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ZusammenfassungDas biopsychosoziale Schmerzkonzept stellt gegenwärtig den Schwerpunkt schmerztherapeutischer Behandlungsprogramme dar. Jedoch kann damit die Komplexität chronischer Schmerzen, insbesondere ihre Bedeutung für die Betroffenen, nur unzureichend erfasst werden. Denn ein Kernaspekt des Phänomens chronischer Schmerz wird bislang nur in Einzelfällen berücksichtigt: sein existenzieller Charakter. Chronische Schmerzen können das Selbst- und Weltverständnis, die Lebenswünsche und -ziele, letztlich die gesamte Integrität der Betroffenen bedrohen. Selbstaussagen Erkrankter zeigen, dass chronischer Schmerz immer ein existenzielles Widerfahrnis darstellt und den Menschen in seiner Gesamtheit erfasst. Dies wird durch zwei Aspekte deutlich: zum einen durch die existenzielle Verzweiflung am Schmerz, zum anderen durch Fragen der Sinngebung und Neuorientierung. Allerdings berücksichtigen gängige Therapiekonzepte den existenziellen Charakter mit derartigen Herausforderungen bislang nicht adäquat. Chronischer Schmerz sollte daher stets unter einer umfassenden Perspektive wahrgenommen und behandelt werden. Hierbei sind die Aspekte Einzigartigkeit anerkennen, zum Ausdruck verhelfen und dem Er-leben Raum geben zur Unterstützung Erkrankter in ihrer Auseinandersetzung mit dem Schmerz besonders zu berücksichtigen.

Worldwide, the COVID-19 pandemic has a significant impact on daily life. First studies describe a negative impact of pandemic stressors even on individuals without previous mental illnesses. The home lockdown and the shutdown of pain clinics make it difficult for all patients to get the healthcare they need.The aim of this study was to investigate to what extent patients with chronic pain felt affected by the pandemic and its consequences on pain treatments, focussing on the beginning of the outbreak.A prospective noninterventional study.Medical University Center .One-hundred and forty-nine patients, suffering from chronic pain, treated at a large German interdisciplinary pain center, were studied over a period of 2 months at the beginning of the pandemic. Data from patient charts and questionnaires were evaluated. Patients were asked about postponements or cancellations of pain therapy, the possible effect on pain levels, depression, anxiety and stress, and the impact of intensified hygiene measures. Results were compared to those from standardized and validated questionnaires from the same patients (German version of the depression, anxiety, and stress scale = DASS) at the time of the first contact in the pain clinic.Eighty-four (56.4%) patients reported cancelled or postponed treatments during the pandemic. Those chronic pain patients with delayed or cancelled treatments reported significantly more pain and psychological distress. The delay or discontinuation of treatments resulted in a deterioration of symptoms. From the patients' point of view this deterioration was unrelated to the timing of treatment and not secondary to increased hygiene measures. In both groups, patients showed a significant amelioration of the DASS values compared to the values they had at the beginning of treatment, despite the negative effects of the COVID-19 pandemic on care structures. The majority of the patients do not think that the quality of pain treatment was significantly affected by the intensified hygiene requirements.The limitations of the study are the small number of patients because of the limitation to a short period of time at the beginning of the pandemic and the return rate of 40.2% of the study consents.Even in the event of a pandemic-related restriction of the care structures, patients with chronic pain benefit from pain therapy. Limitations such as the increased hygiene measures caused by the pandemic were not considered detrimental to the therapeutic measures.

Dear Editor, Chronic pain syndromes pose a challenge for interdisciplinary teams of pain specialists. We report a patient who presented with a neuropathic trigeminal pain syndrome after repeated resection of an epidermoid tumour involving the trigeminal ganglion. Multiple therapeutic approaches—including chronic motor cortex stimulation, intrathecal drug application and deep brain stimulation (DBS) to the periventricular/periaqueductal grey and sensory thalamus—did not lead to a sustained relief of pain with a persistent rating of 7-9 on the visual analogue scale (VAS). A magnetic resonance imaging (MRI) scan was suspicious for a malposition of the previously implanted clinically non-functional DBS electrodes. The DBS system was completely removed surgically. The patient underwent diffusion tensor magnetic resonance imaging (DTI). Imaging was performed on a clinical 3-T MRI system (Magnetom Trio Tim System 3 T; Siemens, Erlangen, Germany). DTI: single-shot, two-dimensional, SE EPI; TR, 10,000 ms; TE, 94 ms; diffusion values, b = 0 s/mm2 and b = 1,000 s/mm2; diffusion directions, 61; slice count, 69; voxel size, 2.0 × 2.0 × 2.0 mm3; acquisition time, 11:40 min. Deformation correction of the EPI sequence according to Zaitsev et al. [1]. DTI tractography: StealthViz-DTI system (Medtronic Navigation, Louisville, USA); FA level, 0.2; minimal fibre length, 10 mm; seed density, 5.0; maximal fibre cut-off angle, 50°. Tractography as shown here used the MCP coordinates of the previous (removed) and newly implanted electrodes. Three-dimensional visualisation and rendering of tracked fibres were performed with Amira (Konrad Zuse Zemtrum, Berlin, Germany and Visualization Sciences Group, SAS Bordeaux, France); electric stimulation as previously described [2]. At the day after imaging, two DBS electrodes were implanted stereotactically, assisted with the DTI technology (MCP coordinates cross-checked with DTI fibre-tracking results: VCP: laterality 11 mm, 2-mm anterior to PC, verticality at level of ACPC plane; PVG/PAG: 5-mm laterality, 2-mm anterior PC, verticality at level of ACPC plane). DTI tractography analysis revealed that the previously misplaced DBS electrodes were touching the median polysynaptic pain system (MPNS) (Fig. 1a-c, blue arrows). The newly placed electrodes (as displayed with helical computed tomography) now in addition reached the medial and trigeminal lemniscal systems (Fig. 1d, e). The patient’s VAS dropped almost instantaneously and remained stable with fluctuating levels between 2 and 5 over a period of 15 months. Fig. 1 a–c Deep brain stimulation (DBS) electrode positions (postoperative computed tomography superimposed onto preoperative T2-weighted MRI scans): a axial view at the level of the inter-commissural plane; b coronal view; c parasagittal view. Blue ... Recently, DBS of the medial lemniscus in neuropathic pain after planning with tractography has been described [3]. This line of investigation is likely to be fruitful in the light of successful stimulation of fibre tracts in other indications [2, 4–6]. The PAG/MPNS system is concerned with autonomic, emotional and pain function. In the context of DBS, the connectivity of the PAG has been previously addressed utilising the DTI technology [7, 8]. In accordance with our own tractography studies [9], we are convinced that one previously described upstream projection [8] is confluent with the ATR system that at different levels (midbrain, PAG, prefrontal cortex, bed-nucleus of the stria terminalis) connects with the MFB system. Recently we have shown in a pilot study that direct stimulation of the MFB has strong anti-depressive effects [6]. Since PAG/PVG stimulation is located in a supposed connection hub of MFB/ATR, it is possible that PAG stimulation alters the network balance of the ATR system in favour of the MFB system and diminishes emotional and somatic pain. We have elaborated on the limitations of the DTI technology in our previous publications [2, 4, 5]. This report strengthens the idea of the application of the DTI tractography technology for DBS surgery in neuropathic and nociceptive pain and, moreover, for the thorough analysis of the electrode positions obtained with respect to the fibre systems, which in addition to computation of somatic pain are concerned with emotion processing.

For more than 3 decades, spinal cord stimulation (SCS) has successfully been employed to treat neuropathic pain. Psychological factors are assumed to be important for the efficacy of SCS. However, the impact of psychological factors on the outcome of SCS has only rarely been studied.The aim of this study was to determine the influence of psychological factors such as anxiety and depression, perceived disability, and self efficacy on the outcome of SCS in a representative clinical sample.Retrospective study.Academic university interdisciplinary pain center.We reviewed the records of 60 consecutive patients who had been treated at our institution with lumbar, thoracic, or cervical neurostimulators between July 1, 2008, and June 30, 2012. Information with respect to age, gender, diagnosis, age at time of implantation, disease duration, the preoperative Hospital Anxiety and Depression Test, German Version (HADS-D), the Pain Disability Index (PDI) and preoperative pain scores on an 11 point Numeric Rating Scale (NRS) were recorded. In addition, a questionnaire was mailed to participants that contained the following items: pain scores on the NRS with and without stimulation, time intervals of stimulation, paresthesia coverage, treatment satisfaction and medication intake, anxiety/depression (HADS-D and Beck Depression Index II [BDI-II]), PDI, and self efficacy using the Fragebogen zur Erfassung der schmerzspezifischen Selbstwirksamkeit (FESS).Preoperative HADS-D, PDI, and NRS pain scores were not different in those patients with an unsuccessful trial and those who underwent IPG implantation. Long-term outcomes were not affected by pre-implantation HADS-D or PDI scores. FESS scores showed a strong inverse correlation with HADS-D, BDI-II, and PDI scores and showed a tendency towards correlation with the percentage of pain reduction. HADS-D and PDI scores improved after SCS therapy.Retrospective study.The outcome of SCS therapy could not be predicted on the basis of tested psychological factors anxiety/depression and pain-related disability. FESS correlated inversely with HADS-D, BDI-II, and PDI scores and showed a tendency towards correlation with the percentage of pain reduction. Further research is needed to define the impact of psychological factors on SCS outcomes.

Background: For more than 3 decades, spinal cord stimulation has successfully been employed to treat neuropathic pain. Cervical spinal cord stimulation, despite now being standard in many hospitals, has only rarely been subjected to a critical review within the literature. Objectives: The aim of this study was to determine the efficacy of cervical spinal cord stimulation (SCS) in a representative clinical sample. We also wanted to evaluate how factors such as stimulation parameters, unwanted paresthesia of the trunk and legs, and changes in paresthesia status due to head movement and how they affect SCS effectiveness. Study design: Retrospective study. Setting: Academic university interdisciplinary pain center. Methods: We reviewed the records of patients who had been treated at our institution with cervical neurostimulators from November 1, 2001 through October 31, 2011. Information regarding age, gender, diagnosis, age at time of implantation, duration of disease, lead position, hardware in use, revision operations, and stimulation parameters were recorded. In addition, a short telephone interview was conducted, which contained the following items: pain scores on the numeric analog scale (NAS) with and without stimulation, time intervals of stimulation, paresthesia coverage, changes in paresthesia coverage by head movements, unwanted paresthesia of the trunk and legs, treatment satisfaction, and medication intake. Results: Twenty-three patients were treated. Eighteen patients proceeded to an implantable pulse generator (IPG) implant. In one patient, the system was removed after 4 years despite optimal function, because the patient was no longer experiencing pain. Average NAS pain scores were 6.8 (range 5.5 - 10.0, standard deviation [SD] 1.7) without, and 2.8 (range 0 - 7.5, SD 2.2) with neurostimulation. Fourteen revisions (5 due to lead dislocation, 5 due to lead breakage and 4 IPG revisions) were necessary in 9 of the 18 patients during a mean follow-up of 6.2 years. Most patients reported complete paresthesia coverage. Four patients reported unwanted paresthesia of the trunk or lower limb and 11 patients reported changes in paresthesia with head movements. In both instances, pain reduction was not affected. Limitations: Retrospective study. Conclusions: Cervical spinal cord stimulation appears to be effective in the treatment of neuropathic upper limb pain. Complications are not significantly more frequent than in SCS for lower limb pain. Changes in paresthesia with head movements and unwanted paresthesia did not affect the outcome. Key words: Spinal cord stimulation, cervical, neuropathic pain, clinical efficacy, paresthesia, paresthesia coverage, changes in paresthesia, brachial plexus lesion, nerve root avulsion, stimulation parameters