Tag: Pain

Posted on

Prevalence, Severity, and Impact of Foraminal and Canal Stenosis Among Adults With Degenerative Scoliosis

Neurosurgery 69:1181–1187, 2011 DOI: 10.1227/NEU.0b013e31822a9aeb

Management approaches for adult scoliosis are primarily based on adults with idiopathic scoliosis and extrapolated to adults with degenerative scoliosis. However, the often substantially, but poorly defined, greater degenerative changes present in degenerative scoliosis impact the management of these patients.

OBJECTIVE: To assess the prevalence, severity, and impact of canal and foraminal stenosis in adults with degenerative scoliosis seeking operative treatment.

METHODS: A prospectively collected database of adult patients with deformity was reviewed for consecutive patients with degenerative scoliosis seeking surgical treatment, without prior corrective surgery. Patients completed the Oswestry Disability Index, SF-12, Scoliosis Research Society 22 questionnaire, and a pain numeric rating scale (0-10). Based on MRI or CT myelogram, the central canal and foraminae from T6 to S1 were graded for stenosis (normal or minimal/mild/moderate/severe).

RESULTS: Thirty-six patients were included (mean age, 68.9 years; range, 51-85). The mean leg pain numeric rating scale was 6.5, and the mean Oswestry Disability Index score was 53.2. At least 1 level of severe foraminal stenosis was identified in 97% of patients; 83% had maximum foraminal stenosis in the curve concavity. All but 1 patient reported significant radicular pain, including 78% with discrete and 19% with multiple radiculopathies. Of those with discrete radiculopathies, 76% had pain corresponding to areas of the most severe foraminal stenosis, and 24% had pain corresponding to areas of moderate stenosis.

CONCLUSION: Significant foraminal stenosis was prevalent in patients with degenerative scoliosis, and the distribution of leg pain corresponded to levels of moderate or severe foraminal stenosis. Failure to address symptomatic foraminal stenosis when surgically treating adult degenerative scoliosis may negatively impact clinical outcomes.

Posted on

Safety of microvascular decompression for trigeminal neuralgia in the elderly

J Neurosurg 115:202–209, 2011. DOI: 10.3171/2011.4.JNS101924

Microvascular decompression (MVD) offers an effective and durable treatment for patients suffering from trigeminal neuralgia (TN). Because the disorder has a tendency to occur in older persons, the risks of surgical treatment in the elderly have been a topic of recent interest. To date, evidence derived from several small retrospective and a single prospective case series has suggested that age does not increase the complication rate associated with surgery. Using a large national database, the authors aimed to study the impact of age on in-hospital complications following MVD for TN.

Methods. Using the Nationwide Inpatient Sample (NIS) for the 10-year period from 1999 to 2008, the authors selected all patients who underwent MVD for TN. The primary outcome of interest was the in-hospital mortality rate. Secondary outcomes of interest were cardiac, pulmonary, thromboembolic, cerebrovascular, and wound complications as well as the duration of hospital stay, total hospital charges, and discharge location. An elderly cohort of patients was first defined as those 65 years of age and older and then redefined as those 75 years and older.

Results. A total of 3273 patients who underwent MVD for TN were identified, having a median age of 57 years. Within this sample, 31.5% were 65 years and older and 10.7% were 75 years and older. The in-hospital mortality rate was 0.68% for patients 65 years or older (p = 0.0087) and 1.16% for those 75 years or older (p = 0.0026). In patients younger than 65 years, the in-hospital mortality rate was 0.13% (3 deaths among 2241 patients). As analyzed using the chi-square test (for both 65 and 75 years as the age cutoff) and the Pearson rank correlation coefficient, the risk of cardiac, pulmonary, thromboembolic, and cerebrovascular complications was higher in older patients (that is, those 65 and older and those 75 and older), but the risks of wound complications and CNS infection were not. The risk of any in-hospital complication occurring in a patient 65 years and older was 7.36% (p < 0.0001) and 10.0% in those 75 years and older (p < 0.0001). There was no difference in the total hospital charges associated with age. The duration of the hospital stay was longer in older patients, and the likelihood of discharge home was lower in older patients.

Conclusions. Microvascular decompression for TN in the elderly population remains a reasonable surgical option. However, based on data from a large national database, authors of the present study suggest that complications do tend to gradually increase in tandem with an advanced age. While age does not act as a risk factor in isolation, it may serve as a convenient surrogate for complication rates. The authors hope that this information can be of use in guiding older patients through decisions for the surgical treatment of TN.

Posted on

Randomized controlled trial of percutaneous vertebroplasty versus optimal medical management for the relief of pain and disability in acute osteoporotic vertebral compression fractures

J Neurosurg Spine 14:561–569, 2011. DOI: 10.3171/2010.12.SPINE10286

Osteoporotic vertebral compression fractures (VCFs) are a major cause of increased morbidity in older patients. This randomized controlled trial compared the efficacy of percutaneous vertebroplasty (PV) versus optimal medical therapy (OMT) in controlling pain and improving the quality of life (QOL) in patients with VCFs. Efficacy was measured as the incidence of new vertebral fractures after PV, restoration of vertebral body height (VBH), and correction of deformity.

Methods. Of 105 patients with acute osteoporotic VCFs, 82 were eligible for participation: 40 patients underwent PV and 42 received OMT. Primary outcomes were control of pain and improvement in QOL before treatment, and these were measured at 1 week and at 2, 6, 12, 24, and 36 months after the beginning of the treatment. Radiological evaluation to measure VBH and sagittal index was performed before and after treatment in both groups and after 36 months of follow-up.

Results. The authors found a statistically significant improvement in pain in the PV group compared with the OMT group at 1 week (difference -3.1, 95% CI -3.72 to -2.28; p < 0.001). The QOL improved significantly in the PV group (difference -14, 95% CI -15 to -12.82; p < 0.028). One week after PV, the average VBH restoration was 8 mm and the correction of deformity was 8°. The incidence of new fractures in the OMT group (13.3%) was higher than in the PV group (2.2%; p < 0.01).

Conclusions. The PV group had statistically significant improvements in visual analog scale and QOL scores maintained over 24 months, improved VBH maintained over 36 months, and fewer adjacent-level fractures compared with the OMT group.

Posted on

Surgical treatment of trigeminal neuralgia. Results from the use of glycerol injection, microvascular decompression, and rhizotomia

Acta Neurochir (2010) 152:2125–2132. DOI 10.1007/s00701-010-0840-1

The study aims to assess the efficacy and safety of surgical treatment of trigeminal neuralgia (TN) in our department and to identify prognostic factors.

Methods Seventy patients receiving surgical treatment for TN during the period 2003–2004 were included in this retrospective study. The surgical procedures used were glycerol injection (GI), microvascular decompression (MVD), or rhizotomia (RIZ). All patients were divided into spontaneous onset TN type1 (brief lancinating pain) or TN type 2 (continuous pain component). Two patients had bilateral TN; each side was regarded as a separate case. These 70 patients had a total of 160 interventions (110 GI, 40 MVD, and ten RIZ) performed in the period 1998–2007. Data were obtained by chart review and telephone interview. Patients provided information about pre- and postoperative pain characteristics including subtype, duration, intensity, and the use of antiepileptic drugs. Outcome was evaluated using a pain vector diagram.

Results To quantify self-reported pain, we developed a new vector-based pain diagram. The subtype of TN was shown to be a very important prognostic factor. One year after MVD, 90% of patients with type 1 TN still had positive effect, whereas this was only true in 73% of patients with type 2 TN. After RIZ, the results were 71% and 33% for types 1 and 2, respectively. For comparison, GI had a significant lower effect but if the treatment led to hypoesthesia, 41% continued to have a positive effect 1 year after surgery, compared to only 24% if postoperative sensation was normal. Type 2 TN was found to be dominated by women with left-sided TN outside the V2 dermatome and with a lower probability of a neurovascular conflict. As expected, 1/5 of the cases developed postoperative hypoesthesia in the face following a nerve destructive procedure (RIZ and GI). Using MVD, the risk of serious side effects was about 4%. Complementary and alternative treatment had no general or permanent effect in the investigated population—quite the contrary.

Conclusions Regarding prognosis and outcome, we find that it is very important to classify TN in subgroups (types 1 and 2). Dealing with medically treatment-resistant type 1 TN, MVD and RIZ are reasonably safe and effective interventions. The surgical results dealing with type 2 TN are still very poor. All patients with medically treatmentresistant TN should be offered referral to a neurosurgical unit with experience in treating this painful disease. We recommend using a vector-based pain diagram when evaluating the outcome of multiple interventions.

Posted on

Retreatment of trigeminal neuralgia with Gamma Knife radiosurgery: is there an appropriate cumulative dose?

J Neurosurg 111:359–364, 2009


Trigeminal neuralgia (TN) is a disorder of the trigeminal nerve that results in intense episodic pain. Primary treatment with Gamma Knife surgery (GKS) is well established; however, a significant number of patients experience recurrence of TN over time. Repeat GKS can be performed, but the retreatment dose has not been well established. In this study, the authors present their institutional retreatment results and compare them with other series.

Methods
Between December 2003 and January 2006, 28 patients were treated at Tufts Medical Center with repeat GKS for recurrence of TN. All patients had been initially treated with GKS at this institution, and only those with significant pain improvement were offered retreatment. The maximum dose was prescribed using a single isocenter; the 4-mm collimator was used. The initial median GKS dose was 80 Gy, the median retreatment dose was 45 Gy, and the median cumulative dose was 125 Gy. The median time between GKS procedures was 18.1 months. Facial pain outcomes were defined using the Marseille scale. Excellent outcome was defined as no pain (with or without medications), and good outcome was defined as > 50% pain relief. Toxicity was categorized as none, mild, or bothersome. The median clinical follow-up after the second GKS was 19.7 months. Our clinical outcomes were compared with 8 previously reported retreatment series (including 1 abstract), both for rate of pain control and for rate of complications.

Results
Outcomes after the second GKS were excellent in 29% (8 patients), good in 32% (9), and poor in 39% (11). Four patients (14%) experienced no improvement after repeat GKS. Eight patients (29%) experienced new trigeminal nerve dysfunction, including numbness (11%), paresthesia (14%), dysesthesia (4%), taste alteration (11%), and bite weakness (4%). None of these were bothersome. No patient developed corneal numbness. Univariate analysis failed to reveal any significant predictors of pain control or complications.

Seven published peer-reviewed retreatment series and the authors’ data (total 215 patients) were analyzed. There was a cumulative dose-response relationship for both pain control (p = 0.04) and new trigeminal dysfunction (p = 0.08). Successful pain control was strongly correlated with development of new dysfunction (p = 0.02). A cumulative dose > 130 Gy was more likely to result in successful (> 50%) pain control, but was also more likely (> 20%) to result in development of new dysfunction.

Conclusions
Successful retreatment of patients in whom the initial GKS treatment fails is feasible. Patients who respond initially may be at a higher risk of retreatment-related complications. There appears to be a dose-response relationship for both pain control and development of new side effects. It is important to counsel and treat patients individually based on this dose-response relationship.

Proudly powered by WordPress