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BACKGROUND AND PURPOSE: Spinal cord stimulation is a well-known treatment of rigorously selected failed-back surgery syndrome patients. Efficacy levels over 50% of pain relief have been reported in long-term studies. The objective of this multicenter prospective evaluation was to analyze the cost to benefit ratio of spinal cord stimulation treatment for failed back surgery syndrome patients. METHODS: Nine hospitals (pain evaluation and treatment centers) were involved in the study. Forty-three patients were selected and implanted between January 1999 and January 2000. For each patient, pre- and post-operative evaluations (6, 12 and 24 months after implantation) were performed to assess pain relief and economical impact on pain treatment costs. RESULTS: After 24 months, mean 60% pain relief was achieved as assessed with the neuropathic pain score using a Visual Analog Scale (success rate=70%), whereas low-back pain was moderately reduced (29%). The Oswestry Disability questionnaire score was improved by a mean 39%. Costs of pain treatment (medication, consultation, other) are reduced by a mean 64% (1705 Euro) per patient per year. CONCLUSIONS: This study confirms a clear analgesic effect on neuropathic sciatalgia, and moderate attenuation of low-back pain. One particular interest of this study is the medico-economic prospective evaluation showing that the initial cost of the implanted device is compensated by a significant, early, and stable reduction in the cost of associated pain therapies.

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The use of intraspinal narcotics has been widely accepted as pain relief treatment for intractable cancer pain. Intraspinal low doses of morphine induce a potent selective long lasting analgesia. To avoid repetitive lumbar puncture, a drug delivery device was surgically implanted in 41 patients. The surgical procedure is described. The mean amount of morphine needed was 1.48 +/- 0.25 mg per day at time of surgery, rising to 6.86 +/- 1.47 mg per day after a mean survival time of 65 days. Tolerance became a major problem in 18 patients, which nearly all were selected at a late disease stage and previously received narcotics for pain relief. However, no clear-cut prognostic factor had a predictive value for the appearance of tolerance. In some cases, it could be successfully treated by intraspinal injection of local anaesthetics or clonidine. CSF leakage was noted in 11 patients; this was a challenge for us, as no other authors reported such a high rate for this complication. Aseptic meningitis was noted three times. In all cases but one, the symptoms resolved with appropriate treatment.

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A case of opiate accidental overdose is reported where 8 mg morphine were given by spinal injection. The rapid onset respiratory depression was treated by naloxone alone administered as a continuous infusion (6 mg), together with additional intravenous injections.

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The technique is of interest in deep bone pain in terminal metastasized cancer, but early relapses often occur. The hypoalgesia or analgesia obtained does not seem to result from endocrine mechanisms only, nor from the release of endogeneous opioid peptides. This neuroadenolysis seems to interfere in the pain pattern either through still unknown neurotransmitters, or through the dissociation of fibers transmitting pain to the floor of the diencephalon.

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Twenty five healthy pregnant women received an epidural injection (at levels varying from T11-T12 to L3-L4) of morphine (2 or 3 mg in 10 ml of saline solution 9 p. thousand) in order to achieve pain relief for delivery. The degree of dilation never exceeded 5 cm at time of injection. Pain level decreased in 22 cases (88 p. cent) but only 16 women (64 p. cent) were fully satisfied. Hypoalgesia begun after 25 minutes and disappeared after 19 hours. No respiratory or haemodynamic changes were noted. On the other hand, the duration of the first stage of labour decreased. The best results are seen when injection is achieved at highest levels, facing spinal cord segments supplying the cervix and the perineum. No newborn showed any sign of respiratory or neurologic depression.

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Low dose morphine epidurals (0.5 to 4 mg) provide a good way of controlling either per or postoperative pain (210 cases) or chronic, somatic, intractable pain (282 cases). Selective and metameric medullar hypoalgesia is induced at a level which varies with the level of injection. There is an acquired tolerance which restricts the use of such injections to the short-term monitoring of somatic pain. In other types of psychogenic and deafferentiation pain, there is little or no sedation, but there are maximum secondary dysphoric effects. The degree of combination of these dysphoric effects with hypoalgesia is of diagnostic interest of the type of pain involved, and of prognostic interest when both somatic and deafferentation pains are present.

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The authors report their experience with 35 guanethidine intravenous local injections in algodystrophic and neurotrophic syndromes. Although excellent results are obtained in post-traumatic algodystrophies which are treated early, they are less remarkable in long standing sequelae due to injuries of the nervous system, and where, at best, only an antalgic effect can be expected.

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Pain due to bone metastasis in hormonodependent cancer (of the breast or the prostates more particularly) can be relieved by surgery directed at the endocrinic system. The most efficient techniques are hypophysectomies and hypophysiolysis (or neuroadenolysis). The intrasellar injection of alcohol through the transnasal-transsphenoidal route is a fairly simple procedure which can be carried out on such fragile patients without too much risk. The authors here report the first results obtained with this procedure in 12 pateints. Full sedation of pain is achieved in 30 to 40 p. cent of the cases. The duration of analgesia varies and pain frequently returns. One of the advantages of this procedure lies in the fact that such an injection may be repeated if necessary. The intrasellar injection of alcohol is but one of the many techniques available to practitioners working in the field of intractable pain.

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