Peripheral nerve stimulation in intractable neuropathic pain.

Peripheral nerve stimulation (PNS) is a neurostimulation analgesic technique. PNS is utilized to treat peripheral neuropathic pain. It is highly sophisticated and a specialized technique used where other forms of treatment have failed. This paper describes the PNS procedure, its therapeutic principles, indications, and the comprehensive care for patients after the PNS implant. First, we summarize our experience using this type of invasive treatment. In the second part, a case of intractable neuropathic pain following repeated surgery to the ulnar nerve is reported. Prior to PNS, the patient underwent multiple types of antineuralgic treatment with no significant result. Only after the PNS application, was a significant analgesic effect achieved.

Cystic adventitial disease of the popliteal artery: report on three cases and review of the literature.

BACKGROUND: During the past nine years three cases of cystic adventitial disease of the popliteal artery have been diagnosed and treated in our medical institution. Different approaches were used in the treatment in all these cases. The purpose of this report is to summarise the current knowledge of the etiology, presentation, diagnostics and treatment of this condition, with the addition of new cases. METHODS: Information about three new cases is presented and discussed together with that from the relevant publications obtained from the Pubmed database. Results. In the first case resection with synthetic graft interposition was used. Nine years after the surgery the patient is without any signs of recurrence, but he experienced local thrombolysis of the occluded graft and repeated PTA of hemodynamically significant anastomotic stenoses. The second case treated with US-guided aspiration has demanded repeated reinterventions due to recurrence; nevertheless, the result is satisfactory. In the last instance, the cyst was evacuated and excised. Six months after the surgery the patient is symptom-free and without signs of recurrence. CONCLUSIONS: CAD of the popliteal artery is a rare vascular condition. However, it must be considered in the differential diagnosis, especially in middle-aged male patients without evidence of atherosclerotic disease in whom intermittent claudication has developed suddenly with a rapid progression or with fluctuation in severity. Duplex ultrasound and MRA are the the best diagnostic methods. Based on the existing knowledge, the treatment of choice is surgery (either evacuation with the removal of the cystic wall or resection and grafting).

Total spondylectomy of C2: report of three cases and review of the literature.

STUDY DESIGN: A report on 3 patients undergoing total spondylectomy of the C2 vertebra for tumor and the technique for C1-3 reconstruction. OBJECTIVE: To illustrate the feasibility of complete resection of the C2 vertebra with preservation of the vertebral arteries and cervical nerve roots. BACKGROUND: Total spondylectomy provides improved progression free survival in many patients with locally aggressive spinal tumors. However, the perceived technical demands of effectively preserving both vertebral arteries, maintaining cervical nerve roots, and biomechanical reconstruction of the cranial-cervical junction often dissuades surgeons from carrying out total spondylectomy of the C2 vertebra. METHODS: A review of 3 patients undergoing total C2 spondylectomy for tumor (thyroid adenocarcinoma, chordoma, and solitary plasmocytoma) was done. The surgical procedure that was undertaken and the technique used are described. RESULTS: Postoperatively, all 3 patients had uneventful postoperative recovery with gradual improvement in their neurologic functions. CONCLUSION: Preservation of bilateral vertebral arteries and all cervical nerve roots is feasible when carrying out intralesional total spondylectomy in patients with C2 vertebral body tumors and should be considered in patients thought to benefit from total C2 vertebra excision. In an attempt to augment construct stability and provide anterior column load sharing, we have used mesh cage and iliac crest graft between C1 and C3 held in place with a short cervical plate without complications.

Smoking cessation or reduction with nicotine replacement therapy: a placebo-controlled double blind trial with nicotine gum and inhaler.

BACKGROUND: Even with effective smoking cessation medications, many smokers are unable to abruptly stop using tobacco. This finding has increased interest in smoking reduction as an interim step towards complete cessation. METHODS: This multi-center, double-blind placebo-controlled study evaluated the efficacy and safety of nicotine 4 mg gum or nicotine 10 mg inhaler in helping smokers (N = 314) to reduce or quit smoking. It included smokers willing to control their smoking, and participants could set individual goals, to reduce or quit. The study was placebo-controlled, randomized in a ratio of 2:1 (Active:Placebo), and subjects could choose inhaler or gum after randomization. Outcome was short-term (from Week 6 to Month 4) and long-term (from Month 6 to Month 12) abstinence or reduction. Abstinence was defined as not a single cigarette smoked and expired CO readings of <10 ppm. Smoking reduction was defined as a reduction in number of cigarettes per day by 50% or more versus baseline, verified by a lower-than-baseline CO reading at each visit during the same periods. RESULTS: Significantly more smokers managed to quit in the Active group than in the Placebo group. Sustained abstinence rates at 4 months were 42/209 (20.1%) subjects in the Active group and 9/105 (8.6%) subjects in the Placebo group (p = 0.009). Sustained abstinence rates at 12 months were 39/209 (18.7%) and 9/105 (8.6%), respectively (p = 0.019). Smoking reduction did not differ between the groups, either at short-term or long-term. Twelve-month reduction results were 17.2% vs. 18.1%, respectively. No serious adverse events were reported. CONCLUSION: In conclusion, treatment with 10 mg nicotine inhaler or 4 mg nicotine chewing gum resulted in a significantly higher abstinence rate than placebo. In addition a large number of smokers managed to reduce their cigarette consumption by more than 50% compared to baseline.

Is the biliary manometric perfusion test effective in the evaluation of balloon dilatation treatment success of benign biliary strictures?

BACKGROUND: The success of balloon dilatation treatment of benign biliary strictures (BBS) is usually evaluated by 'clinical test'. For objective evaluation of treatment success, measurement of the pressure inside the biliary tree after treatment has been proposed. AIM: The aim of this article is to assess the role of biliary manometric perfusion test (BMPT) in the evaluation of treatment success of BBS and to assess the long term biliary patency after evaluation by BMPT. MATERIALS AND METHODS: From February 2003 to January 2008, 12 patients (median age 53.5 years) after balloon dilatation treatment were evaluated by BMPT. BMPT was done after a mean of 3 dilatations over a mean period of 6.85 months. An intrabiliary pressure less than 20 cm of water during the test was considered as success threshold. RESULTS: The pressures during BMPT were less than 20 cm of water in 11 out of 12 patients. Subsequently the drain was removed and patients were followed up clinically. Two patients on follow-up required re-intervention 13 days and 11 months later. The remaining 9 patients had no evidence of biliary obstruction at a mean following of 15.3 months. Using the statistical Kaplan-Meier analysis, the probability of biliary patency up to 9 months was 90.9% and at 1, 2 and 3 years was 77%. CONCLUSION: BMPT is effective in the evaluation of treatment success of BBS. It is simple, cost effective, gives immediate results and helps us to determine the treatment end point.

Lesser saphenous vein aneurysm and popliteal vein aneurysm: report of two cases and review of the literature.

BACKGROUND: During the last ten years we diagnosed two cases of venous aneurysm. The purpose of this report was to point out a certain risk of the thrombembolism of superficial venous aneurysms and to review our experience in the management of superficial and deep venous aneurysms. METHODS: The presentation and management of these lesions were reviewed and discussed together with other cases from available literature. RESULTS: In the first case an aneurysm of lesser saphenous vein with a possible threat of thrombembolism was revealed and surgically solved with saphena resection. Ten years after the surgery she is still symptom free. In the second case a small fusiforme popliteal vein aneurysm without any evidence of mural thrombus was diagnosed. The patient was treated conservatively with regular venous duplex imaging follow up. Two years later the disease has been stable. CONCLUSIONS: Superficial venous aneurysms can have a certain risk of the thrombembolism. Since surgical therapy is very simple, it can be recommended in all cases. Nevertheless, trombembolism is more common in deep venous aneurysms, especially popliteal ones, in which surgical repair can be based on their pathological features and presentation or can be indicated in all cases.

Endovascular treatment of abdominal aortic paraanastomotic pseudoaneurysms after surgical reconstruction.

PURPOSE: To evaluate the efficacy of endovascular treatment of paraaortic postoperative abdominal aortic pseudoaneurysms. MATERIALS AND METHODS: From April 1996 to November 2007 five men with paraaortic postoperative abdominal aortic pseudoaneurysm underwent endovascular treatment. Average age was 64.2 years (range 54-73). The average time interval between the primary surgery and endovascular treatment was 12.4 years (4 months-23 years). Three patients were treated by aortouniiliacal stentgrafts and two patients by tube stentgrafts. RESULTS: Technical success rate was 100%. Pseudoaneurysms were primarily excluded from circulation without perioperative complications in all patients. At follow-up (mean 38.5 months) there were no deaths and no endoleaks. In one patient thrombosis of stentgraft was found and it was successfully treated by thrombectomy. All pseudoaneurysms still continued to be excluded from circulation in the last follow-up. CONCLUSION: Endovascular treatment is minimally invasive, effective and safe option of surgery for paraaortic postoperative pseudoaneurysms.

Functional magnetic resonance imaging of cerebral activation during spinal cord stimulation in failed back surgery syndrome patients.

Spinal cord stimulation (SCS) consisting of electrical stimulation of the dorsal spinal cord using epidural electrodes has been shown to relieve chronic neuropathic pain. To analyze the cerebral activation patterns related to SCS, and to evaluate the effects of SCS on the processing of acute experimental pain, we performed functional magnetic resonance imaging (fMRI) on eight patients suffering from failed back surgery syndrome who were also being treated with SCS for severe pain in their legs and lower back. Three types of stimulation were used, each lasting 36s: (i) SCS, (ii) heat pain (HP) applied to the leg affected by neuropathic pain, and (iii) simultaneous HP and SCS. During SCS, we found increased activation of the medial primary sensorimotor cortex somatotopically corresponding to the foot and/or perineal region, contralateral posterior insula, and the ipsilateral secondary somatosensory cortex (S2). Decreased activation was seen in the bilateral primary motor cortices and the ipsilateral primary somatosensory cortex corresponding to the shoulder, elbow and hand. Compared to separately presented HP and SCS, simultaneous HP and SCS showed statistically significant activation of the bilateral inferior temporal cortex and the ipsilateral cerebellar cortex. The activation of the primary motor cortex, insula and S2 during SCS may directly interfere with the processing of neuropathic pain. When SCS is associated with heat pain, the paralimbic association cortex and cerebellum show activation exceeding the sum of activations resulting from separate SCS and heat pain stimulation. The explanation of this could possibly rest with the continuous comparisons of simultaneous pain and somatosensory sensations occurring in a single dermatome.

Biliary manometric perfusion test in the evaluation of benign biliary stricture treatment--a case report.

BACKGROUND: Benign biliary strictures treated radiologically by percutaneous dilatation treatment are usually evaluated by 'clinical test'. For objective evaluation of treatment success, measurement of the pressure inside the biliary tree has been proposed. AIM: The aim of this article is to report our experience with the measurement of the pressure in the biliary tree after treatment, to present the biliary manometric perfusion test (BMPT) as an alternative method of treatment evaluation and to demonstrate why the perfusion test is a better method of evaluation. MATERIALS AND METHODS: A 65 year old lady with post operative biliary stricture and symptoms of jaundice was treated in our Department with percutaneous dilatation treatment and long-term drainage. The perfusion test (BMPT) was adopted for evaluating treatment success after the treatment for 9 months. An intrabiliary pressure less than 20 cms of water during perfusion test was considered success threshold. RESULTS: The test was carried out without any complications and the pressure inside the biliary tree was less than 20 cms of water during the test. Eventually the drain was removed. On follow-up at 6 months the patient developed no recurrence of jaundice and the quality of life improved clinically. Periodic liver function tests during follow-up were normal. CONCLUSION: The perfusion test (BMPT) is promising efficacious alternative method for the evaluation of radiological treatment of benign biliary strictures. It helps us to decide the end points in treatment and also helps in identifying patients who might later develop strictures.

Effects of spinal cord stimulation on the cortical somatosensory evoked potentials in failed back surgery syndrome patients.

OBJECTIVE: To evaluate the functional activation of the somatosensory cortical regions in neuropathic pain patients during therapeutic spinal cord stimulation (SCS). METHODS: In nine failed back surgery syndrome patients, the left tibial and the left sural nerves were stimulated in two sessions with intensities at motor and pain thresholds, respectively. The cortical somatosensory evoked potentials were analyzed using source dipole analysis based on 111 EEG signals. RESULTS: The short-latency components of the source located in the right primary somatosensory cortex (SI: 43, 54 and 65ms) after tibial nerve stimulation, the mid-latency SI component (87ms) after sural nerve stimulation, and the mid-latency components in the right (approximately 161ms) and left (approximately 168ms) secondary somatosensory cortices (SII) were smaller in the presence of SCS than in absence of SCS. The long-latency source component arising from the mid-cingulate cortex (approximately 313ms) was smaller for tibial and larger for sural nerve stimuli during SCS periods compared to periods without SCS. CONCLUSIONS: SCS attenuates the somatosensory processing in the SI and SII. In the mid-cingulate cortex, the effect of SCS depends on the type of stimulation and nerve fibers involved. SIGNIFICANCE: Results suggest that the effects of SCS on cortical somatosensory processing may contribute to a reduction of allodynia during SCS.

Bioactive glass-ceramics in facial skeleton contouring.

The removal of certain facial-bone defects is a prerequisite to restoration of function, stability, and appearance. Synthetic bone substitutes are beneficial in cases where other operative techniques would be an unacceptable burden for a patient. Satisfactory results can be achieved in one surgical intervention with low costs and low demand on technical equipment. Osteoconductive, biocompatible, non-resorbable glass-ceramic implants based on oxyfluoroapatite and wollastonite permit osteointegration--a direct physical and chemical bond between live bone tissue and the implant without formation of a fibrous capsule. They display better stress durability in simulated body fluid than hydroxyapatite implants do. This material was used for facial skeletal framework, contour restoration in 44 cases under conditions where other solutions were doubtful. Patients were observed for 24.8 months. Immediate healing occurred without any adverse reaction. The main problem was extrusion, observed in 20.45% cases over a 2-3 month period after the implantation. All cases, with one exception, were solved with a satisfactory final result by reoperation, implant size reduction, and increased soft tissue cover. This approach was found to be a suitable technique, especially for patients exhausted by prior incompetent treatment but still dissatisfied with their appearance. Successful reconstruction with a bone substitute may remarkably increase quality of life for affected persons and, at the same time, reduce surgery-related time and costs.