Large-scale real-world data on a multidisciplinary approach to spinal cord stimulation for persistent spinal pain syndromes: first evaluation of the Neuro-Pain® nationwide screening and follow-up interactive register.

Introduction: Spinal cord stimulation is a common treatment option for neuropathic pain conditions. Despite its extensive use and multiple technological evolutions, long term efficacy of spinal cord stimulation is debated. Most studies on spinal cord stimulation include a rather limited number of patients and/or follow-ups over a limited period. Therefore, there is an urgent need for real-world, long-term data. Methods: In 2018, the Belgian government initiated a nationwide secure platform for the follow-up of all new and existing spinal cord stimulation therapies. This is a unique approach used worldwide. Four years after the start of centralized recording, the first global extraction of data was performed. Results: Herein, we present the findings, detailing the different steps in the centralized procedure, as well as the observed patient and treatment characteristics. Furthermore, we identified dropouts during the screening process, the reasons behind discontinuation, and the evolution of key indicators during the trial period. In addition, we obtained the first insights into the evolution of the clinical impact of permanent implants on the overall functioning and quality of life of patients in the long-term. Discussion: Although these findings are the results of the first data extraction, some interesting conclusions can be drawn. The long-term outcomes of neuromodulation are complex and subject to many variables. Future data extraction will allow us to identify these confounding factors and the early predictors of success. In addition, we will propose further optimization of the current process.

Safety and efficacy of percutaneous pulsed radiofrequency treatment at the C1-C2 level in chronic cluster headache: a retrospective analysis of 21 cases.

We performed a study of the safety and efficacy of percutaneous pulsed radiofrequency (PRF) treatment directed at C1 and C2 levels as performed at our local pain clinic in refractory chronic cluster headache (CCH) patients. We identified 21 CCH patients treated with PRF (240 s, max. 45 V, max. 42 °C) directed at the ganglion and/or nerve root of C1 and C2. Data were collected through retrospective analysis of patients' files and include demographic variables, onset and duration of the headache, mean attack frequency, and prior pharmacological treatment. Safety and reduction of attack frequency in the first 3 months after a first PRF treatment was the primary outcome parameter of this study. All patients had been treated with at least two prophylactic drugs and 19 (90%) had previously been treated with verapamil, lithium, and topiramate. Ten patients (47.6%) reported no meaningful effect, four patients (19%) reported a meaningful reduction of < 50%, and seven patients (33.3%) reported a reduction in headache burden of at least 50% in the 3 months following treatment. Two patients reported occurrence or increase in frequency of contralateral cluster attacks. No other adverse events were reported or detected at follow-up. Upper cervical PRF treatment appears to be a safe procedure that could prove effective in the treatment of patients with refractory CCH and warrants a prospective study.

Migration of pump for intrathecal drug delivery into the peritoneal cavity. Case report.

BACKGROUND: We report on a patient in whom a subfascially implanted pump for the intrathecal delivery of baclofen spontaneously migrated into the peritoneal cavity. CASE DESCRIPTION: A 54-year-old male patient presented with a refilling problem of a drug pump that had been implanted 16 months earlier subfascially through a right-sided incision 10 cm below the costal margin. Because we were unable to refill the pump even under fluoroscopy, we presumed a backward turning of the pump. At exploration, we found that the deeper part of the pocket had spontaneously eroded and had caused the migration of the pump into the peritoneal cavity. The peritoneum and the abdominal wall were closed and the pump was placed in a subcutaneous pouch. We suppose that the migration of the pump was due to its particular implantation site with the lower extent of the device at or below the level of the linea semilunaris. Below this line, the aponeuroses of all 3 lateral abdominal muscles pass in front of the rectus muscle, leaving only the transversal fascia underneath the rectus, which is not a solid layer. Not considering this anatomical detail may facilitate the inward migration of implanted material. CONCLUSION: When creating a pocket for subfascial implantation, a high subcostal incision should be used so that the lower extent of the pocket will still be above the level of the linea semilunaris, hence ensuring a strong fascial layer between the pump and the peritoneum.

Central pain: an overview.

Central pain is a particular form of neuropathic pain. Due to lesions in the spinothalamocortical pathways, ectopic neuronal discharges can occur into different neurons of the spinal cord and brain. Functional MRI, and positron emission tomography might be able to visualize ongoing pain activity which is, sometimes the consequence of spinothalamocortical lesions. Sometimes the patient experiences a burning ice-like sensation. This is more frequent in spinal cord lesions than in brain injuries. Some adrenergic, gabergic neurotransmitters, glycine, prostanoids and glutamate may play a role in pain transmission. These transmitters can induce changes in the neuronal membrane potential. Consequently, amitriptyline as an adrenergic reuptake inhibitor and the sodium channel blockers are the drugs of first-choice. A test procedure with placebo, opioids, lignocaine, propofol and ketamine might give some insight into advanced drug treatment. If oral or transdermal drug delivery is not indicated or ineffective, the intrathecal administration route can be attempted with baclofen, clonidine, opioids and midazolam. Invasive electrostimulation is the last treatment option. Thalamic stimulation can be tried in spinal cord injuries, and sensory motor cortex stimulation is sometimes the last resort for brain lesions associated with pain.