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All Posts Tagged: Chronic Pain

Postoperative chronic pain

 

 

This category includes a number of conditions such as the so-called failed back / failed neck pain syndrome. Many of these patients continue to suffer from pain, although clinical and imaging tests (X-rays, MRI scans, etc.) do not identify any cause of their pain.

Implantation of spinal cord stimulators in the spine

Postoperative chronic painIn selected cases , implantation of spinal cord stimulators in the spine may help.The correct diagnosis of the syndrome made by specialized doctors (anesthesiologists, neurologists, or neurosurgeons) and the correct choice of patients who may benefit from it is a prerequisite. The stimulator is implanted in the patient’s body, usually in the abdomen. After a short period of training it can be used by the patients themselves through a simple remote control, depending on the intensity and location of their symptoms. It significantly improves symptoms by controlling pain in the exact area where it occurs. The implant operation is relatively simple. The surgery lasts 30-45 minutes, under general anesthesia, and the duration of postoperative treatment is 2-3 days. The use of the system can start during the hospitalization of the patient and its beneficial effects are immediately felt. About 2 in 3 patients in this category are relieved of their symptoms and no longer need to take chronic medication with all its possible side effects.

 

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Post-traumatic pain

 

 

This describes the type of pain that persists after an injury, and is usually identified with neuropathic pain, i.e. pain that is not due to the injury itself, but to the chronic irritation of a nerve or nerves, and that lasts after the patient’s injuries have healed. Modern neurosurgery can help in the cases when chronic post-traumatic pain is diagnosed and medication is not enough.

Implantation of spinal cord stimulators in the spine

The implantation of spinal cord stimulators in the spine offers significant relief to most of these patients (approximately 60%). A prerequisite is the correct diagnosis of the syndrome, made by specialized doctors (anesthesiologists, neurologists, or neurosurgeons) and the correct choice of patients who may benefit from it. The stimulator is implanted in the patient’s body, usually in the abdomen, and after a short period of training it is used by the patient themselves, through a simple remote control, depending on the intensity and location of the patient’s symptoms. It significantly improves symptoms by controlling pain in the exact area where it occurs. The implant operation is relatively simple. The surgery lasts 30-45 minutes, under general anesthesia, and the duration of postoperative treatment is 2-3 days. The use of the system can start during the hospitalization of the patient and its beneficial effects are immediately felt.

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Ghost member pain

 

 

This is a relatively rare disorder, attested in patients who have had a limb amputated, and after a period of time they start feeling pain in the missing limb. The mechanism of this disorder is not very well known, but it seems that it involves centers of the spinal cord and possibly the brain. There are special surgeries placing electrodes in areas of the brain that can treat the problem in selected patients. Selective spinal cord areas may also be selectively destroyed (DREZ lesion – destruction of the posterior spinal cord entry zone), and results have been promising.

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Complex Regional Pain Syndrome

 

 

This is the name given to the syndrome that used to be called reflex sympathetic dystrophy and heartburn. There are 2 distinct types of this syndrome. In type I no nerve injury can be found, while in type II the nerve injury is given. It can occur in patients who have undergone an injury or surgery at the upper or lower limbs. The onset of the syndrome is thought to be related to some form of inflammation in the affected nerve; unfortunately often it does not respond to the usual analgesic treatment. It is often accompanied by redness of the limb and reaction even to non-painful stimuli. Sometimes even a simple touch on the affected area can cause pain.

Modern treatments

Contemporary neurosurgery can suggest a modern treatment to these patients who continue to suffer despite taking medication, or if medication cause serious side effects. The implantation of spinal cord stimulators in the spine offers significant relief to 60-80% of these patients. The correct diagnosis of the syndrome made by specialized doctors (anesthesiologists, neurologists, or neurosurgeons) and the correct choice of patients who may benefit from it is a prerequisite. The stimulator is implanted in the patient’s body, usually in the abdomen. After a short period of training it can be used by the patients themselves through a simple remote control, depending on the intensity and location of their symptoms. It significantly improves symptoms by controlling pain in the exact area where it occurs. The implant operation is relatively simple. The surgery lasts 30-45 minutes, under general anesthesia, and the duration of postoperative treatment is 2-3 days. The use of the system can start during the hospitalization of the patient and its beneficial effects are immediately felt.

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Trigeminal neuralgia

Trigeminal neuralgia is a neurological condition characterized by painful episodes involving the face. The pain is extremely sharp, it lasts for a few seconds, and it is often caused even by mild stimuli, such as chewing, smiling, touching the affected area, shaving, brushing your teeth, etc. Quite often, this is an unbearable pain that significantly affects the quality of life and requires aggressive treatment.

Conservative treatment

The first line treatment for neuralgia is medication. Medication used includes carbamazepine, pregabalin, and others; some of these are classified as antiepileptic drugs. In the majority of patients, they adequately control pain symptoms. Antidepressants could also be used, always under the strict supervision of the treating physician. If these fail to control the symptoms, there are invasive treatments that could have positive results.

Mild invasive treatment: Radiofrequency ablation, with electrophysiological control, on the CT scanner

This is the most modern, minimally invasive and safest methodof treating neuralgia. The use of the CT scanner is 100% accurate in accessing the target, minimizing the possibility of injury to other tissues (for example, a large vessel). With ideal targeting, the patent foramen ovale (exit point of the trigeminal nerve) is accessed.

At the same time, in order to minimize the possibility of causing painful anesthesia on the nerve, electrophysiological control and test ablation are performed, for the immediate assessment and more accurate localization of the treatment result, which the patient can perceive immediately. This method allows us to have a success rate of over 93%, almost as much as with open surgery, but without the risks involved in surgery.

This method was first published in 2004 in the international literature and is constantly gaining popularity. We have applied it to more than 500 patients in the last 5 years in Greece, and we have published our excellent results. Its only disadvantage is that it must be repeated every 2-4 years. This operation is performed under local anesthesia and conscious sedation and requires a hospital for only 2-3 hours (day hospitalization).

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4. Surgical treatment

When conservative treatment and mild management fail, there is an indication for surgery. This is carried out under general anesthesia and involves a small removal of bone in the area behind the ear, followed by decompression of the nerve at the point where it comes in contact with vessels in the area. It is now proven by clinical and surgical experience that neuralgia is caused by the close proximity of the trigeminal nerve to the vessels of the location where it arises from the brain. The arteries mostly can transmit their pulse, “pounding” the nerve and causing the neuralgia.

Surgical treatment has significant advantages and disadvantages. It is the most effective treatment with a success rate of over 90%, without causing catastrophic nerve damage, with all its consequent risks. There is a reduced need to take medication, therefore their often serious adverse events, especially associated with long-term use, are also reduced. At the same time, however, it is still a serious operation with ~ 1% mortality rate and 10-15% rate for temporary or permanent morbidity (hemorrhaging, meningitis, cerebrospinal fluid leakage from the wound). It requires about a week of hospital stay post-operatively.

The improvement in surgical techniques is constantly reducing mortality and morbidity rates.

Let us mention the older methods, i.e. the infiltration of the trigeminal nerve with alcohol or glycerol, offering temporary or even medium-term relief of symptoms. Balloon compression of the ganglion has also been used, causing pressing damage to the trigeminal nerve in order to relieve pain. Percutaneous stereotactic radiofrequency rhizotomy (PSR) is another option; using a special navigator, where radiofrequency is applied on the trigeminal nerve (thermal destruction) or it receives a glycerol injection (chemical destruction). This offers relief but there can be side effects, the most important being anesthesia dolorosa (painful anesthesia), a condition that is difficult to treat.

Another modern technique is stereotactic radiosurgery with γ-knife (Gamma Knife Radiosurgery), a method that does not require open surgery, i.e. it is non invasive, but is very expensive, it takes time to relieve the symptoms and does not have high success rates (50-60%).

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Diabetic peripheral neuropathy

 

 

A large percentage of the population suffers from diabetes. In a percentage of the diabetic patients, microangiopathy develops due to chronic hyperglycemia and due to the poor condition of the small vessels of the upper and lower limbs. These small vessels supply blood to the small nerves that are distributed in the arms and legs. Neuropathy gradually develops due to poor perfusion of these nerves. The patient initially complains of decreased sensation and numbness in the hands and feet. This symptom may then develop into pain that is not controlled by painkillers. In some cases, invasive treatments are required to treat these symptoms; these treatments include subcutaneous electrode placement with a special pacemaker, which relieves many diabetic patients.

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