[Cost-benefit evaluation of spinal cord stimulation treatment for failed-back surgery syndrome patients]. / Evaluation coût/bénéfice du traitement des lombosciatalgies post-operatoires par stimulation médullaire.

BACKGROUND AND PURPOSE: Spinal cord stimulation is a well-known treatment of rigorously selected failed-back surgery syndrome patients. Efficacy levels over 50% of pain relief have been reported in long-term studies. The objective of this multicenter prospective evaluation was to analyze the cost to benefit ratio of spinal cord stimulation treatment for failed back surgery syndrome patients. METHODS: Nine hospitals (pain evaluation and treatment centers) were involved in the study. Forty-three patients were selected and implanted between January 1999 and January 2000. For each patient, pre- and post-operative evaluations (6, 12 and 24 months after implantation) were performed to assess pain relief and economical impact on pain treatment costs. RESULTS: After 24 months, mean 60% pain relief was achieved as assessed with the neuropathic pain score using a Visual Analog Scale (success rate=70%), whereas low-back pain was moderately reduced (29%). The Oswestry Disability questionnaire score was improved by a mean 39%. Costs of pain treatment (medication, consultation, other) are reduced by a mean 64% (1705 Euro) per patient per year. CONCLUSIONS: This study confirms a clear analgesic effect on neuropathic sciatalgia, and moderate attenuation of low-back pain. One particular interest of this study is the medico-economic prospective evaluation showing that the initial cost of the implanted device is compensated by a significant, early, and stable reduction in the cost of associated pain therapies.

[The endonasal approach to pituitary adenomas: experience in 105 procedures]. / Intérêt de la voie d'abord endonasale pour l'exérèse des adénomes hypophysaires.

OBJECTIVE: The endonasal approach to the sella turcica is supposed to simplify surgical techniques and reduce the risk and sequelae linked to removal of pituitary adenomas. We report our experience with 105 procedures using this approach. METHOD: The series included 45 men and 60 women, aged 17 to 83 years. Their intrasellar lesions were: 43 non-functional adnomas, 37 prolactinomas, 7 GH- adenomas, 9 corticotrop adenomas, 9 miscellaneous lesions (abscess, Rathke cleft cysts, empty sella). Mean duration of the procedures was 50 minutes. Mean hospital stay was 4 days. RESULTS: There were no deaths. Morbidity included: 1 (0.95%) rhinorrhea associated with meningitis which cured without sequelae, 11 (10.5%) transient diabetes insipidus lasting no longer than 48 hours, 2 cases of permanent diabetes insipidus (1 non-functional macroadenoma, 1 pituitary abscess), 1 transient hyposmia (3 months), 2 transient nasal obstructions. There were no cases of septal perforation, nasal deformation, partial or complete mucosal anesthesia, nasal pain, dental pain, or epistaxis. CONCLUSION: This surgical approach is easier to perform and causes less rhinological sequelae than the sublabial transsphenoidal approach. It allows an as effective tumor removal than the latter. Hospitalization stay is significantly shortened.

[Course of headaches associated with cAVMs after radiosurgery]. / Evolution des céphalées associées aux malformations artério-veineuses cérébrales après radiochirurgie.

The purpose of this study is to evaluate the response of headaches associated with cerebral arteriovenous malformations following radiosurgery and determine the factors that are associated with a positive outcome. From our series of 700 patients whose cAVM was treated by radiosurgery, this study includes 109 patients (48 males, 61 females) with a mean age of 32 when radiosurgery was performed. Headaches resolved in 37 patients (53.7%), decreased in 14 patients (20.3%), persisted in 16 patients (23.2%), and even increased in frequency in 2 (2.9%). Headaches disappeared 2 years following radiosurgery in the majority of patients (31 out of 37: 83.3%). The disappearance rate of headaches was better when it was the only sign of the malformation (64%) or preceded an epileptic seizure (60%) with respect to the case when it preceded cerebral hemorrhage (34.8%). Headaches having the best response were those with 1 to 2 episodes per month (64.9%) and whose episode duration was less than 3 hours (67.6%). Unilateral headaches accounted for 86.5% of resolved headaches whereas bilateral headaches were only 8.1% and even less were the diffuse ones (5.4%). The best evolution was obtained for those associated with a parietal location of the cerebral arteriovenous malformation, followed by rolandic (respectively 55.5% and 50%). Occipital malformation was associated with headache disappearance in 38.1% and temporal with 34.3%, whereas frontal location was associated with headache disappearance in only 25% of the cases. Headache disappearance was often correlated with cerebral arteriovenous malformation outcome after radiosurgery (64.9% of disappearance in case of complete obliteration). However, in 24.8%, headaches disappeared prior to the malformation obliteration and were associated with a decrease of the flow, of the nidus volume or with the nidus disappearance with the persistence of a precocious venous drainage. Headaches disappeared in spite of the malformation persistence in 5.4% of the cases. We found de novo headaches in one patient one year following RS. Another patient presented an episode of headache 12 hours following RS. The course of headaches associated with cerebral arteriovenous malformations after radiosurgery is positive in the majority of cases and correlated to the malformation outcome. This correlation suggests a link between cerebral arteriovenous malformations and headaches and the equal benefit of radiosurgery on both of them.

[Pain therapy]. / Traitement de la douleur.

NEW OPIOID ANALGESICS: Progress in pain reliet has recently been achieved with the introduction of new opioid analgesics such as tramadol and the pediatric preparation of codeine phosphate as well as powerful long-release opioids which can be administered per os, or percutaneously for transdermal fentanyl. CO-ANALGESICS: Other drugs, mainly antidepressants and anti-convulsants, can be usefully combined with analgesics. New serotonin uptake inhibitors and anticonvulsants (gabapentin and lamotrigin) have the advantage of better tolerance. None of these drugs has marketing approval in France for their pain relieving effects. The same is true for clonidine and neostigmine which, after spinal infusion, potentialize opioids and for ketamine which can relieve neuropathy pain by dissociative anesthesia. NEW ANTI-MIGRAINE DRUGS: New drugs have been developed for specific types of pain such as migraine. The new "triptans" are tolerated better than sumatriptan and is reimbursed by the national social security. REFRACTORY NEUROPATHY PAIN: Indications for electrical stimulation techniques conducted in a neurosurgery unit have been identified. Stimulators may be implanted in spinal or supra-spinal localizations. REGULATORY ASPECTS: New legislation has reorganized health care for pain relief in France. The new texts take into consideration personnel training, the health care network and progress in therapeutics.