Download Message from Chairman - Neurosurgery On-Call

Pain
NEWS
A A N S / C N S
Editor:
Kim J. Burchiel, MD, FACS
Assistant Editor:
Shirley McCartney, PhD
In This Issue…
3
Peripheral Nerve Stimulation for the Treatment
of Occipital Neuralgia
5
Of Interest at the 49th
Annual CNS Meeting
6
SCS for Refractory Angina
Pectoris
7
Pain Patterns in Chronic
Low Back Pain compared
to 3D Assessment
8
Laminectomy v Percutaneous Electrode Placement in
27 Patients Undergoing
SCS for Intractable Pain
10
Faces of Pain: The Expression of Anguish by
Classical Roman Masters of
Marble and Oil
11
A Prospective, Randomized, Controlled Clinical
Trial Comparing Intrathecal Narcotic Analgesia to
Standard Medical Management in Benign Pain
13
About the Section on Pain
14
Calendar of Events
S e c t i o n
o n
October 1999
Vol.6 Issue 2
P a i n
Message from Chairman
Kenneth A. Follett, MD, PhD
Transition and
Opportunity
This is a time of
transition and
opportunity within
the AANS/CNS
Joint Section on
Pain. Several new
officers and council
members were
Kenneth A. Follett, MD, PhD
elected during the
Section business meeting in April. Dr. Jeffrey
Brown has completed his term as Section
Chairman. On behalf of members of the
Section, I thank him for the guidance and
contributions he provided the Section during
his term. In particular, I acknowledge his
accomplishments in producing the Section on
Pain CD-ROM publication, “Interventional
Therapies in Neurosurgical Pain Management 1999.” In this electronic publication,
Dr. Brown and his coeditor, Christopher
Chittum, have assembled twenty audio/video
lectures from the recent Section on Pain
satellite symposium on pain management, in
which some of the nation’s leading experts in
the field of neurosurgical pain management
discuss the most current techniques for the
treatment of pain. The CD-ROM is available
for purchase through the Section on Pain and
the AANS. The first edition of this CDROM, produced by Drs. Brown and Chittum
following the 1998 satellite symposium on
neurosurgical pain management, received
outstanding reviews. It has generated substantial interest as an educational tool, not only
within neurosurgery but in other disciplines
as well, and has been recognized as a prototype for future electronic publications. Drs.
Brown and Chittum are to be commended for
their tremendous effort in producing this
novel educational resource.
It is with pleasure that I assume the Chairmanship of the AANS/CNS Joint Section on
Pain. Jaimie Henderson (St. Louis, MO) has
been elected vice-chairman. New Executive
Council members include John Gorecki
(Durham, NC), John Oakley (Seattle, WA), and
Oren Sagher (Ann Arbor, MI). Michael Munz
(Philadelphia, PA) has been selected as the new
Continuing Medical Education Liaison for
the Section on Pain. Drs. Giancarlo Barolat
and Richard Weiner have completed terms on
the Executive Council. We appreciate the
contributions each of these individuals has
made to the Section and look forward to their
on-going participation in Section activities.
The Section on Pain is relevant to all
neurosurgeons. Pain is the most common
reason that people seek medical attention.
Most neurosurgeons do not consider themselves to be “pain doctors,” and pain, per se, is
not a disorder that most neurosurgeons want
to treat; yet much of what we do as neurosurgeons is pain management because so many
of the disorders we treat present as pain.
Neurosurgeons who don’t think of themselves
as “pain doctors” should think for a moment
about their own practices. How many of your
patients present with a complaint of pain?
How many of your patients have pain after
surgery? How many of your patients take
medications for pain relief? How do you
manage patients with pain when surgery isn’t
the answer?
Because pain cuts across many areas of
neurosurgery, the Section on Pain should be a
resource for all neurosurgeons. The Section
has worked toward accomplishing this
continued on page 2
Chairman’s message
continued from front page
purpose through its educational projects and service. At past
AANS and CNS meetings, the Section on Pain has sponsored
symposia that provide information of fundamental importance
to practicing neurosurgeons, such as management of failed
back surgery syndrome, and reviews of medical and legal issues
pertaining to long-term opioid use for chronic pain. At the
most recent AANS annual meeting, members of the Section
on Pain directed a practical course pertaining to minimallyinvasive procedures for management of spinal pain syndromes.
This course had broad appeal to neurosurgeons and generated
an overwhelmingly positive response from participants. The
Section’s satellite symposium on pain management, held in
conjunction with the 1999 annual AANS meeting, was offered
to all neurosurgeons interested in expanding their knowledge
about neurosurgical pain management and also received very
positive evaluations by participants. We will continue working
to meet the needs of neurosurgeons in upcoming symposia at
the CNS 1999 in Boston. Scheduled symposia include a
Consultant’s Corner for difficult pain management problems,
featuring participants from a variety of neurosurgical disciplines, and sessions on postoperative pain control, including
assessment of pain in the pediatric population, pain control in
the substance abuse patient, and new approaches to postoperative pain management in the lumbar spine surgery patient.
This is a time of transition within the Section as new officers
and council members assume their roles. This is also a time of
opportunity. As Chairman, I would like the Section on Pain to
be a section that works for all neurosurgeons. To accomplish
this goal, the Section needs the participation of all neurosurgeons, including those who do not consider themselves to be
“pain doctors.” I encourage those of you who are already
members of the Pain Section to be active within the Section.
Those of you who are not members should consider joining
the Section to help us develop programs that will be beneficial
to you. Feel free to communicate with Section leaders regarding issues of concern about pain and its treatment, and to let
us know how the Section on Pain can best serve as a resource
to you and your practice. I can be contacted at [email protected] or 319-356-2771. I welcome your comments and suggestions about Section activities and encourage
your active participation in the Section on Pain.
CD-ROM:
"Interventional Therapies in
the Neurosurgical
Treatment of Pain"
The Joint Section on Pain has produced a CDROM entitled "Interventional Therapies in Neurosurgical Pain Management". The CD is based on the
highly successful and well-attended Satellite Symposium held preceding the AANS Annual meeting in
1998. Each of the twenty-five lectures delivered at the
symposium can be viewed. Speakers' slides are
digitized and synchronized to the audiotaped presentations. Slides can be enlarged for clearer study. One
may take as much time as needed to understand them
best. The lectures can be easily reviewed on any
computer with a CD-ROM drive. The CD should
serve as an excellent curriculum for the neurosurgical
treatment of pain for neurosurgeons with a general
practice, for those with special interest in pain neurosurgery and for residents in every training program in
neurosurgery. It can be purchased through the Joint
Section on Pain and the AANS and can also be order
on line at
http://www.aans.org/sections/pain/teaser.html.
A sample presentation, Chronic Pain Types
and Treatment Algorithms by Robert M. Levy, will
soon be available as an example of the CD-ROM
content.
Colleagues:
An application for membership in the Joint Section
on Pain can be found on page 15 of this issue or at
http://www.ohsu.edu/som-neurosurgery/news/
membershipapp.html. We encourage you to
forward this application to colleagues with interests in
pain management.
The goals of the Section are to assure the highest
quality of medical care for the management of patients
with pain problems and to assure an appropriate
Kenneth A. Follett MD, PhD
University of Iowa
socioeconomic and political climate conducive to the
effective and efficient delivery of medical care to
patients with pain problems.
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PAIN SECTION NEWSLETTER
Minimally invasive peripheral nerve stimulation for the treatment of occipital neuralgia
Michael Oh, MD and Donald Whiting, MD, FACS
Department of Neurosurgery Allegheny General Hospital
Pittsburgh, PA
INTRODUCTION
Occipital neuralgia (ON) is a chronic pain syndrome characterized by lancinating pain extending from the suboccipital
region to the cranial vertex.1,9,16 The etiology of occipital
neuralgia includes trauma, fibrositis, myositis, fracture of the
atlas and compression of the C-2 nerve root, C1-2 arthrosis
syndrome, alantoaxial lateral mass osteoarthritis, hypertrophic
cervical pachymeningitis, cervical cord tumor, Chiari malformation, and a variety of medical conditions.1,4,6,8,10,16,22,23
Treatment of ON usually involves the use of chronic opioids
and neuromodulators,1,4 but may also include transcutaneous
electrical nerve stimulation, external orthosis, steroid injection, nerve blocks, neurolysis,15,22 neurectomy,17 rhizotomy and
ganglionotomy,7,10,19,24 C1-C2 fusion,11 and radiofrequency
ablation.3
Peripheral nerve stimulation (PNS) has been used for neuropathic
pain since 196525 and has been proposed as a treatment for ON.5,1214,18,20,21,25,26
We describe the use of a laminectomy-type lead (Resume
IITM ) for the treatment of chronic occipital neuralgia.
CASE HISTORY
The patient is a 44 year old male who suffered from eight
years of occipital neuralgia secondary to direct trauma to the
occipital region. He had not lost consciousness nor did he
suffer any cervical injury. He reported headaches 8-10 times
per day, which were refractory to medical treatment under the
guidance of a multidisciplinary pain clinic. Prior occipital
nerve injections provided transient relief of his pain. Neurologic examination was normal as were preoperative radiographic studies.
Components of Occipital Nerve Stimulator
Figure 1— Quadripolar ResumeII TM lead
PROCEDURE
A two-stage operation for the placement of a RESUME IITM lead
and ITREL 3TM generator was performed (Figure 1 and 2, respectively). In the first stage, a MedtronicTM peripheral nerve stimulator
with subcutaneous tunneling was performed under intravenous
sedation and local anesthesia (See Figure 3 on page 4).
Intraoperative testing of the peripheral nerve stimulator
provided complete relief of symptoms. The lead was connected to the external generator and the patient had a 24 hour
home trial stimulation with excellent relief of his pain. The
following day, the stimulator was internalized and placed in a
subcutaneous pocket in the left infraclavicular region using
intravenous sedation and local anesthesia. The patient was
discharged to home the same day.
RESULTS
The occipital nerve stimulator was initially set with the
following parameters: electrode 1 as positive and electrode 2 as
negative, amplitude 8.0 volts, pulse width 330 microseconds,
rate 85 pulses/sec. At 1 month follow-up, he reported 100%
relief of pain without paresthesia using the stimulator 78% of
the time and the amplitude limit was lowered to 5.8 volts At
his 6 month follow-up, his stimulator settings were: electrode
1-positive and 2-negative; pulse width-300 msec; rate-85
p.p.s.; amplitude limit-2.5 volts; and cycling mode- on-15 sec,
off-40 sec, 4-sec soft start. The patient continued to have
100% relief of pain symptoms using the stimulator 90% of the
time. He reported no paresthesias and continued to be off of
all pain medications, except a nonsteroidal which he was
taking for arthritic knee pain.
continued on page 4
Figure 2— ITREL 3 TM Generator.
(Courtesy of Medtronic, Inc., Minneapolis, MN)
PAIN SECTION NEWSLETTER
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October 1999
3
continued from page 3
DISCUSSION
There are many reports on the effective treatment of peripheral neuropathies with peripheral nerve simulation.5,1214,18,20,21,25,26
In a recent review,14 peripheral nerve stimulation
for painful neuropathies of nerve injury origin was reported to
have good effect in 82.5%, whereas the response rate in other
kinds of pain were 25-50%.
Only a handful of reports, however, describe the use of
peripheral nerve stimulators for the treatment of occipital
neuralgia.20,21,26 Waisbrod et al.,26 reported on one patient who
suffered from greater occipital neuralgia and had a “very good
result” from PNS. Picaza et al.20,21 reported on six patients
with ON treated with PNS. Two patients had excellent results,
one had a good outcome, two had poor outcomes, and one
case was reported as a failure.
Our patient initially required high intensity stimulation for
pain suppression. However, the amplitude limit was decreased
to 8.5 v, 5.0 v, 3.5 v and 2.5 v at the 2 week, 2 month, 4 month,
and 6 month visits, respectively. At his 6-month settings, our
patient has an expected battery life of approximately 4 years.
Although late recurrence of pain following PNS is reported to
occur 12-24 months after implantation,21 based on the consistently decreasing voltage required in our patient, we expect that
he will have continued pain relief throughout the life of the
battery.
The technique described in this paper is a simple and
effective procedure for the treatment of ON. It is minimally
invasive, reversible, adaptable, and preserves the option for
ablative procedures. In contrast, cuff electrodes involves
extensive dissection of the nerve with the possibility of nerve
injury, neuroma, and compression from scar formation, as well
as a longer hospital stay. More invasive procedures, such as
dorsal nerve root section, involves risk of injury to vital neural
and vascular structures, and requires 3-4 days of hospitalization, including one day in the intensive care unit10. Adaptability of PNS allows therapy to be suited to the individual and
adjusted for side effects.
Placement of Occipital Nerve Stimulator
Figure 3— A 1 cm vertical incision was made 1 cm
medial to the mastoid body, just inferior to the
nuchal line. The electrode was then passed through
a subcutaneous tunnel extending to the midline
above the trapezius fascia.
REFERENCES
1. Anthony M: Headache and the greater occipital nerve. Clinical Neurology and Neurosurgery 94:297-301, 1992
2. Bogduk N: The clinical anatomy of the cervical dorsal rami. Spine 7:319-30, 1982
3. Blume HG: Radiofrequency denaturation in occipital pain: a new approach in 114 cases.
Adv. Pain Res. Ther. 7:691-8, 1976
4. Brown CR: Occipital neuralgia: symptoms, diagnosis, and treatment. Practical Periodontics & Aesthetic Dentistry
8:557-558, 1996
5. Campbell JN, Long DM: Peripheral nerve stimulation in the treatment of intractable pain. J Neurosurg 45:692-9, 1976
6. Clavel M, Clavel P: Occipital neuralgia secondary to exuberant callus formation: case report.
J Neurosurg 85:1170-1, 1996
7. Dubuisson D: Treatment of occipital neuralgia by partial posterior rhizotomy at C1-3. J Neurosurg 82:581-586, 1995
8. Ehni G, Benner B: Occipital neuralgia and the C1-2 arthrosis syndrome. J Neurosurg 61:961-965, 1984
9. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for
headache disorder, cranial neuralgias and facial pain. Cephalgia 8(Suppl 7): 10-73, 1988
10. Horowitz MB, Yonas H: Occipital neuralgia treated by intradural dorsal nerve root sectioning.
continued on page 5
Cephalagia 13:354-60, 1993
4
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PAIN SECTION NEWSLETTER
continued from page 4
11. Joseph B, Kumar B: Gallie’s fusion for alantoaxial arthrosis with occipital neuralgia. Spine 19:454-5, 1994
12. Law JD, Swett J, Kirsch WWM: Retrospective analysis of 22 patients with chronic pain treated by peripheral nerve
stimulation. J Neurosurg 52:482-5, 1980
13. Long DM: Electrical stimulation for relief of pain of chronic nerve injury. J Neurosurg 39:718-729, 1973
14. Long DM: The current status of electrical stimulation of the nervous system for the relief of chronic pain. Surgical
Neurol 49:142-44, 1998
15. Magnusson T, Ragnarsson T, Bjornsson A: Occipital nerve release in patients with whiplash trauma and occipital
neuralgia. Headache 36:32-6, 1996
16. Merskey H. Classification of chronic pain. Pain (Suppl3): 57, 1986
17. Murphy JP: Occipital neurectomy in the treatment of headache: Results in 30 cases. Maryland Med J 18:62-66, 1969
18. Nashold BS Jr, Goldner JL, Mullen JB, Bright DS: Long-term pain control by direct peripheral-nerve stimulation. J Bone
Joint Surg (AM) 64-A:1-10, 1982
19. Onofrio BM, Campa HK: Evaluation of rhizotomy: Review of 12 years’ experience. J Neurosurg 36:751-5, 1972
20. Picaza JA, Hunter SE, Cannon BW: Pain suppression: chronic effects: Neurosurg 1:226-227, 1977
21. Picaza JA, Hunter SE, Cannon BW: Pain suppression by peripheral nerve stimulation: Chronic effects of implanted
22. Poletti CE and Sweet WH: Entrapment of the C2 root and ganglion by the alanto-epistrophic ligament: clinical syndrome
and surgical anatomy. Neurosurgery 27:228-291, 1990
23. Star MJ, Curt JG, and Thorne RP: Alantoaxial lateral mass osteoarthritis: A frequently overlooked cause of severe
occipitocervical pain. Spine 17:71-6, 1992
24. Steechison MT, Mullin BB: Surgical treatment of greater occipital neuralgia: an appraisal of strategies. Acta Neurochir
131:236-40, 1994
25. Sweet WH. Control of pain by direct electrical stimulation of peripheral nerves. Clin Neurosurg 23:103-11, 1976
26. Waisbrod H, Panhans C, Hansen D, Gerbershagen HU: Direct nerve stimulation for painful peripheral neuropathies.
J Bone Joint Surg (Br) 67:470-472, 1985 devices. Appl Neurophsiol 40: 223-234, 1977/78
Of Interest at the CNS
49th Annual Meeting
October 30–November 4, 1999 Boston
Learning Objective: At the conclusion of this session
participants will be able to describe methods of assessing and
treating post operative pain in patients undergoing neurosurgical procedures.
Section on Pain I
Consultants Corner on Pain
2:00-5:30 PM
Tuesday, 5 October 1999
2:00-2:20 PM
2:20-2:30 PM
Learning Objective: At the conclusion of this session
participants will be able to compare and contrast different
strategies for management of pain.
2:40-2:50 PM
2:50-3:30 PM
3:30-4:00 PM
4:00-5:30 PM
2:00-2:50 PM
2:50-3:30 PM
3:30-4:00 PM
4:00-5:30 PM
Consultant’s Corner
Oral Posters
Coffee Break with Exhibitors
Open Papers 792-801
Section on Pain II
Postoperative Pain Management in the Neurosurgical
patient
2:00-5:30 PM
Wednesday, 6 October 1999
2:30-2:40 PM
Assessing Pain in Pediatric patients
Pain Management Following Spine
Surgery: Epidurally-applied Analgesics
Pain Management for the Substance Abuse
Patient
Discussion
Oral Posters
Coffee Break with Exhibitors
Open Papers 842-851
Section on Pain I
Tuesday, 5 October 1999,
4:00-5:30 PM Open Papers 792-801
Ronald Tasker Award
792. Motor Cortex Stimulation for Chronic Neurpathic
Pain. Literature Review and Results from a
Pro-spective Audit. Nikki Maartens, Dawn Carroll,
Tipu Aziz, Carole Joint.
PAIN SECTION NEWSLETTER
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October 1999
5
Spinal Cord Stimulation for refractory
angina pectoris
Peter A. Pahapill, MD, PhD, FRCS(C)
University of Toronto
Canada
In spite of advances in revascularization techniques,
pharmacological therapy and risk factor modification,
there remains a subset of the coronary population with
refractory angina pectoris (RAP). Patients with refractory
angina pectoris represent an expanding population. It is
estimated that in the United States 30,000 such patients
exist; about 2-3 per cardiologist. Most of these patients
have had previous multiple bypass and angioplasty procedures. Their continued angina despite these interventions, and frequent emergency room visits and hospital
admissions are often due to small areas of intense ischemia
arrhythmias. These patients are generally somatically and
socially disabled with a poor quality of life and significant
limitations in activities of daily living.
Standard spinal cord stimulation (SCS) techniques have
been used extensively outside North America for the
treatment of RAP since the 1980’s. The first publication on
SCS for angina appeared in 1987. Presently, the number
one indication for SCS in Europe is RAP; the second being
peripheral vascular disease. It has provided angina patients
with increased exercise capacity and time to onset of angina
with reduced ST-segment depression, myocardial ischemia
and intake of nitrates. Extensive research in Europe has
eliminated concerns regarding the possible danger of
masking myocardial infarction with SCS. Over 1000 cases
of SCS for RAP have been performed in Europe over the
last two decades.
We have followed two patients (ages 53 and 74) for over
one year after implantation of their SCS system for RAP.
Both patients had undergone previous multiple revascularization procedures and continued to experience daily
angina with frequent emergency room visits prior to
implantation. One patient has a cardiac pacemaker.
Using standard percutaneous techniques under local
anesthesia, quadripolar electrodes were implanted approaching the C7-T1 epidural space through the T3-T4
level. Intraoperative test stimulations were performed to
ensure stimulation-induced parasthesias in the area of the
patients’ angina prior to implantation of an ITREL-III
pulse generator in each patient. Because of its high
success rate, the major European centers utilizing these
techniques for RAP have abandoned the use of extended
trial periods of stimulation through externalized leads
prior to final implantation of the SCS system.
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October 1999
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PAIN SECTION NEWSLETTER
Implantation under local anesthesia is well tolerated
with a minimum hospital stay in this subgroup of patients with known increased surgical risks. In our two
patients the number of angina attacks has been reduced
by 70%; the duration of attacks by 60%; the intake of
nitrates by 90%; and the emergency room visits have
been reduced from 1.5 visits per week to zero. In
general, stimulation parameters are initially individualized, but then require only minimal adjustments. As long
as certain guidelines are followed, SCS can be offered to
RAP patients with cardiac pacemakers. Best results are
obtained with a multidisciplinary team approach involving both the cardiologist and the neurosurgeon.
Although dramatic improvements in quality of life
occur with SCS without concealing myocardial infarction, its mechanism of action is unclear. Consideration
has been given to a descending dorsal column influence,
with sympathetic modulation and stimulation-induced
alterations in neurohormones receiving attention as
possible contributors. Pain alleviation with SCS is
fundamental as it relieves the symptoms that further
aggravate and contribute to the vicious pain cycle leading
to worsening myocardial ischemia and thus “breaks the
chain of pain”.
Increasing numbers of angina patients with their
associated escalating costs to the health care system has
stimulated interest in alternate approaches of management. SCS for RAP is a safe and simple technique that
has enjoyed excellent results in the majority of patients
with minimal cost. As more randomized control studies
are published (1) and results underlying the significant
cost benefits of these techniques to health care systems
become more available, it is probable that the use of SCS
in patients with RAP will increase in North America in
the new millennium.
1. Mannheimer C., Eliasson T., Augusinsson L.E., et.
al. Electrical stimulation versus coronary artery
bypass surgery in severe
angina pectoris. The
ESBY study. Circulation 97: 1157-1163, 1998
Pain Patterns in Chronic Low Back
Pain compared to 3D Assessment
Fernando G. Diaz, MD, PhD and Hun K. Park, MD, PhD
Department of Neurosurgery/Wayne State University
Detroit, MI
In studies of the incidence and prevalence of low back pain
(LBP), it has been identified as the second leading cause of
restricted activity days and work absenteeism. Data from the
National Center for Health Statistics indicates that chronic
disability resulting from LBP affected 4.8 million Americans.
Acute injury to the lower back demonstrates the link between a
patient’s perception of pain and tissue injury. The pain after
immediate injury results in guarding of the low back during the
healing process. However, those patients with pain of duration
more than 6 months develop a different perception of their pain
which is not linked to the acute tissue injury. It is generally
accepted that chronic low back pain contributes to the psychological factors manifested as the chronic pain syndrome. These
patients sustain progressive physical and emotional deterioration
resulting in depression, anxiety and decreased physical activity. In
order to understand the patient’s psychosocial dynamics, the
assessment of chronic pain must include information on patient
personality and their perception of the pain.
Pain drawings (PD) have been used clinically to assess the
efficacy of pain management as a complement to verbal pain
descriptions. It is important to understand how reliable the
patient’s description of severity and location of the pain is and
how it responds to the treatment. Therefore, the main objective
of the study was to delineate the reliability of PD with concurrent
psychophysical measurement in assessing spatial anatomical pain
distribution. We compared simultaneously pre and posttreatment PD patterns of chronic low back pain with multidimen-
sional pain scale (MPS) using an interactive computer
program.
Patients with chronic low back pain (16 patients, mean
duration of pain 43 months, 9 male and 7 female) without
organic brain dysfunction were evaluated at the clinic. Patients
were introduced to MPS system for the first time. Then the
patients were asked to assign values to the pain descriptions
presented serially on computer. Each office visit, patients record
thier status in the MPS system, the physician can then analyse the
pain rating index based on a geometric calculation. Pain drawing
data was analyzed for trunk, lower extremities and combination
using a quantification method. Pearson correlation test was
carried out to examine the repeatability for the PD and MPS
parameters.
For short term treatment effect during the office visit, trunk
PD (p<0.01) showed significantly reduced value which was also
found at both intensity and sensory dimensions of the MPS scale
(p<0.02). However, long term evaluation by trunk PD (p<0.02)
did not match with the result of sensory dimension (p>0.17) while
intensity decreased significantly (p<0.03). The correlation
coefficient for pain drawing reliability failed to obtain greater
value over MPS (PD:0.56±0.02, MPS:0.97±0.05). In our study,
the confinement of the PD has been questioned.
In conclusion pain drawing can be an important tool for pain
intensity measurement, yet not for the sensation of pain in
prolonged back pain.
Save These Dates!
Congress of Neurological
Surgeons
Annual Meeting
October 30–November 4, 1999 Boston
American Association of
Neurological
Surgeons
Annual
Meeting
April 8–13, 2000
San Francisco
PAIN SECTION NEWSLETTER
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October 1999
7
Laminectomy v Percutaneous Electrode Placement in 27 Patients Undergoing Spinal Cord Stimulation for Intractable Pain
JC Leveque, BA, Alan T. Villavicencio, MD and John Gorecki, MD
Duke University Medical Center/Neurosurgery
Durham, NC
INTRODUCTION
Increasing numbers of patients are receiving percutaneously
placed electrodes in order to reduce costs and to take
advantage of minimally invasive techniques. Although
percutaneous techniques are associated with several attractive advantages, there is currently no objective evidence
evaluating which electrode systems have better long-term
outcomes. The purpose of this study was to evaluate the
long-term efficacy of spinal cord stimulation (SCS) using
open laminectomy versus percutaneous-styled electrodes.
We reviewed our institutional experience with SCS using
modern electrode systems over the past 6 years. A comparison of outcome using modern percutaneous and laminectomy electrodes is presented.
METHODS
Forty-one patients were identified who underwent SCS at
Duke University Medical Center between December of
1992 and January of 1998. Twenty-four patients (59%) were
male and 17 (41%) were female. All patients were referred
for SCS from a multidisciplinary pain clinic having completed at least 6 months of conservative treatment with
physiotherapy, pain medications and in some cases epidural
injections. Routine psychological evaluation was performed
in all patients prior to treatment.
The majority of patients (59%) were diagnosed with
failed back surgery syndrome (FBSS), followed in number
by complex regional pain syndrome (CRPS) I and II (17%),
neuropathic pain syndromes (10%), stroke (2%), and all
other etiologies (12%).
All patients were screened with a temporary electrode
system in order to establish satisfactory relief of pain before
internalization of a permanent system. Trial stimulation was
performed through the use of a percutaneous catheter-type
electrode (Pisces Quadripolar electrode, Medtronic Corporation, Minneapolis, MN) in 27 patients, and through use
of a laminectomy-type electrode (Resume electrode,
Medtronic Corporation, Minneapolis, MN) in the other 14
patients. Temporary electrodes were tested over a period
ranging from 1 to 14 days. During this testing period, pain
relief and improvements in activity levels were assessed. If
trial stimulation reduced the patient’s pain greater than
50%, the system was internalized and connected to an
implanted subcutaneous pulse generator (ITREL II and III,
Medtronic Corporation, Minneapolis, MN).
After screening 41 patients, 27 (66%) proceeded to
undergo permanent implantation. Following permanent
electrode placement, patients were examined after six
weeks. Follow-up was then conducted at 3 to 6 month
intervals for the first year and annually thereafter. All
patients in this study were followed for a minimum of 6
months. Pre- and postoperative pain levels were based on
the administration of a visual analog scale (VAS) which
rated pain severity from 0 to 10. A modified outcome scale
(Table 1) was used to compare the long-term efficacy of
SCS with other treatment methods reported in the literature such as reoperation in patients with failed back syndrome. There was no significant difference in
demographics between patients who underwent percutaneous electrode placement when compared to patients who
underwent laminectomy (Table 2).
RESULTS
Fifteen of the 27 patients (56%) had permanent thoracic
electrodes placed percutaneously and 12 (44%) via laminectomy. Pre- and postoperative VAS scores are compared in
(Table 3). Visual analog scores decreased an average of 4.6
for patients undergoing SCS placement via laminectomy in
the thoracic region (two-tailed t-test, P<0.0001). Patients
who underwent percutaneous placement of thoracic electrodes had an average decrease in VAS of 3.1 (two-tailed ttest, P<0.001). Table 4 illustrates the long-term results
using a modified outcome scale (defined in Table 2).
One hundred percent of the 12 patients who underwent
laminectomy-styled electrode for SCS in the thoracic region
had >50% pain relief at long-term follow-up; 90% of these
patients did not require the use of narcotics (Table 1). No
patients in this group had what was defined as a poor outcome.
Percutaneous electrodes were associated with a good or
excellent outcome in 53% of patients, fair in another 27% and
poor in 21%. Electrodes placed through laminectomy exhibited significantly greater pain relief at long-term follow-up
when compared to percutaneous electrodes as measured by
the 4 tier outcome grading scale (P = 0.02).
There was no mortality directly associated with surgery.
There were no episodes of spinal cord compression or injury,
bacterial meningitis, or other life-threatening infection.
Overall, 16 of the 27 patients (59%) with permanent electrodes required a total of 36 repositioning procedures. There
were slightly more revisions required per patient in the
continued on next page
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October 1999
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PAIN SECTION NEWSLETTER
continued from page 8
percutaneously placed electrodes: 1.4 revisions per patient
compared with 1.25 revisions per patient in the laminectomy
group. This difference was not statistically significant.
DISCUSSION
Spinal cord stimulation is a safe and useful, minimally
invasive procedure for the treatment of chronic pain.
Recent technical advances in multichannel systems with
have led to improved clinical results and fewer complications. This study contrasted the long-term clinical outcome
of 27 patients who had undergone permanent SCS utilizing
modern multichannel percutaneous or laminectomy-styled
electrodes. The data presented suggests that laminectomystyled electrodes can be expected to achieve approximately
92% good or excellent results and another approximately
8% fair in the reduction of pain. Percutaneous electrodes
were associated with more than 50% good or excellent
results and another 25% fair. Although patients were not
prospectively randomized to each of the two treatment
arms, laminectomy-styled electrodes appear to be associated with improved long-term effectiveness over those
placed percutaneously. These data are currently being used
as a rationale to perform a randomized, controlled study.
Excellent - pain free or very little remaining pain, off
Table 2—Biographical Information in 27 Patients
who Underwent Placement of Permanent
Electrode for SCS
narcotics
Demographic
Laminectomy Percutaneous
Information
Electrodes
Electrodes
Mean Age (range)
50 (39-69)
53 (24-74)
Table 1—Four Tier Long-Term Outcome Scale
Good - residual pain evident, but significantly improved
(>50%) and off narcotics
Fair -
FBSS* (%)
6 (50)
9 (60)
Causalgia (%)
3 (25)
2 (13)
residual pain evident, but significantly improved
Neuropathic (%)
3 (25)
1 (7)
(>50%), using narcotics
Stroke (%)
0 (0)
1 (7)
Other (%)
0 (0)
2 (13)
Poor - less than 50% pain relief
*FBSS - Failed back surgery syndrome
Table 3—Evaluation of Long-term outcome
Using a Visual Analog Scale (VAS) in Patients
Undergoing SCS
Laminectomy Percutaneous
Electrodes
Electrodes
Mean Follow-up (months)
8.6
10.3
Total Patients
12
15
Preoperative VAS (range)
8.4 (7-10)
8.5 (6-10)
Postoperative VAS (range)
3.8 (3-7)
5.4 (0-10)
Table 4—Evaluation of Long-term Outcome
Using a Modified Outcome Scale in Patients
Undergoing SCS
Laminectomy Percutaneous
Electrodes
Electrodes
Mean Follow-up (months)
8.6
10.3
Total Patients
12
15
Excellent (%)
6 (50)
4 (27)
Good (%)
5 (42)
4 (27)
Fair (%)
1 (8)
4 (27)
Poor (%)
0 (0)
3 (20)
PAIN SECTION NEWSLETTER
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October 1999
9
Faces of Pain: The Expression of Anguish by
Classical Roman Masters of Marble and Oil
Jeffrey A. Brown, MD
Medical College of Ohio
Toledo, OH
Classical art depicts the anguish and joy of Man in carefully
hewn marble or painted oil. In this review the emotion of pain
as portrayed in Classical Roman, Renaissance and modern art
through the facial features that connote acute and chronic pain
is evaluated. Perhaps strongest depiction of acute pain is found
in a panel of the painting, Massacre of the Innocents by Matteo
di Giovanni. Painted in 1482, it is located in Siena in the the
beautiful church of Sant’Agostino. Sites such as this were where
the patients, a word that literally translates as “sufferers” came
for solace. Their beauty likely did provide it. It was here that the
statuary and oil paintings of the great artists were kept. Greek
and later Roman sculpture grew out of the traditions of Egyptian culture. The figures depicted by the Egyptians lacked the
immediacy of any emotion.
When the Greeks added an element of emotion, it was in the
twisting of the torso and not in the face (even if one were to be
found) as in the wellknown “Winged Victory
of the Nike of
Samothrace.” Similarly
in the “Venus de Milo,”
the look is for eternity
and the emotion is in the
movement of the torso
not the face. Da Vinci’s
portraiture was later
modeled after this
approach. How do the
eyes and lips of the Mona
Lisa differ from the
power of Van Gogh’s fierce self-portraits?
The earliest portrayal of pain is in a detail of Odysseus using a
fire-sharpened stake to blind the Cyclops Polyphemus, a story
from the Odyssey. The image is on a jar painted in Athens that
dates to about 650 BC and is located in the Eleusis, Museum. It
shows the open eyes and mouth and upward gaze that will typify
this emotion. Another vase painting, from 470 B.C., depicts the
hunter Actaeon being devoured by his hounds for accidentally
viewing the nude Goddess Artemis. This vase is found in the
Boston Museum of Art.
The myth of Laocoon was retold in “The Aeneid” by Virgil.
The priest Laocoon had warned the Trojans of the wooden
horse. His warning however interfered with the ill-fated course
of events, infuriating Apollo who sent sea serpents to destroy
him and his sons. The amazing naturalism displayed in the
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PAIN SECTION NEWSLETTER
modeling is characteristic of the Hellenistic period. It contrasts
the adult body with those of the adolescents and the strained
muscles of the father making almost superhuman effort to free
himself with the relaxing muscles of his collapse.
The image called
“Giant” shows one of
many defeated and dying
Titans (earth giants) from
the Great Altar of Zeus,
from Pergamon, which
represents the mythological battle of the Gods and
Giants. This particular
giant is being bitten by a
huge hunting dog
assisting the goddess
Artemis. The Altar was
built and sculpted about
180-160 BC; the figures
are 2.3 m tall — roughly
twice human scale. The
Altar today is erected
inside the Pergamon museum in Berlin. The Pergamonian art
style includes the design both of the Laocoon and the “Dying
Galatian Soldier,” Greek (and Roman) sculptors were more
interested in representing movement than emotion or pain.
Torture of any kind is rarely shown. The moment before or the
moment after a traumatic event is more likely to be represented.
The whole body was considered part of a portrait or of a
representation of a idea. When distorted facial features were
represented, they were usually part of a genre representation of
“humans” who are neither immortals nor respectable citizens.
Slaves, peasant farmers, foreigners, and the grotesque or
disabled could be shown “realistically” as comic, drunken, lewd,
suffering, or hilarious — because they were not expected to
adhere to social standards of appropriate behavior and appearance.
The painting “Sosias” is on the tondo (inside) of a wine cup
(kylix) and is attributed to the Sosias Painter. It was made about
500/490 BC in Athens and shows the Greek hero Achilles
binding a wound in the arm of his friend Patroklos, a scene
from the Trojan War in Homer’s Iliad. The cup is in the
collection of the Antikensammlung, Berlin. Here is found an
continued on page 12
A Prospective, Randomized, Controlled Clinical Trial
Comparing Intrathecal Narcotic Analgesia to Standard
Medical Management in Benign Pain
John Gorecki, MD, Linda Rubin RN, MPH, Ketan Bulsara, MD and John Pracyk, MD
Duke University Medical Center
Durham, NC
The development of intrathecal narcotic delivery as a treatment
for chronic pain is a milestone in the history of pain management
that is as important as the introduction of long acting narcotics or
anterolateral cordotomy. There is a well-documented literature
supporting the use of intrathecal narcotic analgesia (INA) for pain
associated with cancer. In contrast all of the literature for intrathecal narcotic infusion for benign pain is retrospective. This
retrospective literature only establishes that chronic intrathecal
narcotic delivery reduces pain to some degree in up to 60% of
patients for up to 3 years. In spite of the weak supporting data for
the use of INA for benign pain sales figures show that more
pumps are being sold to treat benign pain than to treat pain due
to cancer (1249 cancer; 2964 benign). For this reason we initiated
the first prospective randomized controlled but not blinded study
of intrathecal narcotic analgesia for chronic benign pain.
The following are results obtained from a preliminary review of
both non-randomized patients from the pilot portion of this
study and patients that have been randomized, 46 patients were
screened, 25 patients undertook trial dosing and 21 patients had
pumps implanted.
The goals of the study are to demonstrate better pain control,
the safety of, and the cost associated with intraspinal morphine.
The study should also determine the incidence of tolerance and
provide supporting data to develop useful patient selection
criteria. The control group is managed in our multidisciplinary
pain clinic and receives all recommended therapies for pain
management including medication, physical methods, psychological intervention, and anatomical surgery, augmentative
surgery, as well as ablative surgery. Follow up is for five years in
order to document long term efficacy, mechanical complications
and tolerance. In order to demonstrate a 25% difference between
the study and control group with a P value of 0.05 the investigation requires 246 study subjects.
Candidates for the study have suffered from pain for more than
6 months and the pain has resulted in a mean pain score of at least
7/10. Furthermore patients are only considered for the study if
corrective surgery such as repeat nerve root decompression or
fusion is not indicated, the pain narcotic responsive and the usual
medical management results in unpleasant side effects. The
patients must be able to read English and be able to travel back
and forth to Duke on a monthly basis. A surprising number of
patients were excluded for psychological reasons (these cases will
be evaluated separately and reported in the future) and a number
of patients could not commit to the follow up necessary for pump
refills.
Pain scores are used as a measure of outcome. The pain score is
recorded by the patient who calls a toll free telephone number
three times per day for the first four days of each month. The
voice mail documents the date and time of the call. In this way we
believe that we are collecting more accurate data. A pain diary, an
alternative method of collecting the same data could be forged in
the office waiting room. The dosing of intrathecal narcotic is
based upon the recorded pain scores. Whenever patients fail to
call in a particular score the missing value is assigned a zero for
the purposes of calculating narcotic refill doses. This is an
incentive for the patient to provide the data accurately. In
addition we collect data about quality of life based upon a
subjective four point scoring system also provided by the patient.
We collect Beck depression scores, McGill pain questionnaire,
and sickness inventory profiles. In addition all health care visits
made by the patient are documented. A review of these visits will
assist in calculating the cost of medical care in the study and
control groups.
The mean Verbal Digital Pain score for the entire group of
patients prior to pump implantation was 9.3. There was no
difference between patients receiving the pump or the control
group. With the pump implanted the pain score fell to 3.1. In the
control group the pain score fell to 5.6. Statistical analysis was not
performed since all patients were not randomized. Prior to
surgery %% of patients were actively working. At present review
for the patients with morphine pumps one quarter are actively
involved in gainful employment. This is particularly meaningful
since many of the patients are over the age of 65.
Patient visits to health care professionals remain frequent due
to the need for refills approximately once per month (45 days for
a 30 cc pump delivering 0.5 cc per day or 90 days for a 50 cc
pump delivering 0.5 cc per day). Most patients have been able to
limit visits to refill dates. For some patients this means the
elimination of frequent emergency room visits associated with
episodic pain exacerbation that occurred before the device was
implanted. Emergency room visits occurred as frequently as once
per week. The mean annual visit rates were 26 prior to entering
the study, 20 in the control group, and 13 in the pump group.
The average cost of the pump trial is calculated to be about
continued on page 12
PAIN SECTION NEWSLETTER
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October 1999
11
continued from page 10
early image of chronic pain. The soldier’s head is turned
down. The active wrinkles of facial expression are absent. The
eyelids are hanging, half-closed, mouth partially open, jaw
sagging, as if the energy to
demonstrate expression is now
depleted.
The Dying Galation Soldier
represents the classic depiction of
ennobling chronic pain. Head
turned down, expression drained,
energy exhausted. It is located in
the Capitolene Museum in Rome
and, as mentioned, is likely
Pergomonian in origin.
=Another statue found in Rome
is known as Spinario, or Boy
Plucking a Thorn from the Foot. It was first named Fedele
(Faithful) because it was thought that it was a portrait of
Marcius, a Roman messenger who would not delay his mission
even though he was painfully tortured by a thorn in his foot.
The statue stands in the center of room in the Palazzo dei
Conservatori in Rome atop one of Rome’s seven hills.
The Ugolino group by Carpeaux depicts a horrifying story
from Dante’s Inferno. The traitorous Count Ugolino was
imprisoned and sentenced to death by starvation with his sons.
Carpeaux depicts the moment when the Count gives up all
hope, gnawing at his fingers in despair, as his dying children
offer their enfeebled bodies to him for food. They realize that
they can not survive This imagery emphasises the suffering
quality to human pain, but it is the same theme seen in the
Laocoon, suggesting that the greatest pain is that of the parent
who survives while his children die. This is spiritual not
physical pain. In the final stages of anguish, often in the
crucified Christ image, the eyes return to a heavenward gaze.
Eyes may remain closed, face reanimated, but there no longer is
the torment of acute or chronic pain.
continued from page 11
$3,000. The average cost of pump implantation $13,000. We
are in the process of obtaining accurate data about the cost of
refills however it has been difficult to document reimbursement
levels for the drug. To date we have had to remove one system for
infection, which obviously impacts the cost of the modality. No
other pump systems have required reoperation, but one other
system was removed for failure to maintain relief of pain.
Side effects of intrathecal narcotics include nausea, itching, and
urinary retention. These side effects are almost universal but selflimited. Elderly patients have much more trouble with nausea,
and may need to temporarily accept less than ideal pain control
associated with lower doses until this subsides.. Catheter fracture
is a costly and time-consuming event. Catheter malfunctions
have occurred in our Cancer and Baclofen group but to date not
in the benign group.
The effect of INA on testosterone was particulary interesting
especially in the female patients. Almost all women described a
desirable increase in libido associated with initial pain control
during the first 6 months. The initial increased libido was then
followed by a progressive decline in libido with a corresponding
fall in testosterone level. Male patients did not describe the
period of increased libido. Nearly all patients endorsed some
sexual dysfunction at entry into the study, which often worsened
following intrathecal morphine in male patients.
Not all patients obtained a positive response to intrathecal
narcotics. We currently implant a temporary intrathecal catheter
and administer a test bolus of 1mg of morphine (0.5mg for those
over 55). The patient is observed for 23 hours. A portable
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October 1999
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PAIN SECTION NEWSLETTER
disposable patient controlled external pump delivers a constant
infusion of morphine after the initial bolus dose. Fourteen
percent of the patients failed the trial. Two out of three patients
failing the trial had central pain which supports the notion that
central pain is not narcotic responsive.
Fifteen percent of the patients with implanted pumps failed to
maintain good pain control and one patient had the unit removed. Curiously this patient eventually went on to receive
repeat fusion with remarkably good pain relief. This underscores
the fact that the ability of the surgical community to determine
which patients are not candidates for anatomical surgery requires
more sophistication. Infection resulted in the removal of one
pump from a patient receiving good pain relief. Another patient
lost pain relief after functioning well for 36 months. There was no
evidence of catheter malfunction and the patient was offered a
drug holiday prior to changing medication which she refused.
She committed suicide at another institution.
In conclusion we present the first randomized controlled study
of intrathecal narcotics in benign pain. Pain control can be
effective in 74% of patients over the long term. So far based upon
scores, quality of life measures, and work status it appears that
intrathecal narcotic analgesia has a useful role in the treatment of
benign pain. It may be difficult to prove that this relatively
expensive treatment is cost effective however much more data is
being collected to address this important question. More specific
selection criteria need to be developed for choosing candidates
for intrathecal narcotic analgesia from the many patients with
chronic pain of benign origin.
About The Section on Pain
Purpose:
■
In the field of pain management, provides liaison and
involvement with other specialties and organizations.
■
Helps communications between AANS and CNS via
joint section status.
■
Provides help in resident curricula planning, especially in
the area of pain management.
■
Promotes Journal of Neurosurgery and Neurosurgery
manuscript submissions in pain management.
■
Fosters international communication and collaboration
in neurosurgical procedures for pain.
■
Reaches out to and encourages involvement by part of
neurosurgery somewhat outside mainstream.
■
Increases role of neurosurgeon in multidisciplinary field
of pain management.
Founders:
Philipp Lippe, MD, Andrew Shetter, MD, Benjamin Crew,
MD, Hubert Rosomoff, MD, Joe Seres, MD,
Philip Gildenberg, MD, Ronald Young, MD, John Loeser,
MD, David Kline, MD, and Frank Mayfield, MD
Officers:
Chairman: Kenneth A. Follet, MD, PhD
E-mail: [email protected]
Term: 2001
Vice-Chairman: Jaimie M. Henderson, MD
E-mail: [email protected]
Term: 2001
Secretary-Treasurer: Kim J. Burchiel, MD
E-mail: [email protected]
Term: 2001
The Following books are
available @
http://www.aans.org/marketpl/
amazon.html#pain
Anesthesia and Pain Management for the
Pediatrician
by Lynne R. Ferrari (Editor)
Published: May 1999
The Management of Pain
by Michael A. Ashburn (Editor), Linda J. Rice (Editor)
Published: February 1998
Oxford Textbook of Palliative Medicine (Oxford
Medical Publications)
by Derek Doyle (Editor), Geoffrey W. C. Hanke (Editor),
Neil MacDonald (Editor)
Published: January 1998
Neural Blockade in Clinical Anesthesia and
Management of Pain
by Michael J. Cousins (Editor), Phillip Bridenbaugh
Published: January 1998
Special Activities:
■
Consensus Conference on the Neurosurgical Management of Pain (1993).
■
Education Guidelines for Neurosurgeons in Training
(1995) .
■
Development of guidelines for certification in pain management with the American Board of Pain Medicine.
■
Development of standardized outcome measures with
the American College of Pain Medicine (1995).
Proceedings of the 8th World Congress on Pain
(Progress in Pain Research and Management, V. 8)
Interface/Liaison:
■
American Academy of Algology.
■
American Pain Society.
■
American Academy of Pain Medicine.
Neurosurgical Management of Pain
by B.C. Jensen, Troels Staeheli World Congress on Pain
1996 Vancouver
Published: June 1997
Image-Guided Pain Management
by P. Sebastian Thomas (Editor)
Published: January 1997
by Robert M. Levy and Richard B. North
Published: November 1996
Web Site:
■
http://www.aans.org/sections/pain/summary.html
PAIN SECTION NEWSLETTER
■
October 1999
13
Poster Presentation
Selected poster from the 67th Annual meeting of the
American Association of Neurosurgeons
April 24-29, 1999
Techniques and Outcomes of Thoracoscopic
Sympathectomy
J. Patrick Johnson, MD* Samuel Ahn, MD* William Choi,
MD+ Jeffrey Masciopinto, MD++
Kee Kim, MD# Aaron Filler, MD* Antonio DeSalles, MD*
* Los Angeles, CA
+
Montreal, Canada
++
Denver, CO
#
Sacramento, CA
Thoracic sympathectomy is an important method of
treatment for palmar hyperhidrosis and upper extremity
pain disorders. Earlier surgical procedures were highly
invasive, with known morbidity, acceptable outcomes, and
established recurrence rates that were the limitations to
considering surgical treatment. Thorascopic sympathectomy is a minimally invasive procedure that allows detailed visualization of the sympathetic ganglia and minima
postoperative morbidity; however, outcome studies of this
technique have been limited.
The authors treated 39 patients who underwent 60
thorascopic sympathectomy procedures.
The outcomes in this series were equivalent to previously
established open surgical techniques; however, operative
morbidity rates, hospital stay, and time of return to normal
activity were substantially reduced. Complications and
recurrence of symptoms were also comparable to previous
reports. Overall patient satisfaction and willingness to
repeat the operative procedure ranged from 66% to 96% in
all patients. The hyperhidrosis patients had uniformly
high success rates (>90%) whereas the patients with pain
syndromes had more variable long-term successful outcomes (i.e. 60%-90%).
Patients and physicians should consider minimally
invasive thoracoscopic sympathectomy procedures as an
option to treat sympathetically mediated disorders because
of the reduced morbidity and at least equivalent outcome
rates in comparison to previous treatments.
Calendar of Events
8-13 April 2000
68th American Association of Neurological Surgeons
Annual Meeting
Location:
San Francisco, CA
WWW:http://www.aans.org/meetings/
aans/summary.html
23-28 September 2000
50th Congress of Neurological Surgeons Annual Meeting
Location:
San Antonio, TX
WWW:http://www.aans.org/meetings/cns/
26-29 October 2000
3rd National Trigeminal Neuralgia Conference
Location:
Pittsburgh PA, hosted
by the University of Pittsburgh.
2-5 November 2000
19th Annual Scientific Meeting American Pain Society
Contact:
American Pain Society
4700 W. Lake Avenue
Glenview, IL 60025-1485
Location:
Hyatt Regency Atlanta, Atlanta, GA
Phone:
847-375-4715 Fax:
847-375-4777
E-mail:
[email protected]
April 2001
69th American Association of Neurological Surgeons
Annual Meeting
Location:
TBD
19-22 April 2001
20th Annual Scientific Meeting American Pain Society
Contact:
American Pain Society
4700 W. Lake Avenue
Glenview, IL 60025-1485
Location:
Phoenix, AZ
Phone:
847-375-4715 Fax:
847-375-4777
E-mail:
[email protected]
16-21 September 2001
XII World Congress of Neurological Surgery
Location:
Convention & Exhibition Centre,
Sydney, Australia
WWW:http://www.nsa.on.net/wfns.htm
E-mail:
[email protected]
29 September-4 October 2001
51st Congress of Neurological Surgeons Annual Meeting
Location:
San Diego, CA
21-26 September 2002
52nd Congress of Neurological Surgeons Annual Meeting
Location:
Philadelphia, PA
14
October 1999
■
PAIN SECTION NEWSLETTER
Application for Membership
AANS/CNS Section on Pain
I. Biographical
Name: __________________________________________________________________________________
Birth Place: __________________________________
Birth Date: _______________________________
Citizenship __________________________________
Home Address: _______________________________
Office Address: ____________________________
___________________________________________
________________________________________
Fax: _________________ Phone: __________________
Fax: __________________ Phone: ______________
II. Category of Membership Requested:
❑ Active
❑ Associate
❑ Corresponding
III. Education
Premedical collegiate education (institutions/dates) _________________________________________________
Final degree (institutions/dates) ________________________________________________________________
Medical education (institutions/dates)____________________________________________________________
Final degree (institutions/dates) ________________________________________________________________
Internship or equivalent (institutions/dates) _______________________________________________________
Residency or other graduate training (institutions/dates) ______________________________________________
Residency training institution __________________________________________________________________
Completion (or expected completion) Date _______________________________________________________
IV. Membership, Certification and Practice
Are you now certified by the American Board of Neurological Surgery?
Are you certified in neurosurgery by another examining board?
❑ Yes/Year ______
❑ Yes/Year ______
❑ No
❑ No
Are you a member of:
❑
American Medical Association
❑
Local or regional medical society
Name: _________________________________________________
❑
State or provincial medical society Name: _________________________________________________
❑
American Association of Neurological Surgeons
❑
Congress of Neurological Surgeons
❑
American Academy of Pain
❑
International Association for the Study of Pain
❑
American Pain Society
Medical Licensure State ____________________________
Dates ____________________________
Signature _______________________________________
Date _____________________________
Please return completed application to:
Section on Pain
Membership Department
22 South Washington Street
Park Ridge, IL 60068
U.S. POSTAGE
22 South Washington Street
Park Ridge, Illinois 60068-4287
FIRST CLASS
AANS/CNS Section on Pain
PAID
Des Plaines, IL
Permit No. 329
Section on Pain Council
Michael Munz, MD
Philadelphia, PA
Vice Chairman
Jaimie Henderson, MD
St. Louis, MO
Council Members
John Gorecki, MD
Durham, NC
Chairman
Kenneth Follett, MD, PhD
Iowa City, IA
Secretary/Treasurer
Kim Burchiel, MD
Portland, OR
Joint Section on Pain Newsletter
Editor
Kim J. Burchiel, MD
Assistant Editor
Shirley McCartney, PhD
John Oakley, MD
Seattle, WA
Richard K. Osenbach, MD,
Charleston, SC
Oren Sagher, MD
Ann Arbor, MI
This newsletter is sponsored in part by an
educational grant from Medtronic, Inc.
Richard Simpson, Jr, MD, PhD
Houston, TX
http://www.medtronic.com/
neuro/apt/whatis.html
Newsletter Contributors
Jeffrey Brown, MD
Fernando Diaz, MD, PhD
Kenneth Follett, MD, PhD
John Gorecki, MD
J. Patrick Johnson, MD
J.C. Leveque, BA
Michael Oh, MD
Peter Pahapill, MD, PhD
Hun Park, MD, PhD
Alan Villavicencio, MD
Donald Whiting, MD