Further experience with extradural motor cortex stimulation for treatment of advanced Parkinson's disease. Report of 3 new cases.

AIM: To report the results obtained with the extradural motor cortex stimulation in Parkinson's disease. METHODS: Three patients were submitted to MRI images and functional MRI in order to identify the upper limb motor area. Then a quadripolar electrostimulator was introduced in the extradural space, through 2 burr holes. RESULTS: Unilateral, extradural motor cortex stimulation relieves, at least partially, but sometime dramatically, the whole spectrum of symptoms in advanced Parkinson disease: tremor and rigor bilaterally in all limbs; akinesia; standing, anteropulsion, gait; motor performance; dysphagia; speech and swallowing. Also the symptoms of long term dopa syndrome--dyskinesias, and other secondary effect of L-dopa administration, psychiatric symptoms--are improved. CONCLUSION: The results seems do not fade away with time. Drug dosage may be reduced by 50%. We suggest early employ of transdural motor cortex stimulation.

The important role of pain in neurorehabilitation. The neurosurgeon's approach or (neurorehabilitation: the neurosurgeon's role with special emphasis on pain and spasticity).

Pain syndromes due to peripheral or central nervous system damage, or both, may hinder neurorehabilitation. Control of pain may be obtained by ablative or augmentative procedures. Of the ablative modes only DREZ and Cordectomy are still being employed in cases of pain due to Brachial Plexus Avulsion and conus and cauda damage at T9-L1: in both pain is not simply due to "deafferentiation". The augmentative procedures include spinal cord, deep brain and cortical stimulation. Subarachnoid infusion of drugs (midazolam, clonidine, baclofen, etc.) is a new avenue open to control pain. Indications, results and mechanisms of action of those procedures in neuropathic pain are discussed on the basis of literature and personal experience.

Peri- and postoperative pain valutation in carpal tunnel release of median nerve compression.

We analysed 108 patients, operated on day surgery, for carpal tunnel release of median nerve compression, to evaluate peri- and postoperative pain. We made in all cases a short intertenarian incision (25 mm) with microsurgical technique and local anaesthesia using mepivacaine 2% without vasoconstrictor. We evaluated pain for local anaesthetic infiltration as VRS (Verbal Rating Scale) 6,3 median-time to the first possible analgesic assumption (in all cases paracetamol 500 mg), total analgesic assumption, pressure algometry (to evaluate "allodiny") after the first 48 hours and subjective pain intensity by a numerical pain scale. Pain intensity on first drug assumption (after a mean time of 7 hours from the end of surgery) had a mean VAS value of 2,15; while after a second assumption of analgesic (after a mean time of 15 hours from surgery) had a mean VAS value of 2. Mean total analgesic assumption was 1,64 tablets of paracetamol 500 mg. From these data we may deduce that peri- and postoperative pain following median nerve decompression with this technique and anaesthesia, has a moderate intense peak of brief duration, for local anaesthetic infiltration (that seems to be the most painful event) and modest and not constant pain in the postoperative time (more evident 7 and 15 hours from the end of surgery). It may be useful association with mepivacaine bicarbonate solutions or injecting less painful local anaesthetic.

Functional thalamic depression in a case of reversible central pain due to a spinal intramedullary cyst. Case report.

In this report the authors discuss a case of central pain of spinal cord origin due to a spinal thoracic intramedullary cyst. Single-photon emission computerized tomography with technetium-99m hexamethylpropyleneamineoxime showed thalamic hypoperfusion contralateral to the affected leg. Surgical evacuation resulted in total relief of the pain and normalization of the thalamic alteration. The reader can infer from these findings that functional alterations in thalamic processing may be important in the genesis of central pain.

The thalamocingular loop: recordings from the past.

It has been shown recently that a portion of the cingular cortex (area 24) is involved in the perception of pain. Older electrophysiological studies in neurosurgical patients, which could not be explained on the basis of previous anatomical data, support this notion.