Neuroablative Techniques Research Articles

Innervation and Neuronal Control of the Mammalian Sinoatrial Node a Comprehensive Atlas.

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Balancing Consult Team Staffing Levels and Service Commitments (313)

population and the potential uses of interventional pain management techniques. Appropriate candidates for interventional therapy will be identified. Neuraxial drug delivery systems (epidural and intrathecal) for pain management will be discussed, as well as peripheral and autonomic nerve blockade for palliative care. The use of spinal cord stimulation, neuroablative techniques, and neurosurgical techniques for pain control will be discussed. Review of the literature, recommendations, and guidelines by professional organizations and governmental agencies, and consensus of experts will guide the palliative care practitioner in formulating a strategy for consideration of these techniques in patients. The efficacy, potential adverse effects, and complications associated with these techniques will be discussed.

Radiofrequency and cryoablation for cancer pain

Prevalence of pain in patients with cancer is high and is a feared and burdensome symptom. There has been a paradigm shift away from the World Health Organization ladder with adoption of interventional treatments early on in the treatment of cancer pain. Intentional destruction of nerves (neurolysis) with chemical (alcohol or phenol), heat (radiofrequency), or cold (cryo) are treatment modalities used to treat cancer pain. These management modalities have become both mainstays of cancer pain therapy and adjuvants to medical management. Chemical neurolysis with phenol or alcohol are commonly used for sympathetic neurolysis. Radiofrequency ablation (conventional and pulsed) and cryoablation are widely used in the treatment of nonmalignant pain. The published data on the use of theses modalities in the cancer population consist mainly of case reports. At the University of Texas MD Anderson Cancer Care Center, neuroablative techniques are frequently used to control refractory cancer pain. The evolution, histologic effect of radiofrequency and cryoablation, and their application are reviewed herein. Common clinical applications and specific techniques conducted at MD Anderson Cancer Care Center are used as examples of how these techniques can be applied to treat cancer related pain.

Síndrome postlaminectomía lumbar I: Tratamiento del dolor mediante técnicas intervencionistas

Chronic low back pain and ciatica after surgery is one of the main reasons for referring patients to multidisciplinary pain units (MPU). The future expansions of MPU have promted neurosurgeons in Spain to re-enter the field of chronic pain management and to recover their enthusiam, that have been lost severel years ago for various reasons. We do not intend dealing with the new instrumented surgical options for the post-laminectoy pain, but rather into the indications and descriptions of the interventional techniques for lumbar and sciatic pain managemet. Currently there are a great number of percutaneous techniques to achieve pain control in the post-laminectomy syndrome. Traditional neuroablative techniques at the spinal cord or the cerebral levels are not any longer indicated. Nonetheless, lumbar sympathectomy and thermo-neurolisis either with chilling or heating, are back in favour, due to the development of new devices and applications. Neuromodulation techniques which are also applicable to this pathology will be the subjet of another article. Pulsed radio-frecuency apperars to favour the safe application of electricity to the dorsal root ganglion or to the root itself thus avoiding the fear of permanent root and/or ganglion thermal lesions that frecuently occurred with the older techniques. Several strategies for pain relief are described, step by step and real figures are depicted in order to make the procedures more understandable and for the easier transmission of knowledge.

Decision-Making for Neurosurgical Treatment of Disabling Spasticity in Adults

When spasticity becomes harmful and leads to further functional losses despite physical therapy and appropriate medications, patients may benefit from intrathecal baclofen (ITB) therapy, botulinum toxin injections or selective ablative surgical procedures. The surgical lesions can be made at the level of the peripheral nerves, spinal root, spinal cord, or dorsal root entry zone. We describe the decision-making process for the treatment of hyperspasticity in the lower and upper limbs in paraplegic and hemiplegic patients. Briefly, ITB is indicated for paraplegic or tetraplegic patients with diffuse spasticity, especially when from a spinal origin. Neuroablative techniques are indicated for severe focalized spasticity in the limbs after BT injections fail. Frequently, complementary orthopedic surgery may be useful in patients with associated contractures and deformities.

Diagnosis and management of trigeminal nerve disorders

Diagnosis and management of trigeminal nerve disorders

Application of spinal ablative techniques for the treatment of benign chronic painful conditions: history, methods, and outcomes.

The literature on current neuroablative techniques for treating benign chronic painful conditions is comprehensively reviewed. To provide the reader with an understanding of the indications, techniques, and outcomes for the various ablative procedures used to treat chronic pain syndromes. Neuromodulatory techniques are rapidly supplanting the traditional neuroablative procedures used to treat many types of pain. A MEDLINE search was conducted for each of the following procedures: radiofrequency facet denervation, cordotomy, myelotomy, sympathectomy, DREZotomy, rhizotomy, and ganglionectomy. In the review of each article, special attention given to the outcome, length of follow-up, complications, and number of patients. Summaries of this data were compiled to provided historical perspective, current techniques, indications, and outcomes for each of the aforementioned procedures. The outcomes cited for each procedure generally represent the data from the three or four largest series with adequate follow-up length. The aforementioned procedures have 30% to 90% success rates, with success defined as at least a 50% reduction in perceived pain. These results tend to diminish with time. However, most are associated with a significant degree of morbidity and relatively high complication rates. In addition, many of the techniques lead to deafferentation pain syndromes. Ablative spinal techniques offer pain relief for many patients, but the use of these methods should be considered carefully in the light of available nondestructive procedures that may achieve similar goals with potentially lower morbidities.

The surgical management of spasticity

Neurosurgery is only considered for severe spasticity following the failure of noninvasive management (adequate medical and physical therapy). The patients are carefully selected, based on rigorous multidisciplinary clinical assessment. In this we evaluate the contribution of the spasticity to the disability and any residual voluntary motor function. The goals for each patient are: (a) improvement of function and autonomy; (b) control of pain; and (c) prevention of orthopaedic disorders. To achieve these objectives, the surgical procedure must be selective and reduce the excessive hypertonia without suppressing useful muscle tone and limb functions. The surgical procedures are: (1) Classical neuro-ablative techniques (peripheral neurotomies, dorsal rhizotomies) and their modern modifications using microsurgery and intra-operative neural stimulation (dorsal root entry zone: DREZotomy). These techniques are destructive and irreversible, with the reduced muscle tone reflecting the nerve topography. It is mainly indicated when patients have localized spasticity without useful mobility. (2) Conservative techniques based on a neurophysiological control mechanism. These procedures are totally reversible. The methods involve chronic neurostimulation of the spinal cord or the cerebellum. There are only a few patients for whom this is indicated. Conversely, chronic intrathecal administration of baclofen, using an implantable pump, is well established in the treatment of diffuse spasticity of spinal origin. From reports in the literature, we critically review the respective indications in terms of function, clinical progression and the topographic extent of the spasticity.

Surgical pelvic neuroablation for chronic pelvic pain: a systematic review

Objective To determine, from the best available evidence, the effectiveness of surgical pelvic neuroablative techniques as treatment for primary and secondary dysmenorrhoea. Design Systematic review of randomized controlled trials (RCTs). Subjects Women with primary or secondary dysmenorrhoea. Interventions Surgical neuroablative techniques including uterine nerve ablation and presacral neurectomy. Main outcome measures Pain relief (both short- and long-term) and adverse effects. Results Laparoscopic uterine nerve ablation (LUNA) has been shown by one small study to be effective for primary dysmenorrhoea up to 12 months. A larger study showed no significant difference between LUNA and laparoscopic presacral neurectomy (LPSN) in pain relief for primary dysmenorrhoea up to 6 months, but LPSN was significantly more effective beyond 6 months. For dysmenorrhoea secondary to endometriosis, two trials found no significant difference in pain relief afforded by LUNA plus conservative laparoscopic surgery for endometriosis vs. conservative laparoscopic surgery alone. Presacral neurectomy (PSN) plus conservative surgery for endometriosis at laparotomy vs. conservative surgery for endometriosis at laparotomy showed no significant difference in overall pain relief, although there was a significant difference in relief of midline abdominal pain. Adverse events overall were significantly more common following PSN; these included constipation, urinary urgency, painless labour and one case necessitating a laparotomy for presacral haematoma 2 days after PSN. Conclusions There is insufficient evidence to recommend the use of surgical pelvic neuroablation in the management of dysmenorrhoea, regardless of cause. Further scientifically rigorous RCTs should be undertaken.

Long-term effects of nerve blocks in chronic pain

Regional blockade techniques have been of crucial importance for decades in chronic pain therapy, but in recent years some developments have made a new definition of the status of invasive procedures necessary. The realization of chronic pain as a multifactorial process led to the establishment of an interdisciplinary approach to pain therapy, leaving blockades as only one step in a multimodal therapy. The mainstay of local anaesthetic blocks now is diagnostic and prognostic, but correct interpretation of the results is limited by different factors, and controlled studies on the diagnostic value of local anaesthetic blockade are lacking. In cancer pain, invasive procedures are necessary in only a few cases. Some neuroablative techniques can offer long-term pain reduction. In non-cancer pain, neurodestructive procedures should be reserved for some special indications (e.g. lumbar sympathetic neurolytic blocks in ischaemic diseases). In a great number of chronic pain conditions the sympathetic nervous system is involved or even has a central status. In the acute stage of these diseases sympathetic blockades can be the therapy of choice. There is no disease in which different invasive procedures are performed so frequently and so uncritically as in chronic low back pain. Up to now, however, all controlled studies of invasive procedures only demonstrated short-term effects and failed to prove long-term efficacy. Therefore any invasive technique should only be performed in well-selected patients over a defined period and with a limited number of blockades.

Neuroablative techniques for cancer pain management

Neurolytic/neurodestructive blockade can be therapeutic for some pain syndromes. In general, it is fell that the longer a pain syndrome is present, the less likely that nay single intervention including neurolytic/neurodestructive blockade, will be singularly successful. A balanced program is recommended and should include physical modalities along with medical, surgical, and anesthetic intervention when required. In this article the reader studies the technologies and techniques of neurodestruction which can be utilized clinically as part of balanced analgesia.

Practice Guidelines for Cancer Pain Management

Practice Guidelines for Cancer Pain Management

Cancer pain management. Current strategy.

Pain is among the most prevalent symptoms experienced by cancer patients. A strategy for the management of cancer pain is now widely accepted, and when well implemented, is usually effective. Unfortunately, many oncologists are ill-prepared for the task of pain assessment and management, and the outcomes achieved in clinical practice are often suboptimal. The various elements in the pain management strategy are described. Patient assessment, the use of primary therapies and systemically administered nonopioid and opioid analgesics are pivotal to the strategy. Practical aspects of opioid pharmacotherapy encompass drug selection and dosing considerations including selection of an appropriate route of administration, dose titration, and the management of side effects. Specific approaches are described for the treatment of patients for whom an acceptable balance between relief and side effects of opioids is not achieved. These comprise noninvasive interventions, including the use of adjuvant analgesics, psychological therapies, and physiatric techniques, and invasive interventions, such as the use of intraspinal opioids, neural blockade, and neuroablative techniques. Finally, the use of sedation in the treatment of patients with pain that is refractory to other interventions is addressed. The skilled application of this strategy can provide adequate relief to the vast majority of patients, most of whom will respond to systemic pharmacotherapy alone. Patients with refractory pain should see specialists in pain management or palliative medicine who can address these difficult problems.

Polarised views on treating neurogenic pain

This study aimed to identify areas of disagreement in the management of neurogenic pain. A short questionnaire was mailed to 179 consultants with an interest in chronic pain (response rate 89%). The questionnaire listed 11 specific conditions involving nerve pain (e.g., post-herpetic neuralgia, causalgia) together with 11 treatments (e.g., antidepressants, neurectomy). Consultants were asked to rate the use of each treatment for each condition as ‘appropriate’, ’no value or positively harmful’ or ‘no opinion’. Much disagreement emerged about the value of each therapy for each condition: in almost every instance at least some consultants disagreed with the majority view. The dissenting minority was greater than 20% of those who gave an opinion for 48 of the 121 applications of therapy asked about. The appropriateness of treatments for trigeminal neuralgia, amputation stump pain and phantom pain was most often in dispute and there was little consensus on the value of nerve blocks. There were a few areas of near agreement. Antidepressants and anticonvulsants were mostly identified as appropriate for all the conditions listed and there was some agreement that strong opioids and the neuroablative techniques were appropriate for cancer pressure or infiltration of nerves but, with a few exceptions, of no value for all other neurogenic pain conditions. Divergence of views about treatments may indicate a lack of credible evidence on the value of therapies or a lack of professional knowledge. Where published evidence is clear, the consequences for patients may be under-use of useful therapies or potential iatrogenic harm.