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432 COMBINED USE OF SPINAL CORD STIMULATION AND INTRATHECAL THERAPY FOR TREATMENT OF COMPLEX REGIONAL PAIN SYNDROME TYPE 1
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Conclusions: The satisfactory outcome of these two patients demonstrated that stereotactic anterior cingulotomy would be a valuable alternative in management of patients with intractable neuropathic pain caused by spinal cord trauma. 429 THE THERAPEUTIC STRATEGY THAT IS APPLIED IN THE CLINIQUE GALENUS CASE REPORT OF A PATIENT WITH UNDETERMINED NEUROPATHIC PAIN A. Vaso, A. Mitrushi, P. Pifti. The Clinique “Galenus”: Multidisciplinary Medical Centre for the Treatment of the Chronic Pain and that of the Cancer, Tirana, Albania Introduction: The casuistic represents a disabled female patient, 42 years old with undetermined neuropathic pain, since more than 9 years, started after the surgical intervention of laminectomy performed for a discal hernia at the level of the L5/S1 vertebrae. Objectives: Putting into evidence the update treating methods undertaking to a patient with neuropathic pain. Methods/results: In the long history of the disease are included consecutively the update methods of the treatment of the neuropathic pain: 1. In 2001 the patient performed the operation of the laminectomia at the level of the L5/S1 vertebrae, which resulted unsuccessful for the pain release. 2. For 7–8 years has been treated by anti-inflammatory drugs and analgesics. 3. In the 2008 the patient was presented at the Clinique “Galenus”, a multidisciplinary Medical Centre for the treatment of the chronic pain in Tirana. After the first diagnostic evaluation, was done the epidural injection with interlaminated method at the level of the laminectomia. 4. After that the patient followed a rehabilitating program not yet with satisfied impact. 5. The re-installation of the pain was accompanied by trophic wounds, allodynia, and sudomotore changes. Further examinations suggested the diagnosis of the extensive fibrosis that included the intervenoused zone and epidural area, without concern on paravertebral sympathetic ganglion. 6. Lastly a bilateral epidural injection and radiofrequency of the dorsal branch of the concerned spinal ganglion removed the symptoms. Conclusions: The therapeutic methods against the neuropathic pain must be associated with periodic diagnostic procedures. The most significant ones are: epidural injections, sympathetic blocks, radiofrequency, rehabilitation. 430 ELECTRO-ACUPUNCTURE MAPPING: A NOVEL TECHNIQUE TO PREDICT FEASIBILITY AND OUTCOME OF PERIPHERAL NERVE AND SUBCUTANEOUS STIMULATION IN NEUROPATHIC PAIN C. Wille1 , A. Schmitz2 , J. Vesper1 . 1 Neurosurgical Department, 2 Department of Anaesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany Introduction: Peripheral nerve stimulation (PNS) is known to deliver targeted relief of neuropathic pain in peripheral nerve disorders. All patients need invasive electrode placement and external test stimulation before feasibility and outcome become apparent. A minimally invasive method to determine favourable electrode position and predict stimulation outcome is missing. Objectives: Aim of this ongoing single centre open label trail is to validate electro-acupuncture mapping as a test tool for PNS. Technique and preliminary results of five patients are presented. Methods: Patients with mononeuropathy and pharmacoresistant neuropathic pain are included. A rectangular pattern of acupuncture needles is placed subcutaneously to cover the proximity of the pain area. The pattern is scanned with 180ms impulses at 2Hz and 80Hz. All patients receive a subcutaneous or perineural octrode
(SJM) at the site with most suitable effects for pain reduction. A generator (EON mini, SJM) is implanted after successful external stimulation. PD-Q, VAS, MOS Sleep Scale, FFbH and SF 12® are used for standardized follow up. Results: 5 patients with posttraumatic neuropathic pain have been treated. Electrode placements were subcutaneously in 4 and perineural in 1 patient. Electro-acupuncture predicted stimulation results correctly in all 5 patients with sufficient pain reduction in 4 and no lasting therapeutic effects in 1 patient. Median follow up is 6 months. Conclusion: Electro-acupuncture is a minimal invasive technique used for pain management in TCM. Utilized as a mapping tool prior to PNS our preliminary results suggest a predictive value regarding optimal electrode placement and stimulation outcome. 431 TREATMENT OF NEUROPATHIC PAIN WITH INTRATHECAL ZICONOTIDE E. Vogt, L.M. Macrea, W. Schleinzer. Swiss Paraplegic Center, Nottwil, Switzerland Introduction: Neuropathic pain is a considerable burden that affects patients in all activities of daily living. Ziconotide is the only N-type calcium channel blocker approved for the intrathecal treatment of chronic pain. Objectives: In this first preliminary studies we evaluated the effect of Ziconotide on patients with severe neuropathic pain syndromes. Methods: Prospective cohort study on patients with an implanted intrathecal pump or catheter in which the standard intrathecal medications has failed. Results: We report on ten patients patient with an already implanted intrathecal pump in which intrathecal Ziconotide was tested. The median age 48 (60% were males). There were three patients with intractable brachial plexus avulsion pain, two patients with spinal cord injury pain, two patients with failed back surgery, one patient with traumatic painful radial nerve injury, one with osteoporosis deformans of thoracic spine and one patient with a complex regional pain syndrome CRPS-type-II of the hand. Therapy is actually continued in four patients (two brachial plexus lesions, CRPS and osteoporosis) with a mean followup of 395 days. In three patients the trial had to be stopped because of psychiatric side effects (mean Ziconotide dose 7.2 mcg). In three patients the trial was stopped because of lack of therapeutic effect (mean Ziconotide dose 14.1 mcg). Conclusions: Ziconotide may be an therapeutic option in patients with refractory neuropathic pain conditions and an implanted intrathecal pump. Therapeutic failure and psychiatric symptoms are the major limitations of the therapy. 432 COMBINED USE OF SPINAL CORD STIMULATION AND INTRATHECAL THERAPY FOR TREATMENT OF COMPLEX REGIONAL PAIN SYNDROME TYPE 1 A. Yakovlev1 , S. Karasev2 . 1 Comprehensive Pain Management of the Fox Valley, Appleton, WI, USA; 2 Comprehensive Pain Management of the Fox Valley, Samara, Russia Introduction: Patients with complex regional pain syndrome (CRPS) type 1 may continue to experience intractable pain despite conventional treatments including pain medications, sympathetic blocks and physical therapy. Spinal cord stimulation (SCS) has been used to treat patients with CRPS type 1. Unfortunately not all the patients have adequate pain control despite the use of neuromodulation techniques. Objectives: Consideration of the multiple device therapy for management of severe intractable pain patients with CRPS type 1. Methods: The patient is 42 year old female with history of CRPS type 1 right upper extremity who underwent placementnt of SCS which gave the patient excellent pain relief for 16 months
Posters / European Journal of Pain Supplements 4 (2010) 47–146
after implantation of RestoreUltra rechargeable generator and two 8-electrode standard Octad Leads (Medtronic Inc., Minneapolis, MN) at C4-C5-C6 level. Later the pain in the right arm came back despite adequate stimulation. She failed conservative therapy and repeated sympathetic blocks. She had successful intrathecal trial with morphine and two weeks later underwent intrathecal pump placement. Results: After implantation of intrathecal device the patient reported complete relief of the pain by combined use of SCS and intrathecal pump. She was able to discontinue use of all oral pain medications. She also was able to return to social, occupational and sport activities. Conclusions: The multiple device therapy can be effective and safe option in the management severe intractable pain for patients who exhausted traditional and even advanced treatments like neuromodulation techniques.
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conservative treatment and sympathetic blocks. She underwent successful trial of percutaneous placement of two 8-electrode epidural leads (Medtronic Inc., Minneapolis, MN). Epidural access was gained at the L1/L2 interspace with final leads positioned at T9-T10-T11. During SCS trial patient reported greater than 50% improvement of the pain and two weeks later underwent placement of permanent leads and RestorePRIME non-rechargeable generator. Results: After final implantation, patient had excellent pain relief at 12 months. She discontinued use of all oral pain medications. She had improvement of functional capacity. The patient’s walking distance increased from less than 30 m to more than 400 m. Conclusions: SCS can be effective option in the management of intractable pain related to alcoholic neuropathy in selected patients who in the past exhausted all available treatments and also lead to functional improvement for this type of patients. This technique with comparatively low invasiveness is relatively easy to perform and a safe procedure for otherwise intractable condition.
433 PERIPHERAL NERVE STIMULATION FOR TREATMENT OF INTRACTABLE NEUROPATHIC FACIAL PAIN A. Yakovlev, S. Karasev, V. Yakovleva. Comprehensive Pain Management of the Fox Valley, Appleton, WI, USA Introduction: The treatment of patients with neuropathic facial pain developed after facial surgery or trauma can be difficult. Control of pain can be challenging to achieve, despite multiple treatment modalities available in the field of pain management. Medical treatment is often ineffective and wrought with intolerable side effects. Surgical approaches are not reliable. Peripheral nerve stimulation (PNS) has been used to treat a variety of neuropathies, including supraorbital, ileoinguinal, occipital, post-herpetic, and trigeminal with excellent relief of pain. Management of neuropathic facial pain using PNS can be effective modality. Objectives: Alternative treatment of neuropathic facial pain. Methods: Six patients suffering from intractable neuropathic facial pain underwent PNS placement. One of them was male and five were females aged from 22 to 74. The patients failed conservative therapy and received no pain relief after different nerve blocks. The patients underwent successful two days trial of percutaneous placement of one or two 8-electrode leads. The leads were placed in mandibular, infraorbital or supraorbital areas. Two weeks later the patients underwent implantation with permanent leads placed subdermally and RestoreULTRA (Medtronic Inc.) rechargeable generators.. Results: At 12 months post-implant, the patients continued to report good pain control and improved functional status. All patients were able to decrease or discontinue use of pain medications. Conclusions: PNS may be a safe and effective technique for patients with neuropathic facial pain who in the past exhausted all available treatments. PNS is an important adjuvant treatment which may make its own niche in the therapy algorithm for this group of patients. 434 SPINAL CORD STIMULATION FOR TREATMENT OF ALCOHOLIC NEUROPATHY; A CASE REPORT A. Yakovlev, S. Karasev, V. Yakovleva. Comprehensive Pain Management of the Fox Valley, Appleton, WI, USA Introduction: Patients with alcoholic neuropathy may suffer from intractable pain in the extremities and functional incapacitation despite conventional medical treatment and physical therapy. Spinal cord stimulation (SCS) has been used to treat patients with pain in the upper and lower extremities related to peripheral neuropathy from different causes. Objectives: Application of SCS for treatment of pain related to alcoholic neuropathy. Methods: The patient is 46 year old female with history of chronic bilateral leg pain related to alcoholic neuropathy who failed
Thoracic eight-electrode leads. 435 COMPARATIVE STUDY BETWEEN CONTINUOUS ULTRASONIC GUIDED SUPRASCAPULAR NERVE BLOCK, INTRA-ARTICULAR CORTICOSTEROID AND OR PHYSIOTHERAPY IN RELIEF CHRONIC SHOULDER PAIN M. Yosry1 , M.E. Abdelshafi2 , A.F. Elmulla3 , E. Al-Dosoky Al-Shahawy4 , M. Abdou Aly4 , E. Abdul-Kader Eliewa4 . 1 Pain Management and Anesthesia, Cairo University, Giza, 2 Pain Management and Anesthesia, Zagazig University, Zagazig, 3 Pain Management and Anesthesia, Alexandria University, Alexandria, 4 Rheumatology & Rehabilitation, Zagazig University, Zagazig, Egypt Introduction: Shoulder pain is one of the most common complaints in pain clinics and rheumatology departments. Objectives: We compared the effectiveness of continuous suprascapular nerve block versus intra-articular corticosteroid injection and/or physiotherapy in management of chronic shoulder pain. Methods: 50 patients (63 shoulders) with chronic shoulder pain were invited to participate the study. shoulders were randomly divided into (Group I) include 23 shoulders received continuous suprascapular nerve block under ultrasound guidance plus rehabilitation program. Group II include 20 shoulders received intra-articular injection of steroid in addition to rehabilitation program while Group III include 20 shoulders received rehabilitation program only. The patients were followed up for 12 weeks and reviewed for Pain, disability, and range of movement data at weeks 1, 4, and 12 after each treatment. Results: From the first week to 12 weeks, there was marked improvement in pain score in all times of follow up, and the best improvement in group I, while disability score showed improvement but with non significant difference over the three time periods. Highly significant mean changes were found in group I (p = 0.001)
Posters / European Journal of Pain Supplements 4 (2010) 47–146
Conclusions: The satisfactory outcome of these two patients demonstrated that stereotactic anterior cingulotomy would be a valuable alternative in management of patients with intractable neuropathic pain caused by spinal cord trauma. 429 THE THERAPEUTIC STRATEGY THAT IS APPLIED IN THE CLINIQUE GALENUS CASE REPORT OF A PATIENT WITH UNDETERMINED NEUROPATHIC PAIN A. Vaso, A. Mitrushi, P. Pifti. The Clinique “Galenus”: Multidisciplinary Medical Centre for the Treatment of the Chronic Pain and that of the Cancer, Tirana, Albania Introduction: The casuistic represents a disabled female patient, 42 years old with undetermined neuropathic pain, since more than 9 years, started after the surgical intervention of laminectomy performed for a discal hernia at the level of the L5/S1 vertebrae. Objectives: Putting into evidence the update treating methods undertaking to a patient with neuropathic pain. Methods/results: In the long history of the disease are included consecutively the update methods of the treatment of the neuropathic pain: 1. In 2001 the patient performed the operation of the laminectomia at the level of the L5/S1 vertebrae, which resulted unsuccessful for the pain release. 2. For 7–8 years has been treated by anti-inflammatory drugs and analgesics. 3. In the 2008 the patient was presented at the Clinique “Galenus”, a multidisciplinary Medical Centre for the treatment of the chronic pain in Tirana. After the first diagnostic evaluation, was done the epidural injection with interlaminated method at the level of the laminectomia. 4. After that the patient followed a rehabilitating program not yet with satisfied impact. 5. The re-installation of the pain was accompanied by trophic wounds, allodynia, and sudomotore changes. Further examinations suggested the diagnosis of the extensive fibrosis that included the intervenoused zone and epidural area, without concern on paravertebral sympathetic ganglion. 6. Lastly a bilateral epidural injection and radiofrequency of the dorsal branch of the concerned spinal ganglion removed the symptoms. Conclusions: The therapeutic methods against the neuropathic pain must be associated with periodic diagnostic procedures. The most significant ones are: epidural injections, sympathetic blocks, radiofrequency, rehabilitation. 430 ELECTRO-ACUPUNCTURE MAPPING: A NOVEL TECHNIQUE TO PREDICT FEASIBILITY AND OUTCOME OF PERIPHERAL NERVE AND SUBCUTANEOUS STIMULATION IN NEUROPATHIC PAIN C. Wille1 , A. Schmitz2 , J. Vesper1 . 1 Neurosurgical Department, 2 Department of Anaesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany Introduction: Peripheral nerve stimulation (PNS) is known to deliver targeted relief of neuropathic pain in peripheral nerve disorders. All patients need invasive electrode placement and external test stimulation before feasibility and outcome become apparent. A minimally invasive method to determine favourable electrode position and predict stimulation outcome is missing. Objectives: Aim of this ongoing single centre open label trail is to validate electro-acupuncture mapping as a test tool for PNS. Technique and preliminary results of five patients are presented. Methods: Patients with mononeuropathy and pharmacoresistant neuropathic pain are included. A rectangular pattern of acupuncture needles is placed subcutaneously to cover the proximity of the pain area. The pattern is scanned with 180ms impulses at 2Hz and 80Hz. All patients receive a subcutaneous or perineural octrode
(SJM) at the site with most suitable effects for pain reduction. A generator (EON mini, SJM) is implanted after successful external stimulation. PD-Q, VAS, MOS Sleep Scale, FFbH and SF 12® are used for standardized follow up. Results: 5 patients with posttraumatic neuropathic pain have been treated. Electrode placements were subcutaneously in 4 and perineural in 1 patient. Electro-acupuncture predicted stimulation results correctly in all 5 patients with sufficient pain reduction in 4 and no lasting therapeutic effects in 1 patient. Median follow up is 6 months. Conclusion: Electro-acupuncture is a minimal invasive technique used for pain management in TCM. Utilized as a mapping tool prior to PNS our preliminary results suggest a predictive value regarding optimal electrode placement and stimulation outcome. 431 TREATMENT OF NEUROPATHIC PAIN WITH INTRATHECAL ZICONOTIDE E. Vogt, L.M. Macrea, W. Schleinzer. Swiss Paraplegic Center, Nottwil, Switzerland Introduction: Neuropathic pain is a considerable burden that affects patients in all activities of daily living. Ziconotide is the only N-type calcium channel blocker approved for the intrathecal treatment of chronic pain. Objectives: In this first preliminary studies we evaluated the effect of Ziconotide on patients with severe neuropathic pain syndromes. Methods: Prospective cohort study on patients with an implanted intrathecal pump or catheter in which the standard intrathecal medications has failed. Results: We report on ten patients patient with an already implanted intrathecal pump in which intrathecal Ziconotide was tested. The median age 48 (60% were males). There were three patients with intractable brachial plexus avulsion pain, two patients with spinal cord injury pain, two patients with failed back surgery, one patient with traumatic painful radial nerve injury, one with osteoporosis deformans of thoracic spine and one patient with a complex regional pain syndrome CRPS-type-II of the hand. Therapy is actually continued in four patients (two brachial plexus lesions, CRPS and osteoporosis) with a mean followup of 395 days. In three patients the trial had to be stopped because of psychiatric side effects (mean Ziconotide dose 7.2 mcg). In three patients the trial was stopped because of lack of therapeutic effect (mean Ziconotide dose 14.1 mcg). Conclusions: Ziconotide may be an therapeutic option in patients with refractory neuropathic pain conditions and an implanted intrathecal pump. Therapeutic failure and psychiatric symptoms are the major limitations of the therapy. 432 COMBINED USE OF SPINAL CORD STIMULATION AND INTRATHECAL THERAPY FOR TREATMENT OF COMPLEX REGIONAL PAIN SYNDROME TYPE 1 A. Yakovlev1 , S. Karasev2 . 1 Comprehensive Pain Management of the Fox Valley, Appleton, WI, USA; 2 Comprehensive Pain Management of the Fox Valley, Samara, Russia Introduction: Patients with complex regional pain syndrome (CRPS) type 1 may continue to experience intractable pain despite conventional treatments including pain medications, sympathetic blocks and physical therapy. Spinal cord stimulation (SCS) has been used to treat patients with CRPS type 1. Unfortunately not all the patients have adequate pain control despite the use of neuromodulation techniques. Objectives: Consideration of the multiple device therapy for management of severe intractable pain patients with CRPS type 1. Methods: The patient is 42 year old female with history of CRPS type 1 right upper extremity who underwent placementnt of SCS which gave the patient excellent pain relief for 16 months
Posters / European Journal of Pain Supplements 4 (2010) 47–146
after implantation of RestoreUltra rechargeable generator and two 8-electrode standard Octad Leads (Medtronic Inc., Minneapolis, MN) at C4-C5-C6 level. Later the pain in the right arm came back despite adequate stimulation. She failed conservative therapy and repeated sympathetic blocks. She had successful intrathecal trial with morphine and two weeks later underwent intrathecal pump placement. Results: After implantation of intrathecal device the patient reported complete relief of the pain by combined use of SCS and intrathecal pump. She was able to discontinue use of all oral pain medications. She also was able to return to social, occupational and sport activities. Conclusions: The multiple device therapy can be effective and safe option in the management severe intractable pain for patients who exhausted traditional and even advanced treatments like neuromodulation techniques.
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conservative treatment and sympathetic blocks. She underwent successful trial of percutaneous placement of two 8-electrode epidural leads (Medtronic Inc., Minneapolis, MN). Epidural access was gained at the L1/L2 interspace with final leads positioned at T9-T10-T11. During SCS trial patient reported greater than 50% improvement of the pain and two weeks later underwent placement of permanent leads and RestorePRIME non-rechargeable generator. Results: After final implantation, patient had excellent pain relief at 12 months. She discontinued use of all oral pain medications. She had improvement of functional capacity. The patient’s walking distance increased from less than 30 m to more than 400 m. Conclusions: SCS can be effective option in the management of intractable pain related to alcoholic neuropathy in selected patients who in the past exhausted all available treatments and also lead to functional improvement for this type of patients. This technique with comparatively low invasiveness is relatively easy to perform and a safe procedure for otherwise intractable condition.
433 PERIPHERAL NERVE STIMULATION FOR TREATMENT OF INTRACTABLE NEUROPATHIC FACIAL PAIN A. Yakovlev, S. Karasev, V. Yakovleva. Comprehensive Pain Management of the Fox Valley, Appleton, WI, USA Introduction: The treatment of patients with neuropathic facial pain developed after facial surgery or trauma can be difficult. Control of pain can be challenging to achieve, despite multiple treatment modalities available in the field of pain management. Medical treatment is often ineffective and wrought with intolerable side effects. Surgical approaches are not reliable. Peripheral nerve stimulation (PNS) has been used to treat a variety of neuropathies, including supraorbital, ileoinguinal, occipital, post-herpetic, and trigeminal with excellent relief of pain. Management of neuropathic facial pain using PNS can be effective modality. Objectives: Alternative treatment of neuropathic facial pain. Methods: Six patients suffering from intractable neuropathic facial pain underwent PNS placement. One of them was male and five were females aged from 22 to 74. The patients failed conservative therapy and received no pain relief after different nerve blocks. The patients underwent successful two days trial of percutaneous placement of one or two 8-electrode leads. The leads were placed in mandibular, infraorbital or supraorbital areas. Two weeks later the patients underwent implantation with permanent leads placed subdermally and RestoreULTRA (Medtronic Inc.) rechargeable generators.. Results: At 12 months post-implant, the patients continued to report good pain control and improved functional status. All patients were able to decrease or discontinue use of pain medications. Conclusions: PNS may be a safe and effective technique for patients with neuropathic facial pain who in the past exhausted all available treatments. PNS is an important adjuvant treatment which may make its own niche in the therapy algorithm for this group of patients. 434 SPINAL CORD STIMULATION FOR TREATMENT OF ALCOHOLIC NEUROPATHY; A CASE REPORT A. Yakovlev, S. Karasev, V. Yakovleva. Comprehensive Pain Management of the Fox Valley, Appleton, WI, USA Introduction: Patients with alcoholic neuropathy may suffer from intractable pain in the extremities and functional incapacitation despite conventional medical treatment and physical therapy. Spinal cord stimulation (SCS) has been used to treat patients with pain in the upper and lower extremities related to peripheral neuropathy from different causes. Objectives: Application of SCS for treatment of pain related to alcoholic neuropathy. Methods: The patient is 46 year old female with history of chronic bilateral leg pain related to alcoholic neuropathy who failed
Thoracic eight-electrode leads. 435 COMPARATIVE STUDY BETWEEN CONTINUOUS ULTRASONIC GUIDED SUPRASCAPULAR NERVE BLOCK, INTRA-ARTICULAR CORTICOSTEROID AND OR PHYSIOTHERAPY IN RELIEF CHRONIC SHOULDER PAIN M. Yosry1 , M.E. Abdelshafi2 , A.F. Elmulla3 , E. Al-Dosoky Al-Shahawy4 , M. Abdou Aly4 , E. Abdul-Kader Eliewa4 . 1 Pain Management and Anesthesia, Cairo University, Giza, 2 Pain Management and Anesthesia, Zagazig University, Zagazig, 3 Pain Management and Anesthesia, Alexandria University, Alexandria, 4 Rheumatology & Rehabilitation, Zagazig University, Zagazig, Egypt Introduction: Shoulder pain is one of the most common complaints in pain clinics and rheumatology departments. Objectives: We compared the effectiveness of continuous suprascapular nerve block versus intra-articular corticosteroid injection and/or physiotherapy in management of chronic shoulder pain. Methods: 50 patients (63 shoulders) with chronic shoulder pain were invited to participate the study. shoulders were randomly divided into (Group I) include 23 shoulders received continuous suprascapular nerve block under ultrasound guidance plus rehabilitation program. Group II include 20 shoulders received intra-articular injection of steroid in addition to rehabilitation program while Group III include 20 shoulders received rehabilitation program only. The patients were followed up for 12 weeks and reviewed for Pain, disability, and range of movement data at weeks 1, 4, and 12 after each treatment. Results: From the first week to 12 weeks, there was marked improvement in pain score in all times of follow up, and the best improvement in group I, while disability score showed improvement but with non significant difference over the three time periods. Highly significant mean changes were found in group I (p = 0.001)