Helder Picarelli

Repetitive Transcranial Magnetic Stimulation Is Efficacious as an Add-On to Pharmacological Therapy in Complex Regional Pain Syndrome (CRPS) Type I

UNLABELLED Single-session repetitive transcranial magnetic stimulation (rTMS) of the motor cortex (M1) is effective in the treatment of chronic pain patients, but the analgesic effect of repeated sessions is still unknown. We evaluated the effects of rTMS in patients with refractory pain due to complex regional pain syndrome (CRPS) type I. Twenty-three patients presenting CRPS type I of 1 upper limb were treated with the best medical treatment (analgesics and adjuvant medications, physical therapy) plus 10 daily sessions of either real (r-) or sham (s-) 10 Hz rTMS to the motor cortex (M1). Patients were assessed daily and after 1 week and 3 months after the last session using the Visual Analogical Scale (VAS), the McGill Pain Questionnaire (MPQ), the Health Survey-36 (SF-36), and the Hamilton Depression (HDRS). During treatment there was a significant reduction in the VAS scores favoring the r-rTMS group, mean reduction of 4.65 cm (50.9%) against 2.18 cm (24.7%) in the s-rTMS group. The highest reduction occurred at the tenth session and correlated to improvement in the affective and emotional subscores of the MPQ and SF-36. Real rTMS to the M1 produced analgesic effects and positive changes in affective aspects of pain in CRPS patients during the period of stimulation. PERSPECTIVE This study shows an efficacy of repetitive sessions of high-frequency rTMS as an add-on therapy to refractory CRPS type I patients. It had a positive effect in different aspects of pain (sensory-discriminative and emotional-affective). It opens the perspective for the clinical use of this technique.

The effects of repetitive transcranial magnetic stimulation (rTMS) over the motor cortex on complex regional pain syndrome patients

Objective: There are many evidences that repetitive transcranial magnetic stimulation (rTMS) of the motor cortex is effective in relief of chronic pain. The aim of this study was to evaluate the analgesic effects of rTMS in patients with refractory complex regional pain syndrome (CRPS). Methods: Twenty-three patients presenting with CRPS of the hand were randomly selected and treated with conventional treatment (analgesics, adjuvant medications and physical therapy) plus sham-TMS or rTMS to the motor cortex opposite the affected limb: 100% MT, 10 hz, 10 s trains, 25 trains daily, 10 daily sessions. The Visual Analogical Scale of Pain (VAS), McGill Questionnaire, Pain Impact Questionnaire (PIQ-6), Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), Hamilton Depression and Anxiety Rating Scales and SF-36 Questionnaire were the instruments used for the evaluation. The groups were comparable with regards to socio-demographics, mood and pain intensity. Evaluations were performed before, during TMS treatment and up to three months the end of the treatment. Results: There was a significant reduction in VAS scores favoring the rTMS group up to the seventh follow-up day (p<0.05). The mean reduction in the rTMS group was of 4.65 cm (fall of 50.9%) against 2.18 cm (fall of 24.7%) in sham group during treatment. Improvement in VAS scores was independent of other variables, except for improvement in emotional aspects in the SF-36. Conclusions: During rTMS sessions, there was significant and positive improvement in pain experience of CRPS patients regardless of mood, function or quality of life effects.

434 PREDICTION OF RESULTS OF MOTOR CORTEX STIMULATION IN TREATMENT OF BRACHIAL PLEXUS AVULSION PAIN BY TRANSCRANIAL MAGNETIC STIMULATION

Background and aims. Faced with rising healthcare costs, payers increasingly require evidence on costs and cost effectiveness of healthcare technologies. To date, information on the cost effectiveness of spinal cord stimulation (SCS) for neuropathic pain due to failed back surgery syndrome (FBSS) has been limited. A recent decision analytic model analysis showed that the addition of SCS to usual care is potentially cost effective. However, the report authors highlight the need for more definitive data, i.e. health-related quality of life, healthcare resources and costs. European survey on utilities and resource utilisation in failed back surgery syndrome (SURF) was set up with the aim of collecting such data. Methods. Between January 2005 and September 2006 data was collected in FBSS patients who had had been implanted with SCS or were receiving conventional medical management (CMM) across nine centres in France, Spain, Germany and UK. Generic health-related quality of life data was collected using the EQ-5D. Health care resources were assessed retrospectively and costed at 2005-6 prices. Cost effectiveness is reported as the incremental cost per quality adjusted life year (QALY). Results. Data has been collected on a total of 169 neuropathic patients with FBSS. This data will be used to populate the previously published economic model with the purpose of reassessing the cost-effectiveness of SCS. Conclusions. This presentation presents costs and quality of life data collected in the SURF project and updates the cost effectiveness of SCS vs. CMM in patients with neuropathic pain due to FBSS.

144 REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (rTMS) OF THE MOTOR CORTEX IMPROVES CRPS PAIN

effect of treatment. We compared a group of patients with an acute herniated disc (AHD), known to be a condition with an inflammatory component, to patients with spinal stenosis (SST). Methods: We studied 8 patients with AHD and 5 patients with SST. After appropriate diagnostic procedures a 5 minute PRF procedure was performed with 10 msec pulses at 45 V. CRP was measured before and 3 hours following the procedure. The clinical condition was scored on the NRS before treatment and after 2 months. Results: There was a fall in CRP level of 21.2% in the AHD patients (p = 0.0009). In the patients with SST there was a 2.36% fall (n.s.). In the AHD group one patient was operated 3 weeks following the procedure. In the other 7 patients the NRS fell from 8.25 before treatment to 0.86 after 2 months. In the SST group the NRS fell from 9.33 to 3.32. Conclusions: PRF has an anti-inflammatory effect when it is applied for inflammatory conditionsPRF may also be clinically effective in less inflammatory conditionsWe postulate that PRF changes the environment of a complex system that is formed by the immune and the nervous systems togetherFurther studies along these lines are needed

903 ANALGESIC EFFECTS OF EPIDURAL MORPHINE IN THE TREATMENT OF REFRACTORY NEUROPATHIC PAIN RELATED TO BRACHIAL PLEXUS AVULSION

challenging. We wanted to find out the efficacy of 500mcg intrathecal diamorphine. We also wanted to know the common side effects or complications after intrathecal diamorhine. Methods: We conducted a prospective audit of 25 patients undergoing elective revision hip surgery. All the patients had standard General Anaesthetic with invasive monitoring. Patients were given prophylactic Ondansatron and dexamthesone as antiemetics. All patients had intrathecal diamorphine 500mcg.for post-operative pain relief and were also prescribed morhine PCA. Patients were monitored for 24 hrs on post-operative surgical unit. Pain was assessed at regular intervals by using VAS scale. Results: Our study group patients had male:female ratio 56:44. Agerage age was 62 years. All patients had VAS pain score of <1. Average duration of pain relief prior to use of morphine PCA was 11.2 hrs. Common side effects were nausea/vomiting (28%) and pruritus (16%). None of our patient had respiratory depression or sedation score of more than 1. Conclusion: Intrathecal diamorphine 500mcg can be safely used for the post-operative pain relief after revision hip surgery. Nausea/vomiting remains commonly occuring problem despite prophylactic antiemetics.

424 Repetitive transcranial magnetic stimulation over the motor cortex can change the pain perception in patients with complex regional pain syndrome

PRF treatment in lumbosacral monoradiculopathy (L4-L5-S1). Design. Multicentric, prospective, open-label, nonrandomized trial. Setting. Multicenter (public and private hospitals, Italy). Inclusion criteria. All patients affected by lumbar monoradiculopathy for more than four months, nonsurgically treated. Interventions. In all patients it has been used a PFR treatment for 240 s using Pasha Cath, on the target root, through sensory neurostimulation (<0.3 V). Effectiveness assessments. NRS, Oswestry Disability Questionnaire and analgesic therapy at baseline and third month. Results. Follow-up in progress.

598 TRANSCRANIAL MAGNETIC STIMULATION AS A TOOL FOR PREDICTION OF MOTOR CORTEX STIMULATION RESULTS IN TREATMENT OF BRACHIAL PLEXUS AVULSION PAIN

Spinal cord stimulation (SCS) has become an established pain treatment for patients with angina pectoris not suitable candidates for coronary bypass grafting or intraarterial invasive technique. The implants are well tolerated, and side effects are mostly lead migration, discomfort due to the pulse generator or pain located to the fixation of the lead. The abstract describes five case reports with unusual neurological complications likely due to spinal cord stimulation devices. The patients (age 49–74 years) developed widespread constant paraesthesia or burning sensations weeks after implantation of SCS devices. The symptoms were constant and not related to activation of the pulse generator. Four of the patients had the devices explanted and their symptoms decreased in intensity during the nest months. None of the patients had a history of previous skin disease, known contact allergy or dermatitis related to the stimulation device. Four of the patients agreed to an allergological investigation to clarify if an allergic mechanism could be rendered probable. The four patients were patch tested according tested according to standard procedure with the European Standard Series supplemented with a series of epoxy and isocyanate chemicals known to be potential contact allergens, and samples of all stimulation device components supplied by the product manufacturer. None of the four patients had any current dermatitis and they all had negative patch tests to all test chemicals and product ingredient samples. In the four patients examined, discomfort due to SCS could not be related to an allergic reaction mechanism.