Combined intrathecal baclofen and morphine infusion for the treatment of spasticity related pain and central deafferentiation pain.

OBJECTIVES: Complex pain syndromes due to spasticity and central deafferentation often fail to respond to medical therapy and create challenging problems in the pain management. So far, only spasticity associated musculosceletal pain has been reported to respond to intrathecal baclofen application [1, 2]. METHODS: We report the treatment of severe neuropathic pain in a patient with ED and the combined intrathecal application of baclofen and morphine in 5 patients with severe spasticity related pain. RESULTS: Continuous intrathecal baclofen infusion resulted in a pain free period of 20 months in the patient with ED. Patients with spasticity treated with intrathecal application of baclofen and morphine were pain free for a mean period of 2 years. CONCLUSION: Intrathecal baclofen and morphine application proved to be effective in spasticity related and central deafferentation pain and should therefore be considered in the management of these patients.

The punctate midline myelotomy concept for visceral cancer pain control--case report and review of the literature.

INTRODUCTION: Nauta et al. first reported on a successful punctate midline myelotomy (PMM) at the spinal cord Th 10 level for the treatment of intractable pelvic cancer pain. CASE STUDY: The authors published another case history of a patient with multiple anaplastic carcinomas of the small intestine, peritoneal carcinosis and retroperitoneal lymphomas, suffering from severe visceral pain in the hypo-, meso-, and epigastrium. Nauta's PMM was successfully performed at the level Th 4. Narcotic medication was tapered from 30 mg i.v. morphine per hour preoperatively to 5 mg per hour within 5 days postoperatively. Pain intensity decreased from 10 to 2-3 on the visual analog scale. Only minor transient side effects appeared postoperatively. Pain reduction remained until the patient died from the extended disease five weeks later. DISCUSSION: Meanwhile Nauta et al. reported on 5 additional patients, in whom PMM led to a sufficient pain reduction. Another paper reported on sufficient control of visceral pain due to advanced stomach cancer after a modified Th 1-2 PMM. CONCLUSION: PMM sufficiently controls not only pelvic visceral pain, but also visceral pain generated in the meso- and epigastrium. The findings support the concept of a midline dorsal column visceral pain pathway.

Spinal type IV arteriovenous malformations (perimedullary fistulas) in children.

OBJECTS: Intradural perimedullary spinal arteriovenous fistula (AVF) is a synonym for type IV spinal arteriovenous malformation (AVM). It is an important clinical differential diagnosis in all patients with slowly progressive or acute spinal symptoms. Perimedullary AVFs are rare in the paediatric age group. We report the treatment regimen and the clinico-radiological findings for these malformations at our institution. METHODS: Of four paediatric patients, three individuals with persistent fistulas after endovascular treatment were operated on. The malformations were obliterated completely in all patients without any morbidity. In three patients previously documented neurological symptoms resolved during follow-up. CONCLUSIONS: If slowly progressive or acute radicular or medullary symptoms arise in children, a spinal arteriovenous malformation should be ruled out by MRI. A combined endovascular and surgical treatment of paediatric spinal AVM type IV (perimedullary AVFs) carries a low risk of morbidity and is reasonably effective.

Continuous intrathecal clonidine administration for the treatment of neuropathic pain.

In many cases, the treatment of neuropathic pain by intrathecal opioids fails to meet expectations. In a trial involving 10 patients, the intrathecal administration of clonidine combined with opioids in the treatment of chronic pain was introduced in our department for the first time. Eight patients with neuropathic pain syndromes were subjected to a continuous intrathecal clonidine application in addition to intrathecal morphine. At an average dose of 44 microg clonidine/day, a 70-100% reduction in pain was achieved. Residual non-neuropathic pain in 4 of 8 patients was successfully treated with clonidine and low doses of opioids. On the basis of the results achieved so far, we recommend that clonidine should be routinely tested for intrathecal drug administration, especially in patients with a prominent neuropathic pain component.