Cases reported "Pain, Intractable"

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1/36. Ventral transdural herniation of the thoracic spinal cord: surgical treatment in four cases and review of literature.

    BACKGROUND: A specific cause of progressive brown-sequard syndrome has been identified: a ventral herniation of the thoracic spinal cord through the dural sleeve on one side. METHOD: Four female patients who were affected by a progressive Brown Sequard syndrome related to a transdural spinal cord herniation have been investigated and were submitted to surgery and postoperative evaluation. FINDINGS: The MRI scan showed atrophy and forward displacement of the spinal cord on one side and adhesion of the spinal cord to the dura mater. CT myelography demonstrated the disappearance of the premedullar rim at the level of the herniation and the shadow of the extradural herniation. Surgical treatment consisted in the excision of the arachnoid cyst when there was one, section of the dentate ligament, release of the adhesions, detachment of the spinal cord from the hernial orifice, and lastly suture of the dural tear or placement by a patch. Follow-up examination showed motor improvement with persistent sensory deficit in two cases and stabilisation in two cases. INTERPRETATION: The cause of the dural tear, either traumatic or congenital could not be confirmed in the four cases. Symptoms probably occur when herniation fills the orifice and strangulation happens which explains the late appearance and progressive evolution of this myelopathy. Mobilisation of the herniated spinal cord back into the intradural space can be achieved by surgery and may stop the evolution of the symptoms and signs.
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ranking = 1
keywords = operative
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2/36. Punctate midline myelotomy. A new approach in the management of visceral pain.

    Nauta et al. reported on a successful punctate midline myelotomy (PMM) for the treatment of intractable pelvic pain. The authors describe an other case history of a patient with multiple anaplastic carcinomas of the small intestine, peritoneal carcinosis and retroperitoneal lymphomas, suffering from severe visceral pain in the hypo-, meso-, and epigastrium. Nauta's PMM was successfully performed at the Th4 level. Narcotic medication was tapered from 30 mg i.v. morphine per hour pre-operatively to 5 mg per hour within 5 days postoperatively. Intensity of pain decreased from 10 to 2-3 on the visual analog scale. Only minor transient side effects appeared and the patient was discharged 5 days postoperatively. The pain reduction was maintained until the patient died from the extended disease five weeks later. We conclude that punctate midline myelotomy sufficiently controls not only pelvic visceral pain, but also visceral pain generated in the meso- and epigastrium. The findings support the concept of a midline dorsal column visceral pain pathway.
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ranking = 3
keywords = operative
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3/36. paraplegia following intraoperative celiac plexus injection.

    The technique for percutaneous and open neurolytic celiac plexus injection, using ethanol or phenol, for relief of intractable pancreatic cancer pain has been well described. Prospective randomized studies, demonstrating safety and efficacy with few complications, have led to widespread acceptance and use of this palliative procedure. The complications of neurolytic celiac plexus injection are rare, and are usually minor. However, transient or permanent paraplegia has been reported previously in 10 cases. The case described herein represents the third reported case of permanent paraplegia following open intraoperative neurolytic celiac plexus injection using 50% ethanol. The literature surveying the indications for this procedure, routes of administration, known complications, and their pathophysiology are reviewed.
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ranking = 5
keywords = operative
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4/36. Neuropathic pain syndrome as an occult manifestation of injury of the spinal cord after surgical repair of aortic coarctation.

    Injury to the spinal cord injury with paraplegia, is a rare complication of surgical repair of aortic coarctation recognized immediately post-operatively. We present the case of a 41-year-old male undergoing surgery for restenosis at the site of a repair. Intra-operatively, he suffered inadvertent injury to an intercostal arterial branch during isolation of the aorta below the graft. Over the following months, he developed unusual symptoms involving the legs and genitourinary tract which, only after extensive investigations, were attributed to ischemic damage to the spinal cord related to the surgery. We suspect that similar syndromes reflecting injury to the spinal cord injury may be unrecognized following surgical repair of coarctation.
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ranking = 2
keywords = operative
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5/36. Asleep-Awake-Asleep general anesthesia for open cervical rhizotomy: case report and description of the technique.

    The authors describe the technique of Asleep-Awake-Asleep anesthesia for open dorsal rhizotomy in a 78-year-old female patient, admitted to the hospital with intractable pain in the distribution of C2 dermatome following a road traffic accident. The patient was anesthetised and the rhizotomy performed using the intradural approach. anesthesia was conducted by Total Intravenous anesthesia using a Target Controlled Infusion system. The patient was awakened twice intraoperatively to verify success of the rhizotomy. Complete pain relief was obtained and maintained at 1 year follow-up.
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keywords = operative
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6/36. Post-colposuspension syndrome following a tension-free vaginal tape procedure.

    A 51-year-old nurse underwent an uneventful TVT procedure. Two weeks postoperatively she developed intractable suprapubic pain directly over the iliopectineal ligaments consistent with a "post-colposuspension syndrome". This failed to respond to conservative therapy and she subsequently underwent exploration of the retropubic space. The TVT sling was found to be densely adherent to the iliopectineal ligaments, from which it was dissected free and then divided, leaving the part where it passes through the endopelvic fascia intact. The pain resolved immediately and the woman remained continent. This diagnosis should be considered in a woman presenting with groin pain following a sling procedure.
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ranking = 1
keywords = operative
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7/36. Stereotactic mesencephalotomy for pain relief. A plea for stereotactic surgery.

    Rostral mesencephalic reticulotomy (RMR) for pain relief was performed in 34 patients with intractable pain. Most of these patients have been followed for a long period of time postoperatively, the longest follow-up period being 11 years. Contrary to the commonly prevailed bias in the past that mesencephalotomy may be a surgical intervention with potential risk, these patients of RMR have continued to substantial improvement postoperatively in terms of their preoperative intractable painful dysesthesia after a long period of time. The results of pain relief for denervation pain as well as for nondenervation pain are surprisingly good even after unilateral procedures. There was no operative mortality. Postoperative disturbance of ocular motility has been reduced. RMR has its scientific basis in that the medial part of the reticular formation rather than the classical lateral spinothalamic tract has more significance in the central conduction of nociceptive impulses through the midbrain level, which was verified by intraoperative neuronal recording with a tungsten microelectrode. The present report emphasizes that stereotactic mesencephalotomy, if performed meticulously and precisely, is a safe surgical procedure for pain relief. Results of MRI and sensory manifestations of a patient 11 years after RMR are also presented.
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ranking = 6
keywords = operative
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8/36. Relief from chronic pelvic pain through surgical lesions of the conus medullaris dorsal root entry zone.

    Dorsal root entry zone (DREZ) lesions are effective in treating specific pain syndromes, most notably post-brachial plexus avulsion. There is limited experience, however, with lesions in the conus medullaris. We review the case of a patient having pelvic pain and urinary retention who failed to improve despite multiple prior interventions. Her pain was completely relieved after DREZ lesions were placed bilaterally at S2, S3, S4 and S5. The intraoperative sensory and motor evoked potential monitoring used to define the level is described in detail.
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ranking = 1
keywords = operative
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9/36. Testicular denervation. A new surgical procedure for intractable testicular pain.

    Chronic testicular pain has many different aetiologies. Identification and treatment of an underlying problem resolve the issue in most cases. However, a proportion of patients with chronic testicular pain have no demonstrable aetiological factor and pose a difficult treatment problem. All of these patients are initially treated by non-surgical measures. Various operations advocated in the literature for non-responders include epididymectomy, scrotal orchiectomy and inguinal orchiectomy, all of which have a significant failure rate. We describe a hitherto unreported operative procedure in a series of 4 patients, with immediate and lasting relief of their pain.
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ranking = 1
keywords = operative
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10/36. Severe intraoperative hypertension and opioid-resistant postoperative pain in a methadone-treated patient.

    patients who are treated with methadone present challenges for the anesthesiologist. We report the untoward effects of rapid preoperative methadone tapering on the operative and perioperative course of a patient who required emergency surgery. The patient's exaggerated stress response to surgery and severe intractable postoperative pain might have resulted from unrecognized methadone withdrawal. Continuation of methadone treatment in patients who have surgery may prevent exaggerated intraoperative hemodynamic responses to surgical stimuli and unnecessary postoperative suffering.
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ranking = 14
keywords = operative
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