Long-term outcomes of spinal cord stimulation with percutaneously introduced paddle leads in the treatment of failed back surgery syndrome and lumboischialgia.

OBJECTIVE: The study aims to evaluate the long-term clinical and technical efficacy of recently developed percutaneously introducible plate electrodes for spinal cord stimulation. METHODS: Twenty-one patients diagnosed with failed back surgery syndrome (FBSS) or lumboischialgia were implanted with a small profile plate-type electrode. Patients were followed-up long term and were asked at baseline, after trial, and during each follow-up visit to score their pain on a visual analog scale (VAS) for pain now, worst pain last week, least pain last week, and mean pain last week. Pain location, electrophysiologic parameters, and number of reprogrammings were collected as well. Furthermore, each patient was asked if he/she would redo the procedure post trial and at each of the follow-up visits. RESULTS: A total of 21 patients were prospectively followed up long term. With a mean follow-up of 40.8 months, a significant mean reduction in patient self-reported pain from baseline to postoperative of 75.79% pain reduction was seen at follow-up 1 and 62.52% at follow-up 2. A significant decrease was obtained for, respectively, pain at the present moment, VAS pain worst last week, VAS pain least last week, and VAS pain mean last week in comparison with baseline VAS scores. All patients indicated that they would redo the procedure. CONCLUSION: Percutaneous implantation of small profile paddle leads in patients with FBSS and lumboischialgia produces favorable results over the long term that are at least comparable with surgical implanted paddle leads. The percutaneous approach also allows nonsurgically trained pain physicians to introduce paddle leads. Indices like if patients would redo the procedure may be more appropriate for analyzing long-term outcomes than the arbitrarily taking 50% reduction in VAS scores.

Relative adrenal insufficiency in patients with severe acute pancreatitis.

OBJECTIVE: Inadequate cortisol levels and adrenal dysfunction may play a role in the pathophysiology of severe acute pancreatitis. This study aimed to analyse the incidence of relative adrenal insufficiency (RAI) in these patients, to identify factors associated with RAI and to describe how adrenal responsiveness affects outcome. DESIGN: Prospective observational multicenter study. PATIENTS: Twenty-five patients with severe acute pancreatitis. INTERVENTIONS: A short Synacthen test (SST) was performed within 5 days after admission to the hospital. The incidence of RAI, defined as an increment after SST of less than 9 microg/dl was the primary endpoint of the study. Serum cortisol was measured at baseline and at 30 and 60 min after administration of 250 microg adrenocorticotropic hormone. MEASUREMENTS AND RESULTS: Median baseline cortisol level was 26.6 microg/dl, and increased to 43.2 microg/dl and 48.8 microg/dl after 30 min and 60 min respectively. RAI was found in 16% of all patients and in 27% of patients with organ dysfunction. Patients with RAI were more severely ill and had higher SOFA scores from days 4 to 7 after admission. All patients with RAI developed pancreatic necrosis, and all of them needed surgical intervention. Twenty-eight-day mortality was significantly higher in patients with RAI (75% vs. 5%, p =0.007). Patients who died had a lower increment in cortisol levels after the SST than patients who survived. CONCLUSION: RAI is frequent in patients with severe acute pancreatitis and organ dysfunction. It occurs in patients with more severe pancreatitis and is associated with increased mortality.