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Mario Meglio, Beatrice Cioni, and Gian Franco Rossi

T wenty years after the first report of spinal cord stimulation (SCS) for pain relief in man 35 there is still skepticism regarding this technique. This might be due in part to the difficulties of managing patients with chronic pain, to technical problems related to the devices used, and to the lack of objectivity in assessing the results of stimulation. It might also be ascribed to the natural attitude of the surgeon toward handling these problems in more aggressive and definitive ways. Nine years of personal experience with this technique have convinced

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Carroll P. Osgood, Manuel Dujovny, Ronald Faille, and Munir Abassy

P osterior sensory rhizotomy remains part of the contemporary neurosurgical armamentarium although its use for chronic pain syndromes remains controversial. Success rates reported recently have varied from 25% to 64%. 3, 4, 6, 10 Afferent axons of the ventral roots were believed until recently to constitute only a very small percentage of all ventral root myelinated fibers. Coggeshall, et al. , 1 reported substantial percentages of small, unmyelinated axons, 0.6 to 1.5 µ in diameter in the ventral lumbosacral roots of the cat, macaque, and man. In

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Dirk Rasche, Patricia C. Rinaldi, Ronald F. Young, and Volker M. Tronnier

Object

Electrical intracerebral stimulation (also referred to as deep brain stimulation [DBS]) is a tool for the treatment of chronic pain states that do not respond to less invasive or conservative treatment options. Careful patient selection, accurate target localization, and identification with intraoperative neurophysiological techniques and blinded test evaluation are the key requirements for success and good long-term results. The authors present their experience with DBS for the treatment of various chronic pain syndromes.

Methods

In this study 56 patients with different forms of neuropathic and mixed nociceptive/neuropathic pain syndromes were treated with DBS according to a rigorous protocol. The postoperative follow-up duration ranged from 1 to 8 years, with a mean of 3.5 years. Electrodes were implanted in the somatosensory thalamus and the periventricular gray region. Before implantation of the stimulation device, a double-blinded evaluation was carefully performed to test the effect of each electrode on its own as well as combined stimulation with different parameter settings.

The best long-term results were attained in patients with chronic low-back and leg pain, for example, in so-called failed–back surgery syndrome. Patients with neuropathic pain of peripheral origin (such as complex regional pain syndrome Type II) also responded well to DBS. Disappointing results were documented in patients with central pain syndromes, such as pain due to spinal cord injury and poststroke pain. Possible reasons for the therapeutic failures are discussed; these include central reorganization and neuroplastic changes of the pain-transmitting pathways and pain modulation centers after brain and spinal cord lesions.

Conclusions

The authors found that, in carefully selected patients with chronic pain syndromes, DBS can be helpful and can add to the quality of life.

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Ronald F. Young, Richard Kroening, Wayne Fulton, Robert A. Feldman, and Israel Chambi

A pparently the first individual to employ therapeutic electrical stimulation of the human brain was J. Lawrence Pool in 1954. 33 Subsequently, Pool and colleagues 34 and Heath and Mickle 18 used chronic electrical stimulation of the septal area and supraoptic nuclei for the treatment of chronic pain. In the early 1960's, Mazars, et al. , 29 treated patients suffering from deafferentation pain with electrical stimulation of the thalamus. The identification by Reynolds 35 of the phenomenon of “stimulation-produced analgesia” provided a major impetus to

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Krishna Kumar, Gary Hunter, and Denny D. Demeria

to various malignancies, 2, 5, 9, 12, 16 but it is now well accepted as a means to treat chronic pain from such nonmalignant pathologies as failed back syndrome, peripheral vascular disease, peripheral neuropathies, multiple sclerosis, and complex regional pain syndrome I. 1, 13, 20 For patients with chronic pain that does not respond to CPTs such as oral medications, physiotherapy, chiropractic therapy, acupuncture, muscle relaxation techniques, and behavior modification, the benefits of IDT can be significant with acceptable side effects. 17 The side

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John D. Loeser

T he proper role of dorsal rhizotomy in the relief of chronic pain has been a subject of debate since the first review of this operation by Abbe 1 in 1911. In his paper he assigned credit to Dr. C. L. Dana for first suggesting this type of surgery in 1888; Abbe did his first dorsal rhizotomy on the last day of that year. He admits that Sir Victor Horsley did the first dorsal rhizotomy 7 days earlier but claims priority for the operation on the basis of his own correspondence with Dana. For the next 50 years sporadic reports of the efficacy of dorsal rhizotomy

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Malte Schroeder, Lennart Viezens, Christian Schaefer, Barbara Friedrichs, Petra Algenstaedt, Wolfgang Rüther, Lothar Wiesner, and Nils Hansen-Algenstaedt

D egeneration of an IVD results in disc-related disorders, including herniation and chronic DDD. These disorders are often accompanied by acute or chronic pain. 9 , 40 The most common causes of disc degeneration are compositional changes of the IVD that compromise the biomechanical disc properties, thus impairing its function. 45 , 49 The understanding of the pathophysiological development of radicular pain has changed, from the assumption of a pure mechanical compression of the nerve root, to the notion of a more complex mechanism involving both

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Shelby Sabourin, Justin Tram, Breanna L. Sheldon, and Julie G. Pilitsis

results of this study build off a previously published study by our laboratory that found particular success utilizing MDC methodology and ROC curve analysis to determine MCID thresholds for limited outcome instruments. 17 The current study used a similar methodology as the previous study, but instead enrolled a larger cohort of patients and included 12-month postoperative outcomes. Furthermore, our study included patients with chronic pain who received SCS therapy for FBSS, CRPS, and neuropathy, whereas the previous study strictly examined patients with FBSS. Although

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Jay D. Law, John Swett, and Wolff M. Kirsch

the peripheral nerves, at or distal to the painful pathology. Summary of Cases Series Characteristics Patients were selected for this surgery according to the following characteristics. All had severe, chronic pain, refractory to all low-risk methods of treatment. No patient had suffered pain for less than 1 year, and the average preoperative duration of pain was 4.7 years. There were 22 patients in the series, 15 of whom were male. They were operated on between August, 1971, and July, 1978. In all but two cases, the pain was caused by traumatic

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Tracy Cameron

excluded from the evaluation if it involved any one of the following criteria. 1) It was a review article, case study, or foreign-language article. 2) It included nonhuman animals. 3) Patients received implants before 1981. Safety Analysis Selection Criteria Criteria included the following 1) Patients exhibited chronic pain of the trunk and/or limbs and 2) complications were listed. An article was excluded from the evaluation if it met any one of the following criteria: 1) no complications were listed; 2) was a review article; 3) was a foreign-language article