[Pain and poverty]. / Armut und Schmerz.

BACKGROUND: Poverty is an important problem in Germany. The health effects of poverty can lead to a higher risk of disease and the arising of chronic affections. On the other hand chronic illness may support the development and continuance of poverty. The context of chronic pain and poverty has not been analyzed so far. OBJECTIVES: We investigated the correlation between chronic pain and poverty. MATERIALS AND METHODS: In a prospective manner we interviewed 20 patients with pain syndromes during our consultation hour regarding their household income. Further, data from the German Federal Statistical Office were analyzed with respect to the correlation between the incidence of a chronic pain diagnosis and household income. RESULTS: At 1546 €, the average household income of the patients studied was below the poverty level. The analyzed data showed that women suffered from chronic pain more often than men did and also had a lower income. Another economic inequality was found between Eastern and Western Germany. There was a statistically significant correlation between income and the incidence of the diagnostic codes for chronic pain (R52.1, 2, 9) for men. CONCLUSION: Our investigation showed the correlation between chronic pain and poverty. A commitment and cooperation of German medical associations and federal politics is necessary to overcome this sociopolitical issue.

[Nummular headache : Subcutaneous peripheral nerve field stimulation as an individual therapeutic attempt]. / Münzkopfschmerz : Subkutane periphere Nervenfeldstimulation als individueller Therapieversuch.

BACKGROUND: Subcutaneous peripheral nerve field stimulation (sPNFS) is an established procedure for the treatment of chronic localized neuropathic pain of peripheral origin. The treatment of nummular headache primarily focuses on conservative methods with limited prospects of success. The role of sPNFS in the treatment of nummular headache has not been investigated as yet. QUESTION: Is the sPNFS an option in the management of nummular headache? MATERIALS AND METHODS: In addition to a summary of established methods in the treatment of nummular headache, sPNFS as a possible form of therapy is discussed. RESULTS: A positive effect of sPNFS in terms of the treatment of nummular headache is shown. DISCUSSION: sPNFS stimulates free subcutaneous nerves and transmits a pleasant form of paraesthesia in the area of pain. If regular conservative therapy has already been exhausted, then sPNFS might be an effective new option in the treatment of nummular headache. sPNFS is a minimally invasive and low-risk procedure. However, the high treatment cost and restrictions regarding fitness to undergo MRI are points of criticism. Further studies are needed to define its potential and role in the treatment of nummular headache.

[Spinal cord stimulation for thalamic pain: Case report and review of the current literature]. / Hochzervikale Rückenmarkstimulation bei Thalamusschmerz : Fallbericht und Übersicht zur aktuellen Literatur.

BACKGROUND: Spinal cord stimulation (SCS) is an established procedure for treatment of chronic neuropathic pain of peripheral origin. The efficacy of SCS in case of central poststroke pain (CPSP), especially thalamic pain, has not been adequately proven. OBJECTIVES: The efficacy of SCS as an extracranial neurostimulation method for the management of central pain syndrome was investigated. MATERIALS AND METHODS: In this study, relevant pharmacological and nonpharmacological measures for central pain management were reviewed. A case of successful SCS for thalamic pain after ischemic insult is presented. Explanatory approaches of pathophysiological processes and a review of the current literature underline our results. RESULTS: In the case presented, SCS was found effective in the treatment of thalamic pain. CONCLUSION: The efficacy of SCS might be caused by segmental and supraspinal processes and collaboration of activating and inhibiting pathways. The integrity of the spinothalamic tract is mandatory. SCS is a treatment option for central pain syndrome, especially thalamic pain. Comparable studies confirm the potency of this technique. In contrast to other neuromodulation procedures spinal cord stimulation is less invasive, has a lower perioperative risk and is often less expensive. Further studies are needed to define its potential and role in the treatment of thalamic pain.

[Spinal cord stimulation at the level of the conus medullaris : treatment option for therapy-resistant postoperative neuralgia of the pudendal nerve]. / "Spinal cord stimulation" in Höhe des Conus medullaris : Behandlungsoption bei therapierefraktärer postoperativer Neuralgie des N. pudendus.

Injuries of the pudendal nerve, due to a perineal tear during delivery for example, can cause significant and debilitating neurological deficits. Aconuresis and anal incontinence, as well as sensory loss of the outer genitals or even impotency in men are the well known consequences. In addition some patients suffer from a severe neuropathic pain syndrome which is resistant to conservative treatment options. Epidural spinal cord stimulation at the level of the terminal cone of the spinal cord may be a new and successful therapeutic concept in otherwise untreatable cases.

Electrophysiologic analysis of snap amplitude in orthodromic and antidromic studies.

In 1966, Buchthal and Rosenfalk established that the sensory nerve action potential (SNAP) amplitude increased with increasing number of nerve fibers. Lambert and Dyck's in vitro study of the sural nerve, however, found the SNAP amplitude of a single fascicle was equivalent to the SNAP amplitude of the entire nerve. The current study confirmed Buchthal and Rosenfalk's original findings, and discovered an in vivo equivalent to Lambert and Dyck's findings. Ten subjects were used as their own controls. Orthodromic stimulation of both the index and middle fingers stimulated individually versus simultaneously revealed a significant increase in amplitude (p < 0.001). When the recording and stimulating electrodes were reversed, without physically changing the electrodes on the subject, there was no significant difference between the antidromic SNAP amplitudes recorded from separate fingers, or from both fingers simultaneously. Although in both cases the number of recorded nerve fibers approximately doubled, the effect on the SNAP amplitude was very different. This seemingly paradoxical result can be explained by electrophysiologic differences in the recording methods, without using the concept of fiber density.

Short Psychological Intervention as a Perioperative Pain Reduction Treatment in Spinal Neurosurgery.

STUDY AIMS: The aim of the present pilot study was to test the feasibility of an innovative Short Psychological Intervention (SPI) for back pain patients as part of an acute inpatient neurosurgical treatment. Fear and fear-avoidance beliefs have been shown to influence the functional outcome in chronic back pain (CBP) patients. Therefore, a reduction of fear and fear-avoidance beliefs should improve the functional outcome and reduce pain in the acute neurosurgical setting. PATIENTS AND METHODS: 39 patients were studied in a randomized prospective longitudinal study. The patients had severe degenerative spinal disease and had undergone posterior lumbar interbody fusion. RESULTS: All patients enrolled in the study were investigated in the immediate preoperative period and 6 weeks postoperatively using a package of standardized questionnaires in which pain intensity, fear-avoidance beliefs, and physical fitness were recorded. In 19 of the patients, the surgical procedure was supplemented by a SPI based on methods to increase self-efficacy by reducing fear-avoidance beliefs. While the intervention group reported a significantly greater reduction in the highest pain intensity and a better physical fitness compared to the control group, we did not find a significant decrease in fear-avoidance beliefs in the intervention group at the second time of assessment, possibly due to the relatively small sample size. CONCLUSIONS: The study confirmed that psychological interventions can offer significant benefits when used in the acute inpatient setting as the outcome of surgery can be positively influenced. Future studies should focus on cost savings related to improved postoperative recovery and a possible reduction of chronic postoperative pain.

[Neuralgia of the genitofemoral nerve after hernioplasty. Therapy by peripheral nerve stimulation]. / Neuralgie des N. genitofemoralis nach Hernioplastik. Therapie durch periphere Nervenstimulation.

The peripheral nerve stimulation (PNS) is an established therapy in the management of neuropathic pain. Here, we describe a case of successful epifascial stimulation in the proximity of the genitofemoral nerve, which was injured during an endoscopic hernioplasty. During the following months the patient developed an intense neuropathy of this nerve, which we now treated by permanent PNS with an 8-polar electrode. During the 1 year follow-up the patient described a pain reduction of nearly 70%. There were no adverse events until now. In conclusion, PNS is a promising procedure in the treatment of neuralgia after hernioplasty.

Outcome after decompressive craniectomy in patients with severe ischemic stroke.

Decompressive craniectomy after space occupying infarction of the middle cerebral artery (MCA) tends to decrease mortality and increase functional outcome. The aim of this retrospective study was to evaluate mortality rates and functional outcome in our centre and to identify predictors of prognosis. The charts of 30 consecutive patients (6 women, 24 men, mean age 59.3 +/- 11.0 years) who underwent craniectomy after space occupying MCA-infarction from 1996 to 2002 were analyzed. Functional outcome was assessed by semistructured telephone interview as Barthel-Index, modified Rankin scale and extended Barthel-Index. Five patients (mean age 67.2 +/- 6.1 years) died within 5.2 +/- 2.4 days (range 2-8 days) after the first symptoms due to herniation. Nine patients (mean age 63.1 +/- 7.1 years) died 141.0 +/- 92.5 days (range 40-343) after stroke onset due to internal complications. 16 patients survived (mean surviving time 2.1 +/- 1.5 years, mean age 54.1 +/- 11.4 years). Mortality was related to age and the number of risk factors/comorbidity, and functional outcome was dependent on the number of risk factors/comorbidity. Our small observational, retrospective study suggests that hemicraniectomy in patients with space occupying MCA-infarction decreases mortality rate and increases functional outcome. Further randomized trials may prove useful to better define the indications, timing and prognosis for this procedure.