Predictive value of hypoxia in advanced head and neck cancer after treatment with hyperfractionated radio-chemotherapy and hypoxia modification

Purpose. Hypoxia has predictive value in head and neck cancer (HNC). It has been well described, albeit in a small number of clinical Centres. The aim of this study was to describe our experience using the polarographic probe technique to assess the predictive value of tumour oxygenation in patients with advanced HNC treated with hyperfractionated radio-chemotherapy. Hypoxia modification was induced using percutaneous spinal cord stimulation (SCS). Methods/patients. Male patients (n = 12; stage IVb n = 8; IVa n = 4; mean age 58: range 46-70 years) with advanced HNC were evaluated. Planned therapy was hyperfractionated-radiotherapy, oral tegafur (precursor of 5-fluorouracil) and hypoxia modification using SCS. Pre-treatment analyses included: haemoglobin levels and tumour oxygenation (using the Eppendorf polarographic probe device). Oxygenation was expressed as median-pO2 (in mmHg) and hypoxia as the percentage of pO2 values ≤5 mmHg (HP5) and ≤2.5 mmHg (HP2.5). Results. Lower haemoglobin levels were directly correlated with median pO2 (p = 0.017) and inversely correlated with HP5 (p = 0.020) and more advanced stages (IVb vs. IVa; p = 0.028). Patients who subsequently developed systemic metastasis had tumours that were more hypoxic, with lower median pO2 (p = 0.036) and higher HP5 (p = 0.036). The subgroup of patients with HP2.5 above the median (the most hypoxic tumours) had lower loco-regional control (p = 0.027), cause-specific survival (p = 0.008), and overall survival (p = 0.008). Conclusions. Higher tumour hypoxia showed predictive value in HNC in our study, and was significantly associated with lower overall survival, cause-specific survival, and loco-regional control. Tumour hypoxia determination could be used to select patients who would most benefit by hypoxia modification during chemo-radiotherapy of HNC (AU)

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Predictive value of hypoxia in advanced head and neck cancer after treatment with hyperfractionated radio-chemotherapy and hypoxia modification.

PURPOSE: Hypoxia has predictive value in head and neck cancer (HNC). It has been well described, albeit in a small number of clinical Centres. The aim of this study was to describe our experience using the polarographic probe technique to assess the predictive value of tumour oxygenation in patients with advanced HNC treated with hyperfractionated radio-chemotherapy. Hypoxia modification was induced using percutaneous spinal cord stimulation (SCS). METHODS/PATIENTS: Male patients (n = 12; stage IVb n = 8; IVa n = 4; mean age 58: range 46-70 years) with advanced HNC were evaluated. Planned therapy was hyperfractionated-radiotherapy, oral tegafur (precursor of 5-fluorouracil) and hypoxia modification using SCS. Pre-treatment analyses included: haemoglobin levels and tumour oxygenation (using the Eppendorf polarographic probe device). Oxygenation was expressed as median-pO2 (in mmHg) and hypoxia as the percentage of pO2 values ≤5 mmHg (HP5) and ≤2.5 mmHg (HP2.5). RESULTS: Lower haemoglobin levels were directly correlated with median pO2 (p = 0.017) and inversely correlated with HP5 (p = 0.020) and more advanced stages (IVb vs. IVa; p = 0.028). Patients who subsequently developed systemic metastasis had tumours that were more hypoxic, with lower median pO2 (p = 0.036) and higher HP5 (p = 0.036). The subgroup of patients with HP2.5 above the median (the most hypoxic tumours) had lower loco-regional control (p = 0.027), cause-specific survival (p = 0.008), and overall survival (p = 0.008). CONCLUSIONS: Higher tumour hypoxia showed predictive value in HNC in our study, and was significantly associated with lower overall survival, cause-specific survival, and loco-regional control. Tumour hypoxia determination could be used to select patients who would most benefit by hypoxia modification during chemo-radiotherapy of HNC.

Modification of loco-regional microenvironment in brain tumors by spinal cord stimulation. Implications for radio-chemotherapy.

The effectiveness of radiotherapy and chemotherapy in high grade gliomas (HGG) depends on tumor micro-environment. We summarize our experience of the influence of spinal cord stimulation (SCS) on this micro-environment. Patients with HGG (n = 26) were assessed pre- and post-SCS, using: (1) Doppler in middle cerebral arteries (MCA) and (2) in common carotid arteries (CCA); (3) tumor blood-flow using single photon emission computed tomography (SPECT); (4) tumor-pO(2) (mmHg) using polarographic probes (eight tumor areas from five patients); and (5) tumor glucose metabolism using (18)F-fluoro-2-deoxyglucose ((18)FDG) positron emission tomography ((18)FDG-PET). Pre-SCS: tumor blood-flow was lower (P < 0.001) than peri-tumor areas and healthy contra-lateral areas. Tumor-pO(2) was lower (P < 0.042) than healthy tissue. Tumor glucose metabolism was higher than peri-tumor areas (P = 0.017) and healthy contra-lateral areas (P = 0.048). Post-SCS: there were increases in: MCA blood-flow (P ≤ 0.002), CCA blood-flow (P ≤ 0.013), tumor blood-flow (P = 0.033), tumor glucose metabolism (P = 0.027) and tumor-pO(2) (P = 0.022). The percentage of hypoxic values decreased (P = 0.007). SCS can modify tumor micro-environment. The potential usefulness of SCS in improving the effectiveness of radio-chemotherapy in HGG needs to be evaluated.

Opioides en el dolor raquídeo. Relación riesgo/beneficio y estrategia apropiada para su utilización / Opioids in spinal pain. Risk/benefit ratio and an appropriate strategy for their use

En los últimos años se ha observado un incremento notable en el uso de los opioides en España, por lo que queda ampliamente superada nuestra tradicional posición en el furgón de cola de los prescriptores de opioides en Europa. Este crecimiento se ha reflejado también en el tratamiento de uno de los síndromes dolorosos de mayor prevalencia: el dolor raquídeo. Sin embargo, la eficacia de los opioides administrados de forma crónica para el tratamiento del dolor raquídeo no está clara, aunque cada vez sí son más patentes los riesgos que hemos de asumir: adicción, conductas aberrantes, probable incremento en el tiempo de incapacidad laboral y múltiples efectos secundarios, como la hiperalgesia o el estreñimiento rebelde al tratamiento. Teniendo en cuenta una relación riesgo/beneficio estrecha para este tratamiento, planteamos que estos fármacos sólo los han de prescribir facultativos que puedan realizar un seguimiento atento de los pacientes, pacientes en los que se han agotado otras opciones terapéuticas, incluidas diferentes técnicas antiálgicas y a los cuales habremos informado ampliamente de su correcta utilización y posibles efectos secundarios (AU)

In the last few years there has been a notable increase in the use of opioids in our country, overcoming our traditional position at the end of the queue of opioid prescribers in Europe. This growth has also been reflected in the treatment of highly prevalent pain syndromes, such as spinal pain. However, the efficacy of opioids administered chronically for spinal pain is not clear, due to the risks that have to be assumed being obvious: addiction, aberrant behaviour, probable increase in time off sick and the many secondary effects, such as hyperalgesia or persistent constipation with treatment. Taking into account the narrow risk/benefit ratio for this treatment, we assume that these drugs have been prescribed only by physicians who can closely follow up the patients, patients in whom other options are exhausted, including different analgesic techniques and those who will have been amply informed on their correct use and possible side effects (AU)

Neuralgia del Trigémino. Revisión del tratamiento médico y quirúrgico / Trigetninal neuralgia. A Review of the medical a surgical managetnent

La neuralgia del trigémino se caracteriza según la IASP por ser un cuadro de dolor recurrente "dolor paroxístico, unilateral, severo, penetrante, de corta duración, localizado en la distribución de una o varias de las ramas del V par craneal". Puede ser esencial o sintomática, secundaria a esclerosis múltiple o a lesiones tumorales en el ángulo pontocerebeloso. Se trata de un cuadro de dolor neuropático en muchas debido a compresiones vasculares en el tronco cerebral S. Su prevalencia es relativamente alta y posiblemente esté aumentando al alargarse la supervivencia general de la población. El tratamiento médico representa el primer escalón terapéutico para el control del dolor. La carbamacepina es el fármaco más utilizado y más eficaz, aunque puede presentar efectos adversos. Las dosis oscilan entre 300-1200 mgr/día. Otros fármacos como la tizanidina no ofrece mejores resultados, la tocainida ofrece iguales resultados y el pimozide mejores resultados, aunque todos ellos con mayores efectos secundarios. La lamotrigina, se ha demostrado más efectiva, pero el grupo de pacientes es escaso y las reacciones cutáneas son más frecuentes. Las dosis de lamotrigina oscilan entre 200-400 mgr/día. El baclofeno también es un fármaco complementario. Otras medicaciones como el clonacepan, gabapentina, oxcarbamacepina, fenitoína, valproato sódico no se han demostrado eficaces todavía según estudios basados en la evidencia científica. El tratamiento quirúrgico puede realizarse a tres niveles. 1- periférico; 2- ganglio; 3 raíz del trigémino en la fosa posterior. La cirugía descompresiva de la fosa posterior es la única técnica que no origina hipo o anestesia en alguna o todas las ramas del trigémino al ser la única modalidad terapéutica quirúrgica no destructiva. La decisión de la modalidad terapéutica a aplicar debe hacerse después de analizar el estado físico del paciente, y tras la exposición de las diferentes técnicas con sus ventajas e inconvenientes, teniendo muy en cuenta la experiencia previa del médico que realizará el procedimiento quirúrgico. La termocoagulación con radiofrecuencia del ganglio de Gasser posee ventajas e inconvenientes pero carece de mortalidad, consiguiéndose alivio en el 75% de los pacientes. La rizotomía retrogasseriana con glicerol consigue alivio persistente en el 55% de los casos. La microcompresión percutánea del ganglio de Gasser con balón de Fogarty precisa anestesia general obteniéndose alivio persistente en el 76% de los casos. La descompresión microvascular obtiene buenos resultados en el 77% de lo casos y un riesgo de mortalidad del 1% en manos muy expertas. La radiocirugía estereotáctica del ganglio de Gasser consigue porcentajes de alivio del dolor alrededor del 70%. La neuralgia del trigémino es una entidad de difícil manejo con porcentajes discretos de alivio del dolor mediante tratamiento farmacológico. Las técnicas intervencionistas percutáneas incluyendo la radiocirugía estreotáctica son una alternativa eficaz para el control del dolor. Salvo pacientes jóvenes o que expresamente lo soliciten, la descompresión microvascular debería ofrecerse en último lugar (AU)

Trigetninal neuralgia is defined by the International Association for the Study of Pain (IASP) as a paroxistic, unilateral, severe, penetrant pain of short duration and localized in the distribution of one or several trigeminal nerve branches. It can be idiopathic or sintomatic, secundary to múltiple sclerosis or due to tumoral lesions in the cerebelo pontine angle in the posterior fossa. Is a neuropathic pain due in its idiopathic form to vascular compression of the trigeminal root. Its prevalence is rather high and posible is increasing due to the improvement of live expectancy of the polulation. The medical treatment is the first step for pain control Carbamacepine is the most used and usefull drug to treat this pain condition, although it can induce side effects. Doses of 300-1200 mgr/day can be very effective. Other drugs as tizanidine are not better than carmacepine. Tocainide offers similar results and pimozide better results, but showing higher side effects. Lamotrigine is also effective but there are few series to confirm the results. Adverse skin reactions are frecuent using this drug. Lamotrigine dayly doses ranged between 200-400 mgr. Baclofeno is also a complementary drug in refractary cases. Other medication as clonacepam, gabapentine, oxcarbamacepin, phenitoin and sodic valproate, have not shown better results. The surgical treatment can be done at different levéis. 1-peripheric; 2- ganglion; 3- trigeminal root in the posterior fossa. Decompressive surgery in the posterior fossa is the only thechnic that don't give rise to hipoesthesia or anaesthesia in the some or all trigeminal branches after the procedure becuse is not destructive. To take the decission for a particular interventional or surgical thecnique, its necessary to look first at patient's phisical state, describe to them pros and cons of every technique, bearing in mid the experience of the physisian who is going to perform the procedure. Radiofrecuency thermocoagulation of Gasserian ganglion its have advantages and disadvantages but has no mortality, obtaining persistent pain relief in 75% of patients. Glicerol rhyzotomy achive paain relief in 55% of cases. Percutaneous microcompression of trigeminal ganglion with Fogarty's balloom needs general anaesthesis achieven persisting pain relief in 76% of cases. Microvascualr decompression obtain long term results in 77% of patients with a mortality rate of 1% in very expert hands. Stereotactic radiosurgery of Gasserian ganglion obtain long term good results in 70% of cases. Management of trigeminal neuralgia is very difficult with a low percentage of good results achieved with medication only. Percutaneous interventional techniques including stereotactic radiosurgery are a valid alternative for pain relief. Only in young patients or in case of personal decission, microvascular decompression, should be offer as the last choice (AU)

Neuralgia del trigémino. ¿Cuál es la mejor técnica percutánea? / Trigeminal neuralgia: which is the best percutaneous technique?

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Neuroelectroestimulación medular en el síndrome doloroso regional complejo Tipo I. Estudio de casos / Spinal cord stimulation in the Complex Regional Pain Type I. Cases report

Presentamos 5 pacientes con diagnóstico de Síndrome Doloroso Regional Complejo Tipo I que han sido tratados mediante neuroestimulación medular. El tiempo de seguimiento medio fue de 6 años con un resultado bueno. No se presentaron complicaciones con los neuroestimuladores ni infecciones del sistema en ningún caso. El objetivo principal del tratamiento rehabilitador es conseguir la funcionalidad máxima con un tratamiento individualizado y adaptado a las necesidades de cada paciente incluyendo los fármacos, agentes tópicos, administración de sustancias epidurales y terapia psicológica. La neuroestimulación medular es un método terapéutico útil para el tratamiento del dolor y un medio de ofrecer alivio persistente a los pacientes cuando otros tratamientos han fracasado (AU)

We presented 5 patients with diagnosis of Reflex Sympathetic Dystrophy that they have been treated with spinal cord stimulation. The mean follow up was 6 years with a good result. Complications with the neuro-stimulation nor infections of the system in any case did not appear. The primary target of the rehabilitation treatment is to achieve the highest functionality with an individualized treatment and adapted to the necessities of each patient including drugs, topical agent, administration of epidurals substances and psychological therapy. The Spinal cord neuro-stimulation is a useful therapeutic method for the treatment of the pain and means to offer persistent lightening to the patients when other treatments have failed (AU)

Spinal cord stimulation in the treatment of post-stroke patients: current state and future directions.

A decrease in cerebral blood flow (CBF) and brain metabolic activity are well-known complications of stroke. Spinal cord stimulation (SCS) is successfully being used for the treatment of several low-perfusion syndromes. The aim of this chapter is to describe the data that support the effect of SCS on CBF and the use of SCS in the treatment of stroke and cerebral low perfusion syndromes. In addition, we present our relevant studies. Since April 1995, we have assessed 49 non-stroke patients. The following parameters were measured pre- and post-stroke: (1) CBF in healthy contralateral tissue by single photon emission computed tomography (SPECT), (2) systolic and diastolic velocity in the middle cerebral artery (MCA) by transcranial Doppler, (3) blood flow quantification in the common carotid artery (CCA) by color Doppler, and (4) glucose metabolism in healthy contralateral tissue by positron emission tomography (PET). Our results showed that during cervical SCS there was a significant (p < 0.001) increase in systolic (> or =21%) and diastolic (>26%) velocity in the MCA, and CCA blood flow (> or =51%) as well as glucose metabolism (44%). We concluded that cervical SCS (cSCS) can modify CBF and brain metabolism. Its potential role in the management of stroke and low-perfusion syndromes is further investigated by experimental studies and reports describing clinical experience. Appropriate clinical trials are warranted.

The role of spinal cord stimulation in the management of patients with brain tumors.

High grade gliomas (HGG) have decreased blood flow resulting in hypoxia, limited access by chemotherapeutic agents, and reduced radiation-sensitivity. Spinal cord stimulation (SCS) has been used successfully in the treatment of pain and ischemic syndromes. The present article summarizes our investigations into the effects of SCS in patients with HGG. Before their scheduled radio-chemotherapy, 23 patients with HGG were assessed pre- and post-SCS using several evaluation techniques: (1) transcranial Doppler (TCD) for middle cerebral artery blood flow; (2) color Doppler for common carotid artery blood flow; (3) single photon emission computed tomography (SPECT) for tumor blood flow; (4) polarographic probe technique for tumor pO2 measurement; (5) positron emission tomography (PET) for tumor glucose metabolism. Pre-SCS, the tumors were more ischemic and more hypoxic than healthy tissues. Post-SCS, there was significant: (1) increase in blood flow measured by TCD (> or =18%), color Doppler (> or =61%) and SPECT (15%), (2) increase in oxygenation and decrease (> or =45%) in percentage of hypoxic values <10 mmHg and <5 mmHg, and (3) increase (43%) in glucose metabolism. Our studies show that SCS can modify loco-regional blood flow and oxygen supply, as well as glucose-metabolism in HGG. This suggests that SCS could prove useful as an adjuvant treatment to radio-chemotherapy. These data merit further confirmatory studies.

Cerebral blood flow increase in cancer patients by applying cervical spinal cord stimulation.

INTRODUCTION: Generally, high-grade gliomas and head and neck tumors have decreased loco-regional blood flow resulting in reduced delivery of chemotherapy and oxygen, as well as an increases in radiation resistance to radiotherapy. The aim of this study was to analyze the effect of cervical spinal cord electrical stimulation (cSCS) on cerebral blood flow in patients with those tumors. PATIENTS AND METHODS: We have evaluated 27 cancer patients with 12 with high grade gliomas and 15 with advanced head and neck tumors, who had cSCS devices placed after tumor diagnoses and before the commencement initiating of radio-chemotherapy. They were 12 high grade gliomas and 15 advanced head and neck tumors. Before and after cSCS, cerebral blood flow was assessed bilaterally by transcranial Doppler. RESULTS: During cSCS there was a significant (p<0.001) increase in systolic (mean > 22%) and diastolic (> 29%) blood-flow velocities in both, healthy and tumor middle cerebral arteries. The analyses by subgroup of tumors showed similarly significant outcomes findings. CONCLUSIONS: The results suggest that neuro-stimulation spinal cord electrical stimulation can increase cerebral blood flow in cancer patients. The implication is that this technique could be useful in modifying locoregional ischemia in brain tumors thus improving the outcomes of after radio-chemotherapy. Further research is in progress to confirm the advantages of the technique.

Cerebral blood flow increase in cancer patients by applying cervical spinal cord stimulation

Introducción. Los gliomas de alto grado y los tumores avanzados de cabeza y cuello generalmente tienen un flujo sanguíneo disminuido. Esto produce una disminución de la llegada de quimioterapia agentes quimioterápicos y oxígeno, lo que lleva a un aumento de la resistencia a la radioterapia y a la quimioterapia. El objetivo de este estudio fue analizar el efecto de la electroestimulación epidural de la médula espinal cervical(EME) sobre el flujo cerebral en pacientes con esos tumores. Material y métodos. Hemos evaluado 27 pacientes oncológicos portando dispositivos de EME, que fueron colocados después del diagnóstico y antes de empezar el tratamiento con radio-quimioterapia. Se trata de 12 pacientes con gliomas de alto grado y 15 pacientes con tumores avanzados de cabeza y cuello. Antes y después de la EME se determinó bilateralmente el flujo sanguíneo en las arterias cerebrales medias mediante Doppler transcraneal. Resultados. Durante la EME se produjo un aumento significativo (p<0.001) de la velocidad sistólica (mean media >=22%) y diastólica (>=29%) del flujo en la arteria cerebral media, tanto del hemisferio ipsilateral al tumor como del hemisferio sano. El análisis por subgrupos de tumores mostró también resultados semejantes. Discusión. Los resultados sugieren que la EME es capaz de aumentar el flujo sanguíneo cerebral en pacientes oncológicos. La principal implicación de este hallazgo sería su potencial utilidad para modificar la isquemia local y regional de los tumores cerebrales, y así intentar mejorar el efecto de la radioterapia y quimioterapia. Están en marcha estudios adicionales para confirmarlos potenciales efectos beneficiosos de la técnica

Introduction. Generally, high-grade gliomas and head and neck tumors have decreased loco-regional blood flow resulting in reduced delivery of chemotherapy and oxygen, as well as an increases in radiation resistance to radiotherapy. The aim of this study was to analyze the effect of cervical spinal cord electrical stimulation (cSCS) on cerebral blood flow in patients with those tumors. Patients and methods. We have evaluated 27 cancer patients with 12 with high grade gliomas and 15 with advanced head and neck tumors, who had cSCS devices placed after tumor diagnoses and before the commencement initiating of radio-chemotherapy. They were 12high grade gliomas and 15 advanced head and neck tumors. Before and after cSCS, cerebral blood flow was assessed bilaterally by transcranial Doppler. Results. During cSCS there was a significant(p<0.001) increase in systolic (mean >22%) and diastolic(>29%) blood-flow velocities in both, healthy and tumor middle cerebral arteries. The analyses by subgroup of tumors showed similarly significant outcomes findings. Conclusions. The results suggest that neuro-stimulation spinal cord electrical stimulation can increase cerebral blood flow in cancer patients. The implication is that this technique could be useful in modifying locoregional ischemia in brain tumors thus improveing the outcomes of after radio-chemotherapy. Further research is in progress to confirm the advantages of the technique

Situación actual de la cirugía de la columna vertebral degenerativa aplicada al manejo del dolor lumbar crónico. Estenosis de canal. Discopatia degenerativa, resultados basados en la evidencia científica / Present state of degenerative back surgery and its implications in the management of chronic lumbar pain, canal stenosis and degenerative disk disease. Evidence based outcomes

La búsqueda de soluciones terapéuticas para pacientes con síndromes de dolor postlaminectomía o dolor lumbar crónico constituye uno de los aspectos fundamentales de la carga de trabajo de las Unidades de Dolor Crónico. A la luz de los resultados de las publicaciones científicas y revisiones que han seguido los principios de la “medicina basada en la evidencia”, cuando se analizan los resultados de la cirugía de la hernia dis-cal, se observa, cómo no existe todavía en la literatura mundial ningún trabajo científico correctamente realizado que compare la cirugía y el tratamiento conservador sin ningún tipo de sesgo científico en la recogida de datos. Por esa razón, se siguen buscando soluciones no quirúrgicas a este problema. Un aspecto fundamental a tener en cuenta a la hora de analizar los resultados de la cirugía de la columna, es lo que se denomina en los medios económicos de la bolsa Americana la “burbuja de la cirugía de columna”. La literatura científica no muestra evidencias claras en los estudios coste-beneficio de muchas técnicas de cirugía instrumentada de la columna sobre el tratamiento conservador. No ha sido demostrado que la cirugía de fusión vertebral y el reemplazo del disco intervertebral sea mejor que el tratamiento conservador. Destacar, que actualmente, “existen relaciones entre la industria y el dolor lumbar” y que también “existe una industria del dolor lumbar”. No obstante, “el mercado de la cirugía de la columna”, sigue aumentando, ya que los pacientes siguen demandando soluciones para resolver su dolor de espalda. La marea de la evidencia científica parece que va en contra de la fusión espinal en la enfermedad discal degenerativa, el dolor discogénico y el dolor lumbar inespecífico. Después de dos décadas de avances tecnológicos en este campo, el resultado de las fusiones espinales es mediocre. Estudios epidemiológicos recientes muestran que la “fusión espinal” debe aceptarse como “un método no probado o experimental para el tratamiento del dolor lumbar crónico”. La literatura quirúrgica sobre la fusión espinal en los últimos 20 años según revisiónes Cochrane establece que: 1- ésta es incompleta, no fiable y descuidada; 2- la instrumentación parece que aumenta ligeramente la tasa de fusión; 3- la instrumentación no mejora los resultados clínicos en general, careciéndose de estudios particulares de subgrupos de pacientes. Se precisan estudios aleatorios que comparen los resultados quirúrgicos con la historia natural, el placebo o el tratamiento conservador. Las Guías Europeas para el manejo del dolor crónico lumbar, muestran como existe una “fuerte evidencia” que indica que la cirugía compleja y demandante de la columna vertebral lumbar en la que se emplean diferentes formas de instrumentación espinal, no es más efectiva que una simple, más segura y mas barata fusión posterolateral sin instrumentación. Otros estudios recientes ponen de manifiesto cómo se está produciendo una tendencia hacia la utilización de “técnicas mínimamente invasivas”, abandonando las fusiones transpediculares, lo que nos indica claramente que debemos aplicar correctamente el conocimiento basado en la evidencia científica acumulado a lo largo de por lo menos 20 años. Todo ello, nos permite, recomendar el “abandono de la senda instrumentista” en gran cantidad de indicaciones actuales, y buscar otros caminos en el campo del tratamiento conservador y rehabilitador correctamente aplicados, utilizando antes de la cirugía descompresiva y de fusión vertebral todos los recursos intervencionistas que actualmente ofrece el tratamiento moderno del dolor crónico (AU)

The finding of therapeutical solutions for patines suffering of chronic low back pain and failed back syndrome is one of the main work load that Chronic Pain Units have to manage every day. The results displayed in publications done following the “principles of evidence based medicine”, shows that still there is not any correctly done study that compares the conservative and surgical treatments in the manegement of her-niated lumbar disc. For that reason , we are still triying to find new treatment options in the nonsurgical field of her-niated lumbar disc. When we analize the published results of the spine surgery, we must beard in mind what have been call in the “American Stock and Excahnge” “the bubble of spine surgery”. The scientific literature does not show clear evidence in the cost-benefict studies of most instrumented surgical interventions of the spine compare with the conservative treatments. It has not been yet demostrated that fusion surgery and disc replacement are better options than the conservtive treatment. It´s necesary to point out that at present “there are relationships between the industry and back pain and there is also an industry of the back pain” . Nontheless, the “market of the spine surgery” is growing up because patients are demanding solutions for their back problems. The tide of scientific evidence seams to go against of the spinal fusions in the degenerative disc disease, discogenic pain and inespecific back pain. After decades of technological advances in this field, the results of spinal fusions are mediocre. Recent epidemiological studies show that “spinal fusion must be accepted as a non proved or experimental method for the treatment of back pain”. The surgical literature on spinal fusion published in the last 20 years following the Cochrane’s method stablish that: 1- this is at least incomplete, not realiable and careless; 2- the instrumentation seems to sligthy increase the fusion rate ; 3- the instrumentation doesn’t improve the clinical results in general, lacking studies in subgroups of patients. We still are needing randomized studies to compare the surgical results with the natural history of the disease, the pacebo effect, or the conservative treatment. The European Guidelines for lumbar chronic pain management shows a strong evidence indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper posterolateral fusion without instrumentation. Recently, the literature published in this field, is showing us a tendency to use again “minimally invasive techniques”, abandon transpedicular fusions, and indicating clearly that we must apply the knowledge based on the scientific evidence accumulated at least along the last 20 years. In conclussion, based in the modern information, we must recomend the abandon of the instrumented pathway in a great number of present indications for spine surgery, and look for new management strategies in the field of rehabilitation and conservative treatments correctly apply, using before the decompresive and instrumented surgery all the intervention-al techniques that are presently offer in the field of modern chronic pain treatment (AU)

¿Por qué las Unidades del Dolor deben ser multidisciplinarias? / Why pain units must be multisdisciplinary?

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Effect of cervical spinal cord stimulation on regional blood flow and oxygenation in advanced head and neck tumours.

BACKGROUND: Tumour ischaemia leads to decreased delivery of oxygen, chemotherapy and radiosensitisers. Hypoxia in head and neck (H&N) tumours is an important adverse prognostic factor. Spinal cord stimulation (SCS) is a well-established neurosurgical technique in the treatment of several ischaemic syndromes. This prospective study evaluated the effect of cervical-SCS on common carotid artery (CCA) blood flow and tumour oxygenation in patients with advanced H&N cancer. PATIENTS AND METHODS: Sixteen patients with advanced H&N tumours were enrolled. Cervical-SCS devices were inserted subcutaneously prior to commencement of scheduled chemoradiotherapy. Pre- and post-SCS measurements were as follows: (i) tumour oxygenation (mmHg) using polarographic probes; (ii) blood flow quantification (ml/min) and diastolic and systolic velocimetry (cm/s) in the CCA using colour Doppler. RESULTS: After SCS, median tumour oxygenation increased in two-thirds of patients (34%; P = 0.023), all patients had improved CCA blood flow (50%; P <0.001) and almost all patients showed an increased CCA diastolic velocity (26%; P = 0.003) and systolic velocity (20%; P = 0.011). CONCLUSIONS: Cervical-SCS increased tumour oxygenation and CCA blood flow, and could enhance the loco-regional delivery of oxygen, radiosensitising and chemotherapeutic drugs. Cervical-SCS as adjuvant in chemoradiotherapy of these tumours warrants further investigation.

Aspectos neuroquirúrgicos del tratamiento del dolor crónico en el tercer milenio. Las unidades multidisciplinarias del dolor / Neurosurgical aspects of the management of chronic pain in the third millennium. Multidisciplinary pain units

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Avances en el diagnóstico y tratamiento del dolor simpático / Advances in the diagno sis and management of sympathetic pain

Objetivos: El dolor persistente en algunos pacientes está relacionado con la actividad del sistema nervioso simpático (SNS), existiendo por lo tanto pacientes con dolor simpático mantenido (DSM) y pacientes con dolor independiente del simpático (DIS). Recientemente, los síndromes de DSM denominados distrofia simpática refleja (DSR) y causalgia, han pasado a denominarse síndromes de dolor regional complejo (SDRC) tipos I y II respectivamente .En el momento actual no es posible diagnosticar un DSM exclusivamente por la historia clínica y por la sintomatología, siendo preciso la realización de una serie de pruebas complementarias de laboratorio y bloqueos regionales .Material y métodos: El DSM debe diagnosticarse después que éste es suprimido tras un bloqueo de la inervación simpática aferente a la zona de la lesión. El bloqueo de los re c e p t o res alfa adrenérgicos con fentolamina intravenosa ha desplazado a los clásicos bloqueos regionales ganglionares. Los bloqueos ganglionares simpáticos con anestésico local (BGSAL), es más probable que den falsos positivos que con la fentolamina. Para el diagnóstico de una DSR/SDRC I, se utilizan no sólo los bloqueos simpáticos sino una serie de pruebas de laboratorio como la termometría, la desmineralización ósea en las radiografías, la gammagrafía ósea en tres fases, la termografía infrarroja y los estudios sensoriales cuantitativos. Concretamente, la teletermografía infrarroja está considerada como un método no invasivo de eficacia comp robada. Recientemente, se han añadido una serie de tests de laboratorio que facilitan el diagnóstico de hiperactividad simpática. Concretamente, se trata del test cuantitativo del reflejo axonal sudomotor (TCRAS); el test termorregulador de la sudoración (TTS); y el test de la sudoración en re p oso. Para el estudio de la función vasomotora en los SDRCI, los más usados son la termometría y la teletermografía infrarroja. Dado que no existe una respuesta similar en cada caso, el tratamiento de estos síndromes dolorosos debe ser flexible e individualizado, combinando el tratamiento farmacológico, el rehabilitador y la utilización de las técnicas intervencionistas, concretamente los bloqueos simpáticos regionales, la simpaticolisis o una anestesia regional continua. Finalmente, en el algoritmo terapéutico, juegan un papel muy importante las técnicas de neuromodulación, como son la estimulación medular, la estimulación de nervios periféricos y, finalmente, la infusión espinal de medicamentos. Conclusiones: Actualmente, existen nuevas técnicas de laboratorio que facilitan el estudio y diagnóstico de aquellos cuadros de dolor persistente en los que se sospecha la mediación del sistema nervioso simpático. Los resultados de las distintas estrategias de tratamiento y la aplicación dinámica de los algoritmos diagnóstico-terapéuticos, concluyen, que en estos momentos existe un amplio arsenal terapéutico para el control del DSM. Lo más importante para conseguir su curación es sospechar su presencia en las fases iniciales de la enfermedad, antes de que se presenten cambios irreversibles, tanto físicos como psicológicos (AU)

Diffuse axonal injury with or without an evacuated intracranial hematoma in head injured patients. Are they different lesions?

The general classification of head injury proposed by Marshall et al., based on admission CT scan findings, might mask a group of patients who have Diffuse Brain Injury (DI) in addition to intracranial haematomas. The aim of this study was to assess possible differences in outcome with respect to the level of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) between a group of patients with DI: III-IV (Marshall's classification) after the evacuation of an intracranial haematoma (group A) and another group with DI: III-IV in the absence of a mass lesion (group B). We prospectively studied 129 patients with isolated and closed severe head injury (GCS < 9). In group A (n = 61), the median percentage of hours with ICP > 20 mmHg and CPP < 70 mmHg was 42.8 and 18, respectively and 17 (28%) survived with GOS 4-5. In group B (n = 68), median values of 20 and 5.5 hours were obtained for ICP > 20 and CPP < 70 respectively, whilst 39 (57.3%) survived with favourable outcomes. When we analysed the effects of the DI: III-IV in both groups of patients, we found that the differences in percentage of time with ICP > 20 and CPP < 70 were statistically significant (p < 0.01) and patients in group A had a higher morbidity and mortality (p < 0.05). This study has demonstrated that the levels of ICP, morbidity and mortality in patients with DI: III-IV and an evacuated mass lesion were higher than in patients with DI: III-IV without a mass lesion.

Safety and efficacy of intrathecal baclofen infusion by implantable pump for the treatment of severe spinal spasticity: a spanish multicenter study.

Objective. To assess long-term efficacy, safety and functional benefit of intrathecal baclofen for severe spinal spasticity. Materials and Methods. This prospective multicenter study was performed in two stages: the first one consisted of an intrathecal bolus injection of baclofen, and the second of a continuous intrathecal baclofen infusion by means of an implantable pump. The sample consisted of 72 adult patients with severe spinal spasticity. Sixty-four were implanted and followed for 36 months. Muscular tone, spasms, and functional scales were evaluated before and periodically after administration of the drug, with a follow-up period of 36 months. Results. A very significant decrease in tone and spasms was observed in all cases (p < 0.001). Tolerance appeared during the first 12 months, increasing doses from a mean initial dose of 83.2 µg (range 25-200 µg) to a mean final dose of 270 µg (range 25-800 µg). Later on, efficacy remained stable, except in cases of mechanical problems of the infusion system.

[Transthoracic approach to the spinal column]. / Abordaje transtorácico de la columna vertebral.

Thoracotomy is used to approach and treat anterior spinal lesions arising from various causes. Between 1990 and 1997, we treated 56 patients (40 men and 16 women) between 14 and 67 years old (mean 38.4). All had spinal lesions that were impossible or difficult to reach by a posterior approach. Thirty-one (55.3%) had suffered spinal damage, 8 (14.3%) had spinal deformities, 7 (12.5%) had metastatic tumors, 5 (8.9%) had herniated discs, 4 (7.1%) had Pott's disease and 1 (1.8%) had osteolysis at D6. Thoracotomy was left-sided in 35 cases (62.5%) and right-sided in 19 (33.9%). Video-assisted thoracoscopy was used twice (3.6%). The level of incision was based on the site of the lesion, and the pleural cavity was opened in all cases except one. The posterolateral pleuro-diaphragmatic fold was dissected and the diaphragm opened for retroperitoneal access in 37 cases (66.1%) of thoracolumbar disease. Orthopedic treatment consisted of autologous bone grafts in all cases and placement of a Kaneda splint in 32 cases (57.1%). One patient had to undergo surgery a second time due to inappropriate placement of the vertebral splint. Pneumothorax occurred in one patient after removal of pleural drains. The incision became infected in one patient, and one case of ileal paralysis was observed. Overall, morbidity was 7.1%. We conclude that thoracotomy offers a good alternative approach to spinal lesions. Results are good and morbidity low.

Transcutaneous electrical nerve stimulation and spinal cord stimulation for pain relief in reflex sympathetic dystrophy.

35 patients with the diagnosis of reflex sympathetic dystrophy in a late stage have been treated with transcutaneous electrical nerve stimulation (TENS). 6 out of the 35 were also submitted to spinal cord stimulation (SCS). The follow-up was from 10 to 36 months. The results obtained were TENS group: 25% excellent, 45% good, 10% fair, 20% poor; in the SCS group: 16.6% excellent; 66.6% good and 16.6% fair. In the long run these results are better than those obtained with sympathetic blocks and sympathectomy. TENS and SCS have no effect on osteoporosis or ankylosis.