Management Of Intractable Pain Research Articles

PO243 / #898 USE OF FLUOROSCOPY-GUIDED BILATERAL SPLANCHNIC NERVE BLOCK AS AN OPTIMAL ALTERNATIVE TO CELIAC PLEXUS BLOCK FOR MANAGEMENT OF CHRONIC INTRACTABLE PAIN SECONDARY TO CHRONIC PANCREATITIS: E-POSTER VIEWING

The pain associated with chronic pancreatitis (CP) can be debilitating, often leading to excessive use and misuse of narcotic analgesics. Splanchnic nerve block is a technique aimed at interrupting the neural conduction causing abdominal pain [1]. Previous studies focused, predominantly, on using this technique for treating pain associated with upper gastrointestinal malignancies. However, it can provide great relief for those with persistent pain from CP [2]. We describe a case report for management of intractable pain from CP with fluoroscopic guided bilateral splanchnic nerve block in a young female with opioid-use disorder (OUD) and status post distal pancreatectomy.

Spinal Cord Stimulators: An Analysis of the Adverse Events Reported to the Australian Therapeutic Goods Administration.

BackgroundSpinal cord stimulators are used to treat intractable pain. Placebo-controlled trials of spinal cord stimulators typically involve short-term treatment and follow-up, so long-term safety and efficacy are unclear.AimThe aim of the study was to describe the adverse events relating to spinal cord stimulators reported to the Therapeutic Goods Administration of Australia between July 2012 and January 2019.MethodsAdverse events were coded by seriousness, severity, body system affected, type of event, action taken, and attribution of fault. Data on the number of stimulators implanted and removed were sourced from the Admitted Patient Care Minimum Data Set.ResultsFive hundred twenty adverse events were reported for spinal cord stimulators. Most events were rated as severe (79%) or life-threatening (13%). Device malfunction was the most common event (56.5%). The most common action taken in response to an adverse event was surgical intervention with or without antibiotics (80%). The ratio of removals to implants was 4 per every 10 implanted.ConclusionsSpinal cords stimulators have the potential for serious harm, and each year in Australia, many are removed. In view of the low certainty evidence of their long-term safety and effectiveness, our results raise questions about their role in providing long-term management of intractable pain.

Intractable Pain Management by Combined Korean Medicine Treatment Including Acupotomy in Lumbar Disc Herniation: A Case Report

Intractable Pain Management by Combined Korean Medicine Treatment Including Acupotomy in Lumbar Disc Herniation: A Case Report

Commentary: Management of Intractable Pain in Patients With Implanted Spinal Cord Stimulation Devices During the COVID-19 Pandemic Using a Remote and Wireless Programming System.

GENERAL COMMENTARY article Front. Neurosci., 05 August 2021Sec. Neural Technology Volume 15 - 2021 | https://doi.org/10.3389/fnins.2021.696830

Intrathecal Drug Therapy in Chronic Pain Management

Chronic pain impacts the quality of multiple functional domains, including family life, workplace performance, social interactions, and sleep patterns. The management of chronic pain continues to pose many challenges to healthcare providers. Intrathecal drug delivery systems (IDDS) provide an effective therapy for patients suffering from chronic pain intractable to medical management. to identify best practices and provide guidance to clinicians to ensure safety and optimize intrathecal drug delivery for chronic intractable pain management. This is a review article, The search was performed in MEDLINE, Embase, Pubmed and CINAHL Plus in the same date range with the following mediacl terms. Intrathecal drug (IT) delivery has many benefits compared with oral or parenteral routes for pain control. First, it allows for the use of significantly lesser doses of opioids. Second, it bypasses the first pass effect and the blood brain barrier. Third, patients typically experience fewer adverse effects (AEs) due to the decreased total dose of opioid used. However, IT therapy may be associated with complications related to many factors, including those related to the IT pump itself (e.g., mechanical failure), pump pocket fills, issues surrounding preparation of the IT medication and programming of the pump for medication release, and complications following pump implantation surgery. Optimal use of this therapy depends on a thorough understanding of intrathecal physiology and anatomy as well appreciation of physicochemical properties of administered medications and the mode of IT delivery.

Management of intractable pain in patients treated with hemorrhoidectomy for mixed hemorrhoids.

Post-hemorrhoidectomy pain is common, usually temporary, and responsive to analgesics. However, some patients experience prolonged, intractable anal pain, which is refractory to conventional analgesics and adversely effects quality of life. We aimed to evaluate the efficacy of a combination injection containing local anesthesia and steroids for the treatment of intractable post-hemorrhoidectomy anal pain. This study included five patients with intractable post-hemorrhoidectomy anal pain who presented between July 2015 and November 2018. Milligan-Morgan hemorrhoidectomy (M-M) with a sclerosant injection had been performed in three patients and stapled hemorrhoidectomy (SH) along with external hemorrhoidectomy in two. For the purpose of this study, all patients received local combination injections containing ropivacaine and triamcinolone acetonide. The primary outcome was the visual analogue scale (VAS) score, and secondary outcomes included the Pittsburgh Sleep Quality Index (PSQI) score, adverse reactions, and recurrence. Prior to treatment, the VAS score was 8 in one patient and 5-7 in four, and the PSQI score was ≥16 in all patients. The injection was administered once (n=4) or twice (n=1). Rapid pain resolution was achieved on the day of treatment (VAS scores 0-3), and patients reported undisturbed sleep the same night. VAS scores were 0-2 (n=4) and 1-3 (n=1), and the PQSI scores were 0-6 (n=4) and 11-15 (n=1) at the 6-month follow-up. No patient reported significant pain or adverse reaction. Intractable post-hemorrhoidectomy anal pain is rare but significantly effects quality of life. While conventional analgesia may be ineffective, the local injection of anti-inflammatory and analgesic drugs may be a useful treatment strategy.

Pituitary Radiosurgery for Management of Intractable Pain: Tokyo Women's Medical University Experience and Literature Review.

Surgical or chemical hypophysectomy has historically shown good effectiveness in management of intractable pain but has often been accompanied by serious complications. In contrast, high-dose irradiation of the pituitary gland and stalk provides comparable analgesic effects and is associated with minimal morbidity. Although its physiological mechanism remains elusive, pituitary radiosurgery using the Gamma Knife has demonstrated high clinical efficacy and safety in cases of both cancer pain and noncancer pain. According to the available data, this treatment provides at least a temporary analgesic effect in >80% of patients, usually within hours to days after the procedure. Although the pain relief is most prominent and durable in cases of metastatic bone disease, it is not limited to that pathological condition or to cases of hormone-dependent cancers. Nevertheless, the low-quality studies reported to date cannot support any meaningful clinical recommendations on use of pituitary radiosurgery. Therefore, additional well-elaborated clinical and basic investigations, preferably performed in a multi-institutional and prospective fashion, are clearly needed and may bolster further developments of this highly promising treatment modality.

Intravenous lidocaine and magnesium on responses of A-δ and A-β nerve fibers at non-affected and affected areas in three cases of neuralgias

Intravenous magnesium and lidocaine have been used for the management of intractable pain individually or in combination. A study reported on the positive effects when used in combination on neuralgia when antiepileptic drugs failed, but nobody has clarified how the combination works. The aim of the present case report is to see how a combination of intravenous magnesium and lidocaine influenced electrically-evoked responses of peripheral A-δ and A-β nerve fibers at non-affected and affected areas in three patients with neuralgia. For nociceptive stimulation, a method of intraepidermal electrical stimulation (IES) was used for the selective activation of cutaneous A-δ fibers, using a stainless steel concentric bipolar needle electrode. For tactile stimulation, similar cutaneous sites were stimulated for cutaneous A-β fibers using the same electrode. Three patients with intractable trigeminal neuralgia or intercostal neuralgia were treated using an intravenous infusion of a combination of 1.2g of magnesium and 100mg of lidocaine for one hour. Although all patients experienced sound pain relief after the combined intravenous infusion therapy, the combination had a different effect on electrically-evoked responses of peripheral A-δ and A-β nerve fibers at non-affected and affected areas in each patient.

Management of Intractable Pain in Patients With Implanted Spinal Cord Stimulation Devices During the COVID-19 Pandemic Using a Remote and Wireless Programming System.

As COVID-19 rampages throughout the world and has a major impact on the healthcare system, non-emergency medical procedures have nearly come to a halt due to appropriate resource reallocation. However, pain never stops, particularly for patients with chronic intractable pain and implanted spinal cord stimulation (SCS) devices. The isolation required to fight this pandemic makes it impossible for such patients to adjust the parameters or configuration of the device on site. Although telemedicine has shown a great effect in many healthcare scenarios, there have been fewer applications of such technology focusing on the interaction with implanted devices. Here, we introduce the first remote and wireless programming system that enables healthcare providers to perform video-based real-time programming and palliative medicine for pain patients with a SCS implant. During the COVID-19 pandemic from January 23, 2020, the date of lockdown of Wuhan, to April 30, 2020, 34 sessions of remote programming were conducted with 16 patients. Thirteen of the 16 patients required programming for parameter optimization. Improvement was achieved with programming adjustment in 12 of 13 (92.3%) cases. Eleven of the 16 (68.8%) patients reported that the system was user-friendly and met their needs. Five patients complained of an unstable connection resulting from the low network speed initially, and three of these patients solved this problem. In summary, we demonstrated that a remote wireless programming system can deliver safe and effective programming operations of implantable SCS device, thereby providing palliative care of value to the most vulnerable chronic pain patients during a pandemic.Clinical Trial Registrationwww.clinicaltrials.gov, identifier NCT 03858790.

Anti‐plexin D1 antibody–mediated neuropathic pain

AbstractNeuropathic pain (NeP) is an intractable pain caused by a lesion or disease of the somatosensory nervous system. NeP is often challenging to manage because most of the mechanisms remain to be elucidated. Recent investigations in the field of autoimmune neurology have demonstrated that specific autoantibodies against antigens in the somatosensory pathway can cause NeP. Detection of pathogenic autoantibodies in NeP adds to the understanding of the mechanism of pain, which might aid in the development of novel immunotherapies. Therefore, it is necessary to explore novel NeP‐related autoantibodies to improve the management of intractable pain. Recently, we screened serum autoantibodies that bound to pain‐conducting small dorsal root ganglion (DRG) neurons and their nerve terminals in the dorsal horns of NeP patients. We detected a novel autoantibody that bound to unmyelinated C‐fiber–type small DRG neurons. The positive rate in patients with NeP was 10%. We identified plexin D1 as the target antigen. NeP patients with plexin D1‐IgG developed burning pain and thermal hyperalgesia. The main comorbidities were allergy, collagen vascular disease, and cancer. Plasma exchange and intravenous methylprednisolone pulse therapy are effective for NeP in patients with plexin D1‐IgG, indicating that these autoantibodies might be pathogenic in NeP. Indeed, our in vitro study demonstrated that plexin D1‐IgG induced the membrane hyperpermeability of DRG neurons. In this review, we describe the discovery of plexin D1‐IgG and discuss the association between plexin D1 and pain, allergy, and cancer.

Central Neuropathic Pain and Complex Regional Pain Syndrome Following Brachial Plexus Injury Treated Successfully With Dorsal Root Entry Zone Lesioning

Abstract INTRODUCTION Central neuropathic pain (CNP) and complex regional pain syndrome (CRPS) present as chronic, unrelenting, and disabling pain resulting from central and peripheral nervous system injuries. For patients who have failed conservative management, dorsal root entry zone (DREZ) lesioning may serve as an alternative for the management of intractable pain. METHODS A 36-yr-old male presented with complete right brachial plexus injury and avulsion of nerve roots following a motorcycle accident. He developed disabling type I CRPS of the right upper extremity. After failing medical therapy, he underwent a trial of conventional SCS using 2 percutaneous leads in the upper cervical spine but did not get topographical coverage. He underwent a second SCS trial with the placement of a paddle lead using burst therapy, but his initial partial pain relief subsided after 3 d. Subsequently, he underwent SCS removal, C2 to T1 right DREZ lesioning, and C4 to T1 laminoplasty. The patient gained a significant pain relief and became more functional. Five months postoperatively, he experienced an improvement in his pain and narcotic consumption. RESULTS Using an insulated neurotomy electrode, 2-mm-deep lesions were made at 75°C for 15 s. A total of 83 lesions were made from T2 to C3. Each lesion was spaced 1 mm apart. The impedance was less than 1000 ohms, which was consistent within an area of injury. Somatosensory and motor-evoked potentials were at baseline during the case without significant changes. CONCLUSION When SCS fails, lesioning of the dorsal root entry zone is a useful tool in the armamentarium for the management of refractory brachial plexus neuropathic pain.

6 Neurosurgical interventions in psychiatry

<i>Retired from clinical practice Jan 2014.</i> <i>Brian qualified from Cambridge University (with Part 2 in Experimental Psychology) and The London Hospital Medical College, 1973. FRCS (England) 1978. Wellcome Trust Research Fellowship – studies on functions of the dopamine systems led to MD (Cantab). Neurosurgical training at the (Royal) London Hospital, with additional special interest in functional neurosurgery. Appointed consultant neurosurgeon at University Hospital of Wales, Cardiff, 1988. Service development: surgical management of intractable pain. Service development: neurosurgery for mental disorder. President, International Neuromodulation Society, 2000–2003. Published widely on therapeutic neurostimulation.</i> <i>2016 – Senior editor, series of evidence-based guidelines on therapeutic neurostimulation and on intrathecal drug delivery.</i> The evolution of “psychosurgery”, now better referred to as Neurosurgery for Mental Disorders (NMD), will be reviewed and discussed in relation to historical context and attitudes. Key considerations for the future will be highlighted. The early history is often regarded now with embarrassment and even horror. The eminent physiologist John Fulton, whose 1935 London lecture triggered the notorious epidemic of radical and relatively indiscriminate frontal lobe surgery, had serious reservations. He knew that intellectual and affective functions could be separated anatomically and was probably the first to advocate more selective procedures, to avoid the sometimes devastating side effects. However, “lobotomy” was given impetus by the eminence of its pioneers, Moniz and Freeman, and by respected neurosurgeons elsewhere, including the UK. The socio-economic benefit of the liberation from asylums of large numbers of indefinite-stay patients for whom, it should be remembered, no drug treatment was available until 1954 (chlorpromazine; antidepressants in 1958), clearly provided great encouragement. However, Walter Freeman’s cavalier approach in the USA helped to close this first chapter. A technically much more specific approach (“Chapter 2”) became available in 1947 when stereotactic neurosurgery for humans (it had long been used in animal experiments) was introduced. Case-selection also gradually improved, moving away from treating schizophrenia and from “correcting” behaviour, towards relieving affective disorders. Anterior capsulotomy was introduced in 1951 and (stereotactic) cingulotomy in 1962. Developments continued, for example subcaudate tractotomy using yttrium⁹⁰ seeds, of which more than 1300 were performed in London from 1961 until the 1990s. There was still much opposition but when a US Congress Commission was convened in 1974, expecting to ban “psychosurgery”, the evidence of benefit and relative absence of harm was now so compelling that it won official approval. The more refined procedures have continued with demonstrable success but in relatively small numbers. Between 1993 and 2008, 55 patients underwent bilateral anterior capsulotomy in Cardiff, 45 for depression. The 24 for whom full datasets were available showed an overall improvement of 52%, with a 75% -or-more improvement in 10. There were no significant changes in executive function, attention and concentration, or immediate and delayed memory, and the adverse-effect profile showed it to be safe. However, antagonism continued to be encountered. Deep brain stimulation (DBS) for psychiatric disorders is not new but it re-emerged in 1999 as a more flexible and superficially more acceptable alternative to traditional lesioning (“Chapter 3 ”). The relative advantages and disadvantages will be discussed. The future for NMD (“Chapter 4”) for otherwise intractable cases should be exciting, with developments in imaging and other technologies and with increasing understanding of targeted conditions. However, the need to exercise great caution, along with issues of consent and regulation, are paramount. NMD is only one tool and its successful and continuing use depends heavily upon cultural attitudes.

Efficacy of peripheral nerve block and rehabilitation combined with psychological and social support for intractable pain management in a pediatric patient with complex regional pain syndrome

Efficacy of peripheral nerve block and rehabilitation combined with psychological and social support for intractable pain management in a pediatric patient with complex regional pain syndrome

Comparison of the Effects of Intermittent Boluses to Simple Continuous Infusion on Patients' Global Perceived Effect in Intrathecal Therapy for Pain: A Randomized Double-Blind Crossover Study.

Intrathecal drug delivery (ITDD) is commonly used for intractable pain management. A paucity of good-quality studies in chronic noncancer patients and concerns over increased dosages have focused interest on different modes of administration. The aim of this international multicenter randomized double-blind crossover trial was to compare the efficacy of the same daily dose of drugs administered by intermittent boluses vs simple continuous infusion. Eligible patients implanted with a programmable ITDD device were randomized to receive two weeks of either intermittent boluses or a simple continuous flow in period 1, followed by a crossover to the alternative mode of administration. The primary outcome measure was the Patients' Global Impression of Change (PGIC) scale. The mean proportion of positive responders (at least "minimally improved") was 38.4% in the continuous condition vs 37.3% in the bolus (difference in proportions = 1.1%, 95% confidence interval [CI] = -21.8-24.0%, P = 0.93). The mean PGIC in the continuous condition was 3.8 vs 3.9 in the bolus (mean difference = -0.1, -0.6-0.4, P = 0.72). Exploratory analyses revealed a tendency for the mean proportion of positive responders to be higher at low vs high flow rates for both bolus and continuous administrations. Two patients were withdrawn from the study due to adverse events during the bolus phase, both with symptoms of increased pain, and one patient with additional symptoms of numbness and urinary retention. The mean PGIC and proportion of positive responders was not substantially different after intermittent bolus vs continuous administration.

Neuromodulation in intractable pain management: outcomes and predictors of revisions of spinal cord stimulators.

OBJECTIVE Spinal cord stimulators (SCSs) appear to be safe and efficacious for chronic intractable back pain. Although there are many reports on percutaneous SCSs, there are very few studies on outcomes of paddle lead SCSs. In addition, the predictors of requirement for SCS revision have not been well established. Here, the authors review the outcome of a case series and attempt to identify the predictors of SCS revisions. METHODS The clinical and radiological information of 141 patients with intractable chronic pain who underwent SCS implantation within the past 20 years was retrospectively reviewed. Paddle lead SCSs were used in this series. Statistical analysis was conducted using Kaplan-Meier curves and Cox proportional-hazards regression. RESULTS Among 141 cases, 90 (64%) did not require any revision after SCS implantations. Removal of the SCS was required in 14 patients. The average pain score was significantly reduced (preimplantation score of 8 vs postimplantation score of 1.38; p < 0.0001). Younger age, male sex, obesity, a preimplantation pain score ≥ 8, and the presence of neuromuscular pain were identified as predictors of the overall requirement for SCS revision. However, only a preimplantation pain score ≥ 8 was identified as a predictor of early failure of the SCS. CONCLUSIONS Implantation of a paddle lead SCS is a relatively less invasive, safe, and effective procedure for patients with intractable back pain. Revision of the procedure depends on many factors, including younger age, male sex, associated neuromuscular pain, and severity of the pain. Therefore, patients with these factors, for whom implantation of an SCS is planned, should be closely followed for the possible requirement for revision.

P160. Transcranial magnetic stimulation in chronic neuropathic pain – A prospective study of 45 patients

Introduction Chronic neuropathic disorders remain difficult to treat. Analgesic medication often achieve only an insufficient effect, therefore other non-pharmacological treatment has to be considered. One option for management of intractable pain is stimulation of the motor cortex by implantation of an epidural electrode. This effect of invasive stimulation could be replaced by transcranial magnetic stimulation. Objectives The objective of the study was to observe the pain reducing effect of non-invasive transcranial magnetic stimulation (rTMS) in patients suffering from different types of chronic neuropathic pain. Materials and methods The study was prospective. We included patients suffering from chronic pain syndroms, such chronic facial pain, poststroke pain, phantom pain and FBSS. The corresponding primary motor cortex has been stimulated with high-frequent, repetitive transcranial magnetic stimulation (rTMS). Stimulation was daily repeated. The individual pain level was assessed by the visual analogue scale (VAS) and documented daily for three weeks. The first follow up was done after 6 weeks. Results We included 45 patients (24 female/21 male) between 31 and 78 years of age. The follow up was done at least after six weeks, further intervals were determined individually with a maximum follow up time of 4 years. A pain reduction in terms of a decrease in the VAS scale was obtained in 58% of patients over all groups, ranging from 2 to 8 points on VAS with a mean value of 3,6. Regarding the etiology of pain we observe a responding rate of 72% in the facial pain group, 40% in the poststroke pain group, 25% in the FBSS group and no responding in the phantom pain group. The pain reduction occurred with a delay between 4 days and 3 weeks, and showed a long term effect up to 10 months. Conclusion Non-invasive transcranial magnetic stimulation seems to be applicable for neuropathic pain syndromes. In chronic facial pain we could observe a higher responding rate than in any other chronic pain syndrome. Pain reduction has a long term effect, which outlast the stimulation period.

Successful Management of Refractory Headache and Facial Pain due to Cavernous Sinus Meningioma with Sphenopalatine Ganglion Radiofrequency.

Headaches and facial pain can be extremely difficult to manage for the patient and the clinician. In the medical literature, it has been suggested that the autonomic reflex plays an important role in the pathophysiology of facial neuralgia. The sphenopalatine ganglion is the largest parasympathetic ganglion outside the cranium. It is an easy accessible target for pain management. The application of radiofrequency nerve ablation was described in the medical literature. In this case report, we describe a 54-year-old female. She was diagnosed with a cavernous sinus meningioma. She underwent surgical resection and gamma knife radiosurgery. She was suffering from an intractable hemifacial pain for many years. Her pain started shortly after surgery and continued throughout many years. Sphenopalatine ganglion block in multiple occasions was able to provide temporary relief. The patient's intractable hemicranial headaches and hemifacial pain responded to the sphenopalatine ganglion radiofrequency nerve ablation. The pain response remained unchanged for 12 months after procedure. This case report increased our current knowledge about the sphenopalatine ganglion role in the headache and facial intractable pain management. The failure of available antalgic medications to adequately control pain in similar patients underscores the need to develop an algorithm for therapies.

Lumbar paravertebral blockade as intractable pain management method in palliative care

Optimal symptoms control in advanced cancer disease, with refractory to conventional pain treatment, needs an interventional procedure. This paper presents coadministration of local anesthetic (LA) via paravertebral blockade (PVB) as the alternative to an unsuccessful subcutaneous fentanyl pain control in a 71-year old cancer patient with pathological fracture of femoral neck, bone metastases, and contraindications to morphine. Bupivacaine in continuous infusion (0.25%, 5 mL · hour−1) or in boluses (10 mL of 0.125%–0.5% solution), used for lumbar PVB, resulted in pain relief, decreased demand for opioids, and led to better social interactions. The factors contributing to an increased risk of systemic toxicity from LA in the patient were: renal impairment; heart failure; hypoalbuminemia; hypocalcemia; and a complex therapy with possible drug-drug interactions. These factors were taken into consideration during treatment. Bupivacaine’s side effects were absent. Coadministered drugs could mask LA’s toxicity. Elevated plasma α1-acid glycoprotein levels were a protective factor. To evaluate the benefit-risk ratio of the PVB treatment in boluses and in constant infusion, bupivacaine serum levels were determined and the drug plasma half-lives were calculated. Bupivacaine’s elimination was slower when administered in constant infusion than in boluses (t½ = 7.80 hours versus 2.64 hours). Total drug serum concentrations remained within the safe ranges during the whole treatment course (22.9–927.4 ng mL−1). In the case presented, lumbar PVB with bupivacaine in boluses (≤ 137.5 mg · 24 hours−1) was an easy to perform, safe, effective method for pain control. Bupivacaine in continuous infusion (≤150 mg · 12 hours−1) had an acceptable risk-benefits ratio, but was ineffective.

P 122. Transcranial magnetic stimulation in neuropathic facial pain – A prospective study of 17 patients

Introduction Atypical facial pain as a kind of neuropathic disorders could occur after traumatic lesions and remains difficult to treat. One option for management of intractable pain is stimulation of the motor cortex by implantation of an epidural electrode. This effect of invasive stimulation could be replaced by transcranial magnetic stimulation. Objectives The objective of the study was to observe the pain reducing effect of non-invasive transcranial magnetic stimulation (rTMS) in patients suffering from atypical facial pain, and furthermore to detect whether there is a predictive value for invasive motor cortex stimulation (MCS). Materials and methods The study was prospective but not randomized. We included patients suffering from chronical neuropathic facial pain. Seven patients suffered from posttraumatic pain, 10 patients suffered from idiopathic atypical facial pain. The primary motor cortex has been stimulated with high-frequent, repetitive transcranial magnetic stimulation (rTMS). Stimulation was daily repeated for a period of 9 days. The individual pain level was assessed by the visual analogue scale (VAS) and documented daily for three weeks. The first follow up was done after 6 weeks. Results We included 17 patients (13 female/4 male) between 32 and 75 years of age. The follow up was done at least after six weeks, further intervals were determined individually. The mean follow up was 4,6 months with range from 6 weeks to 2,5 years. A pain reduction in terms of a decrease in the VAS scale was obtained in 13 patients, ranging from 2 to 8 points with a mean value of 3,9. The pain reduction occurred with a delay between 4 days and 3 weeks, and showed a long term effect from 3 weeks up to 6 months. Two patients successfully underwent an invasive motor cortex stimulation. Conclusion Non-invasive transcranial magnetic stimulation seems to be applicable for some kind of neuropathic pain, i.e. atypical facial pain. Pain reduction has a long term effect. Furthermore, it may be used as a positive predictor for invasive motor cortex stimulation.

Prior Surgery Determines Islet Yield and Insulin Requirement in Patients With Chronic Pancreatitis

Total pancreatectomy with islet autotransplantation (TP-IAT) is safe and effective in the management of intractable pain associated with chronic pancreatitis (CP). Prevention of pancreatogenic diabetes after TP-IAT is related to islet yield from the diseased pancreas. The purpose of this study is to compare islet yield and insulin requirement in the 76 patients who underwent different surgical procedures before TP-IAT at the Medical University of South Carolina between 2009 and 2011. Patients were grouped into four categories based on the operation they had before TP-IAT: transduodenal sphincteroplasty/no prior surgery (n=50), Whipple or Beger procedure (n=14), distal pancreatectomy (n=8), or lateral pancreaticojejunostomy (n=4). Islets were harvested from pancreases of those patients at our current good manufacturing practice facility. Total unpurified islets were transplanted into patients via portal vein infusion. Pancreatic fibrosis, islet yield, cell viability, and insulin requirement were measured. The pancreases of transduodenal sphincteroplasty/no prior surgery and Whipple or Beger procedure patients were less fibrotic and had higher islet yield compared with those who had distal pancreatectomy or lateral pancreaticojejunostomy. Higher islet yield also correlated with a greater diabetes-free rate and a lesser insulin requirement at the following intervals: preoperative, postoperative, and 6 months after TP-IAT. Prior surgery is strongly correlated with the extent of pancreatic fibrosis, islet yield, and insulin requirements in CP patients undergoing TP-IAT. The history of prior pancreatic resection and drainage procedures may be used to predict postoperative islet function and help to determine the optimal timing for TP-IAT in CP patients.