Stereotactic radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Each year a greater number of patients with trigeminal neuralgia (TN) undergo radiosurgery, including a large number of patients who are candidates for microvascular decompression (MVD). METHODS: The case characteristics and outcomes of 117 consecutive patients who underwent radiosurgery were retrieved from a prospectively maintained database. The mean patient age was 67.8 years; and the majority (58%) of patients had undergone surgery previously. The dependent variable for all analyses of facial pain was complete pain relief without medication (excellent outcome). Median follow-up duration was 26 months (range 1-48 months). The actuarial rate of achieving and maintaining an excellent outcome was 57% and 55% at 1 and 3 years, respectively, after radiosurgery. A greater percentage of patients who had not previously undergone surgery achieved and maintained excellent outcomes (67% at 1 and 3 years) than that of patients who had undergone prior surgery (51% and 47% at 1 and 3 years, respectively; relative risk [RR] = 1.77, 95% confidence interval [CI] 1.01-3.13, p = 0.04). New persistent trigeminal dysfunction was noted in 43 patients (37%). Tolerable numbness or paresthesias occurred in 29 patients (25%), whereas bothersome dysesthesias developed in 14 patients (12%). Only a radiation dose of 90 Gy correlated with new trigeminal deficits or dysesthesias (RR = 3.10, 95% CI 1.64-5.81, p < 0.001). Excellent outcomes in patients with new trigeminal dysfunction were achieved and maintained at rates of 76% and 74% at 1 and 3 years, respectively, after radiosurgery, compared with respective rates of 46% and 42% in patients who did not experience postradiosurgery trigeminal dysfunction (RR = 4.53, 95% CI 2.03-9.95, p < 0.01). CONCLUSIONS: Radiosurgical treatment provides complete pain relief for the majority of patients with idiopathic TN. There is a strong correlation between the development of new facial sensory loss and achievement and maintenance of pain relief after this procedure. Because the long-term results of radiosurgery still remain unknown, MVD should continue to be the primary operation for medically fit patients with TN.

Are single fractions of radiotherapy suitable for plantar fasciitis?

The use of radiotherapy for plantar fasciitis has never been reported in Australasia and is scarcely found in the English language medical literature, but it is commonly used in Europe, especially in Germany. In Europe, treatment courses consisting of multiple small fractions have been associated with high levels of pain relief. In the present report, the use of single fractions or radiotherapy was evaluated by reviewing seven consecutive patients referred for treatment and by applying objective and subjective criteria for pain relief. One patient died of unrelated causes soon after treatment and one declined to receive radiotherapy. Four patients each received a single dose of 8 Gy resulting in complete pain relief. One patient was treated with 8 Gy and 12 weeks later was retreated achieving partial pain relief. A follow-up interview was conducted after a mean of 15.6 months, ranging from 1.5 to 30 months. No acute or late effects occurred; however, the possibility that delayed effects may yet occur, particularly carcinogenesis, cannot be excluded. Radiotherapy for this common condition should be investigated further as it might be safer and more effective than other methods currently in use.

Radiotherapy of vertebral hemangiomas

The paper presents the analysis of results of treatment with radiotherapy of 14 cases of vertebral hemangiomas. All patients were irradiated in accordance with conventional schedule fractionated doses, using 2 Gy per fraction. The total radiation dose amounted to 20 Gy (1 case), 24 Gy (4 cases) and 30 Gy (9 cases). The degree of pain relief and lesion reossification was assessed 1 months and 6 months after completion of radiotherapy. Complete pain relief 1 month post radiotherapy was noted in 5 cases (on average patients claimed that radiotherapy resulted in a 70% decrease of pain syndromes). Six months post radiotherapy complete pain relief was noted in 8 cases (on average patients reported a 90% decrease in pain). Signs of reossification were observed in cases 6 months after treatment. No correlation was noted neither between the degree of pain relief and reossification, nor between the total delivered dose and the degree of pain relief. The obtained results allow to conclude that conventionally fractionated radiotherapy (using 20-24 Gy as total dose) is a good method of analgetic treatment of vertebral hemangiomas probably based on the anti-inflammatory effect of radiation.

On-demand nalbuphine for post-operative pain relief.

Twenty-five patients with moderate to severe pain after major upper abdominal surgery chose to receive nalbuphine on demand from a Cardiff Palliator for pain relief. An initial i.v. injection of nalbuphine 20 mg was followed by 5 mg given over 90s in response to each successful demand. A maximum of 20 doses (100 mg) hr-1 of nalbuphine was available, plus additional bolus doses. Twelve patients obtained good pain relief and completed the 5 hour observation period. 13 patients withdrew from the study, 8 because of inadequate pain relief and 2 because of side-effects. At least half the patients who complained of inadequate pain relief at the time had no subsequent memory of the events. Despite high dosage in some cases (up to 200 mg in an hour) no clinically important cardiovascular or respiratory effects were observed.

Thalamic relay nucleus stimulation for relief of intractable pain. Clinical results and beta-endorphin immunoreactivity in cerebrospinal fluid

Chronic implantation of a stimulating electrode in the thalamic relay nucleus (11 cases), in the periaqueductal gray (1 case) and in the internal capsule (2 cases) was performed in fourteen cases which suffered from intractable pain. All these cases could get pain relief at least initial two months. Ventricular fluids were collected before and after stimulation with optimal combination of parameters, and measurements of beta-endorphin were performed by radio-immunoassay. Intrathecal morphine (1mg) injection was performed in eight cases. Cerebrospinal fluids were collected by lumbar tap before and 24 hours after morphine injection. beta-endorphin immunoreactivity was measured by the same method. pain relief was judged to be excellent if the patient so claimed, and if he discontinued analgesics. pain relief was thought to be good when it was not completely controllable by stimulation but was sufficiently improved that the patient could do without analgesics. It was thought to be fair when patient could not discontinue analgesics, and poor when patient could not get pain relief. We usually attempt to prevent the stimulation-tolerance by administration of the monoamine precursors , i.e., 1-dopa and 1-tryptophan, on the basis of the experimental observation reported previously. In somatogenic pain patients, the thalamic relay nucleus stimulation was performed in 7 cases (excellent; 3, good; 1, fair; 3) and the periaqueductal gray stimulation in one case (good).(ABSTRACT TRUNCATED AT 250 WORDS)

Multi-fractionated wide-field radiation therapy for palliation of multiple symptomatic bone metastases from solid tumors.

PURPOSE: This was a pilot study to explore the toxicity and response of multi-fractionated wide-field radiation therapy (MF-WFRT) in patients with multiple symptomatic osseous metastases. PATIENTS AND METHODS: From February 1997 to April 1998, a total of nine patients (5 lung cancer, 3 breast cancer, 1 prostate cancer) were treated with MF-WFRT. The patients received 1.5 Gy per fraction (twice a day) to a total dose of 7 Gy in 3 days for the upper body and a total dose of 9 Gy in 3 days for the lower body. Ten treatments in nine patients were carried out with this technique (2 upper half-body, 5 lower half-body, 3 mid-body; one patient had both upper mid-body and lower-half body treatments). RESULTS: pain relief was complete in two patients (20%) and eight (80%) achieved better than 50% pain relief. Seventy-five percent of pain responders achieved pain relief within one week of MF-WFRT. The pain relief was long-lasting and continued without need of reirradiation for 45% of the remainder of the patients' lives. The incidence of gastrointestinal complications was low, basically Grade 1-2 toxicity. Four patients (40%) experienced Grade 3-4 hematological toxicity. Hematological toxicity was treated with blood transfusion or G-CSF. General tolerance was excellent, and no pneumonitis or radiation-related deaths occurred. CONCLUSION: This treatment modality appears to be well tolerated and effective. The optimal indications, dose, and fractionation for MF-WFRT should be further explored in randomized studies.

Cognitive orientation as predictor of pain relief following acupuncture.

The study investigated the role of beliefs concerning pain relief after treatment. Following the cognitive orientation theory, we hypothesized that beliefs concerning goals, norms, oneself, and general beliefs would predict the extent of improvement following acupuncture. Subjects were 30 Israeli chronic-pain patients (22 women, 8 men; mean age 41.6 years). They were administered a questionnaire assessing the 4 belief types, and control measures assessing personality traits, demographic variables, and pain characteristics. All underwent 4-6 acupuncture sessions. Improvement was determined by patient and physician ratings, and an index based on medication, subjective evaluations, and duration of resting. There were two follow-ups. Three improvement groups were defined: none (n = 8), slight (n = 12), and high (n = 10). These groups did not differ on any of the variables tested except the 4 belief types. A discriminant analysis with belief types as predictors enabled correct classification of the patients in 83% of the cases. A stepwise regression analysis showed that beliefs accounted for 85% of the variance. Discussion focuses on the nature of pain relief and the role of beliefs in disease.

Gamma Knife radiosurgery for treatment of trigeminal neuralgia: idiopathic and tumor related.

Sixty patients with trigeminal neuralgia who did not have a response to pharmacologic treatment (including 22 who had no response to conventional surgical treatment) underwent stereotactic radiosurgical treatment with the Leksell Gamma Knife. A radiosurgical maximum dose of 70 Gy was delivered to the trigeminal nerve root adjacent to the pons via a 4-mm collimator helmet in 51 patients who presented with trigeminal neuralgia unrelated to tumors. In these patients, the root was localized by stereotactic MRI. Follow-up assessment of pain relief was accomplished by a third party not involved in the patients' clinical care. Within a latency period of 1 day to 4 months following the treatment, 38 of 51 patients (74.5%) were completely free of pain and eventually all medications were tapered off. An additional seven patients (13.7%) experienced reductions in pain from 50 to 90% and utilized little or no medications. Patients who had no prior surgical intervention fared much better than those who had previous surgery to relieve their facial pains. At last follow-up, a mean of 16.3 months (range 6-36 months) after treatment, 41 patients (80.4%) remained pain-free or had marked pain reduction. There were four patients with recurrent pain. All 26 patients with classical symptoms of trigeminal neuralgia with no atypical features who had no prior surgery, had complete or nearly complete pain relief, and none of these patients had recurrent pain. Nine patients with trigeminal neuralgia due to tumors received standard radiosurgical treatment directed at their tumors, and eight of nine (88.8%) had pain relief. Of the total of 60 patients treated for trigeminal neuralgia, 49 (81.7%) experienced complete or nearly complete relief of pain at last follow-up. Only one patient with pre-existing facial sensory loss due to a tumor had a mild increase in facial numbness. No other patient experienced either loss of facial sensation or any other complication. Gamma Knife radiosurgery appears to be a minimally invasive, safe, and effective therapy of trigeminal neuralgia.

Problems related to dorsal root entry zone lesions.

Several clinical problems related to the dorsal root entry zone lesions (DREZLs) in 15 patients with chronic pain are presented and discussed in terms of ratings of pain relief following surgery, development of sensory or motor weakness and postmortem histologies. Subjective pain relief exceeding 70% was achieved at around 2 weeks after the operations in most patients (13/15), and then decreased in some to 30 from 70% in the follow-up observations. Our new "objective" pain relief score was tested in these patients. A significant positive correlation between subjective pain relief and our objective pain relief scale was found, but some discrepancies between them were also found during the follow-up. Sensory loss, motor weakness, paraesthesia and a new pain were found as complications in 12, 7, 4 and 6 patients, respectively. Postmortem histological findings of the spinal cord in two patients with systemic lupus erythematosus and uterine cancer, who received bilateral DREZLs twice and bilateral DREZLs plus commissural myelotomy, respectively, indicate that care should be taken to avoid extension of the coagulation beyond the dorsal horn.

1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study.

From January 1980 through December 1984, 454 patients were evaluated with facet joint injections. All had the chief complaint of low-back pain, normal neurologic examinations and no root tension signs. Three hundred and ninety completed the protocol, which included a lumbar motion pain assessment before and after facet injection. A total of 127 variables were studied. There were 229 males and 161 females with a median age of 38. Facet joint arthrograms were performed prior to intra-articular injection of local anesthetic and cortisone. Initial mean pain relief was only 29%. Variables correlating significantly (P less than 0.05) with more postinjection pain relief were older age, prior history of low-back pain, normal gait, maximum pain on extension following forward flexion in the standing position, and the absence of leg pain, muscle spasm and aggravation of pain on Valsalva. Greatest pain relief immediately after injection was seen with lumbar extension and rotation, motions reported to stress the facet joints or aggravate pain of facet joint origin. Patients with more pain on lumbar extension and rotation as a group, however, did not get more pain relief. From this study we were not able to identify clinical facet joint syndromes or predict patients responding better to this procedure. The facet joints were not commonly the single or primary source for low-back pain in the great majority (greater than 90%) of patients studied.