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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. 2 October 1999 ■ 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 ■ 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 October 1999 ■ 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 ■ 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. 6 October 1999 ■ 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 ■ 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 8 October 1999 ■ 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 ■ 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 10 October 1999 ■ 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 ■ 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 12 October 1999 ■ 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