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Background There is a relative paucity of long-term follow-up of treatment of brainstem cavernous angiomas. This has led to uncertainty and a lack of consensus regarding optimum therapy, especially radiosurgery. Methods Report of a single case with a 24-year follow-up. Results This patient was minimally symptomatic before her radiosurgery procedure. She developed an acute complication, from which she incompletely recovered. Two decades later she has become more symptomatic, with new deficits, and magnetic resonance imagings disclose progressive brainstem atrophy. Conclusions Long-term follow-up of patients treated with radiosurgery is important.

BACKGROUND Enthesopathies are a common cause of axial pain that is amenable to "minimally invasive" therapy. OBJECTIVE To evaluate the effectiveness of injection therapy for enthesopathies. DESIGN Single blinded, randomized, and cross-over study. METHODS Thirty-five patients diagnosed as having painful enthesopathies as a major pain generator were studied. Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery. Patients were injected either with anesthetics alone or with anesthetics combined with phenol-glycerol proliferant prolotherapy. Outcomes were analyzed both clinically at the time of regular follow-ups, and by a series of multipart questionnaires. RESULTS Patients received a total of 86 injections, 39 with local anesthetics, and 47 with prolotherapy. By clinical assessment patients obtained excellent to good relief of pain and tenderness after 80% of prolotherapy injections, but only 47% after anesthetics alone. By questionnaire, 66% reported excellent to good relief after prolotherapy vs. 34% after anesthetics alone. Patients reported improvement in work capacity and social functioning following both types of injections, but a greater reduction in focal pain intensity following prolotherapy injections. The mean and median durations of persistent relief were 2.4 and 1.75 months with prolotherapy vs. 1.8 and 0.75 months with anesthetics alone. Roughly 10% obtained greater than six months of relief from either injection. In the crossover portion of the study, patients reported that prolotherapy injections following initial anesthetic-only injections provided much better relief than that achieved after their anesthetic-only injections, and that anesthetic-only injections following initial prolotherapy injections failed to provide relief as good as that achieved after their prolotherapy. Subsequent to this study, only four of 35 patients required additional spine surgery, but 29 of the 35 patients requested additional injections. CONCLUSIONS Injection therapy of painful enthesopathies can provide significant relief of axial pain and tenderness combined with functional improvement, even in "failed back syndrome" patients. Phenol-glycerol prolotherapy provides better and longer lasting relief than injection with anesthetics alone. Prolotherapy provides over six months of relief for some patients but generally provides relief for only a few months. However, most patients described good to excellent relief, felt that the injections had been beneficial, and requested additional injections for recurrent or residual focal pain.

Object. Sensory ganglionectomy offers theoretical advantages over rhizotomy but remains controversial because reported success rates vary widely. The authors sought to add to the available data on this subject and to review technical aspects of the surgery. Methods. This retrospective chart review included 19 patients, in whom 22 operations were performed and 35 sensory ganglia were resected between May 1995 and May 1999. The eight women and 11 men ranged in age from 27 to 75 years (median age 40 years, average age 42.3 years). All patients had undergone extensive therapy and a mean of 2.4 previous operations (median three, range zero—eight operations) for their pain, all without long-term pain relief. Duration of symptoms varied, from 1 month (for the cancer patient) to 15 years (mean 5.9, median 4 years). Preoperatively, all patients underwent diagnostic selective nerve root blocks, which temporarily relieved their targeted pain. The duration of follow up averaged 22 months (median 13, range 1.5 [to death of the cancer patient]—58 months). Before undergoing the first ganglionectomy, nearly all patients rated their targeted pain as 8 to 10 (average 9.6, median 10) on an analog (0–10) pain scale. At 6 months all patients rated their ganglionectomy-specific pain as an average of 4.5 (median 4, range 0–8), and pain reduction of 50% or more was achieved in 74%. At 1 year or more the 13 patients available for study rated their pain as an average of 4.3 (median 4.5, range 0–9). There were no severe complications, residual pain was never worse than presurgical pain, and no patient experienced significant or lasting new motor deficits. Conclusions. Dorsal root ganglionectomy has a useful role in the treatment of a variety of refractory pain states, especially those involving radicular pain.

Objective To document the value of bilateral anterior cingulotomy for patients with intractable chronic noncancer pain. Methods Twenty-three patients who underwent 28 cingulotomies between 1979 and 1996 for chronic refractory pain were sent questionnaires regarding their subjective response to the surgery and its impact on their pain. Questions dealt with pre- and postoperative pain, ability to resume work or usual activity, medications, family and social interactions, and overall benefit of cingulotomy. Results were compared with long-term (average, 8 yr) clinical follow-up. In 13 patients, pain was predominantly caused by lumbar adhesive arachnoiditis or "failed back." The remainder had venous occlusive disease, ischemic bilateral leg pain, phantom leg pain, postoperative neck pain, or atypical facial pain. Results Eighteen patients returned questionnaires; two patients died of unrelated causes. Seventy-two percent of patients reported improvement in their pain, 55% were no longer taking narcotics, 67% noted improvement in their family life, and 72% noted improvement in their social interactions. Fifty-six percent of patients reported that the cingulotomy was beneficial, and 28% returned to their usual activities or work. Thirty-nine percent of patients developed transient or well-controlled seizures. Five patients required a second cingulotomy, and one patient did well despite developing brain abscesses. Patient assessments corresponded closely with clinical assessments. Conclusion Bilateral anterior cingulotomy is safe for patients with refractory chronic pain. Seizures reported in this series were well controlled with medication. More than half of all respondents thought they had a positive outcome and that cingulotomy was beneficial to them. There were no deaths related to the procedure.

Object. Trigeminal neuralgia or tic douloureux is a disease affecting older individuals, and thus, office-based “minimally invasive” therapy is inherently attractive. The author sought to determine whether injection of peripheral trigeminal branches with neurolytic solutions offers a simple, less invasive therapy, with low risk for patients with one- or two-division trigeminal neuralgia that is unresponsive to pharmacotherapy.Methods. This retrospective study focused on a review of case charts from 18 patients treated for tic douloureux. Sixty injections of 10% phenol in glycerol were given to the 18 patients, six of whom had undergone other neurosurgical procedures. The median patient age was 74 years, ranging from 36 to 94 years. There were nine women and nine men. Forty-six injections were administered into the infraorbital nerve in its canal in the midface, 11 percutaneous injections were administered into the mandibular nerve just proximal to the mandibular canal in the ramus of the jaw, and three injections were administered into supraorbital nerves. Eighty-seven percent of injections brought marked or total relief initially. Of those injections that provided initial relief, 37% still provided relief after 1 year and 30% after 2 years, with relief lasting for a median of 9 months after each injection. Most patients whose pain recurred after months of relief requested a repeated procedure, rather than undergo a ganglion nerve block procedure or open surgery. There were no serious complications or dysesthetic pain. Facial sensory loss generally recovered within 6 months and was well tolerated.Conclusions. Office-based injection of trigeminal branches is a useful technique for neurosurgeons who treat trigeminal neuralgia. It is easily repeated and can provide immediate pain relief of intermediate duration.

Tyrosine hydroxylase immunocytochemistry was used to reveal the sympathetic postganglionic axons that sprout to form basket-like skeins around the somata of some primary sensory neurons in dorsal root ganglia (DRGs) following sciatic nerve injury. Ultrastructural observations in rats revealed that these sprouts grow on the surface of glial lamellae that form on the neurons. Sciatic nerve injury triggers glial cell proliferation in the DRG, and the formation of multilamellar pericellular onion bulb sheaths, primarily around large diameter DRG neurons. We infer that these glia participate in the sprouting process by releasing neurotrophins and expressing growth supportive cell surface molecules. Many DRG cell somata, and their axons in intact nerves and nerve end neuromas, express α2A adrenoreceptors intracytoplasmically and on their membrane surface. However, sympathetic axons never make direct contacts with the soma membrane. The functional coupling known to occur between sympathetic efferents and DRG neurons must therefore be mediated by the diffusion of neurotransmitter molecules in the extracellular space. Sympathetic basket-skeins were observed in DRGs removed from human neuropathic pain patients, but the possibility of a functional relation between these structures and sensory symptoms remains speculative.

Hope, false hope, and self-fulfilling prophecy are important aspects in the practice of medicine for all practitioners but are especially important in the field of neurosurgery, which deals with devastating, terrifying, and often fatal illnesses. The American Board of Medical Specialties and the Accreditation Council of Graduate Medical Education have jointly defined 6 “general competencies” that define a competent physician and should be part of the curriculum of all residency programs. One of these 6 is interpersonal and communication skills. A true test of this competence is the ability to harness the powerfully beneficial forces of hope and motivation and to avoid the destructiveness of false hope and self-fulfilling prophecy.

Between June 1979 and May 1994, I performed 148 unilateral or bilateral sympathectomies on 247 limbs in 110 patients using a percutaneous radiofrequency technique, usually on an outpatient surgery basis. Patient ages ranged from 10 to 81 years, with 45 male and 65 female patients. Four patients had unsuccessfully undergone prior open surgical sympathectomy. Patients suffered from hyperhidrosis, vascular occlusion, Raynaud's disease or other chronic vasculopathies, painful causalgia or reflex sympathetic dystrophy, or Prinzmetal's angina. The sympathectomy technique has evolved over this 15-year period and is currently in its third phase. Changes in the procedure were based on anatomic and clinical/radiographic correlations and careful patient follow-up. Current modifications have reduced the frequency of both early and late failures. The present technique (Phase III) relies on neuroleptanalgesia with superficial local anesthesia only and does not require general anesthesia, intubation, or lung collapse. Two 18-gauge radiofrequency TIC needle electrodes (Radionics, Burlington, MA) are used. A series of three lesions is rostrocaudally made at each of the ganglion sites selected in an attempt to destroy the entire fusiform ganglion. Lesion sites are targeted by C-arm fluoroscopy and electrical stimulation, which produces a threshold of sensory awareness of > 1.0 V. Lesion effectiveness is monitored by bilateral finger plethysmography and hand skin temperature measurement. With the Phase III technique, the sympathetic activity in 96% of operated limbs after 2 years and in 91% of operated limbs after 3 years continues to be completely or largely interrupted. By comparison, I achieved similar success in 83 and 72% operated limbs with the Phase I technique and in 77 and 71% with the Phase II technique. Symptomatic pneumothorax, in six patients, has been the only serious complication. When necessary, a subsequent operation can easily be performed and is effective.

Intrathecal methylprednisolone acetate (IT-MPA) treatments have been reported to be beneficial and safe for the treatment of low back problems and especially "failed back" problems, which include adhesive arachnoiditis. Other reports, however, have stressed the potential dangers of this treatment and have advised against its use. Many of these papers implicate the propylene glycol included in the methyl-prednisolone as being potentially harmful. Since the literature is rather extensive and clearly conflicting, it is difficult for those who treat patients with "failed back" problems to ascertain the risk/benefit ratio of this form of treatment, so a literature review and analysis has been undertaken. Published literature clearly attests to the usefulness and general safety of IT-MPA when used within certain limits. Although several studies implicate IT-MPA as a potential cause of arachnoiditis or other neurologic injury, most of the evidence is circumstantial and most complications followed multiple, large-dose, or frequent injections.

Enthesopathies are a common cause of axial pain that is amenable to "minimally invasive" therapy.To evaluate the effectiveness of injection therapy for enthesopathies.Single blinded, randomized, and cross-over study.Thirty-five patients diagnosed as having painful enthesopathies as a major pain generator were studied. Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery. Patients were injected either with anesthetics alone or with anesthetics combined with phenol-glycerol proliferant prolotherapy. Outcomes were analyzed both clinically at the time of regular follow-ups, and by a series of multipart questionnaires.Patients received a total of 86 injections, 39 with local anesthetics, and 47 with prolotherapy. By clinical assessment patients obtained excellent to good relief of pain and tenderness after 80% of prolotherapy injections, but only 47% after anesthetics alone. By questionnaire, 66% reported excellent to good relief after prolotherapy vs. 34% after anesthetics alone. Patients reported improvement in work capacity and social functioning following both types of injections, but a greater reduction in focal pain intensity following prolotherapy injections. The mean and median durations of persistent relief were 2.4 and 1.75 months with prolotherapy vs. 1.8 and 0.75 months with anesthetics alone. Roughly 10% obtained greater than six months of relief from either injection. In the crossover portion of the study, patients reported that prolotherapy injections following initial anesthetic-only injections provided much better relief than that achieved after their anesthetic-only injections, and that anesthetic-only injections following initial prolotherapy injections failed to provide relief as good as that achieved after their prolotherapy. Subsequent to this study, only four of 35 patients required additional spine surgery, but 29 of the 35 patients requested additional injections.Injection therapy of painful enthesopathies can provide significant relief of axial pain and tenderness combined with functional improvement, even in "failed back syndrome" patients. Phenol-glycerol prolotherapy provides better and longer lasting relief than injection with anesthetics alone. Prolotherapy provides over six months of relief for some patients but generally provides relief for only a few months. However, most patients described good to excellent relief, felt that the injections had been beneficial, and requested additional injections for recurrent or residual focal pain.

Object. Acute traumatic central cord syndrome has been classically thought to be caused by a hemorrhage that primarily affects the central part of the spinal cord and that destroys the axons of the inner part of the corticospinal tract devoted to the motor control of the hands. Some authors, however, have proposed that its pathogenesis is based on the destruction of the motor neurons supplying the muscles of the hand. To test the validity of these two theories, the authors retrospectively studied the magnetic resonance (MR) images obtained in 18 cases of acute traumatic central cord syndrome (ATCCS) to assess the presence of intramedullary blood and to define the distribution of the abnormal signal intensities in the cervical spinal cord. Methods. The authors used the American Spinal Injury Association (ASIA) motor scale to assess upper- and lower-limb deficits and to evaluate its metameric distribution. The abnormal intramedullary signal was then compared with the distribution of the motor deficit. All MR imaging sessions performed in the acute stage revealed a hyperintense signal on T 2 -weighted sequences without any signal change suggesting the presence of intramedullary blood. The localization of this signal was distributed predominantly from the C3-4 to the C5-6 disc levels The mean ASIA motor score was 74.3 of 100. with an unequal representation between the upper and lower limbs (32 of 50 compared with 42.3 of 50, respectively). The metameric distribution of the deficit was also unequal, with a major deficit in hand function (C8-T1) compared with the more proximal cord segments (5.2 of 10 compared with 7.8 of 10, respectively). This demonstrates the absence of any correlation between the hyperintense signal and the motor deficit distribution. Conclusions. Acute traumatic central cord syndrome cannot be explained by the injury to the gray matter at the level of motor neurons supplying the hand muscles. In agreement with recently published data, the results of this series confirm the absence of intramedullary hemorrhage and corroborate the hypothesis that ATCCS may be explained by the impairment of the corticospinal tract, which can be affected globally.

RE: Epstein, NE. Reoperation rates for acute graft extrusion and pseudarthrosis after one-level posterior corpectomy and fusion with and without plate instrumentation: etiology and corrective management. Surg Neurol 2001; 56:73–81. Reoperation rates after one-level ACF were evaluated in 48 nonplated and 35 plated patients. Of the 48 nonplated patients, 3 developed immediate graft extrusions requiring replacement; 2 others developed symptomatic pseudarthrosis within 6 months postoperatively, requiring posterior wiring and fusion. Of the 35 plated patients, 1 suffered plate displacement 6 weeks postoperatively, and 3 developed pseudarthrosis within 6 months requiring posterior wiring and fusion. The author concludes that plating does not appear to reduce pseudarthrosis or graft extrusion rates.

A case of acute subdural hemorrhage caused by rupture of an anterior communicating artery aneurysm is presented. The patient is a young man who presented with an acute onset of neurologic symptoms; computed tomography revealed subdural hemorrhage in the absence of associated subarachnoid or intraparenchymal bleeding.

[reaction: see text] A remarkably general lithium heteroatom assisted TMSCN or TBSCN addition to aldehydes and ketones has been discovered. The process provides excellent selectivities and high rates. Conformationally constrained ketones such as camphor, fenchone, and nopinone give excellent diastereoselectivities with TMSCN. Reduction of 2 provided diastereopure amino alcohol 3 in good yield. alpha- and beta-Methyl cyclohexanones with TBSCN-LiOR afford high diastereoselectivities and yields.

Sympathetically mediated or sympathetically dependent pain encompasses a spectrum of conditions that have in common the factor that the pain can be relieved, at least temporarily, through sympathetic interruption.1–11 The pain may be accompanied by, or may be caused by, dystrophic changes or impaired circulation, but can occur without these physical concomitants and often is accompanied by considerable psychological distress. Sympathetically mediated pain most commonly affects the extremities or causes a specific type of cardiac pain. Diagnostic sympathetic blocks are important not only to determine when pain is sympathetically mediated, but also because one or more sympathetic blocks may provide permanent pain relief. Unfortunately, temporary relief from sympathetic diagnostic blocks does not guarantee permanent relief of the sympathetically mediated pain by sympathectomy, and the sympathectomy may fail to reverse the associated vascular or dystrophic changes. Sympathetically mediated pain states are not uncommon, but are frequently difficult to diagnose or to diagnose with certainty, and their management frequently challenges the skill and perseverance of the clinician.

Methotrexate (MTX) alone has a limited effect against malignant brain tumors, but we previously demonstrated a beneficial synergism between MTX and radiation therapy (XRT) against RT-9 gliosarcoma. Because the beneficial effects of that study were limited by systemic toxicity and poor brain penetration of MTX, we have continued our studies using direct intracerebral MTX therapy. Male CD-Fisher rats with intracerebrally implanted RT-9 gliosarcoma and indwelling brain tumor catheters were treated with intracerebral injections of MTX, whole-brain XRT, or a combination of both. MTX was given either as one of two "high-dose" treatments, on the basis of whole-body doses, or two "low-doses," on the basis of average brain weight. MTX alone at lower doses and XRT alone each prolonged survival moderately. High-dose MTX was highly toxic, but low-dose MTX was well tolerated. Combined MTX and XRT caused a significant prolongation of survival in all animals that survived treatment long enough to die from tumor growth.

Management of a patient with a failed back following unsuccessful back surgery poses a serious problem to all health practitioners who attempt to aid these unfortunate sufferers. Neurosurgeons, orthopedists, psychiatrists, family practitioners, physical therapists, nurses, and even marriage counselors all too often find themselves frustrated in their therapeutic efforts. Many of these patients fail to respond to prolonged therapy, but the situation is certainly not hopeless. The list of therapeutic possibilities is, in fact, quite long and varied. Unfortunately, in many instances the failure to achieve success must be attributed to a lack of flexibility and versatility in the therapeutic efforts expended on these patients. One’s approach to these problems must be based on a systematic awareness of the potential therapies available and careful tailoring of therapeutic efforts to the patient’s specific symptoms, physical findings, and psychologic makeup.

In the United States, approximately two thirds of all patients enrolled in chronic pain centers suffer from the failed back syndrome. Neurosurgeons perform 100,000 operations for lumbar disc disease every year, and orthopedic surgeons perhaps perform a similar number.6 It is estimated that between 20% and 40% of these operations are unsuccessful and result in the failed back syndrome. Dr. William Sweet, former Professor and Chairman of Neurosurgery at the Massachusetts General Hospital, has estimated that, in contrast, only approximately 10% of patients enrolled in European pain clinics suffer from the failed back syndrome.7 The reasons for this discrepancy are likely to be multiple, including, perhaps, Europeans’ greater stoicism and a less supportive acceptance of disability and non-productivity.

Patients with the failed back syndrome should usually be treated initially with nonspecific and generally safer therapies. When simpler therapies fail, continued successful therapy must be based on a precise understanding of the disorder to permit an appropriate choice of specific therapy. As our knowledge of the complexity of the disorders that may cause the failed back syndrome increases, it becomes more apparent that the “wastebasket diagnoses” of postoperative back, chronic lumbar derangement, or even the all-encompassing term failed back syndrome are not sufficiently precise to permit accurate therapy for many patients. Attempts at diagnosing precise causes of the failed back syndrome should be undertaken in a systematic fashion. A carefully taken history is vitally important in all aspects of medicine, and this dictum holds true in understanding the causes of the failed back syndrome.

Much of what is currently written about treatment of pain patients, including failed back syndrome patients, assumes, recommends, or even proposes to mandate a team approach. In practice, how valuable is this approach? Are those who insist that it is the only valid approach correct in this assumption, or are they merely overly zealous?