Medial Gamma Knife thalamotomy for intractable pain.

OBJECTIVEAblative procedures are still useful in the treatment of intractable pain despite the proliferation of neuromodulation techniques. In the paper the authors present the results of Gamma Knife thalamotomy (GKT) in various pain syndromes.METHODSBetween 1996 and 2016, unilateral GKT was performed in 30 patients suffering from various severe pain syndromes in whom conservative treatment had failed. There were 20 women and 10 men in the study population, with a median age of 80 years (range 53-89 years). The pain syndromes consisted of 8 patients with classic treatment-resistant trigeminal neuralgia (TN), 6 with postherpetic TN, 5 with TN and constant pain, 1 with TN related to multiple sclerosis, 3 with trigeminal neuropathic pain, 4 with thalamic pain, 1 with phantom pain, 1 with causalgic pain, and 1 with facial pain. The median follow-up period was 24 months (range 12-180 months). Invasive procedures for pain release preceded GKT in 20 patients (microvascular decompression, glycerol rhizotomy, balloon microcompression, Gamma Knife irradiation of the trigeminal root, and radiofrequency thermolesion). The Leksell stereotactic frame, GammaPlan software, and T1- and T2-weighted sequences acquired at 1.5 T were used for localization of the targeted medial thalamus, namely the centromedian (CM) and parafascicularis (Pf) nucleus. The CM/Pf complex was localized 4-6 mm lateral to the wall of the third ventricle, 8 mm posterior to the midpoint, and 2-3 mm superior to the intercommissural line. GKT was performed using the Leksell Gamma Knife with an applied dose ranging from 145 to 150 Gy, with a single shot, 4-mm collimator. Pain relief after radiation treatment was evaluated. Decreased pain intensity to less than 50% of the previous level was considered successful.RESULTSInitial successful results were achieved in 13 (43.3%) of the patients, with complete pain relief in 1 of these patients. Relief was achieved after a median latency of 3 months (range 2-12 months). Pain recurred in 4 (31%) of 13 patients after a median latent interval of 24 months (range 22-30 months). No neurological deficits were observed.CONCLUSIONSThese results suggest that GKT in patients suffering from severe pain syndromes is a relatively successful and safe method that can be used even in severely affected patients. The only risk of GT for the patients in this study was failure of treatment, as no clinical side effects were observed.

Gamma Knife Surgery for Recurrent Trigeminal Neuralgia in Cases with Previous Microvascular Decompression.

BACKGROUND: Microvascular decompression (MVD) and Gamma Knife surgery (GKS) are the primary treatments for trigeminal neuralgia (TN). However, many patients require further surgical treatment after initial surgery for recurrent TN. The aim of this study was to evaluate efficacy and safety of GKS for recurrent TN cases with prior MVD. METHODS: From October 2008 to June 2015, 658 patients at West China Hospital underwent GKS as the only surgical treatment, and 42 patients underwent GKS with prior MVD. The single 4-mm isocenter was located at the cisternal portion of the trigeminal nerve in all patients. Median maximum prescription dose was 85 Gy (range, 70-90 Gy). RESULTS: Median follow-up time was 6.2 years (range, 1.1-10 years). The percentage of patients with or without previous MVD within 1 year was 56.81%, and the percentage of patients who were pain-free was 74.74%. The recurrence rates within 10 years were 49.11% and 43.74% for patients with and without MVD, respectively. Also, 9.52% and 11.04% of patients with and without previous MVD experienced complications as a result of GKS during the long-term follow-up period. Patients who underwent previous MVD showed a significantly lower pain-free rate compared with patients without previous MVD (P = 0.01). There was no statistical significance in the recurrence rate (P = 0.82) or the complications (P = 0.93) in the 2 groups during the long-term follow-up period. CONCLUSIONS: For patients with recurrent TN who previously underwent MVD, GKS remains an efficacious and safe mode of treatment.

Stereotactic Radiosurgery for the Treatment of Chronic Intractable Pain: A Systematic Review.

BACKGROUND: Since the advent of neuromodulation, the role and efficacy of stereotactic radiosurgery (SRS) for chronic pain has not been carefully scrutinized. OBJECTIVE: To perform a systematic review to evaluate the clinical efficacy, both short- and long-term, of SRS for the treatment of chronic intractable pain. METHODS: A systematic search in PubMed, Web of Science, and PsycINFO was performed using keywords and controlled vocabulary. The search included peer-reviewed articles reporting clinical outcomes of SRS for chronic pain with a minimum 3-mo follow-up for nonmalignant and 1 mo for malignant pain. RESULTS: Six articles (113 patients) were evaluated on the basis of radiation target (thalamus vs pituitary) and pain etiology (malignant vs nonmalignant). Across studies, at least 35% of patients were reported to have lasting significant pain relief. By cohort, clinical success was achieved in 51% of pituitary SRS, at least 23% of thalamic SRS, 39% of nonmalignant, and at least 33% of malignant pain patients. Adverse events were noted in 21% of patients; the majority related to hormonal deficits from pituitary SRS. CONCLUSION: Despite decreased utilization, SRS is effective for select patients with chronic pain and is associated with an acceptable complication rate. Pituitary SRS is superior in patients with cancer-related pain (87% success), while thalamic SRS is superior in patients with nonmalignant pain (65% success). Because reports of SRS for pain largely stem from a period before the common use of neuromodulatory and intrathecal therapies, the efficacy in patients who fail such therapies remains unclear and requires further characterization.

Effects of Targeted Proton Radiation on Spinal Cord in a Porcine Model: A Pilot Study.

AIM: To determine whether proton radiation can be used to treat chronic intractable pain. The focus of this study was on the biological effects of spinal cord irradiation. MATERIALS AND METHODS: Proton radiation (0-25 Gy, single fraction) was applied to the spinal cord within L3-L5 of Yucatan mini-pigs (n=20). Skin reaction, body mass and behavior were monitored. At euthanasia, blood and spinal cord were analyzed. RESULTS: Skin morbidity was mild and overall health for the 5-20 Gy-treated groups was good based on behavior and weight gain up to 8.5-9 months post-exposure. The 25 Gy-treated animals developed hind limb weakness at 2.5-3 months and were euthanized. Radiation had a significant effect on white blood cell count (p<0.05), with the 25 Gy-treated mini-pigs having the highest number of all three major leukocyte populations. A few differences were also noted for erythrocyte parameters, but the blood chemistry panel was normal. Apoptosis in the targeted portion of the spinal cord was elevated in the 20- and 25 Gy-treated groups versus 0 Gy (p<0.05) based on the terminal deoxynucleotidyl transferase dUTP nick-end labeling assay. There was a trend (p<0.1) for a radiation effect on glial fibrillary acidic protein expression, with the highest value being found after 25 Gy. Histology showed no difference between 0 versus 25 Gy. CONCLUSION: The data demonstrated that a small segment of the spinal cord can be readily targeted using proton radiation; doses ranging from 5-20 Gy were well-tolerated in an animal model with radiosensitivity similar to humans. Future studies with a pain model should use ≤15 Gy.

[Ultrasound-guided Sciatic Nerve Block (Pulsed Radiofrequency) for Intractable Cancer Pain Caused by Sacral Bone Metastasis].

We report a case of successful pulsed radiofrequency stimulation of the sciatic nerve for intractable cancer pain caused by sacral bone metastasis of non-small cell lung cancer. A 57-year-old man who suffered from intractable left femoral pain was diagnosed with cancer metastasis to the sacral bone and lumbar spine. Oral oxycodone relieved the pain at rest but he could not walk or remain sitting due to the pain during exercise. Oxycodone rescue or increase did not relieve the pain, but induced drowsiness. Given that sciatic nerve block with mepivacaine was effective, we performed pulsed radiofrequency with ultrasound guidance twice. Pulsed radiofrequency relieved the left femoral pain and he could sit for hours and walk uneventfully. Our finding suggest that ultrasound-guided pulsed radiofrequency of the sciatic nerve effectively relieves intractable left femoral pain caused by sacral bone metastasis.

Role of radiotherapy in the management of heel spur.

AIMS AND BACKGROUND: The purpose of this study is to investigate the use of low-dose radiotherapy (RT) in benign painful heel spur management. METHODS: Between the years of 2009 and 2012, in Gulhane Military Medical Academy Radiation Oncology Department, patients with heel spur undergoing radiotherapy for pain relief were analyzed retrospectively. In the evaluation of treatment response, Verbal Numeric Scale (VNS) scoring method was used to compare the pain status before and after radiotherapy. Age, gender, laterality, VNS score before RT, VNS score after RT, RT doses of the patients and patients undergoing second course of radiotherapy were recorded. All patients received 8 Gy RT in two fractions with Co-60 teletherapy machine. Statistical Package for Social Sciences, version 16.0 was used for data analysis with the level of significance set at p < 0.05. RESULTS: The total number of patients receiving RT for heel spur pain was 450. Median age was 52 years (range 40-85 years). Two hundred and ninety-two (65%) of the patients were women and 158 (35%) were men. Radiologically calcaneal spurs were bilateral in 432 (96%) patients, whereas unilateral left in 8 (1.8%) patients and unilateral right heel location in 10 (2.2%) patients. Ten (2.2%) of the patient group received second course of RT due to refractory pain. Comparative evaluation of VNS scores before and after RT revealed statistically significant pain relief by radiotherapy (p < 0.05). CONCLUSION: Low-dose radiotherapy is an effective and reliable painkilling treatment method that can be used in the treatment of epin calcanei refractory to medical and surgical treatment.

Pulsed radiofrequency on dorsal root ganglia for chronic pain / Radiofrequência pulsada no gânglio da raiz dorsal para tratamento de dor crônica

Objective: Evaluate clinical outcome of dorsal root ganglia (DRG) pulsed radiofrequency (PRF) treatment in neuropathic pain of patients with radiculopathy regarding improvement of pain and degree of patients? satisfaction. Method: Forty-five procedures in cervical and lumbossacral spine. Data collected by phone call interviews (independent researcher). Evaluation done after one month and at minimum three months follow-up. Analyzed data included objective and subjective improvement, and degree of satisfaction. Results: Outcome much better in 31%, 36% better, 24% unchanged, 9% worse. At initial evaluation, relief was rated: 24% excellent, 16% good, 27% moderate, 33% poor. At late evaluation, 27% excellent, 18% good, 7% moderate, 49% poor. Degree of satisfaction was high (82% of patients reported they certainly or probably would repeat the procedure). Conclusion: PRF was effective and safe in selected patients. Most patients were satisfied and would repeat/recommend the procedure...

Objetivo: Avaliar a evolução clínica do tratamento com radiofrequência pulsada (RFP) de gânglio da raiz dorsal (GRD) na dor neuropática em pacientes com radiculopatia, considerando melhora da dor e grau de satisfação dos pacientes. Método: Quarenta e cinco procedimentos na coluna cervical e lombossacra. Os dados foram coletados por meio de entrevistas telefônicas (pesquisador independente). Avaliação inicial feita após um mês e final no mínimo de três meses de acompanhamento. Dados analisados incluíram melhora objetiva, subjetiva e o grau de satisfação. Resultados: Evolução ?muito melhor? em 31%, ?melhor? em 36%, ?inalterado? em 24%, ?pior? em 9%. Na avaliação inicial: 24% ?excelente?, 16% ?bom?, 27% ?moderada?, 33% ?pobre?. Na avaliação final, 27% ?excelente?, 18% ?bom?, 7% ?moderada?, 49% ?pobre?. O grau de satisfação foi elevado (82% dos pacientes relataram que certamente ou provavelmente repetiriam o procedimento). Conclusão: RFP foi eficaz e segura em pacientes selecionados. A maioria dos pacientes ficou satisfeita e repetiu/recomendou o procedimento...

Pulsed radiofrequency treatment within brachial plexus for the management of intractable neoplastic plexopathic pain.

We report on the use of pulsed radiofrequency (RF) within the plexus for the management of intractable pain in three patients with metastatic or invasive plexopathy. The patients were a 38-year-old woman with a history of breast cancer 6 years earlier whose computed tomography (CT) scans revealed a mass lesion at the infraclavicular part of the right brachial plexus, a 68-year-old man diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the right humerus invading the axillary region of the right brachial plexus, and a 67-year-old woman diagnosed with advanced lung cancer whose CT scans revealed a bone metastasis in the left humerus invading the axillary region of the left brachial plexus. Ultrasound-guided pulsed RF was performed within the interscalene brachial plexus. During the follow-up period, their intractable pain was moderately controlled.

[The effect of strontium-89 therapy in a patient with cholangiocellular carcinoma].

A 77-year-old man was diagnosed as having cholangiocellular carcinoma. The patient underwent partial right hepatectomy in June 2008, and multiple bone metastases occurred approximately 9 months after surgery. He refused salvage chemotherapy and radiation therapy. Although he had been treated with opiate analgesics, he was unable to sit up owing to severe pain in the left ilium. He was hospitalized because of buttock pain and left leg numbness. Even a combination of fentanyl patch, gabapentin, and subarachnoid block was ineffective in controlling pain. Strontium-89 (89Sr) therapy was successful in eliminating the intractable pain, and there were no serious side effects during therapy. The patient was discharged from the hospital, and he received palliative care at home for a short period.

A feasibility study of percutaneous Radiofrequency Ablation followed by Radiotherapy in the management of painful osteolytic bone metastases.

OBJECTIVES: To determine whether Radiofrequency Ablation (RFA) followed by Radiotherapy (RT) (RFA-RT) produces better palliation in terms of pain than RT alone in patients with osteolytic bone metastases. METHODS: Patients with solitary bone metastases and a pain score of least 5 or more on the VAS scale were selected. Fifteen patients were treated with RFA-RT (20 Gy delivered in 5 fractions of 4 Gy over 1 week) and were compared with a matched group (30 subjects) treated by RT. RESULTS: A complete response in terms of pain relief at 12 weeks was documented in 16.6% (5/30) and 53.3% (8/15) of the subjects treated by RT or RFA-RT, respectively (p = 0.027). The overall response rate at 12 weeks was 93.3% (14 patients) in the group treated by RFA-RT and 59.9% (18 patients) in the group treated by RT (p = 0.048). Although recurrent pain was documented more frequently after RT (26.6%) than after RFA-RT (6.7%) the difference did not reach statistical significance. The morbidity related to RT did not significantly differ when this treatment was associated with RFA. CONCLUSIONS: Our results suggest that RFA-RT is safe and more effective than RT. The findings described here should serve as a framework around which to design future clinical trials.

Percutaneous radiofrequency treatment for refractory anteromedial pain of osteoarthritic knees.

OBJECTIVE: Although severe knee osteoarthritis with refractory pain is commonly treated surgically, this is often not an option for patients with poor health status or unwillingness to undergo major surgery. We examined the efficacy of radiofrequency application to sensory nerves as a novel alternative treatment for refractory knee pain. METHODS: This study was an open-label, nonrandomized, and controlled study. Patients complaining of refractory anteromedial knee pain associated with radiological osteoarthritis (moderate or severe) were included. They were assigned to one of two groups: those receiving radiofrequency thermocoagulation (N = 18) or those receiving nerve block (N = 17), depending on the time period that they were referred to the clinic. Radiofrequency current or local anesthetics was applied to the medial retinacular nerve and the infrapatellar branch of the saphenous nerve. Western Ontario McMaster Universities osteoarthritis index score, pain visual analog scale (VAS), and patient's global assessment were assessed with a minimum follow-up of 6 months. RESULTS: Radiofrequency treatment significantly decreased knee pain as measured by VAS for 12 weeks compared with the control group. In terms of responders, more patients in the RF group responded to the treatment than in the control group. The differences were statistically significant at 4 weeks, 8 weeks, and 12 weeks in pain VAS. Eight patients (44%) treated with radiofrequency rated excellent or good but only three (18%) in the control group rated good, although the difference was not statistically significant. CONCLUSIONS: Some patients were able to benefit substantially from radiofrequency treatment. Even if its effective period is limited, radiofrequency application is a promising treatment to alleviate refractory anteromedial knee pain with osteoarthritis. Further experience and technical improvements are needed to establish its role in the management of knee osteoarthritis.

Successful treatment of severe extremity pain in myelofibrosis with low-dose single-fraction radiation therapy.

Myelofibrosis (MF) is characterized by cytopenias/cytoses, leukoerythroblastic blood picture, bone marrow fibrosis, and extramedullary hematopoiesis. Extremity bone pain can be a feature of MF. There has been one case report of a patient with MF and bone pain treated with radiation. We treated five patients with MF and extremity pain with radiation at our institution between 2004 and 2010. All patients had severe pain unresponsive to narcotic medication. Radiation was one fraction of 100 to 600 cGy. Most patients saw improvement in the pain within days and achieved a complete response within days to weeks.The response lasted between 1 month and 2 years. Retreatment was performed in four patients and achieved a durable response in three patients. No patients reported any acute or late side effects from radiation.Bone involvement in MF can cause disabling pain, but single-fraction low-dose radiation is a safe and effective treatment, often leading to a durable response. Retreatment is also safe and effective inpatients who experience recurrent pain.

Critical organ preservation in reirradiation brachytherapy by injectable spacer.

PURPOSE: This case series study evaluated the feasibility and effectiveness of an interstitial high-dose rate brachytherapy (HDR-BT) procedure combined with an at-risk organ-sparing procedure. METHODS AND MATERIALS: Thirty patients who were scheduled for reirradiation treatment for recurrent cancer after receiving a median dose of 60 Gy (range, 44-70 Gy) in 2-Gy fractions of previous external beam treatment were enrolled. Thirteen patients had lesions in the head and neck, and other lesions were located in the axilla, skeleton, breast, pelvis, and abdominal wall. Chief complaints included local masses (for 25) and refractory pain (for 21). After high-dose rate brachytherapy applicator needle implantation, an optimal CT-based three-dimensional brachytherapy plan was created with a virtual at-risk organ shift from the target. According to the plan, hyaluronic acid gel was injected to maintain the shift during irradiation. The prescribed dose was the result of an individualized tradeoff between target dose and at-risk organ dose, to avoid serious complications. A single-fraction dose of 18.0 Gy (median, equivalent to 75.6 Gy at an alpha/beta value of 3; range, 16-20 Gy) was applied to the tumor. RESULTS: The at-risk organ dose decreased from 9.1 +/- 0.9 Gy to 4.4 +/- 0.4 Gy (mean +/- standard deviation, p < 0.01), and the normal tissue complication probability decreased from 60.8% +/- 12.6% to 16.1% +/- 19.8% (p < 0.01). The shift effect lasted at least 4 hours and disappeared gradually. Distinct tumor shrinkage in 20 of 21 eligible patients, including tumor disappearance in 6 patients, pain reduction in 18 of 21 eligible patients, and no unexpected late toxicity greater than grade 2 were observed during the 19.5-month observation period. CONCLUSIONS: This at-risk organ-sparing preservation procedure may provide a safe and efficient reirradiation treatment.

Intricacies of dose in laser phototherapy for tissue repair and pain relief.

Inaccurate measurement and incorrect reporting of dosages are major shortcomings of phototherapy articles. As many as 30% of published reports in the field either lack relevant information needed to determine a dosage or report dosages that are altogether inaccurate. The high prevalence of dosage-related mistakes in published reports suggests that dosage determination errors are common among clinicians and other end-users. This special article is designed to advance understanding of the relevant parameters used in phototherapy for tissue repair and pain relief, particularly among clinicians and others who may not be completely familiar with the technology. I define and discuss five key parameters that influence dosage, including 1) radiant power, 2) radiant energy, 3) power density, 4) energy density, and 5) wavelength, and use hypothetical cases to demonstrate how factors such as beam spot size, size of lesion, mode of treatment (contact, noncontact, or scanning), frequency of treatment, dose per treatment, and cumulative dose affect dosages and treatment outcomes. The potential effects of patient-related factors, such as etiology, pathology, tissue optical density, depth of target tissue, and skin pigmentation are discussed concurrently and strategies are suggested to improve dosage determination.

[Strontium-89: a desirable therapeutic for bone metastases of prostate cancer].

OBJECTIVE: To evaluate the efficacy of strontium-89 (89Sr) in the treatment of painful bone metastases of prostate cancer. METHODS: A total of 116 patients with painful bone metastases of prostate cancer received bilateral orchiectomy and incretion, followed by intravenous injection of 89Sr at the dose of 1.48-2.22 MBq (40-60 microCi)/kg. The clinical effects were evaluated by follow-up analysis. RESULTS: After the 89Sr treatment, appetite and sleep were evidently improved in 33.6% and 56.0% of the patients respectively, the applied dose of anodyne reduced in 61.2%, pain alleviated in 83.6%, with an absolute palliation rate of 24.1%. Pain relief started at 3-21 (10.2 +/- 6.5) days and lasted 3-12 (5.3 +/- 2.2) months. Flare ache occurred in 31.9% of the patients. Compared with pre-treatment, the mean score on Karnofsky's performance status (KPS) was 20.0% higher, and the WBC count decreased to 3.0-3.9 x 10(6)/L in 18.1% of the patients. Whole body bone scintigraphy of 53 followed-up patients showed that 39 (73.6%) of them exhibited an obvious decrease in the number of metastases, 10 (18.9% remained in a stabilized state and only 4 (7.5% deteriorated. CONCLUSION: 89Sr, capable of inhibiting bone metastasis, palliating pain and improving the quality of life with few adverse effects, can be used as a desirable therapeutic for painful bone metastases of prostate cancer.

[Treatment of painful bony metastases with Samarium 153-EDTMP in prostate carcinoma]. / Traitement des metastases osseuses douloureuses par le Samarium 153-EDTMP dans le cancer de la prostate.

UNLABELLED: THE OBJECTIVE of this work is to evaluate a new therapy, the metabolic radiotherapy to the 153Samarium-EDTMP, of recent introduction in Tunisia, in the painful bony metastasis treatment observed at the patients affected of cancer of the prostate. METHODS: It is about a retrospective survey with a receding of 40 months, achieved through 45 files of patients having benefited all of this new treatment for painful bony metastases in relation with a prostatic adenocarcinoma and collected by three centers of Nuclear Medicine of the capital: the institute Salah Azaiez (state-controlled), the Center CERU (deprives) and the Military hospital (HMPIT). RESULTS: We tried to appreciate essentially four parameters: the therapeutic efficiency, the factors influencing the answer in the treatment, the toxicity of the treatment and the sources of failure. We observed a positive answer in 92,1% of the cases, this answer was complete in 36,5% of the cases. The results gotten after multiple administrations show that the cures could be repeated with results comparable to those of the first cure. The therapeutic efficiency is at least equivalent to those of the other therapeutic means, with nearly non-existent secondary effects. The only toxicity is of hematological order; it is the most often moderate and reversible with a complete recuperation at the end of 8 weeks. Besides, the effect on the pain came with an improvement of the quality of life of the patients treaties. CONCLUSION: Its precocious introduction in the taken in charge of the metastatic patients, would allow them to benefit better from its efficiency, simplicity and weak toxicity and therefore to enjoy a better quality of life.

Radiotherapy for Erdheim-Chester disease.

A 42-year-old woman suffered from pain in both legs, and fever. She was diagnosed with Erdheim-Chester disease (ECD), based upon bone biopsy. Initially, she received steroid therapy, which led to temporary improvement. However, bone pain in the right femur was so progressive that, as a trial course of radiation therapy, she was given a total dose of 18 Gy in ten fractions to the right distal femur. She showed a gradual response, and the local pain became controllable. Erdheim-Chester disease (ECD) is an uncommon, non-Langerhans form of histiocytosis, which is characterized by radiological and pathological findings, but its treatment is still controversial. We here present a representative case report of radiotherapy for ECD.