Tratamiento del dolor neuropático por desaferentización mediante lesión DREZ, resultados a largo plaz / Treatment of neuropathic deafferentation pain using DREZ lesions; long-term results

Introducción: El dolor por desaferentización secundario a lesiones medulares, avulsión del plexo braquial y otras lesiones de nervios periféricos, es a menudo refractario a tratamientos convencionales. Este trabajo evalúa la eficacia a largo plazo de la cirugía de lesión DREZ (Dorsal Root Entry Zone) en diversos síndromes de dolor neuropático por desaferentización. Pacientes y métodos: Se presenta una serie de 18 pacientes con dolor refractario por desaferentización tratados mediante lesión DREZ con radiofrecuencia. La eficacia inmediata y a largo plazo se valoró mediante la escala visual analógica (EVA) preoperatoria y postoperatoria, la valoración subjetiva del paciente, la reincorporación laboral y la reducción de la medicación analgésica. Resultados: El dolor en la EVA disminuyó significativamente de 8,6 antes de la cirugía a 2,9 de media al alta (p<0,001). A largo plazo, con un seguimiento medio de 28 meses (6-108), el dolor se mantuvo en 4,7 en la EVA (p<0,002). El porcentaje de pacientes con un alivio moderado a excelente del dolor fue de 77% al alta y 68% a largo plazo. El 67% de los pacientes redujo la medicación analgésica y el 28% se reincorporó al trabajo. Los mejores resultados se obtuvieron en los pacientes con avulsión del plexo braquial con una mejoría significativa del dolor a largo plazo en todos los casos. Conclusiones: La lesión DREZ por radiofrecuencia es un tratamiento eficaz y seguro para el dolor neuropático refractario por desaferentización (AU)

Introduction: Deafferentation pain secondary to spinal cord injury, brachial plexus avulsion and other peripheral nerve injuries is often refractory to conventional treatments. This study evaluates the long-term efficacy of spinal DREZ (Dorsal Root Entry Zone) lesions for the treatment of neuropathic pain syndromes caused by deafferentation.Patients and methodsA series of 18 patients with refractory deafferentation pain treated with radiofrequency DREZ lesions is presented. The immediate and long-term efficacy was measured with the Visual Analogue Scale (VAS) before and after treatment, the patient's subjective evaluation, the percentage of patients returning to work and the reduction in pain medication. Results: Pain on the VAS significantly decreased from 8.6 preoperatively to 2.9 (p<.001) at discharge. Over the long-term, with a mean follow-up of 28 months (6-108) pain remained at 4.7 on the VAS (p<0.002). The percentage of patients with moderate to excellent pain relief was 77% at discharge and 68% at the last follow-up. Pain medication was reduced in 67% of the patients and 28% returned to work. The best results were obtained in patients with brachial plexus avulsion, with a significant long-term pain relief in all cases. Conclusions:Radiofrequency DREZ lesion is an effective and safe treatment for refractory neuropathic pain caused by deafferentation (AU)

Treatment of neuropathic deafferentation pain using DREZ lesions; long-term results.

INTRODUCTION: Deafferentation pain secondary to spinal cord injury, brachial plexus avulsion and other peripheral nerve injuries is often refractory to conventional treatments. This study evaluates the long-term efficacy of spinal DREZ (Dorsal Root Entry Zone) lesions for the treatment of neuropathic pain syndromes caused by deafferentation. PATIENTS AND METHODS: A series of 18 patients with refractory deafferentation pain treated with radiofrequency DREZ lesions is presented. The immediate and long-term efficacy was measured with the Visual Analogue Scale (VAS) before and after treatment, the patient's subjective evaluation, the percentage of patients returning to work and the reduction in pain medication. RESULTS: Pain on the VAS significantly decreased from 8.6 preoperatively to 2.9 (p<.001) at discharge. Over the long-term, with a mean follow-up of 28 months (6-108) pain remained at 4.7 on the VAS (p<0.002). The percentage of patients with moderate to excellent pain relief was 77% at discharge and 68% at the last follow-up. Pain medication was reduced in 67% of the patients and 28% returned to work. The best results were obtained in patients with brachial plexus avulsion, with a significant long-term pain relief in all cases. CONCLUSIONS: Radiofrequency DREZ lesion is an effective and safe treatment for refractory neuropathic pain caused by deafferentation.

[Management of recurrent trigeminal neuralgia after failed microvascular decompression]. / Manejo de la recidiva de la neuralgia del trigémino tras descompresión microvascular.

OBJECTIVE: To evaluate the surgical management of patients with trigeminal neuralgia after failed microvascular decompression. PATIENTS AND METHODS: Between 1993 and 2002, exploration of the posterior fossa was performed in 60 patients with trigeminal neuralgia. Records were analyzed retrospectively for those patients who needed another surgical procedure due to recurrence of pain, describing which procedure was performed, postoperative results and complications, and also the intraoperative findings when posterior fossa reexploration was realized. RESULTS: Eighteen patients had trigeminal neuralgia recurrence requiring a new surgical intervention, that consisted in a fossa posterior reexploration in nine patients and percutaneous radiofrequency termal rhizotomy in the other nine patients. Among the repeat operations, there was negative exploration in 7 patients (77%), and a partial sensory rhizotomy was performed. Most of thermocoagulations (5/9) were performed in old patients or patients with anestesic contraindication for the fossa posterior reexploration. CONCLUSION: Fossa posterior reexploration is an effective and safe surgical attitude in the treatment of recurrent trigeminal neuralgia after failed microvascular decompression. Partial sensory rhizotomy is recommended when the reexploration is negative.

[Ruptured aneurysms presenting with subdural hematoma: management without angiography]. / Hematomas subdurales de causa aneurismática: estrategia terapéutica sin angiografía diagnóstica.

INTRODUCTION: Ruptured aneurysms on rare occasions cause subdural hematomas as described in literature. Sudden deterioration and coma is a common feature in those patients and a emergent surgical attitude is prompt required, even without confirmation with angiography. CASE REPORTS: We described three cases with acute subdural hematomas and little or no subarachnoid hemorrhage caused by ruptured aneurisms who presented with rapid neurologic deterioration. Urgent craniotomy and evacuation of the hematoma was performed without previous angiography in the three patients. In two patients the aneurysm was found during surgical exploration and subsequently clipped; in the remaining patient the aneurysm was embolized postoperatively. CONCLUSIONS: The occurrence of a subdural hematoma caused by the rupture of an intracranial aneurysm must be suspected in spontaneous subdural hematomas, especially in association with disproportioned conscious deterioration. All the three patients we report debuted with sudden conscious deterioration. If a ruptured aneurysm causing subdural hematoma is suspected, early surgical intervention is required even if angiography is not available. Severe neurological deficit and uncal herniation might still be reversible if provided decompression can be carried out in promptly. Angiography availability should not postpone surgery. Aneurysm presence should be ruled out whether by surgical exploration or by delayed angiography. Posterior communicating aneurysm are related to formation of subdural hematoma.

Hematomas subdurales de causa aneurismática: estrategia terapéutica sin angiografía diagnóstica / Ruptured aneurysms presenting with subdural hematoma: management without angiography

Introducción. Ocasionalmente, la ruptura de un aneurisma puede producir hemorragias subdurales, tal como se describe en la literatura. Es característica en estos pacientes la presencia de un deterioro neurológico rápido y coma, lo que obliga a realizar una intervención quirúrgica urgente, incluso en ausencia de confirmación angiográfica de la causa de la hemorragia. Casos clínicos. Describimos tres pacientes con hematomas subdurales (HSD) agudos en ausencia de hemorragia subaracnoidea, causados por ruptura de aneurismas y que se presentaron con deterioro neurológico rápido y signos de herniación uncal. En los tres pacientes se realizó una craneotomía urgente con evacuación del hematoma, sin angiografía previa. En dos pacientes se localizó intraoperatoriamente el aneurisma responsable de la hemorragia y se realizó el clipaje del mismo, mientras que en otro paciente el aneurisma se embolizó de forma posquirúrgica. Conclusiones. En los HSD espontáneos debe sospecharse un posible origen aneurismático, especialmente cuando se asocian a un deterioro desproporcionado del nivel de conciencia para el grado de compresión. Ante la sospecha de la ruptura de un aneurisma, es necesario intervenir quirúrgicamente, incluso si no se dispone de forma rápida de la posibilidad de realizar una arteriografía cerebral urgente. Los déficit neurológicos graves y los signos de herniación uncal pueden revertir si se evacua urgentemente el hematoma y se resuelve el efecto compresivo. La localización y el subsiguiente tratamiento del aneurisma pueden realizarse mediante la exploración quirúrgica de los vasos del polígono de Willis o por angiografía cerebral posoperatoria. Los aneurismas de la arteria comunicante posterior se relacionan con la formación de HSD (AU)

Introduction. Ruptured aneurysms on rare occasions cause subdural hematomas as described in literature. Sudden deterioration and coma is a common feature in those patients and a emergent surgical attitude is prompt required, even without confirmation with angiography. Case reports. We described three cases with acute subdural hematomas and little or no subarachnoid hemorrhage caused by ruptured aneurisms who presented with rapid neurologic deterioration. Urgent craniotomy and evacuation of the hematoma was performed without previous angiography in the three patients. In two patients the aneurysm was found during surgical exploration and subsequently clipped; in the remaining patient the aneurysm was embolized postoperatively. Conclusions. The occurrence of a subdural hematoma caused by the rupture of an intracranial aneurysm must be suspected in spontaneous subdural hematomas, especially in association with disproportioned conscious deterioration. All the three patients we report debuted with sudden conscious deterioration. If a ruptured aneurysm causing subdural hematoma is suspected, early surgical intervention is required even if angiography is not available. Severe neurological deficit and uncal herniation might still be reversible if provided decompression can be carried out in promptly. Angiography availability should not postpone surgery. Aneurysm presence should be ruled out whether by surgical exploration or by delayed angiography. Posterior communicating aneurysm are related to formation of subdural hematoma (AU)

Trigeminal nucleus caudalis dorsal root entry zone radiofrequency thermocoagulation for invalidating facial pain.

INTRODUCTION: Facial pain syndromes occasionally result in desperate clinical settings completely unresponsive to any known therapy. Trigeminal nucleus caudalis dorsal root entry zone (DREZ) lesion is reported to be of benefit in such cases. In 1982 Nashold performed the first DREZ caudalis lesion in a patient with anaesthesia dolorosa. PATIENTS AND METHODS: From 1994 to 2002 we have performed six DREZ caudalis lesions on five patients with extremely invalidating facial pain resistant to multiple pharmacological and surgical therapies. Pain was secondary to previous craniofacial surgery in all but one case. Pain presented as anaesthesia dolorosa or atypical facial pain so severe as to interfere with personal hygiene and even to prevent patients from oral feeding. A midline suboccipital approach was used and radiofrequency lesions (at the trigeminal nucleus caudalis in the cervicomedullary junction) were made at 1-mm intervals, 75 (o)C for 15 seconds each along the ipsilateral posterolateral sulcus from the cervical DREZ up to the obex. RESULTS: Pain relief was complete and permanent in two patients. Three patients experienced significant improvement but pain recurred in two (weeks to a few months after the procedure). No patient's pain was made worse. A patient with persistent postoperative nasolabial pain was re-operated on (improving again but ultimately remaining unchanged). Air venous embolism related to the sitting position (3 patients) during surgery and bradycardia due to manipulation in medulla (2 patients) occurred during some of the procedures without any cardiovascular or neurological repercussion. Postoperative complications included mild and transient ataxia and monoparesia (3 patients). DISCUSSION: Facial pain secondary to craniofacial surgery is known to be among the least responsive to treatment and a true challenge for pain clinicians. Actual indications for this procedure, operative technical details and the results of our series compared to previous reports are reviewed. CONCLUSION: Trigeminal nucleus caudalis radiofrequency thermocoagulation is an effective neurosurgical procedure for the treatment of chronically debilitating and desperate facial pain syndromes with acceptable morbidity.

Termocoagulación por radiofrecuencia de la zona de entrada de la raíz dorsal del nucleus caudalis trigeminal en dolor facial invalidante / Trigeminal nucleus caudalis dorsal root entry zone radiofrequency thermocoagulation for invalidating facial pain

Introducción. Los síndromes dolorosos faciales crónicos pueden generar situaciones clínicas desesperadas dada su falta de respuesta a múltiples tratamientos. Algunos de estos pacientes parecen beneficiarse de la lesión del nucleus caudalis trigeminal en la zona de entrada de la raíz dorsal (DREZ) de la unión bulbo-medular. Nashold y cols realizaron en 1982 el primer procedimiento DREZ caudalis en una paciente con anestesia dolorosa. Pacientes y métodos. En el período 1994-2002 hemos realizado seis lesiones DREZ caudalis en cinco pacientes con dolor facial extremadamente invalidante y rebelde a múltiples tratamientos farmacológicos y quirúrgicos. El dolor fue secundario a cirugía craneofacial previa en cuatro casos. La forma de presentación del dolor fue de anestesia dolorosa o algia facial atípica tan graves como para interferir o impedir la alimentación e incluso la higiene. Se emplearon abordajes suboccipitales en línea media y se realizaron lesiones mediante radiofrecuencia en la unión bulbomedular a intervalos de 1 mm, a 75°C, durante 15 segundos a lo largo del surco posterolateral ipsilateral al dolor. Resultados. Dos pacientes experimentaron alivio completo y permanente del dolor. Tres pacientes mejoraron de forma significativa pero sólo uno de ellos de forma duradera. Ningún paciente empeoró con el procedimiento. Un paciente fue reoperado por persistencia de dolor a nivel nasogeniano. Embolismo aéreo relacionado con la posición sentada (3 pacientes) y bradicardia (2 pacientes) por manipulación bulbar ocurrieron durante la cirugía, sin repercusión neurológica ni hemodinámica. Las complicaciones postoperatorias fueron ataxia y monoparesia leves y autolimitadas (3 pacientes).Discusión. El dolor facial neuropático secundario a cirugía craneofacial es de los más difíciles de manejar y representa un verdadero reto para los médicos que tratan dolor crónico. En este trabajo se revisan las indicaciones actuales del procedimiento, los detalles técnicos y los resultados de la serie frente a la literatura. Conclusión. La termocoagulación por radiofrecuencia del nucleus caudalis trigeminal es un procedimiento neuroquirúrgico efectivo, con una morbilidad aceptable, para el tratamiento de síndromes dolorosos faciales crónicos muy debilitantes (AU)

Brain ganglioglioma with large extension to subarachnoid space.

A case of temporal ganglioglioma with large leptomeningeal growth is presented. This unusual spread has not been previously described in these tumors.

Intratumoural and intraventricular human lymphoblastoid alpha interferon (HLBI) for treatment of glioblastoma multiforme.

A series of ten patients with glioblastoma multiforme were treated with human lymphoblastoid alpha interferon (HLBI) as a single therapy after partial surgical resection (5 cases) or stereotactic biopsy (5 cases). Treatment consisted of intratumoural administration of HLBI (15 x 16(6) IU) every month (8 cases) or in the continuous intraventricular infusion of HLBI (1.8 x 10(6) IU daily) in 15-day cycles (2 cases) until rapid growing of the tumour and important neurological deterioration. The treatments were well tolerated. As judged from data from control groups, the patients demonstrated no improvement in mean survival time and follow-up CT-scan showed rapid progression of the tumour in all cases.