The beneficial effect of spinal cord stimulation in a patient with severe cerebral ischemia and upper extremity ischemic pain.

Spinal cord stimulation (SCS) is used in the treatment of chronic pain, ischemia because of obstructive arterial disease, and anginal pain. Recently, a number of studies have described the effects of the high cervical SCS, including increased cerebral blood flow, although the underlying mechanisms are unknown. This case report describes a patient with a severe complex ischemic condition affecting both cerebral and upper limb blood flow with an associated complex regional pain syndrome in upper limb. While all previous clinical treatments proved ineffective, cervical SCS afforded satisfactory results. Possible mechanisms underlying the cervical SCS effect are discussed.

[Patient satisfaction with spinal cord stimulation for failed back surgery syndrome]. / Satisfacción del paciente con síndrome de dolor de raquis postquirúrgico portador de un sistema de neuroestimulación medular.

INTRODUCTION: The incidence of failed back surgery syndrome is about 40%. We studied the efficacy of and patient satisfaction with use of a spinal cord stimulator to treat this syndrome. MATERIAL AND METHODS: A period of 72 months of experience with implanted spinal cord stimulators was analyzed in this observational, descriptive study of patients who were included retrospectively. Patients met criteria for failed back surgery syndrome according to the taxonomy of the International Association for the Study of Pain. A chi2 test was used to compare qualitative variables. Results for quantitative variables were compared by analysis of variance. Statistical significance was set at P < 0.05. RESULTS: Thirty-four patients were studied. Both lumbar back and radicular pain assessed on a visual analog scale (VAS) decreased significantly from the mean overall score of 6. As time passed, fewer patients felt the system met their expectations. More patients said the system met their expectations in the first months after implantation (73.5%) than at a later interview (55.9%). Seventeen complications were reported, the most common being mechanical difficulties with the implanted stimulator. None of the complications were serious. Use of additional medication to control pain decreased in 38.2% of the cases. A total of 73.5% of the patients considered the implanted stimulator to be beneficial and 67.6% would have a spinal cord stimulator implanted again. CONCLUSIONS: Spinal cord stimulation improves lumbar back pain in patients with failed back surgery syndrome and reduces the amount of additional medication taken to control pain. It is important for patients to adjust their expectations about the implanted stimulator.

Use of botulinum toxin in the treatment of chronic myofascial pain.

BACKGROUND: Myofascial pain syndrome (MPS) is defined as acute or chronic pain with sensory or motor autonomic symptoms, referred from active myofascial triggering points with associated dysfunction. Previous studies have suggested the usefulness of botulinum toxin A (BTX-A) in the treatment of MPS since it is capable of controlling muscular spasms, as well as other alternative mechanisms of action. OBJECTIVES: To analyze the efficacy of BTX-A treatment and its effect on daily life activities assessing pain reduction using a visual analogue scale (VAS); degree of improvement in physical impairment and disability scoring in the Oswestry low back pain questionnaire; and psychologic status using the Hospital Anxiety and Depression Scale (HAD), in patients suffering from MPS. METHOD: An open-label interventional prospective trial was conducted in 77 patients diagnosed of refractory MPS (defined as the presence of muscle spasm with pain on mobilization or stretching, plus the existence of trigger points with associated referred pain), resistant to both conservative management and to physical therapy. The BTX-A dosages for the different muscles were chosen according to a standardized protocol. Electromyographic guidance was used to localize the motor end plate prior to injection in superficial muscles; while fluoroscopic guidance was employed to evidence intramyofascial spread of the contrast solution within deep muscles. The assessment of treatment efficacy was based on a pain VAS applied before enrollment, at 15, 30, and 90 days and upon completion of the study; the Lattinen test to establish a relationship between pain intensity and its corresponding impact on daily living; and the HAD scale to assess psychologic stress, performed both before treatment and at the end of the study; and the Oswestry Questionnaire was used to evaluate patients' ability to carry out daily life activities according to their degree of physical impairment and disability scores. RESULTS: The global analysis revealed a positive correlation between the VAS score prior to treatment and the scoring at 15, 30, and 90 days. This correlation was maintained when analyzing independently for superficial or deep muscles. The correlation coefficients for HAD scores and the Lattinen test values showed a significant association between pre- and post-treatment findings. No adverse events were recorded for 83.1% of the cases. CONCLUSIONS: The results of this study are consistent with other studies showing the efficacy of BTX-A for treating pain in MPS. The evaluation of the psychologic dimension of this disorder and its associated disability can provide valuable information for the adequate management of these patients and for assessing treatment outcome.