CT-guided chemical rhizotomy of the C1 root for occipital neuralgia

Summary Sensation in the parasagital occipital region is usually provided by fibres from the second cervical root via the greater occipital nerve. In the case presented occipital neuralgia could be relieved only by coagulation of the C1 nerve root with 96% ethyl alcohol. Possible explanations for this observation are discussed and a technique for CT-guided treatment is described.     

脑瘫痉挛解除后足畸形的变化

痉挛型脑瘫58例行L_2—S_1节段的选择性脊神经后根切断术,术后患者的下肢痉挛均巳解除.通过术前术后足畸形的对比,发现SPR术能使多数痉挛所致足畸形在术后得以完全矫正,并减轻痉挛与软组织挛缩同时存在的足畸形的严重程度,预防软组织挛缩,避免足畸形加重,而对跟骨畸形影响较小.本组病例中扁平外翻足畸形多见,在治疗中是一个值得重视的问题.     

Percutaneous Procedures for Trigeminal Neuralgia

Microvascular decompression is the gold standard for the treatment of trigeminal neuralgia (TN). However, percutaneous techniques still play a role in treating patients with TN and offer several important advantages and efficiency in obtaining immediate pain relief, which is also durable in a less invasive and safe manner. Patients’ preference for a less invasive method can influence the procedure they will undergo. Neurovascular conflict is not always a prerequisite for patients with TN. In addition, recurrence and failure of the previous procedure can influence the decision to follow the treatment. Therefore, indications for percutaneous procedures for TN persist when patients experience idiopathic and episodic sharp shooting pain. In this review, we provide an overview of percutaneous procedures for TN and its outcome and complication.     

Central projection of calcitonin gene-related peptide (CGRP)- and substance P (SP)-immunoreactive trigeminal primary neurons in the rat

Substance P (SP) is implicated in transmission of primary afferent nociceptive signals. In primary neurons, SP is colocalized with calcitonin gene-related peptide (CGRP), which is another neuropeptide marker for small to medium primary neurons. CGRP coreleased with SP augments the postsynaptic effect of SP and thereby modulates the nociceptive transmission. This study demonstrates the distribution of CGRP-like immunoreactivity (-ir) and SP-ir in the lower brainstem of normal rats and after trigeminal rhizotomy or tractotomy at the level of subnucleus interpolaris (Vi). By comparing the results obtained from normal and deafferented rats, we analyzed the central projection of trigeminal primary nociceptors. The CGRP-immunoreactive (-ir) trigeminal primaries projected to the entire rostrocaudal extent of the spinal trigeminal nucleus, the principal nucleus (PrV), the paratrigeminal nucleus (paraV), and the lateral subnucleus of solitary tract nucleus (STN) on the ipsilateral side. The trigeminal primaries projecting to the spinal trigeminal nucleus, paraV and STN also contained SP-ir. The ipsilateral trigeminal primaries were the exclusive source of CGRP-ir terminals in the PrV, the Vi and the dorsomedial nucleus within the subnucleus oralis (Vo). The medullary dorsal horn (MDH) and the lateral edge of Vo received convergent CGRP-ir projection from the ipsilateral trigeminal primaries and other neurons. The glossopharyngeal and vagal primaries are candidates for the source of CGRP-ir projection to the Vo and the MDH, while the dorsal root axons supply the MDH with CGRP-ir terminals. In addition, contralateral primary neurons crossing the midline appear to contain CGRP and to terminate in the MDH. J. Comp. Neurol. 378:425–442, 1997. © 1997 Wiley-Liss, Inc.     

Long-term results after percutaneous retrogasserian glycerol rhizotomy in patients with trigeminal neuralgia

Summary We have evaluated the long-term results of percutaneous retrogasserian glycerol rhizotomy (PRGR) in 60 patients with classical trigeminal neuralgia. Complete initial pain relief was achieved in 93% of the patients. Numbness was initially reported by 3/4 of the patients and at follow-up by 1/3, while long-lasting dysaesthesias were an important side effect in 38% of previously untreated patients. The half-life of the method was 47 months in our material, and this figure compares favourably with other previously reported series. The method carries a significant risk of long-lasting and troublesome sensory disturbances. Another disadvantage of the method, reported in the present long-term study, was the high incidence of recurrent neuralgia.We are unable to identify predictors of recurrent neuralgia after PRGR, although major recurrences were more common in patients with unchanged facial sensation postoperatively.In conclusion, PRGR offers safe and reliable relief of pain in patients with trigeminal neuralgia. In spite of the high incidence of recurrence and of long-lasting dysaesthesias it is, in our opinion, the method of choice in the elderly, and particularly suitable for patients at high risk.     

Selective dorsal rhizotomies in the treatment of spasticity related to cerebral palsy

Rationale Selective dorsal rhizotomy (SDR) is a surgical technique developed over the past decades to manage patients diagnosed with cerebral palsy suffering from spastic diplegia. It involves selectively lesioning sensory rootlets in an effort to maintain a balance between elimination of spasticity and preservation of function. Several recent long-term outcome studies have been published. In addition, shorter follow-up randomized controlled studies have compared the outcome of patients having undergone physiotherapy alone with those that received physiotherapy after selective dorsal rhizotomy. Materials and methods In this account, we will discuss the rationale and outcome after SDR. The outcome is addressed in terms of the gross motor function measurement scale (GMFM), degree of elimination of spasticity, strength enhancement, range of motion, fine motor skills, activity of daily living, spastic hip, necessity for postoperative orthopedic procedures, bladder and sphincteric function, and finally possible early or late complications associated with the procedure. Conclusion We conclude that SDR is a safe procedure, which offers durable and significant functional gains to properly selected children with spasticity related to cerebral palsy.     

儿童脑瘫的外科治疗

儿童脑瘫是一种严重致残性疾病.本文报告23例经脑立体定向术和选择性脊神经根切断手术方法治疗的结果,结合文献对该病的手术原理及有关问题进行讨论.     

选择性脊神经后根切断术神经反射变化的研究

目的:目前较为流行的选择性脊神经后根切断术治疗儿童脑瘫的手术中,选择低阈值的神经亚束进行切断是手术的关键。但手术中发现神经后根亚束阈值变化很大,为更好理解这一方法的理论根据和解释产生这些变化的原因,我们用狗为实验动物模型进行去大脑、慢性脊髓化的选择性脊神经后根切断术(selective posterior rhizotomv,SPR),前后神经后根兴奋性和肢体肌肉反应级别变化的研究。万法:将动物分成三组,分别进行SPR手术,进行脊神经后根亚束阈值的测定,并对阈值的两倍刺激效应和阈下刺激的时间空间总和效应进行研究。结果:在去大脑操作中短时间内阈值有大范围波动,部分脊神经后根切断后其阈值变化于5～10man内可达其基值的10倍左右。30s内用阈值量恒定的电流刺激后根,同侧下肢肌肉反应级别差异较大。另外,两倍阈值量刺激常使肌肉病理级别反应增加,这在对照组也有表现。邻近神经后根阈下刺激的时间、空间总和效应使对照组刺激阈电流变小,而肌肉反应级别并未变化。结论:这一实验结果表明目前广泛应用的SPR手术神经后根阈电流的不稳定因素来自脊髓本身,临床应用的阈值往往超过实际阈值,两倍阈电流刺激使病理反应级别增加。因此SPR手术判断神经阈值的电生理方法有待进一步改进。     

Percutaneous thermocontrolled differential retrogasserian rhizotomy for idiopathic trigeminal neuralgia

Summary Percutaneous thermocontrolled radiofrequency trigeminal rhizotomy enables the clinical destruction of pain fibres with preservation of touch sensation, thereby avoiding deterrent side-effects caused by conventional methods. The long-term results in 400 consecutive patients with idiopathic trigeminal neuralgia who underwent this procedure are reported. Satisfactory pain relief was achieved in 93.3% of cases. The follow-up period ranged from one to six years. The technique and its rationale are analysed, and the results, side-effects, indications, and limitations are discussed.     

Sacral anterior root stimulation: Prerequisites and indications

An intact sacral reflex arc, or at least an intact second motor-neuron and a detrusor being able to contract, are the two prerequisites for implanting an anterior sacral root stimulator. Transrectal electrostimulation or direct needle stimulation of the sacral roots may reveal if patients despite absent or only weak detrusor contractions on routine investigation are suitable. Patients with a complete midthoracic paraplegia are the ideal candidates, but tetraplegics also benefit. Patients with incomplete lesions and preserved pain sensations are suitable provided that they can undergo posterior sacral root rhizotomy. Non-traumatic spinal cord lesions follow the same rules, provided that the type of lesion does not allow recovery and is not progressive. Myelomeningocele patients may be suitable provided that the pathoanatomy of the sacral roots permits the operation (may be possible only in thoracolumbar myelomeningocele). Vesico-uretero-renal reflux is no contraindication; it may even be a strong indication, if a low compliance bladder or high detrusor contractions are the main reasons for it. In most patients the procedure should or must be combined with posterior sacral root rhizotomy in order to normalize a low compliance, to abolish spontaneous reflex contractions, and to achieve continence. The benefit of following these rules is reflected in our own series of 30 patients. In all of them the operation has improved considerably the quality of life and no patient so far has regretted the operation.