EFFICACY, SAFETY, COMPLICATIONS OF INTERVENTIONAL TECHNIQUES: SPINAL CORD STIMULATION A. Koulousakis. Department of Stereotaxy & Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany Introduction: The method of spinal cord stimulation (SCS) for the treatment of chronic pain, is established since more than 40 years. In the past years we see more clinical literature, which show the evidence and efficacy of SCS in the treatment of chronic neuropathic pain especially FBSS and CRPS I (North 2005, Kumar 2008). The cost-effectiveness of SCS implantation in these two pain syndromes has been well studied. The selection of patients is of utmost importance. SCS implantation is most effective in managing patients with neuropathic pain. In patients with mixed nociceptive and neuropathic pain (eg, FBSS), only those with predominant radicular pain should be considered. Patients with a past or current history of substance abuse are also typically excluded. Following a thorough assessment by a pain specialist, an assessment of psychosocial issues by an experienced practitioner is important. Methods: Since 1977 we have treated more than 1600 patients with SCS for mainly chronic neuropathic pain. The treatment has changed from radiofrequency systems and monopolar leads, to multiple leads or paddle leads and rechargeable fully implantable impuls generators. Evaluation was performed according to CSS (Cologne Score Scale). That includes VAS (Visual Analogue Score) 0–10, pain reduction 0–10 and QOL (Quality of Life) 0–10. The length follow-up is 20 years. Results: Best results were seen in patients with radicular leg pain (mean pain reduction 60%). In 40% of the patients the opioid reduction was more than 50%. About 15% returned to work. Similar results are documented for patient with CRPS I. In this group we additionally see improved motor function and reduction of the oedema. The long term results show reduction in improvement but even after ten years more than 40% of the patients have a pain reduction of 40%. The technical development of the hardware, helps to further improve the results. Summary: SCS is a safe, efficient and cost effective method in the treatment of chronic neuropathic pain. SCS should be the first step of the invasive Pain-therapy, after WHO I. The meanly success factor is the early treatment before chronification, (North 2003) and if possible before the usage of any opioids.
32 NEUROPATHIC PAIN MANAGEMENT: EFFICACY, SAFETY, COMPLICATIONS OF INTERVENTIONAL TECHNIQUES: RADIOFREQUENCY TECHNIQUES I. Kouroukli. Hippokratio Hospital of Athens, Athens, Greece In clinical practice, the use of RF may be successful at reducing several chronic pain states such as trigeminal neuralgia (TGN), chronic low back pain, postherpetic neuralgia, and complex regional pain syndrome (CRPS). Although RF procedures have been in clinical use for more than 25 years, evidence regarding its efficacy and safety is still lacking. The treatment of TGN with selective RF was recently assessed in 1860 patients in whom drug treatment had failed because of lack of efficacy or severe side effects1 . Results showed that in the 78.8% of excellent cases, pain disappeared immediately; in the 17.5% of good cases, pain was lessened but not relieved completely; in 3.7% of ineffective cases, the patients remained in pain even after a second round of therapy. All complications resolved within seven days; no severe complications occurred. In a retrospective study 2 of 152 consecutive cases of primary TGN which was undertaken to analyze clinical parameters such as effective rate, ineffective rate, and the rate of complications of patients treated with RFT. Results showed a very high effective rate of 94.1% and a low ineffective rate of 2.6%. The rate of complications was 15.8%. In 2001, a systematic review of RCTs3 on RF procedures for spinal pain found six trials that met the inclusion criteria. It was concluded that there is moderate evidence that RF lumbar facet denervation is more effective for chronic low back pain than placebo. Limited evidence exists for efficacy of RF neurotomy in chronic cervical zygapophyseal joint pain after flexion-extension injury. There is limited evidence that RF heating of the dorsal root ganglion is more effective than placebo in chronic cervicobrachialgia. RF has been used for neuropathic pain indications to provide prolonged sympathetic interruption. The use of RF lumbar sympatholysis has been evaluated in the long-term management of patients with sympathetically maintained neuropathic pain who had previously responded to sympathectomy or sympathetic blocks. Despite early successful sympathetic block with RF, longlasting pain relief was difficult to obtain. It was concluded that individualized patient management is necessary when considering RF sympatholysis in the treatment of patients with SMP. Radiofrequency techniques have the advantage of being technically simple, safe with very few complications. There is a real need for further high-quality RCTs to determine its efficacy. To enable future well-designed RCTs, efforts should be made to standardize the diagnostic criteria, the procedure, and documentation of treatment outcome.
Keynote Session: Stimulation of the Central Nervous System – Mechanisms and Management 33 SPINAL CORD STIMULATION FOR NEUROPATHIC PAIN R. North. The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, USA The efficacy of SCS as a treatment of chronic neuropathic pain has improved during more than 40 years of clinical use. SCS has the advantage of being minimally invasive and reversible. Also, an evenless invasive screening trial offers evidence of treatment outcome before implantation in individual patients. The best results occur when the right equipment is correctly implanted in appropriately selected patients by experienced clinicians.
Oral presentations / European Journal of Pain Supplements 4 (2010) 1–46
There have been a variety of economic studies on intrathecal pumps ranging from cost modelling to cost utility analyses. Intrathecal analgesia is found to be more cost-effective than systemic medication beyond 3 to 6 months for cancer pain and beyond 11 to 22 months for non-cancer pain. Cost analysis by Bedder et al suggests that an external pump system should be used if patient’s survival is expected to be less than 3 months. Kumar et al looked at the cost of implanting a programmable drug delivery pump vs. conservative treatment of chronic pain. Successful outcomes were measured using the pain scales, ODI (Oswestry Disability Index) and QOL (Quality of Life). Further clinical studies are needed to evaluate the efficacy and safety of new intrathecal drugs (e.g. ziconotide, gabapentin), the combination of intrathecal drugs, the potential complications of therapy or those related to these devices and the proper selection of patients to receive these treatments. 31 NEUROPATHIC PAIN MANAGEMENT: EFFICACY, SAFETY, COMPLICATIONS OF INTERVENTIONAL TECHNIQUES: SPINAL CORD STIMULATION A. Koulousakis. Department of Stereotaxy & Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany Introduction: The method of spinal cord stimulation (SCS) for the treatment of chronic pain, is established since more than 40 years. In the past years we see more clinical literature, which show the evidence and efficacy of SCS in the treatment of chronic neuropathic pain especially FBSS and CRPS I (North 2005, Kumar 2008). The cost-effectiveness of SCS implantation in these two pain syndromes has been well studied. The selection of patients is of utmost importance. SCS implantation is most effective in managing patients with neuropathic pain. In patients with mixed nociceptive and neuropathic pain (eg, FBSS), only those with predominant radicular pain should be considered. Patients with a past or current history of substance abuse are also typically excluded. Following a thorough assessment by a pain specialist, an assessment of psychosocial issues by an experienced practitioner is important. Methods: Since 1977 we have treated more than 1600 patients with SCS for mainly chronic neuropathic pain. The treatment has changed from radiofrequency systems and monopolar leads, to multiple leads or paddle leads and rechargeable fully implantable impuls generators. Evaluation was performed according to CSS (Cologne Score Scale). That includes VAS (Visual Analogue Score) 0–10, pain reduction 0–10 and QOL (Quality of Life) 0–10. The length follow-up is 20 years. Results: Best results were seen in patients with radicular leg pain (mean pain reduction 60%). In 40% of the patients the opioid reduction was more than 50%. About 15% returned to work. Similar results are documented for patient with CRPS I. In this group we additionally see improved motor function and reduction of the oedema. The long term results show reduction in improvement but even after ten years more than 40% of the patients have a pain reduction of 40%. The technical development of the hardware, helps to further improve the results. Summary: SCS is a safe, efficient and cost effective method in the treatment of chronic neuropathic pain. SCS should be the first step of the invasive Pain-therapy, after WHO I. The meanly success factor is the early treatment before chronification, (North 2003) and if possible before the usage of any opioids.
32 NEUROPATHIC PAIN MANAGEMENT: EFFICACY, SAFETY, COMPLICATIONS OF INTERVENTIONAL TECHNIQUES: RADIOFREQUENCY TECHNIQUES I. Kouroukli. Hippokratio Hospital of Athens, Athens, Greece In clinical practice, the use of RF may be successful at reducing several chronic pain states such as trigeminal neuralgia (TGN), chronic low back pain, postherpetic neuralgia, and complex regional pain syndrome (CRPS). Although RF procedures have been in clinical use for more than 25 years, evidence regarding its efficacy and safety is still lacking. The treatment of TGN with selective RF was recently assessed in 1860 patients in whom drug treatment had failed because of lack of efficacy or severe side effects1 . Results showed that in the 78.8% of excellent cases, pain disappeared immediately; in the 17.5% of good cases, pain was lessened but not relieved completely; in 3.7% of ineffective cases, the patients remained in pain even after a second round of therapy. All complications resolved within seven days; no severe complications occurred. In a retrospective study 2 of 152 consecutive cases of primary TGN which was undertaken to analyze clinical parameters such as effective rate, ineffective rate, and the rate of complications of patients treated with RFT. Results showed a very high effective rate of 94.1% and a low ineffective rate of 2.6%. The rate of complications was 15.8%. In 2001, a systematic review of RCTs3 on RF procedures for spinal pain found six trials that met the inclusion criteria. It was concluded that there is moderate evidence that RF lumbar facet denervation is more effective for chronic low back pain than placebo. Limited evidence exists for efficacy of RF neurotomy in chronic cervical zygapophyseal joint pain after flexion-extension injury. There is limited evidence that RF heating of the dorsal root ganglion is more effective than placebo in chronic cervicobrachialgia. RF has been used for neuropathic pain indications to provide prolonged sympathetic interruption. The use of RF lumbar sympatholysis has been evaluated in the long-term management of patients with sympathetically maintained neuropathic pain who had previously responded to sympathectomy or sympathetic blocks. Despite early successful sympathetic block with RF, longlasting pain relief was difficult to obtain. It was concluded that individualized patient management is necessary when considering RF sympatholysis in the treatment of patients with SMP. Radiofrequency techniques have the advantage of being technically simple, safe with very few complications. There is a real need for further high-quality RCTs to determine its efficacy. To enable future well-designed RCTs, efforts should be made to standardize the diagnostic criteria, the procedure, and documentation of treatment outcome.
Keynote Session: Stimulation of the Central Nervous System – Mechanisms and Management 33 SPINAL CORD STIMULATION FOR NEUROPATHIC PAIN R. North. The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, USA The efficacy of SCS as a treatment of chronic neuropathic pain has improved during more than 40 years of clinical use. SCS has the advantage of being minimally invasive and reversible. Also, an evenless invasive screening trial offers evidence of treatment outcome before implantation in individual patients. The best results occur when the right equipment is correctly implanted in appropriately selected patients by experienced clinicians.