Randomized double-blind controlled study of bedtime low-dose amitriptyline in chronic neck pain.

BACKGROUND: Amitriptyline has well-established efficacy in several chronic pain conditions. While optimal treatment for chronic neck pain (CNP) remains controversial, amitriptyline was not tested for CNP. We evaluated the effect of bedtime amitriptyline in the management of CNP. METHODS: A total of 220 patients suffering from idiopathic CNP were randomized to receive either placebo pill (n = 108) or 5 mg of amitriptyline (n = 112) at bedtime for 2 months. Primary outcome measure was visual analog scale (VAS) for pain. Secondary outcome measures were neck pain disability index (NPDI), Bergen Insomnia Score (BIS) and Hospital Anxiety and Depression Scale (HAD), measured before and at the end of 2 months of treatment, with the percentage of patient satisfaction measured at the end of follow-up only. RESULTS: Eight of 112 patients (7.14%) in the amitriptyline group withdrew from the study because of intolerance. Amitriptyline group showed significantly lower VAS scores than placebo group (3.34 ± 1.45 vs. 6.12 ± 0.92; p < 0.0001), which corresponds to a 53.06 ± 20.29% of improvement from baseline pain as compared to 14.41 ± 11.05%, respectively (p < 0.0001). Similar significant improvements were observed with lesser extents for secondary outcome measures: NPDI, BIS, HAD-A, HAD-D and percentage of patient satisfaction. CONCLUSION: Low-dose amitriptyline is effective for the management of idiopathic CNP with few side effects and high patients' satisfaction. SIGNIFICANCE: This randomized controlled trial is the first to show the effectiveness and tolerance of a medication, low-dose amitriptyline, in managing idiopathic chronic neck pain and its related comorbidities. The optimal treatment of this condition was still controversial in the literature. It extends the indication of low-dose amitriptyline to another chronic pain condition.

Functional exploration for neuropathic pain.

Neuropathic pain (NP) may become refractory to conservative medical management, necessitating neurosurgical procedures in carefully selected cases. In this context, the functional neurosurgeon must have suitable knowledge of the disease he or she intends to treat, especially its pathophysiology. This latter factor has been studied thanks to advances in the functional exploration of NP, which will be detailed in this review. The study of the flexion reflex is a useful tool for clinical and pharmacological pain assessment and for exploring the mechanisms of pain at multiple levels. The main use of evoked potentials is to confirm clinical, or detect subclinical, dysfunction in peripheral and central somato-sensory pain pathways. LEP and SEP techniques are especially useful when used in combination, allowing the exploration of both pain and somato-sensory pathways. PET scans and fMRI documented rCBF increases to noxious stimuli. In patients with chronic NP, a decreased resting rCBF is observed in the contralateral thalamus, which may be reversed using analgesic procedures. Abnormal pain evoked by innocuous stimuli (allodynia) has been associated with amplification of the thalamic, insular and SII responses, concomitant to a paradoxical CBF decrease in ACC. Multiple PET studies showed that endogenous opioid secretion is very likely to occur as a reaction to pain. In addition, brain opioid receptors (OR) remain relatively untouched in peripheral NP, while a loss of ORs is most likely to occur in central NP, within the medial nociceptive pathways. PET receptor studies have also proved that antalgic Motor Cortex Stimulation (MCS), indicated in severe refractory NP, induces endogenous opioid secretion in key areas of the endogenous opioid system, which may explain one of the mechanisms of action of this procedure, since the secretion is proportional to the analgesic effect.

[Evacuation of chronic subdural hematomas with the Twist-Drill technique: Results of a randomized prospective study comparing 48-h and 96-h drainage duration]. / Evacuation des hématomes sous-duraux chroniques par la technique du twist-drill. Résultats d'une étude randomisée prospective entre un drainage de 48 heures et un drainage de 96 heures.

BACKGROUND AND PURPOSE: Technical modalities for the evacuation of chronic subdural hematomas are still controversial. The Twist-Drill technique with closed-system drainage is becoming more widely used, but the influence of drainage duration on outcome has not been studied yet and therefore is still being debated. METHODS: A prospective randomized study was conducted, comparing the results between two drainage durations. Forty-eight hours (Group I; n=35 patients) and 96 h (Group II; n=30 patients). RESULTS: The two groups had almost identical characteristics due to randomization. The mean volume of liquid drained was 120 ml in the first group and 285 ml in the second, a statistically significant difference. The rate of incomplete evacuation versus the rate of recurrence did not show any significant difference between Group I (5.7 % and 11.4 %, respectively) and Group II (3.3 % and 10 %, respectively). The rate of postoperative complications was 10.7 % in Group I but 26.9 % in Group II, with a respective 3.8 % and 11.4 % mortality rate, proving a statistically significant difference. Clinical improvement observed at discharge was 85.7 % and 84.6 % in Group I and Group II, respectively. CONCLUSION: With comparable recurrence and improvement rates, our study demonstrates that it is much more advantageous to remove the catheter at 48 h than leave it in for a longer duration. Not only is bed rest reduced, but the rate of morbidities is also significantly decreased.

Motor cortex stimulation for pain control induces changes in the endogenous opioid system.

BACKGROUND: Motor cortex stimulation (MCS) for neuropathic pain control induces focal cerebral blood flow changes involving regions with high density of opioid receptors. We studied the possible contribution of the endogenous opioid system to MCS-related pain relief. METHODS: Changes in opioid receptor availability induced by MCS were studied with PET scan and [(11)C]diprenorphine in eight patients with refractory neuropathic pain. Each patient underwent two preoperative (test-retest) PET scans and one postoperative PET scan acquired after 7 months of chronic MCS. RESULTS: The two preoperative scans, performed at 2 weeks interval, did not show significant differences. Conversely, postoperative compared with preoperative PET scans revealed significant decreases of [(11)C]diprenorphine binding in the anterior middle cingulate cortex (aMCC), periaqueductal gray (PAG), prefrontal cortex, and cerebellum. Binding changes in aMCC and PAG were significantly correlated with pain relief. CONCLUSION: The decrease in binding of the exogenous ligand was most likely explained by receptor occupancy due to enhanced secretion of endogenous opioids. Motor cortex stimulation (MCS) may thus induce release of endogenous opioids in brain structures involved in the processing of acute and chronic pain. Correlation of this effect with pain relief in at least two of these structures supports the role of the endogenous opioid system in pain control induced by MCS.

Acute Korsakoff-like amnestic syndrome resulting from left thalamic infarction following a right hippocampal hemorrhage.

Korsakoff-like amnestic syndromes have been rarely described following structural lesions of the central nervous system. In this report, we describe a case of acute Korsakoff-like syndrome resulting from the combination of a left anteromedian thalamic infarct and a right hippocampal hemorrhage. We also review the literature relevant to the neuropathology and pathophysiology of Korsakoff syndrome and anterograde amnesia.

[Infections after missile head injury. Experience during the Lebanese civilian war]. / Infections et plaies crAnio-cérébrales par arme à feu.

OBJECTIVE: Establish the risk factors for infection following missile head injuries (MHI). METHODS: Between 1975 and 1990, 500 cases of MHI were admitted, with only 272 responding to inclusion criteria. After initial evaluation including CT scan for 177 patients, all underwent craniectomy with debridement and duroplasty. A retrospective study was undertaken in order to identify the risk factors that increase the infection rate. RESULTS: The global infection rate was 11.39%. Among the studied factors, those increasing the infection rate were: coma on admission (17.6% vs 7.6%), penetrating wounds (12.93% vs 7% for tangential wounds), intracerebral trajectory length over 6 cm (18.42% vs 6.32%), air sinuses effraction (25.8% vs 9.54%), a surgical delay over 72 hours (41.6% vs 10.6%), inadequate duroplasty (28% vs 7.33%), cerebrospinal fluid (CSF) fistulae (58.62% vs 5.76%). The presence of postoperative bone fragments did not increase the infection rate (11.4% vs 11.2%). DISCUSSION AND CONCLUSION: Adequate duroplasty and aggressive treatment of CSF fistulae decrease the infection rate. There is no need to reoperate on residual bone fragments after adequate debridment. A delay of 24 to 48 hours should be considered, to facilitate the procedure without increasing the infection risk.

Acute paraplegia revealing an intraspinal neurenteric cyst in a child.

The authors report a case of intraspinal neurenteric cyst in a 22-month-old child, who presented with acute paraplegia following a vesicourethrogram. Despite 8 days' delay in surgical decompression, he made a complete neurological recovery. Neurenteric cysts are rare congenital lesions of the spinal canal lined with an epithelium of endodermal origin. They are usually located at the cervicothoracic junction and present with progressive mild to moderate signs of myelopathy. This is a unique case in regard both to its clinical presentation and to the excellent outcome after 8 days of complete paraplegia.

[Growing fracture of the orbital roof. A case report]. / Fracture évolutive du toit de l'orbite.

We report a case of growing fracture of the orbital roof in a 5-year-old child. The presenting sign was a pulsatile orbital mass. This child had a history of a minor head injury with orbital impact 2 years ago. Cerebral CT scan revealed a diastatic fracture of the right orbital roof. On MRI a leptomeningeal cyst extending in the orbital cavity was shown. Frontal craniotomy with direct repair of the dural and bone defects was performed. The outcome was excellent. In the literature the exact pathophysiology of the growing fractures is still debated but a dural laceration along the fracture line is noted in all the cases. They are mostly located in the cranial convexity, and rarely affect the skull base. Only 5 similar cases were found in the relevant literature. Growing fracture of the orbital roof should be suspected if ocular symptoms appears in childs who have sustained a head injury several months or years ago.