Epidurale Rückenmarkstimulation zur Therapie chronischer Schmerzen

High-Frequency Spinal Cord Stimulation for the Treatment of Chronic Low Back and Leg Pain: Implantation Technique of Percutaneous Leads and Implantable Pulse Generator

Spinal cord stimulation (SCS) is an evidence-based, reversible but invasive procedure for the treatment of chronic pain syndromes: for example, in patients with failed-back-surgery syndrome or complex regional pain syndrome. A more recent, similar technique uses high-frequency stimulation for SCS and follows a different mechanism of action that does not result in paresthesia. This Technical Note and video present surgical instructions of a "2-way cut-down" technique for a high-frequency SCS trial period and permanent implantation of an implantable pulse generator.

Impact of shock-wave therapy on the clinical and functional status of patients with coronary heart disease

Aim. To study of the impact of shock-wave therapy (SWT) on the functional status of patients with coronary heart disease (CHD). Subjects and methods. Thirty-four CHD patients (including 33 men) with left ventricular (LV) asynergic segments, as evidenced by echocardiography (EchoCG), were examined. Their mean age was 60.1±1.76 years. All the patients received a SWT cycle according to the standard scheme. The patient examination protocol involved EchoCG, dobutamine EchoCG, treadmill exercise EchoCG, and tissue Doppler EchoCG, which were performed at baseline, immediately and one month after the end of a SWT cycle. Results. Following a SWT cycle, all the patients were noted to have a significant decrease in mean angina pectoris and heart failure functional classes and in the frequency of daily intake of nitrates. EchoCG showed that at baseline the LV ejection fraction (EF) was 51.1±1.02%; end- diastolic volume index, 71.5±3.6 ml/m2; end-systolic volume index, 34.4±2.2 ml/m2. According to exercise EchoCG, the tolerance threshold was 6.4±0.1 Меts (Bruce protocol); the total exercise time of 5.05±0.23 min was achieved in an average of 75.2±1.32%. Immediately and one month after a SWT cycle, there was an increment in EF from 51.1±1.02 to 55±0.8 and 57±1.7%, respectively; a substantial increase in the tolerance threshold to 8.17±0.24 and 9.45±0.34 Меts, as compared to the baseline values. The exercise time increased up to 6.41±0.17 and 7.7±0.29 min immediately and one month after SWT, respectively. The increment in EF in response to exercise was 8.54±2.12, 14±1.5, and 16±1.2% at baseline, immediately and one month after SWT, respectively. Moreover, myocardial relaxation and diastolic function improved. Conclusion. Shock-wave therapy in patients with CHD is accompanied by their improved functional status, which is manifested by increased tolerance threshold and exercise duration, a rise in rest and exercise LV EF, better relaxation of LV, and its diminished stiffness.

[SCS as a treatment option for failed back surgery syndrome]

Unfortunately, 10-40 % of patients still experience pain after spinal surgery. There are many reasons for the patients' complaints. If no identifiable cause, such as a recurrent disc herniation, is visible, this is referred to as failed back surgery syndrome. However, this definition includes a variety of possible underlying causes of the pain, which result in just as many different therapeutic approaches. In addition to pharmacological, behavioral and physical therapy, also neuromodulation techniques can be offered; the best known method is spinal cord stimulation (SCS). The following article describes evidence-based studies with regard to the beneficial treatment of failed back surgery syndrome with conventional tonic SCS and new developments in spinal cord stimulation addressing the treatment of chronic refractory back pain.

Cardiac shock wave therapy and myocardial perfusion in severe coronary artery disease

BACKGROUND

Ultrasound guided cardiac shock wave therapy (CSWT) is a noninvasive therapeutic option in the treatment of chronic-refractory angina. Clinical trials have shown that CSWT reduces angina symptoms, improves regional systolic function, LV ejection fraction, myocardial perfusion and quality of life parameters. Absolute measurements of myocardial perfusion before and after CSWT have not been performed so far.

METHODS AND RESULTS

We studied a total of 21 CCS III patients with history of CAD and multiple interventions who suffered from disabling angina despite individually optimized medical therapy. An N-13 NH3 PET perfusion scan under adenosine was performed before and after CSWT treatment. CSWT was well tolerated in all patients. Absolute perfusion under adenosine of the global left-ventricular myocardium did not change under therapy or minimal coronary resistance. The treated segments, however, showed in terms of both perfusion and resistance a mild but significant improvement, by 11 and 15 %, respectively, whereas no change could be observed in the remote segments. Considering a threshold of increased perfusion of 5 %, 10 (77 %) out of 13 patients with a better target perfusion improved in their CCS class, whereas 3 (43 %) out of 7 patients without improved target perfusion improved in their CCS class too.

CONCLUSION

Standard CSWT has the potential to improve myocardial perfusion of the therapy zone and clinical CAD symptomatology without affecting global myocardial perfusion. As a noninvasive and well tolerated therapeutic option, these data suggest the use of CSWT in patients with end-stage CAD.

[Interventional pain therapy. Results of a survey among specialized pain physicians in Germany]

BACKGROUND

Interventional pain therapy aims to treat pain which is refractory to pharmacologic and noninterventional treatment. Due to the partly lacking evidence and recommendations it remains unclear when interventional methods should be applied within the treatment pathway. This study assesses the current state of interventional methods in Germany and their leading indications comparing with the recommendations found in the literature.

METHODS

An online survey was conducted among German physicians specialized in pain therapy concerning the number of interventions they perform per quarter, which supporting measures they use, and their indications for sympathetic blocks, sensory blocks, intrathecal administration, and spinal cord stimulation.

RESULTS

A total of 109 physicians (23.5 %) participated in the survey. Blocks are most often performed on the stellate ganglion (94 %) and on the superior cervical ganglion (82 %). They are supported by anatomical landmarks and less often by imaging control. Both classic neuropathic pain diagnoses (e.g., complex regional pain syndrome) and diagnoses with a neuropathic pain component (e.g., peripheral arterial disease, tumor pain, and back pain) were considered as indications to perform interventional procedures.

CONCLUSION

Although there is no clear evidence on interventional procedures in the current literature, these methods are often performed by the respondents. Anatomic landmarks are most frequently used for orientation. The German pain physicians who responded consider especially neuropathic pain as an indication to perform interventional procedures for pain therapy.

[Neuromodulation for neuropathic pain]

In pain therapy neurostimulation procedures have replaced the previously used lesional methods with only very few exceptions. This is especially true for neuropathic pain, i.e. pain which occurs as a direct consequence of a lesion or disease of the somatosensory system. Nowadays, various stimulation procedures are included in the neurosurgical and anesthesiological armamentarium for pain therapy, depending on the site of damage. This article gives an overview of the currently used invasive stimulation procedures and the indications.

[Complex regional pain syndrome: A current review]

Complex regional pain syndrome (CRPS) may develop following fractures, limb trauma, or lesions of the peripheral or central nervous system. The clinical picture consists of a triad of symptoms including autonomic, sensory, and motor dysfunction. Diagnosis is based on clinical signs and symptoms according to the Budapest criteria. Therapy is based on an individual and multidisciplinary approach. Distinct methods of physical therapy and pharmacological strategies are the mainstay of therapy. Pharmacotherapy is based on individual symptoms and includes steroids, free radical scavengers, treatment of neuropathic pain, and agents interfering with bone metabolism. In some cases invasive methods may be considered.

[Chronic chest pain]

BACKGROUND

Chest pain is a symptom commonly reported by persons in the general population and represents a differential diagnostic challenge.

MATERIAL AND METHODS

The paper is based on a narrative review with a selective search of the literature in Medline for reviews and guidelines on the prevalence and treatment of non-malignant diseases with chronic chest pain in gastroenterology, gynecology and cardiology.

RESULTS

The prevalence and current treatment recommendations for the different forms of gastroesophageal reflux disease (GERD), erosive and non-erosive types and irritable esophagus, non-cardiac chest pain, refractory angina in coronary heart disease and postmastectomy nand poststernotomy syndromes are presented. In cases of failure of the established therapy of a single medical discipline, an interdisciplinary assessment including psychosocial issues is recommended. Evidence-based guidelines are available for the management of GERD and of refractory angina. Treatment of postmastectomy and poststernotomy syndromes is based on case reports and expert opinion.

CONCLUSION

There is a need for controlled studies on the symptomatic treatment of pain in irritable esophagus, non-cardiac chest pain, postmastectomy and poststernotomy syndromes.

[Development of epidural spinal cord stimulation. Fortieth anniversary of the first implantation in Germany]

Spinal cord stimulation is nowadays an established therapy for various neuropathic and vasculopathic pain syndromes after more conservative measures have failed. However, 40 years ago, only 5 years after the first worldwide implantation in the US, this therapy was promoted in Germany. In 1972, the first devices were implanted in the Departments of Neurosurgery at the Universities Hannover and Freiburg. These pioneering efforts and the establishment of the therapy are intimately associated with three names: Jörg-Ulrich Krainick, Uwe Thoden, and Wolfhard Winkelmüller. Nowadays about 1700 spinal cord stimulation systems are implanted annually in Germany. The development of spinal cord stimulation from the beginnings up to now taking into special consideration the early years in Germany are presented.