Treatment of refractory, chronic low back pain with botulinum neurotoxin A: an open-label, pilot study.

OBJECTIVE: To study the short- and long-term effects of botulinum neurotoxin A (BoNT-A, Botox, Allergan Inc.) on refractory chronic low back pain. DESIGN: The effect of botulinum neurotoxin A on chronic low back pain was prospectively studied in 75 patients with repeated treatments over a period of 14 months. Pain intensity (visual analog scale [VAS]), pain frequency (pain days), and perceived functional status (Oswestry scale) were assessed at baseline, 3 weeks, and at 2, 4, 6, 8, 10, 12, and 14 months. BoNT-A was injected into para-spinal muscles at 4-5 levels (between L1 and S1) unilaterally or bilaterally. The dose per site varied from 40 to 50 units. The total dose per session ranged from 200 to 500 units. Reinjections were performed at 4 months only when pain returned. RESULTS: At 3 weeks, 40 patients (53%) and at 2 months, 39 patients (52%) reported significant pain relief. The change in VAS, Oswestry score, and pain days was significant compared with baseline at 2 months after each injection period (P < 0.005) and remained so over subsequent treatments. Among initial responders, 91% continued responsiveness over the length of the study. Three patients (4%), after the first treatment, had a mild flulike reaction that lasted 2-5 days. CONCLUSION: Botulinum neurotoxin A may be beneficial in patients with chronic low back pain. A favorable initial response predicts subsequent responsiveness. The treatment is well tolerated, and side effects are mild and transient.

Treatment of chronic low back pain with successive injections of botulinum toxin a over 6 months: a prospective trial of 60 patients.

OBJECTIVES: The aim of this study was to evaluate the effects of two successive neurotoxin treatments for chronic low back pain using multiple pain rating scales in an open-label, prospective study. METHODS: Adult patients with chronic low back pain received multiple paraspinal muscle injections with a maximum dosing of 500 units of botulinum A toxin per session. Those with a beneficial clinical response received a second treatment at 4 months. Pain was assessed by visual analog scale (VAS), modified low back pain questionnaire (OLBPQ), and a clinical low back pain questionnaire (CLBPQ) at baseline, 3 weeks, 2 months, 4 months, and 6 months after the first treatment. RESULTS: Eighteen women and 42 men, ages 21 to 79 years (mean 46.6 years), with low back pain of a mean duration of 9.1 years were included. Significant improvement in back and radicular pain occurred at 3 weeks in 60% and at 2 months in 58% of the cohort. Beneficial clinical response to the first injection predicted response to reinjection in 94%. A significant minority of patients had a sustained beneficial effect from the first injection at 4 (16.6%) and 6 months (8.3%). Two patients had a transient flu-like reaction after the initial treatment. CONCLUSIONS: Botulinum toxin A improves refractory chronic low back pain with a low incidence of side effects. The beneficial clinical response is sustained with a second treatment.

Superior semicircular canal dehiscence: a new indication for middle fossa craniotomy. Case report.

Superior semicircular canal dehiscence is a recently described condition resulting in pressure-induced vertigo in affected patients. The diagnosis is established with the appearance of characteristic electronystagmographic and neuroimaging findings. This condition is amenable to surgical treatment by resurfacing of the dehiscence in the defect in the middle cranial fossa floor with preservation of superior semicircular canal function. The authors report on the treatment of a 35-year-old man with superior semicircular canal dehiscence by a joint neurosurgical and otolaryngological team.

Thoracic hemivertebra excision in adults via a posterior-only approach. Report of two cases.

Hemivertebrae are a common cause of congenital scoliosis. Depending on their location and the magnitude of the resultant deformity, they may be asymptomatic or require treatment. In the past, treatment has focused on prevention of deformity progression in growing children. Little has been written about congenital scoliosis presenting in adulthood. Because the aging of the spine is a kyphosing process and hemivertebrae often present with a local segmental kyphotic alignment, this can become symptomatic. Excision of hemivertebrae is well established as a safe and effective procedure when treatment is required. Initially this was conducted via a combined anterior-posterior approach. Recently some authors have indicated that in the lumbar spine hemivertebra resection can safely and effectively be achieved via a single posterior transpedicular approach. The authors report two adult cases in which they performed posterior transpedicular lateral extracavitary excision of a thoracic, fully segmented hemivertebrae. Essentially complete correction of the deformity was achieved. There were no neurological complications. The patients were spared a thoracotomy and no chest tubes were required.

Endoscopic image-guided transethmoid pituitary surgery.

OBJECTIVE: We describe a new endoscopic transethmoid approach for pituitary surgery and to compare it with other surgical techniques. STUDY DESIGN AND SETTING: Eleven patients undergoing pituitary surgery from September 2000 through January 2002 underwent an image-guided endoscopic transethmoid procedure to remove pituitary tumors. Ease of approach, resection, exposure of the surgical field, and operative complications were documented. RESULTS: Endoscopic ethmoidectomy permits enhanced exposure and simplified tumor resection. The use of one nostril to stabilize the endoscope and the other to pass instruments affords a bimanual procedure that avoids the difficulty of small nares and keeping the scope fixed while exchanging instruments. Operative morbidity was low with no significant complications in this pilot study. CONCLUSIONS: This approach opens a generous operative exposure while safely allowing room to endoscopically maneuver and affords direct access should revision surgery be needed. SIGNIFICANCE: This procedure uses a technique familiar to otolaryngologists and may be used for pituitary and other skull base tumors.

Identification of an alternatively spliced RNA for the Ras suppressor RSU-1 in human gliomas.

Previous studies demonstrated that the Ras suppressor, RSU-1, localizes to human chromosome 10p13, a region frequently deleted in high grade gliomas, and that RSU-1 expression inhibited the tumorigenesis of a glioblastoma cell line. We have now examined RNA from human glial tumors for RSU-1 expression by RT-PCR using primers for the 5' and 3' ends of the RSU-1 open reading frame. Analysis of the amplified RSU-1 cDNA demonstrated that in addition to the entire 858 bp RSU-1 open reading frame, a shorter 725 bp RSU-1 fragment was amplified as well. Sequencing of this product revealed that it encoded a RSU-1 cDNA product which was missing a single 133 bp internal exon. This exon-deleted product was found in 30% of the high grade gliomas studied and 2/3 oligodendrogliomas, but not in other CNS tumors, bladder or colon tumors or normal tissue. The exon-deleted RSU-1 product was infrequently detected in RNA from human tumor cell lines. Expression of an HA-tagged form of the deleted RSU-1 protein in transfected Cos 1 cells revealed that the protein was unstable, with a half life of less than 1 h, in contrast to the full length HA-tagged Rsu-1 protein which was stable for more than 4 h. These results suggest that the alternative splicing of the RSU-1 RNA to produce the exon-deleted form constitutes a mechanism for reduction or loss of functional Rsu-1. Because the expression of Rsu-1 can inhibit malignant growth of glioblastoma cells, the depletion of Rsu-1, via the production of the alternatively spliced form of RSU-1, may inhibit growth regulation in tumors.