Cryoneurolysis for zygapophyseal joint pain: a retrospective analysis of 117 interventions.

PURPOSE: Lumbar facet joint syndrome (LFJS) is the cause of pain in 15-54% of the patients with low-back pain. There are few studies of cryotherapy for LFJS, focusing mainly on pain scores rather than further outcome measures. The aim of the study was to determine the long-term outcome after cryoneurolysis of lumbar facet joints, looking at pain scores, pain-related impairment patient satisfaction, and pain-related anxiety/depression. METHODS: The study design was a retrospective observational study. In a 4-year period, 117 cryoneurolyses were performed in 91 patients under CT guidance in the prone position. Data from patient charts and questionnaires pre- and post-treatment were evaluated. RESULTS: The mean pain rating sank from 7.70 before treatment to 3.72 post treatment. In the post-interventional 3 months follow-up, this value rose to 4.22. At follow-up (mean 1.7 years, range 6-52 months), the mean visual analogue scale (VAS) was 4.99. The pain disability index revealed statistically significant improvements in the following items: familiar and domestic duties, recreation, social activities, profession and vitally indispensable activities (p < 0.05). Hospital anxiety and depression scale (HADS) scores for depression showed a statistically significant decline after therapy, whereas scores for anxiety did not. A subgroup of patients who did not benefit from cryoneurolysis had elevated depression scores. CONCLUSIONS: Cryoneurolysis for LFJS can lead to favourable results with sustained pain relief, amelioration of pain-related disability and reduction of depression scores.

Chronic low back pain: course of disease from the patient's perspective.

Chronic back pain often leads to permanent disability and-apart from significant human suffering-also creates immense economic costs. There have been numerous epidemiological studies focussing on the incidence and the course of chronic low back pain. Less attention has been paid to the impact of subjective perception of the disease and the degree of healthcare use of these patients. The aim of this study was to gather data about patients with chronic low back pain and compare these data with patients suffering from chronic pain in other body regions. The first 300 pain questionnaires collected by the interdisciplinary pain centre at the University Hospital in Freiburg between January 2000 and September 2001 were analysed. This pain questionnaire is a modified version of the pain questionnaire of the DGSS (Deutsche Gesellschaft zum Studium des Schmerzes-German Chapter of the IASP). It collects demographic and socioeconomic information, as well as information regarding the course of the disease, and the subjective description of pain and the pain-related impairment. The subjective view of the course of disease, shows differences between patients with low back pain and patients with chronic pain of other origin, particularly regarding physical strain as the assumed cause of pain, but also regarding the frequency of prior treatments and cures. The subjective perception of the course of the pain disorder in patients with low back pain compared to patients with chronic pain in other parts of the body shows differences mainly related to the capacity for physical exertion. The frequency of ineffective prior treatments and cures underlines the necessity for early initiation of effective pain treatment aimed at prevention of the pain disorder becoming chronic.

Hemidystonia due to a contralateral parieto-occipital metastasis: disappearance after removal of the mass lesion.

A patient presented with left-sided hemidystonia. CT revealed a contralateral parieto-occipital mass lesion compressing the basal ganglia, which were spared by the mass. After microsurgical resection of the tumor, which was verified histologically as a metastasis of a large-cell anaplastic carcinoma, the movement disorder dissolved completely.

Molecular size distribution of somatostatin-like immunoreactivity in the cerebroventricular fluid of neurosurgical patients.

The molecular size distribution of somatostatin-like immunoreactivity (SLI) in the cerebroventricular fluid of patients with Parkinson's disease, dystonic syndromes, multiple sclerosis, basal and midline tumors, epilepsy and pain syndromes was investigated by separation with a Sephadex G-50f column and subsequent radioimmunoassay of the eluate. Marked heterogeneity of SLI was observed in most of the pools investigated. The most conspicuous feature of the elution profiles was the preponderance of the peak coeluting with synthetic somatostatin-14, whereas the peaks comigrating with synthetic somatostatin-28 and attributable to precursor-like SLI represented only minor or trace amounts of total immunoreactivity. These findings are consistent with the greater biological activity of somatostatin-14 in the human central nervous system, whereas somatostatin-28 appears to represent the more active form in the pituitary and in the intestinal mucosa. Solely in the case of brain tumor patients, some differences could be seen, resulting in an approximately equal distribution of somatostatin-14 and somatostatin-28 in two pools of ventricular fluid and by the detection of a degradation product of somatostatin-14 in another one. These observations could be explained by a lowered barrier function as a consequence of increased intracranial pressure in case of brain tumors, which is well in accordance with a markedly elevated total protein content being a sign of a lowered barrier function.

Ventricular fluid neuropeptides in Parkinson's disease. I. Levels and distribution of somatostatin-like immunoreactivity.

We have measured somatostatin-like immunoreactivity SLI in cerebroventricular fluid of patients with Parkinson's disease (PD) and other extrapyramidal disorders with hyperkinesia. Patients with PD showed a significantly lower concentration of SLI when compared with levels in control patients with chronic stable multiple sclerosis or temporal lobe epilepsy. Less markedly decreased levels of SLI were also noted in patients with torsion dystonia. Of two patients with Huntington's disease one showed a high and one a medium concentration of SLI. According to the site of the stereotactic cannula, verified by ventriculopathy, SLI concentrations in CSF specimen obtained from the foramen Monro tended to be higher than in specimen from a supraforaminal level. Of 5 other patients with lateral and third ventricle being accessible during the passage of the stereotactic cannula, 4 showed higher SLI concentrations in the third ventricle compared to the lateral ventricle. High performance liquid chromatographic analysis combined with radioimmunoassay showed molecular heterogeneity of SLI in CSF. The ratio of SST-14 to SST-28 was higher in the third ventricle than in the lateral ventricle.

CT-stereotaxic drainage of colloid cysts in the foramen of Monro and the third ventricle.

Colloid cysts in the foramen of Monro and third ventricle account for 0.5% to 1% of all intracranial space-occupying lesions. The introduction of computerized tomography (CT) and magnetic resonance imaging has represented a major advance in the early detection of these cysts. The risks associated with the management of benign space-occupying lesions by open surgical procedures have made it necessary to search for safer techniques. The CT-stereotaxic method provides a simple, precise, and safe method of puncturing deep-seated space-occupying cysts. Between January, 1979, and December, 1984, 12 patients with colloid cysts in the foramen of Monro and third ventricle were operated on by this method. The operations were successful, and there were no intraoperative or postoperative complications. The advantages of the CT-stereotaxic method are discussed and the results are presented.

CT-guided stereotactic fibrinolysis of spontaneous and hypertensive cerebellar hemorrhage: long-term results.

The surgical indication for spontaneous cerebellar hemorrhage is not as controversial as the operative management of intracranial hemorrhage. Timing of the operation is crucial: intervening too early can produce an additional strain on the patient and an increased risk, while waiting too long to evacuate the hematoma can be fatal. This dilemma may be a factor in the relatively high mortality and morbidity rates following both operative and conservative treatment that have been reported in the literature (42.5% and 30%, respectively). In long-term studies on 14 patients, the authors have shown that stereotactic puncture and fibrinolysis for cerebellar hemorrhage is a valuable alternative to treatments used currently. The method consists of computerized tomography (CT)-guided stereotactic puncture and partial evacuation of the hematoma. After fibrinolysis with urokinase, the residual hematoma can be completely evacuated via a catheter introduced into the cavity of the hematoma. Only one of the 14 patients died in the direct postoperative phase; the remaining patients were enjoying a good to very good quality of life 6 months after the acute event. Two patients subsequently died as a result of pneumonia and cerebral infarction, respectively; both conditions were unrelated to the hemorrhage. The authors conclude that the CT-guided stereotactic method is simple, effective, and safe, and can be applied to patients of any age.

The treatment of posttraumatic tremor by stereotactic surgery. Symptomatic and functional outcome in a series of 35 patients.

The authors report the long-term results of stereotactic surgery for severe posttraumatic appendicular tremor in 35 patients. The tremors developed after severe head trauma in 33 patients (94%) and after mild to moderate head trauma in two (6%). In all but one, the tremor was most evident during activity. The amplitude of the kinetic tremor was greater than 5 cm in 33 patients (94%) and greater than 12 cm in 19 patients (54%). All were severely incapacitated in their daily living activities due to the tremors. The 35 patients underwent 42 stereotactic operations; five patients were reoperated on the same side and two were treated with a bilateral staged procedure. The contralateral zona incerta was the stereotactic target in 12 patients and was targeted in combination with the base of the ventrolateral (oroventral) thalamus in 23 patients. Long-term postoperative follow-up review was obtained in 32 patients (mean follow-up period 10.5 years). Persistent improvement of tremor was noted in 88%. The tremor was absent or markedly reduced in 65%. Functional disability was assessed and quantified with a modified form of an established rating scale for patients with tremor; it was reduced from a mean value of 57% of maximum disability to 37% over the long term (p < 0.001). Follow-up lesion assessment was obtained in 18 patients by multiplanar magnetic resonance imaging and at autopsy in one patient whose death was unrelated to surgery. As in previous studies, the frequency of persistent side effects was relatively high (38%). These consisted mainly of aggravation of preoperative symptoms. The results are compared to those of a total of 55 patients reported from 1960 to 1992. The occurrence of dystonia and dystonic postures is discussed. Stereotactic surgery is a powerful tool to alleviate posttraumatic tremor and to improve functional disability. However, as there is considerable risk of persistent morbidity in patients after severe head trauma, the operation should be restricted to selected cases with disabling tremor.

Cervical CT-guided, selective nerve root blocks: improved safety by dorsal approach.

Cervical transforaminal blocks are frequently performed as a treatment of cervical radicular pain. These blocks are performed mostly under fluoroscopy, but a CT-guided technique also has been described. We describe a modification that leads to a more extraforaminal than transforaminal and equally selective nerve root block.

A new safety device to prevent bleeding complications during stereotactic biopsy--the "stereotactic" Doppler sonography. Technical note.

To further reduce the incidence of haemorrhagic complications during stereotactic biopsy, the use of a microvascular Doppler system is proposed. The microprobes are fitted into the biopsy cannula to detect vessels in the neighbourhood of the target point. The first clinical results are promising.

Intracranial calcified deposits in neurofibromatosis type 2. A CT study of 11 cases.

CT examinations of 11 consecutive patients with neurofibromatosis type 2 (NF-2) revealed non-tumoral intracranial calcified deposits in seven cases. Abnormal calcification of the choroid plexus was found in six cases. Calcification in the cerebellar hemispheres was observed in four cases. In two cases nodular calcifications on the surface of the cerebral hemispheres were detected. Our findings and the data in the literature show that non-tumoral calcifications of different locations can be regarded as part of the NF-2 syndrome.

CT-ventriculography to control the passage of cerebrospinal fluid. Technical note.

In conventional ventriculography used to confirm free passage of cerebrospinal fluid (CSF), bony overprojections often makes it difficult to visualize the contrast medium in the cranio-spinal subarachnoid spaces. CT-ventriculography offers an alternative. Because of the high density resolution, even small amounts of contrast material can be seen in the subarachnoid spaces of the cranio-cervical region. Its usefulness is demonstrated in a series of 15 cases.

[CT stereotactic biopsy in the differential diagnosis of deeply situated intracerebral hematomas]. / CT-stereotaktische Biopsie zur Differentialdiagnose der tief gelegenen intrazerebralen Hämatome.

The diagnosis of intracerebral haematomas, especially of those which are relatively small, occupy little space and are deeply situated, presents considerable problems. The problem is even greater when the expected acute case history and the acute beginning of the symptoms do not occur and unusual localisations are found. The consequences of this are false diagnoses and the treatment of these patients within the framework of blanket diagnosis "intracerebral tumours" or "space occupying processes" without any confirmation of the histological diagnosis. - Using a sample of 26 patients where the histological diagnosis of non-recent intracerebral hemorrhages had been confirmed (out of a series of 818 CT-stereotactically biopsied patients punctured by us from the beginning of 1983 until the end of 1984), the problem of establishing a diagnosis is exposed. - A histological diagnoses should in any case be confirmed before any thorough and deep-reaching therapy is begun, since false diagnoses and misinterpretations can cause serious consequences for the patient.

Bilateral ballismus in children.

Bilateral ballismus is extremely rare. We found 23 reported cases, and only 2 of these were in children. In older patients the movement disorder is usually due to cerebrovascular disease, but in younger patients a variety of aetiopathological causes may be found. There are few data regarding medical treatment. There have been no previous reports on stereotactic operations. We report on two severely disabled children who underwent stereotactic surgery. A 9-year-old boy suffering from bilateral ballismus after meningoencephalitis was operated on bilaterally (two operations 1 year apart). Another 9-year-old boy, who was suffering from progressive, presumably degenerative, basal ganglia disease, was operated on unilaterally. The nosological and conceptual controversies differentiating bilateral ballismus as a phenomenological entity are reviewed. The therapeutic options, indications, and special problems of stereotactic surgery in these rare cases are discussed.

[Stereotactic evacuation and early rehabilitation in space-occupying cerebral hemorrhage]. / Stereotaktische Hämatomentleerung und Frührehabilitation bei raumfordernder Gehirnblutung.

The choice of treatment in intracerebral hematoma remains controversial as long as there are no prospective, randomized trials from multiple centers. Recent experiences showed a lower mortality rate after stereotactic evacuation of intracerebral hematoma. However according to the present study (60 patients) the quality of survival and duration of hospital stay seems to be dependent on early and intensified rehabilitation and physiotherapy.

Sympathetic nervous system and pain: a clinical reappraisal.

The target article discusses various aspects of the relationship between the sympathetic system and pain. To this end, the patients under study are divided into three groups. In the first group, called "reflex sympathetic dystrophy" (RSD), the syndrome can be characterized by a triad of autonomic, motor, and sensory symptoms, which occur in a distally generalized distribution. The pain is typically felt deeply and diffusely, has an orthostatic component, and is suppressed by the ischemia test. Under those circumstances, the pain is likely to respond to sympatholytic interventions. In a second group, called "sympathetically maintained pain" (SMP) syndrome, the principal symptoms are spontaneous pain, which is felt superficially and has no orthostatic component, and allodynia. These symptoms, typically confined to the zone of a lesioned nerve, may also be relieved by sympathetic blocks. Since the characteristics of the pain differ between RSD and SMP, the underlying kind of sympathetic-sensory coupling may also vary between these cases. A very small third group of patients exhibits symptoms of both RSD and SMP. The dependence or independence of pain on sympathetic function reported in most published studies seems to be questionable because the degree of technical success of the block remains uncertain. Therefore, pain should not be reported as sympathetic function independent until the criteria for a complete sympathetic block have been established and satisfied.

[Effect of xylitol on increased intracranial pressure]. / Die Wirkung von Xylit auf den gesteigerten Hirndruck

Increased intracranial pressure could be lowered by means of 250 ml 40% xylite (1,2,3,4,5-pentanpentol) in 17 patients, the average dosage amounted to 1.36 mg/kg, the lowering of the pressure to 54.4 plus or minus 18.4%. The effect lasted 109.5 plus or minus 35.4 min; the maximum occurring after 50.4 plus or minus 14.8 min. With the exception of 3 patients who complained of slight gastrointestinal disturbances, no side reactions were observed. Paralleling the lowering of CSF-pressure increased diuresis occurred amounting to 400% (including the infusion volume). The maxima of diuresis and lowering of CSF-pressure concur. Simultaneously we can see a highly significant lowering of urine potassium and a slightly significant lowering of sodium within the first 2 h, which after 3 h is clearly receding. There was no significant change in the values of serum electrolytes, bilirubin and transaminases (SGOT and SGPT); the residual urea was just a little lowered. The lowering of CSF-pressure after xylite surpasses the effect of the same dosage of sorbit and fructose.

Computed tomography in cases of multiple sclerosis: problems of differential diagnosis in cases with atypical findings.

The value of computed tomography in the diagnosis of multiple sclerosis is undisputed. The examination is usually carried out as a routine part of the examination program. We report on the CT results of 112 patients with confirmed or suspected MS. Seventy-three patients were examined without, 39 with intravenous administration of a contrast medium. In 41% of the patients, isolated or multiple hypodense foci were found as a manifestation of a multilocular demyelinization process. In 17.8%, only cerebro-atrophic changes were encountered. In 30.3% of the cases the CT showed normal results. In the group of patients examined with a contrast medium, a pathological contrast medium concentration was found in 30.7%. The differential diagnostic demarcation against other diseases of the CNS with similar CT findings and problems of differential diagnosis with MRI are discussed.

Stereotactic interstitial irradiation of diencephalic tumors with iridium 192 and iodine 125: 10 years follow-up and comparison with other treatments.

The only possible treatment of non-removable tumors of the diencephalon or recurring tumors invading the diencephalon after partial resection or percutaneous radiotherapy is interstitial irradiation (Curie therapy). With the CT/MRI stereotactic method, biopsy for histological tumor classification can be performed and 125I or 192Ir implanted, provided the neuroimaging methods show the delimitation of the tumor, its diameter does not exceed 3 cm and, given the patient's condition, focal irradiation seems advisable. As of 31 August 1987, a total of 1883 cases had been stereotactically biopsied and interstitially irradiated. The indications and results are reported in 204 patients under 18 years of age with diencephalic and deep-seated astrocytomas, after a follow-up period of up to 10 years; the data were compared for tumor resection, percutaneous irradiation, and for interstitial irradiation. The latter proved to be the most effective treatment.