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Microvascular decompression in patients with trigeminal neuralgia and multiple sclerosis
S21 0
Stereotactic and Functional Neurosurgery - Pain and Frameless Stereotaxy
repositioning the offending vessel, particularlywhen it is an arterioscleroticand tortuous vertebral artery and of straightening the axis of the 5th cranial nerve by thorough resection of surrounding thick arachnoid membrane and careful monitoring of the 8th cranial nerve function. We emphasizethat the new tactics adopted in Group B have made the follow up results of MVD more satisfactory than those in Group A.
I0-28-410 I Microvascular decompression in patients with trigeminal neuralgia and multiple sclerosis
G. Broggi, A. Franzini, D. Servello, I. Dones. Dept. of Neurosurgery. [satuto NazionaleNeurologico "C. Besta" Milano, Ita[y From 1990 to 1995, out of 210 patients operated upon with microvascular decompression (MVD) of a cranial nerve in the posteriorfossa, 12 patients were affected by typical trigeminal neuralgia pain, and MultipleSclerosis (M.S.). The selection criteria to propose to these patients for MVD surgeryincluded: (1) MS diagnosis supported by C.S.F. examinations and MRI (2) Stabilized neurological condition lasting almost two years (3) Absence of demyelinating areas in the pons and medulla, corresponded to trigeminal nuclei anatomy at MRI In all cases but one, a significant vascular conflict on the trigeminal nerve, as jUdgedby the surgeon and by an external neurOlogist on the operativevideo, was found at the surgery. At the long term follow-up (4 to 2 ys). 9 patients who had immediaterelief of symptoms remain pain free. In the 3 patients in whom the MVD procedure was ineffective, including the patient without neurovascularconflict, a percutaneous R.F. thermorizotomy was performed, with benefit but with sensory trigeminal deficit. These data suggest that neurovascular conflicts playa relevant role in the pathogenesis of trigeminal neuralgia in MS patients in whom altered myelin susceptiblemay be expected. Finally the chance to obtain pain disappearance without drugs that may worsen other symptoms of the disease and without sensory deficits must be considered.
I pain and improved perfusion in advanced
10 -28-411 Dorsal column stimulation for control of ischemic peripheral vascular disease Krishna Kumar, John Burgess, A. Verma. University of Saskatchewan, Regina, canada Dorsalcolumnstimulation (DCS) was used in 50 patientsfor pain associated with lower extremity ischemic vascular disease considered to be nonreconstructable. Macrocirculation was studiedby measuringimprovements indoppler peak blood flow studies (PFV), pulse volume recordings (PVR) and claudification distance, while microcirculationwas quantified by measuring transcutaneous partial pressure of oxygen (TcP02) over dorsum of fool. Thirty-nine patients who had a follow-up between 6 and 36 months form the basis of this report. 30/39 (77%) of these cases were considered successful. 9/39 cases failed, with 6 necessitating below knee amputation suggesting increased foot salvage with stimulation. Mean pain relief in the successful group was 75% vs. 20% in failures. The TcP02 increased 122% with successvs, - 3% with failures. The TcP02 tends to increase both in the target and control foot. In successful patients with preimplant TcP02 < 30 mmHg, TcP02 increased significantly 45.5 ± 17 (p < 0.05). Patients with TcP02 of less than 10 or transcutaneouscarbon dioxide partial pressure > 90 invariably end up in amputation within the first three months.Trophic ulcers <2 cm did not heal if TcP02 failed to rise over 25 mm on stimulation. The rate of ulcer healing was 20%. In successful cases the improvement in pain and TcP02 values also correlate with increased blood flow velocities with average increase of 40.4 ± 40.2 cm/sec. (p < 0.05). PVR increased from 5.9 ± 4.8 to 13.4 ± 5.2 (p < 0.01), at the metatarsal level. DCS appeared to be a useful therapeutic modality in selected patients with nonreconstructable ischemic vascular disease by controllingpain and improved perfusion.The mechanismof this beneficial effect is not yet clearly understood.
I0-28-412
1
Clinical results of the microsurgical junctional DREZ coagulation for treatment of deafferentation pain syndromes
B. Prestor, J. Susterslc, V.V. Dolenc. Departmentof Neurosurgery. UHC, Ljubljana, Slovenia In the treatment of intractable deafferentation pain, different neurosurgical procedures in the dorsal root entry zone (DREZ) have proved most effective. The purpose of the study is to demonstrate and evaluate a modified microneurosurgical coagulation procedure in the DREZ, and to analyse clinical results of junctional coagulation DREZ lesions in different pain syndromes. A total of 36 patients (27 males, 11 females) with intractabledeafferentation pain was treated by surgery. The causes of pain syndromeswere: brachialplexus avulsion(BPA)
Thursday, 10 July 1997
(21 cases), postherpetic pain (3 cases), phantom pain (3 cases), peripheral nerve injury (3 cases), reflex sympatic dystrophy (2 cases), spinal cord transsection (1 case) and syringomyelia (5 cases). With the help of microscope the DREZ area of the involved sensory roots was carefully localized. Using a bipolar forceps, on tip of which the depth of penetration was marked (2- 3 mm), a junctional coagulation lesion extended along the DREZ of the pain producing spinal cord segments was made. All the procedures included intraoperative neuromonitoring of the spinal cord evoked potentials using the subpial recording technique. In BPA result was good with more than 50% pain relief in 19 cases out of 21 (90.5%), excellent in 17 cases (80.9%) with more than 70% pain relief, and complete pain relief was achieved in 10 cases out of 21 (47.6%). Follow-upwas 12 to 76 months. In other pain syndromes with follow-up of 18 to 72 months, we achieved excellent result in 10 cases (58.8%), good result in 6 cases (35.3%), and no pain relief in 1 case (5.3%). Transient postoperative neurological disturbancewas revealed in 6 cases (15.8%) lasting up to 8 weeks, permanent disturbance occurred in 1 case (2.6%). The best results were obtained in the cases with deafferentation pain history of more than 1 year. Clinical results of junctional coagulation DREZ lesions in the treatment of deafferentation pain syndromes are very promising. Postoperativecomplications are rare and transient. We believe that the junctional coagulation in a depth of 2-3 mm includesall the structuresimportantfor the generationof deafferentation pain in the DREZ extending to the 5th Rexed's lamina.
I0-28-4131
Neuropathic pain and intrathecal baclofen
T. Taira,H. Kawamura, T. Tanikawa, H. Kawabatake, H. Iseki, A. Ueda, K. Takakura. Dept. of Neurosurgery. Tokyo Womens Medica[College Tokyo, Japan Introduction: Intrathecal administration of baclo!en has become an established treatment for severe spasticity. Baclofen is scarcely known, however, to have an antinociceptive effect. Accumulated evidences suggest its analgesic effect even on neuropathic pain and this is compatible with findings in animal studies. Neuropathic pain is very difficult to treat and development of a new treatment modality is mandatory. We reportour experienceof spinal intrathecalbaclofenfor various types of neuropathicpain and discuss about the possible mechanisms. Malerials and Methods: We investigated thirty patients with neuropathic pain cifvarious origin; poststrokecentral pain: 18, pain due to spinal cord injury: 6, diabetic neuropathy: 2, other neuropathic pain of peripheralorigin: 4. Baclofen (50--100 /1g) was injected through a lumbar puncture once a day and a pain scale was plotted chronologically. Results : Pain relief was noted in 13 (72%) patients with poststroke central pain, 3 (50%) with spinal cord injury and all the patients with peripheral neurogenic pain (100%). Pain relief always started 1-2 hours after the injection and continued for 10--24 hours. Allodynia and hyperalgesia, if present, were also suppressed. Pinpricksensationdid not change at the normal body surface. Side effects were minimal and transient. All the patients did not respond to oral baclofen. Discussion: The presentfindings support the hypothesisthat relative unbalance betweenexcitatory system (NMDA) and inhibitory system (GABA/91ycine) results in neuropathicpain. Because intrathecal baclofen relieves even bilateral neuropathic pain, which is most difficult to manage, a chronic infusion trial is feasible.
I0-28-4141
Feasibility of Iinac radiosurgery through a new planning system A. DeinsbergerI , G. Lanner 1, J . Tidstrand2 , H. Rausch2 . 1 Clinic of
Neurosurgery. Klagenfurt A, 9026 Klagenfurt, Austria, 2 Clinic of Radiation Oncology. Klagenfurt A, 9026 Klagenfurt, Austria In January 1996 we beganat the Clinic of NeurosurgeryKlagenfurtin collaboration with our departmentof Radiation Oncology with Unac Radiosurgery using a new Radiosurgical System; a combination of the University of Florida System with the X-Knife Planning System, Radionics. We use the portable hand on device coupled to the Unac as described by Friedman and Bova in 1989. High precision bearingsin that device control all patients and gantry movements. As a result radiation beam accuracy of the isocenter is improved to 0.2 mm, equal to the Gamma unit. As planning software we use the X-Knffe Treatment Plan from the Radiosurgical System developed in Boston; a program running on a high level 3-D graphics computer workstation to calculate and optimize beam dose to the target volume. In the first 6 months we have treated with this new system 25 patients with 30 lesions. 17 metastases and 7 meningeomas especially located at the skull base. All metastases from adenoid lung cancer and oat cell carcinoma showed good response to the treatment. One metastases from an undifferentiated lung carcinoma responded to radiosurgery for 4 months and began to grow up so surgery became necessary. We had a tumor control rate of 94.1% (16 out of 17).
Stereotactic and Functional Neurosurgery - Pain and Frameless Stereotaxy
repositioning the offending vessel, particularlywhen it is an arterioscleroticand tortuous vertebral artery and of straightening the axis of the 5th cranial nerve by thorough resection of surrounding thick arachnoid membrane and careful monitoring of the 8th cranial nerve function. We emphasizethat the new tactics adopted in Group B have made the follow up results of MVD more satisfactory than those in Group A.
I0-28-410 I Microvascular decompression in patients with trigeminal neuralgia and multiple sclerosis
G. Broggi, A. Franzini, D. Servello, I. Dones. Dept. of Neurosurgery. [satuto NazionaleNeurologico "C. Besta" Milano, Ita[y From 1990 to 1995, out of 210 patients operated upon with microvascular decompression (MVD) of a cranial nerve in the posteriorfossa, 12 patients were affected by typical trigeminal neuralgia pain, and MultipleSclerosis (M.S.). The selection criteria to propose to these patients for MVD surgeryincluded: (1) MS diagnosis supported by C.S.F. examinations and MRI (2) Stabilized neurological condition lasting almost two years (3) Absence of demyelinating areas in the pons and medulla, corresponded to trigeminal nuclei anatomy at MRI In all cases but one, a significant vascular conflict on the trigeminal nerve, as jUdgedby the surgeon and by an external neurOlogist on the operativevideo, was found at the surgery. At the long term follow-up (4 to 2 ys). 9 patients who had immediaterelief of symptoms remain pain free. In the 3 patients in whom the MVD procedure was ineffective, including the patient without neurovascularconflict, a percutaneous R.F. thermorizotomy was performed, with benefit but with sensory trigeminal deficit. These data suggest that neurovascular conflicts playa relevant role in the pathogenesis of trigeminal neuralgia in MS patients in whom altered myelin susceptiblemay be expected. Finally the chance to obtain pain disappearance without drugs that may worsen other symptoms of the disease and without sensory deficits must be considered.
I pain and improved perfusion in advanced
10 -28-411 Dorsal column stimulation for control of ischemic peripheral vascular disease Krishna Kumar, John Burgess, A. Verma. University of Saskatchewan, Regina, canada Dorsalcolumnstimulation (DCS) was used in 50 patientsfor pain associated with lower extremity ischemic vascular disease considered to be nonreconstructable. Macrocirculation was studiedby measuringimprovements indoppler peak blood flow studies (PFV), pulse volume recordings (PVR) and claudification distance, while microcirculationwas quantified by measuring transcutaneous partial pressure of oxygen (TcP02) over dorsum of fool. Thirty-nine patients who had a follow-up between 6 and 36 months form the basis of this report. 30/39 (77%) of these cases were considered successful. 9/39 cases failed, with 6 necessitating below knee amputation suggesting increased foot salvage with stimulation. Mean pain relief in the successful group was 75% vs. 20% in failures. The TcP02 increased 122% with successvs, - 3% with failures. The TcP02 tends to increase both in the target and control foot. In successful patients with preimplant TcP02 < 30 mmHg, TcP02 increased significantly 45.5 ± 17 (p < 0.05). Patients with TcP02 of less than 10 or transcutaneouscarbon dioxide partial pressure > 90 invariably end up in amputation within the first three months.Trophic ulcers <2 cm did not heal if TcP02 failed to rise over 25 mm on stimulation. The rate of ulcer healing was 20%. In successful cases the improvement in pain and TcP02 values also correlate with increased blood flow velocities with average increase of 40.4 ± 40.2 cm/sec. (p < 0.05). PVR increased from 5.9 ± 4.8 to 13.4 ± 5.2 (p < 0.01), at the metatarsal level. DCS appeared to be a useful therapeutic modality in selected patients with nonreconstructable ischemic vascular disease by controllingpain and improved perfusion.The mechanismof this beneficial effect is not yet clearly understood.
I0-28-412
1
Clinical results of the microsurgical junctional DREZ coagulation for treatment of deafferentation pain syndromes
B. Prestor, J. Susterslc, V.V. Dolenc. Departmentof Neurosurgery. UHC, Ljubljana, Slovenia In the treatment of intractable deafferentation pain, different neurosurgical procedures in the dorsal root entry zone (DREZ) have proved most effective. The purpose of the study is to demonstrate and evaluate a modified microneurosurgical coagulation procedure in the DREZ, and to analyse clinical results of junctional coagulation DREZ lesions in different pain syndromes. A total of 36 patients (27 males, 11 females) with intractabledeafferentation pain was treated by surgery. The causes of pain syndromeswere: brachialplexus avulsion(BPA)
Thursday, 10 July 1997
(21 cases), postherpetic pain (3 cases), phantom pain (3 cases), peripheral nerve injury (3 cases), reflex sympatic dystrophy (2 cases), spinal cord transsection (1 case) and syringomyelia (5 cases). With the help of microscope the DREZ area of the involved sensory roots was carefully localized. Using a bipolar forceps, on tip of which the depth of penetration was marked (2- 3 mm), a junctional coagulation lesion extended along the DREZ of the pain producing spinal cord segments was made. All the procedures included intraoperative neuromonitoring of the spinal cord evoked potentials using the subpial recording technique. In BPA result was good with more than 50% pain relief in 19 cases out of 21 (90.5%), excellent in 17 cases (80.9%) with more than 70% pain relief, and complete pain relief was achieved in 10 cases out of 21 (47.6%). Follow-upwas 12 to 76 months. In other pain syndromes with follow-up of 18 to 72 months, we achieved excellent result in 10 cases (58.8%), good result in 6 cases (35.3%), and no pain relief in 1 case (5.3%). Transient postoperative neurological disturbancewas revealed in 6 cases (15.8%) lasting up to 8 weeks, permanent disturbance occurred in 1 case (2.6%). The best results were obtained in the cases with deafferentation pain history of more than 1 year. Clinical results of junctional coagulation DREZ lesions in the treatment of deafferentation pain syndromes are very promising. Postoperativecomplications are rare and transient. We believe that the junctional coagulation in a depth of 2-3 mm includesall the structuresimportantfor the generationof deafferentation pain in the DREZ extending to the 5th Rexed's lamina.
I0-28-4131
Neuropathic pain and intrathecal baclofen
T. Taira,H. Kawamura, T. Tanikawa, H. Kawabatake, H. Iseki, A. Ueda, K. Takakura. Dept. of Neurosurgery. Tokyo Womens Medica[College Tokyo, Japan Introduction: Intrathecal administration of baclo!en has become an established treatment for severe spasticity. Baclofen is scarcely known, however, to have an antinociceptive effect. Accumulated evidences suggest its analgesic effect even on neuropathic pain and this is compatible with findings in animal studies. Neuropathic pain is very difficult to treat and development of a new treatment modality is mandatory. We reportour experienceof spinal intrathecalbaclofenfor various types of neuropathicpain and discuss about the possible mechanisms. Malerials and Methods: We investigated thirty patients with neuropathic pain cifvarious origin; poststrokecentral pain: 18, pain due to spinal cord injury: 6, diabetic neuropathy: 2, other neuropathic pain of peripheralorigin: 4. Baclofen (50--100 /1g) was injected through a lumbar puncture once a day and a pain scale was plotted chronologically. Results : Pain relief was noted in 13 (72%) patients with poststroke central pain, 3 (50%) with spinal cord injury and all the patients with peripheral neurogenic pain (100%). Pain relief always started 1-2 hours after the injection and continued for 10--24 hours. Allodynia and hyperalgesia, if present, were also suppressed. Pinpricksensationdid not change at the normal body surface. Side effects were minimal and transient. All the patients did not respond to oral baclofen. Discussion: The presentfindings support the hypothesisthat relative unbalance betweenexcitatory system (NMDA) and inhibitory system (GABA/91ycine) results in neuropathicpain. Because intrathecal baclofen relieves even bilateral neuropathic pain, which is most difficult to manage, a chronic infusion trial is feasible.
I0-28-4141
Feasibility of Iinac radiosurgery through a new planning system A. DeinsbergerI , G. Lanner 1, J . Tidstrand2 , H. Rausch2 . 1 Clinic of
Neurosurgery. Klagenfurt A, 9026 Klagenfurt, Austria, 2 Clinic of Radiation Oncology. Klagenfurt A, 9026 Klagenfurt, Austria In January 1996 we beganat the Clinic of NeurosurgeryKlagenfurtin collaboration with our departmentof Radiation Oncology with Unac Radiosurgery using a new Radiosurgical System; a combination of the University of Florida System with the X-Knife Planning System, Radionics. We use the portable hand on device coupled to the Unac as described by Friedman and Bova in 1989. High precision bearingsin that device control all patients and gantry movements. As a result radiation beam accuracy of the isocenter is improved to 0.2 mm, equal to the Gamma unit. As planning software we use the X-Knffe Treatment Plan from the Radiosurgical System developed in Boston; a program running on a high level 3-D graphics computer workstation to calculate and optimize beam dose to the target volume. In the first 6 months we have treated with this new system 25 patients with 30 lesions. 17 metastases and 7 meningeomas especially located at the skull base. All metastases from adenoid lung cancer and oat cell carcinoma showed good response to the treatment. One metastases from an undifferentiated lung carcinoma responded to radiosurgery for 4 months and began to grow up so surgery became necessary. We had a tumor control rate of 94.1% (16 out of 17).