Erfahrungen mit der retroganglionären Glycerin-Rhizotomie in der Behandlung der Trigeminusneuralgie

From August 1981 to May 1993 a total of 1263 percutaneous retrogasserian glycerol rhizotomies after Hakanson were performed. The intervention was performed with X-ray monitoring under local anaesthesia and rarely lasted longer than 20 min. It achieved good results in the treatment of idiopathic trigeminal neuralgia (TN) and symptomatic trigeminal neuralgia due to multiple sclerosis (TNMS). Some 97% of the TN patients were completely free of pain after the intervention. The recurrence rate within 5 years was 12.8%. Some 94.7% of the TNMS patients were immediately free of pain, but within 2-5 years they experienced a high recurrence rate of 40.2%. The results in the patients with atypical facial pain were more disappointing: only 66.6% were pain-free immediately after the intervention, and the recurrence rate was 31%. With respect to the side effects immediately postoperatively, herpetic eruptions were found in 43.2% of cases. They occurred on the 3rd postoperative day and persisted for 2-3 weeks before being relieved by local virostatic therapy. Hypaesthesia and hypalgesia were present in the early postoperative follow-up in half of our patients. Both these reductions of sensitivity have a tendency to regress. Later, after 2 years, there was reduction in sensitivity of this type in only 20% of cases. In the follow-up 17.5% of our patients complained of dysaesthesia and in 21.4% corneal sensitivity was reduced or lost. We believe that glycerol rhizotomy, owing to its effectiveness, easy applicability, slight distress for the patients and low side effects, should be recommended as a first measure for non-conservative treatment of idiopathic trigeminal neuralgia as well as trigeminal neuralgia in multiple sclerosis.     

Einsatz der physikalischen Therapie bei der Behandlung der kraniomandibulären Dysfunktion

Background

The possible advantages of physiotherapy in the treatment of craniomandibular disorders (CMD) is controversially discussed. A prospective randomized study was carried out to evaluate the effectiveness of physical therapy for treatment outcome in CMD using objective and subjective parameters.

Patients and methods

A total of 26 patients suffering from an arthrogenic craniomandibular disorder and exhibiting painfully restricted mouth opening were randomized in two groups. Twelve patients were treated solely with a Michigan splint, and 12 received supplementary physical therapy. Before treatment a clinical examination including maximum active and passive mouth opening was carried out, electronic recording of jaw movements was performed and subjective pain level was evaluated using visual analog scales. After 3 months of therapy, improvement was evaluated.

Results

In both groups, there was a significant improvement in lower jaw mobility after treatment compared to the baseline, while subjectively measured pain decreased (p<0.05).

Conclusion

Additional physiotherapy has a positive impact on the treatment outcome in patients suffering from craniomandibular dysfunction, especially for pain reduction and functional parameters.     

Stellenwert der Neuromodulation bei Funktionsstörungen der Hand

Manuelle Medizin - Funktionsstörungen der Hand umfassen Bewegungsstörungen und Schmerzen. Die Ursache kann lokal in der Hand, im Arm, im Thoraxbereich, in der Halswirbelsäule, im...     

Behandlung der Diarrhö mit Loperamid in der Palliativmedizin

Diarrhea is a distressing symptom which limits the quality of life in patients receiving palliative care and is associated with high morbidity and mortality. In patients with AIDS, it is a more common problem than for other entities (e.g., cancer). Loperamide is considered the first choice medication for the symptomatic treatment of diarrhea. This literature review examines the efficacy of loperamide in the symptomatic treatment of diarrhea in palliative care. Two databases (Medline and Embase) were searched through June 2012. A total of 286 studies were identified, but only 7 met the inclusion criteria (1 cohort and 6 experimental studies) in which loperamide (alone or in combination) was tested. There is a lack of significant studies which investigate the efficacy of loperamide in the symptomatic treatment of diarrhea. Two trials indicated superiority of loperamide over placebo. In comparison with octreotide, the results were contradictory. The combination of acetorphan with loperamide was more effective than acetorphan alone, but the combination of loperamide with diphenoxylate was inferior to octreotide. The identified studies revealed methodical problems. A definite recommendation for administration of loperamide can, therefore, not be derived from this work. The English full-text version of this article is available at SpringerLink (under “Supplemental”).     

Ergebnisse der mikrochirurgischen vaskulären Dekompression bei der Trigeminusneuralgie

INTRODUCTION: From 1 August 1983 to 6 June 1992, 284 patients underwent decompression of the trigeminal root in the rear part of the skull as treatment for tic douloureux. According to preoperative diagnosis and intraoperative inspection, a space-occupying process was the cause of the typical neuralgia in 13 cases (4 meningiomas, 3 epidermoid tumours, 3 acoustic neuromas and 2 trigeminal neuromas). In 271 cases (95.4%) microsurgical vascular decompression according to Jannetta was carried out. METHODS: The majority of patients were between 45 and 75 years of age. The follow-up period ranged from 10 months to 9.3 years (average 59.45 months). The results of the long-term investigations are based on standardized questionnaires completed by 202 patients. Of the total of 271 patients operated upon by Jannetta's technique, 261 (96.3%) were free of pain immediately after the operation. The main causes of failure were misdiagnosis (myoarthropathy, cluster headache) and incorrect indications (encephalomyelitis disseminata, trigeminal neuropathy following peripheral lesion). In 3 cases vascular displacement and complete decompression of the trigeminal root were impossible because the basilaris was exceptionally long. RESULTS: In the long term, 87.6% of the patients operated on remained free of pain or improved sufficiently to require no further carbamazepine medication. Relapses developed in 7.4% of cases, and except for operative revision and rhizolysis of the trigeminal root in a case of relapsed trigeminal neuralgia, thermo-controlled high-frequency lesion of the gasserian ganglion was carried out in a second operation. The complications of the Jannetta operation were hypoacusis and anacusis (4%), hyposmia (1%), dizziness (3.5%) and chronic subdural haematoma (1 case). Neither postoperative bacterial meningitis nor any lethality was recorded. In 94.5% of cases the patients expressed positive opinions of the operation and its results, while 4% regretted having the operation and 1.5% were undecided. The question as to whether the operation had significantly improved the quality of life was answered in the affirmative by 88.4% of the patients. DISCUSSION: In summary, the long-term results confirm that microsurgical vascular decompression can be offered as the method of choice for treatment of trigeminal neuralgia in younger patients, and in older patients when cardiopulmonary risk factors and cerebrovascular processes can be eliminated. Alternative methods are high-frequency lesionsing of the gasserian ganglion according to Sweet and chemorhizolysis of the gasserian ganglion, but these must be restricted exclusively to the treatment of typical trigeminal neuralgia with tic douloureux. Persistent neuropathic pain caused by atraumatic or drug-induced lesion to the trigeminal nerve cannot be positively influenced either by surgical decompression or by destructive operations on the gasserian ganglion.     

Was gibt es Neues in der Therapie der Fibromyalgie?

Zusammenfassung Das Konzept zur Behandlung der Fibromyalgie (FM) umfasst psychotherapeutische, hier v. a.. verhaltenstherapeutische Maßnahmen sowie physikalische und pharmakologische Behandlungsansätze. Neben den bekannten medikamentösen Interventionen wurden aus den Erkenntnissen zur möglichen Pathogenese des FM-Schmerzes 3 neuere Substanzen als Therapieoptionen mit allerdings differierenden ersten Studienergebnissen getestet: NMDA-Rezeptorantagonisten (Schmerzreduktion, aber bisher kein breiterer Einsatz), NK1-Rezeptorantagonisten (enttäuschende Ergebnisse in allerdings nur einer Studie bei FM) und 5-HT₃-Rezeptorantagonisten (gute Wirksamkeit in einer Untergruppe von FM-Patienten). Zur Therapie der FM darf der Hinweis nicht fehlen, dass eine ganze Reihe von Begleitsymptomen, die mitunter zumindest phasenweise den Schmerz in den Hintergrund treten lassen können, möglicherweise mittels anderer Substanzen spezifischer behandelt werden können bzw. müssen.