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Treatment approaches: medical/interventional




Chi-Lin Chuang, Mingi Chan-Liao*, Wang-Hin Yip *, Dept. of Radiology and Anesthesia*, Jen-Ai Hospital, Tali, Taichung, Taiwan

Aim of Investigation: Although the majority of patients with tri-geminal neuralgia aising from its second branch can be adequately controlled using phannacotherapy and/or infraorbital nerve block, a percentage of difficult patients however are better managed with maxillary nerve block. In the past, the traditional methods for performing maxillary nerve block has been well-described and all depend on placing the needle in the pterygopalatine fossa (PPF). Unfortunately these methods are sometimes difficult to perform due to anatomic variation and fraught with potential morbidities because of high vascularity of the fossa. Therefore any approach that helps to overcome these disadvantages would be desirable. We hereby describe and compare 2 CT-guided approaches by way of transorbital and coronoid. The anatomy including 3D relationships as well as pros and cons of each technique based on our experience of 5 cases will be presented.

Results: Both approaches resulted in good to excellent pain relief in all of the patients. In the coronoid approach, visualization of PPF was aided by CT which guided the needle readily into the appropriate compartment whereas for the transorbital approach the needle was advanced simply into the foramen rotundum. After satisfactory needle positioning and test block, we used absolute alcohol 0.3 ml for neurolysis. In our modification, the success rate of both approaches was similar and the technique equally easy and safe to perform.

Conclusions: We devised 2 CT-guided approaches to maxillary nerve block for the treatment oftrigeminal neuralgia and suggest that a competent pain clinician should develop some measure of familiarity with these techniques.


R Derby*, B. Eek*, D. P. Ryan*, [SPON: ***], Spinal Diagnostics & Treatment Center, 901 Campus Drive - Suite 310, Daly City, CA 94015, USA.

Aim of Investigation: Intradiscal Electrothermal Annuloplasty (1EA) by catheter, is a new technique to heat the intervertebral disc for the purpose of relieving discogenic pain. This abstract represents the results of the 12-month follow-up investigation of treatment efficacy.

Method: From 5/97 to 10/97 we enrolled our first 22 consecutive patients undergoing the 1EA procedure into a prospective outcome study. Outcome was assessed using within-subjects, before-and-after measures'. Two primary comparative outcome instruments were utilized, viz. a 10-point visual analogue pain scale (VAS) and the 24-point Roland & Morris (RM) Disability questionnaire. At follow-up, patients' satisfaction with the procedure and its outcome were examined using the 4-point NASS Patient Satisfaction Index (PSI). Five Abbreviated NASS subjective improvement-in-activity (SIA) variables were also investigated. Results: A mean 1.5 point decrease on the VAS was found (p< 0.05), the R-M scale returning a mean 3.5 point decrease in disability. The PSI reported that 73% of the sample were satisfied with their outcome, reporting that they would repeat the procedure for the same outcome. From the SIA, 59% of the sample reported an improvement in general overall activity levels, 41% in sitting, 50% in standing, 45% in walking and 41% reported an improvement in their sleeping.

Conclusions: In the early stages of investigation, intradiscal electrothermal annuloplasty appears promising as a technique to reduce chronic pain of discogenic origin, and as a potential alternative to invasive spine surgery. Further study is warranted both to compare efficacy against other intradiscal heating procedures and to assess the precise pathology most successfully treated by the procedure. The current study is ongoing. /. No significant differences were found to exist between outcome at 6-months and 12-months.


Susan M Lord. Deborah Spalding*, Nikolai Bogduk, Musculo-skeletal Research Unit, Newcastle Mater Misericordiae Hospital, Waratah, 2298, Australia

Aim of Investigation: To quantify the technical limitations ofra-diofrequency neurotomy of the cervical medial branches and, thereby, to identify ways in which the procedure might be modified to yield a greater success rate.

Methods: The physical properties ofradiofrequency lesions generated in meat by SMK and RRE-TM electrodes were measured. Dynamic formation of lesions over temperature and time was studied in translucent electrolyte-enhance egg white. Five human cadavers were dissected yielding 10 observations per nerve. The nerve diameter, distance from the underlying bone, and curvature were measured. Variation of the course ofproximal medial branches was determined using wire labelling and radiography. The radiographic appearance of accurately placed radiofrequency electrodes was also recorded.

Results: Radiofrequency lesions were oblate spheroids, extending only marginally beyond the electrode tip. The RRE-TM electrode yielded consistently larger lesions, but maximum effective lesion radius was still only 2.6 0.4mm. The mean diameter of lower cervical medial branches was < 1mm (maximum distance between electrode and nerve = 1.6mm); the third occipital nerve (TON) was thicker, 1.5 0.4mm (maximum distance between electrode and nerve = 1mm). The cephalo-caudad course of the cervical medial branches and their distance from bone was variable. The TON exhibited the widest variation.

Conclusions: Unless procedures are amended to accommodate the variable course of the cervical medial branches, and the TON in particular, treatment is unlikely to yield consistently successful results.

Acknowledgments: Supported by a grant from the Motor Accidents Authority of NSW.


Greg J McDonald*, Susan M Lord. Jayantilal Govind, Nikolai Bogduk, Musculoskeletal Research Unit, Newcastle Mater Misericordiae Hospital, Waratah, 2298, Australia

Aim of Investigation: To evaluate a modified approach to radiofrequency neurotomy of the third occipital nerve (TON) for treatment of chronic neck pain and headache mediated by this nerve.

Methods: We audited the outcomes of 10 radiofrequency neuroto-mies of the TON performed, using a modified technique, between May 1997 - April 1998 Diagnoses had been established, preopera-tively, using comparative local anaesthetic blocks The operative technique was similar to that described by Lord et al (Neurosurgery 1995;36-732-739) save that the RRE-TM electrode was used and more lesions were generated over the C3 articular pillar Minimum follow-up duration was 6 months. Complete pain relief at follow-up was defined as patients stated "pain not present" + "not requiring further treatment" + VAS < 5/100 + McGill Pain Questionnaire total word count < 4/20 + restoration of 4 nominated activities of daily living (unless prevented by comorbidity) Duration of relief = time to return to at least 50% ofpreoperative pain level Complete relief lasting > 90 days was considered a successful outcome

Results Eight of the 10 procedures provided complete relief lasting at least 90 days (success rate == 80%, 95% CI 55-100%) The median duration of relief at the time of audit was 203 days (interquartile range 92 - 309) No major morbidity was encountered Side-effects included temporary post-op hypersensitivity followed by cutaneous numbness in the distribution of the nerve

Conclusions Increasing the size and number of lesions yielded a higher success rate without increasing complications, compared with our previous study These pilot data justify further evaluation of this modified technique

Acknowledgments Supported by grants from the Motor Accidents Authority ofNSW and the International Spinal Injection Society


Borut Prestor, Dept of Neurosurgery, Ljubljana, Slovenia

Aim of Investigation The purpose of the study is to demonstrate and evaluate a modified microneurosurgical coagulation procedure in the DREZ, and to analyse clinical results ofjunctional coagulation DREZ lesions in different pain syndromes

Methods A total of 36 patients (27 males, 11 females) with intractable deafferentdtion pain were treated by surgery The causes of pain syndromes were brachial plexus avulsion (BPA) (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 synngomyeha (5 cases) With the help of microscope the DREZ area of the involved sensory roots was carefully localised Using a bipolar forceps, on tip of which the depth of penetration was marked (2-3 mm), ajunctional coagulation lesion extended along the DREZ of the pain producing spinal cord segments was made All the procedures included intra-operative neuromonitonng of the spinal cord evoked potentials Results- 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-up was 12 to 76 months In other pain syndromes with follow-up 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 disturbance was revealed in 6 cases (15,8 %), permanent disturbance showed in 1 case (2 6 %) The best results were obtained in the cases with deafferentation pain history of more than 1 year Previous neurosurgical procedures reduce the success rate ofmicrosurgical DREZ treatment in deafferentation pain patients

Conclusions: Clinical results ofjunctional coagulation DREZ lesions in the treatment of deafferentation pain syndromes are very promising. Postoperative complications are rare and transient We believe that thejunctional coagulation includes all the structures important for the generation of deafferentation pain in the DREZ extending to the 5th Rexed's lamina


M J Telxeira. W A Cescato, C F Correa, L A Rogano, A B Ala-mmos, Pain Clinic, Univ ofSao Paulo Medical School, Rua. Con-selheiro Brotero 1539, cj 12, Cep 01232-010 Sao Paulo - Brazil

Aim of Investigation Evaluation of the results of treatment of Wallembcrg's syndrome by tngeminal stereotactic nucleotractot-omy

Methods Five patients with severe facial pain after bulbar stroke not controled with psychotropics and anticonvulsants were treated The target points were calculated using a computer stereotomo-graphic reconstruction of brain images Stimulation was used for confirmation of target position Lesions (3) were made using ra-diofrequancy

Results. All patients had immediate alleviation of facial pain after surgery One had full recurrence of pain after 4 weeks and one partial recurrence after 6 months One of them had a repeated procedure The overall final improvement was 80% Temporary upper limb ataxia occurred in 60% of patients The mean follow up period was 14 months

Conclusion The stereotatic tngemmal nuclcotractotomy is a very effective method for treatment of facial pain resulting from Wal-lemberg's syndrome


M van Kleef, T Forouzanfar and W E J Weber, Pain Management and Research Centre, Dcpt ofAnesthesiology, Univ Hospital Maastricht, The Netherlands

Background Atypical facial pain (AFP) is a chronic and mostly intractable pain syndrome One of the treatment methods is blocking the Sphenopalatme Ganglion (SPG) temporarily by local anaesthesia A more permanent interruption of this ganglion can be achieved by means ofradiofrequency (RF) lesions

Objectives. To review the efficacy of an RF lesion of SPG patients suffering from ATP.

Method. We reviewed retrospectively 35 consecutive patients who presented with a history of at least one year of ATP and who underwent an RF-SPG An investigator collected the following data. demographic data, localisation and type of pain. Visual Analog Score (VAS), use of medication, efficacy of treatment measured by four point Lickert scale.

Results Out of 35 patients 12 patients (34%) claimed some form of pain relief The procedure was not effective when the pain was located in the first division of the tngeminal nerve 41% of patients with pain in the second division claimed pain relief When the pain was situated in all the branches of the tngeminal nerve the procedure was effective in all patients

Conclusion RF-SPG is of limited use in patients with AFP Only patients with diffuse AFP and pain located in the second division of the tngeminal nerve may benifit this procedure


RoelofM.AW van Wijk Jos W M Geurts", Evert J Buijs0 Depts ofAnesthesiology ^nze Lieve Vrouwe Gasthuis, P 0 Box 95500, 1090 HM Amsterdam, "Rijnstate Hospital, Amhem, ^niv Medical Center, Utrecht, The Netherlands

Aim of Investigation To investigate the influence of electrical nerve stimulation (ENS) threshold value on outcome ofradiofrequency treatment of the dorsal root ganglion (RF-DRG) in the lower back for chronic segmental pain irradiating to the leg

Methods. Sensory and motor ENS threshold values were determined in 279 patients during RF-DRG procedure Sensory (50 Hz) ENS value limits between 0 5 and 1 0 V were pursued Motor (2 Hz) ENS value was required to be at least 1 5 times sensory ENS value RF-DRG was done at 67C during 90 seconds Results were determined after 2 months, using a 4-point verbal pain scale More than 50% pain relief was considered a success

Results. Sensory ENS values ranged between 0 3 and 25V (mean 0 66 V, sd 0 24) Motor ENS values ranged between 0 75 and 4 00 V (mean 1 54 V, sd 0 54) In 59% of patients RF-DRG was successful There appeared to be no relation between sensory ENS threshold value and outcome of RF-DRG (chi-square, p=0 68) Logistic regression analysis did not show any difference between patients with or without prior low back surgery No unwanted side effects were reported

Conclusions. Sensory ENS threshold value does not influence outcome of RF-DRG As no sensory or motor side effects were reported, the role of ENS in preventing these side effects could not be established


Amoud Vervest'. Peter Theuvenet2 'Pain Clinic, Antonius Hospital, P.O. Box 20000, 8600 BA Sneek, Medical Centre Alkmaar, The Netherlands

Aim of Investigation: The study was performed to clarify the efficacy and safety ofuni- and, especially, bilateral percutaneous an-tero-lateral cordotomy (PC), to treat cancer pain

Methods: In this open longitudinal study, patients with opioid resistant cancer pain were treated with a PC, using the lateral approach at Cl -C2 A Levin Cordotomy Electrode was inserted into the lateral spmothalamic tract Repeated radiofrequency (RF) lesions, at 95 Celsius during 10-15 s , were made with a RF lesion generator (Radionics RFG-3C), until vital sensory input was satisfactorily blocked If necessary, the other side was treated one week later

Results. 153 Patients, 97 M, 56 F, age 63 12 yrs (mean s d ), underwent 224 PC's. In 104 patients a unilaterally and in 49 patients a bilaterally PC was earned out. In 16(10 5%) patients a repeat PC was performed unilateral and in 3 (2 0%) bilateral. Short term results were excellent (pain free) in 145 (94.7%) patients and 7 (4.6%) had a satisfactory result (50% or more pain relief) Once (0 7%), the result was unsatisfactory Mean long term follow-up time (LTFU), in 132 patients, was 4 6 10 1 months (range 71 5 months) At LTFU 112 (84.8%) patients were deceased, 20 (15.2%) were alive LTFU results were excellent in 108 (81 8%) and satisfactory in 18 (13.6%) patients. Six (4 6%) patients reported an unsatisfactory result. Complication rates were low. Permanent bladder dysfunction, 3 times (1 3%), and unilateral paresis with partial recovery, 2 times (0.9%), was only seen after bilateral PC. Temporary complications such as bladder- and motor-dysfunction, post spinal punction headache and sympathicolysis occurred 2 (0 9%), 3 (1.3%), 4 (1 8%) and 2 (0 9%) times, respectively.

Conclusions: In experienced hands, um- and bilateral PC is an effective method of treating cancer pain, with few complications


Kent P Wemmeister. Jesse J Muir, Section of Pain Management and Dept of Anesthesia, Mayo Clinic Scottsdale, Scottsdale, AZ 85024, US

Aim of Investigation To assess the degree of pain relief at various intervals following lumbar facet denervation using radiofrequency lesioning and to assess the degree of patient satisfaction

Methods We reviewed the records of 58 patients who had undergone MNBRF for low back pain over a two-year period Patients were asked to fill out a survey Forty patients participated The mean time since the procedures have been performed was 1 4 years Mean patient age was 70 years Parameters studied included pain levels prior to the procedure, then at intervals up to two years af-terw ard

Results Using a visual analog scale, the mean severity of low back pain prior to procedure was 8 2 Pain levels at given intervals were compared to baseline using the paired t-test See Table 1 Patients reported pain relief for a mean of 5 8 months 14 of 34 stated they were able to reduce their pain medication Side effects all minor were reported by 34% of patients When asked, "Knowing what you know now, would you choose to have this procedure performed9" 23% definitely would, 13% probably would, 27% were unsure, 17% probably would not, and 20% definitely would not

Conclusions When patients report significant improvement in their low back pain after interarticular injection or median branch nerve blocks, the facets can be imputed to be a cause of low back pain While some patients have good response to interarticular injections ofcorticosteroids, many patients do not Facet denervation may be a useful treatment alternative

Acknowledgments Supported by Mayo Clinic Scottsdale funding IRB# 1478-97


T Forouzanfar, M van Kleefand W E J Weber Pain Management and Research Centre, Dept. ofAnesthesiology, Univ Hospital Maastricht, The Netherlands

Background Stellate ganglia (SG) blockades are used for diagnoses and treatment regarding sympathetic pain syndromes One of the treatment modalities is interruption of the stellate ganglion by means of radiofrequency lesion (RF)

Objectives To review the outcome ofRF ofSG in sympathetically maintained pain syndromes, we reviewed 86 RF ofSG procedure Method Medical records containing treatment information were reviewed systematically A MEDLINE search was performed to review indications for this procedure and compare them with our patient group

Results. 39,5% of 221 patients who received a prognostic SG block were submitted to RF of the ganglion Of these RF-treated patients 40,7% noted more then 50% reduction of pain, 54,7% had no effect on pain and 4,7% showed worsening of pain Meta-analyses of 31 research reports showed partial pain relief in 41,3 % of patients, complete pain relief in 37,8% and no pain relief in 20,9%

Conclusion The efficacy ofRF ofSG blockade appears to be in line with other SG block procedures reported in the literature It has been suggested that the effectiveness ofRF ofSG may be im proved by precise localisation of the SG using ultrasound, Computer Tomographic or Magnetic Resonance Imaging


Massimo Leandn. Alberto Gottlleb InterUniv Centre for Pain Neurophysiology, Univ ofGenova & Centre for Pain Relief at the National Cancer Inst Geneva, Largo R Benzi 10, 16143 Genova Italy

Aim of Investigation. To find a reliable neurophysiological method for detecting the extent of lesion to the tngeminal root in the thermorhizotomy operation for tngeminal neuralgia.

Methods In 10 patients the compound action potential of the tngeminal root, evoked by electrical stimulation of the infraorbital nerve, was recorded before and after thermolesion, performed at 65, 70 and 80C for 60sec. Optimal positioning of the thermolesion electrode was performed according to the neurophysio-logical method introduced by Leandn and Gottheb (J Neurosurg 84 929-939 1996) dunng uninterrupted anesthesia Results- A complete compound action potential, from the fastest (approximately 40m/s) to slowest (approximately 3 m/s) fibre activity was recorded in all subjects following supramaximal stimulation of the infraorbital nerve Thermolesions at 65 only reduced activity below 12m/s, whereas higher temperatures affected faster fibres In the few cases so far monitored with this technique a good correlation was established between alterations of the compound action potential and the ensuing sensory deficit We also noticed that pain relief was best obtained when the thermolesion was performed so as to affect the faster fibres

Conclusions The method presented allows a qualitative (size of fibres) and quantitative (amount of fibres) monitonng of the thermolesion This, together with the already published method for optimal localization of the thermolesion (Leandn and Gottlleb J Neurosurg 84- 929-939 1996), represents a highly reliable tool for thermorhizotomy, which can now be performed without any collaboration from the patient

Acknowledgments This study has been supported in pan by the EEC grant BMH-CT95-0502 "Mechanisms of Tngeminal Pain"


Yoshikazu Naganuma. Masahiro Shiotani, Klyosige Ohseto, Pain Clinic, The Kanto Tcishin Hospital 5-9-22 Higashigotanda Shina-gawa, Tokyo, Japan

Aim of Investigation Gassenan Ganglion thermal rhizotomy (GGTR) is normally performed under intravenous anesthesia In order to keep good contact with the patients during lesion making, small amount of local anesthetic was used after locating the electrode tip within the ganglion

Method In heavily premedicated patients with tngeminal neuralgia, Gassenan Ganglion was punctured via foramen ovale under Xray control, secunng the needle tip is in appropnate position and no cerebrospmal fluid flows from the lumen, 0 2ml of 2% mepiva-caine was injected before thermal rhizotomy (90C, 90 sec)

Result From Dec 1993 to Sep. 1998, GGTR was performed on a total of 235 patients with drug resistant tngeminal neuralgia (226 idiopathic, 9 symptomatic) Maxillary region pain which was not covered by infraorbital nerve block and mandibular pain are indicated for the treatment (R 138, L 93, Bilateral 4) Out of 235 cases 182 resulted in pain free, 33 occasional medication, 18 regular medication or unsuccessful and 2 unmeasurable 44 expenenced recurrence and underwent multiple treatment (33 second, 8 third, 3 fourth or more) Undesirable side effects were minimum, 1 unwanted 1st branch anesthesia, 1 dysesthesia, 1 masseter weakness and 1 buccal hematoma

Conclusion' By using local anesthetics lesiomng of Gassenan Ganglion was done keeping the contact with the patients. The follow up period is not long enough though the effect does not seem to be inferior to so far reported technique which is to lesion retro-gassenan fibers under intravenous anesthesia


Welm M & Rabow L, Multidisciplmary Pain Clinic, Mane-bergsgatan 5, S- 112 81 Stockholm, Sweden

Aim of the investigation To study the effects of so-called cryoan-esthesia to see if it was possible with that method to prolong the period of pain relief from local anaesthetic blockades in pain originating from peripheral nerves. Freezing ofpenpheral nerve fibers causes disintegration of the nerve axon and breakdown of the mye-1m sheath, leaving the connective tissue intact Over time, the nerve is able to regenerate and normal performance may return, but until then nerve conduction is expected to be blocked

Matenal and Methods' After informed consent, and after at least 2 tests where selective anaesthetic block of the actual nerve gave total or almost total pain relief, a cryoblockade was earned out with the Lloyd Neurostat (Spembly Medical, Surgical Technology Group). In local anaesthesia the skin was punctured with the cryo-probe and the nerve located with electric stimulation and frozen with carbon dioxide for 60-120 s 62 procedures were carried out on 13 different nerves in 35 patients with chronic pam originating from a peripheral nerve Cryoanalgesia was applied directly on the nerve via an open procedure in 4 of the patients Two patients wanted, and got, the procedure repeated three times

Results Satisfactory pain relief for > two months (usually 3-5 months) was achieved in 18 procedures (29%), for two-weeks to two months in another 36%, while there was a failure, i e pain relief for < two weeks or not at all in 36% We found a correlation between the extent of early pain relief and its duration No serious complications were seen, but there were three local infections and three patients got some temporary allodynia

Conclusion This pilot study has not been able to show that cryoan-algesia is a general solution for patients with penpheral neuropa-thy. Many patients, especially those with a reasonably short history of pain or with a nociceptive component seem, however, to benefit from the procedure, which can then easily be repeated if necessary


Haruyoshi Ikebe. Masahiko Ichimata*, k.oji Itoh*, Shigenon Yo-shitake*, Seiji Hatton*, Takayuki Noguchi* (SPON H Ikebe), Dept ofAnesthesiology, Oita Medical Univ, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan

Aim of Investigation Neurolytic celiac plexus block (NCPB) is commonly used to treat upper abdominal intractable pain Complete NCPB is usually determined by the reduction in the systemic blood pressure However this reduction is not always admitted in the patients who shows good pain relief after the block This mechanism is prescribed by the relative increase in splanchnic blood flow after the sympathetic nerve block in this region To investigate the correlation between NCPB and splanchnic circulation, we measured the hepatic venous blood flow (HVBF) before and after NCPB since HVBF represents splanchnic circulation

Method Fifteen patients who had upper abdominal intractable pain were enrolled Thirteen patients had pancreas cancer and 2 patients had chronic pancreatitis. NCPB was performed by the posterior approach using 99 5% ethanol under prone position at both sides HVBF (a, s and d wave) was determined by ultrasonic pulse Dop-pler technique before, just after and on day 1 after NCPB Verbal rating scale (VRS) ranging from 0 no pain to 10 severest pain was simultaneously descnbed

Results. Mean HVBF increased significantly just after and on day 1 after NCPB VRS was descnbed relative high in 3 and low 12 patients The significant correlation was observed between VRS and HVBF (p=0 0157) The sensitivity and specificity of HVBF measurement to VRS were 100% and 66 6% respectively Conclusions It was suggested that HVBF measurement provide good evaluation after NCPB, especially in the case of the lack of reduction in systemic blood pressure


Edward Rabah. Aguilera C *, Eizo J * and Souyet H*, Dept of Anesthesia and Pain Relief, Hospital San Pablo y AChS Co-quimbo, CHILE

Aim of Investigation. To investigate the efficiency of the Neuro-lytic Block of the Ganglion Impar (sympathetic) in the reduction of pain in patients with irradiated uterine cervix cancer with chronic radiation proctitis A sympathetically mediated pain in these patients was proposed

Methods. Eight patients were studied The mean age was 46,8 years (range 36-57) They had been pelvic irradiated and received mtracavitary radioactive implants into the uterus They developed chronic radiation proctitis with rectal and/or anal pain, accompanied by sensations of burning and urgency without relief with the conventional therapy ofnon-opioid analgesics, opioids, tncyclic antidepressants and adjuvant drugs (WHO ladder) All the patients were submitted to Neurolytic Blocks of the Ganglion Impar we used a 22-gauge 3,5-inch spinal needle (stylet removed) manually bent 30 degrees, advanced through the anococcygeal ligament until retropentoneal tip location over the sacrococcygeal junction 5 ml of 10% phenol were injected The pain was evaluated with VAS score previous the blockade, 2 hours later, 24 hours, 7 days, and monthly evaluations

Results. All the blocks were easy to perform and confirmed by fluoroscopy, without local complications A significant reduction (p< 0,05) in VAS score two hours after the blocks and a highly significant reduction (p<0,001) in VAS score at 24 hours, 7 days and in all the remaining monthly evaluations were found The median follow up was 11 months (range 6-17 months)

Conclusions. The Neurolytic Block of the Ganglion Impar is effective in pain relief of the rectal and anal pain of chronic radiation proctitis


John W. Ritter. M.D , Associate Clinical Professor ofAnesthesiol-ogy, West Los Angeles VA Medical Center, 11301 Wilshire Blvd , Los Angeles, CA 90073

Aim of Investigation: To determine if percutaneous transabdommal celiac plexus neurolysis can be safely performed using computed tomography (CT) guidance

Methods: A 49 year old male with a history of transverse colon carcinoma had severe pain confined to his abdomen Constant infusion of intravenous morphine was unable to control his pain without causing excessive somnolence He could not lie on his abdomen due to the presence ofajejunostomy, a gastnc tube and a Hickman catheter He consented to celiac plexus neurolysis

Procedure: The patient received 1 gram of Ancef before the procedure Ai-tenal oxygen saturation, pulse, blood pressure, and electrocardiogram were monitored In the supine position, CT scans identified the viscera, superior mesentenc artery, celiac artery, aorta and retropentoneal space The abdominal wall was anesthe tized with 10 ml of 1% lidocame Under CT guidance a 15 cm long 22 gage Chiba needle was advanced to the ventral surface of the aorta between the celiac and supenor mesentenc arteries To determine if neurolysis of his celiac plexus would effect his abdominal pain, 20 ml ofO 25% bupivacame was slowly injected Communication with the patient was maintained dunng the procedure Ten minutes after bupivacame injection he stated that his abdominal pain was gone Then 30 ml of 100% ethyl alcohol, with 6 ml oflsoview, was slowly injected in 5 ml aliquots The alcohol spread retropentoneally along the celiac axis The patient did not experience pain

Results The patient's vital signs remained stable dunng the procedure and in the recovery room He did not develop an infection Abdominal pain was eliminated His opioids were tapered off His function and quality of life improved He was able to ambulate and enjoy his hobby of painting

Conclusions CT guided percutaneous transabdommal celiac plexus neurolysis can safely eradicate upper abdominal cancer pain without senous complications

Acknowledgments. Supported by West Los Angeles VA Medical Center Dept of Radiology and VA patient care funds


k.oji Sumikawa. Toru Fujie, Shiro Tomiyasu, Hiroyuki Yamada*, Hiroaki Morooka, Dept ofAnesthesiology, Nagasaki Univ School of Medicine, Nagasaki 852-8501, Japan

Aim of Investigation The splanchnic nerve block is an effective technique to manage intractable pain of upper abdominal cancer, but has a senous disadvantage, i e , pneumothorax or perforation of liver or kidney, which could occur during needle manipulation to retrocrural space Thus we have introduced the transdiscal approach for the block, and evaluated its efficacy in cancer patients

Methods Twenty-seven patients with upper abdominal and/or back pain due to malignancy were studied The T12-L1 mtervertebral disc was venfied with fluoroscopy, and a block needle was inserted into the disc The needle was advanced slowly using loss of resistance technique with saline When the retrocrural space was identified, 5-10ml of contrast medium with local anesthetic was injected, which produced a typical image ofparaaortic and retrocrural spread in biplane radiographs Neurolysis was undertaken with 8-12ml of absolute ethyl alcohol The effects of neurolysis were assessed by pain score before and 5 days after the block with no pain sconng 0 and the pain before the block sconng 10

Results One out of 27 patients failed to undergo the block because of marked spur formation All of other patients showed marked relief of pain, and the mean pain score after the block was 1 6 There was no side effect associated with the approach itself

Conclusions As compared to the conventional celiac plexus block, this technique would make more complete block with a small volume of alcohol Another advantage is the practical approach through either affected or unaffected side, i e , patients are laid in the lateral position with either side upper as they can tolerate


Victor Whizar-Lugo. Susana Carrada-Perez*, Carlos Segovia-Garcia*, Jaime Pma-Garcia*, Ricardo Valdez-Jerez*, Rogelio Her-nandez-Velazco Anestesiologia y Clinica de Dolor Centro Medico del Noroeste Tijuana BC, Mexico 22320

Aim of Investigation To study the useful ofCT scan guidance to perform tngemmal neurolysis

Methods. Nine patients with uncontrolled Vth nerve neuralgia were scheduled for alcohol neurolysis All cases were monitored with EKG, pulse oximetry and intermittent blood pressure An iv line was started and iv midazolam and fentanil were given to produce a slight sedation The blocks were performed on the supine position on the CT scan table. Under local anesthesia, using the standard anatomical landmarks, a 22 gauge Qumcke spinal needle, 8 89 cm long was inserted according with the Gassenan ganglion block technique, until the needle tip reached the base of the skull or a mandibular paresthesia was elicited. Immediately, a series ofCT scan slides were done in order to identified the needle tip position The needle tip was then walked carefully into the foramen ovale, and once a proper position was confirmed with another series of CT scan slides, the stylet was removed, a negative CSF and blood aspiration proved, a 0 2 ml increments of dehydrated 98% ethanol were injected up to 1 ml All but one patient were send home one hour after the procedures were done

Results Adequate pain relief was obtained in 8 patients, and one developed V2 anesthesia dolorosa Eight out of 9 patients were able to stop or decrease their previous medicines

Conclusions CT scan guidance during tngemmal neurolysis affords a precise placement of the needle tip reducing the chance on injecting the neurolytic improperly It is expensive and requires an expert radiologist

Sex/age % analgesia Follow-up (months)
M/45 80 18
F/59 90 24
F/62 100 14
M/78 70 12
M/67 40 9
M/79 80 20
M/65 75 22
M/80 75 18
M/75 90 10


Enka Budai* (SPON ZS Horvath), Tibor Tihanyi*, Lajos Flaut-ner*, Semmelweis Univ of Medicine, 1st Dept of Surgery, 1082 Budapest, Ulloi 78, Hungary Presenting author's workplace Ba-jcsy-Zsilmszky Hospital, Dept ofAnaesthesiology and Intensive Care, 1106 Budapest, Maglodi 89-91, Hungary

Aim of Investigation- The majority of the pancreatic cancer (PC) are currently offered palliative treatment only Pain is often the dominant symptom Coeliac plexus blockade (CPB) by alcohol administration is the most frequent therapy for the specific pain caused by pancreatic cancer

Methods In this report 42 CPB's were studied at 38 patients The median age of 20 male and 18 female was 59 years Diagnosis was proven by histology. Before CPB 36 patients underwent lapara-tomy CPB was made with method ofKappis under radiological control The influence of tumour size and that analgesic drugs taken before CPB on the length of painless period following CPB was examined

Results Up to the first 10 minutes after CPB successive decrease of the blood pressure was observed In cases with tumour size less than 4x4 cm original the pain-free interval reached 90 18 days in average. In contrast to this, patient suffering from tumours larger than mentioned above gained only 11 1 painless days The difference is significant (p<0 001)

Conclusions At patients received strong narcotics, the painless period was very short. We think, that CPB is recommended for patients with non-resectable or recurrent pancreatic cancer smaller than 4 cm in diameter


Henk Konmg. Hans Koster*, Tobias Bruinen*, Pain Relief Unit, Medical Centre Leeuwarden, Henn Dunantweg 2, 8934 AD Leeu-warden. The Netherlands.

Aim of Investigation' This study was undertaken to determine the success-rate and the side-effects of a radiofrequency lesion of the superior cervical ganglion in patients with non-traumatic neck pain and to identify patients who might derive benefit from this method

Methods: A retrospective analysis of all patients with non-traumatic neck pain (n=l 30) who underwent a blockade of the superior cervical ganglion in a two year penod from august 1996 till august 1998 was undertaken

Results A significant pain relief following a temporary blockade of the ganglion cervicalis superior with bupivacain 0 25% was seen in 98 of the 130 patients (75%). In patients with a positive response a radiofrequency lesion was performed. Two months after the radiofrequency lesion of the ganglion cervicalis superior, 67% of the patients had expenenced long-term reduction of the pain The mean pain score was 60 per cent of the onginal pain. A pain reduction of 50% or more was achieved in 46 per cent of the patients Side-effects were worsening of pain complaints in 4% and decreased sensibility in less than 1% of the patients. Patients with cervical spondylosis showed a better response

Conclusions- In cases of chronic neck pain without neurological signs that do not respond to adequate conservative therapy, treatment of the ganglion cervicalis superior might be warranted. Especially patients with cervical spondylosis can benefit from this procedure


Masahiro Shiotam. Klyoshige Ooseto, Yoshikazu Nagamuma, Dept of Pain Clinic, Kanto Tcishm Hospital, Tokyo 141-0022, Japan

Objective To present of our experience, over the past five years, of thoracoscopic sympathicotomy for the disease of upper limb

Design' Retrospective clinical observation study Setting the Kanto Teishin Hospital and an affiliated hospital Japan.

Subjects: 1876 consecutive operations in 943 patients for primary palmar and or axillary hyperhidrosis, in 10 patients for RSD, three patients for thromboangntis obliterans (TAO) and one patients for Raynaud's disease over a penod of five years

Interventions' Thoracoscopic sympathicotomy from below T2 to T3 including the fibers ofKuntz using electrocautery through single site access The patients underwent bilateral simultaneous sympathicotomy for hyperhidrosis, buerger's diseased and Raynaud's syndrome, and unilateral sympathicotomy for RSD

Results For assessment of immediate postoperative success and of complication all patients date were reviewed from date base using personal computer Patients with hyperhidrosis received a postal questionnaire regarding palmar, axillary and plantar sweating, compensatory and gustatory sweating, complication and satisfaction Patients with RSD, TAO and Raynaud's were reported about the change of pain seventy after operation Two patients were convened to open surgery because of intercostal arterial bleeding and were discharged within a week Major complication was not encountered Ten patients required intercostal drainage because of pneumothorax or small bleeding Other patients had an uneventful course and were discharged two days after operation Homer's syndrome developed in five patients. Two patients were observed complete Homer's syndromes and three patients were incomplete

Postal questionnaire was sent to 435 patients and 325 patients (77 9%) responded to the questionnaire In 10 patients with RSD, four of the patients were satisfied with the results Six patients were not satisfied. All of the patients with TAO were excellent results and one patient with Raynaud's disease was not satisfied at all. 97 3% of patients had complete dry hands at the time of follow-up 2%were improved than the preoperative period and reported slight sweating and 0 6%had wet palms. Compensatory and gustatory sweating was observed in 96 2% and 38.0% respectively


M Suchorzewski. E Smigielska*, Wojciech Bozyk, Multidisci-plinary Pain Clinic & Radiology Dept, Nicholas Copernicus Hospital, ul Nowe Ogrody 1-6, 80-803 Gdansk, Poland

Case report The authors present the case of complication during performing celiac plexus neurolysis by Ischia method The patient was 45 years old and he suffered from pain in course of chronic pancreatitis. The complication occurred when the patient was given the contrast medium, because it was injected intramurally to the abdominal aorta's wall. It was diagnosed at once on the ground of acute pain during the injection of the contrast medium Diagnosis was confirmed by: X-ray photos and ultrasonography The intended celiac plexus neurolysis technique was done again after regression of pain and after short patient's observation We have not ascertained any consequences of described complication either just after procedure or 5 months later Conclusions- Sudden, acute pain during injection the contrast medium can be caused by its abdominal aorta's intramural spreading

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.202 - 208


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