Spinal cord stimulation for the management of pain: Recommendations for best clinical practice.

Spinal cord stimulation (SCS) is an accepted method of pain control. SCS has been used for many years and is supported by a substantial evidence base. A multidisciplinary consensus group has been convened to create a guideline for the implementation and execution of an SCS programme for South Africa (SA). This article discusses the evidence and appropriate context of SCS delivery, and makes recommendations for patient selection and appropriate use. The consensus group has also described the possible complications following SCS. This guideline includes a literature review and a summary of controlled clinical trials of SCS. The group notes that, in SA, SCS is performed mainly for painful neuropathies, failed back surgery, and chronic regional pain syndrome. It was noted that SCS is used to treat other conditions such as angina pectoris and ischaemic conditions, which have therefore been included in this guideline. These recommendations give guidance to practitioners delivering this treatment, to those who may wish to refer patients for SCS, and to those who care for patients with stimulators in situ. The recommendations also provide a resource for organisations that fund SCS. This guideline has drawn on the guidelines recently published by the British Pain Society, and parts of which have been reproduced with the society's permission. These recommendations have been produced by a consensus group of relevant healthcare professionals. Opinion from outside the consensus group has been incorporated through consultation with representatives of all groups for whom these recommendations have relevance. The recommendations refer to the current body of evidence relating to SCS. The consensus group wishes to acknowledge and thank the task team of the British Pain Society for their help and input into this document.

Stereotactic proton beam therapy of skull base meningiomas.

PURPOSE: To review outcomes for patients with skull base meningiomas treated using the stereotactic proton beam at the National Accelerator Center (NAC), Republic of South Africa. METHODS AND MATERIALS: Since 1993, 27 patients with intracranial meningiomas have been treated stereotactically with protons at NAC. Of those, 23 were located on the skull base, were large or had complex shapes, and were treated with radical intent. Both stereotactic radiotherapy (SRT, 16 or more fractions) and hypofractionated stereotactic radiotherapy (HSRT, 3 fractions) were used. Eighteen patients underwent proton HSRT, while 5 patients were treated with SRT. The mean target volume for the HSRT group was 15.6 cm(3) (range 2.6-63 cm(3)). The mean ICRU reference dose was 20.3 cobalt Gray equivalent (CGyE), and the mean minimum planning target dose was 16.3 CGyE. The mean clinical and radiologic follow-up periods were 40 and 31 months respectively. The mean volume in the SRT group was 43.7 cm(3), with ICRU reference doses ranging from 54 CGyE in 27 fractions to 61.6 CGyE in 16 fractions. RESULTS: In the HSRT group, 16/18 (89%) of patients remained clinically stable or improved, while 2/18 (11%) deteriorated. Radiologic control was achieved in 88% of patients, while 2 patients had a marginal failure. Among the 5 SRT patients, 2 were clinically better, and 3 remained stable. All SRT patients achieved radiologic control. Three patients (13%), 2 of them in the HSRT group, suffered permanent neurologic deficits. Analyzing different dose/fractionation schedules, an alpha/beta value of 3.7 Gy for meningiomas is estimated. CONCLUSION: Proton irradiation is effective and safe in controlling large and complex-shaped skull base meningiomas.

A tentorial sling in microvascular decompression for trigeminal neuralgia. Technical note.

The key to the successful microvascular decompression of the trigeminal nerve is the maintenance of the separation between the trigeminal nerve and the offending vessel. The authors describe a technique whereby a dural sling is fashioned from the tentorium cerebelli (the anatomy of which is briefly reviewed), which is used to suspend the vessel away from the nerve and is secured by a single hemoclip.

The intertransverse approach to extraforaminal disc protrusion in the lumbar spine.

STUDY DESIGN: This retrospective study describes the typical clinical presentation of the extraforaminal disc herniation in the authors' experience, and the surgical management of this via the intertransverse approach. OBJECTIVES: To establish an accurate preoperative diagnosis that enables the surgeon to plan an operative approach for preserving the apophysial joint. SUMMARY OF BACKGROUND DATA: In the past, failure to recognize the extraforaminal disc herniation (clinically and via investigations) resulted in inadequate management, oftne with destructive surgical approaches to the pathology. This need not be so. METHODS: The records of 40 patients who underwent surgery for extraforaminal disc herniation were analyzed and long-term follow-up was conducted by telephone. Also, the extraforaminal areas of the lumbar spine in cadavers were dissected and examined. RESULTS: Examination of the cadaver specimens confirmed the presence of a fibrous band (always seen at surgery) lateral to the nerve root. The results of surgical decompression of the nerve root via the intertransverse approach were at least comparable with other approaches. There was complete resolution of presenting leg pain in 85% of the patients, 7.5% were left with minimal residual discomfort, and 7.5% derived little or no benefit from surgery. CONCLUSIONS: The extraforaminal disc herniation is a distinct clinical entity that, with a high index of suspicion and the aid of magnetic resonance imaging, can be identified preoperatively. This provides the basis for a planned surgical approach in which destruction of the apophysial joint can be avoided.

Lymphocytic adenohypophysitis. Report of a case with demonstration of spontaneous tumour regression and a review of the literature.

Lymphocytic adenohypophysitis is a rare auto-immune disease usually bearing a temporal relationship to pregnancy. We report a 37-year-old woman with this condition, who presented with bitemporal hemianopia in the postpartum period. She represents the mildest expression of the disease entity yet described, and showed spontaneous tumour regression.

Chronic pain problems. Experience in a pain clinic.

Our experiences during a year of activity in a pain clinic are presented. Most of the patients treated had pain due to malignant disease. The assessment and management of these patients are described together with the treatment given and the result.

Anastomosis of the superficial temporal to the middle cerebral artery in the management of an intracranial aneurysm. A case report.

A patient with a subarachnoid haemorrhage due to a large right-sided internal carotid artery aneurysm presented unusual problems in management. Direct obliteration of the aneurysm was not possible, while ligation of the internal carotid artery as an alternative form of treatment necessitated the provision of an alternative collateral blood supply to the right cerebral hemisphere, the anterior circle of Willis being deficient. This case illustrates a new surgical technique which has a place in the management of selected cases of cerebral ischaemic disease.

Peripheral cerebral arterial aneurysms caused by stabbing.

Aneurysms of peripheral cerebral arteries caused by stabs of the vault are described in 2 patient. The importance of early recognition of this potentially fatal complication of an apparently benign injury of the head is emphasized.

The pitfalls in early diagnosis of childhood spinal compression.

Thirty-one children under the age of 13 years with spinal cord and cauda equina compression are presented. Some of these cases are used to illustrate the problems encountered in the early recognition of compressive lesions involving the spinal cord and cauda equina in the paediatric age group.